Immediate internal fixation of open ankle fractures. Report

This is an enhanced PDF from The Journal of Bone and Joint SurgeryThe PDF of the article you requested follows this cover page.Immediate internal fixation of open ankle fractures. Report ofthirty-eight cases treated with a standard protocolJL Franklin, KD Johnson and ST HansenJ Bone Joint Surg Am. 1984;66:1349-1356.This information is current as of May 1, 2008Reprints and PermissionsPublisher InformationClick here to order reprints or request permission to use material from thisarticle, or locate the article citation on jbjs.org and click on the [Reprints andPermissions] link.The Journal of Bone and Joint Surgery20 Pickering Street, Needham, MA 02492-3157www.jbjs.org

Copyright 1984 by The Journal of Bone and Joint Surgery. incorporatedImmediate Internal Fixation of Open Ankle FracturesREPORT OF THIRTY-EIGHT CASES TREATED WITH A STANDARD PROTOCOLBY JONATHAN L. FRANKLIN, M.D.*, KENNETH D. JOHNSON, M.D.t, AND SIGVARD T. HANSEN, JR. , M.D.*,SEATTLE,WASHINGTONFrom the Harbort’iew Medical Center, SeaitleABSTRACT: We reviewed thirty-eight cases of openankle fractures that had been treated with a standardprotocol: alignment and splinting of the fracture at thescene of injury if possible, antibiotics administered inthe emergency room and continued for forty-eight hours,admission of the patient to the operating room as quicklyas possible, copious irrigation and thorough d#{233}bridementof the wound, immediate rigid anatomical internalfixation, and delayed primary closure at five days. Allof the fractures united, but three patients required subsequentankle fusion because of cartilage damage notedat the initial operation. Of the thirty-five ankles withcomplete follow-up, the functional result was excellentin twenty-six and fair or poor in nine.A protocol of immediate rigid internal fixation anddelayed primary closure for open fractures of the femur andtibia was instituted in 1972 at Harborview Medical Center,a regional trauma center. Use of the protocol. with its subsequentrefinements, produced excellent results with fewcomplications, and a very low infection nate7’52#{176}313436. In1976, under the guidance of one of us (S. T. H. , Jr.), theprotocol was extended to open ankle fractures, on the principlethat immediate anatomical internal fixation enhancessoft-tissue healing and produces a better functional jointwithout increasing the incidence of infection. To assess thevalidity of the protocol with regard to anatomical reduction,ultimate function of the ankle, and infection rate, we havereviewed our cases.Materials and MethodsFrom 1976 to 1981, immediate internal fixation wasperformed on all open ankle fractures at the HanborviewMedical Center. There were forty-two such fractures inforty-one consecutive patients. These were treated accordingto the following protocol.paramedical1 . The fracture is aligned and splinted in the field bypersonnel.2. Administration of an intravenous antibiotic (abroad-spectrum cephalosponin) is begun in the emergencyroom and is continued for forty-eight hours.* Division ofOrthopedic Surgery. University ofTexas Health ScienceCenter at Dallas. Dallas. Texas 75235.1- Department of Orthopaedics. RK-I0. University of WashinglonSchool of Medicine. Seattle, Washington 98195.3. The patient is admitted to the operating room asquickly as possible.4. All wounds are copiously irrigated and thoroughlydebrided in the operating room.5. Internal fixation is applied according to well knownprinciples2426 to provide rigid anatomical fixation with mmimuminternal-fixation apparatus.6. Delayed primary closure is performed five days afterward.There were twenty-eight men and thirteen women, andthe patients ranged in age from eighteen to seventy-threeyears (median, twenty-eight years). Eighteen patients hadinvolvement of the left ankle; twenty-two, ofthe right ankle;and one had injuries to both ankles.Automobile accidents (fourteen) and motorcycle accidents(twelve) were the cause of injury in about 60 percent of the patients. The other injuries resulted from fallsat ground level (five), falls from heights (four), and otheraccidents(seven).The totality of the patients’ injuries can be assessedfrom Table I. Twenty-five patients had multiple fractures;seventeen had associated disruption of ligaments, muscles.tendons. major arteries, on major nerves; and seven (Cases1 , 6, 22, 23, 28, 29, and 39) had significant head injuries.There were