Evidence-based treatment of open ankle fractures - CiteSeerX

$: Evidence-based treatment of open ankle fractures - CiteSeerX$
Arch Orthop Trauma Surg (2011) 131:1545–1553
DOI 10.1007/s00402-011-1349-7
TRAUMA SURGERY

Evidence-based treatment of open ankle fractures

Caroline C. C. Hulsker · Sanne Kleinveld · Chris B. L. Zonnenberg · Mike Hogervorst · Michel P. J. van den Bekerom

Received: 5 April 2011 / Published online: 29 June 2011© The Author(s) 2011. This article is published with open access at Springerlink.com

Abstract Fractures of the ankle are fairly common injuries.Open ankle fractures are much less common and associatedwith severe injuries to surrounding tissues. We haveperformed a systematic review of the literature concerningthe clinical results and complication rates in the treatmentof open ankle fractures. We conducted a search limited tothe following databases: Pubmed/Medline, Cochrane Data-base of Systematic Reviews, Cochrane Clinical Trial Regis-ter and Embase. These were searched from 1968 to April2010 to identify studies relating to the treatment of openankle fractures. Fifteen articles concerning 498 patientswith treatment of an open ankle fracture were identiWed.The number of included patients varied from 11 to 64.There were 2 prospective and 13 retrospective studies. Allarticles were case series and classiWed as Level IVevidence. In 373 cases, open ankle fractures were treated byimmediate internal Wxation. In 125 cases, a conservativetreatment or delayed/other Wxation treatment was followed.Of those patients treated by immediate internal Wxation,81% had satisfactory result. Poor results (15%) were most

commonly due to non-anatomic reductions, articularsurface damage or deep infection. When conservative treat-ment was followed, 76% had satisfactory results. The mostreported complications after immediate internal Wxationwere deep infection (8%) and skin necrosis (14%). There isa lack of high quality literature concerning the (operative)treatment of patients with open ankle fractures. Remarkableis that most authors reported satisfactory results afterperformance of their treatment protocol. Based on the avail-able literature, we formulated guidelines regarding: timingof operative treatment, wound irrigation, the role of internalWxation, wound coverage and closure, the use of antibioticsand additional therapies.

Keywords Ankle fractures · Open/complex/compound · Treatment · Osteosynthesis · Operative procedures · Antibiotics

AbbreviationsAO/ASIFArbeitsgemeinschaft für Osteosynthesefragen/

American Society for Internal FixationOTA Orthopaedic Trauma Association

Introduction

In the treatment of open fractures, the surgeon’s objectivesare to prevent infection, promote fracture healing, andrestore function without complications. [1]. A fracture isconsidered to be open when disruption of the skin andunderlying soft tissues results in a communication betweenthe fracture and the outside environment. The most com-monly used classiWcation for open fractures is the systemdeveloped by Gustilo and Anderson [2], and subsequentlymodiWed by Gustilo et al. [3] (Table 1).

C. C. C. Hulsker (&) · S. KleinveldDepartment of General Surgery, Academic Medical Centre, P.O. Box 22660, Amsterdam DD 1100, The Netherlandse-mail: [email protected]

C. B. L. ZonnenbergDepartment of Orthopaedics and Trauma, Spaarne Hospital, Hoofddorp, The Netherlands

M. HogervorstDepartment of General Surgery, Gelre Hospitals, Apeldoorn, The Netherlands

M. P. J. van den BekeromDepartment of Orthopaedic Surgery, Academic Medical Centre, P.O. Box 22660, Amsterdam DD 1100, The Netherlands

123

1546 Arch Orthop Trauma Surg (2011) 131:1545–1553

Two studies found the Gustilo and Anderson classiWca-tion system to be associated with low interobserver agree-ment [4, 5] In spite of these limitations, the Gustilo andAnderson classiWcation remains the preferred system forcategorizing open fractures since the fracture type corre-lates well with the risk of infection and other associatedcomplications.

