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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. Materials 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. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to identify and report thecomplications associated with the use of circular ring fixation indiabetic patients, and to compare the frequency of complications inpatients without diabetes. We hypothesized that complications withcircular ring fixation occurred more frequently in patients withdiabetes than patients without diabetes. Materials and Methods:Institutional Review Board approval was obtained and patient chartswere retrospectively reviewed from June 2004 and February 2007. Fiftysix consecutive patients undergoing midfoot, hindfoot and/or anklesurgery were treated with circular ring fixation which included 33diabetic patients in the study group and 23 non-diabetic patients inthe control group. Patient demographics, the duration of treatment withthe external fixator, and complications were recorded. Results: Maleshad a greater number of complications compared to females (p = 0.0014).The total number of complications was statistically greater in diabeticpatients (study group) versus non-diabetic patients (control group) (p= 0.003). In multivariate logistic regression, diabetes and male sexwere 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 complicationswith a risk reduction of 78% compared to males. Diabetics have a 7-foldrisk 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. [ABSTRACT FROM AUTHOR]

Background: In stage II PTTD, flexor digitorum longus (FDL) tendon transfer with an adjunctive bony procedure is the most common method of surgical correction. This paper presents an alternative method of fixation with a biotenodesis interference screw (Arthrex Biotenodesis Screw System) that allows proper tensioning of the FDL tendon transfer. Materials and Methods: We retrospectively reviewed 25 consecutive patients who underwent FDL tendon transfer utilizing a biotenodesis interference screw. Intraoperative stability was noted and any loss of correction was assessed postoperatively. Results: Stable fixation was achieved in 24 of the 25 patients who underwent FDL tendon transfer for PTTD. We were not able to achieve stable fixa-tion in one patient due to improper placement of the bone tunnel. This was recognized intraoperatively and did not affect the final outcome. Conclusion: This method is technically easier to perform than the recommended technique by the manufacturer. It can be performed through a slightly smaller incision without disrupting the normal interconnections between flexor hallucis long (FHL) and FDL tendon at the Knot of Henry. [ABSTRACT FROM AUTHOR]

Most ankle injuries improve quickly, but others become long-term problems. Dividing posterior tibial tendon pathology into stages of progression helps physicians determine the optimal treatment modality. Posterior ankle impingement may result when any posterior anatomical structure impinges and causes pain with maximal plantar flexion of the ankle. Most cases of Achilles tendinitis, often seen in runners, are thought to result from repetitive microtrauma and overuse. Chronic injuries to the peroneal tendons are a frequent cause of lateral-sided ankle pain. Inversion injuries to the later-al ankle ligaments are a common injury in athletes; chronic ankle symptoms often develop. Osteochondral lesions of the talus may result in chronic, intra-articular ankle pain. Symptomatic arthritis in the ankle usually is posttraumatic. [ABSTRACT FROM AUTHOR]

Trauma to the tarsometatarsal (TMT) joint complex is named after the French surgeon of Napoleon's era, Lisfranc, who initially described amputation through the midfoot for injuries sustained in battle. Today, Lisfranc injuries encompass a wide spectrum of trauma, from high-energy accidents to lower-energy twisting injuries. Despite advances in treatment, Lisfranc injuries may result in pain, disability, and diminished function for many patients. An overview of the evaluation and treatment for Lisfranc injuries is presented, including a review of the functional anatomy, the mechanism and classification of injuries, and a summary of described treatment recommendations. Lastly, we describe our treatment algorithm outlining a stepwise approach to evaluating and treating Lisfranc injuries. The use of adjuvant imaging studies and stress examination with fluoroscopy are discussed. A comprehensive evaluation, as outlined, allows the surgeon to better understand the personality and severity of each injury, and helps to guide treatment. We believe this approach will help to optimize outcomes for Lisfranc injuries. Copyright © 2006 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Objective: This prospective study was designed to evaluate the rate of surgical site infection (SSI) after foot and ankle surgery in patients with and without diabetes.Research Design and Methods: The study prospectively evaluated 1,465 consecutive foot and ankle surgical cases performed by a single surgeon.Results: The overall SSI rate in this study was 3.5%, with significantly more infections occurring in individuals with diabetes than in those without (9.5 vs. 2.4%, P < 0.001). Peripheral neuropathy, Charcot neuroarthropathy, current or past smoking, and increasing length of surgery were significantly associated with SSI on multivariate analysis.Conclusions: This study demonstrates significant associations between the development of SSI and chronic complications of diabetes. We confirm previous findings that it is peripheral neuropathy and not diabetes itself that most strongly determines the development of postoperative infections in these surgical patients. [ABSTRACT FROM AUTHOR]

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence.Foot ulcerations, infections, Charcot neuroarthropathy, and peripheral arterial disease frequently result in gangrene and lower limb amputation. Consequently, foot disorders are leading causes of hospitalization for persons with diabetes and account for billion-dollar expenditures annually in the US. Although not all foot complications can be prevented, dramatic reductions in frequency have been achieved by taking a multidisciplinary approach to patient management. Using this concept, the authors present a clinical practice guideline for diabetic foot disorders based on currently available evidence, committee consensus, and current clinical practice. The pathophysiology and treatment of diabetic foot ulcers, infections, and the diabetic Charcot foot are reviewed. While these guide-lines cannot and should not dictate the care of all affected patients, they provide evidence-based guidance for general patterns of practice. If these concepts are embraced and incorporated into patient management protocols, a major reduction in diabetic limb amputations is certainly an attainable goal. [ABSTRACT FROM AUTHOR]

