Current Insights On Treating Ankle Fractures In Patients With Diabetes

Visoth Chan, DPM, David Pougatsch, DPM, and Ronald Belczyk, DPM

Recognizing that ankle fractures in patients with diabetes can lead to potentially dire complications, these authors discuss keys to treatment that can reduce risks and improve outcomes.

Ankle fractures in patients with diabetes present challenges in operative and non-operative management. Complications arising from diabetes and its comorbidities such as neuropathy and vasculopathy are compounded by healing and rehabilitation problems that occur more often in patients with diabetes than those without diabetes.

   These chronic issues stay at bay until acute trauma occurs and brings them to the forefront. An ankle fracture in a patient with diabetes can lead to an increased risk of infection, malunion, delayed union, nonunion, Charcot arthropathy, and impaired wound healing. These multiple risks can turn what at first glance appears to be a routine ankle fracture into a difficult case requiring additional strategies to avoid limb loss. It is important to understand the complications that can arise in patients with diabetes who experience ankle fractures. In a limb-threatening scenario, it is also critical to be aware of the treatment options available.

   According to the Centers for Disease Control and Prevention in 2010, 25.8 million people (8.3 percent of the population) in the United States had diabetes.1 Among U.S. residents 65 years of age and older, 10.9 million (26.9 percent of the population) had diabetes. Additionally, about 1.9 million people 20 years of age or older in the United States were newly diagnosed with diabetes in 2010.

   A review of more than 160,000 study patients treated for ankle fractures from 1988 through 2000 showed that 5.71 percent of the patients had diabetes.2 Those with diabetes had a greater overall percentage of in-hospital mortality, postoperative complications, length of hospital stay and non-routine discharge. Many other studies have demonstrated an increased rate of complications in patients with diabetes and ankle fractures including impaired wound healing, infection, impaired fracture healing, loss of reduction, hardware failure and Charcot arthropathy.3-9

What The Literature Reveals About Ankle Fractures In Patients With Diabetes

Many authors have published articles about the incidence and types of complications of ankle fractures in patients with diabetes. These studies reflect the fact that patients with diabetes have an increased risk of complications associated with ankle fractures in comparison to those without diabetes.10,11 Possible complications in this setting include infection, malunion, delayed union, nonunion, Charcot arthropathy; all which typically need further surgical intervention or amputation.

   When it comes to surgical treatment for ankle fractures in patients with diabetes, a study by Blotter and colleagues showed the relative risk for complications was 2.76 times greater in this group in comparison to their control group.4 Jones and coworkers performed a retrospective study comparing 42 patients with diabetes with controls matched for age, sex, fracture type and treatment method.10 They found that 31 percent of patients with diabetes, in comparison with 17 percent of patients without diabetes, developed complications after experiencing closed ankle fractures.

   In another retrospective study, Costigan and colleagues evaluated the outcome of 84 patients with diabetes who received open reduction internal fixation (ORIF) for their ankle fractures.11 Twelve patients (14 percent) developed infections with two of those patients having both infection and Charcot changes. Several patient variables were also present. In this study, peripheral neuropathy and vasculopathy were associated with an increased risk in complications.

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