How To Treat Ankle Fractures In Patients With Diabetes

By Alan R. Catanzariti, DPM, Robert W. Mendicino, DPM, and Travis L. Sautter, DPM

Ankle fractures in patients with diabetes and documented neuropathy present a significant challenge to the clinician. The majority of literature has indicated that ankle fractures in this particular patient population are often difficult to manage and complication rates are reportedly quite high. These poor outcomes are similar for both conservative and surgical treatment. There are several factors implicated in the high complication rates one sees in the management of ankle fractures in patients with diabetic neuropathy. Many of these patients have significant osteopenia. The combination of the osteopenia with neuropathy can often result in significant problems. Treatment for these patients is often very labor-intensive and ideal therapeutic options have yet to be determined when it comes to managing ankle fractures in patients with diabetic neuropathy. Indeed, outcomes have been shown to be generally poor and some factors that have been implicated are beyond the physician’s control. Standard approaches to treating these fractures in non-diabetic patients do not result in good outcomes when one applies these approaches to patients with diabetic neuropathy. Clinicians should also be aware of significant medical and legal issues surrounding the treatment of diabetic ankle fractures. What You Should Know About The Risk Factors Cavanaugh, et. al., presented a study evaluating radiographic abnormalities in patients with diabetic neuropathy. They noted a substantial number of neuropathic fractures in a large number of these patients and also pointed out that a significant number of patients went on to develop a Charcot process. The authors of the study concluded that one should have a high index of suspicion for neuropathic fractures and conditions such as Charcot deformity when managing patients with diabetes and established neuropathy.1 Reddy, et. al., evaluated the mechanical integrity of bone in experimental diabetes. This study determined there was a 37 percent decrease in maximal load, a 25 percent decrease in deformation and maximal load and a 38 percent increase in bending stiffness in comparison to non-diabetic subjects. They concluded that diabetic bone was stiffer and bore less of a load, thus decreasing its energy absorption capacity.2 Ivers, et. al., evaluated 3,654 patients over a two-year period. They tried to determine risk factors that were associated with fractures in patients with diabetes mellitus. They concluded that diabetes-related factors that are significantly associated with an increased risk of fractures include the presence of neuropathy, a duration of diabetes mellitus greater than 10 years and insulin treatment. The authors found that spontaneous fractures develop in this patient population and are often undiagnosed due to the lack of pain sensation.3 Bibbo, et. al., looked at risk factors for complications in diabetic ankle fractures. This study determined that age, hypertension, weight and fracture type were not significant factors in the development of these complications. However, his study demonstrated that neuropathy and peripheral vascular disease were significant factors that resulted in complications.4 Another major problem among patients with diabetes is the development of Charcot after a fracture. Young, et. al., tried to determine which factors were associated with the development of Charcot arthropathy in diabetes. However, this study determined that certain factors including sex, age, insulin use, the duration of diabetes, retinopathy, proteinuria, the level of hemoglobin A1c, weightbearing status and history of previous ulceration provided no statistical value for predicting the development of Charcot arthropathy.5 Complications: What The Literature Reveals When it comes to the surgical management of ankle fractures in patients with diabetes, potential complications include infection, malunion, nonunion and Charcot arthropathy. These complications can be rather difficult to manage and have significant morbidity. In particular, when one is managing diabetic ankle fractures, the treating physician should have a high index of suspicion for the development of Charcot. The incidence of Charcot arthropathy is relatively high following fracture in patients with diabetes mellitus. There are clearly factors other than mechanical overload that are involved.

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