Fractures of the ankle are fairly common injuries. Openankle fractures are much less common and usually causedby high-energy trauma. In most series, an incidence ofabout 5% is reported [6]. The amount of energy in the ini-tial trauma determines the type of injury and prognosis.SigniWcant bone and soft tissue loss, either from the initialinjury or subsequent debridement, can create diYculties inobtaining wound closure, joint congruity and fractureunion. It is not surprising, therefore, that these fracturesoften end in poor results.

Okike and Bhattacharyya already formulated guidelinesfor treatment of open fractures in general [1]. The objectiveof this article is to formulate guidelines for treatment ofopen ankle fractures. These guidelines are based on a sys-tematic review of the literature. The aim was to evaluate theclinical results and complication rates after diVerent (non)operative treatment protocols. Based on these results, rec-ommendations for clinical practice and future researchwere formulated. Principles for treatment of closed anklefractures are not discussed in this review.

Materials and methods

For inclusion and exclusion criteria, we refer to Fig. 1. Thefollowing search terms were used: open/compound/com-plex fractures, ankle/malleolar fractures, treatment out-come, osteosynthesis, debridement, lavage, irrigation,antibiotic treatment and operative treatment. With the helpof a clinical librarian, a search limited to adult humans wasconducted in the following databases: Pubmed/Medline,Cochrane Database of Systematic Reviews, Cochrane Clin-ical Trial Register, Current Controlled Trials, OrthopedicTrauma Association (OTA) annual meetings’ abstracts

archives website and Embase. These databases weresearched from 1968 to April 2010 to identify studies relat-ing to the (non) operative treatment of open ankle fractures.Review articles and expert opinions were excluded becausethese articles do not report on new patient series. Also,reports on surgical techniques and abstracts from scientiWcmeetings were excluded. Furthermore, the lists of refer-ences of retrieved publications were manually checked foradditional studies potentially meeting the inclusion criteriaand not found by the electronic search. The search wasrestricted to articles written in the English, French, Germanand Dutch language.

The search of the literature in this study was performedaccording to the Quorom [7] statement on meta-analysesand limited to published original studies including adultpatients with (non) operative treatment of open ankle frac-tures (AO/ASIF type 44ABC).

All operative techniques and non-operative treatmentmodalities were included. The diagnosis of an open anklefracture was made based on history, physical examinationand standard radiography. Only studies with a minimum ofseven patients were included. Articles concerning the treat-ment of a distal tibial fracture or a tibial pilon fracture (AO/ASIF type 43 A, B, C) were not included. Articles concern-ing open and closed fractures were included when the openankle fractures could be analyzed separately. The Pubmedsearch strategy is shown in Table 2.

Relevant baseline measurements were: use of antibiot-ics, timing of treatment/debridement, use of irrigation, typeof Wxation, coverage and closure, and use of adjunctivetherapies. After an (non) operatively treated open anklefracture, relevant outcome measures of the included studieswere: functional outcome (diVerent scoring systems wereused in the reviewed articles), radiographic osteoarthritis,rate of non/malunion, rate of infection, performing woundculture, rate of secondary surgical interventions. The openankle fractures were classiWed according to the systemdeveloped by Gustilo and Anderson [2], and subsequentlymodiWed by Gustilo et al. [3].

A wound or deep infection is deWned as an invasion ofthe joint or the soft tissues around the joint by pathogenicmicroorganisms. The deWnition of malunion was docu-mented for each article. The rate of malunion according tothe authors’ deWnition was extracted from each article. Thenon-union rate included those fractures that developedosseous non-union after 1-year follow-up. Delayed unionswere not included in the non-union rate if the fractures sub-sequently healed. The secondary surgical procedure rateincluded any reported secondary surgical procedure relatedto the ankle fracture. This also included partial and com-plete hardware removals.

