The Journal of Foot & Ankle Surgery 56 (2017) 336–356 Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org Review Article Ò American College of Foot and Ankle Surgeons Clinical Consensus Statement: Perioperative Management Andrew J. Meyr, DPM, FACFAS 1, Roya Mirmiran, DPM, FACFAS 2, Jason Naldo, DPM, FACFAS 3, Brett D. Sachs, DPM, FACFAS 4,5, Naohiro Shibuya, DPM, FACFAS 6 1 Committee Chairperson and Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA 2 Surgeon, Sutter Medical Group, Sacramento, CA 3 Assistant Professor, Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA 4 Private Practice, Rocky Mountain Foot & Ankle Center, Wheat Ridge, CO 5 Faculty, Podiatric Medicine and Surgery Program, Highlands-Presbyterian St. Luke’s Medical Center, Denver, CO 6 Professor, Department of Surgery, Texas A&M, College of Medicine, Temple, TX article info abstract Level of Clinical Evidence: 5 A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon’s responsibility to consider the clinical variables and to guide the patient through the perioper- Keywords: body mass index ative period. In an effort to address a number of important variables, the American College of Foot and Ankle cigarette smoking Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues Delphi method associated with the perioperative management of foot and ankle surgical patients. glycated hemoglobin Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. prophylactic antibiotic tourniquet vitamin D Executive Statement Patients with open foot and ankle fractures should be treated with antibiotics The following represents a clinical consensus statement The urgency of the treatment of open foot and ankle fractures is Ò sponsored by the American College of Foot and Ankle Surgeons dependent on a variety of factors, including, but not limited to, time, on the topic of perioperative management. A modified Delphi anatomic location, and fracture grade and extent method was undertaken by a 5-member panel in an attempt to Perioperative management of diabetes medications warrants develop consensus on a series of 22 statements using not only the consideration before foot and ankle surgical procedures best available evidence, but also a degree of clinical experience Perioperative management of rheumatoid arthritis medications and common sense. warrants consideration before foot and ankle surgical procedures The panel reached consensus that the following statements were Perioperative management of anticoagulation medications warrants “appropriate”: consideration before foot and ankle surgical procedures Tourniquets can be safely used for most patients undergoing foot and Cigarette smoking should be considered a risk factor for the devel- ankle surgical procedures opment of complications after foot and ankle surgical procedures Prophylactic antibiotic therapy should be considered for foot and Elevated glycated hemoglobin should be considered an independent ankle surgical procedures risk factor for the development of complications after foot and ankle Prophylactic postoperative antithrombotic therapy should be surgical procedures considered for some patients after foot and ankle surgical procedures Foot and ankle surgeons should consider a multimodal approach to postoperative pain management Financial Disclosure: None reported. Foot and ankle surgeons should be aware of objective measures of Conflicts of Interest: None reported. patient satisfaction and postoperative outcomes Address correspondence to: Andrew J. Meyr, DPM, FACFAS, Department of Surgery, Temple University School of Podiatric Medicine, 8th Race Street, Philadelphia, PA 19107. The panel reached consensus that the following statement was E-mail address: [email protected] (A.J. Meyr). “inappropriate”: 1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.10.016 A.J. Meyr et al. / The Journal of Foot & Ankle Surgery 56 (2017) 336–356 337 Foot and ankle surgeons should use routine postoperative radio- Adherence to consensus statements will not ensure successful graphs in the absence of a clinical indication to assess osteotomy, treatment in every clinical situation, and individual physicians should fracture, and/or arthrodesis healing make their ultimate decisions using all available clinical information and circumstances with respect to the appropriate treatment of an The panel reached consensus that the following statements were individual patient. This CCS is on the general topic of perioperative “neither appropriate nor inappropriate”: management of the foot and ankle surgical patient, and its purpose is to address some of the preoperative, intraoperative, and post- Foot and ankle surgical procedures should be considered a low operative considerations facing the foot and ankle surgeon in perioperative risk contemporary practice. Foot and ankle surgeons should use specific hair removal and pre- Materials and Methods operative skin bathing protocols before elective foot and ankle sur- gical procedures Creation of the Panel Preoperative methicillin-resistant Staphylococcus aureus decon- tamination protocols should be performed before elective foot and Believing that the creation of CCSs would be beneficial to its members, the ACFAS ankle surgical procedures enacted an initiative to create such documents for foot and ankle surgeons. This An elevated body mass index should be considered a risk factor for initiative was originally conceived to report on a variety of topics and to replace pre- vious clinical practice guidelines (4–10). To move forward with this initiative, a formal the development of complications after foot and ankle surgical consensus method process was undertaken. Seven experts in the field of foot and ankle procedures surgery were initially sent an invitation by the ACFAS to participate on a panel to A high preoperative blood glucose level should be considered a risk develop a CCS on “perioperative management.” A 5-member panel was eventually factor for the development of complications after foot and ankle convened and tasked with reviewing the published medical data and providing opin- surgical procedures ions about this topic. The panel was chaired by 1 member (A.J.M.) and assisted by ACFAS fi members and staff. During a several-month period, the panel members participated in Foot and ankle surgical procedures involving arthrodesis of the rst an electronic mail dialog, conference calls, and a face-to-face meeting. The stated goal ray should use a period of non-weightbearing immobilization of the panel was to develop a series of CCS questions on the topic of perioperative Specific postoperative incisional care protocols should be used by management that might be of interest and value to foot and ankle surgeons, examine foot and ankle surgeons the current published data relating to these statement questions, and synthesize this information and our consensus opinions for ACFAS members and The Journal of Foot and Ò Ankle Surgery readers. The panel was unable to reach consensus on the following statements: Development of CCS Questions Vitamin D levels should be assessed before all foot and ankle Our first task was the development of a series of CCS questions for inclusion. The arthrodesis procedures topic of perioperative management is broad, and any number of subtopics and specific Foot and ankle surgeons should consider the use of bone stimulation statement questions could be derived from it. Initially, through ACFAS member survey in cases of delayed and nonunion feedback, our collective clinical experience, and the results of an open discussion during an introductory conference call, we developed a preliminary list of approximately 35 to 40 specific topics within the realm of perioperative management to consider as consensus statement questions for inclusion in this CCS. The panel members subse- Introduction quently performed preliminary data reviews and wrote brief synopses on these topics, attempting to answer the questions of (1) whether any guidelines exist on this topic; (2) whether any original investigations have been reported on this topic specific to the foot This document was created to serve as one of a series of clinical and ankle; and (3) whether any other original investigations have been reported on this consensus statements (CCSs) sponsored by the American College of topic specific to other medical specialties, but still potentially relevant. On a subsequent Ò Foot and Ankle Surgeons (ACFAS) (1,2). It is important to appreciate conference call, these initial reviews and synopses were discussed, and the panel made that consensus statements do not represent clinical practice guide- majority decisions resulting in the inclusion and development of 22 CCS questions (Table). lines, formal evidence reviews, recommendations, or evidence-based guidelines. A CCS reflects information synthesized from an organized Formal Literature Review group of experts based on the best available evidence. However, it can also contain, and to some degree, embrace opinions, uncertainties, Comprehensive reviews of the published data were then performed by the panel Ò Ò and minority viewpoints. A CCS should open the door