Table 2.
Critical analysis of the notable publications.
| 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 |
|