Eur J Orthop Surg Traumato! (1995) 5 : 161 - 163

European Joumal of Orthopaedic Surgery& Traumatology © Springer-Verlag 1995

The treatment of infected tibial pilon fractures* Le traitement de l'infection du pilon tibial V. Heppert, P. Hochstein, M. Aymar and A. Wentzensen Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Ludwig Guttmann Str. 13, D-67071 Ludwigshafen, Germany

Summary: A total of 33 patients with infection after pilon f r a c t u r e were retrospectively reviewed from 1988 to 1992. Twenty patients were transfered from peripheral hospitals with active osteitis, 13 patients were treated primarily in our hospital. Factors inducing infection in this group of patients are discussed critically. All patients underwent radical debridement. Restoration of bone stability was required in 72%. Due to the extent of infection, segmental resection had to be p e r f o m e d on 7 patients. Resulting soft tissue defects were closed with free flaps in 11 cases. Infection was controlled in 31 patients (93%), but only 8 couM be classified as " c u r e d " (24%). Two patients had amputations after failure of treatment. Despite successfid therapy, the fimctional results are poor. Therefore, avoiding infection, has top priority in the post fracture treatment. The correct form of osteosynthesis adapted to the soft tissue lesion can lower infection rates significantly. Soft tissue defects, resulting from open fractures or after primary treatment, have to be closed by flap transfer within a short period of

Code Mdary : 5063.0 Correspondence to: V. Heppert

* European Bone and Joint Infection Society Meeting, Miinchen, Germany, October 7-9, 1993

time. The management of the soft tissue is at least as important as the reconstruction of the bone in the treatment of pilon fractures. K e y w o r d s : Pilon tibial fracture - Osteitis - - Surgical flap

The distal leg is the most difficult area to treat in orthopedic surgery [1-5]. Due to a very thin layer of protecting soft tissue, the rate of complications after post fracture bone stabilization is surprisingly high [6]. Especially in combination with soft tissue damage, the treatment of pilon fractures becomes more and more difficult, the rate of infection increases [7], often resulting in chronic osteitis. This leads to long hospitalization periods for the patient. Sometimes, despite all the possibilities of modern reconstructive surgery, limb amputation is inevitable.

Material and methods In this retrospective study, charts from the Berufsgenossenschaftliche Unfallklinik Ludwigshafen were reviewed for the p e r i o d b e t w e e n J a n u a r y 1988 and December 1992. During this time a total of 33 patients were admitted to our septic ward with infection following pilon fracture. According to the classification of soft tissue lesions [8] we found 9 third

degree open and 5 second degree open fractures. Nineteen patients showed a closed 2nd or 3rd degree lesion. The fractures were graded according to the AO classification [9]. 45% of our own patients showed a C3 type, 26% a C2 type. Twenty patients with active osteitis were transferred from peripheral hospitals. Prior to transfer to our hospital various operations (mean 2.8) were performed with a range from 1 to 6. Thirteen patients were treated primarily in our hospital. From those patients, 8 were only suffering from early localized postoperative subcutaneous infection, in the other 5 cases chronic osteitis developed. Looking at the primary treatment of the 33 patients we found, that in 23 cases internal stabilization was performed. In 16 cases plating was done, 7 patients were treated with screws or/and K-wires. In two a conservative regimen was followed. Only 8 fractures were stabilized with external fixator. O u r m a n a g e m e n t e m p h a s i z e s an a g g r e s s i v e o p e r a t i v e approach to the infection. A l l patients with acute postoperative infection had a debridement on the day infection appeared or on the day of admission. In 9 patients we found a stable situation, not requiring immediate plate removal. Following debridement, a permanent drain was placed on top of

