Ankle fractures in diabetics

Outcomes of surgical management of ankle fractures in patients with diabetes

Objective

Ankle fracture surgeries among diabetic are common and can have fatal consequences and serious adverse outcomes. A target hemoglobin A1c (HbA1c) level <8% in all elective surgeries for patients with diabetes is suggested to minimize poor outcomes. We investigated the postoperative outcomes and complications among patients who underwent ankle fracture surgery using HbA1c level as a predictor value.

Methods

This retrospective cohort study was conducted at King Abdulaziz Medical City between January 2016 and December 2022 on all patients with diabetes who underwent open reduction and internal fixation and who had a documented HbA1c level. Radiological outcomes and complications were noted along with the levels of HbA1c and analyzed statistically.

Results

A total of 44 patients were included in the study: 29 women (65.9%) and 15 (34.1%) men. The most frequent ankle fracture type was bimalleolar (54.5%). HbA1c was elevated (54.5%) in patients. A significantly higher proportion of patients who had <8% HbA1c level had radiological union compared to patients who had ≥8% HbA1c level (p = 0.036). Patients who had elevated HbA1c level had more complications although it did not reach statistical significance (p > 0.05). Multivariate regression analysis showed that age and HbA1c level were the significant factors for an uncomplicated and successful ankle surgery.

Conclusion

Poor postoperative outcomes and complications are more common among patients with elevated HbA1c. This suggests that an elevated HbA1c level is associated with a poor treatment outcome. Determination of HbA1c levels may predict potential problems post ankle fracture surgery and improve management outcomes.

Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

How Effective is Fibula Pro Tibia Plating in Treatment of Distal Tibial Fractures: A Pilot Study

Introduction

Despite recent advances, management of distal tibial fractures is challenging, with high rate of complications. Fibula pro tibia plating technique fixes fibula and tibia together, via laterally placed fibular plate without disturbing the tibial soft tissue sleeve. We contemplated this pilot study to assess effectiveness of fibula pro tibia plating in management of distal tibia fibula fractures.

Materials and Methods

A total of 30 patients with distal tibia fibula fractures with fracture line extending within 5cm from tibial plafond were managed with fibula pro tibia plating, with or without minimal articular fixation. Outcome evaluation was done by union, union time, alignment and functional outcome as assessed by AOFAS score.

Results

Mean age in the series was 39.4 years with male to female ratio of 3:2. Mean duration of surgery, blood loss and C arm exposure were 79 minutes (range 52 to 98min), 80ml (range 62 to 102ml) and 48 shoots (range 36 to 81 shoots), respectively. All fractures united in mean union time of 10.2 weeks (range 9 to 14 weeks) with acceptable alignment in all the patients except one. Mean AOFAS score was 86.3 (range 70 to 93) with 29 patients having good to excellent outcome. One patient had varus malunion and in one case infection was seen.

Conclusion

Fibula pro tibia plating can be successfully used to manage complex distal tibia fractures which leaves the soft tissue and periosteal sleeve undisturbed, thus avoiding wound related problems and leading to early union.

Calcaneal tuberosity avulsion fractures - A review

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

Fractures and dislocations of the foot and ankle in people with diabetes: a literature review

Diabetes (DM) increases fracture risk, and bone quality depends on type diabetes type, duration, and other comorbidities. Diabetes is associated with a 32% increased relative risk (RR) of total fractures and 24% increased RR of ankle fractures compared with patients without DM. Type 2 DM is associated with a 37% increased RR of foot fractures compared with patients without DM. The incidence of ankle fractures in the general population is 169/100,000 per year, while foot fractures occur less frequently, with an incidence of 142/100,000 per year. Biomechanical properties of bone are negatively impacted by stiff collagen, contributing to the increased risk of fragility fractures in patients with DM. Systemic elevation of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNFα), interleukin-1β (IL-1β), and interleukin 6 (IL-6), impact bone healing in patients with DM. Fractures in patients with DM, can be associated with poorly regulated levels of RANKL (receptor activator of nuclear transcription factor kappa-b ligand) leading to prolonged osteoclastogenesis, and net bone resorption. One of the most salient factors in treating fractures and dislocations of the foot and ankle is to recognize the difference between patients with uncomplicated and complicated DM. Complicated diabetes is defined as 'end organ damage', and for the purposes of this review, includes patients with neuropathy, peripheral artery disease (PAD) and/or chronic renal disease. Uncomplicated diabetes is not associated with 'end organ damage'. Foot and ankle fractures in patients with complicated DM pose challenges, and surgery is associated with increased risks of impaired wound healing, delayed fracture healing, malunion, infection, surgical site infection, and revision surgery. While patients with uncomplicated DM can be treated like patients without DM, patients with complicated DM require close follow-up and robust fixation methods should be considered to withstand the anticipated prolonged healing period. The aims of this review are as follows: (1) to review pertinent aspects of DM bone physiology and fracture healing, (2) to review the recent literature on treatment of foot and ankle fractures in patients with complicated DM, and (3) to provide treatment protocols based on the recent published evidence.

