Current Insights In Treating Diabetic Foot And Ankle Trauma

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

   During the initial management of diabetic foot and ankle injuries, it is important to consider the underlying osseous injury and its role in contributing to both vascular and/or soft tissue compromise. When it comes to severe deformities to the lower extremity, one may need to reduce the deformity in an urgent manner and determine if vascularity to the lower extremity has improved in order to prevent devastating soft tissue compromise or loss of the limb. In these cases, appropriate consultation to the vascular team may also be necessary at the early stages of treatment.

   It is common for surgeons to apply a spanning “temporary” external fixator for the management of diabetic injuries with compromised vascularity and/or soft tissue envelope. One can utilize the efficiency of a simple “bar to clamp” external fixation apparatus to manage severe acute osseous foot and ankle deformities that are posing a risk to the surrounding soft tissue envelope. The use of a spanning external fixator is paramount to provide fracture reduction and osseous stability while promoting early healing of any soft tissue injuries that are present.

   This type of fixation can also facilitate any plastic and/or vascular surgery procedures that may need to be performed. It can also allow one to closely monitor for any signs of a compartment syndrome.

   The management of open diabetic foot and ankle fractures is even more challenging. It is often best to treat these fractures with serial debridements followed by delayed primary closure or flap coverage. In rare case scenarios, you may see a simple wound which is not contaminated and can be closed with no tension. With these wounds, one can perform thorough irrigation of the wounds and subsequent primary closure.

   However, repeat debridements and irrigations of the open wound may be necessary to further reduce the risk of infection and soft tissue compromise in comparison to uncontaminated wounds that one can close in a primary fashion in the patient with diabetes.

Key Surgical Considerations In Patients With Insensate Diabetic Foot And Ankle Injuries

In formulating a surgical plan, a multitude of factors should influence the procedure selection and surgical technique. The presence of dense peripheral neuropathy, morbid obesity, peripheral vascular disease, smoking history and poor soft tissue envelope often lead to a specialized treatment plan in order to reduce the risk of potential postoperative complications.1-11

   Insensate diabetic foot and ankle injuries require not only absolute osseous stability of the fractured segments or dislocated joints, but stabilization of adjacent joints as well to further prevent pathologic forces that can contribute to a post-op Charcot neuroarthropathy event. Some of the most common treatments surgeons would consider in these situations may include:
• the application of a neutralizing external fixation device in addition to the internal fixation;
• further supplementation of the fixation of the ankle with trans- or extra-articular large Steinmann pins;
• increasing the fixation by utilizing longer plates or double plating techniques;
• the use of bridge plating techniques for midfoot trauma; or
• a primary arthrodesis for the severely comminuted intra-articular fractures.

   Surgeons may utilize various internal fixation techniques for the management of diabetic foot and ankle trauma. Certainly, one does not have to treat every diabetic injury with the aforementioned surgical techniques. When it comes to patients with well controlled diabetes and a lack of other previously discussed comorbidities, you may employ surgical techniques that are common to utilize for foot and ankle trauma in general. Despite the surgical techniques being similar to achieve fracture reduction, longer immobilization and protected weightbearing, once initiated, are highly recommended. In addition, follow-up visits are usually more frequent to closely monitor the patient’s recovery and postoperative adherence issues.

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