Operative management of ankle fractures in patients with diabetes mellitus

BACKGROUND: Multiple studies have documented increased risks associated with treatment of ankle fractures in patients with diabetes mellitus. We reviewed our results in the largest series to date of this complex patient group to determine the frequency of complications. METHODS: Eighty-four patients with diabetes had open reduction and internal fixation using standard fixation techniques for acute, closed ankle fractures. The 51 men and 33 women had an average age was 49.3 (22 to 77) years. The average followup was 4.1 years (11 to 97 months). Seventy-five fractures were closed and nine were open. Thirty-nine patients used insulin and 45 used oral hypoglycemics or diet for control of their diabetes. Diabetic complications, including nephropathy, hypertension, peripheral vascular disease, and neuropathy were evaluated. The management of diabetes, fracture classification, and presence of diabetic complications were assessed with chi-square, ANOVA, and univariate logistic regression to determine the presence of statistical significance for these factors. RESULTS: Twelve of the 84 patients developed postoperative complications. Ten patients developed infections (eight deep and two superficial). Four of 12 patients with preoperative evidence of peripheral neuropathy developed Charcot arthropathy. Ten of 12 patients who had absent pedal pulses preoperatively developed complications (p<0.0001) and 11 of 12 patients with peripheral neuropathy had complications (p<0.0001). A trend towards complications was noted with nephropathy (two of five patients) and hypertension (nine of 12 patients). Open fractures, insulin dependence, patient age, and fracture classification had no significant effect on outcome. CONCLUSIONS: Most patients with diabetes can undergo open reduction and internal fixation of acute ankle fractures without complications. Patients with absent pedal pulses or peripheral neuropathy are at increased risk for complications.     

Treatment of ankle fractures in patients with diabetes

Patients with diabetes mellitus have a higher risk of complications after sustaining an ankle fracture, including fracture displacement, superficial and deep infection, hardware failure, and neuropathic arthropathy. With the increased incidence of diabetes among the aged, the increased incidence of complications due to diabetes mellitus and its sequelae are important to keep in mind when treating ankle fractures.     

Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus

Using a computer database, we conducted a retrospective review of all ankle fractures treated at our institution from March 1985 to October 1996. Twenty-one patients with diabetes mellitus and isolated ankle fractures that were treated operatively met all inclusion criteria. Seven had insulin-dependent diabetes, and 14 had non-insulin-dependent diabetes. A randomly selected control group of 46 patients without diabetes who also underwent operative treatment of ankle fractures during this same time period were matched for age, sex, and fracture severity. The complication rate was 43% with 13 complications in nine patients with diabetes. There were seven (15.5%) complications in the control group. Complications in the diabetic group included seven infections (five deep, two superficial) and three losses of fixation. The complications were more severe in our diabetic population, requiring seven additional procedures including two below-knee amputations; a third patient refused an amputation. No additional procedures were required in our control group. All complications in our control group resolved with treatment. The relative risk for postoperative complications in patients with diabetes who sustained ankle fractures that were treated operatively was 2.76 times greater than the control group's (95% confidence interval, 1.57-3.97).     

Ankle fractures in patients with diabetes mellitus

Diabetes mellitus is considered an indicator of poor prognosis for acute ankle fractures, but this risk may be specific to an identifiable subpopulation. We retrospectively reviewed 42 patients with both diabetes mellitus and an acute, closed, rotational ankle fracture. Patients were individually matched to controls by age, gender, fracture type, and surgical vs non-surgical treatment. Outcomes were major complications during the first six months of treatment. We contrasted secondarily 21 diabetic patients with and 21 without diabetic comorbidities. Diabetic patients and controls did not differ significantly in total complication rates. More diabetic patients required long-term bracing. Diabetic patients without comorbidities had complication rates equal to their controls. Diabetic patients with comorbidities had complications at a higher rate (ten patients; 47%) than matched controls (three patients; 14%, p = 0.034). A history of Charcot neuroarthropathy led to the highest rates of complication. An increased risk of complications in diabetic patients with closed rotational fractures of the ankle are specific to a subpopulation with identifiable related comorbidities.     

