The International Working Group on the Diabetic Foot (IWGDF)/Infectious Disease Society of America (IDSA) classification system of diabetes-related foot infection (DFI) severity requires a severe infection to have the systemic inflammatory response syndrome (SIRS). Subsequent attempts to improve this classification system to include other clinically relevant characteristics (eg, necrosis and osteomyelitis) have not reliably predicted patient outcomes such as amputation. The purpose of this study was to propose an improved classification system based on clinically relevant predictors of amputation at our institution. This was a single-center, retrospective cohort study of 270 unique patients with 346 DFIs. We determined the association between clinical characteristics of each DFI (eg, cellulitis, abscess, necrosis, osteomyelitis, and SIRS) and amputation within 90 days of presentation. We derived a new severity classification system based on the presence of necrosis and compared the performance of this classification system to the IWGDF/IDSA classification system. Our "necrosis classification system" predicted that mild, moderate, and severe DFI had a 20% (95% confidence interval [CI] 2%, 38%), 40% (95% CI [33%, 47%]), and 74% (95% CI [64%, 84%]) risk of amputation within 90 days of presentation, respectively, and discriminated between moderate and mild, and severe and moderate DFI. The IWGDF/IDSA classification system predicted that mild, moderate, and severe DFI had a 29% (95% CI [9%, 49%]), 43% (95% CI [36%, 50%]), and 54% (95% CI [44%, 63%]) risk of amputation within 90 days of presentation, respectively, and did not discriminate between moderate and mild, or severe and moderate DFI. This necrosis classification system discriminated the risk of amputation at 90 days better than the IWGDF/IDSA classification system. Our new classification system may have greater clinical relevance but needs to be validated to confirm its generalizability.Level of evidence: Level III: Retrospective comparative study.

BackgroundThree-Dimensional Distance and Coverage Mapping (DM and CM) generated through weightbearing CT (WBCT) can aid in understanding the complex articular relationship in hallux valgus (HV). Prior studies have demonstrated that subluxation can occur at the hallux metatarsophalangeal (MTP) and metatarsosesamoid articulation with greater deformities. Little is known however about these parameters at the level of the tarsometatarsal (TMT) joint, particularly as it relates to the concept of TMT instability as a cause for HV. The purpose of this study is to evaluate DM and CM characteristics at the first TMT joint through WBCT in a cohort of HV patients relative to controls.MethodsTwenty-nine feet (14 left and 15 right) from 16 individuals (avg age of 56.6 ± 6.2 yrs) underwent WBCT. Twelve feet were clinically diagnosed with HV, without clinical evidence of TMT instability, and formed the experimental group, while the remaining 17 feet, absent of deformity, served as the control group. For distance maps, spatial relationship of the joint was assessed by sampling the surface of one bone and calculating the shortest distance to the opposing bone. A limit of 4 mm was set to ensure the analysis focuses on relevant anatomical gaps. For coverage maps, the region was defined along the longitudinal axis of the 1st metatarsal, with 10% of each end defined to be in contact with the opposing bone. The nearest distance was calculated for this region, with regions of 5 mm or less defined as covered and >5 mm defined as uncovered. Sagittal TMT 1 angle was calculated as a marker of TMT instability. Welch's t-test and Mann-Whitney U were used for statistical analysis.ResultsHallux valgus patients demonstrated significantly increased coverage along the dorsal lateral and plantar lateral quadrant of the MTP joint relative to controls (28.59%, P=.002 and 14.47%, P=.007, respectively) and decreased coverage along the dorsal medial and plantar medial quadrant (-42.63%, P=.002 and -46.69%, P<.001, respectively). No differences in distance mapping at the MTP joint or contact and distance mapping at the TMT joint were observed between groups (Table 1). Sagittal TMT 1 angle was higher in the HV group (1.36° vs 0.6°, P=.02).DiscussionThere is notable discrepancy in coverage at the MTP joint in HV patients relative to those without HV, consistent with subluxation of the hallux MTP joint in HV. Contrary to our hypothesis, no discernable difference was noted at the TMT joint with respect to DM and CM. While sagittal plane angulation was higher in HV, it did not result in appreciable changes in contact and distance mapping at the TMT joint.Level of EvidenceIII: Retrospective case control.

