Fractures and dislocations of the foot and ankle in people with diabetes: a literature review.

Diabetes (DM) increases fracture risk, and bone quality depends on type diabetes type, duration, and other comorbidities. Diabetes is associated with a 32% increased relative risk (RR) of total fractures and 24% increased RR of ankle fractures compared with patients without DM. Type 2 DM is associated with a 37% increased RR of foot fractures compared with patients without DM. The incidence of ankle fractures in the general population is 169/100,000 per year, while foot fractures occur less frequently, with an incidence of 142/100,000 per year. Biomechanical properties of bone are negatively impacted by stiff collagen, contributing to the increased risk of fragility fractures in patients with DM. Systemic elevation of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNFα), interleukin-1ß (IL-1ß), and interleukin 6 (IL-6), impact bone healing in patients with DM. Fractures in patients with DM, can be associated with poorly regulated levels of RANKL (receptor activator of nuclear transcription factor kappa-b ligand) leading to prolonged osteoclastogenesis, and net bone resorption. One of the most salient factors in treating fractures and dislocations of the foot and ankle is to recognize the difference between patients with uncomplicated and complicated DM. Complicated diabetes is defined as 'end organ damage', and for the purposes of this review, includes patients with neuropathy, peripheral artery disease (PAD) and/or chronic renal disease. Uncomplicated diabetes is not associated with 'end organ damage'. Foot and ankle fractures in patients with complicated DM pose challenges, and surgery is associated with increased risks of impaired wound healing, delayed fracture healing, malunion, infection, surgical site infection, and revision surgery. While patients with uncomplicated DM can be treated like patients without DM, patients with complicated DM require close follow-up and robust fixation methods should be considered to withstand the anticipated prolonged healing period. The aims of this review are as follows: (1) to review pertinent aspects of DM bone physiology and fracture healing, (2) to review the recent literature on treatment of foot and ankle fractures in patients with complicated DM, and (3) to provide treatment protocols based on the recent published evidence.

Ankle Joint Salvage for Rigid Flatfoot Deformity.

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

Identifying Risk Factors for Nonunion of the Modified Lapidus Procedure for the Correction of Hallux Valgus.

There is a paucity of literature characterizing risk factors for nonunion associated with the modified Lapidus procedure for correction of hallux valgus. The purpose of this study was to evaluate risk factors associated with nonunion for Lapidus bunionectomies. Patients who underwent modified Lapidus procedure from 2009 to 2018 were retrospectively reviewed. Patient's age, sex, body mass index, prior bunionectomy, history of tobacco use, presence of diabetes mellitus or hypothyroidism, and fixation method were recorded along with pre- and postoperative radiographic parameters. A multiple logistic regression analysis was implemented to estimate the odds of nonunion. Of the 222 patients who met inclusion criteria, nonunion with modified Lapidus procedure was observed in 20 patients (9.01%). Odds of nonunion with modified Lapidus procedure were greater for patients who had undergone previous bunionectomy (odds ratio [OR] = 3.957, 95% confidence interval [CI]: 1.021-15.338), as body mass index increased (OR = 1.091, 95% CI: 1.018-1.170), and as preoperative HV angle increased (OR = 1.108, 95% CI: 1.020-1.203). Odds of nonunion were lower for patients as preoperative intermetatarsal angle increased (OR = 0.739, 95% CI: 0.580-0.941). No significant increased odds of nonunion were found between fixation methods.

The Impact of Hospitalization for Diabetic Foot Infection on Health-Related Quality of Life: Utilizing PROMIS.

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.

Risk Factors for Short-Term Complication After Open Reduction and Internal Fixation of Ankle Fractures: Analysis of a Large Insurance Claims Database.

Although fractures of the ankle are common injuries treated by surgical podiatrists and orthopaedic surgeons specializing in foot and ankle surgery, postoperative complications can occur, often imposing an economic burden on the patient. As health care in the United States moves toward value-based care, cost reduction has primarily focused on reducing complications and unplanned episodes of care. We used a large modern database of insurance claims to examine patterns of complications after open reduction internal fixation of ankle fractures, identifying diabetes mellitus and history of myocardial infarction as risk factors for postoperative infection within 30 days of surgery. Lateral malleolar repair was less likely to lead to infection, or need for repeated surgery, than was medial malleolar fracture repair. Diabetes mellitus, neuropathy, and chronic obstructive pulmonary disease were associated with development of postoperative cellulitis. Patients with a history of cerebrovascular accident were more likely to return to the emergency department or to have a pulmonary embolism. Male sex, presence of lupus, and increased age were associated with repeat surgery.