The management of ankle fractures in patients with diabetes

Patients with diabetes mellitus have higher complication rates following both open and closed management of ankle fractures. Diabetic patients with neuropathy or vasculopathy have higher complication rates than both diabetic patients without these comorbidities and nondiabetic patients. Unstable ankle fractures in diabetic patients without neuropathy or vasculopathy are best treated with open reduction and internal fixation with use of standard techniques. Patients with neuropathy or vasculopathy are at increased risk for both soft-tissue and osseous complications, including delayed union and nonunion. Careful soft-tissue management as well as stable, rigid internal fixation are crucial to obtaining a good outcome. Prolonged non-weight-bearing and subsequently protected weight-bearing are recommended following both operative and nonoperative management of ankle fractures in patients with diabetes.     

Healing time of foot and ankle fractures in patients with diabetes mellitus: literature review and report on own cases

BACKGROUND: It is widely believed that diabetes mellitus affects fracture healing. This assumption is based on a single case report by Cozen (1972), and has never proved by scientific data ever since. OBJECTIVES: To extract from the literature the current knowledge on the outcome of closed ankle and foot fractures in diabetics, and to review own cases from patients' charts. Outcome criteria was the healing time. METHODS: The literature was searched using MEDLINE for the years 1983-2003, under the key words "diabetes and fractures". Own cases of ankle fractures (28 diabetic, and 17 non-diabetic control cases), and of foot fractures (35 diabetic cases with Charcot-fractures) were analysed in retrospect. RESULTS: The literature search yielded 466 hits, but not one single prospective, controlled study on fracture healing time in diabetics. Three papers contained data on healing time of ankle fractures, according to which ankle fractures in diabetics take only a little longer to heal than in non-diabetics. This is consistent with our own cases: in the diabetic subjects (HbA1c 8.5 %), the fractures had healed within 3.5 months (median), versus 3 months in the non-diabetic subjects. According to 3 papers found by MEDLINE search, Charcot-fractures of the foot will heal within 3-7 months; our own cases healed within 3-5 months (median). According to the literature, treatment of Charcot foot fractures is delayed by 3 months, due to polyneuropathy, as in our cases. In non-diabetic subjects treated immediately after trauma, foot fractures will heal within 3 months (according to the literature). CONCLUSION: The present data suggest that diabetes mellitus in general does not affect the healing of foot and ankle fractures, provided effective delivery of standard treatment in time. Diabetic complications may affect the outcome. Prospective controlled trials in fracture healing in diabetics are needed to confirm the present evaluation.     

Foot and ankle survey in adults with diabetes mellitus

The purpose of this study was to examine the foot and ankle care patterns and shoe wear habits in patients with clinically proven diabetes mellitus who were attending diabetes education classes for the first time. One hundred subjects were recruited from outpatient adult diabetes education classes. No attempts were made to select patients on the basis of disease duration or severity. Each subject completed a questionnaire assessing life-style, shoe wear habits, health care status and interaction with healthcare providers. Thirty-seven percent of the subjects reported prior foot problems. Twenty percent had their feet examined regularly and 59% had never had their feet examined. Foot problems reported were: corns 11%, calluses 11%, bunions 3%, ulcers 1%, gout 1%. Sensation was tested using the 5.07 Semmes Weinstein monofilament across seven zones of the plantar surface of the foot. Subjects unable to feel this varied from 5% to 20% in each of the zones. Shoe wear was assessed for fit and style. Thirty percent of the patients had shoes that were too narrow and 81% of the patients with poorly fitting shoes were women. Shoe wear history and factors influencing shoe selection were recorded. Diabetes mellitus is a common disease, often affecting the feet. Preventive care can help patients deal with the manifestations of diabetic neuropathy. This study showed that a low percentage of subjects with diabetes regularly have their feet examined and that a relatively high percentage (31%) wear shoes that are too narrow. Identifying these patients early may allow modification of habits that put their feet at risk.     