Little is known regarding outcomes of talus fracture management among patients with diabetes mellitus. This study aimed to compare post-operative outcomes after open reduction and internal fixation for talus fracture in patients with complicated diabetes, uncomplicated diabetes, and patients without diabetes. We used the PearlDiver database to identify patients who underwent operative repair of talus fractures from 2009 to 2021. Complications were evaluated at 30-days, 90-days, and 1 year of surgery. As we performed multiple separate analyses, to minimize the risk of type 1 error we employed the Bonferroni correction for statistical significance (p< 0.017). The PearlDiver identified 5,232 patients with talus fracture that underwent open reduction internal fixation. Stratified by diabetes status, the "complicated diabetes," "uncomplicated diabetes," and "no diabetes" groups contained 223, 418, and 4591 patients, respectively. Reoperation, acute kidney injury, and myocardial infarction were increased among diabetes patients compared to non-diabetes patients, irrespective of diabetes severity within 3 months of surgery. Furthermore, patients with complicated diabetes were more likely to develop sepsis and wound disruption compared to their non-diabetes counterparts within 3 months. While not statistically significant, complicated diabetes patients were diagnosed with talar non-union at higher rates compared with non-diabetes patients. Further analysis may reveal a clinically significant discrepancy in non-union between these groups. Complicated diabetes is associated with significantly higher risk of multiple adverse events following talus fracture repair., (Copyright © 2024 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: While it is generally accepted that most patients undergoing joint replacement do not require a cardiac stress test, individuals with existing or potential cardiac conditions may be at an increased risk of perioperative complications following primary total knee arthroplasty (TKA). This study aims to analyze the immediate postoperative outcomes of patients who underwent primary TKA, comparing those who had a cardiac stress test with no abnormal results and subsequent cardiac interventions to those who did not undergo a stress test., Materials and Methods: This retrospective cohort study utilized the TriNetX Research Network. The first cohort included patients who underwent a stress test within one year prior to their TKA, had no abnormal results, and did not undergo cardiac catheterization within two weeks post-stress test (Normal Stress Test). The second cohort consisted of patients who did not have a stress test in the year preceding their TKA (No Stress Test). The study analyzed data collected between January 1, 2003, and January 1, 2024. To control for confounding variables, propensity score matching was employed. P < 0.01 was considered significant., Results: A total of 13,881 patients successfully matched in each cohort. Within 30 days following TKA, patients in the Normal Stress Test cohort exhibited a significantly elevated risk of several complications: Transfusion (RR: 1.702), Myocardial Infarction (MI) (RR: 1.908), Acute Renal Failure (ARF) (RR: 1.504), Acute Posthemorrhagic Anemia (RR: 1.245), Wound Dehiscence (RR: 1.549), and Pneumonia (RR: 2.051). These results were consistent at the 90-day follow-up. Notably, the risk of death was only elevated before propensity score matching (RR: 2.115)., Conclusion: Our findings suggest that the underlying conditions prompting the use of a cardiac stress test, including congestive heart failure and renal insufficiency, may themselves be indicative of a higher overall perioperative risk, regardless of the stress test results., Levels of Evidence: Level III: Case-control study or retrospective cohort study., Competing Interests: Declarations. Ethical approval and informed consent: All information within the TriNetX database is compliant with the Health Insurance Portability and Accountability Act (HIPAA) and contains only de-identified aggregate information. As a result, this study was exempt from Institutional Review Board’s (IRB) approval by UT Southwestern IRB. Conflict of interest: The authors report no conflict of interest regarding this work., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Total knee arthroplasty (TKA) is a crucial orthopaedic procedure used to relieve pain from knee joint degeneration. Concurrently, peripheral artery disease (PAD) presents a major challenge, complicating orthopaedic interventions, particularly TKA, due to its impact on vascular health. Despite advances in surgical techniques and care, patients who have PAD undergoing TKA face heightened risks. Our retrospective study aimed to assess the impact of PAD on TKA outcomes., Methods: This retrospective cohort study drew data from a healthcare database platform from January 1, 2003, to January 1, 2024. A total of 245,954 patients aged 18 years and older who underwent primary TKA were identified using relevant Current Procedural Terminology, International Classification of Diseases, 9th Revision codes, and International Classification of Diseases, 10th Revision codes. Patients were categorized into two groups as follows: those who had PAD (+PAD) and those who did not have (-PAD). Propensity score matching was performed, resulting in 15,717 patients in each cohort. Rates of postoperative complications were assessed., Results: Within 30 days post-TKA, patients in the +PAD cohort showed significantly higher risks of complications, including acute posthemorrhagic anemia, wound dehiscence, periprosthetic joint infection, lower extremity deep vein thrombosis, pulmonary embolism, pneumonia, acute renal failure, and death compared to patients in the -PAD cohort. Similar trends persisted at the 90-day mark, with an additional increased risk of transfusion requirement, hematoma, myocardial infarction, and periprosthetic fracture in the +PAD cohort. Furthermore, over a 2-year period, the +PAD cohort faced three times the hazards of lower extremity amputation compared to patients in the -PAD cohort., Conclusions: Given the considerable impact of PAD on TKA outcomes, comprehensive management strategies are crucial to mitigate adverse events, underscoring the need for further research to explore risk stratification and targeted interventions for improved TKA safety in patients who have PAD., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Lower extremity amputation (LEA) is one of the most feared consequences of diabetes mellitus (DM). The purpose of this study was to evaluate the impact of DM on LEA rates in patients at various stages of chronic kidney disease (CKD). A commercially available de-identified database was searched for patients undergoing LEA and for CKD patients, from 2010 to 2023. Patients with DM and patients without DM who were followed for at least 5 years were included. LEA rates were then compared for patients at all 5 CKD stages in patients with and without diabetes. Rates of all LEA were found to be significantly higher at all CKD stages for patients with diabetes (overall, minor and major LEA). Compared to patients without DM who have CKD stage 5 (end stage renal disease), patients with DM and CKD stage 5 have a 30 fold increased likelihood of undergoing overall LEA [OR 30.2 (24.48-37.19), p < 0.001], 29 fold increased likelihood of undergoing minor LEA [28.9i (22.91-36.35), p < 0.001] and 40 times fold increased likelihood of undergoing major LEA [40.1 (26.59-60.42), p < 0.001]. For all stages of CKD, independent of diabetes status, minor LEA were performed with greater frequency than major LEA. In patients with DM, LEA rates significantly increased with CKD progression between stages 2-5 with a substantial jump between stages 4 and 5 [OR 2.6 (CI 2.49-2.74), p < 0.001]. However, CKD progression between stages 1 and 2 was not significantly associated with increased LEA rates (OR 1.1 (CI 0.92-1.21), p = 0.24) in patients with diabetes. Patients with comorbid diabetes have elevated risk for LEA at all stages of CKD compared to those without diabetes., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Inc.)

To investigate risk factors for re-infection and compare the outcomes in people with diabetic foot infections. A retrospective chart review was conducted, and 294 hospitalised patients with moderate to severe diabetic foot infections (DFIs) were analysed for this study. The diagnosis and classification of the severity of infection was based on the International Working Group on the Diabetic Foot (IWGDF) infection guidelines. Skin and soft tissue infections were diagnosed based on clinical observations as per IWGDF classification in addition to ruling out any suspected osteomyelitis (OM) through negative bone culture, MRI or WBC SPECT CT. OM was confirmed by bone culture or histopathology. Clinical outcomes were based on a 12-month follow-up period. All dichotomous outcomes were compared using χ 2 with an alpha of 0.05. The result of this study shows a 48% rate of re-infection in people admitted to our hospital with moderate and severe diabetic foot infections (DFI). Patients with osteomyelitis present during the index admission were 2.1 times more likely to experience a re-infection than patients with soft tissue infection (56.7% vs. 38.0% respectively). In the univariate analysis, risk factors for re-infection included osteomyelitis, non-healing wounds, prolonged wound healing, antidepressants and leukocytosis. In the regression analysis, the only risk factor for re-infection was wounds that were not healed >90 days (HR =2.0, CI: 1.5, 2.7, p = 0.001). Re-infection is very common in patients with moderate and severe diabetic foot infections. Risk factors include osteomyelitis, non-healing wound, prolonged wound healing, antidepressants and leukocytosis., (© 2024 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Objective: Diabetes affects 537 million people globally, with 34% expected to develop foot ulceration in their lifetime. Diabetes-related foot ulceration causes strain on health care systems worldwide, necessitating provision of high-quality evidence to guide their management. Given heterogeneity of reported outcomes, a core outcome set (COS) was developed to standardize outcome measures in studies assessing treatments for diabetes-related foot ulceration., Research Design and Methods: The COS was developed using Core Outcome Measures in Effectiveness Trials (COMET) methodology. A systematic review and patient interviews generated a long list of outcomes that were rated by patients and experts using a nine-point Likert scale (from 1 [not important] to 9 [critical]) in the first round of the Delphi survey. Based on predefined criteria, outcomes without consensus were reprioritized in a second Delphi round. Critical outcomes and those without consensus after two Delphi rounds were discussed in the consensus meeting where the COS was ratified., Results: The systematic review and patient interviews generated 103 candidate outcomes. The two consecutive Delphi rounds were completed by 336 and 176 respondents, resulting in an overall second round response rate of 52%. Of 37 outcomes discussed in the consensus meeting (22 critical and 15 without consensus after the second round), 8 formed the COS: wound healing, time to healing, new/recurrent ulceration, infection, major amputation, minor amputation, health-related quality of life, and mortality., Conclusions: The proposed COS for studies assessing treatments for diabetes-related foot ulceration was developed using COMET methodology. Its adoption by the research community will facilitate assessment of comparative effectiveness of current and evolving interventions., (© 2024 by the American Diabetes Association.)

