- Email: [email protected]
Rigid Internal Fixation of Infected Mandibular Fractures
J Oral Maxillofac Surg 67:1046-1051, 2009
Rigid Internal Fixation of Infected Mandibular Fractures Pushkar Mehra, BDS, DMD,* Emily Van Heukelom, DDS,† and David A. Cottrell, DMD‡ Purpose: To evaluate the treatment outcomes of rigid internal fixation for the management of infected
mandible fractures. Patients and Methods: A retrospective chart review of infected mandible fractures managed by a
single oral and maxillofacial surgeon at a level I trauma center during a 7-year period was accomplished by independent examiners. All patients were treated with incision and drainage, culture and sensitivity testing, extraction of nonsalvageable teeth, placement of maxillomandibular fixation when possible, fracture reduction with bone debridement and decortication, rigid internal fixation of the mandible by an extraoral approach, and antibiotic therapy. The medical and social history was contributory in most patients. The analysis was stratified by the differentiation of the fractures into 2 groups: those with soft tissue infections in the fracture region versus those with hard tissue-infected fractures (biopsy-proven osteomyelitis). Results: A total of 44 patients were included in this study, with an average follow-up of 18.2 months from the date of surgery (range 3 to 48). The treatment protocol was successful in all 18 patients (100%) with soft tissue infected mandibular fractures and 24 (92%) of 26 patients with hard tissue-infected fractures. Conclusions: A protocol consisting of concomitant incision and drainage, mandibular debridement, fracture reduction, and stabilization with rigid internal fixation can be effectively used for single-stage management of infected mandible fractures. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:1046-1051, 2009 Treatment of infected mandible fractures remains controversial. The goals for management include restoration of pretrauma function, form, and occlusion; limitation of pain and disability; elimination of infection; preservation of teeth and bone; and restoration of motor and sensory nerve function. Prolonged maxillomandibular fixation (MMF) or external pin fixation has historically been used to manage such cases. However, current practice supports the use of rigid internal fixation (RIF) of mandible fractures with an associated decrease in treatment duration, a decreased
Received from the Department of Oral and Maxillofacial Surgery, Boston University Medical Center, Boston, MA. *Associate Professor and Director of Residency Training. †Chief Resident. ‡Associate Professor and Chairman. Address correspondence and reprint requests to Dr Mehra: Department of Oral and Maxillofacial Surgery, Boston University Medical Center, 100 East Newton Street, Suite G-407, Boston, MA 02118; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6705-0018$36.00/0 doi:10.1016/j.joms.2008.12.036
need for MMF, promotion of anatomic reduction, and less reliance on patient compliance for a favorable outcome compared with other treatment modalities.1-10 Nonetheless, in acutely infected cases, some current treatment protocols favor other treatment methods such as MMF and external pin fixation with avoidance of plating.11 This report was a retrospective evaluation of the management of soft and hard tissue-infected mandible fractures using antibiotics, surgical debridement, and simultaneous open reduction with rigid internal fixation (ORIF).
Patients and Methods A total of 44 consecutive patients with infected mandible fractures treated by a single surgeon at Boston University Medical Center from 2000 to 2007 were reviewed. The minimal follow-up period for inclusion was 3 months from internal fixation. Data were collected from the inpatient and outpatient clinic records and the radiographic and laboratory results. All patients were treated using the following protocol:
1046
MEHRA, VAN HEUKELOM, AND COTTRELL
1047
FIGURE 1. Panoramic radiograph showing compound fracture of mandible, involving canine and premolar teeth.
FIGURE 3. Adaptation and fixation of large, neutral mandibular fracture plate; first bone screw ⬎1 cm from fracture site.
Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
1. Acquisition of white blood cell-labeled nuclear scans to confirm the presence of inflammation/ infection. 2. Acquisition of purulent specimens for Gram stains, cultures, and sensitivity testing at the initial presentation. 3. Initiation of empirical intravenous antibiotic therapy (penicillin G or clindamycin for penicillin-allergic patients). The first dose of antibiotics was administered intraoperatively after cultures had been obtained. 4. Surgical protocol as follows: A. Incision and drainage of the infected fracture site (Fig 1) using an extraoral approach within 12 hours of presentation. B. Extraction of carious, periodontally involved, or compromised teeth located adjacent to the fracture sites.
C. If osteomyelitis was suspected, debridement and decortication of infected/necrotic bone immediately before placement of RIF. Debridement was accomplished conservatively with the intention to leave the lingual cortex of bone intact whenever possible (Fig 2). D. RIF of the mandible with a noncompression mandibular fracture plate (Stryker-Leibinger). Holes were drilled with a drill guide, and the plates were secured with 2 to 3 2.3-mm diameter screws placed perpendicularly to the plate on either side of the fracture. A minimum of 1 cm was maintained between the fracture site and the first screw (Figs 3, 4). E. Placement of 1 irrigating drain (red rubber catheter) in all patients, and an additional 0.25-in Penrose drain, when indicated for
FIGURE 2. Intraoperative view showing fracture debridement and reduction with lingual cortex preservation.