Ankle Fractures in Diabetic Patients: A Critical Analysis

»

Patients with diabetes are at higher risk for complications after surgical fixation of unstable fractures due to impaired neurovascular functioning and wound-healing capabilities.

»

Patients with uncontrolled diabetes have higher rates of complications when compared with patients with controlled diabetes.

»

Despite higher rates of complications, operative fixation of unstable ankle fractures in diabetic patients reliably leads to a functional lower extremity with an overall lower rate of complications than nonoperative management.

»

Operatively and nonoperatively managed ankle fractures in patients with diabetes should remain non-weight-bearing for an extended period of time.

»

Discussion of risk of poor outcomes including deep infection, loss of reduction, return to the operating room, and risk of arthrodesis or amputation should be explicitly discussed with patients and families when managing unstable ankle fractures in diabetic patients.

Ankle Fractures in Diabetic Patients: Report of Two Cases

Although ankle fractures are very common cases for orthopedic surgeons with an easy diagnosis and very good outcomes either with conservative or with operative treatment, in diabetic patients, these fractures can be complex with difficult solutions. We report two cases with ankle fractures in diabetic patients from our department with demanding diagnostic or therapeutic approaches and poor outcomes. The first case, a 65-year-old man with undiagnosed diabetes mellitus and neglected ankle fracture dislocation because of diabetic neuropathy, underwent open reduction internal fixation with additional external fixation. Early after the operation, he presented with pin-tract infection, and later after the operation, he developed osteomyelitis which led to salvage below-knee amputation. In the second case, a 70-year-old woman with diabetes mellitus and severe coexisting medical comorbidities underwent open reduction internal fixation plus external fixation for an acute fracture-dislocation of the left ankle. Early after the operation, she developed ischemic lesions of the toes with worsened status despite the vascular surgeon's instructions. Although a below-knee amputation could be an acceptable choice, she denied it. As a result, systematic complications led to her death. It is very important for surgeons to follow an algorithm when they have to manage ankle injuries in diabetic patients because, in these patients, ankle fractures are very demanding and misdiagnosed cases with difficult treatment algorithms and often poor outcomes. 

Ankle fractures in the elderly: Current concepts

Ankle fractures remain the third most common musculoskeletal injury in the elderly population. The presence of osteoporosis, significant multiple comorbidities and limited functional independence makes treatment of such injuries challenging. Early studies highlighted high rates of post-operative complications and poor outcomes after surgical intervention. With advances in surgical techniques and a greater understanding of multi-disciplinary team (MDT)-driven peri-operative care and rehabilitation, evidence now appears to suggest improved outcomes for operative management. Approaches must be adapted according to co-morbidities, baseline function and patient wishes. This review article aims to discuss contemporary treatment strategies and the complex challenges associated with the management of the elderly ankle fracture.

Ankle fractures in diabetic patients

Surgical complications are more common in patients with complicated diabetes (presence of inner organ failure, neuropathy).

Of all patients undergoing ankle fracture fixation, approximately 13% are diabetic and 2% have complicated diabetes mellitus.

Non-operative management of ankle fractures in patients with complicated diabetes results in an even higher rate of complications.

Insufficient stability of ankle fractures (treated operatively, or non-operatively) can trigger Charcot neuroarthropathy, and result in bone loss, deformity, ulceration, and the need for amputation.

