Introduction:
Diabetes not only impacts glucose regulation but also exerts significant effects on various organ systems, including the musculoskeletal system. Several studies indicate that diabetes affects bone quality by increasing porosity, reducing strength, and leading to higher fracture rates, particularly hip fractures. The primary cause is the accumulation of advanced glycation end products (AGEs), which alter the biomechanical properties of bone and contribute to low bone turnover. Additionally, diabetic patients experience complications such as Charcot neuroarthropathy, infections, and plantar ulcers, all of which increase the risk of poorer outcomes. This introduction seeks to delve into the diverse orthopedic complications associated with diabetes.
What Orthopedic Complications Can Arise in the Upper Extremities Due to Diabetes?
Orthopedic complications of diabetes affecting the upper extremities encompass a range of issues, which include:
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Adhesive Capsulitis: Also known as frozen shoulder, adhesive capsulitis is an inflammatory condition characterized by stiffness and pain in the shoulder joint. The prevalence of adhesive capsulitis in individuals with diabetes mellitus is around 13.4 percent.
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Trigger Finger: Also known as stenosing tenosynovitis, trigger finger is a condition where a finger can catch or lock in a bent position.
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Carpal Tunnel Syndrome: A condition characterized by compression of the median nerve in the wrist, resulting in symptoms such as weakness, tingling, numbness, and pain in the affected hand and wrist.
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Dupuytren’s Disease: It is a condition characterized by abnormal thickening and tightening of the fascia, a layer of tissue beneath the skin onthe palm.
What Orthopedic Complications Can Arise in the Lower Extremities Due to Diabetes?
Orthopedic complications of diabetes affecting the lower extremities encompass a range of issues, which include:
Hip Fractures: Individuals with type 1 diabetes face a significantly elevated risk—6 to 7 times higher—for hip fractures, whereas those with type 2 diabetes have a comparatively lower risk, at 1.4 to 1.8 times higher. Type 1 diabetes patients are particularly vulnerable to hip fractures by the age of 65. Hip fractures can stem from various factors, including falls, peripheral neuropathy, and diabetes-related renal dysfunction, all of which contribute to increased fall risks. Additionally, certain anti-diabetic medications pose a risk factor for falls due to hypoglycemia, affecting bone quality. Diabetic patients often exhibit a distinct pattern of hip fractures, showing a lower incidence of femoral neck fractures but a higher incidence of fractures like intertrochanteric (IT) and subtrochanteric (ST) fractures.
To prevent fractures, strategies include utilizing Bisphosphonates such as Alendronate, which effectively boosts bone mineral density (BMD) and aids in preventing hip fractures among both diabetic and non-diabetic individuals. Furthermore, anti-sclerostin antibody treatments show promise in enhancing bone strength. Parathyroid hormone (PTH) also demonstrates a modest yet notable impact on bone volume and BMD.
Management: Surgical approaches such as open reduction and internal fixation (ORIF), total hip arthroplasty, percutaneous screw fixation, and hemiarthroplasty are the mainstay treatments for femoral neck fractures. Intertrochanteric fractures are commonly managed with open reduction internal fixation (ORIF). Subtrochanteric fractures typically require treatment involving an intramedullary nail with a screw fixation into the femoral head.
Ankle Fractures: These represent frequent orthopedic injuries, often involving the lateral malleolus of the fibula bone. Such injuries can be categorized as stable, where the inner ankle and ligaments remain intact, maintaining alignment, or unstable, characterized by fractures of the deltoid ligament and inner ankle, resulting in ankle joint instability. It is crucial to distinguish ankle fractures from conditions like Charcot neuroarthropathy, where nerve damage can lead to bone destruction, necessitating careful assessment.