The objective of the study was to compare outcomes in patients with complete surgical resection versus partial resection of diabetic foot osteomyelitis (OM). A post hoc analysis of 171 patients with OM was performed using data from two randomized clinical trials. OM was confirmed with bone culture or histopathology. Surgical culture specimens were obtained from resected bone and sent for histopathology and microbiology. Residual osteomyelitis (RO) was defined as a positive resected margin on culture or histopathology. No residual osteomyelitis (NRO) was defined as no growth from bone culture and no histopathological inflammation in the biopsy of the resection margin. Data from the 12-month follow-up were used to determine clinical outcomes. During the index hospitalization, NRO patients had significantly shorter duration of antibiotic therapy (NRO 21.0, 13.0-38.0 vs. RO 37.0, 20.8-50.0, p <0.01) and more amputations than patients with RO (NRO 89.9% vs. RO 60.9%, p <0.01). During the 12-month follow-up, patients with NRO also had significantly shorter duration of antibiotic therapy (NRO 42, 21.0-66.5 vs. RO 50.5, 35.0-75.0, p = 0.02). During the 12-month follow-up, there was no difference in ulceration at the same site (NRO 3.7%, RO 4.3% p = 0.85), hospitalization (NRO 32.6%, RO 34.8%, p = 0.76), total re-infections (NRO 25.3%, RO 29.3%, p = 0.56), re-infection with osteomyelitis (NRO 13.3% vs. 13.5%, p = 0.36), amputation (NRO 8.8%, RO 5.4%, p = 0.86) and time to wound healing in days (NRO 94, 41.0-365 vs. RO 106, 42.8-365, p = 0.77). Successful treatment of osteomyelitis was achieved by 86.7% and 86.5% of patients. During the index hospitalization, patients with no residual osteomyelitis had more amputations and were treated with antibiotics for a shorter duration. During the 12-month follow-up, patients with no residual osteomyelitis had shorter durations of antibiotics. There were no differences in re-infection, amputation, re-ulceration or hospitalization. Level of evidence: 1., (© 2024 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: The literature is inconclusive regarding the potential complications of tranexamic acid (TXA), an antifibrinolytic drug, for total hip arthroplasty (THA). The purpose of this study is to compare complication rates and patient outcomes between THA patients administered TXA vs. THA patients not administered TXA. Methods: The TriNetX Research network was utilized to generate a cohort of adult patients who underwent THA between 2003 and 2024. These patients were categorized into two subgroups for the retrospective analysis: (1) patients who received TXA 24 h prior to THA (TXA), and (2) patients who did not receive TXA 24 h prior to total hip arthroplasty (no-TXA). The follow-up period was 30 and 90 days. Results: At 30 days following THA, the TXA patients had a reduced risk of transfusion (risk ratio (RR): 0.412; 95% confidence intervals (CI): 0.374, 0.453), reduced risk of DVT (RR: 0.856; CI: 0.768, 0.953), reduced risk of joint infection (RR: 0.808; CI: 0.710, 0.920), but a higher rate of periprosthetic fracture (RR: 1.234; CI: 1.065, 1.429) compared to patients who did not receive TXA. At 90 days following THA, TXA patients had a reduced risk of transfusion (RR: 0.446; CI: 0.408, 0.487), DVT (RR: 0.847; CI: 0.776, 0.924), and periprosthetic joint infection (RR: 0.894; CI: 0.815, 0.982) compared to patients who did not receive TXA. Patients who received TXA had higher rates of periprosthetic fracture (RR: 1.219; CI: 1.088, 1.365), acute postoperative anemia (RR: 1.222; CI: 1.171, 1.276), deep surgical site infection (SSI) (RR: 1.706; CI: 1.117, 2.605), and superficial SSI (RR: 1.950; CI: 1.567, 2.428) compared to patients who did not receive TXA. Conclusions: Patients receiving TXA prior to THA exhibited significantly reduced the prevalence of blood transfusions, DVT, and periprosthetic joint infection following THA. However, superficial SSI and periprosthetic fracture were seen with higher rates in the TXA cohort than in the no-TXA cohort.

Background Current terms used to describe the MRI findings for musculoskeletal infections are nonspecific and inconsistent. Purpose To develop and validate an MRI-based musculoskeletal infection classification and scoring system. Materials and Methods In this retrospective cross-sectional internal validation study, a Musculoskeletal Infection Reporting and Data System (MSKI-RADS) was designed. Adult patients with radiographs and MRI scans of suspected extremity infections with a known reference standard obtained between June 2015 and May 2019 were included. The scoring categories were as follows: 0, incomplete imaging; I, negative for infection; II, superficial soft-tissue infection; III, deeper soft-tissue infection; IV, possible osteomyelitis (OM); V, highly suggestive of OM and/or septic arthritis; VI, known OM; and NOS (not otherwise specified), nonspecific bone lesions. Interreader agreement for 20 radiologists from 13 institutions (intraclass correlation coefficient [ICC]) and true-positive rates of MSKI-RADS were calculated and the accuracy of final diagnoses rendered by the readers was compared using generalized estimating equations for clustered data. Results Among paired radiographs and MRI scans from 208 patients (133 male, 75 female; mean age, 55 years ± 13 [SD]), 20 were category I; 34, II; 35, III; 30, IV; 35, V; 18, VI; and 36, NOS. Moderate interreader agreement was observed among the 20 readers (ICC, 0.70; 95% CI: 0.66, 0.75). There was no evidence of correlation between reader experience and overall accuracy ( P = .94). The highest true-positive rate was for MSKI-RADS I and NOS at 88.7% (95% CI: 84.6, 91.7). The true-positive rate was 73% (95% CI: 63, 80) for MSKI-RADS V. Overall reader accuracy using MSKI-RADS across all patients was 65% ± 5, higher than final reader diagnoses at 55% ± 7 ( P < .001). Conclusion MSKI-RADS is a valid system for standardized terminology and recommended management of imaging findings of peripheral extremity infections across various musculoskeletal-fellowship-trained reader experience levels. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Schweitzer in this issue.

Treatment of calcaneal fractures in patients with diabetes mellitus (DM) is challenging. The purpose of this study was to compare post-operative outcomes after open reduction and internal fixation (ORIF) for calcaneus fracture in patients with complicated DM, uncomplicated DM, and patients without DM. A commercially available de-identified database was queried for all calcaneus fracture diagnoses undergoing ORIF from 2010 to 2021. The patients were separated into three groups for analysis: patients without DM (10,951, 82.6%), uncomplicated DM (1,500, 11.3%) and complicated DM (802, 6.1%). At 1 year, post-operative adverse events were assessed among the three groups. The odds of adverse event(s) for each group were compared between the three groups with and without characteristic matching. In the unmatched cohorts, patients with complicated DM, when compared with patients without DM and patients with uncomplicated DM, had significantly higher rates of all adverse events with exception of DVT. Rates of CNA were significantly higher in patients with complicated DM compared with no DM (OR 107.7 (CI 24.83-467.6) p < 0.0001) and uncomplicated DM (OR 44.26 (CI 3.86-507.93) p = 0.0002). After matching, non-union, AKI, sepsis, surgical site infection, and wound disruption were higher in patients with complicated DM compared with patients without DM. There were no significant differences in the three groups with regard to reoperation, DVT, MI, pneumonia, or below the knee amputation. Patients with DM who underwent ORIF for calcaneus fracture experienced higher rates of post-operative adverse events compared with those patients without DM., (© 2024 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.)

