Current Insights In Treating Diabetic Foot And Ankle Trauma

John J. Stapleton, DPM, FACFAS, and Thomas Zgonis, DPM, FACFAS

The management of diabetic foot and ankle injuries has raised significant debate and controversy over the last few years. Unfortunately, there is still no clear consensus on treatment protocols that necessitate surgical intervention. The main reason for this controversy is because there is no single correct way of treating even the most commonly encountered diabetic foot and ankle fractures and/or dislocations.

   The treating surgeon needs to be able to provide the most successful management and avoid potential inherent complications that are common in the diabetic population. A wide spectrum of injuries can occur that include neuropathic and non-neuropathic fractures, dislocations or both. In addition, concomitant soft tissue injuries present further unique challenges for overall surgical management.

Evaluating And Addressing The Compromised Soft Tissue Envelope

The foot and ankle have a limited amount of soft tissue coverage. Therefore, one needs to pay particular attention to minimizing wound healing complications when managing diabetic injuries. When it comes to patients with diabetes, one needs to ensure medical optimization in order to avoid any potential effects from diabetes, anemia, cardiac, renal, vascular and/or pulmonary disease. The presence of multiple comorbidities can have a deleterious outcome on the wound and bone healing process, and further complicate the patient’s overall medical status throughout the treatment course.

   The utilization of supplementary oxygen to prevent tissue hypoxia and appropriate glucose control are some measures one can initiate in order to reduce the risks of infection and wound healing complications.

   Successful management of diabetic foot and ankle trauma is dependent on detailed knowledge of the vascular anatomy of the foot, ankle and lower extremity. Understanding the boundaries of each angiosome of the foot and ankle, and how it relates to its source artery provides the basis for logical surgical incisions. When treating this patient population, surgeons need to understand that a source artery may be occluded secondary to peripheral vascular disease or trauma, which may lead to a compromised angiosome.

   Accordingly, podiatrists may need to utilize Doppler ultrasound, basic non-invasive vascular studies or pursue further vascular imaging and intervention preoperatively in order to determine if definitive fixation through planned incisions is feasible. A plan for definitive treatment may become challenging when multiple or extensile incisions are required to achieve the necessary osseous reconstruction desired.

   Often, surgeons may need to stage incisions and their associated procedures in order to prevent postoperative skin necrosis and deep infection. Examples of this concept include the use of limited incisions to perform percutaneous plating and/or internal fixation, use of only external fixation, or employing a combination of the two to achieve fracture reduction while minimizing soft tissue compromise.

   In certain situations, it may be better to utilize staged procedures that allow for more direct incisions once the patient’s lower extremity edema subsides. An example of this concept is the management of diabetic calcaneal intra-articular comminuted fractures. In the diabetic patient with a compromised soft tissue envelope, it may be preferable to obtain initial reduction of the calcaneal fracture with external fixation and stage a primary subtalar joint arthrodesis as opposed to performing an open reduction and internal fixation through an extensile lateral incision.

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