Successful treatment of nonunion with an Ilizarov ring fixator after ankle fracture for Charcot arthropathy: a case report
© Nozaka et al.; licensee BioMed Central Ltd. 2014
Received: 12 May 2014
Accepted: 29 July 2014
Published: 7 August 2014
Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. Nonunion and lengthy wound healing in high-risk patients with diabetes, particularly patients with peripheral arterial disease and renal failure, occur secondary to several clinical conditions and are often fraught with complications. Whether diabetic ankle fractures are best treated noninvasively or surgically is controversial.
A 53-year-old Japanese man fractured his right ankle. The fractured ankle was treated nonsurgically with a plaster cast. Although he remained non-weight-bearing for 3 months, radiography at 3 months showed nonunion. The nonunion was treated by Ilizarov external fixation of the ankle. The external fixator was removed 99 days postoperatively, at which time the patient exhibited anatomical and functional recovery and was able to walk without severe complications.
In patients with diabetes mellitus, severe nonunion of ankle fractures with Charcot arthropathy in which the fracture fragment diameter is very small and the use of internal fixation is difficult is a clinical challenge. Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires.
Increasing numbers of patients are being diagnosed with diabetes mellitus, and they are living longer because of improvements in treatment. Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons . Nonunion and lengthy wound healing in high-risk patients with diabetes , particularly patients with peripheral arterial disease and renal failure, occur secondary to several clinical conditions and are often fraught with complications .
Patient’s pretreatment laboratory findings
280 × 104
12.7 × 104
Increasing numbers of patients are being diagnosed with diabetes, and they are living longer because of improvements in treatment [1–3]. Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. Nonunion and lengthy wound healing in high-risk patients with diabetes, particularly in those with peripheral arterial disease and renal failure, as in the present case, are often fraught with complications [1–3]. Whether diabetic ankle fractures are best treated noninvasively or surgically is controversial . Some previous studies have shown that nondisplaced fractures in high-risk patients can be managed nonsurgically in a cast [5, 6]. Treatment entails casting with non-weight-bearing restriction until fracture healing is demonstrated.
McCormack et al. described 26 ankle fractures in patients with diabetes; 19 were treated surgically, and seven were immobilized in casts. The surgical group included one wound complication (5%), four infections (21%) leading to two amputations (11%), and two deaths (11%), for an overall complication rate of 47% . Because the present patient was a high-risk patient with diabetes mellitus, he was managed nonsurgically with a cast in another hospital. Rigid internal fixation was considered to have been difficult because the diameter of the distal fragment was very small. Furthermore, bone softening of the small distal fragment was noted at surgery. Ilizarov external fixation for severe ankle fracture in patients with diabetes mellitus in which the diameter of the fracture fragment is very small and the use of internal fixation is difficult allows suitable fixation to be achieved using multiple Ilizarov wires. It was thought that the frame should extend to the foot (ankle-joint bridging) so that weight-bearing forces would not be transmitted proximally by the talus. This protects the articular surface and decreases problems associated with loosening and infection of the distal tibial pins. It also increases the safety of earlier weight-bearing. After sufficient fracture healing had occurred, the foot ring was removed to allow ankle motion and progressive weight-bearing. More progenitor cells from bone marrow were probably introduced at the site of nonunion by pulverizing the complete bone; more cytokines, such as bone morphogenic protein or basic fibroblast growth factor, were likely introduced from the bone matrix as well . Furthermore, we anticipated that the increased skin tension associated with the use of a locking plate could be prevented. Ankle fractures in patients with diabetes mellitus are characterized by thinning of the subcutaneous tissue, poor dermal extensibility, and senile skin atrophy . The skin also becomes more fragile and susceptible to trauma in these patients, leading to more lacerations and bruising .
Lower-profile metallic implants have significantly reduced soft tissue complications in recent years; however, cases of implant-related soft tissue problems are still encountered, particularly in patients with Charcot arthropathy . Some techniques address osteopenia or wound necrosis, which are important problems in diabetic patients with ankle fractures. In the present case, the patient only underwent daily showering of the pin tract of the external fixator; no other physical pin cleaning was performed , and no pin tract infection developed. Lovisetti et al. reported no cases of pseudoarthrosis or deep infection [11–13]. They attributed their 100% union rate to meticulous preservation of soft tissues in the fracture zone. Treatment of ankle fractures in patients with diabetes mellitus by circular external fixation allows for less soft tissue dissection and is a reliable method for achieving stabilization and healing of distal tibial fractures with fewer soft tissue complications. Use of the Ilizarov external fixator is a safe method for ankle fractures in patients with diabetes mellitus and has the advantage of rigid fixation.
Successful treatment of nonunion despite the presence of Charcot ankle arthropathy might be attributed to chipping. It is believed that immediate weight-bearing improves limb circulation and enhances the healing process based on the fact that the speed of fracture healing is usually proportional to the amount of available circulation to and between the fragments . The present case provides satisfactory evidence that this procedure can be used to successfully manage such nonunions after ankle fracture with Charcot arthropathy. In conclusion, Ilizarov external fixation for severe nonunion of ankle fractures in patients with diabetes mellitus in which the diameter of the fracture fragment is very small and the use of internal fixation is difficult allows suitable fixation to be achieved using multiple Ilizarov wires.
Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
This study received no funding.
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