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Early immobilization of mandibular fractures: A retrospective study
702
DISCUSSION
chronic suppurative osteomyelitis in group 2 treated by this method healed without developing chronic suppurative osteomyelitis. However, based on our experience of many years, coupled with our understanding of the pathology involved, we are reluctant to perform open reductions on fractures where immobilization has been delayed more than 72 hours. Thus, it is not surprising that our group 4 contained only three patients. As outlined in our list of principles, when an open reduction is absolutely necessary, and when immobilization has been delayed, we first treat the patient by closed reduction and/or external pin fixation together with IV antibiotics for a period of 10 to 21 days to resolve the bone infection before proceeding to an open reduction with intraosseous fixation. In Mowlem's classic article he theorized that the normalcy of blood supply is the determining factor in the development of osteomyelitis of the jaws.P We feel that when there has been a delay in treatment of compound fractures, the infection of the spongiosa eventually compromises the blood supply, and as one performs an open reduction and strips the periosteum at the fracture site, it is not surprising that these patients are particularly prone to progress to a chronic suppurative osteomyelitis. In our study of 204 fractures, 9 instances of suppurative osteomyelitis were observed. This represents an infection rate of 4.4%, which is comparable with other reports. These figures include two patients with old, untreated, compound fractures who were admitted with a diagnosis of chronic suppurative osteomyelitis and four other patients who were not compliant with treatment. Focusing only on the compliant patients immobilized within 72 hours of injury, there was a 0% incidence of chronic suppurative osteomyelitis in 111 fractures treated by closed reduction (86 fractures in group 1 and 25 fractures in group 3). Furthermore, of the 50 open reductions performed on compliant patients immo-
bilized within 72 hours on injury (group 3), there was one case of chronic suppurative osteomyelitis, representing an infection rate of 2%. Thus, of the total of 161 fractures treated by closed and/or open reduction with early immobilization in compliant patients, the incidence of chronic suppurative osteomyelitis was 0.6%. The low incidence of chronic suppurative osteomyelitis secondary to the treatment of mandibular fractures supports our principles that stress the early immobilization of compound fractures. The crucial issue is to identify those factors that increase the possible occurrence of chronic suppurative osteomyelitis and to understand why these factors predispose to the development of infection. We feel that early immobilization is the sine qua non in the treatment of compound mandibular fractures. References I. Chuong R, Donoff RB, Guralnick WC: A retrospective analysis of 327 mandibular fractures. J Oral Maxillofac Surg 41:305, 1983 2. Davidson TI\I, Bone RC, Nahum AM: Mandibular fracture complications. Arch Otolaryngol 102:627, 1976 3. Kerr NW: Some observations on infections in maxillofacial fractures. Br J Oral Surg 4:132, 1966 4. Krueger G: Textbook of Oral Surgery (ed 5). St Louis, MO, Mosby, 1979, p 354 5. James R, Frederickson C, Kent NJ: Prospective study of mandibular fractures. J Oral Surg 39:275, 1981 6. Larsen 00, Nielsen A: Mandibular fractures. Scand J Plast Reconstr Surg 10:219, 1976 7. Neal DC, Wagner WF, Alpert B: Morbidity associated with teeth in the line of mandibular fractures. J Oral Surg 36:859, 1978 8. Wagner WF, Neal DC, Alpert B: Morbidiy associated with extraoal open reduction of mandibular fractures. J Oral Surg 37:97, 1979 9. Bradley RL: Treatment of fractured mandible. Am Surg 31:289, 1965 10. Schneider SS, Stern M: Teeth in the Line of Mandibular Fracture. J Oral Surg 29:107, 1971 II. Edgerton MT, Hill E: Fractures of the mandible. Surgery 31:933, 1952 12. Mowlem R: Osteomyelitis of the jaw. Proc R Soc Med 38:452, 1945
J Oral Maxillofac Surg 49;702·703,1991
Discussion Early Immobilization of Mandibular Fractures: A Retrospective Study
Brian Alpert, DDS University of Louisville School of Dentistry, Louisville, KY
Open mandibular fractures have always possessed the potential for significant morbidity. One of the most hor-
rendous complications is osteomyelitis of the fracture site leading to long-term drainage and nonunion. Fortunately, it seldom occurs with modern treatment. Surgeons over the years have advocated various treatment protocols in an attempt to minimize complications. Removal of teeth from the fracture line, retention of teeth, various antibiotic regimens, closed management, rigid fixation, and early treatment have all been suggested. Some authors
703
BRIAN ALPERT