Two reviewers (CH, MB) independently reviewed theliterature searches on title and abstract to identify relevant

Table 1 ClassiWcation system of Gustilo and Anderson [3, 4]

I Wound <1 cm; minimal contamination, comminution and soft tissue damage

II Wound >1 cm; moderate soft tissue damage, minimal periosteal stripping

IIIA Severe soft tissue damage and substantial contamination;coverage adequate

IIIB Severe soft tissue damage and substantial contamination; coverage inadequate

IIIC Arterial injury requiring repair

123

Arch Orthop Trauma Surg (2011) 131:1545–1553 1547

articles for full review. From the full text, using the above-mentioned criteria two reviewers (CH, MB) independentlyselected articles for inclusion in this review. Disagreementwas resolved by group discussion with arbitration by a thirdauthor (CZ) where diVerences remained.

The data from the included studies were extracted (SK)and veriWed by a second author (CZ). Disagreement was

resolved in a consensus meeting or by third party (SK)adjudication when necessary. Studies were not blinded forauthor, aYliation and source [8, 9]. If necessary, authorswere contacted to acquire further information on methodol-ogy and data.

It was the initial intention of the authors to use a strictmethodology for paper analysis, focusing on objectively

Fig. 1 Flowchart summarizing the selection of relevant articles

Search in Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, Current Controlled Trials, Orthopaedic Trauma Association

annual meetings’ abstracts archives website and Embase

622 articles

Inclusion criteria:

Patients with treatment for open ankle fractures

All articles from 1968 onwards which presented patient data concerning treatment of open ankle fractures and concerning >6 patients

The search was restricted to articles written in English, German, French and Dutch

368 articles

47 articlesExcluded articles:

Did not match the language restrictions (n=4)

Not concerning open ankle fractures (n=23)

Expert opinions / review articles (n=5)

Data extraction

Screening related articles and references.

15 articles

Table 2 Pubmed/Medline search strategy

(((((“open fracture”[tw] OR “open fractures”[tw]) OR (“Fractures, Open”[Mesh]) OR (“complex fractures”[tw] OR “complex fracture”[tw]) OR (“compound fracture”[tw] OR “compound fractures”[tw])) AND ((ankle[tw] OR ankles[tw]) OR (“Ankle”[Mesh]))) OR (((“Fractures, Bone”[Mesh:noexp]) OR (“bone fracture”[tw] OR “bone fractures”[tw])) AND (open[tw]) AND ((ankle[tw] OR ankles[tw]) OR (“Ankle”[Mesh]))) OR (((“malleolar fracture”[tw] OR “malleolar fractures”[tw]) OR (“ankle fracture”[tw] OR “ankle fractures”[tw])) AND (open[tw]))) AND ((“Treatment Failure”[Mesh]) OR (treatment[tw]) OR (“operative procedure”[tw] OR “operative procedures”[tw]) OR (“Surgical Procedures, Operative”[Mesh:noexp]) OR (“debridement”[MeSH Terms] OR “debridement”[tw]) OR (“Irrigation”[Mesh:noexp]) OR (Irrigation[tw]) OR (lavage[tw]) OR (“Anti-Bacterial Agents”[Mesh:noexp]) OR (antibiotics[tw]) OR (“Fracture Fixation, Internal”[Mesh]) OR (“internal fracture Wxation”[tw]) OR (osteosynthesis[tw])))

123


measurable variables, separate evaluation of diVerentDanis–Weber and Lauge–Hansen classiWcations and ran-domized controlled trials. These standards had to be aban-doned, however, as almost none of the available papersfulWlled the above-mentioned criteria and data could not bepooled.

The methodological quality of included studies wasassessed by assigning Levels of Evidence as previouslydeWned by the Center for Evidence-Based Medicine(CEBM) [8], referred to in Table 3.

