How To Treat Ankle Fractures In Patients With Diabetes

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In particular, when one is managing diabetic ankle fractures, the treating physician should have a high index of suspicion for the development of Charcot.
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.
When performing surgical treatment of ankle fractures in patients with diabetes, the authors emphasize using an adequate fixation construct for these patients due to the incidence of osteopenia and neuropathy.
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Author(s): 
By Alan R. Catanzariti, DPM, Robert W. Mendicino, DPM, and Travis L. Sautter, DPM

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).
This outcome data included assessments of ankle fracture type and severity, time to full weightbearing and fracture union, and the incidence of nonunion and wound problems. There was also no statistical difference between the demographic and outcome data of patients with type 1 diabetes and the results among those with type 2 diabetes.
Overall, there were no major complications of Charcot arthropathy, limb loss or death in this study population. This study demonstrates a low complication rate for the surgical treatment of diabetic ankle fractures relative to the existing literature.

Final Words
An ankle fracture in a patient with longstanding diabetes mellitus can be a calamity for the patient and the physician who treats this fracture as a routine injury. Therefore, one should manage these patients with special precautions. In order to help achieve the best outcomes, it is essential to consider key factors that may predispose patients with diabetic neuropathy to complications resulting from an ankle fracture.

Dr. Catanzariti is the Director of the Residency Training Program within the Division of Foot and Ankle Surgery at the Western Pennsylvania Hospital in Pittsburgh. He is a Fellow of the American College of Foot and Ankle Surgeons.

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