Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study

Raju Ahluwalia; Caeser Wek; Thomas Lorchan Lewis; Thomas David Stringfellow; Duncan Coffey; Sze Ping Tan; Michael Edmonds; Marco Meloni; Ines L H Reichert; HARnT Collaborative King’s College Hospital, London

doi:10.3390/jcm13133949

Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study

J Clin Med. 2024 Jul 5;13(13):3949. doi: 10.3390/jcm13133949.

Authors

Raju Ahluwalia^{1

2

3}, Caeser Wek^{2

3}, Thomas Lorchan Lewis^{2

3}, Thomas David Stringfellow^{2

3}, Duncan Coffey^{2

3}, Sze Ping Tan^{2

3}, Michael Edmonds^{1

3}, Marco Meloni⁴, Ines L H Reichert^{2

3}; HARnT Collaborative King’s College Hospital, London

Affiliations

¹ Diabetic Foot Clinic, Kings College Hospital, London SE5 9RS, UK.
² Department of Orthopaedics, Kings College Hospital, Bessemer Road, London SE5 9RS, UK.
³ The HARnT Collaborative King's College Hospital, London SE5 9RS, UK.
⁴ Department of Diabetic Foot Unit, University of Tor Vergata, 00133 Roma, Italy.

Abstract

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

Keywords: ankle fracture; complications; diabetes; hindfoot nail; level of evidence: III; neuropathy; observational study; osteosynthesis; outcomes.

Grants and funding

There was no funding to support this study. The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.