Session II - Tibia

Closed Tibia Fractures in Patients with Diabetes Mellitus: Complications and Relative Risk

Christopher B. Hirose, MD; Joseph Borrelli, Jr., MD; Scott Mitchell, MD; William M. Ricci, MD; Washington University School of Medicine, St. Louis, Missouri, USA

Purpose: Diseased vascularity, impaired immunocompetence, and defective neural function are thought to contribute to delay of healing in patients with diabetes. Although it is well-documented that ankle fractures in patients with diabetes have a high incidence of infection, malunion, delayed union, and nonunion, the literature describing the complications of patients with diabetes who sustain tibial shaft fractures is scant. The purpose of this study was to determine whether, and to what extent, patients with diabetes who have tibial fractures are at risk of complication.

Methods: Included in this study were 107 consecutive patients treated for closed tibial shaft fractures at our level I trauma center from 1998 to 2002. Seventeen patients were lost to follow-up, leaving a study group of 15 patients with diabetes and a control group of 75 subjects free of diabetes. There were 55 men and 35 women with an average age of 41 years (range, 18 to 85). The OTA fracture classification in the diabetic group was 10 42A, 2 42B, and 3 42C, and in the non-diabetic group, 48 42A, 18 42B, and 17 42C. Nine patients with diabetes were initially treated nonoperatively and six were treated with an intramedullary nail. Fourteen nondiabetics were treated nonoperatively, 58 were treated with an intramedullary nail, and 3 had plate osteosynthesis. Clinical and radiographic assessment of fracture union and complications was recorded. Nonunion was defined as absence of radiographic evidence of healing over a 9-month period, and delayed union, as lack of evidence of radiographic fracture union at 20 weeks. The average follow-up was 35 weeks for the diabetic group, and 40 weeks for the non-diabetic population. This study was approved by the Institutional Review Board.

.Results: Uncomplicated union occurred in only 3 of the 15 patients with diabetes (20%). Twelve (80%) had complications, including five patients who had more than one. These included five delayed unions, six nonunions, two cases of osteomyelitis, and four skin ulcerations. All six patients treated with intramedullary nails had at least one complication, including two delayed unions (one with osteomyelitis) and four nonunions (one with osteomyelitis). Among the nine patients with diabetes treated without surgery, three healed without complications, three had delayed unions (one with skin ulceration), two had nonunions (both with skin ulceration), and one had only skin ulceration.

Uncomplicated union occurred in 60 of the 75 non-diabetic controls (80%). Fifteen had one or more complications (20%). These included 14 delayed unions, 1 nonunion, 4 cases of osteomyelitis, and 1 skin ulceration. Seven the 58 nondiabetics treated with intramedullary nails had delayed unions, and two also had osteomyelitis.

Conclusion/Significance: Patients with diabetes who sustain a closed tibial shaft fracture are at increased risk for complications compared with nondiabetics. Patients with diabetes treated with intramedullary nails had a much higher risk of nonunion (66%) compared with those treated nonoperatively (22%). The optimal treatment for this group of patients remains unknown; however, nonoperative treatment should be considered for patients with diabetes who sustain tibial shaft fractures.