twenty-four bimalleolan, eight tnimalleolar, fiveisolated lateral malleolan, three isolated medial malleolar,and two pilon-type injuries. The Weber classification” forankle fractures was not used because most of the lesionsinvolved a direct crush injury from external forces, a typeof injury not described in that classification. Soft-tissue injurywas categorized in twelve lesions as grade I (a smallpuncture wound with one centimeter of peniosteal strippingon less), in fourteen as grade II (one to three centimeters ofperiosteal stripping without gross contamination), and insixteen as grade Ill (more than three centimeters of periostealstripping and gross contamination).Harborview Medical Center is a level-I trauma center’7,well equipped to handle immediate fixation ofopen fractures(within twenty-four hours of the patient’s admission).Twenty-eight of the patients in the series were in the operatingroom within five hours after injury. For only onepatient was the delay longer than ten hours, and that delaywas secondary to a severe head injury.Fracture fixation was achieved with well describedtechniques and instrumentation242. In general, the fractureVOL. 66-A, NO. 9. [)ECEMBER 984 I349

IMMEDIATE INTERNAL FIXATION OF OPEN ANKLE FRACTURES I 351FIG.Figs. I-C and l-D: The reduction was maintained six months postoperatively.I-Cduration of cast immobilization averaged eleven weeks.ResultsAdequate follow-up information was obtained forthirty-seven of the forty-one patients (thirty-eight of theforty-two fractures). The follow-up ranged from thirteen tosixty-six months (median, thirty-nine months). Two patients(Cases 13 and 28) were lost from the series because of nofollow-up. Additionally one patient (Case 6) with a brainstemcontusion and bilateral pneumonia died thirteen daysafter injury, and one patient (Case 41 ) with a severe deglovinginjury and multiple foot fractures required a belowthe-kneeamputation eleven days after injury.One of us (J. L. F.) examined twenty-four of the patientsat follow-up and interviewed eleven more by telephone.All of the patients who were interviewed bytelephone had had prior follow-up. either in the Harborviewclinic until the fracture had healed or in the offices of privatephysicians whose records were available to us. One patientwho was included (Case 9) had been followed closely fortwo years in the orthopaedic clinic before being lost tofollow-up, and another patient (Case 16) was followedclosely for four years before he died of unrelated causes.The patients were evaluated clinically for function,range of motion, cosmetic result, and residual pain. Roentgenogramswere evaluated for initial displacement, operativereduction, final result. and evidence of post-traumaticarthritis. Follow-up data in most categories were obtainedfor thirty-seven patients (thirty-eight ankles). Each categoryin Table I contains only the number of patients for whomaccurate data could be obtained.VOL. 66-A, NO. 9, DECEMBER 1984

IMMEDIATE INTERNAL FIXATION OF OPEN ANKLE FRACTURES 1353The patients and their physicians rated function as follows:excellent - without limitation, good - able to jogbut some limitation of athletic participation, fair - able toperform daily activities but unable to jog, and poor - limitedduring daily activities. Only nine of thirty-five patientsrated the result as fair or poor. There was no apparentcorrelation between functional rating and type of fracture,grade of soft-tissue injury, pain, or post-traumatic arthritis.About 70 per cent (nineteen) of the twenty-eight patientswho had been employed before injury returned to theirprevious work within six months. Of the nine patients whowere unable to do so, five had other injuries that preventedtheir return to work. The median time to walking with partialweight-bearing (thirty-nine patients) was seven weeks(range, two to forty-eight weeks). The time to full weightbearing(thirty-six patients) ranged from six to fifty-twoweeks (median, twelve weeks).Three patients (Cases 14, 39, and 40) had significantlimitation of range of motion of the ankle (less than -5degrees of extension); two of them had an associated nervepalsy and the third had severe damage to the ipsilateral kneeand the proximal part of the tibia. Despite these limitationsof range of motion, only one patient rated the function ofthe ankle as fair rather than good. Eleven patients had lessimportant limitations of range of motion (from + 5 to -5degrees of extension) and