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.

One- and Two-Year Analysis of a Five-Year Prospective Multicenter Study Assessing Radiographic and Patient-Reported Outcomes Following Triplanar First Tarsometatarsal Arthrodesis With Early Weightbearing for Symptomatic Hallux Valgus

We report one- and 2-year results of a prospective, 5-year, multicenter study of radiographic, clinical, and patient-reported outcomes following triplanar first tarsometatarsal arthrodesis with early weightbearing. One-hundred and seventeen patients were included with a mean (95% confidence interval [CI]) follow-up time of 16.6 (15.5, 17.7) months. Mean (95% CI) time to weightbearing in a boot walker was 7.8 (6.6, 9.1) days, mean time to return to athletic shoes was 45.0 (43.5, 46.6) days, and mean time to return to unrestricted activity was 121.0 (114.5, 127.5) days. There was a significant improvement in radiographic measures with a mean corrective change of -18.0° (-19.6, -16.4) for hallux valgus angle, -8.3° (-8.9, -7.8) for intermetatarsal angle and -2.9 (-3.2, -2.7) for tibial sesamoid position at 12 months (n = 108). Additionally, there was a significant improvement in patient-reported outcomes (Visual Analog Scale, Manchester-Oxford Foot Questionnaire, and Patient-Reported Outcomes Measurement Information System) and changes were maintained at 12 and 24 months postoperatively. There was 1/117 (0.9%) reported recurrence of hallux valgus at 12 months. There were 16/117 (13.7%) subjects who experienced clinical complications of which 10/117 (8.5%) were related to hardware. Of the 7/117 (6.0%) who underwent reoperation, only 1/117 (0.9%) underwent surgery for a nonunion. The results of the interim report of this prospective, multicenter study demonstrate favorable clinical and radiographic improvement of the HV deformity, early return to weightbearing, low recurrence, and low rate of complications.

Amputation and infection are the greatest fears in patients with diabetes foot complications

AIMS

To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications.

METHODS

478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy.

RESULTS

Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation.

CONCLUSION

Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.

Are Readmission and Reoperation Rates for Lower Extremity Necrotizing Fasciitis Different Between Patients With and Without Diabetes Mellitus?

Necrotizing fasciitis is a condition associated with high morbidity and mortality unless emergent surgery is performed. This study aims to understand the hospital course of diabetic and nondiabetic patients managed for lower-extremity necrotizing fasciitis by identifying factors contributing to readmissions and reoperations. About 562 patients treated for lower-extremity necrotizing fasciitis were selected from the American College of Surgeons-National Surgical Quality Improvement Program database between 2012 and 2017. The unplanned reoperation and readmission rates for all patients during the 30-day postoperative period were 9.4% and 5.3%, respectively. Out of 562 patients with lower-extremity necrotizing fasciitis, 326 (58.0%) patients had diabetes. Diabetes patients were more likely to undergo amputation (p < .00001). Neither readmission (6.1% vs 4.2%, p = .411) nor reoperation (8.6% vs 10.6%, p = .482) were significantly different between patients with and without diabetes. Neither readmission (7.2% vs 4.0%, p = .159) nor reoperation (4.1% vs 3.7%, p = .842) were significantly different between patients undergoing amputation and nonamputation procedures. In simple logistic regression, factors associated with unplanned reoperation included poorer renal function, thrombocytopenia, longer duration of surgery, longer hospital length of stay, postoperative surgical site infection, postoperative respiratory distress, and postoperative septic shock. Body mass index >30 kg/m² was associated with decreased odds of readmission. In multiple logistic regression, surgical site infection was the only predictor of reoperation (adjusted odds ratio 7.32, 95% confidence interval 2.76-19.1), and any amputation was associated with readmission (adjusted odds ratio 4.53, 95% confidence interval 1.20-29.6). Further study is needed to understand patient characteristics to better direct management. However, the current study elucidates patient outcomes for a relatively rare condition.

