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Figure 1. Anteroposterior radiograph of the left ankle. Figure 2. Lateral radiograph of the left ankle.
A 57-year-old woman presents to the emergency department (ED) with left ankle pain and deformity after slipping on ice in her driveway. On physical examination, the skin over the ankle is intact and her dorsalis pedis pulses are weak (+1 bilaterally). Anteroposterior and lateral radiographs of the left ankle are shown in Figures 1 and 2, respectively. The patient has diabetes and is insulin-dependent; her last hemoglobin A1c (HbA1c) level was 9%. A closed reduction is performed in the ED and open reduction and internal fixation is recommended.
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Ankle fractures can have severe consequences in patients with uncontrolled diabetes. Complications such as skin breakdown, delayed wound and fracture healing, and infection are all increased in patients with diabetes who sustain an ankle fracture compared with patients without diabetes.1 For instance, patients without diabetes who undergo ankle open reduction and internal fixation usually maintain non-weight bearing for 6 weeks after surgery, while this time is extended to 10 weeks in patients with diabetes.1
Measuring HbA1c is considered the gold standard test for predicting perioperative risk. Diabetes is associated with an increased risk of poor outcomes following surgical treatment of ankle fracture (ie, poor radiological outcome, high revision rate, or high complication rate), and the risk is particularly high in patients with an HbA1c of more than 6.5%.2,3 In a study by Liu et al, 76.2% of all patients with diabetes and ankle fractures had a postsurgical complication: 88.9% of patients with an HbA1c of more than 6.5% had complications compared with 66.7% of patients with an HbA1c of less than 6.5%.3
A higher risk of wound complications should not preclude surgical fixation in patients with diabetes who have unstable fractures.2,4 Surgical fixation has been shown to establish a more stable, functional lower extremity.
Several studies have found that the time to fracture healing is slower in patients with diabetes than patients without diabetes.1-4 Due the prolonged healing time, a longer period of immobilization is recommended in patients with diabetes. Although a 2017 study found that patients with diabetes may be able to start protected weight bearing 2 weeks after surgery, further research on this topic is needed.2
The transition to full weight bearing is slower in patients with diabetes, who should be advised that early weight bearing on the ankle is linked to increased risk for nonunion, instability, and infection.1
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am. 2008;90(7):1570-1578. doi:10.2106/JBJS.G.01673
- Manway JM, Blazek CD, Burns PR. Special considerations in the management of diabetic ankle fractures. Curr Rev Musculoskelet Med. 2018;11(3):445-455. doi:10.1007/s12178-018-9508-x
- Liu J, Ludwid T, Ebraheim NA. Effect of the blood HbA1c level on surgical treatment outcomes of diabetics with ankle fracture. Orthop Surg. 2013;5(3):203-208. doi:10.1111/os.12047
- Costigan W, Thordarson DB, Debnath UK. Operative management of ankle fractures in patients with diabetes mellitus. Foot Ankle Int. 2007;28(1):32-37. doi:10.3113/FAI.2007.0006
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