Tag Archives: ankle fracture

Intramedullary fixation of distal fibular fractures in a geriatric patient: A case report

Posted on September 30, 2018 | Comments Off on Intramedullary fixation of distal fibular fractures in a geriatric patient: A case report

by Amanda Kamery DPM1*, Craig Clifford DPM MHA FACFAS FACFAOM2

The Foot and Ankle Online Journal 11 (3): 1

Intramedullary rod fixation is presented as a viable treatment option for distal fibular fractures in the geriatric population. This technique leads to a reduction in wound complications, hardware irritation, procedure time and need for subsequent surgeries as seen with traditional open reduction internal fixation for distal fibular fractures in higher-risk patients.

Keywords: ankle fracture, trauma, geriatric, open reduction

ISSN 1941-6806
doi: 10.3827/faoj.2018.1103.0001

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Residency Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author: akamery@kent.edu

Geriatric patients are at an increased risk for sustaining ankle fractures due to increased fall rate and decreased bone density. Surgical repair for such injuries is often complex, due to the standard large incision and relatively bulky fixation which is necessary in the geriatric patient due to their generally poor bone stock [1]. This traditional form of fixation carries a complication rate of up to 30% [2]. Additionally, wound healing complications and hardware irritation is more common in this population due to a poor soft tissue envelope, with wound infection rates ranging from 26-40% [3]. Commonly, subsequent surgeries are necessary to remove hardware or to perform wound debridements [4]. As it is well documented that surgical morbidity increases in this population, it is important to utilize techniques and fixation methods that limit subsequent encounters. In this case report, we present intramedullary fixation for distal fibular fractures as a viable option for the geriatric population.

Case  Report

The patient is a 94-year-old male who presented 5 days after a fall with a Weber B, slightly comminuted, left distal fibular fracture (Figure 1a). Due to the unstable nature and slight displacement of the fracture, surgical intervention with an intramedullary fibular rod was chosen. Intra-operatively under general anesthesia, excellent anatomic reduction was noted after placement of the rod and one syndesmotic screw (Figure 1b).

At 2 weeks postoperatively, the posterior splint and skin staples were removed. The patient transitioned to protected heel touch weight-bearing for 4 weeks. He resumed regular activity and normal shoe wear at 6 weeks postoperatively. There were no wound healing complications or hardware irritation noted throughout the postoperative course. At 12 months follow up, patient reported no ankle pain or limitations in activities of daily living (Figures 2a-b).

 

Figure 1 AP ankle radiograph showing Weber B fracture with slight comminution and displacement (a). Two weeks postoperative AP radiograph showing excellent anatomic reduction with fibular rod and syndesmotic screw (b).

 

Figure 2 Twelve months post operative AP (a) and lateral (b) radiographs showing excellent bony consolidation of fracture fragments and adequate anatomic reduction.

Discussion

Treatment of distal fibular fractures in geriatric patients have an increased risk for postoperative complications which can lead to wound healing issues and subsequent surgeries. It is important to utilize techniques and fixation methods that limit subsequent encounters in order to decrease surgical morbidity in this cohort. The intramedullary fibular rod is an excellent alternative to traditional ORIF in the geriatric population. Our case example demonstrates an ideal patient for this technique, including successful anatomic realignment and uneventful postoperative course.

References

  1. Mitchell JJ, Bailey JR, Bozzio AE, Fader RR, Mauffrey C. Fixation of distal fibula fractures: an update. Foot Ankle Int. 2014;35(12):1367-1375.
  2. Lamontagne J, Blachut PA, Broekhuyse HM, O’Brien PJ, Meek RN. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002;16(7):498-502)
  3. Höiness P, Engebretsen L, Stromsoe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int. 2001;22(8):642-648.
  4. Lee YS, Huang HL, Lo TY, Huang CR. Lateral fixation of AO type-B2 ankle fractures in the elderly: the Knowles pin versus the plate. Int Orthop 2007;31:817–821.

 

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Novel ankle cast designs with non-toxic material

Posted on December 31, 2014 | Comments Off on Novel ankle cast designs with non-toxic material

by Hirsimäki J¹, Lindfors NC², Salo J³pdflrg

The Foot and Ankle Online Journal 7 (4): 5

Foot and ankle immobilization is usually based on circular support, either using casts or boot-like orthoses. Basic requirements for immobilization of the ankle region include reliable support and possibility of full weight bearing during healing. Woodcast® is a novel, freely 3D moldable cast material based on non-toxic components. The material is strong but light weight and can be used as a split or a cast. Our hypothesis was to test in a proof-of-concept type study, whether a new open cast design, leaving the calf area free can be clinically used in ankle immobilization. Thirty patients with an acute ankle fracture or a recently performed ankle arthrodesis were recruited.  Two different types of cast designs were used, one semi-rigid cast and one rigid cast. All fractures and arthrodesis healed well, with no major postoperative complications. Patient satisfaction was high in both groups and slightly higher in the semi-rigid group. This study shows that the ankle area can be immobilized using a novel type of a very light weight Woodcast® material.  By combining soft and hard wood composite materials, an optimal open cast design leaving the calf area free can be performed, allowing full weight bearing and reliable immobilizing of the ankle.

