Schultz Alexander, Poynter Thomas, Wireman Garrett, Sweeney Michael, Likine Elive, Ziegler Craig, Ankem Hari, Zamora Rodolfo, Laco Nicholas, Seligson David
Department of Orthopedic Surgery, University of Louisville, Louisville, KY, USA.
Department of Orthopedic Surgery, University of Louisville, Louisville, KY, USA.
Injury. 2025 Mar;56(3):112177. doi: 10.1016/j.injury.2025.112177. Epub 2025 Jan 24.
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.
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).
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 %.
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.
由于术后并发症的倾向，糖尿病（DM）患者的踝关节和pilon骨折治疗具有挑战性。肢体挽救是这些损伤后的主要关注点，因为膝下截肢（BKA）发生率高得令人无法接受。在不进行关节准备的情况下进行一期逆行胫距跟（TTC）关节钉固定已成为治疗糖尿病患者踝关节和pilon骨折以减轻手术并发症和预防BKA的一种解决方案。该技术可最大限度地减少手术解剖，并且先前已在脆性骨折中证明了其效用，然而，关于在DM患者中使用该技术的研究很少。
对7年内接受不进行关节准备的逆行TTC钉固定治疗的糖尿病患者进行回顾性研究。如果患者骨骼成熟、患有糖尿病且接受不进行关节准备的逆行TTC钉固定治疗，且最短随访期为8个月，则纳入研究。排除接受其他形式固定治疗的患者以及儿童或青少年患者。25名患者符合纳入标准。收集了人口统计学、损伤特征和手术结果的数据。平均随访期为2.45年（四分位距986）。
该队列患者的平均年龄、体重指数（BMI）和糖化血红蛋白（HbA1c）分别为64.6（四分位距9.6）、36.7（四分位距11.5）和7.6%（四分位距1.4）。大多数骨折是由站立时跌倒导致的闭合性旋后-外旋机制。平均住院时间为9.1天（四分位距8）。72%的患者保持了行走能力。该队列中84%的患者实现了肢体挽救。4名患者最终需要进行BKA。HbA1c和骨折相关感染（FRI）是与BKA相关的统计学显著风险因素。HbA1c每增加1%，发生BKA的几率增加2.63倍。手术并发症和再次手术率为56%。
尽管该队列中的大多数患者实现了肢体挽救，但使用该技术观察到术后并发症和再次手术的发生率较高。需要进行前瞻性比较研究，以进一步验证在DM患者中不进行关节准备的逆行钉固定的使用。
