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Successful treatment of nonunion with an Ilizarov ring fixator after ankle fracture for Charcot arthropathy: a case report.

Nozaka K, Shimada Y, Kimura Y, Yamada S, Kashiwagura T, Sakuraba T, Wakabayashi I - BMC Res Notes (2014)

Bottom Line: A 53-year-old Japanese man fractured his right 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.Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan. kk-nozaka@mue.biglobe.ne.jp.

ABSTRACT

Background: 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.

Case presentation: 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.

Conclusion: 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.

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Related in: MedlinePlus

Postoperative radiographs. (a, b) Anteroposterior- and lateral-view plain radiographs after surgery, showing anatomical reduction.
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Figure 2: Postoperative radiographs. (a, b) Anteroposterior- and lateral-view plain radiographs after surgery, showing anatomical reduction.

Mentions: A 53-year-old Japanese man injured his right ankle while walking on a wet road. At the time of the injury, he had been walking with a T-cane following surgical repair of a left hip fracture and had Charcot knee arthropathy in his left knee. He felt pain in the right ankle for 1 week after the injury and presented to another hospital for evaluation. The initial plain X-ray showed a right ankle fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] type 43-A1.3) (Figure 1a, b). The patient also had severe diabetes mellitus, anemia, and chronic kidney disease. He had stopped self-injection of insulin and developed severe hyperglycemia. On physical examination, he had extremely weak pulses and many small ulcers on his lower limbs. Laboratory testing revealed a high level of hemoglobin A1c (10.9%; reference value, <5.8%), low level of hemoglobin (8.9 g/dL; reference range, 13.5–17.0 mg/dL), and high level of serum creatinine (3.8 mg/dL; reference range, 0.8–1.3 mg/dL) (Table 1). The bone mineral density of the lumbar spine (L2–4) (0.549 g/cm2; T-score, -3.78 S.D.) and proximal femur (0.622 g/cm2; T-score, -2.57S.D.) confirmed a diagnosis of osteoporosis. The nerve conduction velocity was very slow, as seen in patients with diabetes mellitus with generalized peripheral neuropathy. Another doctor considered that his anesthetic risk was high; therefore, he was treated nonsurgically. His ankle was placed in a total cast, and he was advised to avoid bearing weight on his right leg. His ankle developed slight swelling and redness approximately 2 weeks after casting; at 1.5 months, his ankle was swollen and erythematous with minor discomfort (Figure 1c, d). Another doctor continued nonsurgical treatment with the plaster cast. Although the patient continued to walk without weight-bearing for 3 months, radiologic assessment at 3 months showed no signs of healing (Figure 1e). The treating doctor considered that the distal tibia fracture fragment was too small to fix with internal fixation, and the patient’s soft tissue condition was poor. The patient was then transferred to our department. We decided to proceed with osteosynthesis with an Ilizarov ring fixator to preserve the joint function. Given the patient’s condition, the risk of skin disorders with the use of bulky internal fixation materials appeared to be high. After admission to our institute, Ilizarov ring fixator surgery was performed with the patient under general anesthesia in the supine position. Five rings were used for the Ilizarov fixator. Maintenance of axial alignment and rotation and correct length adjustment were checked using intensification. The foot was fixed to a foot ring connected to the tibial external fixator (Figure 2a, b). Both ends of the bone fragments were then chipped into small pieces at the injured site using a hammer and osteotome without peeling off the periosteum [4]. After chipping, the sites of nonunion in the fibula and tibia were shortened until they were no longer recognizable. A 1.8-mm Ilizarov wire was passed parallel to the articular surface on the anteroposterior X-ray view of the tibial epiphysis. Five wires were inserted onto the distal tibial ring. The wires were fixed to the rings of the fixator and tensioned. The foot was fixed in the neutral position to avoid both supination and equinus. Postoperative skin necrosis on the medial skin incision was successfully treated with antibiotic ointment (Figure 3a). Full weight-bearing walking was permitted 14 days postoperatively. The external fixator of the foot was removed 6 weeks after surgery (Figure 3b). Radiographs showed healing of the fracture 99 days postoperatively (Figure 4a, b). At the 2-year postoperative follow-up, the patient was satisfied with the outcome and was able to walk with a T-cane. Clinical outcomes were measured using the postoperative American Orthopedic Foot & Ankle Society scale ankle/hindfoot scale score (postoperative score of 94), Short Form-36 (postoperative physical component summary subscore of 47.7, mental component summary subscore of 59.3), and visual analog scale for pain (postoperative score of 0). At the last visit, the patient exhibited 0° and 30° dorsal and plantar flexion, respectively, and the range of motion of the operated ankle almost matched that of the unoperated ankle.


