Limb Salvage After Failed Initial Operative Management of Bimalleolar Ankle Fractures in Diabetic Neuropathy

Primary arthrodesis for diabetic ankle fractures using a modified retrograde femoral intramedullary locking nail combined with lateral plating, surgical technique, and early results of a pilot study

PURPOSE

We aimed to report the early results of performing acute ankle arthrodesis using a modified retrograde femoral intramedullary locking IMN concomitant with plating at the same setting for managing diabetic patients' acute ankle fractures.

METHODS

We prospectively included patients who presented acutely with ankle fractures, where hemoglobin A1C (HbA1C) on admission was > 7%, and the Adelaide Fracture in the Diabetic Ankle (AFDA) algorithm score was 5 or above. All patients were treated by acute ankle arthrodesis using a modified retrograde femoral IMN combined with lateral plating. Functional assessment was reported according to a modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale (AOFAS), and complications were documented.

RESULTS

Six patients had an average age of 55.7 years (37-65). The average HbA1C on admission was 7.9 (7.3-9), and the average AFDA score was 7.3 (6-8). The average operative time was 79.2 min (70-90). All patients, except for one, achieved union at the arthrodesis site after an average of 10.3 weeks (8-14). After an average last follow-up of 9 months (6-12), the average modified AOFAS was 73.2 (82 to 62); four patients had an excellent score and one good. Complications developed in two, one deep infection after 2 weeks treated by metal removal and Ilizarov, and the other patient developed a stress fracture at the tibial end of the nail, which was treated by open reduction and internal fixation using a plate and screws.

CONCLUSION

Using a modified femoral IMN combined with lateral plating is a promising technique to achieve ankle arthrodesis in diabetic patients with acute ankle fractures with acceptable outcomes; however, further studies with larger numbers are needed.

LEVEL OF EVIDENCE

IV.

Successful Primary Treatment of Ankle Fractures in Diabetic Patients with Peripheral Neuropathy Using a Tibiotalocalcaneal Nail: A Case Series

Background

Among diabetics, patients with peripheral neuropathy are at increased risk of developing complications following an ankle fracture. While the outcomes in these patients treated nonoperatively have been poor, the outcomes in those undergoing open reduction and internal fixation are at the best modest. We hypothesize that closed reduction and internal fixation with tibiotalocalcaneal nail is an effective primary procedure in this complication prone patient group.

Methods

A retrospective review of diabetic patients with peripheral neuropathy who underwent acute treatment of an ankle fracture with closed reduction and internal fixation with a tibiotalocalcaneal nail at two Level 1 trauma centers was performed. 30 patients were identified and divided into 2 groups with respect to their postoperative weight bearing protocol: 20 patients in the early weight bearing (EWB) group and 10 patients in the touch-down weight bearing (TDWB). The primary outcome was the rate of return to baseline function and the secondary outcomes included the incidence of wound dehiscence, wound infection, implant failure, loss of fixation, loss of reduction and amputation.

Results

In the EWB group, 15/20 patients returned to their baseline function, 5/20 had wound dehiscence and infection, 2/20 had implant failure, 5/20 had loss of fixation, 4/20 had loss of reduction, and 4/20 underwent amputation. In the TDWB group, 9/10 patients returned to their baseline function, 1/10 had implant failure, 1/10 had loss of fixation. No patients from this group had loss of reduction or underwent amputation.

Conclusion

Treatment with tibiotalocalcaneal nail is an effective primary procedure in this complication prone group of patients, assuming that weight bearing is delayed for six weeks to protect soft tissues and surgical incisions.

Level of Evidence

Level IV, retrospective case series.

Diagnosis and Treatment of Neuropathic Ankle Fractures

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Standard 3-view ankle radiographs are the first-line imaging modality for suspected neuropathic ankle fractures. Computed tomography is helpful to evaluate for concomitant osseous changes and soft-tissue infection.

