Essential Pearls On Treating Diabetic Ankle Fractures

Author(s): 
Keith D. Cook, DPM, FACFAS, Carl Brandon Lindberg, DPM, and Joseph Genualdi, DPM

   The risk of postoperative complications with diabetic ankle fractures is reportedly nearly three times that of non-diabetic groups.18 The aforementioned comorbidities associated with complicated diabetes can result in a high rate of postoperative complications when using traditional hardware and fixation techniques.19

   Patients with diabetes as a whole have decreased bone mineral density and research has proven that osteoporotic fracture healing can benefit from the use of locking plates.20 The technology of locking plates is designed to eliminate toggle, thereby increasing the force needed to produce failure of the hardware.20

   In patients with peripheral arterial disease and neuropathy, open reduction with internal fixation has significant risks for complications of wound healing, fracture malalignment and the development of Charcot neuroarthropathy.12-13 A comprehensive evaluation and ancillary testing as needed should occur prior to taking these patients to the operating room. Researchers have recently described supplemental fixation methods to aid in fracture healing and the prevention of complications. One such method includes standard ORIF with the temporary placement of Steinmann pins across the subtalar and ankle joints.19,21

   An alternative technique involves lateral plating of the fibula with the use of multiple transsyndesmotic screws.22-23 The study authors believe one should not remove these transsyndesmotic screws in the patient with diabetic comorbidities unless complications necessitate removal. The combined use of external and internal fixation may also augment stability and allow for preservation of soft tissue. Both static and dynamic fixation can allow for bone healing with adequate reduction and alignment of the fracture deformity. One may also use percutaneous fixation techniques to prevent soft tissue envelope complications.

In Conclusion

Diabetic ankle fractures can be difficult injuries to treat given the increased rate of complications. Evaluating patients for comorbidities at the time of diagnosis is paramount to selecting proper treatment options in order to minimize complications. Foot and ankle surgeons must be aware of predictors of poor outcomes such as peripheral neuropathy, peripheral arterial disease and a history of Charcot neuroarthropathy.

   For isolated, non-displaced ankle fractures, conservative treatment may be the best option. Following medical optimization of the patient, one can treat displaced ankle fractures with open reduction and internal fixation. The use of locking plates, additional augmented internal fixation and/or external fixation to increase fracture stability all play a role in preventing complications and allowing the fractures to heal properly. Patient education on blood glucose control and adherence with an extended period of non-weightbearing are necessary to promote successful outcomes.

   Dr. Cook is the Director of Podiatric Medical Education at University Hospital in Newark, N.J. He is a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Lindberg is a third-year resident in the Podiatric Medicine and Surgery Residency Program at University Hospital in Newark, N.J.

   Dr. Genualdi is a first-year resident in the Podiatric Medicine and Surgery Residency Program at University Hospital in Newark, N.J.

References

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