The aim was to investigate methicillin-resistant Staphylococcus aureus (MRSA) incidence, conversion and outcomes in diabetic foot infections (DFIs). This is a pooled patient-level analysis of combined data sets from two randomised clinical trials including 219 patients admitted to the hospital with moderate or severe DFIs. Intraoperative bone and tissue cultures identified bacterial pathogens. We identified pathogens at index infections and subsequent re-infections. We identified MRSA conversion (MSSA to MRSA) in re-infections. MRSA incidence in index infections was 10.5%, with no difference between soft tissue infections (STIs) and osteomyelitis (OM). MRSA conversion occurred in 7.7% of the re-infections in patients who initially had MSSA in their cultures. Patients with re-infection were 2.2 times more likely to have MRSA compared to the first infection (10.5% vs. 25.8%, relative risk [RR] = 2.2, p = 0.001). Patients with MRSA had longer antibiotic treatment during the 1-year follow-up, compared to other pathogens (other 49.8 ± 34.7 days, MRSA 65.3 ± 41.5 days, p = 0.04). Furthermore, there were no differences in healing, time to heal, length of stay, re-infection, amputation, re-ulceration, re-admission, surgery after discharge and amputation after discharge compared to other pathogens. The incidence of MRSA at the index was 10.5% with no difference in STI and OM. MRSA incidence was 25.8% in re-infections. The RR of having MRSA was 2.2 times higher in re-infections. Patients with MRSA used more antibiotics during the 1-year follow-up. Furthermore, there were no differences in clinical outcomes compared to other bacterial pathogens., (© 2024 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.)

Multiple disciplines are involved in the management of diabetes-related foot disease and a common vocabulary is essential for clear communication. Based on the systematic reviews of the literature that form the basis of the International Working Group on the Diabetic Foot (IWGDF) Guidelines, the IWGDF has developed a set of definitions and criteria for diabetes-related foot disease. This document describes the 2023 update of these definitions and criteria. We suggest these definitions be used consistently in both clinical practice and research, to facilitate clear communication with people with diabetes-related foot disease and between professionals around the world., (© 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd.)

Background: There are uncertainties regarding the diagnostic criteria, optimal treatment methods, interventions, monitoring and determination of remission of Charcot neuro-osteoarthropathy (CNO) of the foot and ankle in people with diabetes mellitus (DM). The aims of this systematic review are to investigate the evidence for the diagnosis and subsequent treatment, to clarify the objective methods for determining remission and to evaluate the evidence for the prevention of re-activation in people with CNO, DM and intact skin., Methods: We performed a systematic review based on clinical questions in the following categories: Diagnosis, Treatment, Identification of Remission and Prevention of Re-Activation in people with CNO, DM and intact skin. Included controlled studies were assessed for methodological quality and key data from all studies were extracted., Results: We identified 37 studies for inclusion in this systematic review. Fourteen retrospective and observational studies relevant to the diagnosis of active CNO with respect to clinical examination, imaging and blood laboratory tests in patients with DM and intact skin were included. We identified 18 studies relevant to the treatment of active CNO. These studies included those focused on offloading (total contact cast, removable/non-removable knee high devices), medical treatment and surgical treatment in the setting of active CNO. Five observational studies were identified regarding the identification of remission in patients who had been treated for active CNO. We did not identify any studies that met our inclusion criteria for the prevention of re-activation in patients with DM and intact skin who had been previously treated for active CNO and were in remission., Conclusions: There is a paucity of high-quality data on the diagnosis, treatment, and prognosis of active CNO in people with DM and intact skin. Further research is warranted to address the issues surrounding this complex disease., (© 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd.)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This is the first guideline on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes published by the IWGDF. We followed the GRADE Methodology to devise clinical questions in the PACO (Population, Assessment, Comparison, Outcome) and PICO (Population, Intervention, Comparison, Outcome) format, conducted a systematic review of the medical literature, and developed recommendations with the rationale. The recommendations are based on the evidence from our systematic review, expert opinion when evidence was not available, and also taking into account weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to an intervention. We here present the 2023 Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus and also suggest key future topics of research., (© 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd.)

The aim of this paper is to review the recent literature regarding the epidemiology and surgical management of Charcot neuro-osteoarthropathy (CNO). We propose that a fundamental change in the approach and assumptions regarding the historical treatment of active CNO should be considered. Although the true incidence and prevalence of CNO in the US population with diabetes are not known, we estimated the incidence to be 27,602 per year and the prevalence to be 208,880 persons. In persons with diabetes, the incidence of CNO is higher than that of prostate, lung, kidney, and thyroid cancer, and in the entire US population, the incidence of CNO is higher than that of multiple myeloma, soft tissue sarcoma, and primary bone sarcoma. In persons with diabetes, the incidence of CNO is higher than fractures of the femoral shaft, distal femur, tibia, talus, calcaneus and Lisfranc ligament injuries. Surgical techniques have evolved over the past half century, and surgery is the standard for treating displaced fractures and intra-articular injuries. Since CNO is a fracture, dislocation, or fracture dislocation in patients with neuropathy, why do we treat CNO differently? Elsewhere in the skeleton displaced osseous and ligament injuries are treated surgically. Based on the information presented in this manuscript, we suggest that it is time for a paradigm shift in the treatment of persons with CNO. While uncommon, CNO in persons with diabetes is not rare. Given the advances in surgical techniques, surgical intervention should be considered earlier in persons with CNO who are at risk for developing deformity related foot ulceration., (© 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd.)

