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Diabetic foot infections (DFI) are an increasingly common cause of hospitalizations. Once hospitalized with DFI, many patients require some level of amputation, often undergoing multiple operations. With increasing importance on patient-centered metrics, self-reported health-related quality of life (HRQOL) tools have been developed. This prospective cohort study aimed assessed the impact of DFI on HRQOL. Two hundred twenty-four patients completed the 29-item Patient-Reported Outcome Measurement Information System (PROMIS) and 12-Item Short Form (SF-12) survey. Secondary outcomes using the Foot and Ankle Ability Measures survey were obtained and included in the analysis. The study group was comprised of hospitalized patients with DFIs (n = 120), and the control group was comprised of patients with diabetes who were evaluated for routine outpatient foot care (n = 104); diabetic foot screening, wound care, onychomycosis, and/or callosities. Using this cohort, a propensity score-matched sample of hospitalized patients with DFI (n = 35) and control group patients (n = 35) was created for comparative analysis. The 2-independent sample t test was used to test for group differences on each of the PROMIS subscale outcomes. Using PROMIS, we found that hospitalized patients with DFI reported significantly worse HRQOL in 6 of 7 subscales (physical function, anxiety, depression, fatigue, social role, pain intensity; p value range: .0001-.02) compared to outpatients with diabetes evaluated for routine foot care. There was no significant difference between the 2 groups on sleep disturbance (p = .22). Patients hospitalized for DFI report lower HRQOL compared to patients with diabetes receiving routine outpatient foot care.

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.

Background Although the negative effects of diabetes mellitus (DM) on operative outcomes in orthopaedic surgery is a well-studied topic in adults, little is known about the impact of this disease in children undergoing orthopaedic procedures. This study aims to describe the postoperative complications in pediatric orthopaedic surgery patients with DM. Methods Pediatric patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) were retrospectively identified while selecting for elective orthopaedic surgery cases from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-Pediatric) database from 2012 to 2015. Univariate and multivariate analyses were performed to describe and assess outcomes when compared with nondiabetic patients undergoing similar procedures. Results Of the 17,647 patients identified, 105 (0.60%) had DM. Of those 105 patients, 68 had IDDM and 37 had NIDDM. The median age of DM patients was 13.8 years (11.9 to 15.5 y) and 37.1% of all DM patients were male. Comparing DM to non-DM patients, no significant differences were noted in the overall complications (1.4% vs. 1.9%, P>0.05) or reoperation rates (1.2% vs. 1.9%, P>0.05); however, DM patients did have a higher occurrence of unplanned readmissions (4.8% vs. 1.7%; P=0.037). Diabetic patients were statistically more likely to have an unplanned readmission with 30 days (adjusted odds ratio=3.34; 95% confidence interval=1.21-9.24, P=0.021). when comparing IDDM to NIDDM, there was no significant difference in outcomes. Comparing NIDDM to non-DM patients, there was an increased incidence of nerve injury (5.6% vs. 0.18%; P=0.023), readmission rate (11.1% vs. 1.8%; P=0.043), and reoperation rate (11.1% vs. 1%; P=0.013) in nonspinal procedures and an increased incidence of pulmonary embolism (10% vs. 0%; P=0.002) in spinal arthrodesis procedures. NIDDM predicted longer hospital stays (adjusted odds ratio=1.49; 95% confidence interval=1.04, 2.14; P=0.028) compared with nondiabetic patients in extremity deformity procedures. Conclusions The 30-day complication, reoperation, and readmission rates for NIDDM patients were higher than that of non-DM patients. Furthermore, NIDDM is a predictor of longer hospital stays while DM is a predictor of unplanned readmissions. No statistical differences were noted when comparing outcomes of NIDDM to IDDM patients. Level of evidence Level III.

The purpose of this study was to assess the intra- and inter-reader reliability of the 2 Charcot neuroarthropathy classifications (Sanders-Frykberg and Brodsky-Trepman), as well as Eichenholtz staging. We hypothesized that the inter-reader reliability, with respect to these 3 classification systems, would be moderate at best. Digital radiographic images were organized in a digital slide presentation without clinical information. All 5 reviewers underwent a standard training session administered by the principal investigator, reviewing 5 cases of Charcot neuroarthropathy. Images of 55 cases of Charcot neuroarthropathy and 5 normal cases were distributed to each of the 5 physicians electronically, who independently rated all 60 cases according to the 3 classification systems. The 95% confidence interval of the intraclass correlation coefficient estimate for Sanders-Frykberg was 0.9601 to 0.9833 at week 0 and 0.9579 to 0.9814 at week 8, which can be regarded as "excellent" reliability. For Trepman-Brodsky, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.8463 to 0.9327 at week 0 and 0.8129 to 0.9226 at week 8, which can be regarded as "good" to "excellent" reliability. For Eichenholtz, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.6841 to 0.8640 and 0.6931 to 0.8730 at weeks 0 and 8, respectively, which can be regarded as "moderate" to "good" reliability. The classification systems of Charcot neuroarthropathy are an important tool for communication among physicians. Based on the results at our institution, the Sanders-Frykberg classification exhibited the best inter-reader performance. The Trepman-Brodsky classification exhibited good to excellent reliability as well. The intraclass correlation coefficient of the Eichenholtz classification was moderate to good.

Hallux valgus is a complex deformity with a variety of techniques described for correction. A biplanar plating system for triplanar correction system has been developed to address both the translation and rotational component of the hallux valgus deformity and allow an accelerated weightbearing protocol. The purpose of this study was to determine the correction and complications using radiographic parameters and patient reported outcomes. We sought to determine prognostic factors for successful correction, including age, gender, and preoperative deformity. From the medical records, we collected preoperative data. Patient-reported outcomes were obtained using AOFAS Hallux Metatarsophalangeal-Interphalangeal score, FAAM, and SF-12 scores preoperatively and postoperatively. Imaging was reviewed at preoperative and postoperative visits to determine hallux valgus angle, intermetatarsal angle, and tibial sesamoid position. Fifty-seven procedures, in 55 patients, were performed. There were 7 complications and mean follow-up time was 45.7 weeks (+ 28.3 weeks). Age over 62.5 years were associated with an increased risk of complications (p = .018). Males had an increased rate of complications (71%) compared with females. Radiographic parameters were significantly improved from preoperative values at alltime points (p.05). Only the AOFAS Hallux Metatarsophalangeal-Interphalangeal score was statistically significant at 3, 6 and 12 months. We sought to determine the effectiveness of biplanar plating and triplanar correction procedure with early weightbearing. Over a 12 month follow-up period, our results showed significant improvement in deformity and maintained correction. AOFAS Hallux Metatarsophalangeal-Interphalangeal scores significantly improved from the preoperative to the postoperative state. Our results show a nonunion rate of 5.2%, which is comparable to prior studies.