A protocol for treatment of unstable ankle fractures using transarticular fixation in patients with diabetes mellitus and loss of protective sensibility

BACKGROUND: Surgical treatment of ankle fractures in patients with diabetes mellitus is associated with a high complication rate. Diabetic patients with peripheral neuropathy are a particularly difficult group to treat because of their inability to sense deep infection, repeat trauma, and wound complications. The purpose of this study was to evaluate a protocol that included transarticular fixation and prolonged, protected weightbearing in the treatment of unstable ankle fractures in diabetic patients with peripheral neuropathy and loss of protective sensibility. METHODS: The authors retrospectively reviewed the records of 15 patients with diabetes mellitus, unstable ankle fractures (AO classification 44B), and loss of protective sensibility confirmed via testing with a 5.07 Semmes-Weinstein monofilament. Retrograde transcalcaneal-talar-tibial fixation using large Steinmann pins or screws in conjunction with standard techniques of open reduction and internal fixation was used. The postoperative treatment protocol included: 1) short leg, total contact casting and nonweightbearing status for 12 weeks; 2) removal of the intramedullary implants between 12 and 16 weeks; 3) application of a walker boot or short leg cast with partial weightbearing for an additional 12 weeks; and 4) transition to a custom-molded ankle-foot orthosis (AFO) or custom total-contact inserts in appropriate diabetic footwear. RESULTS: The major complication rate for all fractures was 25% (4/16) and for closed fractures was 23% (3/13). These are lower than previously reported rates between 30% (3/10) and 43% (9/21) for diabetic patients with and without neuropathy. The amputation rate for all fractures was 13% (2/16) and for closed fractures alone was 8% (1/13). These are similar to previously reported rates of 10% (2/10) to 20% (2/21). There were no deaths or Charcot malunions in this series. The combination of transarticular fixation and prolonged, protected weightbearing provided 13 of 15 patients with a stable ankle for weightbearing. CONCLUSION: Although these fractures remain a treatment challenge, this study presents a successful, multidisciplinary protocol for treatment of unstable ankle fractures in the most challenging group of diabetic patients - those with loss of protective sensibility.     

Arthrodesis with external fixation in the unstable or misaligned Charcot ankle in patients with diabetes mellitus

The unstable or misaligned Charcot ankle with or without chronic foot ulceration is a major clinical challenge. When it cannot be accommodated with an ankle foot orthosis, surgical treatment is indicated in order to avoid leg amputation. This requires extensive soft tissue release and bony resection to realign the foot and arthrodesis with internal or external fixation. The guidance in the literature favors internal fixation. This article reports results with external fixation in 11 patients (12 feet) over a period of 12 years. External fixation was chosen as the surgical option because of the presence of foot ulcers with the attendent risk of infection. There were 7 tibio-talar and 5 tibio-calcaneal fusions. Compression was applied for 6 weeks with an external frame according to Charnley, followed by 6 weeks with total-contact cast. Weight bearing with a rigid leather brace was allowed after 12 weeks. In one case, transtibial amputation was required due to loosening of the distal pins from osteopenic disintegrating bone. In 11 cases (92%), the foot was successfully realigned and independent walking with a brace retained during the follow-up of median 48 months (10-102 months). Bony union took place in 5 out of 7 cases with tibio-talar fusion and in 1 out of 5 with tibio-calcaneal fusion. The functional result in cases with fibrous union was, however, satisfactory. Although meaningful comparisons of series are difficult to conduct and interpret from, the limb salvage rate was similar to results with internal fixation. The authors consider the results to be encouraging and to be used to develop a higher level of evidence.     

Syme ankle disarticulation in patients with diabetes

BACKGROUND: Syme ankle disarticulation is an amputation level that minimizes disability and preserves function, but it has been used sparingly in patients with diabetes mellitus. Surgeons have avoided this level because of the perceived high risk for wound failure, wound infection, or migration of the heel pad, which makes prosthesis use difficult. METHODS: Ninety-seven adult patients with diabetes mellitus who underwent Syme ankle disarticulation because of a neuropathic foot with an infection or gangrene, or both, during an eleven-year period were studied retrospectively. Selection of the amputation level was made on the basis of clinical examination and an assessment of the wound-healing parameters, i.e., vascular inflow, tissue nutrition, and immunocompetence. The average age of the patients was 53.2 +/- 17.5 years. RESULTS: Eighty-two patients (84.5%) ultimately achieved wound-healing. When threshold levels for vascular inflow (ultrasound Doppler ischemic index of 0.5 or transcutaneous partial pressure of oxygen between 20 and 30 mm Hg) and tissue nutrition (serum albumin of 2.5 g/dL) were met, an overall success rate of 88% was achieved. Total lymphocyte count (an absolute lymphocyte count of 1500) and the smoking of cigarettes during the study period did not appear to impact wound-healing rates. The overall infection rate was 23%, and it was three times greater in smokers. Most infections were managed with local wound care and antibiotic therapy. At a minimum follow-up of two years, all but two patients were able to walk with a prosthesis. Thirty of the ninety-seven patients died at an average of 57.1 months following surgery. CONCLUSIONS: The results of this retrospective review support the value of Syme ankle disarticulation in diabetic patients with infection or gangrene. This function-sparing amputation can be successfully performed with a reasonable risk. Patients managed with a Syme ankle disarticulation appeared to remain able to walk better and to survive longer than similar patients who had a transtibial amputation and served as historical controls. In diabetic patients with dysvascular disease who have adequate vascular inflow to support wound-healing (an ultrasound Doppler ischemic index of 0.5 or a transcutaneous partial pressure of oxygen between 20 and 30 mm Hg), the threshold for the wound-healing parameter of serum albumin appears to be as low as 2.5 g/dL.     

