SLR - July 2021 - Joshua P. Manning

Diabetic Pilon Fractures: Are They as Bad as We Think?

Reference: Oladeji LO, Platt B, Crist BD. Diabetic Pilon Factures: Are They as Bad as We Think? J Orthop Trauma. 2021 Mar 1;35(3):149-153. doi: 10.1097/BOT.0000000000001904. PMID: 32675712.

Level of Evidence: Prognostic Level III 

Scientific Literature Review

Reviewed By: Joshua P. Manning, DPM
Residency Program: Mount Auburn Hospital – Cambridge, MA

Podiatric Relevance: Pilon fractures, fractures involving the tibial plafond, are difficult injuries both for the patient and the treating surgeon due to the increased complication rate. Diabetes affects over 30 million people in the United States, and diabetes is a risk factor for increased complication rate in ankle and pilon fractures. This study elucidates the differences in injury characteristics and complications between a diabetic and non-diabetic pilon fracture population, specifically focusing on differences in high-morbidity complications.

Methods: A retrospective review of patients at a Level 1 trauma center identified patients surgically treated for a pilon fracture between September 1st, 2005 and June 30th, 2015. Electronic medical records were used to extract patient demographic information, medical comorbidities, injury classification (including open, OTA/OA classification, staged management), and mechanism of injury. Mechanism of injury was broken down into high vs low energy and independently categorized as fall, motor vehicle, motorcycle, or other. Complications included amputation, arthrodesis, deep infection and nonunion. Patients were separated into cohorts based on presence of diabetes. There were 279 total fractures, 43 of which were in diabetics. Univariate analysis was then performed with Student t-test (continuous) or Fisher exact test (categorical). Complications that proved significant were then entered into a multivariable logistic regression model.

Results: OTA/AO 43C was the most common fracture pattern seen in both cohorts, but diabetics were significantly more likely to have a concurrent fibula fracture (95.3 percent vs 78.0 percent; p=0.006). High-energy mechanism was the most common cause of fracture without difference between groups, however the mechanism of injury in diabetics was most commonly a motor vehicle accident versus falls from height in nondiabetics (p=0.003). Diabetics were 5.5 times more likely than non-diabetics to require arthrodesis (16.3 percent versus 3.4 percent; p=0.001). Deep infection was 2.7 times more common in diabetics (30.2 percent versus 14.0 percent; p=0.008), and although not statistically significant the diabetics in the study had a higher rate of nonunion and amputation. Overall, diabetics were 3.64 times more likely to experience the studied complications and on regression analysis diabetes was proven an independent risk factor for both arthrodesis and deep infection.

Conclusions: This study is in concordance with current literature establishing diabetes as an independent risk factor for increased complications when undergoing lower extremity surgery. Though there remains a high risk for complications in non-diabetics as well, specific counselling should be had with diabetic patients regarding their risks, and surgeons should modify their approach with these complication rates in mind. This study is retrospective, and multiple surgeons cared for these patients which is a limitation of internal validity. In conclusion, the authors recommend intensive perioperative evaluation and protocols to optimize treatment of diabetic pilon fractures with the knowledge of increased complication rates in diabetic tibial plafond fractures. 

Educational Opportunities