Hallux valgus (HV) is a common condition in which the first ray is deformed, leading to pain and altered joint mechanics. A variety of radiographic measurements are used to evaluate HV. Little is known about measurements used in the assessment of HV on lateral radiographs compared to anteroposterior (AP) radiographs. The primary aim of this study was to correlate lateral measurements with AP measurements pre and postoperatively. The secondary aim was to correlate lateral measurements with patient-reported outcome measures (PROMs) pre and postoperatively. One hundred eighty-three patients were initially enrolled in the study. Two fellowship-trained musculoskeletal radiologists independently performed all measurements. On AP radiographs, hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured. On lateral radiographs, sagittal IMA, Meary's angle, and sagittal first ray length were measured. Measurements were recorded at baseline and 6, 12, and 24 months postoperatively. Intraclass correlation coefficients (ICCs) were used for inter-reader analysis. ICCs were moderate to very strong among readers. There were significant but weak correlations between lateral measurements and AP measurements. For at least 1 timepoint, IMA correlated with sagittal IMA, sagittal first ray length, and Meary's angle. HVA only correlated with sagittal first ray length. These correlations were all weak in magnitude. There were a few significant but weak correlations between the measurements in the study and PROMs. This study showed that sagittal IMA, sagittal first ray length, and Meary's angle are not predictive of AP measurements or patient outcomes and are not useful in preoperative assessment of HV., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Periprosthetic fractures after total knee arthroplasty (TKA) are a challenging problem due to complex fracture patterns, poor bone quality, and a high-risk patient population. Treatment of both periprosthetic fractures and aseptic complications can include revision TKA. In this study, we compared systemic and orthopaedic complications following periprosthetic fracture associated revision TKA to aseptic revision TKA., Methods: This is a retrospective cohort study using data from the years 2010-2020 from a national administrative claims database. Billing codes were used to identify revision TKAs with a diagnosis of periprosthetic fracture or aseptic complications (loosening, dislocation, arthrofibrosis, osteolysis, or prosthetic wear) within one year prior to revision. Pertinent systemic complications and rates of repeat revision TKA, periprosthetic infection, and repeat fractures were compared between the two groups., Results: We identified 9891 periprosthetic fracture associated revision TKAs and 47,071 aseptic revision TKAs. Our study found higher rate of systemic complications including AKI, DVT, wound disruption, hematoma, and surgical site infections in periprosthetic fracture associated revision TKA compared to aseptic revision TKA. Furthermore, we found higher rates of repeat revision TKA, periprosthetic infections, and repeat periprosthetic fractures in fracture associated revision TKA group compared to aseptic revision group., Conclusions: Our work highlights the significant short- and long-term complications associated with periprosthetic fracture associated revision TKA. Future working comparing functional outcomes and optimal surgical techniques are needed., Competing Interests: No conflict of interest to report., (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: As the incidence of childhood obesity continues to rise, so too does the number of obese children who undergo foot surgery. As the childhood obesity epidemic rolls on, pediatric orthopaedic surgeons will encounter obese patients with even greater frequency. Therefore, a comprehensive understanding of the risks associated with obesity is valuable to maximize patient safety. The purpose of this study is to retrospectively evaluate the relationship between obesity and postoperative outcomes in patients undergoing pediatric foot surgery across multiple institutions using a large national database., Methods: Pediatric patients who had undergone foot surgery were retrospectively identified using the American College of Surgeons 2012-2017 Pediatric National Surgical Quality Improvement (ACS-NSQIP-Pediatric) database by cross-referencing reconstructive foot-specific CPT codes with ICD-9/ICD-10 diagnosis codes. Center for Disease Control BMI-to-age growth charts were used to stratify patients into normal-weight and obese cohorts. Univariate and multivariate analyses were performed to describe and assess outcomes in obese compared with normal-weight patients., Results: Of the 3924 patients identified, 1063 (27.1%) were obese. Compared with normal-weight patients, obese patients were more often male (64.7% vs. 58.7%; P =0.001) and taller (56.3 vs. 51.3 inches; P <0.001). Obese patients had significantly higher rates of overall postoperative complications (3.01% vs. 1.32%; P =0.001) and wound dehiscence (1.41% vs. 0.59%; P =0.039). Multivariate analysis found that obesity was an independent predictor of both wound dehiscence [adjusted odds ratio (OR)=2.16; 95% CI=1.05-4.50; P =0.037] and surgical site infection (adjusted OR=3.03; 95% CI=1.39-6.61; P =0.005). Subgroup analysis of patients undergoing clubfoot capsular release procedures identified that obese patients had a higher rate of wound dehiscence (3.39% vs. 0.51%; P =0.039) compared with normal-weight patients. In multivariate analysis, obesity was an independent predictor of dehiscence (adjusted OR=5.71; 95% CI=1.46-22.31; P =0.012) in this procedure group. There were no differences in complication rates between obese and normal-weight patients in a subgroup analysis of tarsal coalition procedures or clubfoot tibialis anterior tendon transfer procedures., Conclusion: Obese children undergoing foot surgery had higher overall complication rates, wound complications, and surgical site infections compared with children of normal weight. As the incidence of childhood obesity continues to rise, this information may be useful in assessing and discussing surgical risks with patients and their families., Level of Evidence: III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Limb salvage is a difficult path for patients to travel as there is no guarantee of the outcome, often the major factor is perfusion. For patients who underwent transmetatarsal amputation (TMA), success rate is crucial as the next option is most likely a major amputation. We performed a 10 years (2010-2020) retrospective review of patients that underwent a TMA and had an angiogram or computed tomography angiography (CTA) perioperatively at the Dallas VA Medical Center. Failure after TMA was defined as a patient requiring a proximal amputation within 1 year. There were 125 TMAs performed between 2010 and 2020 at the institution. Forty-four (35.2%) patients had an angiogram/CTA peri-operative and met the inclusion criteria. Seventeen subjects (38.6%) had a higher level of amputation. Of the 17 failures, 2 (11.8%) patients had no patent vessel runoff to the foot, 9 (52.9%) had one vessel, 4 (23.5%) had two vessels, and 2 (11.8%) had three vessels runoff. One vessel runoff to the foot yielded a high rate of poor outcomes (56.3%) defined as a higher level of amputation. Two or more vessels runoff to the foot had over 75% success of limb salvage with a TMA., (© 2023 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Introduction: In this study, we evaluate how race corresponds to specific complications and costs following total knee arthroplasty (TKA). Our hypothesis was that minority patients, comprising Black, Asian, and Hispanic patients, would have higher complication and revision rates and costs than White patients., Methods: Data from 2014 to 2016 were collected from a large commercial insurance database. TKA patients were assigned under Current Procedural Terminology (CPT-27447) and International Statistical Classification of Diseases (ICD-9-P-8154) codes. Minority patients were compared to White patients before and after matching for age, gender, and tobacco use, diabetes, and obesity comorbidities. Standardized complications, revisions, and total costs at 30 days, 90 days, and 1 year were compared between the groups using unequal variance t tests., Results: Overall, 140,601 White (92%), 10,247 Black (6.7%), 1072 Asian (0.67%), and 1725 Hispanic (1.1%) TKA patients were included. At baseline, minority patients had 7-10% longer lengths of stay (p = 0.0001) and Black and Hispanic patients had higher Charlson and Elixhauser comorbidity indices (p = 0.0001), while Asian patients had a lower Elixhauser comorbidity index (p < 0.0001). Black patients had significantly higher complication rates and higher rates of revision (p = 0.03). Minority patients were charged 10-32% more (p < 0.0001). Following matching, all minority patients had lengths of stay 8-10% longer (p = 0.001) and Black patients had higher Charlson and Elixhauser comorbidity indices (p < 0.0001) while Asian patients had a lower Elixhauser comorbidity index (p = 0.0008). Black patients had more equal complication rates and there was no significant difference in revisions in any minority cohort. All minority cohorts had significantly higher total costs at all time points, ranging from 9 to 31% (p < 0.0001)., Conclusion: Compared to White patients, Black patients had significantly increased rates of complications, along with greater total costs, but not revisions. Asian and Hispanic patients, however, did not have significant differences in complications or revisions yet still had higher costs. As a result, this study corroborates our hypothesis that Black patients have higher rates of complications and costs than White patients following total knee arthroplasty and recommends efforts be taken to tackle health inequities to create more fairness in healthcare. This same hypothesis, however, was not supported when evaluating Asian and Hispanic patients, probably because of the few patients included in the database and deserves further investigation., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To examine the clinical risk factors of perioperative pressure injury (PrI) in older adults with a hip fracture, including preoperative chronic comorbidities and postoperative complications., Methods: In this retrospective study, the authors queried the PearlDiver Patient Records database between January 2011 and January 2020. Data from 54,194 patients without preexisting PrI were included for analyses. Patients were separated into two groups: (1) one or more perioperative PrI and (2) no PrI. Clinical factors as outcome variables include 21 comorbidities and 10 complications., Results: Univariate analyses were computed to compare the variables between groups, and two logistic regression models were developed to find comorbidity predictors and complication predictors. Of all patients, 1,362 (2.5%) developed one or more perioperative PrI. Patients with perioperative PrIs were more likely to be older men. One-year mortality for patients with perioperative PrI was 2.5 times that of patients without PrI. The regression models showed that predictors of perioperative PrI are malnutrition, hypoalbuminemia, frailty, peripheral vascular disease, dementia, urinary tract infection, perioperative red blood cell transfusion, and atrial fibrillation., Conclusions: Screening for these comorbidities and complications may assist in determining the risk of PrI in older adults undergoing hip fracture surgery. Determining PrI risk enables the appropriate prevention strategies to be applied perioperatively., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine inter-reader reliability (IRR) of hallux valgus (HV) related parameters, i.e. intermetatarsal angle (IMA), hallux valgus angle (HVA), lateral round sign of the first metatarsal, tibial sesamoid position (TSP), metatarsus adductus angle (MAA), transverse osseous foot width, 1 st  MT length, MTP osteoarthritis (OA), and distal metatarsal articular angle (DMAA). These were correlated with patient-reported outcome measures (PROMs)., Materials and Methods: A prospective single-arm Level 3 multicenter clinical trial in which standardized radiographs and PROMs were collected at the time of the initial patient visit for pre-operative assessment. Two musculoskeletal radiologists performed measurements blinded to each other's reads and clinical information. Intraclass coefficient and kappa were obtained for inter-reader analysis. A partial spearman rank order was used to correlate the measurements with PROMs., Results: The final cohort size of 183 patients had mean age of 40.77 years, mean body mass index was 26.11 kg/m 2 , with 91.2% females and 8.7% males. There was excellent IRR for HVA (0.96, CI: [0.94,0.97]), IMA (0.92, CI: [0.89,0.94]), transverse osseous foot width (0.99, CI: [0.98,1.00]), and DMAA (0.80, CI: [0.74, 0.85]), good agreement for TSP (0.73, CI:[0.67,0.79]) and MAA (0.67, CI: [0.16, 0.84]), fair agreement for MTP OA (0.48, CI: [0.36,0.59]), and poor agreement for lateral round sign (0.32, CI: [0.11, 0.52]. The negative correlation of increasing transverse osseous foot width with worsening PROMIS physical but better MOxFQ and VAS scores is likely spurious., Conclusion: Good to excellent inter-reader reliability was observed for the most often used measurements for HV assessment without major trends in their correlations with PROMs. Lateral round sign is not a reliable finding in HV deformity., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Competing Interests: Declaration of Conflicting InterestsThe author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Objectives: Compare systemic complications, fracture healing related complications, and reoperation rates for pilon fractures in patients with and without diabetes., Design: Retrospective cohort study., Setting: National administrative claims database with patient records., Patients: Patients from the years 2016 to 2020 with surgically treated closed or open pilon fractures., Intervention: Patients with either closed or open pilon fractures with diabetes were compared to those without diabetes. Subgroup analysis was performed on diabetic patients with and without neuropathy., Outcomes: Postoperative systemic complications at 90 days, fracture healing complications at 90 days and 1 year, and reoperative rates at 90 days and 1 year., Results: 2,654 (31.4%) patients with closed fractures and 491 (28.7%) patients with open fractures had a diagnosis of diabetes. In both open and closed fractures, we identified significantly higher rates of acute kidney injury, cardiac arrest, and surgical site infection in diabetic patients compared to non-diabetic patients. Additionally, we found significantly higher rates of below knee amputations in diabetic patients. Diabetic patients with closed fractures had significantly higher rates of wound healing related reoperations. Patients with advanced diabetic disease, as suggested by the presence of neuropathy, had higher rates of nonunions and post-traumatic arthritis., Conclusions: The data presented here provides updated estimates on complication rates in pilon fractures using large sample size. Additionally, our work identifies differences in outcomes for patients with and without diabetes following pilon fracture surgery. Our data suggests that patients with severe diabetes are prone to higher rates of healing complications and may benefit from additional therapeutic support., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: CONFLICT OF INTEREST The authors of the study have no conflict of interest to report., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Chronic kidney disease (CKD) is a growing disease that affects millions of people in the USA every year. Many CKD patients progress to end-stage renal disease (ESRD), necessitating the use of hemodialysis to alleviate symptoms and manage kidney function. Furthermore, many of these patients have lower bone quality and experience more postoperative complications. However, there is currently limited information on hospitalization information and perioperative complications in this population following procedures such as total knee arthroplasty (TKA). The purpose of this study was to assess the patient characteristics, demographics, and prevalence of postoperative problems among dialysis patients who received TKA., Methods: In this retrospective study, we used the Nationwide Inpatient Sample (NIS) data from 2016 to 2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing TKA who were categorized as dialysis patients, compared with those who were not. Propensity matching was conducted to consider associated factors that may influence perioperative complications., Results: From 2016 to 2019, 558,371 patients underwent TKAs, according to the National In-Sample (NIS) database. Of those, 418 patients (0.1%) were in the dialysis group, while the remaining 557,953 patients were included in the control group. The mean age of the dialysis group was 65.4 ± 9.8 years, and the mean age in the control group was 66.7 ± 9.5 years (p = 0.006). After propensity matching, dialysis group patients had a higher risk of receiving blood transfusions [odds ratio (OR): 2; 95% confidence interval (CI): 1.2, 3.4] and a significantly larger COC in comparison to those in the control group (91,434.3 USD versus 71,943.6 USD, p < 0.001). In addition, dialysis patients had significantly higher discharges to another facility, as compared with the control group patients., Conclusions: The dialysis group had a significantly higher cost of care, higher rates of requiring blood transfusion, and more cases of being discharged to another facility than non-dialysis patients. This data will help providers make informed decisions about patient care and resource allocation for dialysis patients undergoing TKA., (© 2023. The Author(s).)

