Factors associated with nonunion, delayed union, and malunion in foot and ankle surgery in diabetic patients

J Foot Ankle Surg. Mar-Apr 2013;52(2):207-11. doi: 10.1053/j.jfas.2012.11.012. Epub 2013 Jan 11.


The incidence of bone healing complications in diabetic patients is believed to be high after foot and ankle surgery. Although the association of hyperglycemia with bone healing complications has been well documented, little clinical information is available to show which diabetes-related comorbidities directly affect bone healing. Our goal was to better understand the risk factors associated with poor bone healing in the diabetic population through an exploratory, observational, retrospective, cohort study. To this end, 165 diabetic patients who had undergone arthrodesis, osteotomy, or fracture reduction were enrolled in the study to assess the risk factors associated with nonunion, delayed union, and malunion after elective and nonelective foot and/or ankle surgery. Bivariate analyses showed that a history of foot ulcer, peripheral neuropathy, and surgery duration were statistically significantly associated with bone healing complications. After adjusting for other covariates, only peripheral neuropathy, surgery duration, and hemoglobin A1c levels >7% were significantly associated statistically with bone healing complications. Of the risk factors we considered, peripheral neuropathy had the strongest association with bone healing complications.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Arthrodesis
  • Cohort Studies
  • Diabetes Mellitus / epidemiology*
  • Diabetic Foot / complications
  • Diabetic Neuropathies / complications
  • Female
  • Foot / surgery*
  • Fracture Fixation
  • Fractures, Malunited / etiology*
  • Fractures, Ununited / etiology*
  • Glycated Hemoglobin A / analysis
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Operative Time
  • Osteotomy
  • Retrospective Studies
  • Risk Factors
  • Wound Healing*


  • Glycated Hemoglobin A
  • hemoglobin A1c protein, human