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Background:The primary purpose of this retrospective study was to report on a consecutive series of 102 patients with diabetes mellitus (DM) who underwent transtibial amputation (TTA) for chronic infections and nonreconstructable lower extremity deformities. A secondary aim was to compare the outcomes of TTA patients with end-stage renal disease on dialysis (ESRD) to patients without ESRD, and to identify risk factors for mortality after TTA.Methods:This cohort involved a consecutive series of patients who were treated by a single surgeon. The TTA patients were divided into 2 groups for analysis. The study group included those patients with ESRD who underwent TTA, and the control group included those patients who did not have ESRD.Results:At the time of final follow-up, 64 of 102 patients were ambulatory with a prosthesis. There was a significant improvement in ambulatory status after amputation (preoperatively 45.1%, postoperatively 62.7%, P = .02). Wound healing complications (infection and/or dehiscence) occurred in 31 of 102 patients and led to a transfemoral amputation in 4 patients. After TTA patients with ESRD were significantly more likely to die (52.4% vs. 23.5%, p Conclusion:TTA in patients with diabetes was associated with substantial morbidity and mortality. Risk factors that were significantly associated with an increased rate of mortality were the presence of ESRD, age ≥56 years, and inability to ambulate postoperatively.Level of Evidence:Level III, retrospective case controlled study.

Background: Ankle fractures in patients with diabetes mellitus (DM) can be difficult to manage, especially in the presence of peripheral neuropathy. In patients who fail initial operative management, attempts at limb salvage can be challenging, and no clear treatment algorithm exists. This study examined outcomes of different procedures performed for limb salvage in this population. Methods: This study retrospectively reviewed 17 patients with DM complicated by peripheral neuropathy who sustained a bimalleolar ankle fracture and failed initial operative management. Patients were treated with revision open reduction internal fixation (ORIF) (3/17), closed reduction external fixation (CREF) (8/17), or primary ankle joint fusion (3/17 tibiotalocalcaneal fusion with hindfoot nail [TTCN] and 3/17 with tibiotalar arthrodesis using plates and screws [TTA]). Median follow-up was 20 months. Results: The overall rate of limb salvage was 82.3% (14/17). All patients who went on to amputation presented with infection and were treated initially with CREF (3/3). All patients who achieved successful limb salvage ended up with a clinically fused ankle joint (14/14); 9 underwent a primary or delayed formal fusion and 5 had a clinically fused ankle joint at study conclusion after undergoing revision ORIF or CREF with adjunctive procedures. Conclusion: This small study suggests that in this complicated group of patients it is difficult to achieve limb salvage with an end result of a functional ankle joint. CREF can be a viable option in cases where underlying infection or poor bone quality is present. Treatment with revision ORIF frequently requires supplementary external fixator or tibiotalar Steinman pin placement for additional stability. All patients who underwent revision ORIF ended up with clinically fused ankle joints at the end of the study period. Primary fusion procedures (TTA, TTCN) were associated with a high rate of limb salvage and a decreased number of operations. Level of Evidence: Level III, retrospective case series.

Background: The aim of this study was to evaluate weight-bearing radiographs in patients with and without foot ulcers diagnosed with midfoot Charcot neuroarthropathy (CN) secondary to diabetes mellitus. Methods: One hundred fourteen patients with midfoot CN (50 with foot ulcers and 64 without ulcers) were identified and included in this study. Nine radiographic measurements were made (7 in the sagittal plane and 2 in the transverse plane). Results: CN patients with foot ulcers had significantly greater deformity when assessing the lateral-talar first metatarsal angle, calcaneal pitch, cuboid height, medial column height, calcaneal-fifth metatarsal angle, talar declination, and lateral tibiotalar angle. Two measurements in the transverse plane (hindfoot-forefoot angle and AP talar first metatarsal angle) were not significantly different between the 2 groups. Of patients with foot ulcers, 24% had a lateral talar first metatarsal angle of less than −27 degrees and 80% had a negative cuboid height. Conclusion: Sagittal plane deformities were more likely to be associated with foot ulceration in patients with CN than transverse plane deformities. Lateral column involvement was associated with a worse prognosis than medial column involvement, thus we believe progressive deformity of the lateral column should be monitored closely to prevent foot ulceration. Lateral column involvement could be identified by a decrease in the cuboid height, decreased calcaneal pitch, and decreased lateral calcaneal fifth metatarsal angle. This study can assist physicians in stratifying the risk for both ulceration and need for surgery in patients with CN based on reproducible radiographic measurements. Level of Evidence: Level III, comparative series.

