Recognizing that ankle fractures in patients with diabetes can lead to potentially dire complications, these authors discuss keys to treatment that can reduce risks and improve outcomes.
Ankle fractures in patients with diabetes present challenges in operative and non-operative management. Complications arising from diabetes and its comorbidities such as neuropathy and vasculopathy are compounded by healing and rehabilitation problems that occur more often in patients with diabetes than those without diabetes.
These chronic issues stay at bay until acute trauma occurs and brings them to the forefront. An ankle fracture in a patient with diabetes can lead to an increased risk of infection, malunion, delayed union, nonunion, Charcot arthropathy, and impaired wound healing. These multiple risks can turn what at first glance appears to be a routine ankle fracture into a difficult case requiring additional strategies to avoid limb loss. It is important to understand the complications that can arise in patients with diabetes who experience ankle fractures. In a limb-threatening scenario, it is also critical to be aware of the treatment options available.
According to the Centers for Disease Control and Prevention in 2010, 25.8 million people (8.3 percent of the population) in the United States had diabetes.1 Among U.S. residents 65 years of age and older, 10.9 million (26.9 percent of the population) had diabetes. Additionally, about 1.9 million people 20 years of age or older in the United States were newly diagnosed with diabetes in 2010.
A review of more than 160,000 study patients treated for ankle fractures from 1988 through 2000 showed that 5.71 percent of the patients had diabetes.2 Those with diabetes had a greater overall percentage of in-hospital mortality, postoperative complications, length of hospital stay and non-routine discharge. Many other studies have demonstrated an increased rate of complications in patients with diabetes and ankle fractures including impaired wound healing, infection, impaired fracture healing, loss of reduction, hardware failure and Charcot arthropathy.3-9
Many authors have published articles about the incidence and types of complications of ankle fractures in patients with diabetes. These studies reflect the fact that patients with diabetes have an increased risk of complications associated with ankle fractures in comparison to those without diabetes.10,11 Possible complications in this setting include infection, malunion, delayed union, nonunion, Charcot arthropathy; all which typically need further surgical intervention or amputation.
When it comes to surgical treatment for ankle fractures in patients with diabetes, a study by Blotter and colleagues showed the relative risk for complications was 2.76 times greater in this group in comparison to their control group.4 Jones and coworkers performed a retrospective study comparing 42 patients with diabetes with controls matched for age, sex, fracture type and treatment method.10 They found that 31 percent of patients with diabetes, in comparison with 17 percent of patients without diabetes, developed complications after experiencing closed ankle fractures.
In another retrospective study, Costigan and colleagues evaluated the outcome of 84 patients with diabetes who received open reduction internal fixation (ORIF) for their ankle fractures.11 Twelve patients (14 percent) developed infections with two of those patients having both infection and Charcot changes. Several patient variables were also present. In this study, peripheral neuropathy and vasculopathy were associated with an increased risk in complications.
White and coworkers retrospectively evaluated the results of 14 open ankle fractures in patients with diabetes.8 Nine out of 14 fractures had wound complications, five of which resulted in amputation. Only three of the 14 fractures healed without consequence. These studies demonstrate that there is an increased rate of complications with ankle fractures in patients with diabetes.
Regardless of which treatment method one chooses for an ankle fracture in a patient with diabetes, an important component to preventing complications is tight glycemic control. Studies have shown that maintaining proper physiologic glucose levels helps encourage wound healing.12
Researchers have also highlighted the importance of glycemic control for fracture healing in diabetic rat model studies. A study by Beam and colleagues comparing untreated diabetic rats to diabetic rats on an insulin regimen showed improvement in fracture healing in the insulin group.13 Underlining the significance of control is the fact that a 1 percentage point reduction of hemoglobin A1c levels also decreases the rate of complications by 25 to 30 percent.14 Addressing hyperglycemia and maintaining proper glucose levels are vital to reducing the risk of ankle fracture complications in patients with diabetes.
Addressing associated ischemia that can impede fracture and/or wound healing is also necessary. The ankle-brachial index (ABI) is a reproducible, reasonably accurate non-invasive test to detect peripheral arterial disease (PAD).15,16 Other methods for evaluation include segmental pressures and pulse volume recordings (PVRs).17 Segmental pressures assist in locating the lesion and PVRs allow for segmental waveform analysis permitting evaluation of blood flow. However, the presence of an ankle fracture inhibits the use of ABIs, segmental pressures and PVRs. Instead, one can assess local perfusion by measuring the transcutaneous oxygen tension (TcPO2). The TcPO2 values have been helpful in predicting healing in patients with diabetes.18 A TcPO2 value of less than 30 mmHg points toward the need for angiography.19 Any abnormal noninvasive vascular study findings are concerning for limb ischemia and require further evaluation by a vascular specialist.
