Abstract
Research Type:
Level 1 - Randomized controlled trial (RCT), Meta-analysis of randomized trials with homogeneous results
Introduction/Purpose:
Tibiotalocalcaneal (TTC) arthrodesis is commonly used in salvage situations involving the ankle and subtalar joint, often in patients with concomitant diabetes mellitus (DM). Literature has established a higher risk of developing postoperative complications, regardless of the procedure, for patients with DM. Thus, the primary goal of TTC arthrodesis in diabetic patients often shifts away from complete deformity correction, and instead towards limb salvage and ambulatory preservation. The scientific literature describing outcomes of TTC arthrodesis in DM patient populations has grown in recent years; however, a comprehensive systematic review on this topic has yet to be performed. Therefore, the objective of this systematic review was to summarize findings pertaining to TTC arthrodesis in the DM population, with the goal of understanding its outcomes and complications.
Methods:
A qualitative systematic review was conducted, with an initial search conducted on 30 August 2023, using PubMed, SPORTDiscus, CINAHL, and MEDLINE. These four databases were searched from database inception until the search date, and the search algorithm used was “tibiotalocalcaneal” AND (nail OR nails) AND (fusion OR arthrodesis), using the most recent Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria encompassed articles examining the impact of diabetes on TTC arthrodesis outcomes, while exclusion criteria included non-stratified diabetic status, case reports, and non-English articles. Data extraction involved patient demographics, complication rates, and surgical outcomes, and the quality of studies was assessed using the MINORS scale. Due to the relatively small number of articles and heterogenous outcomes, a qualitative and narrative approach was taken. Frequency weighted means (FWMs), along with other descriptive statistics, were used to describe the data.
Results:
Four articles met the inclusion criteria. These observational comparative studies were of moderate quality, with a mean MINORS score of 20.5 ± 1.9 points. The combined patient cohort included 162 patients, evenly split between diabetic and non-diabetic groups, with a mean age of 58.2 ± 2.7 years and a follow-up duration of 35.0 ± 7.4 months. Diabetic patients exhibited higher rates of superficial infection and, in some studies, higher rates of other complications including osteomyelitis, progression of Charcot arthropathy, or post-operative hematoma. Despite this, functional outcomes—including ambulation rates and patient satisfaction scores—and fusion rates were generally favorable and comparable between diabetic and non-diabetic patients. Postoperatively, occurrence of successful arthrodesis, stable pseudoarthrosis, limb salvage rate, and amputation rate were not significantly different between groups.
Conclusion:
In conclusion, this review evaluated TTC arthrodesis outcomes in DM patients. The primary concern for DM patients was found to be superficial wound infection, with a nearly 8-fold greater likelihood. Despite this risk, postoperative success, including radiographic union and functional outcomes, was comparable between DM and non-diabetic patients. The review’s limitations include data collection heterogeneity, the inability to perform a meta-analysis, and reliance on retrospective studies. This review highlights the need for standardized definitions of surgical success and prospective study designs to mitigate retrospective biases.