Key words: Ankle, fracture, immobilization, cast, orthosis, wood, orthopaedic equipment, orthopaedic fixation devices

ISSN 1941-6806
doi: 10.3827/faoj.2014.0704.0005

Address correspondence to: ¹Hirsimäki J, University of Eastern Finland, Yliopistonranta 1, 70211 Kuopio, Finland; Tel: +358 40 753 4415; E-mail: jhirsima@student.uef.fi

² Helsinki University Central Hospital, Department of Orthopaedic and Hand Surgery, Helsinki University, Helsinki, Finland
³ Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland

Immobilisation in fracture treatment has a long history. Fractures have been treated millennia with natural materials such as wood sticks, but it was only until 1852 that Plaster-of-Paris (POP) was first used in fracture treatment. Inorganic calcium based component had been traditionally used in building walls, but it required additional binding material to be used in limb immobilization. Cotton offered this possibility, and it was utilized almost simultaneously by two army doctors, Dutch Antonius Mathysen and Russian Nikolay Pirogov.

It took a long time to get the first commercially available POP on the market (Cellona, Germany 1932). Typically, POP offered sufficient rigidity with relatively thick and heavy layers, allowing at least partial weight bearing. But it was also brittle and did not tolerate water. As a first improvement to POP, fiberglass was introduced to fracture treatment in the 1950s. It is lightweight, rigid or semi-rigid, and tolerates both water and continuous mechanical loading during walking. It is partially moldable with a strong net like support structure as a limiting factor [1-3]. Modern orthopedic plaster casts are commonly based on synthetic plastic that contains up to 25% methylene diphenyl diisocyanate (MDI). Severe issues have been raised in occupational health sector related to use of isocyanates used in modern paints, moldable glues and orthopaedic casting materials like fiberglass and polyurethane [4].

Ankle fractures can be treated in a conservative way when certain criteria are fulfilled. Some centers prefer cast immobilization also after plate fixation, others rely more on ORIF stability and accept functional orthosis or free mobilization. If cast is to be used, it is however of one basic design regardless of material used. The leg and calf area are covered with a circular cast having different additional layers for sufficient stability [5-9]. Different kind of pre-shaped orthosis have come to the market, initially for functional treatment of ankle sprains, and in some studies also for treatment of ankle fractures [10-14].

In 2010, an innovative wood-composite material was introduced for fracture treatment by Onbone Oy, Helsinki, Finland. The Woodcast® material is an ecologically friendly, biodegradable, wood-plastic composite material, with absolutely free three-dimensional (3D) molding properties. Because of its extreme strength and exceptional molding properties, we hypothesized that it could be possible to treat common ankle fractures and postoperative immobilization in ankle arthrodesis with a novel, open cast design. The goal for the cast was to leave the calf area free, and to allow cast removal and reinserting without tools. Absolute requirements were that the new cast design has to be stiff enough to allow full weight bearing.

This proof-of-concept type multicenter trial was conducted in accordance with the ethics principle originating in the latest version of the Declaration of Helsinki, applicable regulatory requirements, including the standards of the International Organization, and Finnish law and regulations. The study protocol was approved by the Ethics Committee of the Helsinki University Central Hospital (HUCH) and informed consent was obtained of the patients. The study was registered at www.clinicaltrials.gov.

Major hypothesis were that novel light weight cast designs could be successful in treatment of ankle fractures and as postoperative supporting device after ankle arthrodesis.

Methods

Casting materials

Woodcast® is a composite of thermoplastic polymer and a woody material approved for clinical use in limb immobilization (European approval in 2010). The material is hard in room and body temperature, but becomes moldable when heated up to +62 oC.  During cooling, it retains moldable down to 45 oC offering extended working time.  When ready, casting hardening can be enhanced with external cooling.  The material is non-toxic, does not release irritant aerosols, and can be handled without protective gloves. It is strongly self-adhesive and slightly adhesive toward padding and bandage materials, but does not attach to skin. It can be composted after use. The Woodcast® materials can be reheated repeatedly without affecting their mechanical properties, and they can be stretched and bent freely in 3D.