BackgroundThis study aimed to evaluate the prevalence and potential associations among lateral ankle sprains (LAS), recurrent LAS, chronic ankle instability (CAI), and CAI by criteria for clinical practice (CAI-C). Chronic ankle instability by criteria for clinical practice is a condition that meets CAI inclusion criteria but also falls under the exclusion criteria defined by the International Ankle Consortium (IAC). Chronic ankle instability by criteria for clinical practice represents a broader clinical definition of CAI.MethodsThis study was a descriptive epidemiological study of the prevalence of LAS, recurrent LAS, CAI, and CAI-C in sports disciplines. A total of 2,175 athletes (1,522 males and 653 females) from 12 sports were surveyed using a structured questionnaire incorporating the Japanese version of the Identification of Functional Ankle Instability. Classification was based on criteria from the IAC.ResultsThe results showed that 52.9% of the participants experienced LAS, and 36.2% had a recurrence. Among those with LAS history, 68.5% had recurrent episodes. Chronic ankle instability was observed in 17.9% of athletes, and CAI-C was present in 32.6%, nearly 1.8 times more prevalent than typical CAI. In particular, the prevalence of CAI-C was more than twice that of CAI in rugby football, cheerleading, and soccer. Furthermore, 90.0% of recurrent LAS cases progressed to CAI-C. Chronic ankle instability was most prevalent in basketball and handball, whereas CAI-C was prevalent not only in these sports but also in soccer and judo, based on adjusted residuals ≥1.96.ConclusionsWe found that the number of participants with CAI-C differed from that of participants with CAI. This finding suggests that CAI may not reflect the entire clinical population with CAI conditions. Therefore, it has been suggested that it is also necessary to identify CAI-C in clinical practice. These findings underscore and support the need to consider tailored prevention programs and clinical attention to at-risk sports to reduce the long-term impact of ankle instability in athletes.Levels of Evidence:Prognostic, Level IV: case series.

PurposeAcross the United States, there is a well-documented projected shortage of orthopaedic surgeons, including those with foot and ankle subspecialty training. We sought to better understand the current state of patient access to orthopaedic foot and ankle surgeons across region, socioeconomic metrics, and rural areas.MethodsIn this cross-sectional analysis, foot and ankle surgeons identified through the American Academy of Orthopaedic Surgeons (AAOS) website were assigned a county, and distribution trends were contextualized by socioeconomic factors, including insurance coverage rates, unemployment rates, poverty rates, and median household income. Surgeon and location data were sourced from September 2024 to November 2024 via the AAOS "Find a Surgeon" directory, with Doximity and Google searches conducted in the event of partially empty profiles.ResultsDisparities in the presence and availability of orthopaedic foot and ankle surgeons by region were identified, with 4 states having only a single orthopaedic foot and ankle surgeon. While the national average of orthopaedic foot and ankle surgeons per million people was 2.87, with the northeast and midwestern regions above this value, the southern and western regions were below the national average. Counties with at least one orthopaedic foot and ankle surgeon had greater median household incomes ($77 459.24 vs $60 682.49; P < .001) and lower poverty rates (11.67% vs 14.20%; P < .001).ConclusionsInequality in the distribution of orthopaedic foot and ankle surgeons is prevalent at the regional, state, and county levels, as well as by rurality and household income/poverty status. Strategies that implement early exposure and/or focused mentorship for the subspeciality in medical school and/or residency can be combined with targeted programs for those interested in the field who wish to practice in underserved areas.

IntroductionThis study evaluates the impact of implementing body mass index (BMI) cutoff points on 6-month postoperative outcomes following total ankle replacement (TAR).MethodsThe Nationwide Readmissions Database (NRD) was queried from 2015 to 2020 to identify 5865 patients undergoing primary elective TAR, stratified into groups by 5 BMI point intervals. Preoperative demographics, comorbidities, postoperative outcomes, and total length of stay (LOS) were analyzed between cohorts, with additional multivariate regression analyses conducted to control for predictors other than BMI.ResultsMultivariate regression analysis of 180-day postoperative outcomes found that preoperative BMI of 40 to 44.9 and ≥45 kg/m2 was significantly predictive of increased risk of overall complication, adverse discharge, and LOS greater than 4 days.ConclusionA BMI above 40 kg/m2 is associated with a significantly increased risk of complications (odds ratio [OR] = 1.960; P < .001), adverse discharge (OR = 2.030; P < .001), and extended LOS (OR = 2.171; P < .001).Levels of Evidence:Level III, Retrospective Cohort Study.