have based their treatment on "experience" and opinion. Others, including myself, have attempted to draw statistical inferences from non randomized data. Unfortunately, data analysis is often biased-we see what we want to see. The aim of the authors in this article was to test the validity of their protocol for management of open fractures. The fundamental tenant of this protocol is immobilization within 72 hours of injury. They assume that open fractures not immobilized within 72 hours are at high risk for development of suppurative osteomyelitis if managed by open reduction and internal fixation (ORIF). They manage such fractures with closed techniques. If ORIF is still deemed necessary, it is preceded by a prolonged course of intravenous (IV) antibiotics. However, they believe that ORIF may be safely done on open mandibular fractures if immobilization is accomplished within 72 hours of injury. Data from 204 fractures of the mandible in 132 patients were provided. Of these, 132 were open fractures. The patients were divided into four groups depending on whether or not they were immobilized within 72 hours and whether they received open or closed reductions (CR). A fifth group included "proper" treatment in "noncompliant" patients. It required some effort to assemble their pertinent data from the narrative. When the closed fractures (rarely associated with suppurative osteomyelitis) were eliminated, the data in Table 1 emerged. If one eliminates the noncompliant patients and those already infected (as the authors have), the data are indeed quite compelling. Yet, when the noncompliant patients are included, the data are closely comparable to that of our previously reported studies, among others. Since our original data were still at hand, I reanalyzed them for comparison. Six cases of osteomyelitis in 129 open mandibular fractures is similar to what was found in our study with teeth in the line of fracture, I which had nine cases of osteomyelitis in 207 open fractures. Of the nine cases of osteomyelitis in our series, four had been immobilized in less than 72 hours and five after 72 hours. The average delay in immobilization for all 207 open fractures was Table 1. Tabulation of Authors' Data for Open Fractures Open Fractures
Immobilized (h)
Group I Group 2 Group 3
51 18 55
<72 >72 <72
Group 4
2
>72
Group 5
6
<72
Totals
132
Treatment
Osteomyelitis
CR CR 470RIF 8 CR 10RIF I CR 30RIF 3 CR
0 3· I 0 I 0 2 2
9
* All 3 fractures were clinically infected at time of treatment.
over 72 hours. Noncompliance with fixation, diet, and antibiotics was quite common in our series. Our antibiotic regimen called for penicillin or a substitute in fairly standard oral doses for no longer than I week following reduction. It is surprising to note that the authors chose to separately categorize four noncompliant patients who had a total of 6 open fractures (group 5). These fractures were immobilized within 72 hours and four still developed osteomyelitis. None of the 27 patients immobilized later than 72 hours were deemed noncompliant. It would seem that the patients were only considered noncompliant if the treatment failed. In our experience with a comparable patient population, patients come to treatment late because they are either suffering from concomitant injuries or medical problems, or they are by nature noncompliant. It is tempting, and indeed human nature, to blame treatment failures on noncompliance. Two of the 79 cases of closed reduction of open fractures developed osteomyelitis regardless of when they were reduced. This compares favorably with our study, I which had 6 of 162, with 3 of the 6 being immobilized later than 72 hours. Both sets of data are suggestive, but hardly compelling. The authors' data on the relationship of ORIF, time of immobilization, and osteomyelitis is, in my opinion, still equivocal. Four of 52 open fractures treated by ORIF developed osteomyelitis. Two of these infected fractures were in noncompliant patients and one in an open fracture that was immobilized later than 72 hours. By contrast, our study of morbidity of the ORIp2 found more support for their premise. In that study, 6 of 100 cases developed osteomyelitis, with 1 of 37 immobilized within 72 hours and 5 of 63 immobilized later than 72 hours. The authors note, and we all recognize, that there are many factors associated with the development of suppurative osteomyelitis in open mandibular fractures. Presence and disposition of teeth in the line of fracture, operative delay, patient compliance, type of fracture, location of fracture, and, most currently, imperfect immobilization, have been, and are being considered. We all have our pet biases. I personally believe, along with the authors, that fractures are less likely to become infected when managed early. However, this concept is hard to substantiate. As pointed out, it is difficult to draw valid statistical inferences from nonrandomized data. The one thing these data most convincingly illustrate is that noncompliant patients do not do well with conventional treatment. They should be managed with techniques that minimize the need for compliance, such as properly executed rigid fixation.