Rigid fixation is recommended. Hindfoot arthrodesis (as primary procedure or after failed ankle fracture management) can salvage the limb in approximately 80% of patients.

Early protected weight bearing can be allowed, provided rigid fixation without deformity has been achieved.

Cite this article: EFORT Open Rev 2020;5:457-463. DOI: 10.1302/2058-5241.5.200025

Increased Rates of Readmission, Reoperation, and Mortality Following Open Reduction and Internal Fixation of Ankle Fractures Are Associated With Diabetes Mellitus

The purpose of this study was to compare the rates of readmission, reoperation, and mortality in patients with and without diabetes mellitus during the 30-day postoperative period after ankle fracture surgery. Patients who underwent operative management for ankle fractures between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program^® database by using Current Procedural Terminology codes for ankle fracture surgery. A total of 17,464 patients undergoing ankle fracture surgery were identified. Of these patients, 2044 (11.7%) had diabetes and 15,420 (88.3%) did not have diabetes. We excluded patients older than 90 years or with inadequate perioperative data. Patients with diabetes had significantly higher rates of readmission (2.84% vs 1.05%, p < .0001), significantly higher rates of unplanned reoperation (2.3% vs 0.74%, p < .0001), and significantly higher rates of mortality (0.7% vs 0.2%, p < .0001) compared with patients without diabetes. Additionally, patients with diabetes had significantly greater age-adjusted odds ratios (ORs) of unplanned readmission (OR 2.40, 95% confidence interval [CI] 1.74 to 3.31, p < .0001), unplanned reoperation (OR 2.56, 95% CI 1.44 to 3.27, p < .0001), and mortality (OR 2.01, 95% CI 1.08 to 3.62, p = .0432) than did patients without diabetes after ankle surgery. In this large-scale retrospective study, we demonstrated that the presence of diabetes significantly increases the risk of unplanned readmission, unplanned reoperation, and mortality during the 30-day postoperative period after ankle fracture surgery.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Effect of the blood HbA1c level on surgical treatment outcomes of diabetics with ankle fractures

OBJECTIVE

To investigate whether blood haemoglobin A 1c (HbA1c) levels was predicative of diabetic patients' responsiveness to surgical treatment of ankle fractures.

METHODS

The relationship between blood HbA1c levels and surgical treatment outcomes of 21 diabetic patients undergoing open reduction internal fixation (ORIF) for ankle fractures was analyzed with Pearson correlation testing and t testing. All patients were treated with ORIF using standard surgical techniques. Treatment outcomes were defined using radiological outcome, the American Orthopaedic Foot and Ankle Score (AOFAS) ankle-hindfoot scale score, surgical revision rate, and complication rate.

RESULTS

HbA1c levels were found to have a statistically significant correlation with poor radiological outcomes (r = 0.547) and AOFAS ankle-hindfoot scores (r = -0.592). Additionally, though rates of poor radiological outcome, revision, and complication were high in the diabetic population as a whole, these rates were considerably higher among individuals with elevated HbA1c (≥6.5%) and considerably lower among individuals with lower HbA1c (<6.5%) levels.

CONCLUSION

Blood HbA1c levels appear to be predictive of risk and complication rates in the surgical treatment outcomes of diabetic patients with ankle fractures.

Diabetic ankle fractures: a review of the literature and an introduction to the Adelaide fracture in the diabetic ankle algorithm and score

Diabetics who have acquired an ankle fracture may be easily missed given their atypical presentation. As such, it is not infrequently seen that these patients are either initially misdiagnosed or ineffectively managed resulting in unnecessary hospital length of stay and procedures. Multiple review articles and retrospective studies have been previously published in the literature, but complete guidelines to assist in accurate diagnosis and cost-effective management for this complex problem do not currently exist. Through a critical analysis of the current literature, a proposed diagnostic and management algorithm and scoring system that can be used to quantify risks in the surgical management are presented for consideration.

