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Ankle Fractures in Diabetics and the Elderly

Ankle Fractures in Diabetics

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Ankle fractures in diabetics are challenging to treat. Patients with diabetes have higher complication rates following both open and closed management of ankle fractures.

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The risk of complications and the chances of diabetic co-morbidities increase dramatically with poor control of the blood glucose level as reflected by a high HbA1C value. The presence of neuropathy increases the chance of a complication by a factor of 4 in diabetics. In addition, more than 40% of diabetic patients also present with peripheral arterial disease. Obesity has been identified as an independent risk factor for complications and poor outcomes in both diabetics and non-diabetics.

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Pathological Variations

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Diabetes affects wound and fracture healing on multiple levels. Clinical and experimental studies have demonstrated a diminished healing capacity of both bone and soft tissues. In type I diabetes the missing anabolic effect of insulin and amylin in early stages, and vascular changes in later stages lead to a manifest osteoporosis with increased fracture risk.

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Chronic hyperglycaemia negatively affects the function of immunocompetent cells like fibroblasts and leukocytes leading to significantly increased rates of infection and other complications as compared to non-diabetics. The combination of these pathological conditions results in a significant delay in bone healing in diabetic patients.

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Management Principles

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Regardless of the specifics of treatment, adherence to the basic principles of preoperative planning, meticulous soft-tissue management, and achieving a stable, rigid fixation with prolonged immobilisation and protected weightbearing are paramount in minimising complications and yielding good functional outcomes.

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Locking plates create a fixed-angle product with less risk of loosening for individual screws. In a cadaveric fibula model, locking plates provided higher biomechanical stability than non-locking plates. Current interlocking plates are pre-contoured and have a low profile in order to contain smaller fragments, provide more locking options, and avoid skin irritation.

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In patients with osteoporotic bone, a pathological external rotation force to the ankle will produce bone avulsions of the distal tibiofibular syndesmosis rather than a purely ligamentous injury. Therefore, direct fixation of the posterior tibial rim and anterior syndesmotic avulsions at the distal tibia or fibula will most likely restore syndesmotic stability. However, trans-syndesmotic screw fixation will enhance stability of the ankle mortise even in the absence of a syndesmotic instability, because it uses the tibia for additional stabilisation of the fibular fixation and doubles the number of cortices purchased by the screws (‘tibia pro fibula’). This technique is therefore of particular use in osteoporotic and diabetic patients and can be combined with the use of a locking plate on the distal fibula.

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Ganesh et al., in an analysis of a nationwide inpatient database, concluded that there was significant increase in in-hospital length of stay and costs for diabetics with ankle fractures compared with non-diabetics.

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Primary arthrodesis is reserved for patients who are at high risk of amputation or failure if primary ORIF is performed. Tibiotalocalcaneal fusion with a retrograde nail provides high stability, but it also results in a completely stiff ankle and hindfoot in patients who are not easy to mobilise.

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Hindfoot fusion with specially designed, curved nails is an excellent treatment option for patients with Charcot neuropathy, because standard techniques of internal fixation will invariably fail in these patients.

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Basques et al. found a 5% adverse event after surgery of the fractured ankle in a population of 4412 patients with a mean age of 51. An infection rate of 1.7% was found. For both of these, IDDM was associated with an increased rate after ankle fracture ORIF, whereas non-insulin-dependent diabetes mellitus was not.

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Adequate control of blood glucose levels is an integral part of the management of diabetic patients with an acute fracture. For every 1% reduction in HbA1C, there is an estimated 25% to 30% reduction in the rate of diabetic complications.

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Complications

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Low-energy open fractures are particularly prone to develop complications, with reported wound complications in up to 64% patients, infection rates of up to 36%, subsequent below-knee amputation in up to 42% and a two-month mortality of 27%. Although the studies available have low patient numbers, the impact of skin ageing in open fractures is well-recognised. These fractures should therefore be regarded as limb-threatening injuries.