nineteen had no limitation (morethan + 5 degrees of extension).The patients and physicians rated the final cosmeticresult as excellent (scars hardly visible), good (injury notvisible when patient wears a nylon stocking), fair (injuryvisible through a nylon stocking but without gross defonmity).or poor (gross deformity and scarring). Only four ofthirty-five ankles were rated as a fair result, despite theseverity of the initial injury; the others were good or excellent.Of the ankles with a fair rating, two had had agrade-Il fracture and two, a grade-Ill fracture. No anklewas given a poor result rating.Nineteen patients reported no pain while six patientsreported moderate pain (occasional pain that limited activity).Three of the six patients with moderate pain were thosein whom a superficial infection developed. Three of the sixalso had evidence of post-traumatic arthritis (Table I).We reviewed the roentgenograms that had been madewhen the patient arrived at Harborview Medical Center,immediately after operation, at the time of bone-healing,and at follow-up examination. The original displacementwas classified according to the distance from the ankle mortiseto the talus: minimum displacement (seven ankles) -less than one centimeter; moderate (twenty-two ankles) -one to two centimeters; marked (six ankles) - two to threecentimeters; and gross displacement (seven ankles) - morethan three centimeters. It is likely that many of the fractureshad been more severely displaced before they were alignedand splinted by paramedics at the scene of the accident.The surgical reduction. evaluated on immediate postoperativenoentgenognams. was rated as follows: anatomicalreduction (fracture lines not visible), nearly anatomical reduction(fracture lines visible but ankle mortise apparentlyanatomical), minimum displacement (one to three millimetersof mortise misalignment), and moderate displacement(three to five millimeters of mortise misalignment).Ninety-five per cent (forty) of the forty-two ankles had anatomicalor nearly anatomical reduction immediately afteroperation, and two ankles had minimum displacement. Posttraumaticarthritis developed in both of these ankles.The time to roentgenographic evidence of healing, determinedby the disappearance of fracture lines and by callusformation, ranged from seven to sixteen weeks (median,9.5 weeks). The final reduction showed minimum displacementin only three of thirty-eight ankles.Roentgenograms made after healing were examined forevidence of post-traumatic arthritis. Slight spurring or narrowingof the joint space was noted in thirteen ankles, threeof which (Cases 18, 3 1 , and 33) required fusion. The mcidenceof post-traumatic arthritis was fairly well distributedamong all grades of injury (three ankles with a grade-I, fivewith a grade-I!, and five with a grade-Ill lesion) (Table I).There were only two superficial infections in the group withpost-traumatic arthritis, which was essentially the same incidenceof infection as that in the remainder of the ankles.In the three ankles that required fusion, significant cartilagedamage was noted at the initial open reduction. Anatomicalfixation despite the cartilage injury facilitated subsequentaccurate fusion. Compared with the other twenty-four ankles,the thirteen with roentgenographic evidence of posttraumaticarthritis had a more limited range of motion, apoorer functional rating, and a higher incidence of pain(TableI).There was only one possible deep infection (Case 9).This case was that of a nineteen-year-old man who sustaineda grade-I trimalleolar fracture when he jumped from a freewaybridge overpass. He was seen at follow-up three andone-half months after injury, complaining of pain and increasedswelling in the ankle. Roentgenograms revealed thatthe distalmost cancellous screw had migrated into the anklejoint, and therefore the screw was removed. At the time nopurulent material could be aspirated from the screw-hole,but Enterobacter cloacae grew on cultures. One week laterthe patient was progressing well clinically, and the decisionwas made not to treat him with antibiotics. He was followedfor two years, with no further evidence of infection.There were five superficial infections: four in patientswith grade-I! soft-tissue injury and one in a patient withgrade-Il! injury. Two of these ankles required a furtherd#{233}bnidement procedure . None required skin-grafting, andnone presented long-term problems.There were no non-unions in this series. There weretwo delayed unions, both of which required bone-grafting.In one of these patients (Case 3 1 , one of the three that hada fusion) a spontaneous fusion of the ankle in good positioneventually developed. The other patient (Case 27) had anexcellent functional result, with no pain or evidence of posttraumaticarthritis. In one patient (Case 24) a post-traumaticsympathetic dystrophy resolved with appropriate physicalVOL. 66-A, NO. 9. DECEMBER 1984