Orthopaedic surgery and the diabetic Charcot foot

Many surgical and nonsurgical options exist with the aim of improving quality of life and preventing amputation in patients with CN. A multidisciplinary approach is necessary to achieve the best outcomes in this high-risk group. Modern advanced diagnostic and imaging techniques have improved knowledge regarding the biomechanics, biology, and pathophysiology of CN. Despite these advances, surgical management has lagged behind and is based largely on retrospective case series and expert opinion. Although the surgeons of today are better equipped to manage CN, the optimal timing and specific method of surgical treatment have yet to be defined. Multicenter, prospective studies may be the best way to study this relatively uncommon problem.

Factors associated with nonunion, delayed union, and malunion in foot and ankle surgery in diabetic patients

The incidence of bone healing complications in diabetic patients is believed to be high after foot and ankle surgery. Although the association of hyperglycemia with bone healing complications has been well documented, little clinical information is available to show which diabetes-related comorbidities directly affect bone healing. Our goal was to better understand the risk factors associated with poor bone healing in the diabetic population through an exploratory, observational, retrospective, cohort study. To this end, 165 diabetic patients who had undergone arthrodesis, osteotomy, or fracture reduction were enrolled in the study to assess the risk factors associated with nonunion, delayed union, and malunion after elective and nonelective foot and/or ankle surgery. Bivariate analyses showed that a history of foot ulcer, peripheral neuropathy, and surgery duration were statistically significantly associated with bone healing complications. After adjusting for other covariates, only peripheral neuropathy, surgery duration, and hemoglobin A1c levels >7% were significantly associated statistically with bone healing complications. Of the risk factors we considered, peripheral neuropathy had the strongest association with bone healing complications.

Diabetic calcaneal fractures

Calcaneal fractures among the diabetic population are severe and complex injuries that warrant careful evaluation in an effort to carry out adequate conservative or surgical management. The complication rates associated with diabetic fracture management are increased and may include poor wound healing, deep infection, malunion, and Charcot neuroarthropathy, each of which can pose a risk for limb loss. The significant surgery-associated morbidity accompanying diabetic calcaneal fractures has led to improved methods of calcaneal fracture management. This article reviews the overall management of diabetic calcaneal fractures, complications, and outcomes.

Double row anchor fixation: a novel technique for a diabetic calanceal insufficiency avulsion fracture

Avulsion fractures of the calcaneal tuberosity represent only 1.3% to 2.7% of calcaneal fractures. These fractures are common pathologically in nature and attributed to decreased bone mineral density. Calcaneal insufficiency avulsion (CIA) fracture in patients with diabetes mellitus is most likely due to Charcot neuroarthropathy (CN) as described by the Brodsky classification (Brodsky 3B). Traditional open reduction and internal fixation is difficult in all calcaneal avulsion fractures because of poor bone quality. The authors report the first known description of the use of fracture fragment excision and double row anchor fixation.A 39-year-old woman with type I diabetes mellitus and a history of CN presented with an avulsion fracture of the calcaneal tuberosity. Excision of the fracture fragment and a gastrocnemius recession and reattachment of the Achilles tendon with double row anchor fixation to the calcaneus were performed. At 1 year, the patient's American Orthopaedic Foot & Ankle Society rearfoot score improved from 27/100 to 88/100. CIA fractures are an infrequently described injury. Because diabetes mellitus is frequently associated with this disease, it most likely represents a CN event. Traditionally, CIA fractures have been operatively treated with open reduction internal fixation. Previous authors have described difficulty with fixation because of poor quality. In the current report, the authors describe a novel operative approach to CIA fractures through the use of double row anchor fixation and excision of the fracture fragments. The authors feel that this previously undescribed treatment is superior to traditional methods and may serve as a new treatment option for all patients who have sustained this unusual pathology regardless of the underlying cause. The current authors provide a novel operative technique that provides inherent advantages to the traditional repair of CIA fractures. We believe CIA fractures represent a CN-type event and care should be taken when evaluating and treating these patients to prevent further sequelae.

Advanced foot and ankle fixation techniques in patients with diabetes

This article presents advanced techniques and current fixation constructs that are advantageous for the management of diabetic foot and ankle trauma and Charcot neuroarthropathy. Both these pathologies are often intimately related, and the fixation constructs that are required often require sound biomechanical concepts coupled with innovative approaches to achieve bone healing and limb salvage.