PurposeThis paper examines how the inferred motives for corporate philanthropy relate to the types of charitable causes supported.Design/methodology/approachPublished data were obtained for 256 publicly traded and private corporations from a variety of sources.FindingsThe results demonstrated that a number of motives were not significantly related to total charitable giving, but were related to how charitable funds were distributed to various charitable causes. Thus, the study provides insights on the strategic use of corporate charity as means of achieving various business objectives and advancing a theoretical understanding of corporate philanthropy strategies.Research limitations/implicationsThis study only investigated some of the presumed motives for corporate philanthropy. Even for the motives investigated in this study, no attempt was made to examine all the motivational factors that determine the level of need for a specific motive. Thus, while the present study provides some of the first evidence of a relationship between motivational factors and data on the types of charitable causes supported, there are other motivational factors that could be investigated in future studies.Practical implicationsThe results have a number of implications for managers of nonprofit organizations such as marketing/targeting potential donors. Additionally, the results could be useful for managers of for profit firms in terms of comparing corporate strategies with competing firms.Originality/valueThe study provides a framework for investigating the relationship between motivational factors and types of charitable causes supported.

Charcot neuroarthropathy is a complication of neuropathy often secondary to diabetes mellitus and most commonly affects the midfoot. In these patients, reconstruction of the foot may be required for limb salvage. A superconstruct technique has previously been described using intramedullary beaming fixation of the midfoot and hindfoot to span the zone of injury. Inclusion of the subtalar joint in the arthrodesis construct is not consistently performed among different surgeons. The aim of this study was to describe midfoot beaming constructs and postoperative complications after midfoot reconstruction with and without subtalar arthrodesis. We reviewed medical records of patients who underwent midfoot Charcot reconstruction with an intramedullary beaming superconstruct. Patients included in the study had at least 3 months of follow-up and had Sanders-Frykberg II/III classification of Charcot neuroarthropathy. Postoperative radiographs were evaluated for evidence of hardware failure at the latest follow-up evaluation. The main variables of interest were: hardware failure or nonunion requiring revision operation, deep infection, and unplanned reoperation. Thirty patients who underwent midfoot reconstruction were included. The mean follow-up was 67.4 ± 25.9 weeks. Twenty-two (73.3%) patients had concomitant subtalar arthrodesis and midfoot beaming. Overall complications were lower in patients with subtalar arthrodesis (40.9%) than those without subtalar arthrodesis (75%) resulting in an odds ratio of 0.271 (0.042-1.338, p = .146). Furthermore, increased number of screws used in the midfoot construct was negatively correlated with complications (r = −0.44, p = .01). An intramedullary midfoot beaming superconstruct with subtalar arthrodesis has previously been proposed to provide better fixation after midfoot beaming Charcot neuroarthropathy reconstruction. Our results suggest including the subtalar joint as part of a superconstruct for the reconstruction of Sanders-Frykberg II/III Charcot results in an 80% lower complication rate than intramedullary beaming alone. We also found an increased number of screws used in the midfoot results in a lower complication rate.

The aim of this study was to report clinical outcomes of moderate and severe foot infections in patients without diabetes. Medical records of 88 nondiabetic patients with foot infections treated at a safety net hospital were retrospectively reviewed. Patients were grouped by the presence of soft-tissue infection (STI) or osteomyelitis (OM). The diagnosis of OM was determined by positive bone culture or histopathology. STIs were defined by negative bone biopsy or negative imaging with magnetic resonance imaging or computed tomography/dual-modality radiolabeled white blood cell single-photon emission computed tomography. Patient outcomes were recorded ≤1 year after admission. Eighty-eight nondiabetic patients admitted to our institution for moderate or severe foot infections were included, 45 OM and 43 STI. No differences were noted in patient characteristics except that OM patients had a higher prevalence of neuropathy (66.7% versus 39.5%, p = .02). OM patients required surgery more often (97.8% versus 67.4%, p.01), a greater number of surgeries (2.0 ± 1.2 versus 1.4 ± 1.3, p = .02), and more amputations (75.6% versus 11.6%, p.01) than STI patients. OM patients had a higher proportion of wounds that healed (82.2% versus 62.8%, p = .04). There were no significant differences in reinfection (35.6% versus 25.6%, p = .36), foot-related readmission to hospital (35.6% versus 23.3%, p = .25), or total duration of antibiotics (13.9 ± 10.2 versus 13.5 ± 12.9, p = .87) between OM and STI patients. In conclusion, OM patients required more surgeries and amputations than patients with STIs; however, they had similar rates of reinfection and readmission within a year after the index hospitalization.

Background Fetal alcohol spectrum disorders (FASD) are preventable adverse outcomes consequent to prenatal alcohol exposure. Supplemental choline confers neuroprotection to the alcohol-exposed offspring, but its actions outside the brain are unclear. We previously reported that prenatal exposure of mice to 4.5 g/kg of alcohol decreased placental weight in females only, but decreased body weight and liver-to-body weight ratio and increased brain-to-body weight ratio in both sexes. Here we test the hypotheses that a lower alcohol dose will elicit similar outcomes, and that concurrent choline treatment will mitigate these outcomes. Methods Pregnant C57BL/6J mice were gavaged with alcohol (3 g/kg; Alc) or maltodextrin (MD) from embryonic day (E) 8.5-17.5. Some also received a subcutaneous injection of 100 mg/kg choline chloride (Alc + Cho, MD + Cho). Outcomes were evaluated on E17.5. Results Alc dams had lower gestational weight gain than MD; this was normalized by choline. In males, Alc decreased placental weight whereas choline increased placental efficiency, and Alc + Cho (vs. MD) tended to further reduce placental weight and increase efficiency. Despite no significant alcohol effects on these measures, choline increased fetal body weight but not brain weight, thus reducing brain-to-body weight ratio in both sexes. This ratio was also lower in the Alc + Cho (vs. MD) fetuses. Alc reduced liver weight and the liver-to-body weight ratio; choline did not improve these. Placental weight and efficiency correlated with litter size, whereas placental efficiency correlated with fetal morphometric measurements. Conclusions Choline prevents an alcohol-induced reduction in gestational weight gain and fetal body weight and corrects fetal brain sparing, consistent with clinical findings of improvements in alcohol-exposed children born to mothers receiving choline supplementation. Importantly, we show that choline enhances placental efficiency in the alcohol-exposed offspring but does not normalize fetal liver growth. Our findings support choline supplementation during pregnancy to mitigate the severity of FASD and emphasize the need to examine choline's actions in different organ systems.