IntroductionThe purpose of this study is to assess the effect of race and ethnicity on the length of stay in hospitals following elective foot and ankle procedures. We aimed to determine whether (1) there are differences in the amount of time spent in a hospital following surgery between black, Hispanic, and white patients and (2) to assess for differences in complications.MethodsA retrospective review of the National Inpatient Sample (NIS) was conducted for 14 different foot and ankle procedures between 2016 and 2021. International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) and International Classification of Diseases, 10th Revision (ICD-10) codes guided the inclusion and exclusion criteria. Patient demographics, comorbidities, and postoperative outcomes and length of stay in hospitals were collected. A biostatistician was used to conduct all analyses. Regression analyses were used to assess differences between length of stay between races. Demographic variables, comorbidities and outcomes were analyzed using χ2 and Fisher exact tests.ResultsThe database search yielded 16,126 patients with a weighted sum of 84,085. White patients were older on average (61.98 years) than black patients (52.30), with an average length of stay of 3.08 days and black patients had an average of 3.35 days (P < .0001). Prevalence of pulmonary embolism, pneumonia, myocardial infarction, and stroke were not significantly different between the groups (P > .05).ConclusionOur study found that minority patients experience longer stays in the hospital following elective foot and ankle procedures. No differences were found between complication rates among the 2 groups. These findings suggest a need for further research into reasons for longer stays in this patient population.

Orthobiologics continues to advance in medicine due to its regenerative capabilities. In fact, there is a vast indication of use with regenerative medicine options such as platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) within the human body for various musculoskeletal conditions. While both options are different, the purpose of each is to promote a natural healing response with specific growth factors, proteins, or cells to aid in this. In this concept review, we present a current update on the literature surrounding these regenerative medicine options specifically with utilization in the foot and the ankle. We have found in our practice that regenerative medicine options offer our patients a nonoperative as well as operative biologic supplemental option for treatment on various foot and ankle conditions with relatively high success rates and overall high patient satisfaction. We hope this review educates the foot and ankle surgeon on this rapidly evolving treatment to enhance patient outcomes and improve quality of care.Levels of Evidence:4.

BackgroundThis study aims to investigate the validity of the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) as predictive tools for adverse outcomes following total ankle arthroplasty (TAA).MethodsThe Nationwide Readmissions Database (NRD) was queried from 2015 to 2020 to identify 29 705 patients undergoing primary TAA. Patients' comorbidity was measured via CCI and ECI scores, and patients who experienced adverse postoperative outcomes (any complication, readmission, mortality, extended length of stay (LOS), and adverse discharge) were identified.ResultsBoth the ECI and CCI comorbidity indices predicted mortality with excellent accuracy (Area under the Curve [AUC] = 0.88 for both). However, ECI outperformed CCI in predicting complications, extended LOS, and adverse discharge, although both had poor predictive capability for these outcomes.ConclusionThese findings indicate that while ECI and CCI are capable of predicting postoperative mortality following TAA, there is a need for alternative models that better predict other postoperative adverse outcomes.Level of Evidence:Level III; Retrospective cohort study.

Lateral intersection syndrome, or fibularis intersection syndrome, is an uncommon overuse condition affecting the lateral aspect of the foot involving the intersection of the peroneus longus and brevis tendons. While intersection syndromes have been described in other anatomic locations, such as the wrist and medial foot/ankle, this pathology remains underreported. This cadaveric study aimed to establish baseline anatomical measurements relevant to lateral intersection syndrome. Eight thawed fresh-frozen cadaveric lower limbs, 4 matched pairs, were dissected, and measurements of key lateral foot structures were recorded, including plantar fascia width, peroneus brevis width, the distance between the peroneus brevis and the plantar fascia, and the distance between the cuboid groove and the fifth metatarsal. The average (mean) plantar fascial width was 4.99 mm, whereas the peroneus brevis width averaged 6.64 mm. A notable laterality difference was identified, with right-sided specimens consistently showing larger measurements compared with the left. Limitations include a small sample size and the use of cadaveric models, which may not replicate in vivo tissues. This study serves as a foundational reference for further research into lateral intersection syndrome and highlights the need for increased clinical recognition of the pathology.Levels of evidence: Level IV Cadaveric Study.

We report the case of an 11-year-old boy with a late-presenting distal tibial Salter-Harris type 2 injury. Before approaching us, he had undergone 2 failed attempts of treatment (closed reduction with plaster cast application and closed reduction and K-wire fixation with plaster cast application). On the 13th day after the injury, the fracture was treated with a closed reduction and metaphyseal canulated cancellous screw fixation and plate fixation of the fibular fracture. At skeletal maturity (4.5 years after the surgery), there was no physeal growth arrest or deformity. We report a favorable outcome in a late-presenting distal tibial Salter-Harris type 2 physeal injury after surgical intervention, which was effective despite the delayed presentation and prior treatment failures.Level of Evidence: Level V.