Open ankle fractures: Factors influencing unplanned reoperation

IntroductionAnkle fractures are amongst the most common open fracture injuries presenting to major trauma centres (MTC) and their management remains a topic of debate. Incidence is increasing particularly in the elderly population however the optimal surgical approach and risk factors for unplanned reoperation remain scarce. We therefore conducted a retrospective case study to analyse our institution's outcomes as well as identify risk factors for early unplanned reoperation.Materials and methodsSixty-five consecutive open ankle fractures were identified using our institutional database between July 2016 and July 2020. Medical records and operation notes were reviewed to identify patient age at injury, Sex, co-morbidities and other co-morbidities, fracture configuration, extent of soft tissue injury, fixation type and post-operative complications. The data was categorised into four groups for analysis, 1) age, 2) AO-OTA classification 3) Sex 4) Gustilo-Anderson grade. Statistical analysis was undertaken to identify predictors of unplanned reoperation.ResultsThe mean age of patients at the time of injury was 60.8. Unplanned reoperation rate was 17.5%. Age and Gustilo-Anderson classification grade were both statistically significant predictors of unplanned reoperation. AO-OTA classification, Sex and Diabetes were not statistically significant factors associated with unplanned reoperation.ConclusionAge and quality of soft tissue envelope are significant risk factors for unplanned reoperation. Patients with these risk factors may benefit from an alternative surgical approach.     

Results after immediate operations of closed ankle fractures in patients with preoperatively neglected type 2 diabetes

Many studies suggest diabetes influences ankle fracture surgical outcomes, but results after immediate surgical treatment of closed ankle fractures (CAFs) in patients with preoperatively neglected type 2 diabetes (PND2) have not been documented. We contrasted the results of the immediate operation on CAF in 36 PND2 patients with those of a matched group of non-diabetic patients, using a case-controlled study. Outcomes were complications and ankle scores during the first 12 months of treatment. Compared with non-diabetic patients, immediate surgical fixation of the CAF in PND2 patients showed similar ankle scores. Immediate surgery in PND2 patient with CAF may increase the risk of postoperative infection compared to non-diabetic controls, but the difference was not statistically significant and did not worsen the final prognosis. These findings suggest that immediate surgical intervention is appropriate in CAF patients with type 2 diabetes.     

Complications of ankle fracture in patients with diabetes

Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to practicing clinicians. Complications of impaired wound healing, infection, malunion, delayed union, nonunion, and Charcot arthropathy are prevalent in this patient population. Controversy exists as to whether diabetic ankle fractures are best treated noninvasively or by open reduction and internal fixation. Patients with diabetes are at significant risk for soft-tissue complications. In addition, diabetic ankle fractures heal, but significant delays in bone healing exist. Also, Charcot ankle arthropathy occurs more commonly in patients who were initially undiagnosed and had a delay in immobilization and in patients treated nonsurgically for displaced ankle fractures. Several techniques have been described to minimize complications associated with diabetic ankle fractures (eg, rigid external fixation, use of Kirschner wires or Steinmann pins to increase rigidity). Regardless of the specifics of treatment, adherence to the basic principles of preoperative planning, meticulous soft-tissue management, and attention to stable, rigid fixation with prolonged, protected immobilization are paramount in minimizing problems and yielding good functional outcomes.