A Protocol for Treatment of Unstable Ankle Fractures Using

FOOT & ANKLE INTERNATIONAL
Copyright  2003 by the American Orthopaedic Foot & Ankle Society, Inc.
A Protocol for Treatment of Unstable Ankle Fractures Using
Transarticular Fixation in Patients with Diabetes Mellitus and Loss
of Protective Sensibility
Mihir M. Jani, M.D.; William M. Ricci, M.D.; Joseph Borrelli, Jr., M.D.; Susan E. Barrett M.D.; Jeffrey E. Johnson, M.D.
Saint Louis, MO
ABSTRACT
23% (3/13). These are lower than previously reported
rates between 30% (3/10) and 43% (9/21) for diabetic
patients with and without neuropathy. The amputation
rate for all fractures was 13% (2/16) and for closed fractures alone was 8% (1/13). These are similar to previously
reported rates of 10% (2/10) to 20% (2/21). There were no
deaths or Charcot malunions in this series. The combination of transarticular fixation and prolonged, protected
weightbearing provided 13 of 15 patients with a stable
ankle for weightbearing. Conclusion: Although these fractures remain a treatment challenge, this study presents
a successful, multidisciplinary protocol for treatment of
unstable ankle fractures in the most challenging group of
diabetic patients – those with loss of protective sensibility.
Background: Surgical treatment of ankle fractures in
patients with diabetes mellitus is associated with a
high complication rate. Diabetic patients with peripheral neuropathy are a particularly difficult group to treat
because of their inability to sense deep infection, repeat
trauma, and wound complications. The purpose of this
study was to evaluate a protocol that included transarticular fixation and prolonged, protected weightbearing
in the treatment of unstable ankle fractures in diabetic
patients with peripheral neuropathy and loss of protective sensibility. Methods: The authors retrospectively
reviewed the records of 15 patients with diabetes mellitus,
unstable ankle fractures (AO classification 44B), and loss
of protective sensibility confirmed via testing with a
5.07 Semmes-Weinstein monofilament. Retrograde transcalcaneal-talar-tibial fixation using large Steinmann pins
or screws in conjunction with standard techniques of open
reduction and internal fixation was used. The postoperative treatment protocol included: 1) short leg, total contact
casting and nonweightbearing status for 12 weeks;
2) removal of the intramedullary implants between 12 and
16 weeks; 3) application of a walker boot or short leg cast
with partial weightbearing for an additional 12 weeks; and
4) transition to a custom-molded ankle-foot orthosis (AFO)
or custom total-contact inserts in appropriate diabetic
footwear. Results: The major complication rate for all
fractures was 25% (4/16) and for closed fractures was
Key Words: Ankle Fracture; Complications; Diabetes
Mellitus; Internal Fixation; Operative Treatment; Peripheral Neuropathy
INTRODUCTION
Surgical treatment of ankle fractures in patients with
diabetes mellitus is associated with major complication
rates ranging from 30% (3/10) to 43% (9/21).1,10,13
These complications include amputation [0 – 20% (2/10)]
as well as infection, malunion, nonunion, and death
[0 – 11% (2/19)] as a result of impaired healing, deep
infection, and sepsis.1,10,11,13 Nonoperative treatment
of ankle fractures in diabetic patients has also been
associated with a higher infection rate compared to
patients without diabetes or diabetic patients treated
surgically.6 Peripheral vascular disease and peripheral
neuropathy associated with diabetes mellitus have been
implicated as the main reasons for the higher incidence
of these complications.6
Although these complications are well known, a
successful protocol for the treatment of such fractures in
diabetic patients with advanced peripheral neuropathy
has not yet been established. Loss of protective
Department of Orthopaedic Surgery, Barnes-Jewish Hospital, The Washington
University School of Medicine, Saint Louis, MO
Corresponding Author:
Jeffrey E. Johnson, M.D.
Associate Professor
Department of Orthopaedic Surgery
Barnes-Jewish Hospital
The Washington University School of Medicine
660 South Euclid Avenue
Campus Box 8233
Saint Louis, MO 63110
E-mail: [email protected]
For information on prices and availability of reprints call 410-494-4994 X226.
838
Foot & Ankle International/Vol. 24, No. 11/November 2003
sensibility often results in the inability of these patients to
sense deep infection, repeat trauma, ulceration, wound
problems, and progression to neuropathic arthropathy.
In addition, the loss of protective sensibility often leads
to noncompliance with the treatment recommendations
for these patients.6 For these reasons, diabetic patients
with unstable ankle fractures and advanced peripheral
neuropathy are a particularly difficult group to manage.
