This document discusses complications of ankle fractures in patients with diabetes. It notes that diabetes is associated with increased mortality, complications, length of stay, and revision rates following ankle fractures. Diabetes can impair fracture healing through mechanisms like glycosylation of collagen and accumulation of sorbitol in tissues. Surgical treatment of ankle fractures in diabetic patients carries higher risks of infection, non-union, Charcot arthropathy, and amputation. Rigid internal fixation and prolonged non-weight bearing casting are recommended. Thorough examination of vascular and neurological status and glycemic control are also important.

1. 18/9/2012
Hiren Divecha (ST5)
Blackpool Victoria Hospital

2.  Ganesh JBJS Am 2005
 160 000 ankle #s
 Increased mortality, complications & LOS with DM
 Wukich Foot Ankle Int 2011
 Compared ankle #s in DM vs complicated DM
 Increased complication & revision rates

3.  Hyperglycaemia  glycosylation
 Collagen, BM
 Intracellular hyperglycaemia  sorbitol
pathway  inositol accum  cell damage
 Occurs in tissues that don’t need insulin for glucose
uptake
 Renal, nerve, optic lens, blood vessels

5.  Uncertain pathogenesis
 Likely due to poor collagen (X) synthesis
 Increased delayed/ non-union/
pseudoarthrosis in elective ankle arthrodeses
 Papa JBJS Am 1993; Stuart CORR 1990; Perlman Foot
Ankle Int 1990
 Increased fracture union times
 Loder CORR 1988; Cozen CORR 1972

6.  History, Comorbidities, Injury, DELAYS
 Diabetes
 Treatment & glycaemic control; HbA1C
 End-organ damage (nephropathy, neuropathy)
 Examination
 Vascularity – pulses, ABPI
 Neurological – neuropathy, SWM 10g
 Wounds
 Delay in initial diagnosis & immobilisation can
result in Charcot arthropathy
 Holmes Foot Ankle Int 1994

7.  Undisplaced, low demand, elderly, unwell,
Charcot
 NWB cast immobilisation until callus seen (8-12
weeks)
 Protected WB further 4-6 weeks
 Consider Total Contact Casting

8.  Open reduction and rigid internal fixation
ESSENTIAL
 Gentle soft tissue handling
 Risks increased:
 Infection – >40%
 Charcot arthropathy – 10%
 Amputation – 10%
 Delayed/ nonunion
 Blotter Foot Ankle Int 1999; Kristiansen Dan Med Bull 1983;
Low Ann Acad Med Singapore 1995; Jones JBJS Br 2005

9.  Consider reduction and delayed internal fixation
to allow soft tissue swelling to settle
 Stabilise either with ex-fix or cast
 Rigid internal fixation
 ? Role for locked distal fibula plates
 Biomechanically superior in osteoporotic bone (Kim J Foot
Ankle Surg 2007)
 NWB cast immobilisation until callus seen (8-12
weeks)
 Protected WB further 4-6 weeks

10.  Vascular & neuro examination
 Gylcaemic control – involve physicians
 Increased risks
 Infection
 Delayed tissue & fracture healing
 Charcot arthropathy
 Rigid fixation essential
 Prolonged NWB immobilisation then protected
WB

11.  Chaudhary et al “Complications of ankle
fracture in patients with diabetes” JAAOS 2008;
16: 159-170
 Wukich et al “Current concepts review: The
management of ankle fractures in patients with
diabetes” JBJS Am 2008; 90: 1570-8
 Dellenbaugh et al “Treatment of ankle fractures
in patients with diabetes” Orthopaedics 2005;
34(5): 383-88