1354 J. L. FRANKLIN, K. D. JOHNSON, AND S. T. HANSEN, JR.FIG. 2-AFigs. 2-A through 2-D: Case 18. This twenty-nine-year-old man sustained a grossly displaced bimalleolar fracture.Fig. 2-A: Roentgenograms made immediately after injury.FIG. 2-B FIG. 2-C FIG. 2-DFigs. 2-B and 2-C: Significant cartilage damage was noted at surgery. Anatomical reduction was achieved and was well maintained at eleven weeks.when these roentgenograms were made and the syndesmosis screw was retiioved.Fig. 2-D: Post-traumatic arthritis is evident on this roentgenogram. made three years after injury. Ankle fusion was eventually required.therapy. One patient (Case 41). with a severe soft-tissue tunes began in the l9405929. Over the next three decades,injury and multiple fractures in the foot, required a below- with the development of antibiotics, advancements in metthe-kneeamputation. allurgy, and improvements in surgical technique, improved. . results were reported in most investigations of openDiscussion fnactures65’#{176}’2’4’6223235. Refinement in the devices avail-The widespread use of internal fixation for open frac- able for internal fixation in the 1970’s appeared to furtherTHE JOURNAL OF BONE AND JOINT SURGERY

IMMEDIATE INTERNAL FIXATION OF OPEN ANKLE FRACTURES 1355enhance the results, and the stability then provided by internalfixation was believed to diminish the incidence ofinfection and promote healing of the injured soft tissues24323.The improvement in results of internal fixation in openfractures of the ankle are difficult to quantitate because noseries comprised exclusively of ankle fractures has beenreported in the literature, and the studies of open fracturesin general, even in recent years, have included only smallnumbers of ankle fractures.In 1972, Ketenjian and Shelton reviewed fifty-five openfractures that had been treated with internal fixation, includingeighteen ankle fractures’9. The infection rate overallwas 7.5 percent, but no infections occurred in the ankles,and no ankle had a non-union, an amputation, or chronicosteomyelitis.In a review of ninety-one open fractures, only one ofthem affecting the ankle, Varma and Rao reported in 1974that the incidence of deep infection was higher in thosetreated non-operatively (22.6 per cent, on twelve of fiftythreefractures) than in those treated with primary internalfixation (13. 1 per cent, or five ofthirty-eight)3#{176}. In 1979, inthe series of Rittmann et al. there were 214 open fractures(including eight malleolan fractures), all but nine of whichwere treated with internal fixation27. The oven-all rate ofosteomyelitis was 7 pen cent (with no infection in the malleolarfractures), but eight (26 per cent) of thirty-one fractureswith grade-Ill soft-tissue injury had an infection. Alsoin 1979, Chapman and Mahoney reported on ninety-fouropen fractures, thirty of them involving the ankl&. Therewere varying degrees of soft-tissue involvement, and theinfection rate was low in lesions with grade-I or II injurythat were treated with primary internal fixation, but washigh (41 pen cent) in the grade-Ill injuries. In the ankles.there were no infections in eighteen with grade-I soft-tissueinjury, but one of nine with grade-li injury and all threewith grade-I!! injury became infected.We attribute the low incidence of infections in our ownseries, especially in ankles with grade-Ill soft-tissue injury,to several parts of our protocol: the use of prophylacticantibiotics beginning in the emergency room, immediateand thorough d#{233}bridement, early reduction and stabilizationof the fractures with modern techniques and implants, andsoft-tissue management by delayed primary skin closure andthe use of skin grafts when necessary. The fact that theprotocol for open ankle fractures that we established wasadhered to by the entire orthopaedic staffcontnibuted greatlyto minimizing infection.We strongly believe that the early stabilization of thefracture fragments maximizes the ability of the soft tissuesto