EDITOR’S CHOICE

Wound Healing Complications in Diabetic

Patients Undergoing Carpal Tunnel and
Trigger Finger Releases: A Retrospective
Cohort Study
Benjamin K. Gundlach, MD,* Christopher B. Robbins, PhD, MPA,* Jeffrey N. Lawton, MD,* John R. Lien, MD*

Purpose To evaluate the association of diabetes and perioperative hemoglobin A1C (HgA1C)
value with postoperative wound healing complications following carpal tunnel release (CTR)
and trigger finger release (TFR).
Methods A retrospective review of diabetic patients who underwent CTR and/or TFR between
2014 and 2018 was performed. Hemoglobin A1C value within 90 days of surgery was
recorded for all diabetic patients. A nondiabetic comparison group was selected from within
the same study period in an approximately 1:1 procedural ratio, although direct matching was
not performed. A chart review was used to examine postoperative wound healing compli-
cations, such as wound infection, wound dehiscence, or delayed wound healing.
Results Two hundred sixty-two diabetic patients and 259 nondiabetic patients underwent 335
and 337 CTR and/or TFR procedures, respectively. There were 36 wound complications in
the diabetic group and 9 complications in the nondiabetic group. Logistic regression analysis
demonstrated an increased association of wound healing complications with diabetic patients
compared to nondiabetic patients. Additionally, an increased association was demonstrated
among diabetic patients with an HgA1C value above 6.5% compared with those with an
HgA1C value below 6.5%.
Conclusions Compared with nondiabetic controls, diabetic patients have increased associated
risk of postoperative wound healing complications following CTR and/or TFR. This
increased association was further demonstrated among diabetic patients with elevated peri-
operative HgA1C values. (J Hand Surg Am. 2021;46(12):1057e1063. Copyright Ó 2021 by
the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Prognostic IV.
Key words A1C, carpal tunnel, diabetes, infection, trigger finger, wound healing.

T
From the *Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI. HE PREVALENCE OF DIABETES mellitus (DM) has

Received for publication October 7, 2019; accepted in revised form May 12, 2021.
J. N. Lawton serves as a consultant for Innomed (Savannah, GA) unrelated to the subject
of this article. No benefits in any form have been received or will be received by the
other authors related directly or indirectly to the subject of this article.
Corresponding author: John R. Lien, MD, Department of Orthopaedic Surgery, Michigan
Medicine, 2098 South Main Street, Ann Arbor, MI 48103; e-mail: jlien@med.umich.edu.
0363-5023/21/4612-0002$36.00/0
https://doi.org/10.1016/j.jhsa.2021.05.009
been estimated to be 12%e14% in the United
States among those aged 20 years and older,
and its incidence continues to increase.1,2 Surgical
outcomes in diabetic patients are reported in many
surgical specialties, including hand surgery. The
literature published in the field of arthroplasty, sports
medicine, as well as foot and ankle has presented
evidence that DM is associated with a higher rate of

