Introduction
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 |
Materials and methods
(((((“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 fixation”[tw]) OR (osteosynthesis[tw]))) |
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 |
Level of evidence | Study type | Number of patiens | Type of fracture | Gustillo classification | Treatment protocol | Follow up | Results | Complication | |
---|---|---|---|---|---|---|---|---|---|
Acello 1995 | III | Retrospective | 33 | Foot: N = 26 | I: 8 II: 7 III: 8 | Debridement , irrigation, AB, immediate ORIF/amputation, delayed closure. | Infection: N = 2 | ||
Ankle: N = 7 | |||||||||
Bray 1989 | III | Retrospective | 31 | Unimalleolar: N = 13 | I: 12 II: III: 10 | Group I(’73-’79): debridement, closed reduction, immobilisation, or delayed ORIF, delayed closure. Group II(’79-’84): debridement, irrigation, AB, immediate ORIF, delayed primary closure | I: 90 months II: 33 months LTFU: 1 | Pain/function both groups same. Group II: better ROM | Both groups 1 infection. |
Bimalleolar: N = 12 | |||||||||
Trimalleolar: N = 6 | |||||||||
Franklin 1984 | III | Retrospective | 38 | Unimalleolar: 8 | I: 12 II: 14 III: 16 | Debridement, irrigation, AB, immediate ORIF, delayed primary closure, NWB 6 weeks | 39 months LTFU: 3 | Function: Excellent: 26 Fair/poor: 9 | Deep inf: 1: Sup. inf: 5, Posttr. arthr. 13. BKA: 1 Del. union: 2 |
Bimalleolar: 24 | |||||||||
Trimalleolar: 8 | |||||||||
Pilon: 2 | |||||||||
Jacque- Maire 1976 | III | Retrospective | 26 | Bimalleolar: 26 of which 11 luxation fractures | I: 5 II: 16 III: 5 | I: debridement, closed reduction, immobilisation | Good: 17 Average/bad: 9 | Posttr. Arthr.: 1 Septic arthr: 1, Pseudoarthrosis: 5 | |
II: debridement and immediate ORIF | |||||||||
Johnson 1993 | III | Retrospective | 22 | Unimalleolar: 6 | I: 6 II: 15 III: 1 | Debridement, irrigation, AB, immediate ORIF | 32 months LTFU: 13 | Clinical result: | Sup. Infection: 2 |
Bimalleolar: 8 | Excellent: 14 | Synostosis: 1 | |||||||
Trimalleolar: 8 | Good: 5 | Loss of red: 1 | |||||||
Poor: 3 | |||||||||
Joshi 2006 | III | Prospective | 30 | I: 11 II: 12 IIIA: 5, B: 2 | Debridement, irrigation, AB, immediate ORIF, soft tissue management according to fracture grade | Functional (ketanjian): Excellent 22 Good 8 Fair: 2 | Sup infection: 4 | ||
Loss of reduction: 2 | |||||||||
Khan 2007 | III | Retrospective | 24 | Group P: fix ex, soft tissue transfer after radical debridement | P: 10.5 m S: 11.4 m | Enneking score: P: 74.6 S: 70.4 | BKA: 2 (one primary treatment) | ||
Time to union: P: 17 w S: 21.6 w | Delayed healing/haematoma flap: 2 | ||||||||
Group S (referrals): fix ex or Ilizarov, removal of infected metalwork when necessary, soft tissue transfer | |||||||||
Lee 2008 | III | Retrospective | 47 | AO type B2 | I: 26 II: 21 III: excl. | Debridement, irrigation, AB, immediate ORIF, primary wound closure | 29 months LTFU 4 | Baird& Jackson ankle score: Excellent/ Good: 90 % | Sup. Infection: 2 |
Skin necrosis: 2 | |||||||||
Ngcelwane 1990 | III | 64 | Weber A: 7 B: 26 C: 24 other: 8 | Clean: 42 | Debridement, irrigation, AB, immediate ORIF: 27 AO, 26 K wires + plaster, 11 plaster only | 23 no pain | Sup infection: 23 | ||
Contam: 22 | 21 pain on WB | Deep inf/sepsis: 9 | |||||||
Nordin 1988 | III | Retrospective | 35 | Bimalleolar: 10 | I: 3 II: 4 III: 4 20 not open 4 not classified | Fix ex | Good 3 | Sup infections: 5 | |
Fair: 3 | |||||||||
Pilon: 25 | Poor: 9 | Deep infections: 3 | |||||||
CRPS: 4 | |||||||||
Pseudoarthrosis: 1 | |||||||||
Arthrodesis: 4 | |||||||||
Paul 1973 | III | Retrospective | 32 | Unimalleolar: 6 | I: Conservative treatment: 15 II: ORIF 11 | I: Deep infections: 4 Amputation; 1 Pseudoarthrosis:3 Posttraum arthr: 10 Ankylosis: 2 II: skinnecrosis: Posttraumatic arthritis: 5 | |||
Luxation fracture: 26 | |||||||||
