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1.
Foot Ankle Spec ; 16(3): 300-306, 2023 Jun.
Article in English | MEDLINE | ID: mdl-34713739

ABSTRACT

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.


Subject(s)
Arthroplasty, Replacement, Ankle , Humans , Arthroplasty, Replacement, Ankle/adverse effects , Arthroplasty, Replacement, Ankle/methods , Surgical Wound Infection/etiology , Quality Improvement , Ankle , Arthrodesis/adverse effects , Arthrodesis/methods , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Retrospective Studies
2.
J Foot Ankle Surg ; 61(6): 1334-1340, 2022.
Article in English | MEDLINE | ID: mdl-35701302

ABSTRACT

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.

3.
J Diabetes Complications ; 36(7): 108222, 2022 07.
Article in English | MEDLINE | ID: mdl-35717355

ABSTRACT

AIMS: To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications. METHODS: 478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy. RESULTS: Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation. CONCLUSION: Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.


Subject(s)
Arthropathy, Neurogenic , Diabetes Mellitus , Diabetic Foot , Amputation, Surgical/adverse effects , Arthropathy, Neurogenic/complications , Blindness/complications , Diabetes Mellitus/etiology , Diabetic Foot/complications , Diabetic Foot/epidemiology , Diabetic Foot/surgery , Fear , Foot , Humans
4.
J Foot Ankle Surg ; 61(6): 1308-1316, 2022.
Article in English | MEDLINE | ID: mdl-35613971

ABSTRACT

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.

5.
Arthrosc Tech ; 11(3): e427-e434, 2022 Mar.
Article in English | MEDLINE | ID: mdl-35256987

ABSTRACT

Soft tissue impingement and arthrofibrosis of the fourth and fifth tarsometatarsal joints can be a source of intractable pain and functional impairment. Arthroscopic debridement of the fourth and fifth tarsometatarsal joints is a minimally invasive method that can provide clinical relief from soft tissue impingement pathologies associated with trauma and degenerative joint disease. Arthroscopic landmarks, four-point arthroscopic inspection, and operative technique will be reviewed.

6.
J Foot Ankle Surg ; 61(6): 1235-1239, 2022.
Article in English | MEDLINE | ID: mdl-35307157

ABSTRACT

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.

7.
J Foot Ankle Surg ; 61(1): 132-138, 2022.
Article in English | MEDLINE | ID: mdl-34373115

ABSTRACT

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 index >30 kg/m2 was associated with decreased odds of readmission. In multiple logistic regression, surgical site infection was the only predictor of reoperation (adjusted odds ratio 7.32, 95% confidence interval 2.76-19.1), and any amputation was associated with readmission (adjusted odds ratio 4.53, 95% confidence interval 1.20-29.6). Further study is needed to understand patient characteristics to better direct management. However, the current study elucidates patient outcomes for a relatively rare condition.


Subject(s)
Diabetes Mellitus , Fasciitis, Necrotizing , Databases, Factual , Fasciitis, Necrotizing/surgery , Humans , Lower Extremity/surgery , Patient Readmission , Postoperative Complications/epidemiology , Postoperative Complications/surgery , Reoperation , Retrospective Studies , Risk Factors
8.
J Foot Ankle Surg ; 60(5): 917-922, 2021.
Article in English | MEDLINE | ID: mdl-33947590

ABSTRACT

Patients with diabetes mellitus that undergo ankle fracture surgery have higher rates of postoperative complications compared to patients without diabetes mellitus. We evaluated the rate of complications in insulin-dependent diabetes mellitus patients, non-insulin-dependent diabetes mellitus patients, and patients without diabetes in the 30-day postoperative period following ankle fracture surgery. We also analyzed hospital length of stay, unplanned readmission, unplanned reoperation, and death. Patients who underwent operative management for ankle fractures between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database using Current Procedural Terminology codes. Multiple logistic regression was implemented. Adjusted odds ratios were calculated along with the 95% confidence interval. A total of 19,547 patients undergoing ankle surgery were identified from 2012 to 2016. Of these patients, 989 (5.06%) had insulin-dependent diabetes mellitus, 1256 (6.43%) had noninsulin-dependent diabetes mellitus, and 17,302 (88.51%) did not have diabetes mellitus. Compared to patients without diabetes, patients with insulin-dependent diabetes mellitus had significantly greater adjusted odds of superficial surgical site infections, deep surgical site infections, osteomyelitis, wound dehiscence, pneumonia, unplanned intubation, mechanical ventilation, urinary tract infection, cardiac arrest, bleeding requiring transfusion, sepsis, hospital length of stay, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery. We demonstrate that insulin-dependent diabetes mellitus is a strong predictor of 30-day postoperative complications, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery.