Background: Previous reports using the Short Form-36 as a generic measure of quality of life have demonstrated reduced quality of life in patients with Charcot neuroarthropathy (CN). The aim of this study was to assess self-reported quality of life using the SF-36 and a region-specific assessment (the Foot and Ankle Ability Measure [FAAM]), hypothesizing that patients with diabetes and CN would have lower self-reported scores than patients with diabetes and no foot disease. Methods: Fifty patients with diabetes and CN were included in the study group. Fifty-six patients with diabetes and no pedal complaints comprised the control group. Quality of life was assessed with the SF-36 and the FAAM. Results: Patients with CN were more likely to have type 1 diabetes mellitus, were more likely to use insulin, had greater duration of diabetes, and were more likely to be neuropathic than patients in the control group. Patients with CN reported mean FAAM activities of daily living (ADL) scores that were 2 standard deviations below the control group and sports scores that were 1 standard deviation lower. There was no notable difference between the SF-36 mental component summary scores between the CN and control groups. SF-36 physical component summary scores in patients with CN were notably lower than scores in the control group. Conclusion: CN is associated with reduced quality of life as measured with the SF-36 and FAAM. To the best of our knowledge, this is the first study directly comparing self-reported outcome assessments in patients with both diabetes and CN and patients with diabetes without foot complaints. Level of Evidence: Level III, comparative series.

Background: Patients with diabetes who sustain an ankle fracture are at increased risk for complications including higher rates of in hospital mortality, in-hospital postoperative compli-cations, length of stay and non-routine discharges. The purpose of this study was to retrospectively compare the complications associated with operatively treated ankle fractures in a group of patients with uncomplicated diabetes versus a group of patients with complicated diabetes. Complicated diabetes was defined as diabetes associated with end organ damage such as peripheral neuropathy, nephropathy and/or PAD. Uncomplicated diabetes was defined as diabetes without any of these associated conditions. Our hypothesis was that patients with uncomplicated diabetes would experience fewer complications than those patients with complicated diabetes. Materials and Methods: We compared the complication rates of ankle fracture repair in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes and calculated odds ratios (OR) for significant findings. Results: At a mean followup of 21.4 months we found that patients with complicated diabetes had 3.8 times increased risk of overall complications 3.4 times increased risk of a non-infectious complication (malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis when compared to patients with uncomplicated diabetes. Open ankle fractures in this diabetic population were associated with a three times higher rate of complications and 3.7 times higher rate of infection. Conclusion: Patients with complicated diabetes have an increased risk of complications after ankle fracture surgery compared to patients with uncomplicated diabetes. Careful preoperative evaluation of the neurovascular status is mandatory, since many patients with diabetes do not recognize that they have neuropathy and/or peripheral artery disease. Level of Evidence: III, Retrospective, Case Control Study

Background: An increased rate of complications has been clearly shown in diabetic patients undergoing operative treatment for displaced ankle fractures. To date, no studies have specifically looked at the complication rates following the operative management of pilon fractures in this difficult patient population. We performed a retrospective review to determine the rates of complications in diabetic patients undergoing operative fixation of tibial pilon fractures compared with a control group of patients without diabetes. M aterials and Methods: The trauma registry was utilized to identify all patients who underwent primary treatment for a tibial pilon fracture between January 2005 and June of 2007 at a single Level 1 trauma center. A minimum of 6-month followup was required for inclusion. A chart and radiographic review was completed to identify the complications seen in each patient population. Specifically, we looked at the rate of infection (superficial and deep), the rate of nonunion or delayed union, and the rate of surgical wound complications. Results: A total of 14 fractures in 13 diabetic patients, and 69 fractures in 68 non-diabetic patients met inclusion criteria. In the diabetic patient group, the average age was 48 years, the average BMI was 35, and 36% of the fractures were open. In the non-diabetic group, the average age was 47 years, the average BMI was 29, and 35% of the fractures were open. Only the difference in BMI was statistically significant. The infection rate was 71% for diabetic patients (43% deep infection), and 19% for non-diabetic patients (9% deep infection) [ p < 0.001, odds ratio 10.719 (95% confidence interval 2.914 to 39.798)]. Overall, the rate of non-union/delayed union was 43% in the diabetic group versus 16% in the non-diabetic group [ p = 0.02, odds ratio 3.955 (95% confidence interval 1.145 to 13.656)]. The rate of surgical wound complications was 7% in both the non-diabetic and diabetic patient groups. Conclusion: The management of tibial pilon fractures in diabetic patients is difficult, with a high rate of complications compared to non-diabetic patients. These results mirror those previously reported for ankle fractures in diabetic patients. Level of Evidence: IV, Retrospective Case Series

