title: Neuropathy and poorly controlled diabetes increase the rate of surgical site infection after foot and ankle surgery.
abstract: BACKGROUND
  This prospective study was designed to evaluate the frequency of surgical site infection in patients treated with foot and ankle surgery. Our hypothesis was that patients with complications of diabetes are at increased risk for surgical site infection compared with patients without diabetes and patients with diabetes who do not have diabetic complications. Another goal was to compare the association of neuropathy with surgical site infection in both nondiabetic and diabetic patients.
  
  
  METHODS
  Two thousand and sixty consecutive surgical cases were evaluated. Group 1 included nondiabetic patients without neuropathy, Group 2 included nondiabetic patients with neuropathy, Group 3 included patients with diabetes but no diabetic complications, and Group 4 included patients with diabetes who had at least one complication of diabetes.
  
  
  RESULTS
  The surgical site infection rate in this study was 3.1%. Patients with complicated diabetes had a 7.25-fold increased risk of surgical site infection compared with nondiabetic patients without neuropathy and a 3.72-fold increased risk compared with patients with uncomplicated diabetes. Patients with complicated diabetes had a nonsignificant 1.54-fold higher rate of surgical site infection compared with nondiabetic patients with neuropathy. Nondiabetic patients with neuropathy had a significant 4.72-fold increased risk of surgical site infection compared with nondiabetic patients without neuropathy. Despite this, nondiabetic patients with neuropathy did not have a significantly higher rate of surgical site infection than patients with uncomplicated diabetes, and the frequency of surgical site infection in the group with uncomplicated diabetes was not significantly different from that in the nondiabetic patients without neuropathy. Multivariable logistic regression analysis demonstrated that peripheral neuropathy and a hemoglobin A1c of ≥8% were independently associated with surgical site infection.
  
  
  CONCLUSIONS
  Complicated diabetes increases the risk of surgical site infection after foot and ankle surgery. Patients who had diabetes without complications did not have a greater risk of surgical site infection compared with nondiabetic patients without neuropathy. The presence of neuropathy increases the risk of surgical site infection even in patients without diabetes. Poor long-term glycemic control is also associated with an increased risk of surgical site infection.
  
  
  METHODS
  Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 2100 Jane Street, Pittsburgh, PA 15203. E-mail address for D.K. Wukich: wukichdk@upmc.edu.
authors.forename: Dane K
authors.initials: DK
authors.lastname: Wukich
authors.affiliation: Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 2100 Jane Street, Pittsburgh, PA 15203. E-mail address for D.K. Wukich: wukichdk@upmc.edu.
authors.forename: Brandon E
authors.initials: BE
authors.lastname: Crim
authors.affiliation: Phoenix VA Healthcare System, 650 East Indian School Road, Phoenix, AZ 85012.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Frykberg
authors.affiliation: Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, 127 Parran Hall, Pittsburgh, PA 15213.
authors.forename: Bedda L
authors.initials: BL
authors.lastname: Rosario
mesh_terms: D000842:Ankle / Q000601:surgery*; D001786:Blood Glucose / Q000378:metabolism; D016022:Case-Control Studies; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000150:complications; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000150:complications; D003929:Diabetic Neuropathies / Q000097:blood / Q000150:complications* / Q000517:prevention & control; D005260:Female; D005528:Foot / Q000601:surgery*; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D008297:Male; D008875:Middle Aged; D010523:Peripheral Nervous System Diseases / Q000097:blood / Q000150:complications*; D011446:Prospective Studies; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000097:blood / Q000209:etiology*
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin