In many LMICs, those in the middle class, including health professionals, have a high incidence of obesity
Patients over 40 undergoing surgery should have a fasting or random glucose evaluation as diabetes is often undiagnosed or if previously diagnosed is inadequately treated and can lead to perioperative wound complications.
Patients with diabetic foot sores often present late, when osteomyelitis is already present and conservative wound management unlikely to succeed. A Syme or below-knee amputation (BKA) is all too often the end result, after multiple ray resections and partial foot amputations fail. A similar problem is seen with neuropathic arthropathies (Charcot joints), particularly around the foot and ankle where progressive joint destruction leads to bony deformities producing chronic pressure wounds that lead to osteomyelitis (Fig. 3.2). Fusion of neuropathic joints has a high failure rate but should be considered before the wounds develop. Otherwise a BKA is a common outcome.
Fig. 3.2
(a) Chronic draining sinus of hind- and midfoot Charcot joints from diabetes. (b) Lateral X-ray showing destruction of talonavicular, calcaneocuboid, and midtarsal joints with flattening of the longitudinal arch. (c) AP X-ray showing osteoporosis, joint destruction, and pathologic fractures
Neoplastic Disease
Primary or secondary (metastatic) neoplasias of the musculoskeletal system increase with age (see Chap. 42). Again, because of late presentation, the vast majority of patients are beyond hope of cure (Fig. 3.3). The unavailability of adjuvant treatments, such as chemo- and radiation therapy, compounds the problem. Metastatic disease is the most common of the bony neoplasms, and the habitual primaries from the lung, breast, and prostate all increase with age.
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