VOL. 98-B, No. 9, SEPTEMBER 2016 1197  FOOT AND ANKLE Fluoroscopy-guided reduction and fibular nail fixation to manage unstable ankle fractures in patients with diabetes A RETROSPECTIVE COHORT STUDY B. D. Ashman, C. Kong, K. J. Wing, M. J. Penner, K. E. Bugler, T. O. White, A. S. E. Younger From University of British Columbia, Vancouver, Canada  B. D. Ashman, MD, FRCSC, Orthopaedic Resident, Department of Orthopaedic Surgery  C. Kong, MD, Orthopaedic Resident, Department of Orthopaedic Surgery University of British Columbia, 3114 - 910 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.  K. J. Wing, MD, FRCSC, Orthopaedic Surgeon, Division of Distal Extremities, Department of Orthopaedics  M. J. Penner, MD, FRCSC, Orthopaedic Surgeon, Division of Distal Extremities  A. S. E. Younger, MB ChB FRCSC, Orthopaedic Surgeon, Division of Distal Extremities, Department of Orthopaedics University of British Columbia, St. Paul’s Hospital, 530 – 1144 Burrard Street, Vancouver, BC, V6Z 2A5, Canada.  K. E. Bugler, BA, MRCS, Orthopaedic Registrar  T. O. White, MD, FRCSed (Orth), Consultant Orthopaedic Trauma Surgeon, Knee and Pelvic Fracture Surgery The Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK. Correspondence should be sent to Dr A. S. E. Younger; e-mail: asyounger@shaw.ca ©2016 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.98B9. 37140 $2.00 Bone Joint J 2016;98-B:1197–1201. Received 26 October 2015; Accepted after revision 4 May 2016 Aims Patients with diabetes are at increased risk of wound complications after open reduction and internal fixation of unstable ankle fractures. A fibular nail avoids large surgical incisions and allows anatomical reduction of the mortise. Patients and Methods We retrospectively reviewed the results of fluoroscopy-guided reduction and percutaneous fibular nail fixation for unstable Weber type B or C fractures in 24 adult patients with type 1 or type 2 diabetes. The re-operation rate for wound dehiscence or other indications such as amputation, mortality and functional outcomes was determined. Results Two patients developed lateral side wound infection, one of whom underwent wound debridement. Three other patients required re-operation for removal of symptomatic hardware. No patient required a below-knee amputation. Six patients died during the study period for unrelated reasons. At a median follow-up of 12 months (7 to 38) the mean Short Form-36 Mental Component Score and Physical Component Score were 53.2 (95% confidence intervals (CI) 48.1 to 58.4) and 39.3 (95% CI 32.1 to 46.4), respectively. The mean Visual Analogue Score for pain was 3.1 (95% 1.4 to 4.9). The mean Ankle Osteoarthritis Scale total score was 32.9 (95% CI 16.0 to 49.7). Conclusion Fluoroscopy-guided reduction and fibular nail fixation of unstable ankle fractures in patients with diabetes was associated with a low incidence of wound and overall complications, while providing effective surgical fixation. Cite this article: Bone Joint J 2016;98-B:1197–1201. Ankle fractures are common 1 and are usually treated by open reduction and internal fixation (ORIF). 2,3 The fibular plate is inserted through a lateral incision over a bony prominence which can result in wound complications in at- risk individuals, potentially leading to amputation. Diabetes mellitus can result in a poor wound healing environment through hyperglycemia-induced irreversible protein glycosylation and tissue hypoxia via macro- and micro-vessel arteriosclerotic disease. 4 Consequently, patients with diabetes are at higher risk of wound breakdown or loss of fracture fixation following standard ORIF of displaced ankle fractures. 2,5,6 Where possible non-operative treatment with prolonged cast immobilisation for ankle fractures in these patients may be recommended to avoid wound complications. 5 This treatment however delays the recovery time and increases the potential for subsequent ankle deformity. 2,5 There is no consensus on the optimal management of ankle fractures in patients with diabetes. 2,7 A technique to obtain fracture reduction and maintain fixation with reduced wound risks would therefore be beneficial. A fibular nail, inserted percutaneously through the tip of the fibula, avoids the long lateral incision and dissection required for plate fixation. 8,9 As an intramedullary device, it does not disrupt the periosteal blood supply, resulting in better local bone blood flow and cellularity at the fracture site 10 therefore optimising the local environment for secondary bone healing. We have previously reported our technique of fibular nailing and its successful application in a cohort of 105 patients. 9 The current retrospective case series reviewed patients at two centres to assess the safety and effectiveness of fluoroscopic reduction and fibular nail fixation in diabetic patients. We