Insulin Dependence Increases the Risk of 30-Day Postoperative Complications Following Ankle Fracture Surgery in Patients With Diabetes Mellitus

Patients with diabetes mellitus that undergo ankle fracture surgery have higher rates of postoperative complications compared to patients without diabetes mellitus. We evaluated the rate of complications in insulin-dependent diabetes mellitus patients, non-insulin-dependent diabetes mellitus patients, and patients without diabetes in the 30-day postoperative period following ankle fracture surgery. We also analyzed hospital length of stay, unplanned readmission, unplanned reoperation, and death. Patients who underwent operative management for ankle fractures between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database using Current Procedural Terminology codes. Multiple logistic regression was implemented. Adjusted odds ratios were calculated along with the 95% confidence interval. A total of 19,547 patients undergoing ankle surgery were identified from 2012 to 2016. Of these patients, 989 (5.06%) had insulin-dependent diabetes mellitus, 1256 (6.43%) had noninsulin-dependent diabetes mellitus, and 17,302 (88.51%) did not have diabetes mellitus. Compared to patients without diabetes, patients with insulin-dependent diabetes mellitus had significantly greater adjusted odds of superficial surgical site infections, deep surgical site infections, osteomyelitis, wound dehiscence, pneumonia, unplanned intubation, mechanical ventilation, urinary tract infection, cardiac arrest, bleeding requiring transfusion, sepsis, hospital length of stay, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery. We demonstrate that insulin-dependent diabetes mellitus is a strong predictor of 30-day postoperative complications, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery.

Is Routine Hardware Removal Following Open Reduction Internal Fixation of Tarsometatarsal Joint Fracture/Dislocation Necessary?

Open reduction internal fixation (ORIF) is an accepted treatment for displaced tarsometatarsal joint (TMTJ) fracture dislocations. In general, hardware is routinely removed after 4 months to allow restoration of joint motion and avoid complications of hardware failure. Because few studies report outcomes of TMTJ fractures with retained hardware, there is little consensus regarding the optimal time for hardware removal or if hardware retention leads to adverse outcomes. We retrospectively reviewed the radiographic outcomes of retained hardware after ORIF of TMTJ fractures/dislocations in 61 patients. The mean age at the time of operation was 37.3 ± 14.9 years. ORIF was performed with 3.5 fully threaded cortical screws. Assessment of clinical and radiographic results was performed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgical treatment. Out of the 61 patients that were included in this study, only 2 demographic variables demonstrated a trend for an adverse outcome. Older age correlated with lost reduction and elevated body mass index correlated with hardware failure. The presence of diabetes was correlated with an increased risk of postoperative infection but not hardware failure. During our follow-up period there were 49 patients (80.3 %) without failure of fixation. In conclusion, our study suggests that routine removal of hardware following open reduction and internal fixation of Lisfranc injuries in patients may not be necessary.

Three-Dimensional Computed Tomographic Characterization of Normal Anatomic Morphology and Variations of the Distal Tibiofibular Syndesmosis

Malreduction of distal tibiofibular syndesmosis (DTFS) leads to poor functional outcomes after ankle fracture surgery. Difficulty achieving anatomic alignment of the syndesmosis is due to variable morphology of the fibular incisura of the tibia and a paucity of literature regarding its morphologic characteristics. We surveyed 775 consecutive ankle computed tomography (CT) scans performed from June 2008 to December 2011, and 203 (26.2%) were included for evaluation. Two observers performed quantitative measurements and qualitative evaluated fibular incisura morphology. Tang ratios for fibular rotation, anterior and posterior tibiofibular distances, fibular incisura depth, and subjective morphologies on CT were assessed using conventional multiplanar reconstruction (MPR) and maximum intensity projections (MIPs). On conventional CT, the mean Tang ratio was 0.97 ± 0.06; the mean anterior tibiofibular distance was 2.17 ± 0.87 mm; the mean posterior tibiofibular distance was 3.52 ± 0.94 mm; and the mean depth of fibular incisura was 3.29 ± 1.19 mm. Five morphologic variations of the fibular incisura were identified: crescentic, trapezoid, flat, chevron, and widow's peak. The most common fibular incisura morphology was crescentic (61.3%), followed by trapezoid shape (25.1%); the least common morphology was flat (3.1%). Interobserver variability with intraclass correlation coefficient (ICC) was slightly higher for all quantitative measures on MPR (ICC = 0.72 to .81) versus MIP (ICC = 0.64 to 0.75). ICC for incisura shape and depth assessments was poor on both modalities (0.13 to 0.38). This comprehensive CT study reports on quantitative and qualitative descriptive measures to evaluate fibular incisura morphologies and fibular orientation. It also defines the frequency of DTFS measures and the interobserver performance on 2 CT evaluation methods.