Fibula-pro-tibia in plating tibial non-unions

PURPOSE

Plating non-unions of the tibial diaphysis often presents the technical problem of poor purchase of screws due to osteoporosis. To improve the stabilization, insertion of one or more screws through the plate across the tibio-fibular space to the fibula (fibula-pro-tibia plating) has been practiced. The aim of this study is to evaluate the effectiveness of the fibula-pro-tibia plating technique in managing difficult diaphyseal tibial non-unions.

METHODS

Between 2000 and 2008, 30 patients with diaphyseal non-union of tibia were managed with this technique. The time between injury and index operation ranged between six and 24 months (average, 11 months). Sixteen patients had three surgical procedures before the index operation, ten had two procedures and four patients had one.

RESULTS

The duration of follow-up ranged between ten and 38 months (average 26 months). The mean healing time was 3.5 months. Complications were minimal and included two cases of delayed union which required regrafting after four months and two cases, which had infected nonunion, had reactivation of the infection, which resolved completely after achieving union and removing the plates. There was no negative effect from this fixation technique on the ankle joint motion.

CONCLUSION

The fibula-pro-tibia plating technique is an effective variation in plating diaphyseal tibial non-unions.

Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes

BACKGROUND

Patients with diabetes who sustain an ankle fracture are at increased risk for complications including higher rates of in hospital mortality, in-hospital postoperative complications, length of stay and non-routine discharges. The purpose of this study was to retrospectively compare the complications associated with operatively treated ankle fractures in a group of patients with uncomplicated diabetes versus a group of patients with complicated diabetes. Complicated diabetes was defined as diabetes associated with end organ damage such as peripheral neuropathy, nephropathy and/or PAD. Uncomplicated diabetes was defined as diabetes without any of these associated conditions. Our hypothesis was that patients with uncomplicated diabetes would experience fewer complications than those patients with complicated diabetes.

MATERIALS AND METHODS

We compared the complication rates of ankle fracture repair in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes and calculated odds ratios (OR) for significant findings.

RESULTS

At a mean followup of 21.4 months we found that patients with complicated diabetes had 3.8 times increased risk of overall complications 3.4 times increased risk of a non-infectious complication (malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis when compared to patients with uncomplicated diabetes. Open ankle fractures in this diabetic population were associated with a three times higher rate of complications and 3.7 times higher rate of infection.

CONCLUSION

Patients with complicated diabetes have an increased risk of complications after ankle fracture surgery compared to patients with uncomplicated diabetes. Careful preoperative evaluation of the neurovascular status is mandatory, since many patients with diabetes do not recognize that they have neuropathy and/or peripheral artery disease.

Open calcaneal fractures in diabetic patients with neuropathy: a report of three cases and literature review

Level of Evidence: V, Case Report

The management of ankle fractures in patients with diabetes

Patients with diabetes mellitus have higher complication rates following both open and closed management of ankle fractures. Diabetic patients with neuropathy or vasculopathy have higher complication rates than both diabetic patients without these comorbidities and nondiabetic patients. Unstable ankle fractures in diabetic patients without neuropathy or vasculopathy are best treated with open reduction and internal fixation with use of standard techniques. Patients with neuropathy or vasculopathy are at increased risk for both soft-tissue and osseous complications, including delayed union and nonunion. Careful soft-tissue management as well as stable, rigid internal fixation are crucial to obtaining a good outcome. Prolonged non-weight-bearing and subsequently protected weight-bearing are recommended following both operative and nonoperative management of ankle fractures in patients with diabetes.

Surgical reconstruction of the Charcot rearfoot and ankle

Charcot arthropathy of the rearfoot and ankle is a complex disorder. To date there are no evidence-based, universally agreed upon treatment protocols. As the number of patients who have these deformities continues to increase, surgeons' skill levels and experience grow as well. With increased technical skill, knowledge, and advances in fixation, these deformities are becoming more manageable. In the future this experience should afford the general community with evidenced-based protocols. This article discusses basic techniques in deformity planning and current uses of internal and external fixation techniques for rearfoot and ankle limb salvage.