Results

Fifteen studies met the inclusion criteria, including 498patients. The number of included patients varied from 11 to64. An overview of the included studies is shown inTable 4. The The publication dates span 35 years. In 1973,Paul et al. published the earliest and in 2008, Lee et al. pub-lished the most recent study. There were 2 prospectivestudies and 13 retrospective studies. All articles were caseseries and were classiWed as level IV evidence. There was awide variation in ankle fracture types from unimalleolar totrimalleolar fractures. The treatments varied from non-operative to extended debridement, irrigation, intravenousantibiotics, ORIF and delayed closure. There was a widevariation in follow-up ranging from 10 [10] to 90 [11]months. DiVerent inclusion criteria (diVerent treatment pro-tocols, trauma-to-treatment intervals and postoperativerehabilitation protocols) prohibited a statistical evaluationand comparison between the studies. Fifteen articles,concerning 498 patients with treatment of an open anklefracture, were identiWed. In 373 cases, open ankle fractureswere treated by immediate internal Wxation. In 125 cases, aconservative treatment or delayed/other Wxation treatmentwas followed. Of those patients treated by immediate inter-nal Wxation, 81% had a satisfactory result. Poor results(15%) were most commonly due to non-anatomic reduc-tions, articular surface damage or deep infection. Whenconservative treatment was followed, 76% had satisfactoryresults. DiVerent scoring systems for outcome were used bydiVerent authors; hence, we can only refer to outcomes as“good”, “satisfactory” or “poor”. The most reported

complications after immediate internal Wxation were deepinfection (8%) and skin necrosis (14%).

Discussion

The complexity of open ankle fractures warrants treatmentby surgeons who are experienced in this Weld and have theability to collaborate with other surgical disciplines toobtain the best possible treatment [12]. In accordance withthe British guidelines, we advised that if this experiencewas not available, prompt referral was advised. Provisionalstabilization with an external Wxator is the optimal treat-ment of damage control before referral to another moreexperienced surgeon [12].

Heterogeneity of data made it impossible to carry outpooling of results. Furthermore, diVerent scoring systemsfor functional outcome were used, which made quantitativeanalysis of functional outcomes impossible.

Timing of operative treatment

Emergency operative treatment has long been the standardof care for open fractures. The origin of the so-called “six-hour rule” is unclear; it is probably based on old studies.

Based on the available evidence it is not possible toreject or conWrm this rule because there are studies in favorof and against this “golden” rule. Some authors suggest thatoperative debridement might not be necessary for low-grade open fractures [13–15]. Poor functional results seemto be associated with inability to achieve anatomical reduc-tion and postoperative loss of reduction of the ankle frac-ture rather than delayed operative treatment [16, 17]. In ourreview, the timing of operative treatment ranged from 2 to19 h. Most of the studies do not report on timing of opera-tive treatment with respect to infection rates, but there is atrend that type of soft tissue damage (high-energy injuries,crush-type soft tissue injury around the ankle, grade IIIopen injuries) is the determinant of postoperative complica-tions as opposed to timing of treatment [16, 17] as long asthis is within 24 h (Grade C) (Table 5).

Wound irrigation

Irrigation is a key component of the eVort to prevent infec-tion after open fracture, as it serves to decrease bacterialload and to remove foreign bodies. Although many guide-lines call for “copious” amounts of irrigation, there are littledata on exactly how much volume should be used in thelavage of open fracture wounds. With regard to the deliveryof irrigation, high-pressure pulsatile lavage is most eVectivefor the removal of bacteria and other contaminants. There isincreasing evidence from animal and in vitro studies that

Table 3 Level of evidence

Level I: high-quality prospective randomized clinical trial

Level II: prospective comparative study

Level III: retrospective case control study

Level IV: case series

Level V: expert opinion

123


Tab

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high-pressure pulsatile lavage may have deleterious sideeVects [11, 18–21]. These eVects include more macroscopicbone damage, reduced mechanical strength at short-termfollow-up and increased depth of bacterial penetration intomuscle [11, 18–21]. However, there is no clear clinical evi-dence in favor of high- or low-pressure pulsatile lavage.Okike and Bhattacharyya concluded that it was not possibleto recommend any particular additive for the irrigation ofopen fracture wounds [1].