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Nonoperative management may be considered for low-demand, elderly, or comorbid patients for whom surgery and anesthesia are contraindicated. However, the presence of comorbidities alone should not necessarily preclude operative intervention. Given the overall poor results of nonoperative treatment in the neuropathic ankle fracture population, operative intervention may in fact be less risky to the patient.

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The authors have 2 preferred treatment techniques. For cases in which the vascular supply and bone stock are adequate, open reduction and internal fixation (ORIF) with locking fixation for the fibula, a medial buttress/hook plate with lag screws for the medial malleolus, multiple syndesmotic screws for additional fixation even in the absence of a syndesmotic injury, and temporary transfixation Steinmann pins from the calcaneus into the tibia are used. For cases in which there is a concern for wound healing or previously failed ORIF, minimally invasive surgical tibiotalocalcaneal arthrodesis with a retrograde locked intramedullary nail is used.

Diabetic Kidney Disease Is Associated With Increased Complications Following Operative Management of Ankle Fractures

Background:

Diabetes mellitus and peripheral neuropathy are established risk factors for complications in operatively treated ankle fractures. Generally, the presence of peripheral neuropathy and diabetic nephropathy have been used as independent variables in studies of diabetic ankle fracture cohorts but are typically treated as binary risk factors. Our purpose was to quantify the effects of risk factors on complication rate specific to diabetic patients undergoing ankle fracture fixation.

Methods:

We identified 617 rotational ankle fractures treated operatively at a single academic medical center from 2010 to 2019, of which 160 were identified as diabetic. Of these, 91 ankle fractures in 90 diabetic patients met criteria for retrospective review of clinical and radiographic data. Criteria included perioperative laboratory studies, including glycated hemoglobin (HbA1c) and estimated glomerular filtration rate (eGFR), as well as follow-up radiographs in the electronic record. We defined complications in this surgical cohort as deep surgical site infection, unplanned return to the operating room, and failure of fixation. Logistic regression was performed and odds ratios (ORs) calculated.

Results:

The overall complication rate was 28.6% (26/91) in this cohort. Median follow-up was 29 weeks (range: 5-520 weeks). Mean perioperative HbA1c in patients who experienced postoperative complications was 7.6% (range: 5.1%-14.2%) compared with 7.8% (range: 5.6%-13.5%) who did not ( P = .69). Diabetic patients with chronic kidney disease (eGFR <60 mL/min per body surface area) (OR 5.29, P = .006) and peripheral neuropathy (OR 4.61, P = .003) were at significantly higher risk of all complications compared with diabetic patients without these comorbidities. Of note, we did not find an association between perioperative HbA1c or body mass index and complication rate.

Conclusion:

Patients with diabetes complicated by chronic kidney disease are at significantly higher risk of complications following operative management of ankle fractures. Our study also corroborated previous reports that within this high-risk cohort, the presence of peripheral neuropathy is a significant risk factor for complications. These sequalae of diabetic disease are manifestations of microvascular disease, glycosylation of soft tissues, and impaired metabolic pathways. Identifying these risk factors in diabetic patients allows for patient-specific risk stratification, education, and management decisions of ankle fractures.

Level of Evidence:

Level III, retrospective cohort study.

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. 

Current concepts and challenges in managing ankle fractures in the presence of diabetes: A systematic review of the literature

BACKGROUND

Ankle fractures in diabetic patients are known to have an increased morbidity. This systematic review aims to evaluate the current evidence in terms of risk profile and inform treatment options.

METHODS

Following the methodology of the Cochrane collaboration, an extensive literature search was conducted. Outcomes included, complications, operative and non-operative management and early weight-bearing.

RESULTS

A total of 40 studies were included. Complication rates were higher in diabetic patients and more so in poorly controlled diabetes, IDDM, or "complicated" diabetes. Supplementary fixation was associated with lower complication rates. Regarding early weight-bearing, similar results to non-diabetics in the stable fracture pattern were found providing there was no evidence of neuropathy.