Diabetes (DM) increases fracture risk, and bone quality depends on type diabetes type, duration, and other comorbidities. Diabetes is associated with a 32% increased relative risk (RR) of total fractures and 24% increased RR of ankle fractures compared with patients without DM. Type 2 DM is associated with a 37% increased RR of foot fractures compared with patients without DM. The incidence of ankle fractures in the general population is 169/100,000 per year, while foot fractures occur less frequently, with an incidence of 142/100,000 per year. Biomechanical properties of bone are negatively impacted by stiff collagen, contributing to the increased risk of fragility fractures in patients with DM. Systemic elevation of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNFα), interleukin-1β (IL-1β), and interleukin 6 (IL-6), impact bone healing in patients with DM. Fractures in patients with DM, can be associated with poorly regulated levels of RANKL (receptor activator of nuclear transcription factor kappa-b ligand) leading to prolonged osteoclastogenesis, and net bone resorption. One of the most salient factors in treating fractures and dislocations of the foot and ankle is to recognize the difference between patients with uncomplicated and complicated DM. Complicated diabetes is defined as 'end organ damage', and for the purposes of this review, includes patients with neuropathy, peripheral artery disease (PAD) and/or chronic renal disease. Uncomplicated diabetes is not associated with 'end organ damage'. Foot and ankle fractures in patients with complicated DM pose challenges, and surgery is associated with increased risks of impaired wound healing, delayed fracture healing, malunion, infection, surgical site infection, and revision surgery. While patients with uncomplicated DM can be treated like patients without DM, patients with complicated DM require close follow-up and robust fixation methods should be considered to withstand the anticipated prolonged healing period. The aims of this review are as follows: (1) to review pertinent aspects of DM bone physiology and fracture healing, (2) to review the recent literature on treatment of foot and ankle fractures in patients with complicated DM, and (3) to provide treatment protocols based on the recent published evidence., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: D.K.W. is a consultant for Orthofix and Stryker Wright Medical, receives royalties from Arthrex serves as President of the International Association of Diabetic Foot Surgeons and serves on the scientific advisory board of Advanced Oxygen Therapy, Inc. K.M.R. is a consultant for Orthofix. G.T.L. is a consultant for Gramercy Extremity Orthopedics and Orthofix. L.L. has received grants or contracts from Osiris, Integra, Cardinal Health, Medimmune, Avazzia, Pluristem, Kent Medical, Smith and Nephew, Tissue Tech and has served as consultant for Integra, Polarityte and Uluru. M.J.J., S.K., and M.V.P. have nothing to disclose. K.M. has received general payments from Arthrex, Stryker, Southern Edge Orthopedics, Medical Device Business, Pylant Medical, and Smith and Nephew. Full details of financial disclosures of the authors can be viewed at https://openpaymentsdata.cms.gov/., (© The Author(s), 2023.)