Role of Wxation

Fixation of open fractures has a number of beneWcialeVects, including protection of soft tissues from additionalinjury by fracture fragments, improvement of wound careand tissue healing, promotion of early mobilization andrehabilitation, and possibly even reduction of the risk ofinfection [22]. The mode of Wxation of open fractures hashistorically been a topic of debate. In our review, immedi-ate open reduction and rigid internal Wxation of open anklefractures is safe and leads to good functional outcome(Grade C). It leads to shorter hospital stay and less jointstiVness when compared with conservative or delayed Wxa-tion [11]. Isolated medial malleolar fractures can be Wxedby a single screw or without screw Wxation [12, 23]. Evenin grade III open ankle fractures, rigid internal Wxation isassociated with good outcome. Fibular plating is not neces-sary at index surgery when the ankle is stabilized by exter-nal Wxation [23]. Deep infection leads to poor outcome and,in one study, all cases with deep infection required anklearthrodesis [17]. Deep infection should be avoided by pre-serving the soft tissues surrounding the fracture site by lav-age, debridements (repeated on demand) and earlyadministration of antibiotics [13, 19]. Only when there isinadequate soft tissue to cover osteosynthesis materials,external Wxation should be considered [17]. Poor outcomeis not only caused by deep infection. A large amount ofbone loss and articular cartilage damage caused by theinjury, inability to achieve articular reduction at operationand postoperative loss of anatomical reduction are associated

with painful secondary osteoarthritis [16, 17, 24]. It isimperative to achieve a congruous ankle mortise to preventearly degenerative ankle joint changes [17, 25], and failureto achieve rigid Wxation may even lead to higher deepinfection rates [26].

Wound coverage and closure

An anterior soft tissue defect resulting from direct injury ofhyper-plantar Xexion of the ankle can be associated withinjury of anterior tibial vessels and disruption of the exten-sor tendons [12]. Reconstruction of the tendons by interpo-sition grafts or tenodesis, and the extensor retinaculum isadvised [12]. Previously, the closure of wounds of openfractures were delayed to prevent infection with contami-nating organisms. This strategy remains the generallyaccepted approach in settings characterized by substantialcontamination. Today, many orthopedic surgeons considerearlier closure of open fracture wounds that have been ade-quately debrided. The trend toward early closure of openfractures conXicts with recommendations for routinedebridement of open fractures [27]. There are a number ofmethods for achieving closure, including direct suturing,split skin grafting and the use of free or local muscle Xaps.The optimal method depends on a number of factors,including the location of the defect, its size, associated inju-ries and patient characteristics such as the amount of func-tion retained and the desired level of function [1].

There is no consensus on the treatment of Grade I and IIopen wounds. Whereas most authors advocate delayed pri-mary closure for most Grade I and II open wounds, somereport leaving these to heal by secondary intention [13, 25]or to close Grade I wounds primarily as long as tension ofthe wound edges is avoided [6]. Some studies do not reporton closure technique after managing an open ankle fractureat all [11, 26, 28, 29]. Most authors have chosen to mentionGustilo grade rather than closure technique when discuss-ing cases of infection, which makes it diYcult to correlateinfection with closure technique. Consensus is that allgross contamination should be cleaned in the emergencydepartment, after which grade I and II open wounds can beleft to heal by secondary intention or delayed primaryclosure (Grade C).

Managing grade III open ankle fractures remains a chal-lenging task. Infection is a major threat to successful treat-ment. Soft tissue coverage of the ankle is limited due to thelack of muscle around it. Free Xaps are the only option forcovering large defects around the ankle [17]. Primary clo-sure of grade III open ankle fractures is discouraged (gradeC). Early institution of surgical debridement and antibioticsseems key to successful management of grade III anklefractures, followed by delayed closure after 2–5 days whensigns of infection are absent. When this is not possible, split

Table 5 Grades of recommendation (given to various treatmentoptions based on the level of evidence supporting that treatment)

Grade A: treatment options are supported by strong evidence (consistent with level I or II studies)

Grade B: treatment options are supported by fair evidence (consistent with level III or IV studies)

Grade C: treatment options are supported by either conXicting or poor-quality evidence (level IV studies)

Grade D: when insuYcient evidence exists to make a recommendation

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skin grafts can be used to cover skin defects on well-vascu-larised beds and free Xaps to cover larger defects [17, 24](grade C).

