Current Insights In Treating Diabetic Foot And Ankle Trauma

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

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.

   For example, one may need to perform a medial column arthrodesis for a neuropathic navicular comminuted fracture. Severe fracture patterns that are not amenable to reconstruction are better to stabilize initially with an external fixator in order to enhance the overall alignment of the osseous segments and in preparation of a staged salvage arthrodesis. One often sees this with certain high-energy pilon and calcaneal fractures.

In Conclusion

Despite the most appropriate surgical management, many diabetic foot and ankle injuries may still have a poor prognosis. For this reason, careful evaluation and incorporation of a healthcare team with knowledge in the overall treatment of diabetes mellitus and its related complications are essential for the patient’s successful recovery.

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