Current Insights On Treating Ankle Fractures In Patients With Diabetes

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

   There has also been argument against non-surgical intervention for diabetic ankle fractures. In a report by Connelly and Csencsitz, five patients with insulin-dependent diabetes received conservative treatment with casting for ankle fractures.5 All patients experienced at least one complication including infection, Charcot arthropathy and malunion. In their series of six ankle fractures, one resulted in a major amputation. The authors of this paper suggested that early surgical treatment is preferable to avoid poor outcomes with diabetic ankle fractures.

   A displaced diabetic ankle fracture warrants surgical attention. However, surgeons must take steps in order to reduce the complications in patients with diabetes undergoing surgical intervention.

   Bibbo and coworkers discussed the significance of adhering to a treatment protocol to help produce a favorable outcome for diabetic ankle fractures.3 First, one should assess the fracture type and bone and soft tissue quality since this will influence the treatment path. If necessary, perform closed reduction of a grossly disfigured ankle fracture to avoid ischemic complications and wound development. At this point, one should assess the stability of the ankle fracture. If one cannot maintain reduction in a splint, consider other alternatives to promote stability. Options at this point include immediate ORIF versus external fixation. External fixators can allow for staged surgical intervention in very unstable ankle fractures or facilitate definitive treatment.

   Authors have shown low wound complication rates with a staged protocol in patients with high-energy pilon fractures.22,23 In this scenario, patients with high-energy pilon fractures are comparable to patients with diabetic ankle fractures since both are at high risk for wound complications and require a period of soft tissue stabilization before open treatment.

   However, since patients with diabetes are at greater risk, it may be more difficult to avoid complications despite the attempt to do so. Strategies for treatment of an ankle fracture with complications can include: multiple debridements, use of an external fixator for stability and accommodation of soft tissue problems, antibiotics, antibiotic-impregnated implants, wound closure with flaps and/or skin grafts, and arthrodesis for definitive treatment.

   Zalavras and colleagues retrospectively reviewed the outcomes of 26 patients without diabetes treated for infection following operative treatment of ankle fractures.24 Eleven of these patients presenting up to 10 weeks postoperatively had debridement with hardware retention if the fracture and hardware was stable. Fifteen patients presenting 11 weeks or more postoperatively had debridement and removal of hardware. Three of the 26 patients required soft tissue coverage via a sural flap after debridement. Patients also received culture-specific antibiotics. Infection recurred in five of 18 patients upon follow-up, three of which were controlled with repeat debridement. The remaining two patients required below knee amputations. This study highlights the difficulty in treating complicated ankle fractures. In this case, the ankle fractures were complicated by postoperative infection.

In Conclusion

Patients with diabetes who experience ankle fractures are at more risk for complications than non-diabetics. Neuropathy, vasculopathy, delayed fracture healing and Charcot arthropathy can turn a routine ankle fracture into a limb-threatening situation. Proper management of diabetes and tight glycemic control are key to avoiding complications. Consult vascular specialists immediately when there is evidence of ischemia or PAD that needs to be evaluated and addressed before planned treatment.

   Many conservative and surgical treatment options exist, but maintaining stability and managing the soft tissue envelope are essential in minimizing complications. When complications arise in diabetic ankle fractures, strategies consisting of multiple surgeries and adjunct treatments are required to prevent limb loss.

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