The purpose of this study was to evaluate a protocol
that included transarticular ankle fixation and prolonged,
protected weightbearing in the treatment of unstable
ankle fractures in this most difficult group of diabetic
patients — those who have lost protective sensibility.
METHODS
A retrospective review of medical records and radiographs of 18 patients with diabetes mellitus who underwent surgical treatment for an unstable ankle fracture
(AO classification 44B)15 between the years 1997 and
2000 was performed. Treatment was conducted at a
single institution by three orthopaedic surgeons.
Inpatient records from the time of surgery and all
outpatient records up to the time of latest follow-up
were fully reviewed. In addition, all available radiographs
were reviewed and included those from the time of
injury, immediately after surgical treatment, and latest
follow-up. Of note, no patients were found to have
clinical or radiographic evidence of Eichenholtz stage I
neuropathic arthropathy before the start of treatment.5
All patients were found to have loss of protective
sensibility via testing with a 5.07 Semmes-Weinstein
(10 g) monofilament.12,14 Testing was performed on the
injured extremity in four locations (plantar surface of
first, third, and fifth metatarsal heads and the great
toe) by applying the monofilament perpendicular to
the skin until it buckled for 1 second. Patients were
visually blinded from testing and were instructed to say
‘‘yes’’ if the monofilament was sensed. Patients were
considered to have lost protective sensibility if they
failed to sense the 5.07 monofilament at one or more
sites.12,14
Each patient was treated according to a protocol that
included ankle and subtalar joint transarticular fixation
and prolonged, protected weightbearing. All patients
underwent closed reduction and percutaneous, retrograde, trans-calcaneal-talar-tibial fixation with screws
(7.3 mm cannulated) or large ( 1/8 – 5/32 inch) Steinmann
pins engaged into a cortex of the tibia (Figs. 1 and 2).
The distal end of the pins were cut off to rest 1 cm
beneath the skin and the skin was closed to prevent
a portal of entry for bacteria. This fixation was used
alone, or as an adjunct to standard techniques of
open reduction and internal fixation of ankle fractures.7
TREATMENT OF UNSTABLE ANKLE FRACTURES
839
Fig. 1: Right ankle of patient PM. Anterior-posterior, oblique, and
lateral radiographs at time of injury demonstrating displaced distal
fibular and medial malleolar fractures and lateral subluxation of
the talus.
Fig. 2: Right ankle of patient PM. Anterior-posterior, oblique, and
lateral radiographs postoperatively showing plate fixation of the
fibula, tension band fixation of the medial malleolus, and retrograde
trans-calcaneal-talar-tibial fixation with one smooth and one threaded
Steinmann pin. The ankle was immobilized for 10 weeks in a total
contact cast. The Steinmann pins were then removed and the ankle
was immobilized for 7 more weeks. The patient was then transitioned
to an ankle-foot orthosis.
Three patients presented with open fractures and were
treated with intravenous antibiotics, urgent irrigation,
and debridement of open wounds, along with fracture
fixation, repeat irrigation and debridement, and finally
delayed wound closure within 48 hours.
The rationale for using retrograde, transarticular,
intramedullary fixation alone in three patients involved
several factors. Two patients (AA and NM, Table 1) were
noncompliant with nonweightbearing status between
the times of closed reduction and splinting in an
emergency room and the first office visit for surgical
planning. The third patient (TB, Table 1) was obese
and essentially nonambulatory and had a history of
psychosis. She failed nonoperative treatment with total
contact casting for several weeks. All three patients
presented with further displacement of the talus,
significant ankle swelling, and breakdown of the skin
L Bimalleolar
R Bimalleolar
R Bimalleolar
R Bimalleolar
L Bimalleolar
L Bimalleolar
R Bimalleolar equivalent
L Bimalleolar
L Medial Malleolar
R Bimalleolar equivalent
L Bimalleolar equivalent
R Bimalleolar equivalent
L Bimalleolar
TB (71)
MB (79)
CG (65)
PM (69)
PM (69)
NM (67)
KM (47)
RW (56)
SG (48)
CD (57)
GP (52)
TA (66)
JS (54)
Closed
Closed
Closed
Open
Closed
Closed
Closed
Closed
Open
Closed
Closed
Open
Closed
Closed
Closed
Closed
IDDM
IDDM
IDDM
NIDDM
IDDM
IDDM
IDDM
IDDM
NIDDM
IDDM
NIDDM
IDDM
IDDM
IDDM
IDDM
IDDM
Open
Insulin
or Closed Dependence
HTN, s/p renal transplant (receiving
chronic immunosuppressive
therapy)
CAD, COPD, PVD
HTN
Obesity, COPD
HTN, COPD
HTN, CHF, ovarian carcinoma
As above
Seizure disorder
HTN
CAD, CRF, HTN
Obesity, Psychosis
CAD
CAD, HTN, atrial fibrillation, CHF
Sarcoidosis
Obesity, HTN
HTN, atrial fibrillation
Medical
Comorbidities
(see Key)
None
None
None
Post-traumatic arthritis
IM + ORIF
IM + ORIF
IM + ORIF
IM + ORIF
IM + ORIF
IM + ORIF
IM + ORIF
IM only
IM + ORIF
IM + ORIF
IM only
IM + ORIF
IM + ORIF
None
None
Deep infection, retained pin in tibia,
post-traumatic arthritis
Retained pin in tibia
Broken pin in tibia
Nonunion of medial malleolus (not
fixated)
None
None
Post-traumatic arthritis
Transtibial amputation
Deep infection, nonunion of medial
malleolus, post-traumatic arthritis
Transtibial amputation
Complications
IM only
IM + ORIF
IM + ORIF
Fixation
(IM ± ORIF)
JANI ET AL.
