Outcomes of Ankle Fractures in Patients with Uncomplicated Versus Complicated Diabetes
UPMC Comprehensive Foot and Ankle Center, Orthopaedic, 2100 Jane St., Pittsburgh, PA 15203, USA. Foot & Ankle International
(Impact Factor: 1.51).
02/2011; 32(2):120-30. DOI: 10.3113/FAI.2011.0120
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.
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.
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.
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.
Available from: Mikko T Ovaska
- "Patients with diabetes have higher complication rates for both open and closed management of ankle fractures (McCormack and Leith 1998, Wukich and Kline 2008, Hak et al. 2011). Wound complication rates as high as 32% and 64% have been reported in diabetic patients following ORIF of closed (Flynn et al. 2000, Jones et al 2005, Wukich et al. 2011) and open (Blotter et al. 1999, White et al. 2003) ankle fractures, respectively. However , there is good evidence that operative management of an unstable ankle fracture in a diabetic patient is more likely to result in a stable and functional lower extremity compared to nonoperative treatment (Bibbo et al 2001, Wukich and Kline 2008). "
Available from: Koji Nozaka
- "Increasing numbers of patients are being diagnosed with diabetes, and they are living longer because of improvements in treatment [1-3]. Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. "
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Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. Nonunion and lengthy wound healing in high-risk patients with diabetes, particularly patients with peripheral arterial disease and renal failure, occur secondary to several clinical conditions and are often fraught with complications. Whether diabetic ankle fractures are best treated noninvasively or surgically is controversial.
A 53-year-old Japanese man fractured his right ankle. The fractured ankle was treated nonsurgically with a plaster cast. Although he remained non-weight-bearing for 3 months, radiography at 3 months showed nonunion. The nonunion was treated by Ilizarov external fixation of the ankle. The external fixator was removed 99 days postoperatively, at which time the patient exhibited anatomical and functional recovery and was able to walk without severe complications.
In patients with diabetes mellitus, severe nonunion of ankle fractures with Charcot arthropathy in which the fracture fragment diameter is very small and the use of internal fixation is difficult is a clinical challenge. Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires.
Available from: Benjamin Alan Lipsky
- "The treatment of ankle fractures in neuropathic individuals is fraught with complications, resulting in increased potential for catastrophic outcomes leading to amputation, severe deformity, and disability (39,40). Rigid internal fixation with augmented methods of achieving stability is indicated in even minimally displaced fractures due to the high risk of progression to the development of CN (49,50). "
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ABSTRACT: The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.
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