Risk stratification in diabetic ankle fractures: a systematic review of reviews and proposal of the MADRAS scoring system

BACKGROUND: Diabetic ankle fractures present significant clinical challenges, with higher rates of complications including infection, non-union, Charcot neuroarthropathy, and amputation compared to non-diabetic patients. Despite this burden, no universally accepted guidelines exist for risk stratification and management. The Adelaide Fracture in the Diabetic Ankle (AFDA) score was proposed in 2014 but has limitations including uniform weighting of risk factors and exclusion of local injury characteristics. This systematic review of reviews aimed to synthesise current evidence and develop an updated, evidence-based risk stratification tool. METHODS: A comprehensive search of Embase, PubMed, and Web of Science was conducted. Eligible studies included systematic and narrative reviews examining outcomes, risk factors, or interventions for diabetic ankle fractures. Risk of bias was assessed using the ROBIS tool. Data were synthesised narratively, and an evidence-informed, consensus-based scoring system was developed by translating observed effect sizes from the included reviews into weighted risk scores. RESULTS: Thirteen reviews were included. Complicated diabetes, particularly peripheral neuropathy, peripheral arterial disease, and prior Charcot neuroarthropathy, emerged as the strongest predictors of adverse outcomes. Non-operative management of unstable fractures was associated with significantly higher complication rates. Based on these findings, we propose the Manchester Ankle Fracture Diabetic Risk Assessment Score (MADRAS), incorporating weighted systemic host factors, local injury characteristics, and modifiable patient factors across a 17-point scale stratifying patients into four management tiers: low risk (0-2), moderate risk (3-5), high risk (6), and very high risk (≥ 7). CONCLUSION: MADRAS addresses limitations of existing frameworks by incorporating evidence-based weightings and local injury factors. Prospective external validation is required before widespread clinical adoption; until then, MADRAS should be regarded as a decision-support tool. This tool may assist clinicians in systematic risk stratification and surgical decision-making for diabetic ankle fractures.