Outcomes of open reduction and internal fixation of calcaneus fractures: A database study comparing patients with and without diabetes.

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

Complications of periprosthetic fracture revision vs aseptic revision of total knee arthroplasty.

Background: Periprosthetic fractures after total knee arthroplasty (TKA) are a challenging problem due to complex fracture patterns, poor bone quality, and a high-risk patient population. Treatment of both periprosthetic fractures and aseptic complications can include revision TKA. In this study, we compared systemic and orthopaedic complications following periprosthetic fracture associated revision TKA to aseptic revision TKA. Methods: This is a retrospective cohort study using data from the years 2010-2020 from a national administrative claims database. Billing codes were used to identify revision TKAs with a diagnosis of periprosthetic fracture or aseptic complications (loosening, dislocation, arthrofibrosis, osteolysis, or prosthetic wear) within one year prior to revision. Pertinent systemic complications and rates of repeat revision TKA, periprosthetic infection, and repeat fractures were compared between the two groups. Results: We identified 9891 periprosthetic fracture associated revision TKAs and 47,071 aseptic revision TKAs. Our study found higher rate of systemic complications including AKI, DVT, wound disruption, hematoma, and surgical site infections in periprosthetic fracture associated revision TKA compared to aseptic revision TKA. Furthermore, we found higher rates of repeat revision TKA, periprosthetic infections, and repeat periprosthetic fractures in fracture associated revision TKA group compared to aseptic revision group. Conclusions: Our work highlights the significant short- and long-term complications associated with periprosthetic fracture associated revision TKA. Future working comparing functional outcomes and optimal surgical techniques are needed.

MRSA infection, re-infection and clinical outcomes in diabetic foot infections.

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

Obesity Increases Risk for Wound Complications After Pediatric Foot Surgery: A Retrospective Cohort Review Using the NSQIP-Pediatric Database.

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

Correlation Between Traditional Anteroposterior Radiographic Measurements With Lateral Radiographic Measurements Following Triplanar Correction of Hallux Valgus and With Patient-Reported Outcomes From a Prospective Multicenter Trial.

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

Success of transmetatarsal amputation for limb salvage in patients with peripheral artery disease.

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

Racial variations in complications and costs following total knee arthroplasty: a retrospective matched cohort study.

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

Charcot neuroarthropathy in persons with diabetes: It's time for a paradigm shift in our thinking.

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

Clinical Risk Factors of Perioperative Pressure Injury in Older Adult Patients with a Hip Fracture.

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

Outcomes of Surgically Treated Pilon Fractures: A Comparison of Patients with and without Diabetes.

OBJECTIVES: Compare systemic complications, fracture healing related complications, and reoperation rates for pilon fractures in patients with and without diabetes. DESIGN: Retrospective cohort study. SETTING: National administrative claims database with patient records. PATIENTS: Patients from the years 2016 to 2020 with surgically treated closed or open pilon fractures. INTERVENTION: Patients with either closed or open pilon fractures with diabetes were compared to those without diabetes. Subgroup analysis was performed on diabetic patients with and without neuropathy. OUTCOMES: Postoperative systemic complications at 90 days, fracture healing complications at 90 days and 1 year, and reoperative rates at 90 days and 1 year. RESULTS: 2,654 (31.4%) patients with closed fractures and 491 (28.7%) patients with open fractures had a diagnosis of diabetes. In both open and closed fractures, we identified significantly higher rates of acute kidney injury, cardiac arrest, and surgical site infection in diabetic patients compared to non-diabetic patients. Additionally, we found significantly higher rates of below knee amputations in diabetic patients. Diabetic patients with closed fractures had significantly higher rates of wound healing related reoperations. Patients with advanced diabetic disease, as suggested by the presence of neuropathy, had higher rates of nonunions and post-traumatic arthritis. CONCLUSIONS: The data presented here provides updated estimates on complication rates in pilon fractures using large sample size. Additionally, our work identifies differences in outcomes for patients with and without diabetes following pilon fracture surgery. Our data suggests that patients with severe diabetes are prone to higher rates of healing complications and may benefit from additional therapeutic support. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total knee arthroplasty in dialysis patients: a national in-patient sample-based study of perioperative complications.

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

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.

Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus (IWGDF 2023).

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

Diagnosis and treatment of active charcot neuro-osteoarthropathy in persons with diabetes mellitus: A systematic review.

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

Definitions and criteria for diabetes-related foot disease (IWGDF 2023 update).

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

Interreader reliability assessment of hallux valgus evaluation on dorsoplantar weightbearing radiographs from a prospective multi-center trial and correlation with patient-reported outcome measures.

OBJECTIVE: To determine inter-reader reliability (IRR) of hallux valgus (HV) related parameters, i.e. intermetatarsal angle (IMA), hallux valgus angle (HVA), lateral round sign of the first metatarsal, tibial sesamoid position (TSP), metatarsus adductus angle (MAA), transverse osseous foot width, 1st MT length, MTP osteoarthritis (OA), and distal metatarsal articular angle (DMAA). These were correlated with patient-reported outcome measures (PROMs). MATERIALS AND METHODS: A prospective single-arm Level 3 multicenter clinical trial in which standardized radiographs and PROMs were collected at the time of the initial patient visit for pre-operative assessment. Two musculoskeletal radiologists performed measurements blinded to each other's reads and clinical information. Intraclass coefficient and kappa were obtained for inter-reader analysis. A partial spearman rank order was used to correlate the measurements with PROMs. RESULTS: The final cohort size of 183 patients had mean age of 40.77 years, mean body mass index was 26.11 kg/m2, with 91.2% females and 8.7% males. There was excellent IRR for HVA (0.96, CI: [0.94,0.97]), IMA (0.92, CI: [0.89,0.94]), transverse osseous foot width (0.99, CI: [0.98,1.00]), and DMAA (0.80, CI: [0.74, 0.85]), good agreement for TSP (0.73, CI:[0.67,0.79]) and MAA (0.67, CI: [0.16, 0.84]), fair agreement for MTP OA (0.48, CI: [0.36,0.59]), and poor agreement for lateral round sign (0.32, CI: [0.11, 0.52]. The negative correlation of increasing transverse osseous foot width with worsening PROMIS physical but better MOxFQ and VAS scores is likely spurious. CONCLUSION: Good to excellent inter-reader reliability was observed for the most often used measurements for HV assessment without major trends in their correlations with PROMs. Lateral round sign is not a reliable finding in HV deformity.

Total Hip Arthroplasty in Nonagenarians - A National In-Patient Sample-Based Study of Perioperative Complications.

Background: Nonagenarians are a rapidly expanding population in the United States. These patients are met with increasing rates of hip arthritis, necessitating the need for total hip arthroplasty (THA). However, there is currently limited information on hospitalization information and perioperative complications in this population. Methods: In this retrospective study, we used the Nationwide Inpatient Sample (NIS) database from 2016-2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing THAs who were categorized as nonagenarians, and those who were not. Results: The NIS database identified 309 100 patients who underwent THAs from 2016-2019. Of those, 1864 patients (.6%) were nonagenarian, while the remaining 307 236 patients were included under the non-nonagenarian category (control). The mean age in the nonagenarian group was 90 years compared to the control group which had a mean age of 65.8 years. There was an increased incidence of mortality rate (nonagenarian group .2%, control group .03%, P < .001), myocardial infarction (MI) (nonagenarian group .1%, control group .02%, P = .01), acute renal failure (ARF) (nonagenarian group 5.4%, control group 1.6%, P < .001), blood anemia post-operatively (nonagenarian group 28.9%, control group 17.2%, P < .001), and deep vein thrombosis (DVT) (nonagenarian group .48%, control group .07%, P < .001) in the nonagenarian group. The COC for the nonagenarian group was higher than that in the control group (P < .001). The mean LOS was longer in the nonagenarian group (3.1 days) in comparison to the control group (1.96 days) (P < .001). Conclusions: Nonagenarians had significantly higher rates of both orthopedics and medical complications than the younger patients undergoing THAs. In addition, the nonagenarian group incurred higher COC. This information is useful for the providers to make informed decisions regarding patient care and resource utilization for nonagenarian patients undergoing THAs.

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.

Comparison of Short-Term Outcomes After Total Ankle Replacement and Ankle Arthrodesis: An ACS-NSQIP Database Study.

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.