Controversy exists as to which treatment modality (conservative versus surgical intervention) is more appropriate for ankle fractures in patients with diabetes. There are only a handful of studies giving specific attention to this subject. McCormack and Leith studied patients with 26 diabetic ankle fractures, 19 of which had an ORIF.7 The remaining seven patients had casting and immobilization. Those patients treated surgically had an overall complication rate of 47 percent (5 percent with wound complications, 11 percent with infections resulting in amputations and two deaths). Patients treated conservatively had no complications. The authors therefore recommended avoiding surgical intervention in the elderly diabetic patient with lower demands.
Schon and Marks reviewed the outcomes of 28 neuropathic ankle fractures in patients with diabetes, all of whom had conservative treatment (immediate immobilization with no weightbearing or delayed immobilization).20 All fractures healed uneventfully without any complications.
There has also been argument against non-surgical intervention for diabetic ankle fractures. In a report by Connelly and Csencsitz, five patients with insulin-dependent diabetes received conservative treatment with casting for ankle fractures.5 All patients experienced at least one complication including infection, Charcot arthropathy and malunion. In their series of six ankle fractures, one resulted in a major amputation. The authors of this paper suggested that early surgical treatment is preferable to avoid poor outcomes with diabetic ankle fractures.
A displaced diabetic ankle fracture warrants surgical attention. However, surgeons must take steps in order to reduce the complications in patients with diabetes undergoing surgical intervention.
Bibbo and coworkers discussed the significance of adhering to a treatment protocol to help produce a favorable outcome for diabetic ankle fractures.3 First, one should assess the fracture type and bone and soft tissue quality since this will influence the treatment path. If necessary, perform closed reduction of a grossly disfigured ankle fracture to avoid ischemic complications and wound development. At this point, one should assess the stability of the ankle fracture. If one cannot maintain reduction in a splint, consider other alternatives to promote stability. Options at this point include immediate ORIF versus external fixation. External fixators can allow for staged surgical intervention in very unstable ankle fractures or facilitate definitive treatment.
Authors have shown low wound complication rates with a staged protocol in patients with high-energy pilon fractures.22,23 In this scenario, patients with high-energy pilon fractures are comparable to patients with diabetic ankle fractures since both are at high risk for wound complications and require a period of soft tissue stabilization before open treatment.
However, since patients with diabetes are at greater risk, it may be more difficult to avoid complications despite the attempt to do so. Strategies for treatment of an ankle fracture with complications can include: multiple debridements, use of an external fixator for stability and accommodation of soft tissue problems, antibiotics, antibiotic-impregnated implants, wound closure with flaps and/or skin grafts, and arthrodesis for definitive treatment.
Zalavras and colleagues retrospectively reviewed the outcomes of 26 patients without diabetes treated for infection following operative treatment of ankle fractures.24 Eleven of these patients presenting up to 10 weeks postoperatively had debridement with hardware retention if the fracture and hardware was stable. Fifteen patients presenting 11 weeks or more postoperatively had debridement and removal of hardware. Three of the 26 patients required soft tissue coverage via a sural flap after debridement. Patients also received culture-specific antibiotics. Infection recurred in five of 18 patients upon follow-up, three of which were controlled with repeat debridement. The remaining two patients required below knee amputations. This study highlights the difficulty in treating complicated ankle fractures. In this case, the ankle fractures were complicated by postoperative infection.
Patients with diabetes who experience ankle fractures are at more risk for complications than non-diabetics. Neuropathy, vasculopathy, delayed fracture healing and Charcot arthropathy can turn a routine ankle fracture into a limb-threatening situation. Proper management of diabetes and tight glycemic control are key to avoiding complications. Consult vascular specialists immediately when there is evidence of ischemia or PAD that needs to be evaluated and addressed before planned treatment.
Many conservative and surgical treatment options exist, but maintaining stability and managing the soft tissue envelope are essential in minimizing complications. When complications arise in diabetic ankle fractures, strategies consisting of multiple surgeries and adjunct treatments are required to prevent limb loss.
Dr. Chan is a third-year resident at White Memorial Medical Center in Los Angeles.
Dr. Pougatsch is a Surgical Limb Salvage Fellow at the Amputation Prevention Center at Valley Presbyterian Hospital in Van Nuys, Calif. and a Clinical Instructor at the College of Podiatric Medicine at Western University of Health Sciences in Pomona, Calif.
Dr. Belczyk is a Fellow of the American College of Foot and Ankle Surgeons, and is board qualified in both foot surgery and reconstructive rearfoot/ankle surgery by the American Board of Podiatric Surgery. He is a consultant physician at the Amputation Prevention Center at Valley Presbyterian Hospital in Van Nuys, Calif. He is the Fellowship Director of the Surgical Limb Salvage Fellowship at Valley Presbyterian and Clinical Assistant Professor Podiatric Medicine and Surgery at the College of Podiatric Medicine at Western University of Health Sciences in Pomona, Calif.
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