Patients

Thirty patients were enrolled in the study. The inclusion criteria were: Finnish or Swedish speaking patient, age between 0-90 years, a non-complicated ankle fracture or a performed elective foot arthrodesis normally requiring cast immobilization. The exclusion criteria were compromised co-operation for any reason, a complicated fracture, other simultaneous or earlier fractures, nerve, vessel or tendon injuries on the index extremity, malignancy and other severe diseases.

Postoperatively the patients were treated with other casting materials for two weeks. After two weeks the postoperative cast was changed either to a Woodcast® semi-rigid ankle cast model (Group 1) or a rigid model (Group 2). The cast technicians were educated for both models and the choice of design depended on the hospital they were working in.

Figure 1. A removable semi-rigid orthosis

Figure 1 A removable semi-rigid orthosis.

The semi-rigid model was made of 80 cm long Woodcast® 2 mm Soft, 40 cm long Woodcast® 4 mm and of a 15 cm peace of Woodcast® 2mm. The Woodcast® 4 mm offers mechanical stability and the Soft product is used to achieve flexibility. The cast material was applied on the anterior part of the extremity leaving the posterior side of the extremity free and then allowed to cool. The cast was then removed and finalized with soft tape around the edges (Figure 1). Padding and Velcro tape were used. During the immobilization period the patients were allowed to remove the cast temporarily.

The rigid cast was made of two 80 cm long Woodcast® 2mm pieces with paddings protecting the skin. A U-shaped casting material was applied from the lateral side, around the heel area and extending to medial side. The other 80 cm piece was cut oblique in two parts and applied anteriorly to stabilize the TC-joint and protect the plantar area during walking (Figure 2).

SONY DSC

Figure 2 A non-removable rigid cast.

Results

All patients completed the study. Thirteen (13/30) patients with ankle fractures were treated with the semi-rigid orthosis (Group 1). In 17/30 cases the rigid cast was used (Group 2) including 10 ankle arthrodesis patients and 7 trauma cases. In Group 1 the average age was 47.5 (the youngest patient being 24, and oldest 66 years old) and in group 2 the average age was 50.1 (the youngest patient being 24, and oldest 76 years old). Applying time was not depended on cast type rather skills of the technician. There were no major difference in immobilization time between Groups 1 and 2 (Table 1).

The orthopedic technicians reported that no primary complications occurred in Group 1, although in one case orthosis soft material broke from the metatarsus area during the last week of immobilization, but didn’t cause complications for the patient. Twelve (12/13) of the patients in Group 1 reported that they removed the orthosis themselves during the immobilization at least once.

Primary complications were reported by technicians in Group 2. Molding the cast was not easy in one case and in six of the cases there were issues applying the cast in correct position because of the multilayer composition. In two of the cases preheating the casting material didn’t occur fast enough.

table1

Table 1 Results of removable semi-rigid orthosis versus non-removable rigid cast.

Patient satisfaction was high in both groups yet superficial skin complications were seen in Group 2. Superficial maceration reported in 6/17 cases, focal compression in the cast 3/17 and 3/17 both simultaneously (Table 1). One rigid cast was changed to the semi-rigid orthosis because of the increased level of moisture in the cast with good results.  There were no skin complications in Group 1. There were no post-operative infections in either of the reported groups.

Discussion

Cast designs used in this study concentrate especially in immobilization of ankle joint and subtalar joint lines. Shortening the distal dimension in the cast gives more freedom to the toes, to the Lisfranc area, and finally to midtarsal Chopart joint line. This more targeted immobilization is possible with the specific material properties, but whether this has an effect on functional recovery remains to be seen in future studies. In acute ankle sprains (grades II & III), functional brace seems to give better outcome than total immobilization of the lower extremity [12,14]. It can be at least assumed that this kind of new material offers possibilities to design functional braces in the near future.

The anteromedial margin of tibia is the area where soft tissue layers are thinnest. This offers a good contact area for bone immobilization, but requires good fitting of cast material. Cast designs used in this study utilize this area as an anchor site for ankle immobilization. Although no direct force measures were included in this study, our emphasis is that this is far more stable than padded circular cast around the whole calf area with soft tissues on the posterior area. No patient had discomfort on this anteromedial area, even with the use of hard material only. The hard version of Woodcast®, 4 mm and 2 mm are extremely stiff and durable materials.  Hard material can be used as an internal support in elastic constructions, but if it is used as the only material attention must be paid on breathability and edges of cast design. Based on our experience in this relative small patient population, skin maceration and compression discomfort can occur in closed cast design. In Group 1, no patients with combined soft and hard material had cast related discomfort. This emphasizes the role of careful cast design, and use of appropriate padding.

The immobilization or the cast itself can cause several complications. Pressure sores are common complications if improper techniques are used. The risk receiving pressure sores increases in patients who suffer from peripheral nerve or vessel disorders. Compartment syndrome may develop due to a too tight cast [15]. Immobilization may also lead to problems such as joint stiffness, muscle atrophy, cartilage degradation, ligament weakening and osteoporosis [9]. Deep venous thrombosis (DVT) is perhaps the most common complication in lower extremity immobilization, with an incidence of 1.1% to 20% in various type of lower limb injuries treated with a circular cast [16]. In this study, no DVT occurred although no prophylactic agents were used. The number of patients in this proof-of-concept study is too low to draw any solid conclusions on this, but it can be assumed that this type of novel cast design leaving the calf muscle area free could even decrease the risk of DVT. If a DVT is suspected, a circular cast has to be removed, but this open design allows ultrasound diagnostics directly with cast on.

Achilles tendon ruptures are prone to wound complications [18]. Although these ruptures were not in the scope of this study, it is evident that this kind of easily removable cast will fit well in treatment of these injuries. One advantage would be to monitor and treat wound complications even with the cast on. It also gives a direct access to healing tendon, either to monitor tendon healing with ultrasound, or possibly to stimulate tendon healing with external pulsating equipment.

Conclusions

This study challenges the long-time circular cast design in ankle immobilization. It seems that even a semi-rigid open wood composite cast is safe and strong enough to stabilize common ankle fractures, and to successfully protect postoperative period after ankle arthrodesis.  Taken together current data is very promising for an open type cast technology, further and larger studies are highly warranted.

References

  1. Colditz J. Plaster of Paris: The Forgotten Hand Splinting Material. J Hand Ther 2002 Apr-Jun;15(2):144-57.(Pubmed)
  2. Lindfors NC, Salo J. A Novel Nontoxic Wood-Plastic Composite Cast. Open Med Dev J 2012; 4:1-5. (Link)
  3. Runumi G, Utpal KN. Study of Effect of NCO/OH Molar Ratio and Molecular Weight of Polyol on the Physico-Mechanical Properties of Polyurethane Plaster Cast. World Appl Sci J 2013; 21(2):276-283. (Link)
  4. Suojalehto H, Linström I, Henriks-Eckerman M-L, Jungwelter S, Suuronen K. Occupational asthma related to low levels of airborne methylene diphenyl diisocyanate (MDI) in orthopedic casting work. Am J Ind Med 2011 Dec;54(12):906-10. (Pubmed)
  5. Lee YS, Chen SW. Lateral fixation of open AO type-B2 ankle fractures: the Knowles pin versus plate. Int Orthop 2009 Aug;33(4):1135–1139. (Pubmed)
  6. Herscovici D, Scaduto JM, Infante A. Conservative treatment of isolated fractures of the medial malleolus. J Bone Joint Surg 2007 Jan;89(1):89-93. (Pubmed)
  7. Van Laarhoven CJHM, Meeuwis JD, Van Der Werken C. Postoperative treatment of internally fixed ankle fractures. J Bone Joint Surg 1996 May;78(3):395-9. (Pubmed)
  8. Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle. J Bone Joint Surg 2000 Mar;82(2):246-9. (Pubmed)
  9. Halanski M., Noonan KJ. Cast and Splint Immobilization: Complications. J Am Acad Orthop Surg 2008 Jan;16(1):30-40. (Pubmed)
  10. Dietrich A, Lill H, Engel T, SchönfelderM, Josten C. Conservative functional treatment of ankle fractures. Orthop Trauma Surg 2002 Apr;122(3):165-168. (Pubmed)
  11. Cooke MW, Marsh JL, Clark M, Nakash R, Jarvis RM, Hutton JL, Szczepura A, Wilson S, Lamb SE. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. Health Technol Assess 2009 Feb;13(13). (Pubmed)
  12. Petersen W, Rembitzki IV, Koppenburg AG, Ellermann A, Liebau C, Brüggemann GP, Best R. Treatment of acute ankle ligament injuries: a systematic review. Orthop Trauma Surg 2013 Aug;133(8):1129–1141. (Pubmed) FORUM
  13. Wykes PR, Eccles B, Thennavan B; Barries JL. Improvement in the treatment of stable ankle fractures: an audit based approach. Injury 2004 Aug;35(8):799-804. (Pubmed)
  14. Polzer H, Kanz KG, Prall WC. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev 2012 Jan;4(2):22-32. (Pubmed)
  15. Pifer G. Casting and splinting: Prevention of complications. Top Emerg Med 2000;22:48-54. (Link)
  16. Patil S, Gandhi J, Curzon I, Hui ACW. Incidence of deep-vein thrombosis in patients with fractures of the ankle treated in a plaster cast. J Bone Joint Surg 2007; 89:1340-3. (Link)
  17. Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical review. J Blood Med 2011 Apr;2:59–69. (Pubmed)
  18. Roderik Metz R, Kerkhoffs G, Verleisdonk EJ, Van der Heijden GJ. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial. BMC Musculoskeletal Disorders 2007 Nov;8:108. (Link)

