There are some problems associated with diabetic ankle
fractures. The biggest problem occurs when what is believed to be a simple
ankle fracture is actually a Charcot ankle. The condition of Charcot ankle may
not be diagnosed and my lead to a bad outcome such as possible amputation.
Diabetic neuropathy often occurs with the loss of protective sensationis and is
a risk factor for Charcot ankle. Diabetic ankle fractures have a lot of
complications (40% complication rate). The amputation rate is about 6% for closed
injuries and about 40% for open injuries. Most significant factor in patients
with ankle fractures who are diabetic is a high risk of infection (up to 20% in
diabetic patients). There is an increased risk of superficial and deep wound
infections. Peripheral neuropathy is the most significant risk factor for
post-operative complications. If the patient is treated with a splint or a
cast, this must be padded very well in order to avoid ulcers or skin
complications. Keep the diabetic patient with an ankle fracture non-weight
bearing for longer period of time. The amount of time spent non-weight bearing
is double the time for a diabetic patient. Diabetic patients with an ankle
fracture usually have a higher incidence of nonunions, malunions, and hardware
failures than with nondiabetic patients. Examine the pulses and check the
circulation. In general, surgery is better for treatment. It is going to take
longer for the fracture to heal, so a good stable fixation is needed that will
support the fracture until it heals (fixation will not be traditional). In
regard to fixation, add more fixation; more screws with the screws going from
the fibula to the tibia. Use spanning external fixator, and use K-wires from
the calcaneus to the tibia. I personally like to use minimally invasive
techniques. I try not to open the fracture in diabetic patients unless
necessary (do it percutaneously with small incision). I start with getting the
fibular length. Next, I fix the medial malleolus percutaneously. The
syndesmosis could also be fixed percutaneously. Red blood cells contain
hemoglobin and when the hemoglobin binds with glucose in the blood, it becomes
glycated. When the hemoglobin binds to oxygen, the cells appear red. The term
HbA1c refers to the glycated hemoglobin. We find that HbA1c levels appear to be
predictive of risk and complication rates in the surgical treatment and outcome
of diabetic patients with ankle fractures. Complication rates are higher among
patients with elevated HbA1c which is more than 6.5%. The normal range of HbA1c
is 4-6%. More than 7% is high. For diabetic ankle fractures, recognize the
Charcot ankle, make sure to examine the circulation and the pulses, and cast or
splint must be well padded. There is a high risk of complication that may lead
to amputation. Loss of protective sensation and peripheral neuropathy is an
important risk factor for Charcot ankle. Delay weight bearing because the
fracture does not heal quickly. When surgery is done, use percutaneous
techniques or good fixation that will allow non-failure of the hardware during
healing time.