Ó 2021 ASSH r Published by Elsevier, Inc. All rights reserved. r 1057

1058 DIABETIC WOUND COMPLICATIONS
adverse events when compared with a nondiabetic
cohort.3e7 Within the field of hand surgery, the as-
sociation of DM and postoperative wound healing
complications has not been demonstrated to the
same degree. Stepan et al8 conducted the largest
study on the effect DM may have on patients un-
dergoing hand surgery. They demonstrated that pa-
tients who have insulin-dependent DM are at a
greater risk of postoperative complications, including
infection, compared with nondiabetic patients across
several different upper-extremity procedures. How-
ever, carpal tunnel release (CTR) or trigger finger
release (TFR) was not assessed in this study, and
HgA1C values were not collected. The effect DM
may have on postoperative wound healing compli-
cations in minor hand procedures, such as carpal
tunnel surgery, is less clear, with many studies failing
to demonstrate an effect.9e12 The main criticism
regarding these prior studies is their small sample
size. Additionally, some lacked a nondiabetic group
to demonstrate a baseline rate of complication.
Glycosylated hemoglobin (HgA1C) is a marker of
long-term glucose control, and its value has been
examined in relation to postoperative outcomes.
Recent studies in adult reconstruction and foot and
ankle surgery have evaluated the association of
HgA1C with adverse events, including surgical site
infection (SSI).4,5,7 Within the field of hand surgery,
diabetic patients are at increased risk of infection, and
this risk is exacerbated with poor glycemic control.13
The rate of infection in patients undergoing hand
surgery is generally low. Harness et al9 showed that
the rate of infection following CTR was 11/3,003 in
all patients and 3/546 among diabetic patients. SSI
following hand surgery in all patients has been esti-
mated to occur in 1.7/1,000 patients, with 10% of
postoperative patients with SSI ultimately requiring a
secondary procedure.14 Diabetic patients who
develop upper-extremity infections experience a
greater number of polymicrobial infections, require
more frequent serial debridement, and undergo a
greater number of amputations for definitive
management.13
Altogether, we find the current body of literature
conflicting in its overall findings and thus, lacking the
ability to answer an important question: are diabetic
patients at increased risk of developing a wound
healing complication following a CTR or TFR?
Examining this relationship was the primary aim of
this study. The secondary aim was to determine if
diabetic patients with poor perioperative glycemic
control have an increased risk of wound healing
complications following these procedures compared
J Hand Surg Am.
with diabetic patients with good perioperative gly-
cemic control.
MATERIALS AND METHODS
We retrospectively reviewed the charts of patients
from our tertiary care institution who underwent open
CTR or TFR over a 4-year period (2014e2018).
Access to and the collection of patient health infor-
mation prior to 2014 was limited because of an
institutional change of electronic medical records
(EMRs) at that time. The procedures were performed
by 7 different fellowship-trained hand surgeons. All
the procedures were performed on an outpatient basis
in an operating room setting using a variety of
anesthetic techniques, ranging from wide-awake with
local anesthesia to general anesthesia. As part of
routine practice at our institution, including for dia-
betic patients, preoperative antibiotics were not
administered for simple hand procedures. All the
procedures were open releases, with no endoscopic
procedures included in either cohort. The experi-
mental cohort consisted of patients who had a pre-
existing diagnosis of DM at the time of surgery
and, additionally, had an HgA1C value documented
within 90 days of the surgery. We did not differen-
tiate patients based on type 1 or type 2 DM, and we
did not collect data on the medical management of
their DM, regardless of whether the patients were
insulin-dependent. The exclusion criteria were any
revision surgery, concurrent bone/fracture surgery
(ie, a CTR with a distal radius fracture treated with
open reduction and internal fixation), autoimmune
disorder, human immunodeficiency virus/acquired
immunodeficiency syndrome, hypothyroidism, ma-
lignancy, systemic immunosuppression/steroid use,
or chemotherapy. Institutional review board approval
was obtained.
Nondiabetic patients were selected in an approxi-
mately 1:1 TFR/CTR ratio. To accomplish this, all
nondiabetic patients who underwent CTR or TFR and
did not meet the exclusion criteria were included
sequentially from October 2016 to December 2017.
This method of comparison group selection was
chosen to ensure that we captured a baseline rate of
complication within our nondiabetic cohort. Given
the limitations in the number of control patients
within the study period, true patient-to-patient age
and sex, body mass index (BMI), and smoking status
matching was not performed.
Patients who underwent multiple procedures dur-
ing separate and distinct surgical encounters over the
study period were included as separate encounters
r Vol. 46, December 2021
 DIABETIC WOUND COMPLICATIONS 1059