Ankle Fractures in the Elderly

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Ankle fractures in the elderly are complex and under-recognised burden which require a multidisciplinary approach to management. Clinical management of ankle fractures is better-defined in young adults and paediatric population; but these fractures present a major challenge in the elderly population.

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The number of ankle fractures in the elderly is increasing and there is no clear evidence in the literature to suggest which treatment method is better. It is predicted that the number of ankle fracture in elderly age group will increase three times by the year 2030.

 

There is no universal treatment protocol for the elderly patient with a fractured ankle. It is important for the treating surgeon to not only focus on treating the fractured ankle but on the patient as a whole, to consider comorbidities, medication, prevention, and treatment goals applying a multidisciplinary approach, similar to current treatment practices of proximal femur fractures.

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Mortality and Morbidity

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Dodd et al. and Varenne et al. who found the risk factors driving postoperative complications to be an increasing age (respectively >65 and >80 years), obesity, diabetes, ASA score > 2 and functional status.

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Elderly patients have higher medical co-morbidities, which increase the risk of significant complications and mortality after sustaining ankle fractures and their treatment. If surgical treatment is opted, the patient may require preoperative optimisation that adds on delay in surgery, increase in length of stay, organising social care and potentially can lead to more risk of complications. The main objectives are achieving a stable fixation, restoring pre-fracture autonomy and control of local and general complications.

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Open fractures can occur even with low-energy trauma due to poor skin quality and use of long-term anticoagulants or steroids in the elderly. These are associated with even higher risks of complications. Toole et al. reported a 27% mortality at 10 weeks following open ankle fractures in the elderly.

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Zaghoul et al. found an overall rate of complications in surgically treated ankle fractures in patients over the age of 60 years to be 21.5% with 10.8% of them being major complications prompting surgical intervention for wound washout, removal of implants, and revision of fixation.

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Bariteau et al. identified a mortality rate of 9.1% at 1 year in patients operated for an ankle fracture compared to 21.5% in a comparable population of non-operated patients.

 

Al-Nammari et al. identified a mortality rate of 35% at six months in a population of 48 patients.

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Basques et al. showed that an ASA ≥ 3 was associated with increased morbidity. Varenne et al. reported an overall incidence of complications of 4.6% and local complications of 23.9% in a retrospective series of 477 ankle fractures, with an average age of 74 years over a period of 7 years.

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A small retrospective series of 50 ankle fractures, with an average age of 64 years, showed a relatively lower rate of complications in patients following ORIF as opposed to MUA or POP (42 vs 8 patients respectively). Although no significant difference was identified in time to fracture union. However this was a small study with disproportionate no of patients in the two groups to draw a justifiable conclusion.

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Regardless of higher risks, Phillips et al. showed that a well managed surgical treatment was better than conservative treatment for ankle fractures in the elderly, both for autonomy, postoperative complications and restoring pre-fracture anatomy.

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A recent study by Hsu et al. supported a more aggressive and less expectant management. They found that older patients with ankle fractures were healthier and had a significantly lower 1-year mortality risk than patients treated for a hip fracture or any other diagnosis.

Non-operative treatment of unstable ankle fractures is associated with a non-union rate between 48 and 73% compared to 0 and 19% after operative treatment. Non-operative treatment is also associated with an increased risk of loss of reduction and subsequent posttraumatic arthritis.

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Complications in this age group can be related to general factors (age, co-morbidities, cause of fall), soft tissue factors (poor circulation, poor healing potential, severity of injury) and bone factors (poor bone quality, complex fracture patterns, method of fixation). After sustaining ankle fractures, regardless of the opted method of treatment, mobility and rehabilitation is challenging and the patient might end up in a wheelchair or have significant reduction in their mobility in the short- or long-term.

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Management 

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Conservative treatment only seems to be successful in stable ankle fractures with good surrounding soft tissue. Pronation-abduction (PA) fractures most commonly affect elderly females and 90% of the cases present as the very unstable injury. Unstable fractures (supination-eversion and pronation-eversion) fractures are better treated by ORIF.

