Outcomes in Treatment of Ankle and Pilon Fractures with Retrograde Tibiotalocalcaneal Nailing Without Articular Preparation in the Setting of Diabetes Mellitus.

Background: Treatment of ankle and pilon fractures in the setting of diabetes mellitus (DM) is challenging due to a propensity for postoperative complications. Limb salvage is a primary concern following these injuries, as below knee amputation (BKA) occurs at an unacceptably high rate. Primary retrograde tibiotalocalcaneal (TTC) joint nailing without articular preparation has emerged as a solution to treat diabetics with ankle and pilon fractures to mitigate surgical complications and prevent BKA. The technique minimizes surgical dissection and has previously demonstrated utility in fragility fracture, however, there are few studies regarding the use of this technique in the setting of DM.

Methods: A retrospective review of diabetic patients treated with retrograde TTC nailing without articular preparation was conducted over a seven-year period. Patients were included in the study if they were skeletally mature, diabetic, and treated with retrograde TTC nailing without articular preparation over a minimum follow up period of eight months. Treatment with other forms of fixation and pediatric or adolescents were excluded. A cohort of 25 patients met the inclusion criteria. Data was collected on demographics, injury characteristics, and surgical outcomes. The average follow up period was 2.45 years (IQR 986).

Results: The averages for age, BMI, and Hemoglobin A1c (HbA1c) of the cohort were 64.6 (IQR 9.6), 36.7 (IQR 11.5), and 7.6 % (IQR 1.4), respectively. A majority of fractures were a closed supination-external rotation mechanism resulting from a fall from standing. The average LOS was 9.1 days (IQR 8). An ambulatory level was maintained in 72 % of patients. Limb salvage was achieved for 84 % of the cohort. Four patients ultimately required BKA. HbA1c and fracture-related infection (FRI) were statistically significant risk factors associated with BKA. For every 1 % increase in HbA1c, there was 2.63-fold odds of developing BKA. The surgical complication and reoperation rate were 56 %.

Conclusion: Although limb salvage was achieved for most patients within the cohort, high rates of postoperative complications and reoperations were observed using this technique. Prospective comparative studies are needed to further validate the use of retrograde nailing without articular preparation in the setting of DM.