Current Insights In Treating Diabetic Foot And Ankle Trauma

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Author(s): 
John J. Stapleton, DPM, FACFAS, and Thomas Zgonis, DPM, FACFAS

   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.

Exploring The Options For Enhanced Stability

The combination of external fixation with internal fixation is often an excellent way of ensuring stability of the diabetic neuropathic lower extremity. One may manage fractures and/or dislocations in a typical fashion and apply either a spanning or circular external fixation to further stabilize the joints. This is typically the case with talar fractures or extrusions, and severely open midfoot, ankle or pilon fractures and/or dislocations.

   Often, even after you have achieved an anatomic reduction, instability may still be present secondarily to severe disruption of the joint capsule and the surrounding ligamentous structures. The surgeon may utilize spanning “delta” external fixation to temporarily stabilize the ankle and rearfoot. Extensions to the forefoot may also be needed to further stabilize any associated midfoot trauma. Surgeons commonly apply a circular external fixation device if they need to manipulate any osseous segments or estimate that the time in the external fixator will exceed six to eight weeks.8-11

   Transarticular fixation is another method to prevent late joint subluxation and/or further stabilize a severe diabetic foot and ankle fracture. The advantage of Steinmann pins is to provide supplementary fixation across unstable ankle fractures in addition to internal fixation.

   One may also use these pins as a primary means of fracture reduction. This technique can be useful for diabetic ankle fractures in geriatric patients or diabetic ankle fractures and/or dislocations that are not amenable to internal fixation due to either severe peripheral vascular disease or soft tissue compromise.3,4

   Surgeons may use multiple internal fixation plates for severely comminuted distal tibia or pilon fractures. Double plating offers increased stability and helps neutralize deforming forces that may occur over the prolonged time it takes for the osseous segments to heal. As in any other case, it is important to minimize soft tissue dissection and maintain the periosteum near the fracture fragments, and only consider multiple plates if the soft tissue envelope is not compromised. Preserving the periosteum is paramount.

   The insertion of multiple internal fixation products must be meticulous. At times, the surgeon may need to place these plates percutaneously. The ultimate goal is to achieve adequate fracture reduction and osseous stability while minimizing any vascular insult to the surrounding soft tissue envelope.

   When it comes to patients with diabetic neuropathy, primary arthrodesis is usually indicated for unstable midfoot neuropathic fractures and/or dislocations, neglected fractures, and pulverized intra-articular fractures.11 Primary arthrodesis of the midfoot is advantageous for the management of complete ligamentous dislocations or comminuted intra-articular fractures, and to further avoid hardware failure, late collapse and an incidence of a Charcot neuroarthropathy.

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