Is Foot and Ankle Surgery Considered Low-Risk?
Foot and ankle surgery cannot be universally classified as low-risk; the risk profile varies substantially based on patient comorbidities, with diabetic patients—particularly those with neuropathy or Charcot neuro-osteoarthropathy—facing significantly elevated complication rates including surgical site infection (9.5%), wound dehiscence, hardware failure, and amputation risk. 1
Risk Stratification by Patient Population
High-Risk Populations
Diabetic patients with neuropathy undergoing foot and ankle surgery face a 9.5% post-operative surgical site infection rate, which represents a substantially elevated baseline risk compared to general surgical populations. 1
Patients with diabetes and Charcot neuro-osteoarthropathy (CNO) experience dramatically higher complication rates, including:
- Significantly elevated amputation rates compared to diabetic patients without CNO 1
- Increased hardware removal requirements 1
- Higher rates of wound dehiscence 1
- Acute kidney injury and pneumonia complications 1
- A 6-12 fold increased risk of major amputation when deformity leads to ulceration 1, 2
Moderate-Risk Populations
Diabetic transplant patients do not show increased surgical complication rates (OR 0.83,95% CI 0.33-2.08) compared to diabetic patients without transplantation, though they demonstrate higher mortality from non-surgical causes during follow-up (14.3% mortality rate). 3
Adult patients with neuromuscular diseases (including cerebral palsy) demonstrate complication rates similar to average populations, with overall wound complication rates of 10%, infection rates of 8%, and nonunion rates of 10% following arthrodesis. 4
Specific Procedure-Related Complications
Surgical Offloading Procedures
Achilles tendon lengthening (ATL) carries specific transfer ulcer risks, with heel ulcer development occurring in 13-15% of patients at 12-24 months follow-up, and up to 47% risk in patients with heel anesthesia and significant post-operative dorsiflexion. 1
Metatarsal head resection procedures demonstrate variable transfer ulcer rates, ranging from 0% to 41% depending on the study, with single metatarsal head resection showing the highest risk (41% at 13.1 months average follow-up). 1
Reconstructive Surgery for CNO
CNO reconstruction is associated with high complication rates requiring careful risk-benefit analysis before surgical intervention, including surgical site infection, wound dehiscence, non-union, and hardware failure. 1
Critical Risk Factors to Assess
Before classifying any foot and ankle surgery as low-risk, evaluate these specific factors:
- Peripheral neuropathy status: Loss of protective sensation dramatically increases complication risk 5, 6
- Peripheral arterial disease: Poor circulation impairs healing and increases infection risk 5
- Active Charcot neuro-osteoarthropathy: Represents a contraindication or requires specialized surgical approach 1, 2
- Foot deformities: Increase technical difficulty and complication potential 5
- History of prior ulceration or amputation: Indicates high-risk status 5, 6
Common Pitfalls in Risk Assessment
Do not assume foot and ankle surgery is uniformly low-risk based solely on the anatomic location or procedure type—patient-specific factors are the primary determinants of surgical risk. 1
Avoid underestimating the inflammatory burden in active CNO, where surgery on an acutely inflamed foot carries substantially higher complication rates than surgery during remission phase. 1
Never overlook vascular status before any surgical intervention, as inadequate perfusion fundamentally compromises healing regardless of surgical technique. 5