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Natural History of Diabetic Foot and Ankle Fractures: A Retrospective Review of 40 Patients

Posted on November 1, 2013 | Comments Off on Natural History of Diabetic Foot and Ankle Fractures: A Retrospective Review of 40 Patients

by Brian T. Dix, DPM1, Alan R. Catanzariti, DPM, FACFAS, Robert W. Mendicino, DPM, FACFASpdflrg

The Foot and Ankle Online Journal 6 (11): 1

Background: Ankle fractures in diabetics with secondary complications are more prone to postoperative complications than ankle fractures in diabetics without secondary complications. This study retrospectively compared the post injury complications of foot and ankle fractures in diabetics with and without secondary complications. Secondary complications of diabetes mellitus include peripheral arterial disease, nephropathy, and/or peripheral neuropathy. Uncomplicated diabetics did not have any of these end organ diseases associated with diabetes. Our hypothesis was that foot and ankle fractures in complicated diabetics would incur more post injury complications than uncomplicated diabetics.
Materials and Methods: We contrasted the post injury complications of foot and ankle fractures in 25 complicated diabetics with15 uncomplicated diabetics.
Results: At an average follow-up of 33.8 weeks we established that foot fractures in complicated diabetics had a non significant trend of a 2.8 times increase in overall post injury complications versus foot fractures in uncomplicated diabetics. Furthermore, with an average follow up of 28.8 weeks we demonstrated a non significant tendency of a 1.4 times increase in overall post injury complications of ankle fractures in complicated diabetics compared to ankle fractures in uncomplicated diabetics. Lastly, with a mean follow up of 33.7 weeks we found insignificant trends of a 1.7 times increase in overall post injury complications and a 2.8 times increase in noninfectious complications (malunion, delayed union, nonunion or Charcot neuroarthropathy) in complicated diabetic foot and ankle fractures contrasted to uncomplicated diabetic foot and ankle fractures.
Conclusion: Foot and ankle fractures in complicated diabetics are presumably at an increased risk of developing a post injury complication compared to uncomplicated diabetics. Specifically, foot fractures should be treated similar to ankle fractures in complicated diabetics with an extended period of non-weight-bearing in a total contact cast. Mandatory post injury clinical evaluation for peripheral arterial disease, peripheral neuropathy and nephropathy should be implemented. This analysis will be used as a template for a future prospective comparative study evaluating foot and ankle fractures in complicated and uncomplicated diabetics with a power analysis to achieve statistical significance.

Key words: Diabetes mellitus, ankle fracture, Charcot arthropathy

Accepted: October, 2013
Published: November, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0611.001

Address correspondence to:1Resident, Department of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA

In 2010 it was projected that 25.8 million people in the United States had diabetes mellitus representing 8.3% of the population with another 7 million undiagnosed.[1]

The first report of diabetes mellitus affecting bone healing was an animal study in 1968 by Herbsman, et al.[2] They found that rats with uncontrolled diabetes mellitus had reduced fracture healing compared to the healthy controls.

Other animal studies have confirmed these results and have found that fractures in diabetic rats treated with insulin improved bone healing.[3-6] In the earliest human case report, Cozen reviewed 9 diabetics with lower extremity fractures and contrasted them with 9 matched controls. He verified a delayed time to union in the diabetic patients.[7]

Several studies have demonstrated increased complications in diabetic ankle fractures compared to the healthy controls.[8-12] However, several recent studies have shown that ankle fractures in diabetics without comorbidities (uncomplicated diabetics) had complication rates similar to the controls. Conversely, complicated diabetics (peripheral neuropathy, nephropathy and peripheral arterial disease) had significantly increased complications.[13-15] However, to the best of our knowledge, in the English literature, there have been no studies examining the natural history of diabetic foot and ankle fractures concomitantly. Thus, a retrospective review of 40 patients with diabetes mellitus who sustained a foot and/or ankle fracture was performed.

Methods and Patients

On July 26, 2012, the Western Pennsylvania Allegheny Health System Institutional Review Board accepted this as an exempt study. A retrospective review of patient charts, radiographs, and operative reports with diagnosis codes for “diabetes mellitus” and “fracture” to the foot and/or ankle was assembled. Complicated diabetics were diagnosed with peripheral neuropathy (PN), peripheral arterial disease (PAD) and/or nephropathy. Uncomplicated diabetics did not have any of these end organ diseases.[16,17] PN was diagnosed when the patient could not detect the 5.07 Semmes Weinstein monofilament. PAD was diagnosed if the patient had been revascularized in the past or when the patient had non palpable dorsalis pedis or posterior tibial pulses.

Nephropathy was diagnosed when the patient had a serum creatinine of > 1.5.[11] Charcot neuroarthropathy was defined as bone fragmentation, bone absorption and boney consolidation.[18]

Superficial infections were categorized based on the need for only oral antibiotics and local wound care. Deep infections were delineated when the wound required intravenous antibiotics and surgical debridment.[11]

A nonunion was defined when a minimum of 9 months has passed and there are no interval changes consistent with a union on serial radiographs. A delayed union had decreased bone healing on serial radiographs.

Data was collected for patients treated between 1/1/2002 – 7/1/2012. Patients less than 18 years old and with incomplete medical records were excluded. The information gathered included age, sex, body mass index (BMI), fracture type, fracture location, fracture treatment, time to union, malunion, nonunion, infection, ulceration, Charcot neuroarthropathy, amputation, PN, nephropathy, and PAD.

The type of treatment was at the judgment of the attending foot and ankle surgeon. All patients with an ankle fracture underwent open reduction and internal fixation (ORIF) with plates and screw fixation of the fibula. Also, the medial malleolar fixation was accomplished with screws or tension banding. Syndesmotic fixation was accomplished with tri-cortical or quad-cortical screws when appropriate. All ankle fractures received preoperative antibiotics with continuation of antibiotics through the hospital course for open fractures. Non-weight-bearing (NWB) was generally instituted for a minimum of 7 weeks in a total contact cast (TCC) with transitioning to weight-bearing (WB) for a minimum of 4 weeks in a fracture walker for postoperative ankle fractures.

Forefoot fractures (toe and metatarsal) were commonly allowed WB in a surgical shoe or fracture walker for at least 2 weeks before transitioning to a sneaker. Patients were usually followed up at 2 week and subsequently 1 month intervals until fracture union. At most visits, medial oblique, anteroposterior and lateral radiographs were obtained to assess fracture healing.

NHDFTable1

Table 1: Frequency by diabetic group (complicated vs. uncomplicated).

NHDFTable2

Table 2: Time-based measures in weeks (complicated vs. uncomplicated).*

Results

There were a total of 40 diabetic foot and ankle fractures with an average follow up of 31.7 (4-137) weeks. Patient ages ranged from 43 to 85, with a mean of 62.00±10.34 (standard deviation). There were a total of 22 females (55%) and 18 males (45%). Patient BMI ranged from 21.81 to 56.35 with a mean of 34.11±5.91. Thirty seven (93%) experienced closed injuries while three (7%) experienced open injuries. Nineteen patients (48%) were treated non-operatively (toe, metatarsal and cuboid fractures) and 21 (52%) were treated operatively (ankle and a calcaneal avulsion fracture).

Twenty five patients possessed a previous diagnosis of complicated diabetes (63%) while fifteen patients had uncomplicated diabetes (37%).

Regarding type of injury, 17 patients experienced an ankle fracture (43%), 12 patients a metatarsal fracture (30%), nine patients a phalanx (toe) fracture (22%), one patient a calcaneal avulsion fracture (2.5%), and one patient a cuboid fracture (2.5%).

When evaluating BMI there was no difference between complicated diabetics (mean=32.64±5.10) and uncomplicated diabetics (mean=36.55±6.51), t (38) = 2.12, p = .25. There was no difference in age between complicated diabetics (mean = 62.32±10.65) and uncomplicated diabetics (mean=61.93±10.15), t (38) = .11, p = .91.

NHDFTable3

Table 3: Complications among foot fractures.

NHDFTabl4

Table 4: Complications among ankle fractures.

NHDFTable5

Table 5: Diabetes complications by post injury complications.

Also, there was no statistical difference between uncomplicated and complicated diabetes with regards to the frequency of sex and treatment (Table 1).

There was no statistical difference between complicated and uncomplicated diabetics regarding the number of weeks WB (8.56±5.64, 7.40±6.70, p = .56) and non-weight-bearing (7.93±4.17, 7.75±3.25, p = .90). Along with no statistical significance among complicated and uncomplicated diabetics (table 2) in weeks to clinical union (10.12±6.35, 9.27±3.44, p=.64) and radiographic union (14.76±7.20, 12.87±5.87, p = .40).

Twenty three foot fractures were included in the retrospective review with an average follow up of 33.8 weeks. (Table 3). Eighteen (78%) were complicated diabetics while five (22%) were uncomplicated diabetics. Ten (56%) of the complicated diabetics experienced a post injury complication.
Conversely, only 1 (20%) uncomplicated diabetic experienced a post injury complication. A two sided Fisher’s Exact test indicated no significant difference in proportion of patients experiencing post injury complications between complicated and uncomplicated diabetic groups (p = .32).

Moreover, there were a total of seventeen ankle fractures with a mean follow up of 28.8 weeks. (Table 4). Seven (41%) had complicated diabetes while 10 (59%) had uncomplicated diabetes. Among complicated diabetics, 4 (57%) experienced a post injury complication, whereas 4 (40%) of uncomplicated diabetics experienced a post injury complication. A two sided Fisher’s Exact test indicated no significant difference in proportion of patients who experienced a post injury complication between complicated and uncomplicated diabetic groups (p = .64).

NHDFTable6

Table 6: Complications among diabetes type.

NHDFTable7

Table 7: Complications among foot and ankle fractures.

Further analyses evaluated the relationship between severity of complicated diabetes (PN+ PAD + nephropathy) and the number of post injury complications sustained by each patient. Eighteen diabetics (72%) were diagnosed with one complicating factor, six (24%) were diagnosed with two complicating factors, and one (4%) was diagnosed with all three complicating factors.

Among all complicated diabetics, 11 (44%) patients experienced no post injury complications, 8 (32%) patients experienced one complication, five (20%) patients experienced two complications, and one (4%) patient experienced three complications (Table 5). A Pearson’s Chi-squared test was conducted indicating no relationship between number of diabetes complicating factors and number of post injury complications, χ2 (2, N = 25) = 3.96, p = .14.

NHDFTable8

Table 8: Non-infectious complications by diabetes type and total fractures.

The relationship between diabetes type and the presence of a post injury complication when collapsing across all types of injuries was conducted (Table 6).Fourteen (56%) complicated diabetics experienced one or more post injury complications. Among uncomplicated diabetics, 5 (33%) experienced one or more post injury complications. A two-sided Fisher’s Exact test indicated no relationship between diabetics type and the presence of injury complications (p = .20). All diabetic foot and ankle fracture complications are described in Table 7. There were no amputations performed in any of the complicated or uncomplicated diabetic foot or ankle fractures.

A non-infectious complication includes any complication involving a malunion, delayed union, nonunion or Charcot neuroarthropathy.13 A total of 9 (47%) complicated diabetic foot and ankle fractures experienced a non-infectious complication and 4 (19%) uncomplicated diabetics experienced a non-infectious complication (Table 8.) A series of Chi-Square analyses were conducted and found no statistical significant relationship between diabetes-type and number of non-infectious complications for foot fractures [χ2 (2, N = 23) = .66, p = .72.], ankle fractures [χ2 (2, N = 17) = 1.54, p = .46] and overall fractures [χ2 (2, N = 40) = 1.95, p = .38].

Discussion

This retrospective review of the natural history of 40 diabetic fractures is the first to evaluate foot and ankle fractures together. In regards to foot fractures (Figure 1), 56% (10/18) of foot fractures in the complicated group experienced a post injury complication while only 20% (1/5) of the uncomplicated group sustained a post injury complication (p = .32). Although not statistically significant, there was a 36% (2.8 times) increase in complications with complicated diabetics who sustained a foot fracture (Table 3). Kristiansen described a diabetic second metatarsal shaft fracture that was allowed to weight bear immediately with a bandage. Three months later the metatarsal fracture developed Charcot neuroarthropathy. He concluded that even metatarsal fractures should be immobilized and weight-bearing must be deferred until fracture healing is complete.[20] The foot fractures (metatarsal, phalanx, and cuboid) in this study were allowed to WB immediately in a surgical shoe or fracture walker. The authors hypothesize that a more aggressive immobilization regimen such as non-weight-bearing or total contact casting should be considered to decrease adverse outcomes in the complicated diabetic group.

NHDFfig1A NHDFfig1B

Figure 1: Radiographs demonstrating a distal phalanx fracture in a complicated diabetic.

