SLR - June 2022 - Aseem Saini, DPM
Reference: Grote, CW, Tucker, W, Stumpff, K, Birt, MC., & Horton, GA.(. Primary arthrodesis for diabetic ankle fractures. Foot Ankle Orthop. 2020 Mar 24;5(1):247301142090884.Level of evidence: IV
Scientific Literature Review
Reviewed By: Aseem Saini, DPM
Residency Program: John Peter Smith Hospital - Fort Worth, Texas
Podiatric Relevance: Unstable ankle fractures in the diabetic population are an inherently difficult pathology to treat for foot and ankle surgeons. Ninety-eight (98) percent of American patients with diabetes have one comorbid condition, and 90 percent of Americans with diabetes have at least two comorbid conditions such as peripheral vascular disease (PVD) peripheral neuropathy and chronic kidney disease (CKD) among others. Treating ankle fractures in this population is difficult for a myriad of reasons: poor/inadequate access to healthcare, the presence of one or several comorbid conditions, and perhaps most importantly the high incidence of postoperative complications. These complications include an increased incidence of both superficial and deep postoperative infections. The presence of peripheral neuropathy in this population of patients adds an additional degree of difficulty. Literature has shown that uncontrolled diabetics with peripheral neuropathy who sustain ankle fractures have a significantly higher risk of developing Charcot arthropathy afterwards. It is for this reason that many advocate for higher levels of fixation during open reduction internal fixation. Some futhermore, call for primary ankle fusions in all diabetic ankle fractures in attempt avoid these complications. The purpose of this study was to investigate the incidence of postoperative complications in patients who underwent primary arthrodesis after sustaining an unstable ankle fracture.
Methods: A total of 13 diabetic patients who underwent primary ankle arthrodesis for traumatic ankle fractures were enrolled in this study. Demographics variables in this study included age, sex, body mass index (BMI) smoking status, American Society of Anesthesiologists (ASA) classification, insulin dependence, presence of diabetic neuropathy, retinopathy, PVD, preoperative hemoglobin A1C, Adelaide Fracture in the Diabetic Ankle (AFDA) scores. Fractures were classified by laterality, mechanism of injury, open vs closed, and fracture pattern. Complications recorded were rates of reoperation, infection, wound healing complications, malunion, nonunion, progression to amputation and postoperative Charcot arthropathy.
Results: Twelve patients underwent primary ankle arthrodesis using a hindfoot nail for tibiotalocalcaneal (TCC) arthrodesis, one patient underwent isolated tibiotalar joint arthrodesis. Seventy-seven (77) percent of patients experienced at least one complication postoperatively. Thirty-eight (38) percent of patients (5/13) required repeat operation, all for infection. Patient’s who required a reoperation on average underwent 2.6 additional procedures to manage the infection. Three patients (23 percent) went on to below the knee amputation for uncontrollable deep infections. Wound complications occurred in 53 percent. One patient developed postoperative Charcot arthropathy. Only two patients consolidated at the tibiotalar and subtalar joints, but most developed asymptomatic non-unions and theferore, a stable extremity was achieved.
Conclusions: The above study aims to discern the utility of primary ankle arthrodesis in this patient population. This study highlights the complexity of treating diabetic ankle fractures, as evidenced by the high rates of reoperation and postoperative infections. Further research is needed to explore outcomes of diabetic patients who undergo primary ankle open reduction internal fixation versus primary ankle arthrodesis. Despite the treatment selected, the results of this study reinforce the need to have an open conversation with patients who fit this category and require some type of surgical intervention for stabilization.