resist infection and to heal, so that optimum functionalresults can be obtained. A recent review article on openfractures by Allgower and Bonder emphasized this importantconcept’ . Three-quarters of the ankles in our series had agood on excellent functional result, and there were no nonunionson residual infections.We believe that all of the elements of our protocolcontributed to the excellence of these results. It should benoted that standard, well accepted principles are inherent inthe protocol and then are applied to open fractures aboutthe ankle, as adapted to the local anatomical lesion. Theuse ofdelayed primary closure, in accordance with Halsted’steachings, is an example of how dead space and tension inthe wound are avoided. Furthermore, our initial routines ofwound care and rapid admission to the operating room mmimizeddamage to the blood supply to the skin and othersoft tissues and prevented further bacterial colonization ofthewound.Although rapid admission to the operating room is encouragedin our protocol, including the use of internalfixation and delayed primary closure, the protocol may beapplied to patients who are seen later than twelve hours afterinjury, especially if the wound had been protected and wellcleaned. However, our series included only one fracture thatwas treated late (ten hours after injury).In other reported series, the more severe the injury tothe soft tissues the higher the infection rate was52732, butno such correlation was evident in our series. Although ourseries included sixteen grade-Ill injuries, the one (possible)deep infection occurred in an ankle with a grade-I injury.The low infection rate may have been due in part to thelocation of the fractures in metaphyseal bone. The ampleblood supply of this cancellous bone may make it moreresistant to infection than cortical bone is.The three ankles that eventually required fusion werenoted at surgery to have significant articular-cartilage damage.It is likely that the thirteen ankles with post-traumaticarthritic changes also had an important injury to the articularcartilage, even though this damage was not specificallynoted at surgery. Cartilage injury and inadequate reductionof the fracture therefore appear to be the important causesof post-traumatic arthritis.We believe that stable internal fixation after accuratereduction , as was achieved in about 90 per cent of the anklesin our series, not only was important per se in achieving asuccessful result but also permitted early walking and physiologicalmotion, which stimulate healing34”’52 and helpto avoid the complications associated with prolongedimmobilization2833.Anatomical reduction is especially important when afracture involves a joint. In the ankle anatomical reductioncan be achieved most effectively with internal fixation. Inmost acute-care facilities. more and more often the techniquesof internal fixation are being applied in closed anklefractures to promote retention of maximum function of theinjured joint. Our series is particularly important because itdemonstrates that the principle just mentioned, and the protocolthat we have outlined, can be extended safely to openfractures about the ankle and perhaps to other fractures aswell.We believe that the proper treatment of the soft-tissueinjuries also is essential to success in all fractures that aretreated with internal fixation, but particularly in open fractures.VOL. 66-A, NO. 9. DECEMBER 1984

1356 J. L. FRANKLIN, K. D. JOHNSON, AND S. T. HANSEN, JR.References1 . ALLGOWER, MARTIN, and BORDER, J. R. : Management of Open Fractures in the Multiple Trauma Patient. World J. Surg. , 7: 88-95, 1983.2. ANDERSON, J. T., and GUSTILO, R. B.: Immediate Internal Fixation in Open Fractures. Orthop. Clin. North America, 11: 569-578, 1980.3. CHAPMAN, M. W.: The Use of Immediate Internal Fixation in Open Fractures. Orthop. Clin. North America, 11: 579-591 , 1980.4. CHAPMAN, M. W. : Management of Open Fractures and Complications. Part III. Role of Bone Stability in Open Fractures. In Instructional CourseLectures, The American Academy of Orthopaedic Surgeons. Vol. 31. pp. 75-87. St. Louis, C. V. Mosby, 1982.5. CHAPMAN, M. W. , and MAHONEY, MICHAEL: The Role of Early Internal Fixation in the Management of Open Fractures. Clin. Orthop. . 138:120-131, 1979.6. CLAFFEY, T. : Open Fractures of the Tibia. In Proceedings of the Australian Orthopaedic Association. J. 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