Management of Diabetic Ankle Fractures Ankle Fracture APMA 2018.pdf · The management of ankle fractures in diabetics: results of a survey of the American Orthopedic Foot and Ankle

Management of Diabetic Ankle FracturesEllianne M. Nasser, DPM, CWS, FACFAS

•Associate, Podiatry – Geisinger Health System

•Assistant Program Director, Podiatric Medicine and Surgery Residency - Geisinger Community Medical Center

Complication Rate

• 2.75 times greater risk 21 DM vs 46 control

Blotter 1999

• 14% overall complication rate 84 ORIF

Costigan 2007

• 25% major complication rate 15 DM

Jani 2003

• 42% DM vs 0% control 26 matched

McCormack 1998

DM with Comorbidities

• No significant difference in DM without comorbidities vs control

• DM with comorbidities 47% complication rate vs 14% for control Jones et al 2004 JBJS

• 3.8 times increased risk of overall complications

• 5 times increased risk for revision surgery Wukich et al 2011 FAI

Infection

• 4 times higher in DM

• 4/6 DM casted infection

• 4/19 DM operatively treated infection Flynn et al 2000

• 26 patients reviewed with post-op infection, 5 DM Zalavras et al 2009

Amputation Rate

• 9.5% BKA Blotter et al 1999

• 3.6% BKA Costigan et al 2007

• 12.5% BKA Jani et al 2003

• 8.7% complicated DM vs 3.4% uncomplicated Wukich et al 2011

Risk Factors for Complications • Peripheral neuropathy

• Surgery duration

• HbA1c>7 Shibuya et al 2013

165 DM arthrodesis/osteotomy/ORIF

• HbA1C in diabetic ankle fractures

Poor radiological outcome, revision, complications, higher with HbA1c>6.5

Liu et al 2013

21 DM ankle ORIF

Nonoperative Treatment• Increased risk for loss of

reduction/malunion McCormack & Leith 1998

• 50% incidence of skin breakdown Zinar and Brown 1994

• Significant complications with casting, advocate early surgical intervention Connolly and Csencsitz 1998

• 21 fold increased odds of complication for nonoptreatment vs operative tx Lovy et al 2016 FAI

Johnson and Yoon 2010, 57yo DM 3 wk casting

Charcot as a complication?

• 17 ankle fractures casted 7.5 weeks Charcot

• TCC 11 weeks then ankle fusion

• 82.4% achieved a stable ankle

• 17.6% BKA Ayoub 2008

• 68yo male

• DM, HTN, Hyperchol, RA, sciatica, CAD, PAD, Afib

• s/p cardiac stenting, fem-pop bypass

• HbA1C: 9.6

• Vit D: 32.9

Operative Treatment Options

• Multiple Syndesmotic Screws

• Locking Plates

• K-wire + Plate

• External Fixation (combined or alone)

• Primary Arthrodesis

• Transarticular Fixation

• Bicortical Medial Malleolar Fixation

• Fibular Nailing

• Minimally Invasive Approach

Multiple Syndesmotic Screws• Cadaver

biomechanical investigation

• Augmented fixation construct stiffer, stronger, more resistant to axial deformation

• Osteopenia not quantified Dunn et al 2004

Transarticular Fixation

• 15 DM with neuropathy treated surgically

• 25% major complication rate

• 13% amputation rate

• Combination of transarticular fixation/ prolonged protected WB = successful protocol

Jani et al 2003 FAI

Bicortical Medial Malleolar Fixation

• 23 ankle fx with comorbidities

4 DM

7 neuropathy

• All bicortical medial mal fixation

• 17.39% complication rate King et al 2012

Minimally Invasive Surgery

• Bazarov et al, JFAS 2018

44 “high risk”

52% DM

27% complication rate, 25% wound dehiscence, 9% infection

• Abdelgaid et al, JFAS 2018

47 “high risk”

57% DM

1 superficial infection

36% excellent outcome AOFAS

• Ebraheim et al, FAS 2018

67 comorbidity group (BMI>30 or DM) vs 43 noncomorbid

Fewer infections than ORIF (0 vs 11)

ORIF - plus

• Wukich et al 2011

Other Pearls…

• Avoid bone reduction clamps Schon and Marks 1995

• Monitor more frequently post-op Dellenbaugh et al 2011

• Incisional Vac

WB Status? NWB increased 2 to 3 fold with neuropathy

Marks et al 2001

12 weeks all patients with neuropathy

Ex-fix if not able to comply with NWB protocol Wukich et al 2011

Protected WB in cast/boot 2 weeks after injury/surgery 73 DM patients

Complication rate lower than that published with prolonged NWB

Bazarov et al 2017

What about the cost??Regan et al 2015

• 2010-2011 NY – 58,748 ankle fractures

• 12.8% had DM

• 1098/7501 “complicated DM”

Ketoacidosis

Hyperosmolarity

Coma

Renal/Optho/Neuro

PVD

• 2.4 days longer LOS

• C-DM $6895 more costly than DM

• Higher in hospital mortality rate

Conclusions

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