Current Insights On Treating Ankle Fractures In Patients With Diabetes
White and coworkers retrospectively evaluated the results of 14 open ankle fractures in patients with diabetes.8 Nine out of 14 fractures had wound complications, five of which resulted in amputation. Only three of the 14 fractures healed without consequence. These studies demonstrate that there is an increased rate of complications with ankle fractures in patients with diabetes.
Pertinent Pearls For Treating Diabetic Ankle Fractures
Regardless of which treatment method one chooses for an ankle fracture in a patient with diabetes, an important component to preventing complications is tight glycemic control. Studies have shown that maintaining proper physiologic glucose levels helps encourage wound healing.12
Researchers have also highlighted the importance of glycemic control for fracture healing in diabetic rat model studies. A study by Beam and colleagues comparing untreated diabetic rats to diabetic rats on an insulin regimen showed improvement in fracture healing in the insulin group.13 Underlining the significance of control is the fact that a 1 percentage point reduction of hemoglobin A1c levels also decreases the rate of complications by 25 to 30 percent.14 Addressing hyperglycemia and maintaining proper glucose levels are vital to reducing the risk of ankle fracture complications in patients with diabetes.
Addressing associated ischemia that can impede fracture and/or wound healing is also necessary. The ankle-brachial index (ABI) is a reproducible, reasonably accurate non-invasive test to detect peripheral arterial disease (PAD).15,16 Other methods for evaluation include segmental pressures and pulse volume recordings (PVRs).17 Segmental pressures assist in locating the lesion and PVRs allow for segmental waveform analysis permitting evaluation of blood flow. However, the presence of an ankle fracture inhibits the use of ABIs, segmental pressures and PVRs. Instead, one can assess local perfusion by measuring the transcutaneous oxygen tension (TcPO2). The TcPO2 values have been helpful in predicting healing in patients with diabetes.18 A TcPO2 value of less than 30 mmHg points toward the need for angiography.19 Any abnormal noninvasive vascular study findings are concerning for limb ischemia and require further evaluation by a vascular specialist.
Controversy exists as to which treatment modality (conservative versus surgical intervention) is more appropriate for ankle fractures in patients with diabetes. There are only a handful of studies giving specific attention to this subject. McCormack and Leith studied patients with 26 diabetic ankle fractures, 19 of which had an ORIF.7 The remaining seven patients had casting and immobilization. Those patients treated surgically had an overall complication rate of 47 percent (5 percent with wound complications, 11 percent with infections resulting in amputations and two deaths). Patients treated conservatively had no complications. The authors therefore recommended avoiding surgical intervention in the elderly diabetic patient with lower demands.
Schon and Marks reviewed the outcomes of 28 neuropathic ankle fractures in patients with diabetes, all of whom had conservative treatment (immediate immobilization with no weightbearing or delayed immobilization).20 All fractures healed uneventfully without any complications.