Severe foot and ankle deformities can be associated with high complication rates and impaired quality of life in patients. Surgical correction using a talectomy procedure has previously been described in many lower extremity pathologies and is a powerful tool for the correction of severe foot and ankle deformity. This study aimed to describe the role of talectomy and the outcomes of this procedure in patients presenting with severe foot and ankle deformity. A review of 45 patients undergoing talectomy by a single surgeon was completed. Data extracted included the cause of deformity, history of infection, body mass index, and relevant comorbidities. Outcome measures of interest were minor or major complications and limb functionality at final follow-up. Statistical analysis was performed by using a Wilcoxon rank sum test and a Fisher exact test looking at variables affecting selected outcome measures. Limb salvage occurred in 38 of 45 patients (84.4%). Patients with an infection history had 89% lower odds of a functional limb at final follow-up (p = .0389). Six of 7 patients (85.7%) who ultimately underwent amputation had a history of prior infection. Women had 8.25 times higher odds of having a functional limb compared with men (p = .047). All 13 patients with major complications had neuropathy (p = .024). Patients with chronic lower extremity deformities can successfully be treated with a talectomy as a part of the reconstructive procedure. This is a challenging patient population that is associated with a high complication rate. Patients with a history of infection should be counseled on the possibility of requiring major amputation.

The objective of the study was to evaluate the effect of the erbium:yttrium aluminum garnet (YAG) laser on diabetic foot ulcers (DFUs) that had not responded to standard care. We retrospectively evaluated 22 nonhealing DFUs that received at least 4 weeks of standard wound care, demonstrated poor healing response, and subsequently were treated with an erbium:YAG laser. We measured the percent wound area reduction (PWAR) for the 4 weeks before initiating laser therapy and the PWAR for 4 weeks after the initiation of laser therapy. Erbium:YAG laser treatment consisted of 2 components: debridement and resurfacing. The laser settings were the same for all treatments. We used the paired t test to compare pretreatment with posttreatment wound area reduction. During the 4-week period before the initiation of laser therapy, the average PWAR was –33.6%. Four weeks after initiating treatment with the erbium:YAG laser, the average PWAR was 63.4% (p = .002) and 72.7% of wounds had ≥50% PWAR. By 12 weeks, 50% of wounds had healed. Erbium:YAG laser therapy accelerated DFU healing in a cohort of patients with ulcers that had been unresponsive to standard of care therapy.

Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.

Background We provide evidence to revise the Infectious Diseases Society of America (IDSA) diabetic foot infection classification by adding a separate tier for osteomyelitis and evaluating if moderate and severe infection criteria improve the classification’s ability to direct therapy and determine outcomes. Methods We retrospectively evaluated 294 patients with moderate and severe infections. Osteomyelitis was confirmed by bone culture or histopathology. Soft tissue infection (STI) was based on negative bone culture, magnetic resonance imaging, or single-photon emission computed tomography. We stratified STI and osteomyelitis using IDSA criteria for moderate and severe infections and compared outcomes and complications. Results Osteomyelitis patients had greater antibiotic duration (32.5 ± 46.8 vs 63.8 ± 55.1 days; P < .01), surgery frequency (55.5% vs 99.4%; P < .01), number of surgeries (2.1 ± 1.3 vs 3.3 ± 2.3; P < .01), amputations (26.3% vs 83.4%; P < .01), reinfection (38.0% vs 56.7%; P < .01), and length of stay (14.5 ± 14.9 vs 22.6 ± 19.0 days; P < .01). There were no differences in moderate and severe STI outcomes except for infection readmissions (46.2% vs 25.0%; P = .02), and acute kidney injury (31.2% vs 50.0%; P = .03). There were no differences in moderate and severe osteomyelitis except the number of surgeries (2.8 ± 2.1 vs 4.1 ± 2.5; P < .01) and length of stay (18.6 ± 17.5 vs 28.2 ± 17.7; P < .01). Conclusions The IDSA classification better reflects outcomes if risk categories are stratified by STI or osteomyelitis and moderate and severe infections are not categorized separately.

Background Distinguishing osteomyelitis from soft-tissue infection of the foot is important because osteomyelitis is associated with more operations, amputation, and prolonged antibiotic exposure. Both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are routinely ordered inflammatory biomarkers for evaluating foot infection. When initial evaluation is inconclusive, advanced imaging is indicated, and high clinical or radiographic suspicion of osteomyelitis may indicate bone biopsy to identify organisms and antibiotic sensitivity. Although ESR and CRP levels are helpful for distinguishing osteomyelitis from soft-tissue infections in patients with diabetes-related foot infections, parameters regarding optimal cutoff values for those tests have not, to our knowledge, been defined. Questions/purposes (1) What are the optimal cutoff values for ESR and CRP to differentiate osteomyelitis from soft-tissue infection in patients with diabetes-related foot infection? (2) Can a diagnostic algorithm be derived to guide interpretation of ESR and CRP to improve recognition of osteomyelitis in the setting of diabetic foot infection? Methods The medical records of 1842 patients between 18 and 89 years of age treated at our institution between January 1, 2010 and February 6, 2017 for foot infection were reviewed. For inclusion, patients must have had a diagnosis of diabetes mellitus, moderate or severe infection, ESR and CRP values within 72 hours of admission, either advanced imaging (MRI or single-positron emission computed tomography/computed tomography [SPECT/CT]) or bone biopsy during admission and must not have had comorbidities that could affect ESR and CRP, such as autoimmune disorders. As such, 1489 patients were excluded, and 353 patients were included in the study. Osteomyelitis was diagnosed by positive bone culture or histopathology. Osteomyelitis was considered to be absent if there was a negative MRI or SPECT/CT result, or negative bone culture and histology findings if imaging was inconclusive. We identified 176 patients with osteomyelitis and 177 with soft-tissue infection. A blinded investigator performed the statistics. Optimal cutoffs of ESR and CRP were determined using receiver operative characteristic (ROC) analysis. A diagnostic algorithm was determined using epidemiologic principles of screening evaluations. Results An ESR of 60 mm/h and a CRP level of 7.9 mg/dL were determined to be the optimal cutoff points for predicting osteomyelitis based on results of the ROC analysis. The ESR threshold of 60 mm/h demonstrated a sensitivity of 74% (95% confidence interval [CI], 67-80) and specificity of 56% (95% CI, 48-63) for osteomyelitis, whereas the CRP threshold of 7.9 mg/dL had a sensitivity of 49% (95% CI, 41-57) and specificity of 80% (95% CI, 74-86). If the ESR is 60 mm/h and CRP level is > 7.9 mg/dL, the likelihood of osteomyelitis is high, and treatment of suspected osteomyelitis should be strongly considered. Conclusions While ESR is better for ruling out osteomyelitis initially, CRP helps distinguish osteomyelitis from soft-tissue infection in patients with high ESR values. Further prospective studies addressing the prognostic value of ESR and CRP are needed, and a more comprehensive diagnostic algorithm should be developed to include other diagnostic tests such as probe-to-bone and imaging. Level of evidence Level III, diagnostic study.