Background: The Foot and Ankle Ability Measure (FAAM) has been shown to be reliable, valid, and responsive in a general orthopaedic population. The purpose of this study was to evaluate validity for the FAAM in individuals with diabetes. It was hypothesized that FAAM scores would relate to measures of physical function while not correspond to measures of mental health. It was also hypothesized that FAAM scores would be different based on reported general health. Materials and Methods: Eighty-three subjects with diabetes and foot and ankle related complaints completed intake information during a routine clinical visit. Subjects had an average age of 60.3 (range, 21 to 93; SD 13.7) years. Subjects were grouped based on their reported general health with 55 (64.7%) and 28 (32.9%), reporting excellent-good and fair-poor general health, respectively. Pearson correlation coefficients were used to assess the relationship between the FAAM and SF-36. As evidence for discriminative validity, one-way ANOVA was used to determine if FAAM scores could distinguish between individuals that reported excellent-good from those that reported fair-poor levels of general health. Results: The FAAM had high correlation to the SF-36 physical function subscale ( r > 0.60) and physical component summary score ( r > 0.70) and significantly ( p < 0.005) lower correlation to the mental health subscale ( r < 0.33) and mental component summary score ( r < 0.30). Oneway ANOVA found those that reported excellent-good general health scored significantly higher on the ADL subscale (57 vs 44 [F(1,82) = 4.6, p = 0.035]) but did score differently on the Sports subscales (32 vs 22 [F(1,70) = 1.7, p = 0.20]). Conclusion: This study offers evidence of validity for the FAAM ADL subscale as an outcome instrument to measure physical function in individuals with diabetes and foot and/or ankle related disorders. Further research is needed for the Sports subscale in individuals with diabetes who are functioning at a higher level. Level of Evidence: III, Retrospective Case Control Series

Background: The purpose of this study was to identify and report the complications associated with the use of circular ring fixation in diabetic patients, and to compare the frequency of complications in patients without diabetes. We hypothesized that complications with circular ring fixation occurred more frequently in patients with diabetes than patients without diabetes. Materials and Methods: Institutional Review Board approval was obtained and patient charts were retrospectively reviewed from June 2004 and February 2007. Fifty six consecutive patients undergoing midfoot, hindfoot and/or ankle surgery were treated with circular ring fixation which included 33 diabetic patients in the study group and 23 non-diabetic patients in the control group. Patient demographics, the duration of treatment with the external fixator, and complications were recorded. Results: Males had a greater number of complications compared to females ( p = 0.0014). The total number of complications was statistically greater in diabetic patients (study group) versus non-diabetic patients (control group) ( p = 0.003). In multivariate logistic regression, diabetes and male sex were the only significant variables associated with wire complications (OR 7.35, 95% CI 1.93-28.04 and OR 0.22, 95% CI 0.05-8584111, respectively). Conclusion: Women are protected from wire complications with a risk reduction of 78% compared to males. Diabetics have a 7-fold risk for any wire complication compared to patients without diabetes. We found no adverse effects of BMI, obesity, age, smoking, neuropathy, or Charcot neuroarthropathy on a satisfactory recovery.Level of Evidence: IV, Retrospective Case Study

Background: Total contact casting (TCC) is effective in offloading the plantar aspect of the foot in patients with diabetes and neuropathic ulcers. These patients are considered at high risk for skin-related complications during TCC because of sensory neuropathy. The purpose of this prospective study was to determine the frequency of complications during treatment of neuropathic ulcers with TCC. Methods: Thirteen patients with 18 neuropathic ulcers were treated with TCC. The same orthopaedic surgeon applied a consecutive series of 82 total contact casts. The initial cast was changed in 3 to 4 days, while subsequent casts were changed weekly. Results: Fourteen complications occurred during the 82 castings (17%). None of the complications required alteration in the treatment protocol. Thirteen of the 14 complications involved skin irritation and the other complication was from a cast that became too tight. Fifteen of the 18 neuropathic ulcers healed with TCC. Conclusions: TCC can be used safely in high-risk patients with neuropathic problems, but minor complications should be anticipated. Major complications that interfere with the treatment of the plantar ulcer can be minimized with careful technique, close follow-up, and thorough patient education.