|
| Study type | Authors, year, and location origin | Prognostic
evidence strength | Patient details | Relevant findings |
|
| Cohort study | Guo et al. [20]
China, 2009 | Level II | (i) Retrospectively selected 72 patients (36 preoperatively neglected diabetes, 36 nondiabetic controls) with closed ankle fractures between 01/03 and 09/07
(ii) Recall of patients for prospective review over 12 months
(iii) Managed either nonoperatively and operatively
(iv) Mean age 54.4 | (i) Increased incidence of infection, nonunion, and Charcot’s arthropathy
(ii) No significant difference in AOFAS and Bray’s ankle score between two groups |
|
| Retrospective study | SooHoo et al. [21]
USA, 2009 | Level II | 57,183 operatively managed ankle fractures (1,219 were complicated diabetic ankle fractures) | Significant increase in complication rates (wound infection, revision operation, and BKA) in complicated diabetic group |
Ganesh et al. [3]
USA, 2005 | Level II | 160,598 nationwide ankle fractures (9174 diabetic ankle fractures) between 1988 and 2000 | Diabetics had significant increase in in-hospital mortality, complications, length of stay, and cost |
|
|
Case control |
McCormack and Leith [22]
Canada, 1998 | Level III | (i) 52 patients (26 diabetic, 26 control) with closed ankle fractures between 04/90 and 01/99
(ii) Mean age 61 (43–78) | Significant increase in complications in both nonoperative and operative fixation in diabetics |
Jones et al. [23]
USA, 2005 | Level III | (i) 84 patients (42 diabetic, 42 control)
(ii) Mean age 57.1 | Significant increase in long-term bracing in diabetics (mean age 53.6, insulin dependant, mean duration of DM 20.3 years, and history of Charcot’s) |
Flynn et al. [24]
Puerto Rico, 2000 | Level III | (i) 98 patients with closed ankle fractures (25 diabetic, 73 nondiabetic) between 01/88 and 31/97
(ii) Mean age 44 (nondiabetic) and 60 (diabetic) | Significant increase in postoperative infection in diabetic group (up to five times), especially with factors: nonoperative management, poor glycaemic control, and neuropathy |
Blotter et al. [25]
USA, 1999 | Level III | (i) 67 surgically treated ankle fractures in patients (21 diabetic, 46 nondiabetic/control) between 03/85 and 10/96
(ii) 4/21 Webber C, 17/21 Webber B
(iii) Mean age 55 (diabetic group) and 53 (nondiabetic/control group) | (i) Significant increase in postoperative complication in diabetic group (43% versus 15%), particularly in the insulin dependent
(ii) 2 cases of postoperative Charcot’s arthropathy in diabetic population
(iii) No diabetic subgroup analysis |
Kristiansen [26]
Denmark, 1983 | Level III | 30 patients (10 diabetic, 20 nondiabetic/control) | Significantly increase in wound infection (60% versus 10%) and hospitalization in diabetics (17 versus 9 days) |
| | Bibbo et al. [27]
USA, 2001 | Level III | (i) 59 patients with isolated ankle fractures (13 diabetic, 46 nondiabetic/control)
(ii) Mean age 55.1 (diabetic), 40.2 (nondiabetic/control)
(iii) Mean followup 46 months (diabetic) and 32 months (nondiabetic/control) | (i) Increased complication rate in diabetics compared to nondiabetics (46% versus 17%)
(ii) None required amputation/arthrodesis
(iii) No information on presence of diabetic complications |
|
|
Case series | Costigan et al. [28]
USA, 2007 | Level IV | (i) 84 diabetic patients with previous ORIF of an ankle fracture over an 8-year period
(ii) Mean age 49.5
(iii) Average followup 4.1 years | Significant increase in complications in diabetics with peripheral neuropathy and peripheral vascular disease |
Ayoub [14]
Egypt, 2008 | Level IV | (i) 17 patients with Charcot arthropathy undergoing tibiotalar arthrodesis
(ii) Mean age 61.6 (57–69)
(iii) Mean followup 26 months | Fusion rates were higher in patients with O2 saturations > 95%, decreased BMI, absence of peripheral neuropathy |
Holmes and Hill [29]
USA, 1994 | Level IV | (i) Assesses relationship of early diagnosis and treatment in 18 patients with diabetic ankle or foot fracture/dislocations between 05/85 and 05/90
(ii) Mean age 55
(iii) Mean followup 27 months | 11/20 had a delay in diagnosis with average time of 1 month between onset of symptoms and diagnosis |
Kline et al. [30]
USA, 2009 | Level IV | (i) 83 tibial pilon fractures (14 diabetic, 68 nondiabetic) between 01/2005 and 06/2007
(ii) Mean age 47.3
(iii) Length of followup 14.5 months (diabetic) and 12.3 months (nondiabetic) | Significant increase in postoperative complications including infection (71% versus 19%) and nonunion/delayed union (43% versus 16%) |
White et al. [31]
USA, 2003 | Level IV | (i) 14 open ankle fractures in 13 patients with diabetes between 01/01/1981 and 31/12/2000
(ii) Mean age 54 (29–80)
(iii) Mean followup 19 months
(iv) 9/13 patients were insulin dependent | 9/14 developed wound complications, 6/14 had below knee amputations (4 of these were at least Gustilo Class III open fractures), and 3/14 healed |
Schon et al. [32]
USA, 1998 | Level IV | 28 diabetic neuropathic ankle fractures (15 undisplaced, 13 displaced) | (i) Undisplaced ankle fractures are amenable to nonoperative management without significant complications
(ii) Of the 13 displaced ankle fractures, high risk of malunion/nonunion if standard ORIF is used |
Low and Tan [33]
Singapore, 1995 | Level IV | (i) 93 surgically treated ankle fractures (83 nondiabetic, 10 diabetic) between 01/1992 and 06/1993
(ii) Mean age 67.5
(iii) Mean followup 16.2 months | (i) 5 reported cases of infection (all diabetics)
(ii) 2/5 requiring below knee amputation, with at least 1/5 having a history of peripheral neuropathy |
|