The aim of the study was to assess the diagnostic value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels in differentiating foot osteomyelitis (OM) from soft tissue infection (STI) in persons without diabetes. We evaluated 102 patients in a retrospective cohort study of nondiabetic patients admitted to our institution with OM (n = 51) and with STI (n = 51). Patient diagnosis was determined through bone culture and/or histopathology for OM and magnetic resonance scan and/or single-photon emission computed tomography for STI. Cutoffs for ESR and CRP to predict OM as identified by receiver operating characteristic were 45.5 mm/h and 3.45 mg/dL, respectively. The ESR cutoff demonstrated a sensitivity and specificity of 49% and 79%, while the values for CRP were 45% and 71%, respectively. The combined sensitivity and specificity for ESR and CRP were 33% and 84%. The positive and negative predictive values were 68% and 60% for ESR and 61% and 56% for CRP, respectively. In conclusion, ESR and CRP demonstrate poor sensitivity and specificity for detecting OM in the nondiabetic foot. These markers have little diagnostic utility in the nondiabetic foot.

Aim Radiographs (X-rays) are used for the preoperative assessment of hallux valgus (HV). Our purpose was to determine how well quantitative measurements of HV on radiographs and MRI correlate with the qualitative soft tissue and internal derangement findings on MRI. Materials and methods After IRB approval, 56 consecutive patients with MRI and radiographs of the foot were retrospectively reviewed. Two trained readers independently evaluated radiographs, measuring hallux valgus angle (HVA) and intermetatarsal angle (IMA). Two separate readers assessed qualitative MRI data by evaluating 21 different soft tissue and bony features. Statistical analysis included inter-reader reliability (IRR) and correlation of quantitative and qualitative findings. Results Excellent IRR (ICC = 0.89–0.96) was observed for radiograph and MRI measurements of the hallux valgus severity. For qualitative assessments on MRI, IRR was good to excellent for all features (ICC = 0.63–0.9). No significant difference was found for HVA or IMA between normal and abnormal qualitative MRI features. No statistically significant correlation between the severity of hallux valgus and injury to hallux joints and supporting structures was found. Conclusion Hallux valgus measurements are reliable on x-rays and MRI and qualitative findings of 1st MTP joint show good to excellent inter-reader agreement on MRI. No statistically significant correlations exist between the severity of hallux valgus and qualitative MRI findings.

IntroductionIncreasing evidence suggests that plantar shear forces and related stresses play a major role in diabetic foot ulcerations. Several orthotic devices are commercially available to reduce plantar shear forces within the shoe. The biomechanical efficacy of these devices was not test

Displaced intra-articular calcaneal fractures are severe, complex injuries that can cause significant long-term functional impairment. Despite the controversies of whether these fractures should be treated operatively or nonoperatively, functional improvement can be seen with confounding variables that can be controlled by the surgeon. This article reviews prognostic factors that are associated with good functional outcomes following operatively treated displaced intra-articular calcaneal fractures.

Lower extremity necrotizing fasciitis (NF) is a severe infection requiring immediate surgery. The aim of this study was to assess patient factors predictive of amputation and mortality in diabetes mellitus (DM) and non-DM patients with lower extremity NF. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was reviewed retrospectively. Out of 674 patients with lower extremity NF, 387 had DM (57.4%). Patients with DM had lower mortality ( P = .004). Increased mortality was independently associated with age >60 years (adjusted odds ratio [aOR] = 3.96, 95% confidence interval [CI] = 1.69-9.77), partial thromboplastin time >38 seconds (aOR = 2.66, 95% CI = 1.09-6.62), albumin

Osteomyelitis is a common complication in diabetic foot ulcers. Accurate and early detection of diabetic foot osteomyelitis (DFO) is key to optimizing clinical outcomes and avoiding amputation. Using bone biopsy histopathology as the gold diagnostic standard, we evaluate the sensitivity and specificity of radiolabeled white blood cell imaging combined with CT (99mTc-WBC SPECT/CT) for the evaluation of DFO. We also assess the ability of the inflammatory markers CRP and ESR to predict osteomyelitis diagnosis by 99mTc-WBC SPECT/CT imaging. Subjects with diabetes and foot ulcerations presenting to a large tertiary care facility were examined by podiatry. Of the 48 subjects who consented to participation, 44 completed imaging, labwork, and underwent biopsy. Serum CRP and ESR were collected within three days of consent. In all cases, WBC imaging studies were performed prior to biopsy. The WBC SPECT/CT scans were read by an experienced Nuclear Medicine radiologist. Pathology was performed in the hospital laboratory and interpreted by a pathologist experienced in MSK infections. SPECT/CT and pathology reads were coded as either positive or negative for osteomyelitis. Sensitivity and specificity of 99mTc-WBC SPECT/CT for DFO diagnosis was 90.9% and 73.7%, respectively. WBC imaging had a PPV of 80.0%, and 87.5% NPV (n=41). CRP and ESR serum levels were grouped according to positive or negative DFO diagnosis as determined by WBC scan. Neither CRP (p=0.9895) nor ESR levels (p=0.8382) were correlated with DFO diagnosis based on WBC imaging results. Using bone biopsy results as the reference standard, radiolabeled 99mTc-WBC SPECT/CT demonstrates sensitivity for DFO. However, CRP and ESR were not found to be predictive in the diagnostic interpretation of 99mTc-WBC SPECT/CT imaging for the diagnosis of DFO. Disclosure A. Sherwood: None. L. A. Lavery: None. O. K. Oz: n/a. K. L. Rubitschung: None. A. L. Killeen: None. P. Crisologo: None. K. Grigoropoulos: None. A. Pajouh: None. J. Kep: None. D. Wukich: Consultant; Self; Orthofix Medical Inc., Wright Medical Group, Other Relationship; Self; Arthrex, Inc. J. La fontaine: None. Funding American Diabetes Association (1-17-ICTS-056 to O.K.O.)

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.

Total knee arthroplasty (TKA) is a very common orthopedic procedure and stiffness is a common complication following TKA. There is extensive data regarding timing and success of Manipulation under anesthesia (MUA) for stiffness following TKA. However, Studies reporting outcome following MUA have often focused on the improvement in ROM and improvement in functional score with very few studies reporting on the revision risk.In this study we retrospectively reviewed PearlDiver insurance database and analyzed the characteristics of the patient undergoing MUA after TKA. We also analyzed the risk of revision at 2 years in a cohort of MUA patients who were matched to patients without MUA.Our study identified 9156 patients who underwent MUA within one year following TKA. MUA was slightly more common in females and risk of manipulation decreases with increasing age. Comparative analysis showed that at two years, patients in the matched MUA cohort (538 patients, 5.99%) were 2.9 times more likely to undergo revision TKA compared to the matched non MUA group (194, 2.16%)OR 2.88 (95% CI-2.44 to 3.41), P 0.05 CONCLUSION: Retrospective database review showed that the risk of revision is higher in patients undergoing MUA after TKA and hence patient should be counselled about the possibility of revision in the future.