Management: The management of ankle fractures carries the risk of complications such as malunion, infections, or even the need for amputations. Therefore, the orthopedic treatment objective should prioritize minimizing these risks. Stable fractures may be managed conservatively without surgery, whereas unstable fractures typically require surgical intervention with precise anatomical reduction and fixation. Maintaining well-controlled blood glucose levels is crucial for diabetic patients undergoing ankle fracture treatment, necessitating stronger fixation methods than those used for non-diabetic individuals. Post-surgery, diabetic patients with ankle fractures, particularly those with neuropathy, should undergo an extended period of non-weight bearing to optimize recovery.
Charcot Neuroarthropathy: A chronic and destructive disease affecting the joints and bone structure in patients with neuropathy, particularly those with diabetes. It occurs in approximately 0.12 percent of diabetic patients.
Charcot neuroarthropathy progresses through three distinct stages:
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In the initial stage, there is destruction of multiple bones in the ankle and foot, accompanied by redness and swelling.
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During the second stage, bone destruction stabilizes, and the affected bones begin to fuse (coalesce).
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In the third stage, the bones solidify in their new position, leading to permanent deformity.
If left untreated or not detected early, Charcot neuroarthropathy can result in foot deformity and instability, increasing the risk of developing ulcers.
Management: Management typically entails safeguarding the foot with restricted weight-bearing while also exploring specialized footwear or braces as potential solutions. In cases of significant deformities, surgical intervention might be required.
Plantar Ulcerations: These wounds, known as plantar ulcers, occur at the bottom of the feet and pose significant risks for diabetic patients. Approximately 25 percent of diabetic individuals are at risk of developing plantar ulcers, with a recurrence rate of about 50 percent. Most plantar ulcers in diabetic patients result from peripheral neuropathy (nerve damage), along with the presence of deformities and trauma. This trio—neuropathy, deformity, and trauma—characterizes the profile of many ulcer patients.
Loss of sensation due to neuropathy is a primary clinical indicator for assessing those at high risk of developing ulcers. Importantly, ulcers that fail to heal carry a heightened risk of developing osteomyelitis, a serious bone infection that can ultimately necessitate amputation if left untreated. Preventive measures for diabetic foot ulcers are essential and include smoking cessation, wearing proper footwear, patient education on foot care, optimizing blood sugar control, and seeking appropriate surgical consultations when needed.
Management: Management of diabetic foot ulcers involves offloading the ulcer site to reduce pressure, achieved through orthotic inserts, suitable footwear, total contact casting, or limiting weight-bearing on the affected foot. Surgical debridement of necrotic (dead) tissue is crucial for promoting healing. Addressing vascular issues contributing to poor circulation in the affected foot is important for wound healing. Typically, healing diabetic foot ulcers can take 2 to 3 months, but severe cases may require 4 months or more to heal completely.
Infections: Diabetic patients undergoing orthopedic surgeries such as spine procedures or joint replacements face an increased risk of surgical site infections (SSI). These infections can manifest as deep incisional, superficial incisional, or organ/space infections at the surgical site. Specifically, periprosthetic orthopedic infections refer to infections around artificial joints and can occur up to one year post-surgery. Such infections not only elevate treatment costs but also diminish quality of life and may, in severe cases, necessitate amputation. Research shows that patients with hyperglycemia are more susceptible to SSIs within the first 30 days after surgery compared to those with normal blood sugar levels.
Management: Preoperative antibiotic therapy is crucial and effective in preventing surgical site infections (SSIs) during orthopedic procedures. However, if SSIs occur despite antibiotic use, they are often attributed to the formation of biofilms on the implant surface. In cases where antibiotics fail due to biofilm formation, management typically involves removing the infected implant.
Conclusion:
The orthopedic complications arising from diabetes pose substantial challenges affecting both the musculoskeletal system and the overall quality of life for those affected. Preventive strategies like patient education, meticulous blood sugar management, smoking cessation, and wearing suitable footwear are crucial to mitigating these complications. Ongoing research and advancements in diabetic orthopedic care are essential to drive improved outcomes and elevate the quality of life for individuals grappling with diabetes-related musculoskeletal issues.