Subject(s)
Ankle Fractures , Diabetes Mellitus , Ankle Fractures/surgery , Humans , Insulin , Patient Readmission , Postoperative Complications/epidemiology , Retrospective Studies , Risk Factors
9.
J Foot Ankle Surg ; 60(3): 440-447, 2021.
Article in English | MEDLINE | ID: mdl-33612405

ABSTRACT

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.


Subject(s)
Prostheses and Implants , Stainless Steel , Biomechanical Phenomena , Equipment Failure , Humans , Materials Testing , Titanium
10.
J Foot Ankle Surg ; 60(3): 461-465, 2021.
Article in English | MEDLINE | ID: mdl-33558095

ABSTRACT

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.


Subject(s)
Bunion , Hallux Valgus , Orthopedic Procedures , Female , Hallux Valgus/diagnostic imaging , Hallux Valgus/surgery , Humans , Male , Middle Aged , Retrospective Studies , Treatment Outcome , Weight-Bearing
11.
J Foot Ankle Surg ; 60(3): 432-435, 2021.
Article in English | MEDLINE | ID: mdl-33549422

ABSTRACT

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.


Subject(s)
Arthropathy, Neurogenic , Diabetes Mellitus , Arthropathy, Neurogenic/diagnostic imaging , Humans , Reproducibility of Results
12.
J Foot Ankle Surg ; 59(6): 1219-1223, 2020.
Article in English | MEDLINE | ID: mdl-32950368

ABSTRACT

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.


Subject(s)
Arthropathy, Neurogenic , Diabetic Foot , Subtalar Joint , Arthrodesis , Arthropathy, Neurogenic/diagnostic imaging , Arthropathy, Neurogenic/surgery , Foot , Humans , Subtalar Joint/diagnostic imaging , Subtalar Joint/surgery
13.
J Foot Ankle Surg ; 59(6): 1229-1233, 2020.
Article in English | MEDLINE | ID: mdl-32921562

ABSTRACT

The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort.


Subject(s)
Arthropathy, Neurogenic , Diabetes Mellitus , Diabetic Foot , Peripheral Arterial Disease , Arthropathy, Neurogenic/surgery , Cohort Studies , Diabetes Mellitus/epidemiology , Humans
14.
Clin Podiatr Med Surg ; 36(3): 469-481, 2019 Jul.
Article in English | MEDLINE | ID: mdl-31079611

ABSTRACT

Reconstruction of the diabetic Charcot foot can be a challenge even for the most experienced foot and ankle surgeon. The first portion of this article discusses the preoperative evaluation with an emphasis on factors that can be modified before surgical reconstruction to help optimize surgical results. The second portion of the article focuses on intraoperative methods and techniques to help improve postoperative outcomes. Surgeons should strive to provide high-quality, cost-effective care by optimizing patient selection and perioperative care. Objective measures of patient outcomes will become increasingly important with the transition from volume-based to value-based care.


Subject(s)
Arthropathy, Neurogenic/surgery , Diabetic Foot/surgery , Ankle Brachial Index , Anti-Bacterial Agents/therapeutic use , Blood Pressure , Calcium Phosphates/therapeutic use , Diabetic Foot/diagnostic imaging , Glycated Hemoglobin/analysis , Humans , Informed Consent , Medical History Taking , Orthopedic Procedures , Physical Examination , Platelet-Derived Growth Factor/therapeutic use , Postoperative Care , Postoperative Complications/prevention & control , Toes/blood supply , Vitamin D/blood
15.
Clin Podiatr Med Surg ; 36(3): 499-523, 2019 Jul.
Article in English | MEDLINE | ID: mdl-31079613

ABSTRACT

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.