Aim This systematic review evaluated the surgical outcomes of various ankle fracture treatment modalities in patients with Diabetes Mellitus as well as the methodological quality of the studies. Methods For our review, four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). The overall methodological quality of the studies was assessed with the Coleman Methodology Score. Data regarding diabetic ankle fractures were pooled into three outcomes groups for comparison: (1) the standard fixation cohort with management of diabetic ankle fractures using ORIF with small or mini fragment internal fixation techniques following AO principles, (2) the minimally invasive cohort with diabetic ankle fracture management utilizing percutaneous cannulated screws or intramedullary fixation, and (3) the combined construct cohort treated with a combination of ORIF and another construct (transarticular or external fixation). Results The search strategy identified 2228 potential studies from the four databases and 11 were included in the final review. Compared to the standard fixation cohort, the minimally invasive cohort had increased risk of hardware breakage or migration and the combined constructs cohort had increased risk of hardware breakage or migration, surgical site infection and nonunion. Limb salvage rates were similar for the standard fixation and minimally invasive cohorts; however, the combined constructs cohort had a significantly lower limb salvage rate compared to that of the standard fixation cohort. The mean Coleman Methodology Score indicated the quality of the studies in the review was poor and consistent with its limitations. Discussion The overall quality of published studies on operative treatment of diabetic ankle fractures is low. Treating diabetic ankle fractures operatively results in a high number of complications regardless of fixation method. However, limb salvage rates remain high overall at 97.9% at a mean follow-up of 21.7 months. To achieve improved limb salvage rates and decrease complications, it is critical is to follow basic AO principles, respect the soft tissue envelope or utilize minimally invasive techniques, and be wary that certain combined constructs may be associated with higher complication rates. Level of evidence 2.

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.

Objective: To investigate the predictive value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in persons with and without diabetes with osteomyelitis (OM). Methods: We evaluated 455 patients in a retrospective cohort study of patients admitted to the hospital with diabetic foot OM (n = 177), diabetic foot soft-tissue infections (STIs) (n = 176), nondiabetic OM (n = 51), and nondiabetic STIs (n = 51). Infection diagnosis was determined through bone culture, histopathologic examination for OM, and/or imaging (magnetic resonance imaging/single-photon emission computed tomography) for STI. The optimal cutoff values of ESR and CRP in predicting OM were determined by receiver operating characteristic curve analysis. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were determined through contingency tables. Results: In persons without diabetes with STI or OM, the mean ESR and CRP differences were 10.0 mm/h and 2.6 mg/dL, respectively. In contrast, persons with diabetes had higher levels of each: 24.8 mm/h and 6.8 mg/dL, respectively. As a result, ESR and CRP predicted OM better in patients with diabetes. However, when patients were stratified by neuropathy status, ESR remained predictive of OM in diabetic patients with neuropathy (75% sensitivity, 58% specificity) but not in diabetic patients without neuropathy (50% sensitivity, 44% specificity). Also, CRP remained predictive irrespective of neuropathy status. A similar trend was observed in patients without diabetes. Conclusions: Previous studies have reported that ESR and CRP are predictive of OM. However, this study suggests that neuropathy influences the predictive value of inflammatory biomarkers. The underlying mechanisms require further study.

Necrotizing fasciitis is a condition associated with high morbidity and mortality unless emergent surgery is performed. This study aims to understand the hospital course of diabetic and nondiabetic patients managed for lower-extremity necrotizing fasciitis by identifying factors contributing to readmissions and reoperations. About 562 patients treated for lower-extremity necrotizing fasciitis were selected from the American College of Surgeons-National Surgical Quality Improvement Program database between 2012 and 2017. The unplanned reoperation and readmission rates for all patients during the 30-day postoperative period were 9.4% and 5.3%, respectively. Out of 562 patients with lower-extremity necrotizing fasciitis, 326 (58.0%) patients had diabetes. Diabetes patients were more likely to undergo amputation (p.00001). Neither readmission (6.1% vs 4.2%, p = .411) nor reoperation (8.6% vs 10.6%, p = .482) were significantly different between patients with and without diabetes. Neither readmission (7.2% vs 4.0%, p = .159) nor reoperation (4.1% vs 3.7%, p = .842) were significantly different between patients undergoing amputation and nonamputation procedures. In simple logistic regression, factors associated with unplanned reoperation included poorer renal function, thrombocytopenia, longer duration of surgery, longer hospital length of stay, postoperative surgical site infection, postoperative respiratory distress, and postoperative septic shock. Body mass index30 kg/m

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a uniplanar metatarsal osteotomy approach in which the metatarsal is cut and shifted over in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be fully addressed with a uniplanar metatarsal osteotomy. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion has historically involved an extended period of non-weightbearing. This study evaluates the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot are eligible for this study. Patients are treated with an TTA procedure using a biplanar plating system with protected near-immediate weightbearing. Outcomes (radiographic, range of motion (ROM), pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), return to weightbearing and activities) are evaluated post-operatively. Two independent musculoskeletal radiologists reviewed radiographic data. These interim results are limited to patients completing at least 6 weeks of follow-up. Results: At time of data cut-off, 74 patients had undergone TTA with at least 6 weeks follow-up. The majority of patients were women (95%) with mean age 41.7 years. The mean (95% confidence interval) time to protected weightbearing in CAM boot was 8.0 (6.4, 9.7) days, return to work was 19.0 (13.6, 24.4) days, and return to full work was 31.5 (22.7, 40.2) days. There was a significant change in radiographic measures pre vs. post procedure and changes were maintained over time (Table). VAS pain score decreased 4 and 6 months post-procedure by 3.9 (3.2, 4.6) and 4.2 (3.5, 5.0), respectively. The mean MOxFQ Index Score pre-procedure was 53.3 (49.5, 57.1) and at month 6 had decreased to 18.6 (12.9, 24.2). Conclusion: These interim findings support that TTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing and demonstrated favorable clinical and patient-reported outcomes. Patients were able to return to full, unrestricted work and activities within just a few months and had meaningful pain reduction after surgery. Patients will continue to be followed for up to 60 months. Clinical/radiographic healing at 12 months and recurrence rates at 24 months, as well as complications and patient satisfaction, will be evaluated. [Table: see text]

Background Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. Questions/purposes To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. Methods A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. Results The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. Conclusions Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. Level of evidence Level II, economic and decision analysis.