CONCLUSION

Diabetes, especially complicated diabetes, presents an increased risk of complications. However non operative management of diabetic ankle fractures do poorly, and with the use of 'ORIF plus' techniques there is no increase in complications from early fixation. The use of external fixation for definitive fixation should be minimised as it is associated with high complication rates.

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

Primary Arthrodesis for Diabetic Ankle Fractures

Background

Treatment of ankle fractures in patients with diabetes is associated with increased complication rates. Ankle arthrodesis is considered a salvage procedure after failed ankle fracture fixation, yet primary ankle arthrodesis has been proposed as a treatment option for patients with significant diabetes-related complications. To date, the characteristics of patients who undergo primary ankle arthrodesis and the associated outcomes have not been described.

Methods

A retrospective review was performed of 13 patients with diabetes who underwent primary arthrodesis for traumatic ankle fracture. Patient demographics were characterized in addition to their diabetes complications, Adelaide Fracture in the Diabetic Ankle (AFDA) score, and fracture type. Outcomes assessed included reoperation rates, infection rates, wound complications, nonunion/malunion, amputation, and development of Charcot arthropathy postoperatively.

Results

Patients who underwent primary arthrodesis had high rates of diabetes complications, average AFDA scores of 6.4, and high rates of severe injuries, including 38.5% open fractures and 69.2% fracture dislocations. The overall complication rate for primary arthrodesis of ankle fractures in diabetes patients was more than 75% in this cohort. Complications included a 38.5% reoperation rate, 38.5% infection rate, 53.8% wound complication rate, and 23.1% amputation rate. Despite a high nonunion rate at the attempted fusion sites, 89.9% of fractures healed and patients had a stable extremity.

Conclusion

This review is the first to characterize the epidemiology and complications of diabetes patients undergoing primary ankle arthrodesis for ankle fractures. In this cohort, patients with multiple diabetic complications and severe injuries underwent primary arthrodesis, which led to an overall high complication rate. Further research is needed to determine the appropriate treatment option for these high-risk patients, and tibiotalocalcaneal stabilization without arthrodesis may be beneficial.

Level of Evidence

Level IV, retrospective case series.

Outcomes of Primary Tibiotalocalcaneal Nailing for Complicated Diabetic Ankle Fractures

BACKGROUND

Ankle fractures in patients with complicated diabetes have significantly increased the rates of complications and poorer functional outcomes when treated nonoperatively, and there have been only modest reductions when treated operatively. We hypothesized that the minimally invasive, robust construct that tibiotalocalcaneal fixation with an intramedullary nail offers would result in high rates of limb salvage, acceptable rates of complications, and less loss of function, in this difficult patient population.

METHODS

This was an institutional review board-approved retrospective study of 27 patients with complicated diabetes who underwent tibiotalocalcaneal nailing of their ankle fracture as a primary treatment without formal joint preparation. Patients with complicated diabetes were defined as having neuropathy, nephropathy, and/or peripheral vascular disease. The mean clinical follow-up was 888 days. Patients were screened for associated risk factors. Data were collected on surgical complications. The outcomes measured included length of hospital stay, loss of ambulatory level, amputation, and time to death. The mean age was 66 years with an average body mass index of 38 and hemoglobin A1c of 7.4. Six fractures were open.

RESULTS

The limb salvage rate was 96%. The average hospital stay was 6 days, and the mean time to weightbearing was 6.7 weeks. The fracture union rate was 88%. The surgical complication rate was 18.5%, with no instances of malunions, symptomatic nonunions, or Charcot arthropathy. Eight patients died by final follow-up (mean, 1048 days). An ambulatory level was maintained in 81% of the patients.

CONCLUSION

With high limb salvage rates, relatively early weightbearing, maintained ambulatory level, and acceptable complication rates, we believe our technique can be considered an appropriate approach to increase the overall survivability of threatened limbs and lives in this patient population.

LEVEL OF EVIDENCE

Level IV, retrospective case series.