References I. Neal DC, Wagner WF, Alpert B: Morbidity associated with
teeth in the line of mandibular fractures. J Oral Surg 36:859, 1978 2. Wagner WF, Neal DC, Alpert B: Morbidity associated with extraoral open reduction of mandibular fractures. J Oral Surg 37:97, 1979
DISCUSSION
chronic suppurative osteomyelitis in group 2 treated by this method healed without developing chronic suppurative osteomyelitis. However, based on our experience of many years, coupled with our understanding of the pathology involved, we are reluctant to perform open reductions on fractures where immobilization has been delayed more than 72 hours. Thus, it is not surprising that our group 4 contained only three patients. As outlined in our list of principles, when an open reduction is absolutely necessary, and when immobilization has been delayed, we first treat the patient by closed reduction and/or external pin fixation together with IV antibiotics for a period of 10 to 21 days to resolve the bone infection before proceeding to an open reduction with intraosseous fixation. In Mowlem's classic article he theorized that the normalcy of blood supply is the determining factor in the development of osteomyelitis of the jaws.P We feel that when there has been a delay in treatment of compound fractures, the infection of the spongiosa eventually compromises the blood supply, and as one performs an open reduction and strips the periosteum at the fracture site, it is not surprising that these patients are particularly prone to progress to a chronic suppurative osteomyelitis. In our study of 204 fractures, 9 instances of suppurative osteomyelitis were observed. This represents an infection rate of 4.4%, which is comparable with other reports. These figures include two patients with old, untreated, compound fractures who were admitted with a diagnosis of chronic suppurative osteomyelitis and four other patients who were not compliant with treatment. Focusing only on the compliant patients immobilized within 72 hours of injury, there was a 0% incidence of chronic suppurative osteomyelitis in 111 fractures treated by closed reduction (86 fractures in group 1 and 25 fractures in group 3). Furthermore, of the 50 open reductions performed on compliant patients immo-
bilized within 72 hours on injury (group 3), there was one case of chronic suppurative osteomyelitis, representing an infection rate of 2%. Thus, of the total of 161 fractures treated by closed and/or open reduction with early immobilization in compliant patients, the incidence of chronic suppurative osteomyelitis was 0.6%. The low incidence of chronic suppurative osteomyelitis secondary to the treatment of mandibular fractures supports our principles that stress the early immobilization of compound fractures. The crucial issue is to identify those factors that increase the possible occurrence of chronic suppurative osteomyelitis and to understand why these factors predispose to the development of infection. We feel that early immobilization is the sine qua non in the treatment of compound mandibular fractures. References I. Chuong R, Donoff RB, Guralnick WC: A retrospective analysis of 327 mandibular fractures. J Oral Maxillofac Surg 41:305, 1983 2. Davidson TI\I, Bone RC, Nahum AM: Mandibular fracture complications. Arch Otolaryngol 102:627, 1976 3. Kerr NW: Some observations on infections in maxillofacial fractures. Br J Oral Surg 4:132, 1966 4. Krueger G: Textbook of Oral Surgery (ed 5). St Louis, MO, Mosby, 1979, p 354 5. James R, Frederickson C, Kent NJ: Prospective study of mandibular fractures. J Oral Surg 39:275, 1981 6. Larsen 00, Nielsen A: Mandibular fractures. Scand J Plast Reconstr Surg 10:219, 1976 7. Neal DC, Wagner WF, Alpert B: Morbidity associated with teeth in the line of mandibular fractures. J Oral Surg 36:859, 1978 8. Wagner WF, Neal DC, Alpert B: Morbidiy associated with extraoal open reduction of mandibular fractures. J Oral Surg 37:97, 1979 9. Bradley RL: Treatment of fractured mandible. Am Surg 31:289, 1965 10. Schneider SS, Stern M: Teeth in the Line of Mandibular Fracture. J Oral Surg 29:107, 1971 II. Edgerton MT, Hill E: Fractures of the mandible. Surgery 31:933, 1952 12. Mowlem R: Osteomyelitis of the jaw. Proc R Soc Med 38:452, 1945
J Oral Maxillofac Surg 49;702·703,1991
Discussion Early Immobilization of Mandibular Fractures: A Retrospective Study
Brian Alpert, DDS University of Louisville School of Dentistry, Louisville, KY
Open mandibular fractures have always possessed the potential for significant morbidity. One of the most hor-
rendous complications is osteomyelitis of the fracture site leading to long-term drainage and nonunion. Fortunately, it seldom occurs with modern treatment. Surgeons over the years have advocated various treatment protocols in an attempt to minimize complications. Removal of teeth from the fracture line, retention of teeth, various antibiotic regimens, closed management, rigid fixation, and early treatment have all been suggested. Some authors
703
BRIAN ALPERT