Background: The optimal therapeutic approach for people suffering with unstable Charcot arthropathy of the midfoot is unclear. The purpose of this study was to examine the cost-effectiveness of three competing treatment strategies for adults suffering with unstable, midfoot Charcot arthropathy. Methods: A Markov model was utilized to compare Charcot reconstruction (CR), primary transtibial amputation (TTA) and lifetime bracing in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated ulcer, and infected ulcer. Data regarding costs and probabilities were obtained from available literature. Primary outcomes included long-term costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). Willingness-to-pay was set at $100,000 USD. Results: TTA failed to show cost-effectiveness in comparison to other strategies available. Lifetime bracing was cost-effective in all clinical scenarios, with ICERs ranging from $6,970 to $15,010. CR was also cost-effective in the non-ulcerated and ulcerated scenarios, and offered the greatest potential for maximal QALYs gained, but failed to show value in the infected ulcer scenario. For CR to be cost-effective in the infected ulcer scenario, costs of surgery would need to lessen to $40,000 or complication rates would need to remain under 50%. The results in the non-ulcerated and ulcerated cohorts were robust to multiple sensitivity analyses. Conclusion: Bracing is a cost-effective option in all stages of Charcot arthropathy while CR appears to be only cost-effective when performed early (i.e., in the non-ulcerated and uncomplicated ulcerated patient). An opportunity for shared-decision making exists in the early stages of Charcot arthropathy, where patient goals and expectations may be assessed while multiple cost-effective options are still available. Disclosure A.E. Fleischer: None. R.H. Albright: None. D.G. Armstrong: None. D. Wukich: Consultant; Self; Orthofix, Wright Medical. Other Relationship; Self; Arthrex.

Over the past 2 decades, an increased number of diabetic Charcot neuroarthropathy reconstructions have been performed. Despite advances in implant technology, arthrodesis complication rates remain high. This study examined the biomechanical properties (4-point bending, cantilever bending, and thread pullout resistance) of intramedullary implants designed for midfoot reconstruction. Large implants included A1 (7.4 mm cannulated stainless steel beam), B1 (6.5 mm solid titanium bolt), and C1 (7.0 mm cannulated titanium beam). Smaller implants included A2 (5.4 mm cannulated stainless steel beam) and C2 (5.0 mm solid titanium bolt). Four-point bending testing compared flexural properties of the body of the implants. Cantilever-bending testing was performed with the maximum bending moment being applied off the main thread of the implant to assess the thread portion. Thread pullout strength was tested by fixing the implants to a Sawbone block on a platform, and the distal portion of the implant in a clamp connected to loading actuator. Implant A1 demonstrated higher stiffness, force to failure, and fatigue compared to implants B1 and C1 (p < .05). Pullout strength of implant A1 was higher than implant B1 (p < .05). Thread fatigue strength of implant A1 was higher than implant C1 (p < .05). Implant A2 demonstrated higher stiffness, force to failure, tip fatigue strength, and thread pullout strength compared to implant C2 (p < .05), while implant C2 demonstrated higher body fatigue failure than implant A2 (p < .05). Alteration of beam/bolt parameters influences the biomechanical performance of implants used in Charcot reconstruction. Greater stiffness resists deformation, providing improved stability. Greater static failure load and fatigue limit improves the implant's ability to withstand higher and repetitive loads before failing This study should stimulate further clinical research to determine if these biomechanical properties translate into reduced implant failure rates and improved clinical outcomes in patients with diabetic Charcot neuroarthropathy.

The traditional Total Contact Cast (TCC) is considered the gold standard for treating plantar diabetic ulcers. A number of prefabricated TCC kits have been introduced, which offer a user-friendly casting process for health care providers. Our objective was to evaluate pressure reduction and gait characteristics after application of a TCC kit (TCC-EZ) and traditional TCC. Fifteen individuals (9 males, 6 females; median age of 51.5 years [range = 40.5-71.2 years]) completed 30-m walking trials while fitted with TCC-EZ and TCC in a randomized order. A pair of automated wireless photogate sensors captured time to traverse the distance and pedobarographic insoles measured and recorded plantar pressures. Paired t tests were used to compare peak pressure, gait speed, and cast weights across the 2 modalities. Peak pressure and cast weight were significantly lower in the TCC-EZ arm (169.6 ± 41.3 kPa vs 214.9 ± 63.2 kPa, P = .0048; and 1.79 ± 0.17 kg vs 2.11 ± 0.25 kg, P = .0004). Contact area and gait speed were not significantly different between the 2 modalities (140.4 ± 25.8 cm2 vs 126.9 ± 37.8 cm2, P = .0228, Cohen’s d = 0.40; and 0.94 ± 0.19 m/s vs 0.83 ± 0.26 m/s, P = .0532, Cohen’s d = .48). TCC-EZ was found to provide more favorable pressure distributions compared with TCC. TCC-EZ is also lighter and may be a preferred treatment modality for patients. More research is necessary to reveal the clinical effectiveness of prefabricated total contact kits.

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/mm3 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

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1–A38. doi:10.2519/jospt.2018.0302

In a multicenter randomized controlled trial (RCT), the use of viable cryopreserved placental membrane (vCPM) for chronic diabetic foot ulcers (DFUs) resulted in a higher proportion of wound closure in comparison to good wound care: 62% versus 21% (p 50% wound area reduction by week 4 and wound closure by week 12. The results of this study mirror previous RCT efficacy data, supporting the benefits of vCPM for DFU management. These results can also influence policy and treatment decisions regarding advanced vCPM technology.

The aim of this study was to assess whether systemic inflammatory response syndrome (SIRS) is correlated with outcomes in diabetic foot infections (DFIs). We retrospectively reviewed 137 diabetic patients admitted to the hospital with Infectious Diseases Society of America moderate and severe DFIs. We used SIRS criteria to define severe infection based on the presence of at least 2 of the following: heart rate >90 bpm, temperature >38°C or 20 breaths per minute, and white blood cell count >12,000/mm3 or

Introduction Charcot neuroarthropathy (CN) is an inflammatory arthropathy associated with bony destruction, dislocation, and deformity in patients with neuropathy. Surgical procedures involving foot and ankle in CN for deformity correction have been shown to result in high rate of complications. The purpose of this study was to compare post-operative outcomes and assess odds of complication after ankle arthrodesis among patients with diabetes-related Charcot neuroarthropathy, non-Charcot patients with diabetes, and non-Charcot patients without diabetes. Methods The PearlDiver Patient Records Database was queried for patients who underwent ankle fusion and maintained at least one year of post-operative follow-up. The following post-operative complications were assessed among groups: overall nonunion and amputation, one-year nonunion, amputation, and hardware removal, 90-day and 30-day surgical site infection, dehiscence, acute kidney injury, and pneumonia, and 90-day myocardial infarction and deep vein thrombosis. The odds and prevalence of each complication for each group were assessed and compared. Results Higher rates of amputation (OR 3.43, CI 2.89–4.06), hardware removal (OR 1.63, CI 1.45–1.83), wound dehiscence (OR 1.75, CI 1.44–2.13), acute kidney injury (OR 2.87, CI 2.32–3.54), pneumonia (OR 1.53, CI 1.13–2.07), and surgical site infection (OR 2.46, CI 2.12–2.85), were observed in patients with diabetes-related CN compared to non-Charcot patients with diabetes. In patients without CN, higher rates of nonunion (OR 1.38, CI 1.19–1.61), amputation (OR 2.26, CI 1.74–2.93), surgical site infection (OR 1.57, CI 1.30–1.90), and acute kidney injury (OR 1.57, CI 1.18–2.09) were observed in patients with diabetes compared to patients without diabetes. Time to hardware removal was significantly shorter in diabetes-related Charcot patients compared to non-Charcot patients without diabetes (368.0 ± 446.7 vs 438.5 ± 487.5 days, P Conclusion Patients with diabetes demonstrated increased odds of nonunion, amputation, surgical site infection, and acute kidney injury compared to patients without diabetes. In the population of patients with diabetes, odds of most of these complications were further increased with the addition of Charcot diagnosis compared to patients without diabetes. Other local and multisystemic medical conditions, including pneumonia and wound dehiscence, also demonstrated increased odds in patients of CN. Level of evidence: Cohort study; Level of evidence, 3.

