Diabetes is a poor prognostic indicator after an acute ankle fracture. Many surgeons avoid essential surgery due to their concerns regarding complications.

We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation methodologies.

Patient records were cross-referenced with departmental databases and a retrospective review of all ankle fractures managed in our department was conducted from 2014. All patients subjected to a retrospective review of their notes and assessment of their follow up for at least 6 months. Radiographs were assessed of the ankle before and at completion of treatment were reviewed independently (RA and FR).

We identified all patients with a diabetic ankle fracture their HB1Ac (for diabetic control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation. Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation. Further sub-analysis conducted to assess differences between diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead.

We identified 64 patients with a diabetic ankle fractures, their fracture pattern and a control group. Thirty-one had conservative treatment; 33 had operative fixation of which 13 had rigid fixation. Compared to the control (n=32) both diabetic groups had a higher risk of possible complication. The relative risk was between 3.1–3.4 (P<0.002) and linked to systematic complications of diabetes e.g. neuropathy 5.9 (P<0.003); HBA1c 4.6 P<0.004); and neuropathy and retinopathy 6.2 P<0.0003). We observed RR is reduced for a complication occurring following surgery with prolonged immobilization (0.86) and rigid fixation (0.65) and NNT required to see a benefit from rigid fixation was 7. The overall RR for a complication was similar between conservative and surgical management (4.6 vs.5.1).

We agree diabetics have a higher risk for complications than non-diabetics, however the risk is not as great as previously reported. There is little difference in surgical or conservative treatment but strong evidence indicating rigid long-segment-fixation with prolonged-immobilization could improve the risk benefit ratio when compared to non- operative management alone but further evaluation is required.

To date, there are no clear guidelines from the National Institute of Clinical Excellence or the British Orthopaedic Association regarding the use of Autologous Blood Transfusion (ABT) drains after elective primary Total Knee Replacement (TKR). There is little evidence to comparing specifically the use of ABT drains versus no drain. The majority of local practice is based on current evidence and personal surgical experience.

We aim to assess whether the use of ABT drains effects the haemoglobin level at day 1 post-operation and thus alter the requirement for allogenic blood transfusion. In addition we aim to establish whether ABT drains reduce post-operative infection risk and length of hospital stay.

Forty-two patients undergoing elective primary TKR in West London between September 2011 and December 2011 were evaluated pre- and post-operatively. Patient records were scrutinised. The patient population was divided into those who received no drain post-operatively and those with an ABT drain where fluid was suctioned out of the knee in a closed system, filtered in a separate compartment and re-transfused into the patient.

Twenty-six patients had ABT drains and 4 (15.4%) required an allogenic blood transfusion post-operatively. Sixteen patients received no drain and 5 (31.3%) required allogenic blood. There was no statistical difference between these two groups (p=0.22). There was no statistical difference (p=0.75) in the average day 1 haemoglobin drop between the ABT drain and no drain groups with haemoglobin drops of 2.80 and 2.91 respectively. There was no statistical difference in the length of hospital stay between the 2 groups (p=0.35). There was no statistical difference (p=0.26) in infection rates between the 2 groups (2 in ABT drains Vs. 0 in no drains). Of the 2 patients who experienced complications one had cellulitis and the other had an infected haematoma, which was subsequently washed out.

The results identify little benefit in using ABT drains to reduce the requirement for allogenic blood transfusion in the post-operative period following TKR. However, due to small patient numbers transfusion rates of 31.3% in the ABT drain group Vs. 15.4% in the no drain group cannot be ignored. Therefore further studies including larger patient numbers with power calculations are required before a true observation can be identified.