Subject(s)
Diabetes Complications , Fracture Healing , Fractures, Bone/surgery , Lower Extremity/surgery , Bone Remodeling , Cardiovascular Diseases/complications , Diabetic Neuropathies/complications , Glycated Hemoglobin/analysis , Glycation End Products, Advanced/metabolism , Humans , Hyperglycemia/complications , Hyperglycemia/prevention & control , Inflammation/complications , Kidney Diseases/complications , Lower Extremity/injuries , Peripheral Arterial Disease/complications , Quality Assurance, Health Care , Quality Indicators, Health Care , Reactive Oxygen Species/metabolism , Stress, Physiological , Vitamin D Deficiency/complications
16.
Int J Low Extrem Wounds ; 18(2): 114-121, 2019 Jun.
Article in English | MEDLINE | ID: mdl-30929530

ABSTRACT

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 <2.0 mg/dL (aOR = 2.84, 95% CI = 1.13-7.37), coagulopathy (aOR = 3.29, 95% CI = 1.24-9.19), higher anesthesia risk category (aOR = 3.08, 95% CI = 1.18, 8.59), chronic obstructive pulmonary disease (aOR = 3.46, 95% CI = 1.13-10.9), postoperative acute respiratory distress syndrome (aOR = 5.24, 95% CI = 2.04-14.4), and postoperative septic shock (aOR = 5.14, 95% CI = 1.94-14.1). Amputation was independently associated with DM (aOR = 4.35, 95% CI = 2.63-7.35) but not mortality. Although DM was associated with more amputations for lower extremity NF, patients with DM had lower mortality than non-DM patients in the bivariate analysis. Further research is needed to investigate outcomes among DM and non-DM patients in the context of lower extremity NF.


Subject(s)
Amputation, Surgical/mortality , Amputation, Surgical/statistics & numerical data , Diabetes Mellitus/epidemiology , Fasciitis, Necrotizing/surgery , Lower Extremity/surgery , Age Factors , Aged , Databases, Factual , Diabetes Mellitus/diagnosis , Diabetes Mellitus/surgery , Fasciitis, Necrotizing/diagnosis , Fasciitis, Necrotizing/epidemiology , Female , Humans , Incidence , Logistic Models , Lower Extremity/physiopathology , Male , Middle Aged , Multivariate Analysis , Postoperative Complications/mortality , Predictive Value of Tests , Prognosis , Reference Values , Retrospective Studies , Risk Assessment , Sex Factors , Survival Analysis , United States
17.
J Foot Ankle Surg ; 58(2): 226-230, 2019 Mar.
Article in English | MEDLINE | ID: mdl-30850094

ABSTRACT

Open reduction internal fixation (ORIF) is an accepted treatment for displaced tarsometatarsal joint (TMTJ) fracture dislocations. In general, hardware is routinely removed after 4 months to allow restoration of joint motion and avoid complications of hardware failure. Because few studies report outcomes of TMTJ fractures with retained hardware, there is little consensus regarding the optimal time for hardware removal or if hardware retention leads to adverse outcomes. We retrospectively reviewed the radiographic outcomes of retained hardware after ORIF of TMTJ fractures/dislocations in 61 patients. The mean age at the time of operation was 37.3 ± 14.9 years. ORIF was performed with 3.5 fully threaded cortical screws. Assessment of clinical and radiographic results was performed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgical treatment. Out of the 61 patients that were included in this study, only 2 demographic variables demonstrated a trend for an adverse outcome. Older age correlated with lost reduction and elevated body mass index correlated with hardware failure. The presence of diabetes was correlated with an increased risk of postoperative infection but not hardware failure. During our follow-up period there were 49 patients (80.3 %) without failure of fixation. In conclusion, our study suggests that routine removal of hardware following open reduction and internal fixation of Lisfranc injuries in patients may not be necessary.