Bimalleolar equivalent, displaced lateral malleolar fracture and medial joint space widening; IDDM, insulin-dependent diabetes mellitus; NIDDM, non-insulin-dependent diabetes mellitus; HTN,
hypertension; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CRF, chronic renal failure; PVD, peripheral vascular disease; IM,
intramedullary; ORIF, open reduction and internal fixation.
R Bimalleolar equivalent
R Bimalleolar
L Bimalleolar equivalent
Side and Type
of Fracture
(R-right, L-left)
AA (69)
RB (66)
LB (60)
Patient and Age
at Surgery
(years)
Table 1: Patient data
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Foot & Ankle International/Vol. 24, No. 11/November 2003
over the medial malleolus. Given these patient factors
and physical exam findings, it was decided to pursue
closed reduction and retrograde, intramedullary fixation
alone to avoid the incisions needed for open reduction
and internal fixation and thus decrease the risk of wound
complications and possible infection.
The postoperative treatment protocol included:
1) short leg, total contact casting and nonweightbearing for 12 weeks using crutches, walker, or a
wheelchair; 2) removal of the intramedullary implants
between 12 and 16 weeks; 3) application of a walker
boot or short leg cast with partial weightbearing for
an additional 12 weeks; and 4) transition to a custommolded ankle-foot orthosis (AFO) or total contact foot
orthoses in appropriate diabetic footwear. Casting was
performed following the principles of total contact
casting often used for treatment of diabetic neuropathic
ulcers.8,16,19,20 Near the end of cast immobilization,
consultation with a certified pedorthist and orthotist
determined the bracing and shoe modifications needed
to accommodate any deformity of the foot and/or
ankle. Often a polypropylene clamshell-type AFO or
a double-upright modified calf-lacer AFO attached to
an extra-depth shoe with an extended steel shank
and rocker sole was recommended for both short-term
and/or long-term use.9
Diabetic foot care education ensued during and after
the immobilization period. Emphasis was made upon
daily inspection of feet, keeping skin soft and supple
with moisturizing creams, use of in-depth shoes made of
soft leather and appropriate to foot width and deformity,
and use of total contact foot orthoses to accommodate
the foot and reduce plantar pressures.
Major and minor complications were defined according to previous studies.1,10,13 Major complications were
defined as those that required further surgical or
medical treatment and were considered possibly limb
or life threatening. These included Charcot neuropathic
malunion, wound dehiscence, deep infection requiring
operative debridement, amputation, and death. Minor
complications were all other complications including
stable malleolar nonunions, retained intramedullary
implants and post-traumatic arthritis (as evidenced by
joint space narrowing and subchondral sclerosis).
RESULTS
Three patients were lost to follow-up and therefore 16
ankles in 15 patients were followed for an average of 69
weeks (range, 16 – 156 weeks) (Table 1). Of those lost to
follow-up, one patient had since died of renal failure and
two patients could not be contacted. Retrograde, transcalcaneal-talar-tibial, intramedullary fixation was used
alone in three ankles and as an adjunct to standard
TREATMENT OF UNSTABLE ANKLE FRACTURES
841
Fig. 3: Right ankle of patient PM. Anterior-posterior, oblique, and
lateral radiographs at 78 weeks follow-up demonstrating healed
fractures and maintenance of joint space. No complications occurred
during the treatment and follow-up period.
techniques of open reduction and internal fixation in
13 ankles (Figs. 1 –3). Mean intraoperative estimated
blood loss was 41 ± 35 mL. Average time of ankle
immobilization from surgery to removal of transarticular
fixation was 12.0 ± 3.2 weeks. Average time from
removal of transarticular fixation to discontinuation
of immobilization was 10.7 ± 6.4 weeks. Mean total
immobilization time was 22.4 ± 8.3 weeks. Fracture
union occurred on average at 18.9 ± 6.4 weeks.
