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Over the past 2 decades, several studies comparing intermediate- and long-term outcomes after total ankle replacement (TAR) versus ankle arthrodesis (AA) have reported differing rates of complications and outcomes. Recently, there has been a dramatic increase in patients undergoing TARs without any epidemiologic studies examining the short-term and perioperative complications. The purpose of this prognostic study was to compare perioperative outcomes after TAR and AA using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database between 2012 and 2017. Patient data were collected from the NSQIP database for surgeries between January 2012 and December 2017 using Current Procedural Terminology codes 27700, 27702, 29899, and 27870. Patients were excluded if treated for fracture, infection, or revision procedures. The outcomes of interest were readmission and reoperation related to initial surgery, surgical site infections, and hospital length of stay. There were 1214 patients included-1027 (84.6%) TAR and 187 (15.4%) AA. The TAR patients were older, had a lower body mass index, and were less likely to have insulin-dependent diabetes. Readmission rate and length of stay was similar between groups. Multivariate regression revealed higher anesthesia severity scores ( P = .0007), diabetes mellitus ( P = .029), and AA ( P = .049) had positive correlations with adverse outcomes. We report a lower complication rate with TAR than previously described. AA arthrodesis is associated with a higher risk of perioperative complications, including deep surgical site infections and reoperations. There were no differences between the 2 groups comparing superficial infection, wound dehiscence, or readmissions in the first 30 days. Levels of Evidence: Level V.

Chronic kidney disease (CKD) is a major concern in patients with foot disease because it is associated with high rates of neuropathy, peripheral vascular disease, and poor wound healing. The purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial transmetatarsal amputation (TMA). Patients who underwent a TMA were retrospectively identified in the American College of Surgeons National Surgical Quality Improvement Program database. Of 2018 patients, reamputation after TMA occurred in 4.4%. End-stage renal disease (ESRD) was associated with 100% increased odds of TMA failure (adjusted odds ratio [OR] = 2.00; 95% CI = 1.10, 3.52), 128% increased odds of major amputation (adjusted OR = 2.28; 95% CI = 1.27, 3.96), and 182% increased odds of 30-day mortality (adjusted OR = 2.82; 95% CI = 1.69, 4.64). In addition, white blood cell count >10 000/mm 3 and deep infection at the time of surgery were independently associated with TMA failure. In conclusion, severe renal dysfunction is associated with TMA failure in the short-term, perioperative period. There was no incremental increase in risk of TMA failure with worsening level of renal function before ESRD. A multidisciplinary approach should be implemented in patients with CKD to prevent foot-related pathologies that may necessitate lower-extremity amputation. Levels of Evidence : Level III: Retrospective cohort study .

Background: The aim of this study was to identify the most-feared complications of diabetes mellitus (DM), comparing those with diabetic foot pathology with those without diabetic foot pathology., Methods: We determined the frequency of patients ranking major lower-extremity amputation (LEA) as their greatest fear in comparison to blindness, death, diabetic foot infection (DFI), or end-stage renal disease (ESRD) requiring dialysis. We further categorized the study group patients (N = 207) by their pathology such as diabetic foot ulcer (DFU), Charcot neuroarthropathy, foot infection, or acute neuropathic fractures and dislocations. The control group (N = 254) was comprised of patients with diabetes who presented with common non-diabetes-related foot pathology., Results: A total of 461 patients were enrolled in this study and included 254 patients without diabetic foot complications and 207 patients with diabetic foot problems. When comparing patients with and without diabetic disease, no significant differences were observed with regard to their fear of blindness, DFI, or ESRD requiring dialysis. Patients with diabetic foot disease (61 of 207, 31.9%) were 136% more likely (odds ratio [OR] = 2.36; 95% CI = 1.51-3.70; P = .002] to rank major LEA as their greatest fear when compared with diabetic patients without foot disease (42 of 254, 16.5%) and were 49% less likely (OR = 0.51; 95% CI = 0.34-0.79; P = .002) to rank death as their greatest fear compared with patients without diabetic foot disease., Conclusion: Patients with diabetic foot pathology fear major LEA more than death, foot infection, or ESRD. Variables that were associated with ranking LEA as the greatest fear were the presence of a diabetic-related foot complication, duration of DM ≥10 years, insulin use, and the presence of peripheral neuropathy., Levels of Evidence: Level II: Prospective, Case controlled study.

Hindfoot and distal leg neuropathic fracture collapse secondary to normal pressure hydrocephalus is a very rare clinical pathology. The authors present a case of a 69-year-old woman who sustained a distal tibiofibular fracture that resulted in a recurvatum deformity with idiopathic neuropathy and gait instability on initial presentation. A subtalar and ankle joint arthrodesis was performed achieving rectus alignment of the lower extremity with no postoperative complications. Her neuropathic etiology was negative for common causative factors, including diabetes, infection, nutritional deficiencies, congenital neuropathy, and trauma. Approximately 6 months postoperatively, the patient had persistent bilateral lower extremity weakness with the sensation of her "feet sticking to the floor" on ambulation. A referral to neurology revealed a normal pressure hydrocephalus as a possible etiology for her gait abnormalities and neuropathy. She required a ventriculoperitoneal shunt, with resolved gait disturbance and associated weakness approximately 1.5 years postoperatively., Levels of Evidence: Therapeutic, Level IV: Case report.