(eg, a patient who underwent a right CTR in 2016 and

TABLE 1. Patient Demographic Data
left CTR in 2017). Any patient who underwent
multiple procedures during a single visit (CTR and Diabetic Nondiabetic
TFR or multiple TFRs) was included as 1 encounter. Variable Group Group
For a patient to be included, the procedures had to Sex
have been separated by at least 3 months, and a Males 98 98
separate HgA1C value had to be available for all Females 164 161
diabetic patients. Mean age (y) 58.4 58.8
Hemoglobin A1C values were collected from all Number of 206 215
diabetic patients’ EMRs or outside shared health re- CTRs
cords. The smoking status and BMI, when available in Number of 129 122
the patients’ EMR, were assessed as documented, TFRs
although these variables were not matched for diabetic Mean BMI 34.0 30.6
and nondiabetic patients. Patients were considered (kg/m2)
active, former, or never smokers. Wound healing Active smokers 33 25
complications were assessed at the first documented Mean HgA1C 7.4
postoperative visit, which was approximately 2 weeks value (%)
after the surgery date. Wound healing complication Median HgA1C 7.2
was defined as: delayed wound healing, continued value (%)
serous drainage, wound dehiscence, or surgical site HgA1C value 39.6
infection following the definitions set by the CDC.15 days from
This was assessed using either the visit diagnosis the time of
surgery (%)
and/or within the text of the visit’s documentation.
Complications occurring after the 2-week post-
operative visit were not regularly assessed in this study
because most patients did not have further follow up the random effect. Statistical significance was set at
scheduled. Among patients who were followed up P ¼ .05.
beyond 2 weeks, none were identified as having late
wound healing complications. RESULTS
Between June 2014 and March 2018, there were 386
Statistical analysis patients with DM who underwent 465 CTR or TFR
The Student t test and chi square test were used to procedures. Further refinement for the available
evaluate differences between continuous and categori- HgA1C values and exclusion criteria narrowed this to
cal variable groups, respectively. The dependent vari- 262 diabetic patients undergoing 335 surgical pro-
able, wound healing complication, was considered a cedures. The control group consisted of 259 nondia-
yes/no binary variable. An estimate of the incidence of betic patients undergoing 337 surgical procedures.
diabetic and nondiabetic wound healing complications There were 61 patients in the diabetic group and 66
(4% vs 0.5%, respectively) was used for a power patients in the control group who underwent multiple
analysis calculation, estimating n ¼ 281 per group. The procedures (Tables 1, 2).
predictors of complications were identified a priori and There were 36 wound healing complications in our
included patient sex, age, perioperative smoking status, diabetic group, with 24 infections requiring antibiotic
BMI, perioperative HgA1C value, and diabetic status. therapy, 9 wounds with dehiscence, and 3 wounds
To determine an HgA1C cutoff point, a series of with serous drainage. There were 9 wound healing
sequential univariate logistic regression models was complications in the nondiabetic group, with 4 in-
used. The patients were separated into 2 groups starting fections requiring antibiotic therapy, 2 wounds with
at an HgA1C value above or below 6.0% and increased delayed healing, 2 wounds with dehiscence, and 1
in 0.1 increments to determine an upper limit of dif- wound with serous drainage. On a per-procedure
ference that was statistically significant between the basis, this equated to a 10.7% incidence of compli-
groups. To determine the independent predictors of cations in the diabetic group and 2.7% incidence in
wound healing complications, while adjusting for the nondiabetic group. One patient in the control
multiple repeated measures, a random-effects, gener- group required admission for intravenous antibiotic
alized linear mixed model was run using binary logistic therapy. The remaining 27 patients with infections
regression, with deidentified patient number as resolved with an outpatient course of oral antibiotic

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1060 DIABETIC WOUND COMPLICATIONS

DISCUSSION
TABLE 2. Number of Wound Complications Based
on the Group and Surgical Procedure In this retrospective study, we report wound healing
complications among diabetic patients undergoing 2
Diabetic Nondiabetic
Wound Complications Group Group
of the most common hand, soft-tissue surgeries: CTR
and TFR. Compared with nondiabetics, diabetic pa-
Infections 24 4 tients have a statistically significant increase in the
TFR 10 2 odds of developing a wound healing complication
CTR 14 2 following this surgery. We acknowledge that this
Delayed wound healing 12 5 finding disagrees with that of previous studies. The
TFR 2 0 prospective study by Mondelli et al10 concluded that
CTR 10 5 there are no differences in the complication rate be-
Total 36 9 tween diabetics and nondiabetics, but their diabetic
cohort had only 24 patients and may have been un-
derpowered to detect a difference between the
groups. Similarly, Thomsen et al12 reported no
complications in either cohort but had a diabetic
monotherapy. There were no patients who required cohort of only 35 patients. Perioperative wound
returning to the operating room in either group healing complications were not a primary outcome
(Table 3). measure for either of these studies. Harness et al9
Diabetic patients were at an increased risk of noted no significant increase in the rate of SSIs in
postsurgical complications compared with nondia- diabetics in a multicenter retrospective review of
betic patients (odds ratio [OR] ¼ 2.66, 95% confi- CTR. Their overall infection rate was low at 0.34%,
dence interval [CI] 1.42e5.0). but their method of screening relied on accurate SSI
Among diabetics, there were 229 encounters with coding via International Classification of Diseases,
an HgA1C value above 6.5%, with 30 wound ninth revision, codes, and infections may not have
complication occurrences, and 107 encounters with been captured in the dataset if they were not correctly
an HgA1C value below 6.5%, with 6 wound coded in the EMR. Our study reviewed the text of
complication occurrences. The median HgA1C value each chart of the postoperative encounters to evaluate
was 7.2%, with a mean of 39.6 days between the date wound healing problems. Additionally, we evaluated
of surgery and HgA1C laboratory draw. wound healing problems other than SSI, such as
Among diabetic patients, those with an HgA1C dehiscence and delayed wound healing, because we
value greater than 6.5% were at increased risk of felt that this was clinically relevant to the post-
developing complications compared with those with operative period. The goal of this study design was to
an HgA1C value below 6.5% (OR ¼ 2.61, 95% CI have adequate power to detect a difference between
1.05e6.54). the cohorts and have more stringent chart review
There were 33 active smokers within the diabetic beyond the International Classification of Diseases,
group and 25 in the nondiabetic group. The possible ninth revision, codes. This may account for the dif-
effect smoking had on wound healing complications ference in our result compared with that of previous
was determined in the whole study (OR ¼ 1.23, 95% studies.
CI 0.40e3.76) and diabetic groups (OR ¼ 4.26, 95% We found that diabetic patients with perioperative
CI 0.56e32.26). HgA1C values above 6.5% have increased odds of
The BMI within 1 year of surgery was available wound healing complications. This was slightly
for 300 diabetic patients and 212 nondiabetic pa- below the cutoff point noted by Werner et al,16 who
tients. The mean BMI across the total group was 32.6 concluded that a perioperative HgA1C value between
kg/m2 (range: 17.9e64.0, SD: 7.6). Mixed-model 7% and 8% could serve as a threshold/cutoff point for
logistic regression was performed on the entire increased risk of SSI. However, their study relied on
group of 512 patients with the available BMI data an insurance database that estimated a lower fre-
(OR ¼ 1.04, 95% CI 1.01e1.08) and among only the quency of wound healing complications following
300 diabetic patients (OR ¼ 1.05, 95% CI CTR/TFR compared with our data. Additionally,
1.00e1.09). This OR represented an increased risk their study did not include noninfectious wound
of wound healing complications for each 1.0- healing complications. An HgA1C value of 6.5% is
incremental increase in the BMI. below the level of 7.0%, which most diabetes and