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.

Background: Nonagenarians are a rapidly expanding population in the United States. These patients are met with increasing rates of hip arthritis, necessitating the need for total hip arthroplasty (THA). However, there is currently limited information on hospitalization information and perioperative complications in this population. Methods: In this retrospective study, we used the Nationwide Inpatient Sample (NIS) database from 2016-2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing THAs who were categorized as nonagenarians, and those who were not., Results: The NIS database identified 309 100 patients who underwent THAs from 2016-2019. Of those, 1864 patients (.6%) were nonagenarian, while the remaining 307 236 patients were included under the non-nonagenarian category (control). The mean age in the nonagenarian group was 90 years compared to the control group which had a mean age of 65.8 years. There was an increased incidence of mortality rate (nonagenarian group .2%, control group .03%, P < .001), myocardial infarction (MI) (nonagenarian group .1%, control group .02%, P = .01), acute renal failure (ARF) (nonagenarian group 5.4%, control group 1.6%, P < .001), blood anemia post-operatively (nonagenarian group 28.9%, control group 17.2%, P < .001), and deep vein thrombosis (DVT) (nonagenarian group .48%, control group .07%, P < .001) in the nonagenarian group. The COC for the nonagenarian group was higher than that in the control group ( P < .001). The mean LOS was longer in the nonagenarian group (3.1 days) in comparison to the control group (1.96 days) ( P < .001)., Conclusions: Nonagenarians had significantly higher rates of both orthopedics and medical complications than the younger patients undergoing THAs. In addition, the nonagenarian group incurred higher COC. This information is useful for the providers to make informed decisions regarding patient care and resource utilization for nonagenarian patients undergoing THAs., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Rigid flatfoot deformity with valgus ankle instability is a complex condition to treat. Thorough clinical and radiographic evaluation is vital to determine treatment strategies. Nonoperative treatment usually relies on bracing or various orthoses. Surgical interventions include ligament reconstruction, osteotomies, arthrodesis, arthroplasty, or a combination of these procedures. Before addressing the ankle deformity, a plantigrade foot is important so a staged approach may be necessary. Misalignment of the ankle replacement can lead to edge loading and early failure. As the implants and our understanding of ankle arthroplasty improve, more patients may benefit from a motion-preserving procedure rather than an arthrodesis., (Published by Elsevier Inc.)

Background: We sought to evaluate clinicians' compliance with national guidelines for tetanus vaccination prophylaxis in patients with high-risk feet., Methods: We retrospectively evaluated 114 consecutive patients between June 1, 2011, and March 31, 2019, who presented to the emergency department with a foot infection resulting from a puncture injury. Eighty-three patients had diabetes mellitus and 31 patients did not have diabetes mellitus. Electronic medical records were used to collect a broad range of study data on patient demographics, medical history, tetanus immunization history and tetanus status on presentation to the emergency department, peripheral arterial disease, sensory neuropathy, laboratory values, and clinical/surgical outcomes., Results: Of the 114 patients who presented to the emergency department with a puncture wound, 53 (46.5%) did not have up-to-date tetanus immunization. Of those patients, 79.2% received a tetanus-containing vaccine booster, 3.8% received intramuscular tetanus immunoglobulin, 3.8% received both a tetanus-containing vaccine booster and tetanus immunoglobulins, and 20.8% received no form of tetanus prophylaxis. Comparing data between patients with and without diabetes mellitus, there were no statistically significant differences in tetanus prophylaxis., Conclusions: Guidelines for tetanus prophylaxis among high-risk podiatric medical patients in this study center are not followed in all patients. Patients with diabetes mellitus are at high risk for exposure to tetanus; therefore, we recommend that physicians take a detailed tetanus immunization history and vaccinate patients if the tetanus history is unclear.

People with spinal cord injury (SCI) are at high risk of developing a pressure injury. It is unclear why some people with SCI develop pressure injury while others with similar predisposing risk factors do not during acute hospitalisation. This may hinder healthcare utilisation to prevent pressure injuries. The purpose of the study was to examine the proof-of-concept objective bedside skin blood flow measurements before a pressure injury develops in spinal cord injured patients during acute hospitalisation. This was an observational study. All participants had acute traumatic SCI and were pressure injury-free upon enrollment. Skin blood flow patterns were collected at both heels under two circumstances: localised pressure for reactive hyperemia, and localised heating for heat hyperemia. Our results showed that reactive and heat hyperemia were successfully induced in all eleven participants. Two participants developed pressure injury and nine did not have pressure injury at discharge. Heat hyperemia was smaller in participants with pressure injury. No difference was observed in reactive hyperemia between the groups. In conclusion, skin blood flow measurements could be obtained at bedside during acute hospitalisation of SCI for the purpose of research. Further examination of a larger group is warranted to determine clinical use of heat hyperemia pattern as predictor for pressure injury development., (© 2022 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

There are multiple factors that lead to the development of the diabetic foot ulceration (DFU). The ultimate goal when treating DFU is to prevent amputation. Initial therapy should include debridement, maintaining a healthy wound environment, and offloading. In the setting of infection or a nonhealing DFU, surgical intervention may be necessary. The goals of this article are to discuss the key aspects of the initial examination, standard nonoperative treatment, and the operative treatment options for patients with DFU., Competing Interests: Disclosure D.K. Wukich is a consultant for Orthofix, Stryker Wright and receives royalties from Arthrex. He is also on the executive board of the International Association of Diabetic Foot Surgeons. K.M. Raspovic is a consultant for Orthofix. M.J. Johnson has no disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the incidence and recovery of acute kidney injury (AKI) in patients admitted to the hospital with and without diabetes mellitus (DM) with foot infections., Methods: We retrospectively reviewed 294 patients with DM and 88 without DM admitted to the hospital with foot infections. The Kidney Disease: Improving Global Outcomes guidelines were used to define AKI. Recovery was divided into three categories: full, partial, and no recovery within 90 days of the index AKI., Results: The AKI incidence was 3.0 times higher in patients with DM (DM 48.5% versus no DM 23.9%; 95% confidence interval [CI], 1.74-5.19; P < .01). Acute kidney injury incidence was similar at each stage in people with and without DM (stage 1, DM 58.1% versus no DM 47.6%; stage 2, DM 23.3% versus no DM 33.3%, and stage 3, DM 18.6% versus no DM 19.1%). Twenty-nine patients with diabetes had a second AKI event and four had a third event. In patients without DM, one patient had a second AKI. Cumulative AKI incidence was 4.7 times higher in people with DM (DM 60.9% versus no DM 25.0%; 95% CI, 2.72-8.03; P < .01). Patients with diabetes progressed to chronic kidney disease or in chronic kidney disease stage 39.4% of the time. Patients without diabetes progressed 16.7% of the time, but this trend was not significant (P = .07). Complete recovery was 3.8 times more likely in patients without diabetes (95% CI, 1.26-11.16; P = .02)., Conclusions: Acute kidney injury incidence is higher in patients with diabetes, and complete recovery after an AKI is less likely compared to patients without diabetes.