Purpose The purpose of this paper is to examine factors affecting the relationship between annual changes in the amount of corporate foundation giving and changes in corporate reputation. The factors investigated included the existing corporate reputation and the economic conditions. Design/methodology/approach Published data were obtained for 77 US corporations during both an upward and downward economic trend. Data for corporate foundation giving were obtained from IRS tax records while data on corporate reputation were obtained from the Reputation Institute’s RepTrak scores. Findings Linear mixed model analyses demonstrated that a firm’s prior reputation moderates the relationship between corporate philanthropy and changes in corporate reputation during a downward trend. That is, changes in corporate charitable giving and corporate reputation covaried positively for firms with an existing favorable reputation. However, for firms with an unfavorable reputation, there was an inverse relationship between changes in corporate giving and corporate reputation. The interaction between the variables was prevalent only during an economic downturn. Practical implications The findings provide firms with relevant information on conditions that affect how changes in charitable giving are likely to impact corporate reputation. Originality/value This study is the first to look at the effects of annual changes in corporate charitable giving on corporate reputation and adds to the research literature by demonstrating the complexity of the relationship by identifying two key factors that should be taken into considerations when developing annual budgets for charitable giving.

Patient-reported outcomes (PROs) have become an important subject in the area of diabetes-related foot complications. Self-reported health-related quality of life (HRQOL) surveys can provide a generic measure of overall health (global) and can be disease specific (i.e., diabetes) or even region specific (i.e., lower-extremity function). Analysis of PRO measures utilizing validated instruments allows health care providers to determine whether medical and surgical treatments are providing patients with the highest level of outcome possible and are actually improving HRQOL. The 36-item Short Form (SF-36), EuroQol five-dimension questionnaire (EQ-5D-5L), and Foot and Ankle Ability Measure (FAAM) are examples of commonly used HRQOL surveys. Low HRQOL has been associated with higher rates of hospital admission and mortality in patients with diabetes. Previous studies have demonstrated that patients with diabetes-related foot disease have low self-reported physical quality of life but do not typically report low mental quality of life. The impact of mental quality of life may be underestimated in these patients using the SF-36. In this article, we will discuss several widely used outcome instruments used to measure patient HRQOL and the impact of diabetic foot disease on HRQOL. As health care providers, we must continue to adjust and modify our treatments to achieve the best patient outcomes and associated high quality of life. Assessing PROs will become increasingly important as health care systems transition from a volume-based reimbursement model to a value-based model.

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.

Peroneal tendon pathology is an important cause of lateral ankle pain and instability. Typical peroneal tendon disorders include tendinitis, tenosynovitis, partial and full thickness tendon tears, peroneal retinacular injuries, and tendon subluxations and dislocations. Surgery is usually indicated when conservative treatment fails. Familiarity with the peroneal tendon surgeries and expected postoperative imaging findings is essential for accurate assessment and to avoid diagnostic pitfalls. Cross-sectional imaging, especially ultrasound and MRI provide accurate pre-operative and post-operative evaluation of the peroneal tendon pathology. In this review article, the normal anatomy, clinical presentation, imaging features, pitfalls and commonly performed surgical treatments for peroneal tendon abnormalities will be reviewed. The role of dynamic ultrasound and kinematic MRI for the evaluation of peroneal tendons will be discussed. Normal and abnormal postsurgical imaging appearances will be illustrated.

The aim of this study was to evaluate the impact of end-stage renal disease (ESRD) on health-related quality of life (QOL) in patients with diabetic foot disease. We compared a group of 30 diabetic patients with ESRD requiring dialysis to a group of 60 diabetic patients without ESRD. Both groups consisted of patients with active diabetic foot disease (ulcer, Charcot, infection) and were matched with regard to age and gender. Self-reported QOL was assessed using the Short Form-36 (SF-36) physical and mental component summary (PCS and MCS) scores and the region-specific Foot and Ankle Ability Measure (FAAM). Diabetic foot patients with ESRD requiring dialysis were found to have significantly higher creatinine levels, lower hemoglobin levels, lower albumin levels, higher rates of peripheral arterial disease, and lower rates of Charcot neuroarthropathy than patients without ESRD. The median PCS was significantly lower in the ESRD group; however, no significant difference was found when comparing the median MCS and FAAM. Patients who ultimately died had a tendency to report lower PCS scores at baseline compared with those patients who did not die ( P = .07). Patients who ultimately required major amputation also reported lower PCS scores at baseline. ESRD negatively affects physical QOL to a greater degree than mental QOL in patients with diabetic foot disease. The SF-36 may not be sensitive enough to capture impaired mental QOL because both groups had relatively high MCS scores. Low physical QOL may be associated with mortality and the eventual need for major amputation.

Surgery for acute and chronic diabetic foot problems has long been an integral component of care. While partial foot amputations remain as important diabetic limb-salvaging operations, foot-sparing reconstructive procedures have become equally important strategies to preserve the functional anatomy of the foot while addressing infection, chronic deformities, and ulcerations. A classification of types of diabetic foot surgery is discussed in accordance with the soft tissue status and acuity of the presenting foot problem. This brief overview from the Association for Diabetic Foot Surgeons describes common conditions best treated by surgical interventions, as well as specific indications. While techniques and indications continue to evolve, effective surgical management of the diabetic foot remains an integral component of care as well as for the prevention of recurrent ulceration.

