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Incidence of Complications and Risk Factors for Nonunion After Ankle Fracture in Diabetes Mellitus

Lawrence A. LaveryDepartment of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

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 DPM, MPH
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David C. LaveryStatistic Consulting, Aurora, CO.

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Tyson GreenImperial Health–Center for Orthopaedics, Lake Charles, LA.

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Nathan HuntOrthopaedic & Spine Center of the Rockies, Fort Collins, CO.

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Matthew MaloneWestern Sydney University, Ingham Institute for Applied Medical Research, Liverpool, Australia.

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Dane WukichDepartment of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

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Background: To evaluate complications and risk factors for nonunion in patients with diabetes after ankle fracture.

Methods: We conducted a retrospective study of 139 patients with diabetes and ankle fractures followed for 1 year. We evaluated the incidence of wounds, infections, nonunions, Charcot’s arthropathy, and amputations. We determined Fracture severity (unimalleolar, bimalleolar, trimalleolar), nonunion, and Charcot’s arthropathy from radiographs. Nonunion was defined as a fracture that did not heal within 6 months of fracture. Analysis of variance was used to compare continuous variables, and χ2 tests to compare dichotomous variables, with α = 0.05. Logistic regression was performed with a binary variable representing nonunions as the dependent variable.

Results: Complications were common: nonunion (24.5%), Charcot’s arthropathy (7.9%), wounds (5.2%), wound site infection (17.3%), and leg amputation (2.2%). Patients with nonunions were more likely to be male (55.9% versus 29.5%; P = .005), have sensory neuropathy (76.5% versus 32.4%; P < .001), have end-stage renal disease (17.6% versus 2.9%; P < .001), and use insulin (73.5% versus 40.1%; P < .001), β-blockers (58.8% versus 39.0%; P = .049), and corticosteroids (26.5% versus 9.5%; P = .02). Among patients with nonunion, there was an increased risk of wounds (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.46–7.73), infection (OR, 2.04; 95% CI, 0.72–5.61), amputation (OR, 7.74; 95% CI, 1.01–100.23), and long-term bracing (OR, 9.51; 95% CI, 3.8–23.8). In the logistic regression analysis, four factors were associated with fracture nonunion: dialysis (OR, 7.7; 95% CI, 1.7–35.2), insulin use (OR, 3.3; 95% CI, 1.5–7.4), corticosteroid use (OR, 4.9; 95% CI, 1.4–18.0), and ankle fracture severity (bimalleolar or trimalleolar fracture) (OR, 2.5; 95% CI, 1.1–5.4).

Conclusions: These results demonstrate risk factors for nonunions: dialysis, insulin use, and fracture severity after ankle fracture in patients with diabetes.

Corresponding author: Lawrence A. Lavery, DPM, MPH, Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, F4.310A, Dallas, TX 75390-8560. (E-mail: larry.lavery@utsouthwestern.edu)