 

Willet et al. conducted a pragmatic RCT (the only RCT available) comparing close contact casting ORIF for unstable malleolar fractures in patients over 60 years of age, comparing functional and clinical outcomes. Patients in both study arms were kept on non- or limited weight-bearing status at the discretion of the treating physician. 620 patients were included, and after 6 months, the Olerud-Molander ankle score (OMAS), post-fracture symptoms, quality of life, pain, ankle motion, patient satisfaction, and mobility were equivalent in both groups. Infection and wound breakdown were more common with surgery.

 

Locking vs Non-locking Plates

 

Bariteau et al. investigated if a combination locked plate with additional fixation options was biomechanically superior in osteoporotic bone and comminuted fracture models. They did not find any statistically significant difference in biomechanical testing for simple fractures treated with a lag screw and plate. For comminuted fractures, locked plating demonstrated statistically significant stiffer fixation.

 

Zahn et al. compared a lateral conventional contoured plate with a locking contoured plate stabilising experimentally induced distal fibular fractures in human cadavers from elderly. They found a higher torque to failure, angle at failure, and maximal torque of the locking plate compared to the conventional plate. In contrast to the non-locking system, fixation with the locking plate was independent of BMD.

 

Dingemans et al. performed a meta-analysis of biomechanical studies on reinforced fixation of distal fibular fractures. (total 13 studies included). They could not show a statistically significant difference between the locking and non-locking lateral plates for torque to failure or torsional stiffness. However, locked plating strength was independent from bone mineral density in four studies suggesting these plates more suitable in the fixation of severe osteoporotic fractures.

 

Fibular Nails

 

Rajeev et al. assessed the functional outcome of a cohort of patients with fragility fractures of the ankle who were treated with a fibular locking nail in a retrospective review of 24 patients and showed a mean duration to fracture union of 8.7 weeks. No wound breakdown or any deep infections were reported. Immediate partial weight-bearing was allowed instead of the usual non-weight-bearing and in the elderly population; this may be of great importance.

 

Retrograde Tibiotalar-Calcaneal Nails

 

In low-demand elderly patients who are not able to partially weightbear and need to maintain their functional autonomy, a retrograde tibiotalar-calcaneal nail has become an increasingly popular option in the recent years. A TTC nail allows the patient to mobilise immediately.

 

Al Namari et al. reviewed the use of TTC nail in frail elderly patients with displaced ankle fractures with mean age of 82 years (61 to 96), 85% females and mean ASA score of 3 or 4. 90% returned to their preinjury level of function. Complications included superficial infection (4%), deep infection (2%), a broken or loose distal locking screw (6%), valgus malunion (4%), and one below knee amputation. There were no cases of non-union, nail breakage, or peri-prosthetic fracture.

 

Jonas et al. studied 31 patients treated with short TTC nail and found no postoperative wound problems. However they had 3 periprosthetic fractures (possibly due to short nails). The use of a long nail, which crosses the isthmus of the tibia, avoids the risk of periprosthetic fractures.

 

Georgiannos et al. performed a prospective RCT comparing TTC nail (43 patients, Trigen nail) and ORIF (44 patients, 1/3 tubular plates) over a period of 7 years and a mean follow-up was 14 months. Mortality rate was 13.9% for TTC nails and 18.1% for ORIF group at one year. In TTC group there were 3 complications (8.1%), significantly shorter hospital stay (5 days) and 28 patients (75.6%) returned to their pre-injury mobility status. In ORIF group, there were 12 complications (33.3%), longer hospital stay (8.4 days) and 26 patients (72.2%) remained at the same mobility level (72.2%). Hence the authors concluded that TTC nailing is a safe and effective method of treatment of unstable ankle fractures in the elderly due to lower risk of complications and allowing immediate return to full weight-bearing.

 

 

References

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