The major complication rate was 25% (4/16) for all
fractures and 23% (3/13) for closed fractures alone.
These included two deep infections requiring operative
irrigation and debridement, and two deep infections
necessitating transtibial amputation (Table 2). Including
all fractures and closed fractures alone, the amputation
rate was 13% (2/16) and 8% (1/13), respectively. One
amputation occurred in patient KM who presented with
an open fracture and an associated large, medial open
wound (Gustilo grade II). Deep infection developed
within 4 weeks, and despite intravenous antibiotics,
Table 2: Major complications
Closed
Open
All
Fractures Fractures Fractures
(n = 13)
(n = 3)
(n = 16)
Deep infection
(requiring and
cleared by
irrigation & debridement only)
Transtibial
amputation
Total rate of
major
complications
2
0
2
1
1
2
23%
33%
25%
842
JANI ET AL.
serial operative debridements, and removal of implants,
his infection could not be cleared and amputation was
performed. A second amputation occurred in patient
SG, who was receiving chronic, immunosuppressive
therapy (azathioprine and prednisone) for a renal
transplant. She developed purulent drainage from the
pin sites in the plantar heel at 8 weeks postoperatively.
Pins were removed and after 6 weeks of treatment with
a culture-specific, intravenous antibiotic (vancomycin),
the drainage resolved. The patient then presented
3 weeks later with a deep infection in the ankle
and in septic shock, and thus an amputation was
performed urgently. Patient RW was not compliant
with nonweightbearing status and developed a deep
calcaneal infection requiring operative irrigation and
debridement.
Minor complications (all clinically asymptomatic)
included four cases of post-traumatic arthritis, three
cases of retained intramedullary implants, and two
stable medial malleolar nonunions. No Charcot malunions or deaths occurred in our series.
Except for the two patients (KM and SG, Table 1) who
underwent amputation, all patients obtained a foot and
ankle on which they were able to bear weight, ambulate
[except patient TB (Table 1) who was nonambulatory
preoperatively], and remain free of ulcers during the
follow-up period.
DISCUSSION
The high complication rate associated with both
nonoperative and surgical treatment of ankle fractures
in diabetic patients has been clearly established.
In a retrospective review of ankle fractures treated
surgically, Low and Tan reported four wound infections
in 10 diabetic patients, two of which resulted in
transtibial amputation.11 Several case-control studies
of surgical treatment of ankle fractures in diabetic
patients have also shown an overall major complication
rate of approximately 43% (9/21) 1,13 and infection
rates as high as 30% (3/10).10 Transtibial amputations
[20% (2/10)] and death [11% (2/19)] are the most
severe of the major complications reported.1,11,13 These
studies do not report the percentage of their patients
who had peripheral neuropathy and loss of protective
sensibility.
The presumed contributing factors leading to these
higher complication rates are a combination of peripheral vascular disease and/or peripheral neuropathy. In a
retrospective review of closed ankle fractures in patients
with diabetes mellitus, Flynn et al. found a significantly
higher rate of infection associated with 1) closed (as
opposed to surgical) treatment, 2) peripheral vascular
disease, 3) poor patient compliance with treatment,
Foot & Ankle International/Vol. 24, No. 11/November 2003
and 4) the presence of peripheral neuropathy.6 Although
diabetic patients with a combination of ankle fractures,
peripheral neuropathy, and peripheral vascular disease
have been established as the most difficult group to
treat,6 no study has evaluated an even more difficult
subset of these patients — those with loss of protective
sensibility.
Loss of protective sensibility results in the inability
to sense deep infection, repeat trauma, ulceration,
wound problems, and development of neuropathic
(Charcot) arthropathy. This level of advanced peripheral
neuropathy can be objectively established by testing
with the 5.07 Semmes-Weinstein (10 gm) monofilament.
Loss of protective sensibility at the 5.07 level has been
associated with a significant increase in the incidence
of neurotrophic ulceration.12,14 Although development
of neuropathic arthropathy has not been associated
with an absolute level of insensibility, when diabetic
patients cannot detect the 5.07 monofilament, we
employ a unique and aggressive regimen for treatment
of ankle fractures.