Sanders 1992 | III | Retrospective | 11 ( 4 chronic OM referrals) | Ankle type 3B: 8 | III B: 11 | Multiple debridements, removal of pre-existing implants, AB (IV and beads), temporary fixation with fix ex or posterior splint. Delayed wound closure with definitive bony stabilisation (ankle fusion/ankylosis) including bone graft , in case of flap 4-6 weeks after flap transfer. NWB 3 months. | 48 months | Mazur ankle fusion score: | Sup. Infection: 1 |
No subsequent infection. | |||||||||
Talus type 3B: 3 | |||||||||
Good: 3 | |||||||||
Poor: 5 | |||||||||
Failure: 3 | |||||||||
Tho 1994 | III | Retrospective | 15 | Weber B: 7 | IIIA: 14 | Debridement, irrigation, AB, immediate ORIF, delayed closure/SSG/flap/by sec. Intention. 6-12 weekscast NWB. | 1-3 years | ROM: good: 7 | Sup. infection: 3 Deep |
III B: 1 | |||||||||
Weber C: 8 | satisfactory: 6 | infection: 3 - > arthrodesis | |||||||
poor: 2 | |||||||||
Osteoarthritis:7 | |||||||||
White 2003 | III | Retrospective | 14 (all diabetes) | Unimalleolar: 1 | I: 1 | Debridement, irrigation, AB, | 19 months LTFU | Sup. Infection: 2 | |
II: 5 | |||||||||
IIIA: 4 | |||||||||
IIIB: 4 | |||||||||
Bimalleolar: 4 | immediate ORIF/fix ex. 1 cast, 2 amputations. Delayed closure/SSG/flaps. | 0 | Deep infection: 5- - > 3 BKA Non unions: 2 | ||||||
Trimalleolar: 4 | |||||||||
Pilon: 5 | |||||||||
Wiss 1989 | III | Prospective | 76 | Weber A: 9 | I: 11 | Debridement, irrigation, AB, immediate ORIF. Gustillo I en II secondary intention. III redebridement delayed primary or partially closed and partially by sec intention | 16.4 months LTFU 5 | Excellent 25 | Deep infection 3 Arthrodesis 5 Arthritis 12 Delayed healing 5 |
II: 23 | |||||||||
Weber B: 26 | III: 28 | Good: 25 | |||||||
Fair 5 | |||||||||
Poor 12 | |||||||||
Weber C: 20 | |||||||||
other: 7 |
Results
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 conflicting or poor-quality evidence (level IV studies) |
Grade D: when insufficient evidence exists to make a recommendation |
Discussion
Timing of operative treatment
Wound irrigation
Role of fixation
Wound coverage and closure
Use of antibiotics
Conclusion
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All gross debris and contamination should be removed in the emergency department (Grade C).
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Cephalosporins should be administered in the emergency department without delay. It is not imperative that wound swabs be taken before administering antibiotics as initial swabs taken do not represent the microbes that eventually cause infection.
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There is no evidence regarding the optimal duration of antibiotic treatment.
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Patients should be taken to the theater within 24 h (Grade C).
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After thorough debridement of all devitalized tissues, irrigation of the wound should be carried out with caution as this may also have deleterious effects on bone and healthy soft tissue (Grade C).
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There is no firm evidence against the use of tourniquets (Grade C).
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Rigid internal fixation should be carried out with the aim of restoring anatomy of the ankle mortise and preventing long-term secondary degenerative changes resulting in pain and stiffness. Only when there is inadequate soft tissue to cover osteosynthesis materials, external fixation should be considered (Grade C).
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Grade I wounds may be closed, primarily if the wound is not under tension, or left open to heal by secondary intention (Grade C).
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Grade II wounds should be left to heal by secondary intention, or be closed primarily at a later time after postoperative infection has been ruled out (Grade C).
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Grade III open ankle injuries should be left open and managed postoperatively by the use of skin grafts or flee flaps (Grade C).