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 DIABETIC WOUND COMPLICATIONS 1061

TABLE 3. Detailed Representation of Complications With Their Subsequent Treatment

HgA1C Tobacco
Value (%) Surgery Complication Treatment Smoking

Diabetic procedures
1 5.9 CTR Cellulitis Cephalexin Never
2 11.5 CTR Cellulitis Cephalexin Former
3 7.2 TFR Purulence Doxycycline Never
4 7.1 CTR Dehiscence Local wound care Never
5* 7.9 CTR Purulence Cephalexin Never
6* 8.3 CTR Purulence Augmentin Never
7 9.1 CTR Purulence Augmentin Never
8 6.2 CTR Serous drainage Local wound care Former
9* 9.7 CTR Cellulitis Cephalexin Never
10* 9.4 CTR Dehiscence Local wound care Never
11 11.2 CTR Purulence Clindamycin Never
12 6.9 CTR Dehiscence Local wound care Never
13 14.5 CTR Purulence Cephalexin Never
14 7.4 TFR Purulence Trimethoprim/Sulfamethoxazole Never
15 8 CTR Dehiscence Former
16 7.4 TFR Purulence Trimethoprim/Sulfamethoxazole Never
17 8.3 CTR Cellulitis Cephalexin Never
18 11.4 CTR Purulence Cephalexin Never
19 6.6 TFR Dehiscence Local wound care Never
20 5.8 CTR Dehiscence Local wound care Never
21 6.3 CTR Purulence Doxycycline Never
22 9 TFR Cellulitis Cephalexin Never
23 7.1 CTR Cellulitis Cephalexin Former
24 6.6 CTR Serous drainage Local wound care Never
25 6.6 CTR Cellulitis Cephalexin Current
26 6 CTR Cellulitis Cephalexin Never
27 7.1 TFR Cellulitis Doxycycline Never
28 7.9 CTR Serous drainage Local wound care Never
29 7.1 CTR Dehiscence Local wound care Never
30 7.3 TFR Cellulitis Cephalexin Never
31 7.9 TFR Purulence Cephalexin Never
32 8.2 TFR Cellulitis Augmentin Never
33 5.9 CTR Dehiscence Local wound care Never
34 8.3 TFR Cellulitis Doxycycline Never
35 6.6 TFR Dehiscence Local wound care Never
36 8.3 TFR Purulence Trimethoprim/Sulfamethoxazole Never
Nondiabetic procedures
1 CTR Purulence Trimethoprim/Sulfamethoxazole Current
2 CTR Purulence Cephalexin Never
3 TFR Purulence Cephalexin Never
4 CTR Delayed healing Local wound care Former
5 CTR Serous drainage Local wound care Never