have based their treatment on "experience" and opinion. Others, including myself, have attempted to draw statistical inferences from non randomized data. Unfortunately, data analysis is often biased-we see what we want to see. The aim of the authors in this article was to test the validity of their protocol for management of open fractures. The fundamental tenant of this protocol is immobilization within 72 hours of injury. They assume that open fractures not immobilized within 72 hours are at high risk for development of suppurative osteomyelitis if managed by open reduction and internal fixation (ORIF). They manage such fractures with closed techniques. If ORIF is still deemed necessary, it is preceded by a prolonged course of intravenous (IV) antibiotics. However, they believe that ORIF may be safely done on open mandibular fractures if immobilization is accomplished within 72 hours of injury. Data from 204 fractures of the mandible in 132 patients were provided. Of these, 132 were open fractures. The patients were divided into four groups depending on whether or not they were immobilized within 72 hours and whether they received open or closed reductions (CR). A fifth group included "proper" treatment in "noncompliant" patients. It required some effort to assemble their pertinent data from the narrative. When the closed fractures (rarely associated with suppurative osteomyelitis) were eliminated, the data in Table 1 emerged. If one eliminates the noncompliant patients and those already infected (as the authors have), the data are indeed quite compelling. Yet, when the noncompliant patients are included, the data are closely comparable to that of our previously reported studies, among others. Since our original data were still at hand, I reanalyzed them for comparison. Six cases of osteomyelitis in 129 open mandibular fractures is similar to what was found in our study with teeth in the line of fracture, I which had nine cases of osteomyelitis in 207 open fractures. Of the nine cases of osteomyelitis in our series, four had been immobilized in less than 72 hours and five after 72 hours. The average delay in immobilization for all 207 open fractures was Table 1. Tabulation of Authors' Data for Open Fractures Open Fractures
Immobilized (h)
Group I Group 2 Group 3
51 18 55
<72 >72 <72
Group 4
2
>72
Group 5
6
<72
Totals
132
Treatment
Osteomyelitis
CR CR 470RIF 8 CR 10RIF I CR 30RIF 3 CR
0 3· I 0 I 0 2 2
9
* All 3 fractures were clinically infected at time of treatment.
over 72 hours. Noncompliance with fixation, diet, and antibiotics was quite common in our series. Our antibiotic regimen called for penicillin or a substitute in fairly standard oral doses for no longer than I week following reduction. It is surprising to note that the authors chose to separately categorize four noncompliant patients who had a total of 6 open fractures (group 5). These fractures were immobilized within 72 hours and four still developed osteomyelitis. None of the 27 patients immobilized later than 72 hours were deemed noncompliant. It would seem that the patients were only considered noncompliant if the treatment failed. In our experience with a comparable patient population, patients come to treatment late because they are either suffering from concomitant injuries or medical problems, or they are by nature noncompliant. It is tempting, and indeed human nature, to blame treatment failures on noncompliance. Two of the 79 cases of closed reduction of open fractures developed osteomyelitis regardless of when they were reduced. This compares favorably with our study, I which had 6 of 162, with 3 of the 6 being immobilized later than 72 hours. Both sets of data are suggestive, but hardly compelling. The authors' data on the relationship of ORIF, time of immobilization, and osteomyelitis is, in my opinion, still equivocal. Four of 52 open fractures treated by ORIF developed osteomyelitis. Two of these infected fractures were in noncompliant patients and one in an open fracture that was immobilized later than 72 hours. By contrast, our study of morbidity of the ORIp2 found more support for their premise. In that study, 6 of 100 cases developed osteomyelitis, with 1 of 37 immobilized within 72 hours and 5 of 63 immobilized later than 72 hours. The authors note, and we all recognize, that there are many factors associated with the development of suppurative osteomyelitis in open mandibular fractures. Presence and disposition of teeth in the line of fracture, operative delay, patient compliance, type of fracture, location of fracture, and, most currently, imperfect immobilization, have been, and are being considered. We all have our pet biases. I personally believe, along with the authors, that fractures are less likely to become infected when managed early. However, this concept is hard to substantiate. As pointed out, it is difficult to draw valid statistical inferences from nonrandomized data. The one thing these data most convincingly illustrate is that noncompliant patients do not do well with conventional treatment. They should be managed with techniques that minimize the need for compliance, such as properly executed rigid fixation.
References I. Neal DC, Wagner WF, Alpert B: Morbidity associated with
teeth in the line of mandibular fractures. J Oral Surg 36:859, 1978 2. Wagner WF, Neal DC, Alpert B: Morbidity associated with extraoral open reduction of mandibular fractures. J Oral Surg 37:97, 1979