Essential Pearls On Treating Diabetic Ankle Fractures

Keith D. Cook, DPM, FACFAS, Carl Brandon Lindberg, DPM, and Joseph Genualdi, DPM

Ankle fractures are very common injuries that foot and ankle surgeons see. An estimated 585,000 ankle fractures occur in the United States each year and 25 percent receive surgical intervention.1 Ankle fractures are the most common intraarticular fracture of a weightbearing surface and account for 9 percent of all fractures.1

   Management of ankle fractures in the subpopulation of patients with diabetes mellitus can prove to be especially challenging due to the high rate of complications associated with diabetes. Complications of diabetic ankle fractures include delayed fracture healing, malalignment, wound complications, infection and the development of Charcot neuroarthropathy.2-4

   Operative management of ankle fractures in patients with diabetes has also been associated with significant increases in hospital length of stay, mortality and cost in comparison to fractures in those without diabetes.5 Unfortunately, diabetic ankle fractures also reportedly have a high complication rate with non-operative treatment.4

What The Research Says About Complications That Affect Fracture Healing

A number of clinical case reports have noted delayed fracture healing with diabetes in comparison to non-diabetic controls.6-8 Researchers have investigated the mechanism for delayed healing in experimental rat models. Lu and colleagues compared diabetic rats to a control group and found them to have decreased expression of osteocalcin, type I collagen and transcription factors that enable the differentiation of osteoblasts.9 Administering insulin resulted in a substantial reversal in these findings.

   In another study, Kayal and coworkers found diabetic rats to have similar cartilage formation during the initial stage of callus formation in comparison to non-diabetic rats. However, on day 16, diabetic rats had decreased fracture callus size, cartilaginous tissue and new bone area in comparison to the control group.10 Additionally, Bibbo and colleagues found the rate of healing in patients with diabetes to be nearly double that of patients without diabetes independent of treatment type.11

   Patients with diabetes and associated comorbidities also have an increased rate of complications. Diabetes-related comorbidities, which may have a negative effect on fracture healing, include peripheral arterial disease (PAD), peripheral neuropathy, Charcot neuroarthropathy and nephropathy.

   Jones and colleagues compared ankle fractures in patients with diabetes to patients without diabetes mellitus, analyzing the outcomes as well as diabetic comorbidities.12 The subgroup of patients with diabetes without comorbidities had similar outcomes in comparison with the control group. However, the authors found that the subgroup of patients with diabetic comorbidities had a higher rate of complications than patients without comorbidities. The study authors also concluded there was no significant difference between conservative and surgical treatment although a history of Charcot neuroarthropathy correlated with the highest rate of complications.

   A study by Costigan and coworkers reported significantly increased rates of complications in diabetic ankle fractures treated with open reduction and internal fixation (ORIF) when there was associated comorbid conditions of PAD and/or neuropathy.13 Additional risk factors that are associated with poor healing potential in patients with diabetes are a history of smoking, hypertension, advanced age and increased body mass index.11

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