Frank Linde

Foot and ankle section

Department of Orthopaedics

University Hospital of Aarhus

Diabetes and

malleolar fractures

• Diabetic complications

and unstable malleolar

fractures • 40% risk of serious

complications when

neuropathy

– Loss of fixation

– Deep infection

– Wound necrosis

– Amputation

• 80% risk of serious

complications in

absence of foot pulse

– Deep infection

– Wound necrosis

– Amputation

Malleolar fractures and diabetes

Frequency

Malleolar

fracures

493

Malleolar

fractures

and diabetes

7 (1,4%)

In-patients, University Hospital of

Aarhus, 2000-2004

Case 1

• 60 years old, type 2 diabetes for 35 years

• Tri-mallolar fracture. • Foot pulses ? • Stable standard fixation

• Wound necrosis

• No foot pulses,

• Toe blood pressure

45 mmHg

• Neuropathy

• Vascular

reconstruction

• Free muscular flap

• Arthrodesis

• Skin coverage,

arthrodesis healed,

no pain

Case 2

• 71 years old, type 2 diabetes, neuropathy.

• Open bi-malleolær fracture, + foot pulses.

• Stable standard fixation • Bilat. wound necrosis –

conservative treatment • 10 weeks in a cast, 6

weeks non-weigtmearing

• Loss of fixation

• Fracture union i

valgus position

• No pain, good

function

• Ostearthrosis –

no problem

Case 3

• 35 years, type 1 diabetes

• Neuropathy • Nephropathy (dialysis) • No foot pulses • Skin necrosis

• Fracture reduction, external fixation, cast

• Non-weight bearing

• Vascular reconstruction not possible

• In patients care

• Discharged from dialysis department

• Loss of fixation

• New more stable fixation

• Skin break down, infection

• Amputation

Kristiansen (Denmark) Dan Med Bull 1983

Malleolar fractures in a 3-years period

Case control study

Diabetes*

Operation

n=10

Diabetes

Cons. treatm.

Controls

Operation

n=20

Serious

complications 3 (30%)** 1 (5%)

*A mixtures of patients with and without diabetic

complications

**No amputations

Blotter et al. (Japan) Foot Ankle Int 1999

Malleolar fractures in a 10-years period

Case control study

Diabetes*

Operation

n=21

Diabetes

Cons. treatm.

Controls

Operation

n=46

Serious

complications 8 (38%)** 3 (8%)

*A mixtures of patients with and without diabetic

complications

**2 amputations

McCormack and Leith (USA) J Bone Joint Surg (Br) 1998

Malleolar fractures in a 6 years period

Case control study

Diabetes*

Operation

n=19

Diabetes*

Cons treatm.

n=7

Controls

Operation

n=26

Serious

complications 6 (32%)** 5 (71%) 0 (0%)

*A mixtures of patients with and without diabetic

complications

**2 amputations

Flynn et al. (USA) Foot Ankle Int 2000

Case control study

Diabetes

Operation

n=19

Diabetes

Cons treatm.

n=6

Controls

Operation

n=68

Serious

complications 4 (27%)* 5 (83%) 5 (7%)

* No amputations

Jones et al. (USA) J Bone Joint Surg (Br) 2005

Malleolar fractures in a 20-years period

Case control study

Diabetes

Without neuropathy

n=21

Diabetes

With neuropathy

n=21

Controls

n=42

Serious

complications 3 (14%) 11 (52%) 5 (12%)

* No information about amputations

Combined analysis Malleolar fractures

Diabetes

With neuropathy

n=118

Controls

n=192

Serious

complications 45 (38%)* 17 (9%)

* 6 amputations (5%)

Jani et al. (USA) Foot Ankle Int 2003

Malleolar fractures in a 2-years period

Diabetes*

Operation**

n=15

Serious

complications 4 (27%)***

* All patients had neuropathy

** Suppl. transfixation of the ankle joint and prolonged non-

weight bearing

*** 2 amputations

Costigan et al. (USA) Foot Ankle Int 2007

Malleolar fractures in a 8-years period

Diabetes with

foot pulses and no

diabetic complications

n=66

Diabetes without

foot pulses

n=12

Serious

complications 1 (2%) 10 (83%)*

* 2 amputations

• Diabetic complications

and malleolar fractures • 40% risk of serious

complications when

neuropathy

– Loss of fixation

– Deep infection

– Wound necrosis

– Amputation

• 80% risk of serious

complications in

absence of foot pulse

– Deep infection

– Wound necrosis

– Amputation

Conclusions

• Diabetics with malleolar fractures with neupathy have a 4 times increased risk of a serious complication (40%) compared to non-diabetics.

• Diabetics with malleolar fractures without foot pulses have a 8 times increased risk of a serious complication (80%) compared to non-diabetics.

• Diabetics with malleolar fractures without diabetic complications have the same prognosis as non-diabetics.

Case 4

• 32 years, type 1 diabetes for 15 years

• Lateral malleolar fracture • Walker for 6 weeks, weight

bearing • After 6 weeks pain free,

normal joint motion

• After a few more weeks, swelling

• No new trauma – Fracture of the tibial epihysis? – Charcot foot ?

• Prolonged casting, non-weight bearing

• Bone union, no pain, excellent dosifleksion, satisfied patient.

Charcot after fracture

Fracture or Charcot

• New fracture after

malleolar fracture is

a Charcot

• If the primary

fracture looks like a

Charcot it is a

Charcot

Guide lines • Identify patients at risk

• Vascular reconstruction if necessary and if possible

• Standard operation technique – Add transfixation of the ankle joint ?

– Cast (contact cast)

• Non-weightbearing until union (2-3 months) – In patients ?

– Wheel chair ?

– Long cast with the knee flexed ?

• Protected weightbearing after union (2-3 months)

• Unstable charcot ankle is treated by fusion (retrograde nail or Ilizarov