Gender Differences on SF-36 Patient-Reported Outcomes of Diabetic Foot Disease

The primary aim of this study was to evaluate the impact of gender on health-related quality of life (HRQOL) using a generic (Short Form-36 [SF-36]) and region-specific (Foot and Ankle Ability Measure [FAAM]) health measurement tool among a matched cohort of male and female patients with diabetes-related foot complications. The HRQOL of 240 patients with diabetic foot disease was measured using the SF-36 and the FAAM surveys. A total of 120 male patients were matched with 120 female patients with the same primary diagnosis, age, type, and duration of diabetes and insulin use. The SF-36 physical component summary (PCS) and mental component summary (MCS) scores were calculated using orthogonal and oblique rotation methods. The median age of the respondents was 54 years (interquartile range = 46-61). No differences in patient characteristics were found between genders. Among the SF-36 subscales, women reported significantly worse physical function ( P = .014) and bodily pain ( P = .021) scores with a trending decrease in general health score ( P = .067). Subsequently, women had worse orthogonal ( P = .009) and oblique PCS scores ( P = .036) than men. However, orthogonal ( P = .427) or oblique ( P = .140) MCS scores did not differ between groups. No significant differences in FAAM scores with respect to gender were appreciated. Our findings suggest that in patients with diabetic foot disease, women tend to report lower physical HRQOL compared with men. In efforts to increase compliance, providers should recognize the impact of gender on patients' perceptions of foot-related complications of diabetes. This knowledge may improve outcomes by adapting more individualized and gender-specific approaches to patients.

Scoring Mental Health Quality of Life With the SF-36 in Patients With and Without Diabetes Foot Complications

The aim of this study was to examine if using orthogonal and oblique factor analysis detect changes in health-related quality of life differently in diabetic patients on the Short Form-36 (SF-36) survey. A total of 155 patients had diabetic foot complications (DFC), and 145 patients had no DFCs. The SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were calculated using scoring coefficients determined by orthogonal and oblique rotation principle component analyses of the subscales. The DFC group had lower orthogonal ( P < .00001) and oblique PCS scores ( P < .00001). However, despite lower Mental Health subscale scores in the patients with DFCs, orthogonal MCS scores ( P = .156) did not differ. In contrast, the oblique MCS scores reflected the difference in the Mental Health subscale ( P = .0005). Orthogonal and oblique PCS scores did not differ significantly. However, orthogonal MCS scores were significantly higher than oblique MCS scores in those with DFCs ( P = .0004) and without DFCs ( P = .005). The shorter, 12-item SF-12 survey demonstrated similar results. Poorer physical function leads to higher orthogonal MCS scores than if determined by oblique scoring coefficients since Physical Function, Bodily Pain, and General Health are weighted more negatively in orthogonal coefficients when calculating the MCS score. Oblique scoring coefficients may address this issue, but further study is necessary to confirm whether oblique MCS scores accurately represent the mental health of patients with diabetic foot disease.

Kinematic Magnetic Resonance Imaging of Peroneal Tendon Subluxation with Intraoperative Correlation

Magnetic resonance imaging (MRI) is a noninvasive modality of choice for the detection of static peroneal tendon pathologic features. The depiction of peroneal tendon subluxation using real-time kinematic MRI has not been previously reported. We describe the MRI and intraoperative correlation of peroneal tendon and retinacular pathologic findings, and the novel use of kinematic MRI in the illustration of peroneal tendon subluxation.