(Continued)

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1062 DIABETIC WOUND COMPLICATIONS
TABLE 3. Detailed Representation of Complications With Their Subsequent Treatment (Continued)
HgA1C
Value (%) Surgery
6 CTR
7 CTR
8 TFR
9 CTR
*Staged bilateral surgery performed in 2 patients at different time points.
endocrine societies have historically used to classify
their patients as well controlled, although these rec-
ommendations have recently changed. The 2019
recommendations of the American Diabetes Associ-
ation call for more rigorous glycemic targets, spe-
cifically an HgA1C value less than 6.5%, in patients
with “little comorbidity and long life expectancy. if
they can achieve it safely without hypoglycemia or
significant therapeutic burden.”17 We do not enforce
a strict HgA1C cutoff of 6.5% in all patients, but we
do counsel diabetic patients on potential additional
surgical risks. This study did not assess the effect that
insulin dependence may have had on our results,
which was previously demonstrated to be an inde-
pendent risk factor for postoperative complication,
compared with nondiabetic patients undergoing more
complex upper-extremity surgery.8 Additionally, we
chose not to differentiate patients based on type 1 or
type 2 DM. Instead, we chose to focus on perioper-
ative HgA1C values because we believed that this
provides an objective quantification of the quality of
an individual patient’s disease management, and it is
a modifiable risk factor in preoperative diabetic
patients.
According to London et al,18 there appears to be a
dose-dependent effect of BMI among obese patients
such that increasing-obesity heightens the risk of
complications following hand, wrist, and elbow sur-
gery. With only a 5% (range: 0%e9%) increase in
the odds of a complication for each 1.0-point increase
in the BMI of diabetic patients, there is minimal
impact in our study. There may have been a con-
founding effect between increasing BMI and HgA1C
value that we were unable to assess with the current
study design.
Tobacco smoking and its associated complications
were not a primary outcome of our study, and we did
not demonstrate a significant effect in either group;
however, in another study, smoking has been found
to be an independent risk factor for postoperative
complications.19 With such a low prevalence of
smokers, our study was not adequately powered to
J Hand Surg Am.
Tobacco
Complication Treatment Smoking
Dehiscence Local wound care Never
Delayed healing Local wound care Current
Cellulitis Cephalexin Never
Dehiscence Local wound care Former
assess the impact of smoking on wound healing
complications, and we included this information to
demonstrate that it did not have a large influence in
our study group.
This study has limitations that should be
recognized. Although age, sex, BMI, and smoking
status were assessed in diabetic and nondiabetic
patients, direct patient-to-patient matching between
the groups was not performed, which prevented the
nondiabetic cohort from acting as a true control
group. Limiting the chart review to 2 weeks after
the surgery may have resulted in the underestima-
tion of our infection rate if there were late-
presenting infections; however, we believed that
majority of the acute postoperative wound healing
problems would have been recognized at the time
of initial follow up. This is a retrospective cohort
study performed at a single institution, which may
have limited its external validity. Some possible
confounding variables not evaluated include nutri-
tional status, renal insufficiency, peripheral neu-
ropathy, insulin dependence, and type 1 versus
type 2 DM, many of which have previously been
shown to be associated with increased post-
operative complications following hand and wrist
operations.8,20 Given the relatively low number of
occurrences of wound healing complications in our
study, we did not feel that our cohort was an
appropriate size to address all of these possible
comorbid conditions as separate independent vari-
ables. Additionally, patients who underwent mul-
tiple procedures during the study’s duration were
included as separate encounters, which could have
served to amplify any underlying confounding ef-
fects. We performed a generalized linear mixed-
model analysis to control for this; however, this
is imperfect, and the effect that these confounding
variables had on the data presented here likely
persists to some degree. Lastly, this study only
assessed wound healing and did not comment on
the short- or long-term patient-reported outcomes
of CTR or TFR.
r Vol. 46, December 2021
 DIABETIC WOUND COMPLICATIONS
Diabetes mellitus is associated with a significantly
increased risk of wound healing problems after soft-
tissue surgery of the hand (CTR and TFR). Further-
more, an elevated perioperative HgA1C value can
help identify patients at a higher risk of surgical
complications. Surgical candidates with DM should
be appropriately counseled prior to surgery.
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