title: A protocol for treatment of unstable ankle fractures using transarticular fixation in patients with diabetes mellitus and loss of protective sensibility.
abstract: 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 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Orthopaedic Surgery, Barnes-Jewish Hospital, The Washington University School of Medicine, Saint Louis, MO 63110, USA.
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Jani
authors.forename: William M
authors.initials: WM
authors.lastname: Ricci
authors.forename: Joseph
authors.initials: J
authors.lastname: Borrelli
authors.forename: Susan E
authors.initials: SE
authors.lastname: Barrett
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Johnson
mesh_terms: D000368:Aged; D016512:Ankle Injuries / Q000150:complications / Q000601:surgery*; D000843:Ankle Joint / Q000601:surgery*; D002370:Casts, Surgical; D002985:Clinical Protocols; D003131:Combined Modality Therapy; D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000503:physiopathology; D017719:Diabetic Foot / Q000150:complications / Q000503:physiopathology; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects; D006801:Humans; D008875:Middle Aged; D009989:Orthotic Devices; D011183:Postoperative Complications; D012189:Retrospective Studies; D020886:Somatosensory Disorders / Q000150:complications / Q000503:physiopathology; D013380:Subtalar Joint / Q000601:surgery*