Unlabelled: Lesser digital deformities may present a surgical challenge to even the most skilled foot and ankle surgeon. Multiplanar toe deformities, including the crossover toe, are especially difficult to correct with reproducible results. Undercorrection, pain, stiffness, and recurrent deformity are well reported throughout foot and ankle literature. The goal of this article is to describe a method of correcting digital deformity utilizing the extensor digitorum brevis tendon transfer and a biotenodesis screw. The controlled tension established with the extensor tendon provides the necessary stability for multiplanar correction of multiplanar digital deformities. This technical tip article should serve as pilot study for future evaluation of this method of correction., Levels of Evidence: Level IV: Case series., (© 2015 The Author(s).)

Introduction: Diabetes mellitus is one of the leading causes of hyperglycemia in the perioperative setting. Hyperglycemia has been shown to cause increased risk of surgical site infections (SSIs) in multiple surgical specialties, but to our knowledge it has not been investigated for orthopaedic foot and ankle surgery. The aim of this study was to determine if hyperglycemia increased the rate of SSI in elective, diabetic patients that required perioperative hospitalization., Methods: A total of 348 consecutive inpatients after foot and ankle surgery were retrospectively evaluated. Patients who had a random serum glucose ≥200 mg/dL during the admission (Group 1) were compared to patients whose serum glucose never exceeded 200 mg/dL (Group 2)., Results: Our 2 groups were similar with regard to age, gender, and body mass index. Twenty-one of 176 patients (11.9%) whose serum glucose was ≥200 mg/dL during the admission developed an SSI as compared to 9 of 172 patients (5.2%) whose serum glucose remained <200 mg/dL (odds ratio = 2.45; 95% confidence interval = 1.09-5.52;, P = .03)., Discussion: Perioperative hyperglycemia ≥200 mg/dL is associated with increased rates of SSI after foot and ankle surgery. Communication with medical consultants is paramount in an effort to improve perioperative glycemic management and reduce the rate of SSI., Levels of Evidence: Prognostic, Level III: Case Control., (© 2015 The Author(s).)

Unlabelled: Squamous cell carcinoma is one of the most common human malignancies; however, it is uncommon in the lower extremity. These lesions require prompt surgical attention and a delay in diagnosis can be harmful to the patient. We present a case report of squamous cell carcinoma with chronic osteomyelitis in a patient without diabetes. Definitive treatment included a transtibial amputation and metastatic workup was negative for active malignancy. Surgeons who treat chronic wounds should be cognizant of the potential for malignant degeneration., Level of Evidence: Therapeutic, Level IV: Case report., (© 2015 The Author(s).)

Introduction: Charcot neuroarthropathy (CN) and diabetic foot ulceration (DFU) are serious complications of diabetes mellitus (DM) that can result in infection, hospitalization, amputation, and have been shown to negatively affect quality of life (QOL). To the best of our knowledge, there are no studies in the literature that have specifically compared QOL in patients with diabetic CN without DFU to a group of patients with diabetic CN and concurrent DFU. The aim of this study was to compare self-reported assessments of QOL in patients with CN to a group of patients with CN and concomitant midfoot ulceration., Materials and Methods: We compared a group of 35 diabetic patients with midfoot CN and no ulcer to a group of 22 diabetic patients with midfoot CN and concurrent DFU. Self-reported outcome was assessed using the Medical Outcome Study Short Form 36 (SF-36) health survey and Foot and Ankle Ability Measure (FAAM)., Results: No significant differences were found when comparing the 2 groups utilizing the SF-36 and FAAM with the exception that CN patients without foot ulcers had lower mean scores on the Bodily Pain Subscale. Both groups demonstrated negative impact on physical QOL and lower extremity function to a greater degree than mental QOL., Conclusion: The presence of ulceration does not appear to significantly impact QOL in patients with CN when compared to patients with CN without ulceration., Levels of Evidence: Prognostic, Level III: Case control., (© 2015 The Author(s).)

Introduction: The aim of this prospective study was to determine the prevalence of neuropathy in diabetic patients undergoing foot and ankle surgery. It was hypothesized that the prevalence of diabetic neuropathy is higher among patients who undergo foot and ankle surgery compared with historical rates of neuropathy in diabetic patients in general., Methods: During a consecutive 42-month period, patient data were prospectively entered for 1859 consecutive patients undergoing foot and ankle surgery. Among the subjects, 394 had been previously diagnosed with diabetes mellitus (DM), and the remaining 1465 did not have DM., Results: The prevalence of neuropathy in patients with and without DM was 77.2% (304 of 394 patients) and 11.7% (172 of 1465 patients), respectively. Patients with diabetic neuropathy were older, had poorer glycemic control, had higher serum creatinine levels, and reported more significant tobacco use than diabetic patients without neuropathy., Conclusion: Nearly 80% of diabetic patients undergoing foot and ankle surgery at a large academic medical center had diabetic neuropathy. Preoperative recognition of this morbid complication of DM is important to appropriately stratify those diabetic patients into a high-risk category.