Non-operative management of unstable ankle fractures in patients with diabetes results in an unacceptably high rate of complications. Operatively managed patients with uncomplicated diabetes seem to fair as well as patients without diabetes. Thus, it is important to recognize patients as either complicated or uncomplicated at the onset of their treatment based on comorbidities. There is limited evidence to guide the management of ankle fractures in patients with diabetes, in particular those deemed complicated. Non-operative management of unstable fractures in diabetic patients should be avoided.

Background: Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration. Methods: Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot. Results: Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7–47.0). Conclusions: Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.

Background: Numerous surgical approaches and treatments for Lisfranc pathology have been described and vary across physicians and surgical specialties. Many incisions to access the tarsometatarsal (TMT) joint complex have been described including single and dual longitudinal as well as transverse. The aim of this study was to retrospectively review and compare complication and fusion rates in patients with a Lisfranc open reduction and internal fixation or arthrodesis utilizing a nontraditional dual incision approach. Incisions were performed dorsal medial to the first TMT and dorsal along the second interspace just medial to the third TMT. Materials and Methods: The medical records of 1 foot and ankle surgeon were reviewed of patients who underwent Lisfranc surgery utilizing a dual incision approach for both elective and traumatic procedures. The study period encompassed January 2006 through December 2016. Statistical analysis was performed using information collected from chart-review as well as radiograph evaluation to examine predictors of complications and fusion rates. Results: Sixty-eight patients reviewed had the nontraditional dual dorsal incisions, 61 with TMT fusions for arthritis or injury, and 7 open reduction and internal fixation for TMT injuries. In total, 180 joint fusions were performed on the first, second, or third TMTs during arthrodesis. Four of 68 patients were revisions of previously failed fusions. All 68 patients (100%) healed soft tissue without complication. Of the 180 joints that underwent arthrodesis 170 (94.4%) fused successfully. Hardware removal occurred in 10 patients (14.7%) due to discomfort. Conclusions: This nontraditional dual incision dorsal approach for Lisfranc surgery has a low wound healing complication rate, in fact none were reported in this sample size of 68 patients. This approach is reproducible for either traumatic or elective procedures of the Lisfranc complex allowing excellent visualization of the medial and central tarsometatarsal joints while removing risk to the neurovascular structures inherent in the more traditional incisions. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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This study was conducted in Al-Kharj town, Central Province of Saudi Arabia (24°8′N and 47°18′E), during the period, January to October 2016 .The climate in the study area is characterized by hot dry season (May-September) and a cool season (October-March) with few rain showers in the cool season, (Table 1). Collection and process of samples:Convenience sampling was employed in this study Thrusfield [9], according to the availability of the camel herds. In the present survey, 107 camel's blood samples were collected from different locations in the area (local herds in 8 locations) at the beginning of the study (i.e. in February). Blood samples were collected in

Level V: Expert opinion.

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