How To Treat Ankle Fractures In Patients With Diabetes

By Alan R. Catanzariti, DPM, Robert W. Mendicino, DPM, and Travis L. Sautter, DPM
Bisphosphonates are indicated for metabolic bone disease and seem to be well tolerated with very few side effects. The objective with bisphosphonate therapy in diabetic patients with ankle fractures is to limit bony destruction during the acute phase of Charcot. Bisphosphonates have been well established for use in early stage Charcot.9,10 One may consider bisphosphonates as a prophylactic measure in this particular group of patients in order to minimize the incidence of Charcot. Pertinent Pearls On Managing Open And Unstable Fractures Open fractures are an especially challenging problem in diabetic patients with established neuropathy. White, et. al., evaluated the treatment of 14 fractures in 13 patients. They achieved complete bony union without complication in only three patients.11 For unstable ankle fractures and significant deformity in patients with diabetes, one should consider surgical management. Surgical options may include ORIF or closed reduction with percutaneous and/or external fixation. As with any type of surgical management, surgeons should emphasize certain precautions. One should allow for a preoperative decrease in edema after the injury before proceeding with surgical treatment. This allows a more healthy soft tissue envelope that might be less prone to soft tissue complications. Surgeons should also develop an adequate fixation construct for these patients due to the incidence of osteopenia and neuropathy. The construct must provide adequate stiffness. We recommend utilizing multiple lag screws, if possible, when fixing a lateral malleolar fracture. We recommend fully threaded cancellous screws below the level of the ankle joint, especially in the presence of osteopenia. We also recommend that surgeons use multiple transsyndesmotic screws through the plate when possible. These transsyndesmotic screws should engage all four cortices. One should also place the medial malleolar screws in such a way that four cortices are engaged as opposed to depending on cancellous bone to support the screws. There have been some other specialized techniques recommended for this particular group of patients. This includes the use of intramedullary screws and intramedullary nails for the fibular fracture.12 Additionally, we often consider employing a supplemental external fixator to neutralize any forces that might affect the internal fixation construct. It is recommended to perform cast changes every seven to 14 days in order to facilitate early recognition of any soft tissue complications. We also recommend obtaining serial radiographs on a more frequent basis in patients with diabetes. Doing so enables one to detect any osseous complications early in the postoperative period. Again, it is recommended to utilize a well-padded or total contact cast following surgery. A Closer Look At Surgical Treatment Outcomes Jani, et. al., established a protocol for treating unstable ankle fractures with transarticular fixation. The goal was to develop a minimally invasive technique to manage these patients and accordingly limit the risks associated with ORIF. They treated 18 ankle fractures in patients with diabetes mellitus. They performed closed reduction followed by percutaneous fixation and protective weightbearing. They reported a major complication rate of 25 percent with two below-knee amputations.13 In unpublished data gathered at the Western Pennsylvania Hospital, we have retrospectively studied the outcomes of ankle fracture treatment in 27 patients with diabetes and 27 non-diabetic patients via a case/control design. We reviewed demographic and outcome data. We performed statistical analysis comparing the diabetic and control group and also compared outcomes in patients with type 1 diabetes and those with type 2 diabetes. The overall complication rate was 30 percent for the diabetic group and 7 percent for the control group. Peripheral vascular disease (p=.010), peripheral neuropathy (p=<.001) and higher patient weight (p=.039) were the only comorbid conditions that were statistically different when we compared patients with diabetes versus a non-diabetic control group (p=.010, p=<.001, respectively). Data analysis revealed the length of hospital stay was the only outcome that was statistically different between the diabetic and control groups (p=<.001).

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