Category: Ankle, Ankle Arthritis Introduction/Purpose: During the last twenty years, studies comparing total ankle replacement (TAR) and ankle arthrodesis (AA) appear to demonstrate lower complication rates with TAR than with AA. However, advances in implant technology and surgical techniques have dramatically reduced complication rates. As a result, studies comparing TAR and AA require more patients to detect differences in rare events. Despite this, few epidemiologic studies have been performed examining short-term outcomes after TAR and AA using a contemporary patient population. The purpose of the current study was to compare perioperative outcomes after TAR and AA using patient data from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database between 2012 and 2017. Methods: We reviewed patient data from ACS-NSQIP database collected between 2012 and 2017 using Current Procedural Terminology (CPT) codes 27700 (TAR), 27702 (TAR), 29899 (AA) and 27870 (AA). Patients were then excluded if they were treated for fractures, infections, non-foot or ankle-related conditions or had revision procedures. Patients were also excluded if they were older than 90 years as ACS-NSQIP does not report age above 90 years. The study population included those treated in inpatient and outpatient settings. The main outcomes of interest were readmission and reoperation related to initial surgery, surgical site complications and hospital length of stay (LOS). Predictors of adverse outcomes were evaluated through multivariate regression of patient demographics, comorbidities and treatment characteristics. Results: Out of 1214 patients included in the study, 187 (15.4%) patients were treated with AA, and 1027 (84.6%) underwent TAR. Patients with AA were younger, had higher body-mass index, higher white blood cell count, more often had diabetes mellitus (DM) treated with insulin, received more dialysis treatment, had higher anesthesia risk classification and were treated in the outpatient setting more often than patients with TAR. Among outcomes, AA patients had longer hospital LOS, more deep surgical site infections and more reoperations than TAR patients. Post-operative readmissions were not significant but were higher in AA patients (2.7% vs. 0.9%, p=0.101). Combining these adverse outcomes, multivariate regression revealed that higher anesthesia risk category (p=0.0007), DM (p=0.029) and AA (p=0.049) had positive correlations with adverse outcomes. Conclusion: Ankle arthrodesis appears to be independently associated with perioperative complications compared to TAR, consistent with previous reports. Although complications were rare, patients with DM and higher anesthesia risk seem to be important factors to consider. Interestingly, patients with DM had fewer adverse outcomes with TAR than AA (3.8% vs. 7.4%). The difference was even greater in DM patients treated with insulin (4.3% vs. 13.3%) although only 38 patients had DM controlled with insulin in the cohort. Further studies are needed to identify patient populations at risk of complications, specifically those with DM.

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Hallux valgus is a complex deformity of the great toe and is a major cause of pain for patients. Despite the variety of techniques, traditional osteotomies often do not address rotational deformities. A novel biplanar plating system was used to perform correction of metatarsal rotation at our institution starting in 2017. The purpose of this study was to determine the correction of rotational deformity and of radiographic parameters, maintenance of this correction (versus recurrence of hallux valgus), complication rates and patient-reported objective survey scores. We sought to determine prognostic factors for successful correction, including age, gender, and time of surgery. Methods: By retrospective chart review, we identified all patients treated by the novel biplanar plating at our institution. We recorded patient demographics, pre-operative range of motion and maltracking, surgical details, operative complications, and any subsequent surgery. Imaging was reviewed at pre-operative and post-operative visits to approximate the hallux valgus angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (TSP). Outcome scores (AOFAS, FAAM, SF12 PCS and MCS) pre- operatively and post-operatively at 3 months, 6 months and 12 months were also recorded. The changes in these radiographic parameters and scores were then computed and analyzed to determine if there was an improvement with surgery. Results: Fifty-seven procedures (in 55 patients) were performed and evaluated. There were 8 complications and average follow- up time was 27.1 weeks (+13.8 weeks). Older age was significantly associated with more complications (p = 0.018). Gender and time of surgery did not show any significant association with complications. Radiographic parameters including HVA, IMA, and TSP were analyzed. At 3 and 6 months post-operatively, these parameters were significantly reduced from pre-operative values. At 12 months, there was a trend towards significant reduction (p values of 0.06, 0.06, and 0.053 respectively); however, there were fewer patients who maintained follow-up during this period. The Outcome scores showed improvement post-operatively, but only the AOFAS score showed statistical significance at 3 and 6 months. Conclusion: Although statistical analysis was limited due to our population size and the retrospective nature of the study, there was an overall improvement in both radiographic parameters and clinical outcome scores. Older patients are also at higher risk of complications. Malrotation correction with this biplanar plating system is a novel technique and does require meticulous training. With continued expansion of our patient database and further longitudinal analysis, we hope to determine not only if correction is maintained over time, but also if the steepness of the learning curve affects the number of complications earlier versus later in each individual surgeon’s experience.

Category: Diabetes, Midfoot/Forefoot Introduction/Purpose: Charcot neuroarthropathy (CN) is a complication of neuropathy secondary to diabetes mellitus (DM) and may involve multiple joints of the foot, in particular the midfoot. Patients with CN deformity associated with infection, ulceration or pre-ulceration are at risk of losing their limb. In these patients, reconstruction of the foot structure through beaming arthrodesis screws for stabilization is often required. In addition to midfoot beaming, previous reports have advocated for subtalar arthrodesis. Fixation of the subtalar joint restricts motion of the hindfoot. This rigid fixation has been hypothesized to offer greater stability and fewer hardware failures. The aim of this study was to describe failure of midfoot beaming screws after midfoot reconstruction of CN with and without subtalar arthrodesis. Methods: We retrospectively reviewed patients with DM diagnosed with CN. Patient radiographs were evaluated for type of midfoot Charcot reconstruction and hardware failure. Patients included in the study had follow up of 3 months or more. The main outcome variable of interest was hardware breakage. Results: Eighteen patients who underwent midfoot reconstruction for CN were included. The average age was 52.7 years (±8.4 years), 10 (55.6%) were male, and the average body-mass index (BMI) was 35.8 kg/m2 (±10.3 kg/m2). The average follow-up time was 6.5 months (±3.7 months). In the current series, thirteen out of 18 (72.2%) patients underwent subtalar fusion along with midfoot fusion. Screw breakage occurred in two patients, one at the 1st tarsometarsal joint and 2nd-4th tarsometarsal screws in another patient at 9 and 6 months respectively. Both patients with screw breakage had subtalar fusion. A third patient who had subtalar fusion subsequently developed collapse of their talus leading to subtalar screw removal 3 months after initial surgery. Patients without subtalar fusion did not experience screw breakage. Conclusion: An extended medial column fixation with subtalar arthrodesis has been previously proposed to provide better fixation after midfoot CN reconstruction with beaming screws as it restricts motion of the hindfoot. However, little to no evidence has been reported in favor of this technique. Our findings suggest that subtalar arthrodesis may result in fixation that is too rigid, which may place the beaming screws at higher risk of breakage. However, the number of observations is a limitation of our study, and further investigation comparing these techniques is needed to fully evaluate the effect of subtalar arthrodesis on midfoot beaming outcomes.

Aims The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations. Methods Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients. Results Major amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively. Conclusions Although short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.