NHDFfig2A NHDFfig2B

Figure 2: Initial and 12 week radiographs of a bimalleolar ankle fracture in a complicated diabetic.

In evaluating 17 operatively treated ankle fractures (Figure 2), the complicated diabetic group had a 57% (4/7) post injury complication rate while the uncomplicated diabetic group had 40% (4/10) post injury complication rate (p = .64). Many studies, including a meta-analysis of 356 ankle fractures, have established an overall increase in complications in diabetic ankle fractures compared to non diabetics.[21-27] Additionally, Wukich, et al., retrospectively confirmed that complicated diabetics had a 3.8 (p = .003) times amplified risk of a post injury complication.[11] In our study, there was a non significant trend of a 17% (1.4 times) increased complication rate for ankle fractures in the complicated diabetic group compared to the uncomplicated diabetic group. However, in the Wukich, et al., study there was total of 59 uncomplicated diabetics and 46 complicated diabetics which achieved statistical significance.[11] To attain statistical significance in our study, approximately 90 additional ankle fractures would need to be evaluated.

Compiling all diabetic foot and ankle fractures there were a total of 25 complicated and 15 uncomplicated fractures. Post injury complications occurred in 56% (14/25) of the complicated diabetics and in 33% (5/15) of the uncomplicated diabetics (p = .20). Also, 47% (9/19) of the complicated diabetics experienced a non-infectious complication compared to only 19% (4/21) of the uncomplicated diabetics (p = .38). Thus, there was a non significant tendency of a 23% (1.7 times) elevated risk of developing a post injury complication in the complicated diabetics with a 28% (2.4 times) increased risk of having a non-infectious complication. This increase is on par with Wukich, et al., who found a 3.4 times increased risk of developing a non-infectious complication ankle fractures in complicated diabetics. Also, the complicated diabetic group took almost 2 weeks longer for radiographic union compared to the uncomplicated diabetic group (14.76±7.20, 12.87±5.87, p = .40). While there was no statistical difference between the groups, the overall increase in healing time for all diabetic fractures is consistent with other studies.[2-7,12,22]

On the other hand, in our study no diabetic fractures resulted in an amputation. The literature has demonstrated amputation rates of diabetic ankle fractures ranging from 4 -17%.[9,23,28] Our 0% amputation rate is most likely due to the fact that we are not located at a level 1 trauma center and only had 3 (7%) open ankle fractures with no open foot fractures. Open diabetic ankle fractures traditionally have very poor outcomes with a 38% amputation rate in a case study by White, et al., in 2003.

A novel analysis evaluated the relationship between the severity of complicated diabetes and the number of post injury complications sustained by each patient. Eighteen diabetics (72%) were diagnosed with one complicating factor and seven (28%) were diagnosed with two or more complicating factors. Six (78%) of the diabetics with 2 or more complicating factors experienced at least one post injury complication compared to 8 (44%) of the diabetics with only 1 complicating factor (p = .14). This also showed a non significant propensity as the number of diabetic complicating factors increases, the amount of complications increases as well (1.7 times higher).

The most obvious weakness of our evaluation was the study being underpowered. This was because of the relatively small number of diabetic patients reviewed. Over 30 patients had to be excluded from the study due incomplete medical records including no height or weight being recorded, complications described too broad for interpretation, and radiographs/charts missing. These patients may have helped influence the data to become significant.

The other main weakness was the retrospective nature of the study. Retrospective studies are based on the correctness of patient charts/radiographs and thus information collected is only as accurate as the medical information documented. Also, this study also did not evaluate other complications such as deep vein thrombosis, thromboembolism, stroke, or myocardial infarction.

Furthermore, there could have been measurement bias as there was not a standard protocol initiated. However, all diabetic ankle fractures did receive ORIF with treatment based on standard fixation principles. Also, all diabetic foot fractures except one calcaneal avulsion fracture, were treated non-operatively in a surgical shoe or fracture walker.

Non-responder bias is also a part of this study since some patients were followed longer than others. If some patients were observed longer more complications could have been discovered. Most foot fractures were followed until fracture union and were not followed up thereafter. Moreover, there also could have been interview bias as the treating foot and ankle surgeon determined if there was a complication and recorded this in the patient’s clinical chart.

Conclusion

Although not statistically significant, the trend of increased complication rate for foot fractures in complicated diabetics leads us to believe that foot fractures should be treated in the same manner as ankle fractures in complicated diabetics. Post injury clinical evaluation for PAD, PN and nephropathy should be considered. This analysis will be used as a template for a future prospective study comparing complicated and uncomplicated diabetic foot and ankle fractures.

References
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