Use of antibiotics

Antibiotic use has been considered the standard of caresince 1974, when Patzakis et al. reported their results ofthe eVect of a Wrst-generation cephalosporin for the man-agement of open fractures [30]. The beneWt of antibioticswas conWrmed by a recent Cochrane systematic review[31], which showed that the administration of antibioticsafter an open fracture reduced the risk of infection by 59%(relative risk, 0.41; 95% conWdence interval, 0.27–0.63).Okike and Bhattacharyya do not recommend the routineuse of cultures either before or after debridement becausethe organisms that are found to be contaminating an openfracture on presentation do not represent the microbes thatwill eventually cause infection [32]. While there is ampledata supporting the administration of antibiotics after openfracture, evidence indicating an optimal regimen is lacking[32]. There is agreement that a Wrst-generation cephalo-sporin should be administered in patients with open frac-tures [6, 15]. Local antibiotic therapy is a useful adjunct tosystemic antibiotics in the management of open fractures[32]. Whether this applies to the treatment of open anklefractures could not be evinced from the articles in thisreview.

Timing of antibiotic administration plays an importantrole. The rate of infection increases when antibiotics arecommenced more than 3 h post-injury [33].

The duration of antibiotic treatment diVered greatly inthe studies of our review, ranging from 24 to 48 h [9, 16,24, 28], 3 days [26, 34, 35] to 5–7 days [13, 36]. One authoradvocates administering antibiotics until discharge fromhospital [29]. It is not possible to extract data which allow acorrelation between postoperative infection and duration ofantibiotic treatment.

Additional therapies

Non-unions of ankle fractures are rare [37], so adjunctivetherapy such as bone grafting as used in tibia and femurfractures is not beneWcial. The use of tourniquets duringoperation is discouraged [34], but no Wrm evidence is avail-able to support this.

Conclusion

There is a lack of high-quality literature concerning the(operative) treatment of patients with open ankle fractures.Most authors reported good results after performance of

their treatment protocol. On basis of the existing literature,we come to the following guidelines.

• All gross debris and contamination should be removed inthe emergency department (Grade C).

• Cephalosporins should be administered in the emergencydepartment without delay. It is not imperative thatwound swabs be taken before administering antibioticsas initial swabs taken do not represent the microbes thateventually cause infection.

• There is no evidence regarding the optimal duration ofantibiotic treatment.

• Patients should be taken to the theater within 24 h (GradeC).

• After thorough debridement of all devitalized tissues,irrigation of the wound should be carried out with cau-tion as this may also have deleterious eVects on bone andhealthy soft tissue (Grade C).

• There is no Wrm evidence against the use of tourniquets(Grade C).

• Rigid internal Wxation should be carried out with the aimof restoring anatomy of the ankle mortise and preventinglong-term secondary degenerative changes resulting inpain and stiVness. Only when there is inadequate soft tis-sue to cover osteosynthesis materials, external Wxationshould be considered (Grade C).

• Grade I wounds may be closed, primarily if the wound isnot under tension, or left open to heal by secondaryintention (Grade C).

• Grade II wounds should be left to heal by secondaryintention, or be closed primarily at a later time after post-operative infection has been ruled out (Grade C).

• Grade III open ankle injuries should be left open andmanaged postoperatively by the use of skin grafts or XeeXaps (Grade C).

Future studies should focus on the choice and duration ofantibiotic treatment, the amount and intensity of irrigationof soft tissues around the ankle and the type of irrigationsolution to be used.

Acknowledgments The authors are grateful to Albertine van Hors-sen for her help with the systematic search and collecting the requiredarticles. The authors did not receive any outside funding or grants insupport of their research or for preparation of this work. Neither theynor a member of their immediate families received payments or otherbeneWts, or a commitment or agreement to provide such beneWts froma commercial entity. Non-commercial entity paid or directed, or agreedto pay or direct, any beneWts to any research fund, foundation, division,center, clinical practice or other charitable or nonproWt organizations,with which the authors, or a member of their immediate families areaYliated or associated.

Open Access This article is distributed under the terms of the Cre-ative Commons Attribution Noncommercial License which permitsany noncommercial use, distribution, and reproduction in any medium,provided the original author(s) and source are credited.

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