162 the osteosynthetic plate. After consolidation of the fracture drain and plate were removed. In 24 patients (72%) the bone was unstable. Operations for stability included septic plate removal and change to AO/Ilisarov Fixator. Depending on the extent of bone infection, callus distraction after segmental resection or a fibula to tibia fusion was done. On the remaining patients numerous further operations had to be performed (mean 3.1). Thirty operations were due to the infection itself, 26 were done to restore bone stability. For closure of the soft tissue defect 6 Latissimus dorsi, 3 Radial forearm flaps and 2 Parascapular flaps were performed. The details are listed in Table 1. We found a predominance of Staph. aureus in 21 patients. Samples showed Staph. epid. in 2 times, Enterococcus and Coli each in one case. Despite clinical evidence of active infection, in 7 patients no bacterial growth was found. According to the bacteriologic testing, all patients received i.v. antibiotics for 10 days. In most cases cefurotoxim was used. Furthermore local antibiotics were administered at the site of infection in 23 cases. Two patients received Gentamycin impregnated polymethylacrylate beads. In 21 cases Gentamycin impregnated collagen, which does not require removal, was used.

Results

At the time of follow-up all patients were drainage free. But only 8 patients (24%) could be cleared as cured. These patients belonged to a group with early postoperative infection. Only one revision was performed and after debridement a drain was placed on top of the underlying osteosynthetic plate. After consolidation of the fracture, metal and drain were removed. At that time there was no sign of infection, by clinical and radiologic appearance. Bacteriology and blood testing of BSR, WBC and CRP were within normal range. 25 patients were, at the time of follow-up, drainage free, but had suffered 78 subsequent operations (mean 3.1). In 23 patients of this group we have no cli-

v. Heppert et al: Infectedtibial pilon fracture nical evidence of infection, but radiographs and laboratory findings are still suspicious. N e v e r t h e l e s s there is no need for operative intervention. In two other cases the infection could not be stopped. Below knee amputation had to be performed. The f u n c t i o n a l o u t c o m e s of the patients were classified into 4 categories: • E x c e l l e n t : Range of motion (ROM) unlimited, no pain. • F a i r : ROM slightly diminished < 1/3, little pain, w a l k i n g u n l i m i t e d • Accepted: ROM severly diminished > 1/3, w a l k i n g up to 30 min, inconstant pain. • P o o r . " Ankylosis, arthrodesis, residual deformity, constant pain, any recurrence of infection. The results were excellent only in 6%, fair in 9%, acceptable in 22% and poor in 63%. A m o n g the p o o r r e s u l t s 3 patients showed a residual deformity, 5 an ankylosis. In 4 cases arthrodesis had to be performed. The infection could be stopped only by below knee amputation in 2 cases.

Table I, Secondary interventions Operation

No.

Revision/Permanentdrainage Necrectomy Septic metal removal External fixator (seconds) Distractionosteogenesis Plating Fibulato tibia Free flap transfer Meshgraft

7 19 4 8 7 2 9 11 7

Table 2. Literature review of infection rates after pilon fracture AO statistic AO (articular only) BGU Ludwigshafen Breiffug/Muhr Kinzl et al. Schnettler/B~3rner Rommens et al.

3.2 5.25 8.8 I0 12.5 13.1 16.7

Table 3. Analysis of infection inducing factors Severityof trauma Operation-tirning Delay injury/op, start Soft tissue trauma Change of fixation Unknown

5 7 12 3 6

Discussion

Fractures of the of the tibial plafond represent only 5-7% of all tibia fractures [10]. But postoperative complication rates are much higher in the distal third of the leg. Rates of nonunion up to 18%, arthrodesis 27%, below knee amputations 6% and up to malunions 42% are reported [ 10-14] with these fractures. The rate of r e p o r t e d infection rates shows a wide range in literature. Details are shown in the review of Table 2. The treatment of intra-articular fractures still is an unsolved problem for orthopedic surgeons, remaining controversial in the literature. To gain a good functional result, the destroyed articular surface has to be restored and deformities of alignment must be corrected. This can be done best by open reduction and internal osteosynthesis [15, 16]. In the past, these procedures were preferred for primary treatment [ 12]. The thin protecting soft tissue layer in the ankle region very often is severely

traumatized in combination with pilon fractures. Recently, the point of interest has turned more and more to the soft tissue lesion. Despite numerous publications [6, 7, 17-19], the importance of soft tissue trauma is still often underestimated. Certainly the development of infection has m u l t i p l e influencing factors. But, analysing our 33 patients, we found u n d e r e s t i m a t e d soft t i s s u e l e s i o n -mostly w i t h G I I - G I I I trauma [8]- in most of our cases (Table 3). Only 8 fractures were stabilized primarily with external fixator, 2 were treated in a conservative manner. Despite the soft tissue trauma, in the m a j o r i t y of patients an internal reduction and fixation was p e r f o r m e d . The influence of the implant c h o i c e on the infection rate is well documented [20]. There are reported infection rates of 12.6% with plating and