Our treatment protocol includes the use of retrograde,
percutaneous, trans-calcaneal-talar-tibial fixation with
or without the use of standard techniques of open
reduction and internal fixation of ankle fractures. The
use of vertical transarticular pin fixation for unstable
ankle fractures was introduced in Europe and popularized in the United States by Childress.2 – 4,21 Childress
recommended the use of this fixation alone when
either local soft tissues were not amenable to standard incisions for open reduction and internal fixation or
when patients were minimally ambulatory or medically
unstable. Overall he reported successful results using
vertical transarticular pin fixation in treating 92 unstable
ankle fractures in nondiabetic patients.3 More recently,
Scioscia and Ziran discussed similar, successful results
in treating 14 severe ankle fractures with vertical transarticular fixation.18 The application of this technique in the
treatment of ankle fractures in diabetic patient with loss
of protective sensibility has been described, but no
clinical series has yet been published.9
Another technique as a method of limb salvage
has been described in the treatment of ankle fractures in diabetic patients with peripheral neuropathy.
Perry et al. noted successful limb salvage in six patients
with diabetes, peripheral neuropathy, and failed initial
fixation of ankle fractures, by using a laterally placed
4.5-mm dynamic compression plate (DCP) and multiple
syndesmotic screws. Two patients in this series developed wound dehiscence necessitating further operative
wound management including eventual plate removal.17
Given this complication, the use of a large compression
plate (along with multiple syndesmotic screws) on the
lateral side of the ankle would likely not succeed as a
method of primary fixation of unstable ankle fractures
Foot & Ankle International/Vol. 24, No. 11/November 2003
in diabetic patients because of 1) a thin or damaged
lateral soft-tissue envelope, or 2) a fracture pattern
that necessitates stabilization of the medial side of the
joint.
Our treatment protocol includes a comprehensive,
multidisciplinary approach to the treatment of unstable
ankle fractures in patients with diabetes mellitus and
loss of protective sensibility. Following our protocol,
we found a lower overall major complication rate of
25% (4/16) among all patients and a major complication
rate of 23% (3/13) among the subset of patients with
closed fractures. Although an amputation occurred in
two patients following our treatment protocol [overall
amputation rate of 13% (2/16)], each patient had
extenuating factors that further compromised his or
her immune status. Patient KM presented with an
open fracture and an associated large, open medial
wound (Gustilo grade II) and patient SG was taking
chronic immunosuppressive therapy for a renal transplant. Among the patients with closed fractures, our
amputation rate was 8% (1/13). No Charcot neuropathic malunions and no deaths (as a direct result of
surgical treatment of the ankle fracture) occurred in our
series.
There were few minor complications overall and
all were clinically insignificant. Retained intramedullary
implants are a unique complication to our protocol.
Although leaving the end of the pins outside the skin
with a 90◦ bend (as reported by Childress)3 would
likely prevent migration proximally, we cut the pins
beneath the skin and closed the associated wound
to decrease the risk of pin site infection and possible
development of deep infection. In addition, the large
size of the pins used ( 1/8 – 5/32 inch) made bending of
the pin tip difficult. To help prevent proximal migration,
pins were placed such that they would engage either
the anterior or posterior cortex of the tibia (Fig. 2).
The use of large cannulated screws obviates the
problem of migration, although they are more difficult to
remove.
Our ultimate goal of treating ankle fractures in diabetic
patients with loss of protective sensibility was to
maintain a foot and ankle that could be braced and allow
weightbearing. The certified pedorthist and orthotist
played a critical role in evaluating and treating our
patients after the immobilization period following an
ankle fracture. They implemented both custom foot
orthoses and various forms of AFOs (as indicated
by presence of deformity and functional status) and
reinforced education in regards to diabetic footwear
and general foot care.9
We have developed a successful protocol for treatment of unstable ankle fractures in the most challenging group of diabetic patients — those with loss of
protective sensibility. As a multidisciplinary approach,
TREATMENT OF UNSTABLE ANKLE FRACTURES
843
our protocol emphasizes 1) aggressive surgical treatment using retrograde, trans-calcaneal-talar-tibial fixation alone or as an adjunct to traditional ankle fracture fixation; 2) prolonged, protected weightbearing
and immobilization that includes total contact casting
to counter swelling, development of deformity, and
noncompliance; 3) involvement of the pedorthist and
orthotist to provide postoperative foot and ankle stability
and protection; and finally 4) patient education on
prevention of further injury to the diabetic foot and
ankle.
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