Successful treatment of nonunion with an Ilizarov ring fixator after ankle fracture for Charcot arthropathy: a case report.

Nozaka K, Shimada Y, Kimura Y, Yamada S, Kashiwagura T, Sakuraba T, Wakabayashi I - BMC Res Notes (2014)

Postoperative radiographs. (a, b) Anteroposterior- and lateral-view plain radiographs after surgery, showing anatomical reduction.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4127037&req=5

Figure 2: Postoperative radiographs. (a, b) Anteroposterior- and lateral-view plain radiographs after surgery, showing anatomical reduction.
Mentions: A 53-year-old Japanese man injured his right ankle while walking on a wet road. At the time of the injury, he had been walking with a T-cane following surgical repair of a left hip fracture and had Charcot knee arthropathy in his left knee. He felt pain in the right ankle for 1 week after the injury and presented to another hospital for evaluation. The initial plain X-ray showed a right ankle fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] type 43-A1.3) (Figure 1a, b). The patient also had severe diabetes mellitus, anemia, and chronic kidney disease. He had stopped self-injection of insulin and developed severe hyperglycemia. On physical examination, he had extremely weak pulses and many small ulcers on his lower limbs. Laboratory testing revealed a high level of hemoglobin A1c (10.9%; reference value, <5.8%), low level of hemoglobin (8.9 g/dL; reference range, 13.5–17.0 mg/dL), and high level of serum creatinine (3.8 mg/dL; reference range, 0.8–1.3 mg/dL) (Table 1). The bone mineral density of the lumbar spine (L2–4) (0.549 g/cm2; T-score, -3.78 S.D.) and proximal femur (0.622 g/cm2; T-score, -2.57S.D.) confirmed a diagnosis of osteoporosis. The nerve conduction velocity was very slow, as seen in patients with diabetes mellitus with generalized peripheral neuropathy. Another doctor considered that his anesthetic risk was high; therefore, he was treated nonsurgically. His ankle was placed in a total cast, and he was advised to avoid bearing weight on his right leg. His ankle developed slight swelling and redness approximately 2 weeks after casting; at 1.5 months, his ankle was swollen and erythematous with minor discomfort (Figure 1c, d). Another doctor continued nonsurgical treatment with the plaster cast. Although the patient continued to walk without weight-bearing for 3 months, radiologic assessment at 3 months showed no signs of healing (Figure 1e). The treating doctor considered that the distal tibia fracture fragment was too small to fix with internal fixation, and the patient’s soft tissue condition was poor. The patient was then transferred to our department. We decided to proceed with osteosynthesis with an Ilizarov ring fixator to preserve the joint function. Given the patient’s condition, the risk of skin disorders with the use of bulky internal fixation materials appeared to be high. After admission to our institute, Ilizarov ring fixator surgery was performed with the patient under general anesthesia in the supine position. Five rings were used for the Ilizarov fixator. Maintenance of axial alignment and rotation and correct length adjustment were checked using intensification. The foot was fixed to a foot ring connected to the tibial external fixator (Figure 2a, b). Both ends of the bone fragments were then chipped into small pieces at the injured site using a hammer and osteotome without peeling off the periosteum [4]. After chipping, the sites of nonunion in the fibula and tibia were shortened until they were no longer recognizable. A 1.8-mm Ilizarov wire was passed parallel to the articular surface on the anteroposterior X-ray view of the tibial epiphysis. Five wires were inserted onto the distal tibial ring. The wires were fixed to the rings of the fixator and tensioned. The foot was fixed in the neutral position to avoid both supination and equinus. Postoperative skin necrosis on the medial skin incision was successfully treated with antibiotic ointment (Figure 3a). Full weight-bearing walking was permitted 14 days postoperatively. The external fixator of the foot was removed 6 weeks after surgery (Figure 3b). Radiographs showed healing of the fracture 99 days postoperatively (Figure 4a, b). At the 2-year postoperative follow-up, the patient was satisfied with the outcome and was able to walk with a T-cane. Clinical outcomes were measured using the postoperative American Orthopedic Foot & Ankle Society scale ankle/hindfoot scale score (postoperative score of 94), Short Form-36 (postoperative physical component summary subscore of 47.7, mental component summary subscore of 59.3), and visual analog scale for pain (postoperative score of 0). At the last visit, the patient exhibited 0° and 30° dorsal and plantar flexion, respectively, and the range of motion of the operated ankle almost matched that of the unoperated ankle.

Bottom Line: A 53-year-old Japanese man fractured his right 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.Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan. kk-nozaka@mue.biglobe.ne.jp.

ABSTRACT

Background: 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.

Case presentation: 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.

Conclusion: 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.

Show MeSH
Related in: MedlinePlus