V. Heppert et al: Infected tibial pilon fracture 3.4% with external fixator in the primary treatment o f tibial fractures. In 7 cases the timing of operation has to be considered. The internal fixation was done outside the commonly accepted 6- to 8-h limit after trauma at the m a x i m u m of posttraum a t i c e d e m a t o u s soft t i s s u e s w e l l i n g . A m o n g our p a t i e n t s were 14 cases w i t h o p e n f r a c t u r e s g r a d e III [8]. T o l o w e r the h i g h i n f e c t i o n rate o f t h e s e fractures, primary radical d e b r i d e m e n t , s o m e t i m e s r e s u l t i n g in a s o f t t i s s u e defect, has to be p e r f o r m e d . D e v e l o p ment of free flap transfer enables the surgeon to do this without thinking of the problems of wound closure. These facts and the benefit for the outcome are well k n o w n [17, 19, 21]. B u t none of the 14 grade OIII patients of our study had had free flap transfer prior to infection appearing. They were transfered to our hospital after conservative treatment o f the soft tissue p r o b l e m s at the time of chronic osteitis. Chronic osteitis requires a very aggressive approach to the site o f infection. All necrotic soft tissue and b o n e has to be removed. Possibilities of bone d e b r i d e m e n t are drilling, saucerization and segment-resection. Resulting b o n e instability could be treated by cancellous b o n e graft, fibula to tibia (9 cases) or septic ankle joint arthrodesis (4 cases). Since introduction of distraction osteogenesis, using the Ilisarov technique (7 cases), the possibilities of bone resection are e x t e n d e d widely. Resulting detects up to 18 cm could be bridged successfully in our patients. The corresponding soft tissue defect was closed in 11 cases by free flap transfer. B y use of these methods, the infection in 31 patients could be treated succ e s s f u l l y . But, a f t e r a l o n g p e r i o d o f hospitalization, there r e m a i n e d a considerable amount o f functional loss in the traumatized extremity. In 2 cases treatment failed, below knee amputation was performed. Learning from these results, we changed our m a n a g e m e n t of pilon fractures. Primary plating is reserved only for p i l o n fractures w i t h o u t s i g n i f i c a n t soft tissue damage. In all other cases we stabilize the fibula by plate and the tibia

163 by external fixator. C h a n g e of method to internal r e d u c t i o n and s t a b i l i z a t i o n o f the articular surface is done secondarily, usually 8 to I4 days after the trauma. T h e above radical m a n a g e m e n t of soft tissue damage is standard in our hospital. With this, we lowered our infection r a t e in the p o s t s t u d y p e r i o d to 7 . 5 % (internal fixation).

Conclusion O s t e i t i s of the t i b i a l p l a f o n d u s u a l l y ends up with a considerable a m o u n t o f functional loss. The costs of therapy are high, long hospitalization periods for the p a t i e n t s are c o m m o n . A v o i d i n g infection has top priority. T h e j u d g e m e n t a n d t h e r a p y o f the surgeon, is most important for the course o f the disease [19]. In cases o f soft t i s s u e t r a u m a t h e e x t e r n a l f i x a t o r is method of choice for primary stabilization of the tibia. Radical debridement of all ischemic and necrotic tissue is crucial for primary treatment and in cases of manifest osteitis. Resulting soft tissue defects have to be closed -mostly by free flap t r a n s f e r - w i t h i n 8 days. In s o m e cases, despite all possibilities of reconstructive surgery, primary amputation is still method o f choice.

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Received March 1st, 1994/Accepted in final fi~rm February 27, 1995