Subject(s)
Device Removal/methods , Foot Injuries/surgery , Fracture Dislocation/surgery , Fracture Fixation, Internal/methods , Fracture Healing/physiology , Tarsal Joints/injuries , Adult , Aged , Female , Foot Injuries/diagnostic imaging , Fracture Dislocation/diagnostic imaging , Fracture Fixation, Internal/adverse effects , Humans , Internal Fixators , Logistic Models , Male , Middle Aged , Multivariate Analysis , Open Fracture Reduction/adverse effects , Open Fracture Reduction/methods , Postoperative Complications/physiopathology , Postoperative Complications/therapy , Prognosis , Retrospective Studies , Risk Factors , Tarsal Joints/diagnostic imaging , Tarsal Joints/surgery , Tertiary Care Centers , Trauma Centers , Treatment Outcome
18.
J Foot Ankle Surg ; 58(3): 470-474, 2019 May.
Article in English | MEDLINE | ID: mdl-30760411

ABSTRACT

The purpose of this study was to compare the rates of readmission, reoperation, and mortality in patients with and without diabetes mellitus during the 30-day postoperative period after ankle fracture surgery. Patients who underwent operative management for ankle fractures between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database by using Current Procedural Terminology codes for ankle fracture surgery. A total of 17,464 patients undergoing ankle fracture surgery were identified. Of these patients, 2044 (11.7%) had diabetes and 15,420 (88.3%) did not have diabetes. We excluded patients older than 90 years or with inadequate perioperative data. Patients with diabetes had significantly higher rates of readmission (2.84% vs 1.05%, p < .0001), significantly higher rates of unplanned reoperation (2.3% vs 0.74%, p < .0001), and significantly higher rates of mortality (0.7% vs 0.2%, p < .0001) compared with patients without diabetes. Additionally, patients with diabetes had significantly greater age-adjusted odds ratios (ORs) of unplanned readmission (OR 2.40, 95% confidence interval [CI] 1.74 to 3.31, p < .0001), unplanned reoperation (OR 2.56, 95% CI 1.44 to 3.27, p < .0001), and mortality (OR 2.01, 95% CI 1.08 to 3.62, p = .0432) than did patients without diabetes after ankle surgery. In this large-scale retrospective study, we demonstrated that the presence of diabetes significantly increases the risk of unplanned readmission, unplanned reoperation, and mortality during the 30-day postoperative period after ankle fracture surgery.


Subject(s)
Ankle Fractures/surgery , Diabetes Mellitus/epidemiology , Mortality , Patient Readmission/statistics & numerical data , Reoperation/statistics & numerical data , Age Distribution , Aged , Amputation, Surgical/statistics & numerical data , Ankle Fractures/epidemiology , Cohort Studies , Comorbidity , Debridement/statistics & numerical data , Female , Fracture Fixation, Internal , Glucocorticoids/therapeutic use , Humans , Hypertension/epidemiology , Kidney Failure, Chronic/epidemiology , Length of Stay/statistics & numerical data , Male , Middle Aged , Obesity/epidemiology , Open Fracture Reduction , Postoperative Complications/epidemiology , Pulmonary Disease, Chronic Obstructive/epidemiology , Retrospective Studies , Sex Distribution , United States/epidemiology
19.
Clin Podiatr Med Surg ; 36(2): 173-184, 2019 Apr.
Article in English | MEDLINE | ID: mdl-30784529

ABSTRACT

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.


Subject(s)
Calcaneus/injuries , Fracture Fixation, Internal , Intra-Articular Fractures/surgery , Calcaneus/surgery , Humans , Treatment Outcome
20.
Foot Ankle Spec ; 12(5): 439-451, 2019 Oct.
Article in English | MEDLINE | ID: mdl-30537872

ABSTRACT

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.


Subject(s)
Amputation, Surgical/adverse effects , Amputation, Surgical/methods , Kidney Function Tests , Metatarsus/surgery , Renal Insufficiency, Chronic/complications , Renal Insufficiency, Chronic/diagnosis , Treatment Failure , Aged , Disease Progression , Early Diagnosis , Female , Humans , Male , Middle Aged , Postoperative Complications/prevention & control , Predictive Value of Tests , Renal Insufficiency, Chronic/prevention & control , Reoperation/statistics & numerical data , Retrospective Studies , Risk Factors
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