Diabetes and malleolar fractures

Transcription

1 Diabetes and malleolar fractures Frank Linde Foot and ankle section Department of Orthopaedics University Hospital of Aarhus

2 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

3 Malleolar fractures and diabetes Frequency In-patients, University Hospital of Aarhus, Malleolar fracures Malleolar fractures and diabetes (1,4%)

4 Case 1 60 years old, type 2 diabetes for 35 years Tri-mallolar fracture. Foot pulses? Stable standard fixation

5 Wound necrosis No foot pulses, Toe blood pressure 45 mmhg Neuropathy

6 Vascular reconstruction Free muscular flap Arthrodesis Skin coverage, arthrodesis healed, no pain

7 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

8 Loss of fixation Fracture union i valgus position No pain, good function Ostearthrosis no problem

9 Case 3 35 years, type 1 diabetes Neuropathy Nephropathy (dialysis) No foot pulses Skin necrosis

10 Fracture reduction, external fixation, cast Non-weight bearing Vascular reconstruction not possible In patients care

11 Discharged from dialysis department Loss of fixation

12 New more stable fixation Skin break down, infection Amputation

13 Kristiansen (Denmark) Dan Med Bull 1983 Malleolar fractures in a 3-years period Case control study Serious complications Diabetes* Diabetes Controls Operation Cons. treatm. Operation n=10 n=20 3 (30%)** 1 (5%) *A mixtures of patients with and without diabetic complications **No amputations

14 Blotter et al. (Japan) Foot Ankle Int 1999 Malleolar fractures in a 10-years period Case control study Serious complications Diabetes* Diabetes Controls Operation Cons. treatm. Operation n=21 n=46 8 (38%)** 3 (8%) *A mixtures of patients with and without diabetic complications **2 amputations

15 McCormack and Leith (USA) J Bone Joint Surg (Br) 1998 Malleolar fractures in a 6 years period Case control study Serious complications Diabetes* Diabetes* Controls Operation Cons treatm. Operation n=19 n=7 n=26 6 (32%)** 5 (71%) 0 (0%) *A mixtures of patients with and without diabetic complications **2 amputations

16 Flynn et al. (USA) Foot Ankle Int 2000 Case control study Serious complications Diabetes Diabetes Controls Operation Cons treatm. Operation n=19 n=6 n=68 4 (27%)* 5 (83%) 5 (7%) * No amputations

17 Jones et al. (USA) J Bone Joint Surg (Br) 2005 Malleolar fractures in a 20-years period Case control study Serious complications Diabetes Diabetes Controls Without neuropathy With neuropathy n=21 n=21 n=42 3 (14%) 11 (52%) 5 (12%) * No information about amputations

18 Combined analysis Malleolar fractures Serious complications Diabetes Controls With neuropathy n=118 n= (38%)* 17 (9%) * 6 amputations (5%)

19 Jani et al. (USA) Foot Ankle Int 2003 Malleolar fractures in a 2-years period Serious complications Diabetes* Operation** n=15 4 (27%)*** * All patients had neuropathy ** Suppl. transfixation of the ankle joint and prolonged nonweight bearing *** 2 amputations

20 Costigan et al. (USA) Foot Ankle Int 2007 Malleolar fractures in a 8-years period Serious complications Diabetes with foot pulses and no diabetic complications n=66 Diabetes without foot pulses n=12 1 (2%) 10 (83%)* * 2 amputations

21 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

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

23 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

24 After a few more weeks, swelling No new trauma Fracture of the tibial epihysis? Charcot foot? Prolonged casting, nonweight bearing Bone union, no pain, excellent dosifleksion, satisfied patient.

25 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

26 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

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