Charcot neuroarthropathy can cause severe deformity of the midfoot, and intramedullary use of beams and bolts has been utilized as a method of definitive stabilization. This systematic review evaluated the outcomes of intramedullary beaming in patients with Charcot neuroarthropathy and determined the methodological quality of the studies. Four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). To assess the methodological quality of the studies, the Coleman Methodology Score was used. The data was pooled into 2 outcomes groups for comparison: (1) Studies that reported on the outcomes of Charcot specific implants (study group). (2) Studies that reported on the outcomes using non-Charcot specific implants (control group). After screening, 16 studies were included. Compared to our control group, our study group had significantly higher rates of overall hardware complications, hardware migration, surgical site infection, reoperation, and nonunion. The study group had significantly lower rates of limb salvage compared to the control group. Our study and control groups did not differ in the rates of hardware breakage, wound healing complications, or mortality. The limb salvage rate was 92% and 97% of patients were still alive at a mean follow-up of 25 months. The mean Coleman Methodology Score indicated the quality of the studies was poor and consistent with methodologic limitations. The quality of published studies on intramedullary implants for Charcot reconstruction is low. Complications when utilizing intramedullary fixation for Charcot reconstruction are high, whether or not Charcot specific implants are used., (Copyright © 2022. Published by Elsevier Inc.)

We report one- and 2-year results of a prospective, 5-year, multicenter study of radiographic, clinical, and patient-reported outcomes following triplanar first tarsometatarsal arthrodesis with early weightbearing. One-hundred and seventeen patients were included with a mean (95% confidence interval [CI]) follow-up time of 16.6 (15.5, 17.7) months. Mean (95% CI) time to weightbearing in a boot walker was 7.8 (6.6, 9.1) days, mean time to return to athletic shoes was 45.0 (43.5, 46.6) days, and mean time to return to unrestricted activity was 121.0 (114.5, 127.5) days. There was a significant improvement in radiographic measures with a mean corrective change of -18.0° (-19.6, -16.4) for hallux valgus angle, -8.3° (-8.9, -7.8) for intermetatarsal angle and -2.9 (-3.2, -2.7) for tibial sesamoid position at 12 months (n = 108). Additionally, there was a significant improvement in patient-reported outcomes (Visual Analog Scale, Manchester-Oxford Foot Questionnaire, and Patient-Reported Outcomes Measurement Information System) and changes were maintained at 12 and 24 months postoperatively. There was 1/117 (0.9%) reported recurrence of hallux valgus at 12 months. There were 16/117 (13.7%) subjects who experienced clinical complications of which 10/117 (8.5%) were related to hardware. Of the 7/117 (6.0%) who underwent reoperation, only 1/117 (0.9%) underwent surgery for a nonunion. The results of the interim report of this prospective, multicenter study demonstrate favorable clinical and radiographic improvement of the HV deformity, early return to weightbearing, low recurrence, and low rate of complications., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Refractory pain to the fourth and fifth tarsometatarsal (TMT) joint can be a source of disability and functional impairment. While pain has been attributed to injury, post-traumatic arthritis, arthrofibrosis, the principal causes of pain in the absence of arthritis are not well elucidated. The purpose of this study is to characterize arthroscopic pathology associated with chronic refractory pain to the fourth and fifth TMT joints. We retrospectively examined 24 patients that underwent arthroscopic surgery of the fourth and fifth TMT joints for refractory pain at our academic institution between 2015 and 2019. We used the Outerbridge classification for chondral lesions, the Kellgren Lawrence radiographic classification for osteoarthritis, and described intraarticular pathologies as acute hypertrophic synovitis, chronic synovial fibrosis, hyaline bands, meniscoid bodies, loose joint bodies, arthrofibrosis. Approximately, 31 of 45 TMT joints (68.9%) presented with radiographic evidence of arthritis. Approximately, 14 of 45 TMT joints (31.11%) were absent of radiographic signs of arthritis. The frequency of soft tissue pathology seen in these patients without radiographic evidence of arthritis was arthrofibrosis (87.5%), chronic synovial fibrosis (75.0%), and acute hypertrophic synovitis (62.5%). This is the first study to report arthroscopic pathologies associated with refractory pain to the fourth and fifth TMT joints., (Published by Elsevier Inc.)

Background: To compare pathogens involved in skin and soft-tissue infections (SSTIs) and pedal osteomyelitis (OM) in patients with and without diabetes with puncture wounds to the foot., Methods: We evaluated 113 consecutive patients between June 1, 2011, and March 31, 2019, with foot infection (SSTIs and OM) from a puncture injury sustained to the foot. Eighty-three patients had diabetes and 30 did not. We evaluated the bacterial pathogens in patients with SSTIs and pedal OM., Results: Polymicrobial infections were more common in patients with diabetes mellitus (83.1% versus 53.3%; P = .001). The most common pathogen for SSTIs and OM in patients with diabetes was Staphylococcus aureus (SSTIs, 50.7%; OM, 32.3%), whereas in patients without diabetes it was Pseudomonas (25%) for SSTIs. Anaerobes (9.4%) and fungal infection (3.1%) were uncommon. Pseudomonas aeruginosa was identified in only 5.8% of people with diabetes., Conclusions: The most common bacterial pathogen in both SSTIs and pedal OM was S aureus in patients with diabetes. Pseudomonas species was the most common pathogen in people without diabetes with SSTIs.

This review article examines contemporary methods and assesses radiographic outcomes and postoperative complications following the modified Lapidus procedure. A systematic review demonstrated significant improvements in intermetatarsal angle, hallux valgus angle, and tibial sesamoid position. We are updating a modified Lapidus technique for achieving triplanar correction of hallux valgus. Two cases of hallux valgus, one primary and one recurrent, are presented. As demonstrated in the systematic review, outcomes of Lapidus procedures create future opportunities. Surprisingly, only 78% of the studies assessed for this review reported on the hallux valgus angle and only 33% reported on tibial sesamoid position., Competing Interests: Disclosure The authors would like to acknowledge that Treace Medical Concepts, Inc., Ponte Vedra Beach, FL provided institutional research support to the authors’ institution. D.H. Do, J.J. Sun, and D.K. Wukich certify that neither they nor any member of their immediate family has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, and so forth) that might pose a conflict of interest in connection with the submitted article. DKW is the principal investigator of an ongoing prospective that is funded by Treace Medical Concepts, Inc., Ponte Vedra Beach, FL. Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research., (Copyright © 2022 Elsevier Inc. All rights reserved.)