FIGURE 4. Immediate postoperative panoramic radiograph showing stabilization of fracture with rigid internal fixation.
Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
1048
INFECTED MANDIBLE FRACTURES
Table 2. CONTRIBUTORY MEDICAL AND SOCIAL FACTORS
FIGURE 5. Irrigating drain placed. This drain was usually kept in place for average of 2 to 5 days or until purulent drainage ceased. Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
patients with significant infection and purulence (Fig 5). The patients remained in the hospital for 2 to 5 days while the drains were advanced. The drains were discontinued when purulent drainage ceased. MMF was continued for 1 week postoperatively. The patients with isolated soft tissue infections were discharged after drain removal with oral antibiotics prescribed for 1 week. Patients with biopsy-proven osteomyelitis underwent percutaneous indwelling catheter intravenous line placement, and intrave-
Table 1. POSTOPERATIVE FINDINGS
Finding Malocclusion (n) Facial nerve injury (n) Permanent Transient Objectionable scarring (n) Operative time (min) Average Range Permanent inferior alveolar nerve damage† (n) During bone debridement During rigid fixation Treatment failure (n)
Group 1 0
Group 2 0
0 12 (66)* 1
0 17 (65)* 0
177 148-240
247 180-265
0 0 0 0
0 0 0 2
NOTE. Data in parentheses are percentages. *Two patients in group 1 and one in group 2 had progressively improving cranial nerve VII paresis until their last follow-up appointment (range 3 to 5 months) but were then lost to follow-up. †Excluding both patients with treatment failure who underwent resection. Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
Factor
Group 1 (n)
Group 2 (n)
Smoking (⬎1 pack daily) Diabetes mellitus NIDDM IDDM HIV AIDS CD4 ⬍ 200 Polysubstance abuse
11 7 4 3 3 0 1 14
17 4 2 2 4 0 0 20
Abbreviations: NIDDM, noninsulin-dependent diabetes mellitus; IDDM, insulin-dependent diabetes mellitus; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency virus. Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
nous antibiotics were continued on an outpatient basis for 4 to 6 weeks. The routine follow-up included examinations at 1, 2, 4, and 6 weeks and the longest point after surgery. At postoperative week 1, the MMF was released, and the patient was placed into guiding elastics, as needed, for a total of 1 to 3 weeks to facilitate correction of minor occlusal discrepancies. MMF was discontinued at postoperative week 6.
Results For the analysis of the results (Table 1), the patients were divided into 2 groups: soft tissue infected fractures (group 1) and hard tissue-infected fractures, biopsy-proven osteomyelitis (group 2). Group 1 included 18 patients with an average age of 44.2 years (range 26 to 62), and group 2 included 26 patents with an average age of 44 years (range 29 to 81). The average follow-up period was 7.7 months (range 3 to 48) after treatment completion. The medical and social history was contributory in 36 of the 44 patients (Table 2). The most common pathogens isolated were alphaor beta-hemolytic streptococcus in 76% of patients. However, 10% of the specimens failed to grow any organism. Methicillin-resistant Staphylococcus aureus was isolated from 3 patients, and 1 case of a fungal infection was documented. Aqueous penicillin G or clindamycin alone was the most frequently used antibiotic (75% of patients). According to the culture and sensitivity data, metronidazole was added in 7 patients for additional anaerobic coverage, vancomycin was used for 3 patients with documented methicillin-resistant S. aureus, and caspofungin was prescribed for the lone fungal infection.
1049
MEHRA, VAN HEUKELOM, AND COTTRELL
Neurosensory disturbance and facial nerve function were evaluated using subjective and objective tests preoperatively and postoperatively. The objective sensory tests included brush stroke, directional discrimination, light touch, 2-point discrimination, and pin-prick sensation. Despite the use of intraoperative facial nerve testing and preservation, transient facial nerve weakness was experienced by one third of the patients in the present series (Table 1). All but 3 cases were fully resolved at the last follow-up visit. The remaining 3 patients had progressively resolving symptoms until their last visit (range 3 to 5 months), but they were subsequently lost to follow-up. This protocol was successful in all 18 patients in group 1 (100%) and in 24 (92%) of 26 patients in group 2. Overall, this represented a 95% success rate for ORIF of infected mandible fractures, comparable to previous studies with a documented success rate of 94% to 100%.
Discussion Infected mandible fractures have classically been managed with prolonged MMF. Although time tested and effective, this treatment might be contraindicated in some patients because of associated medical or psychiatric conditions, as well as in the presence of fractures better managed by open reduction. Furthermore, MMF is less desirable for many patients and surgeons because of poor oral hygiene, speech and dietary restrictions, and the growing popularity of RIF techniques. Regarding RIF, some clinicians believe that the elimination of infection must precede osseous union and that metal acts as a foreign body and should not be placed into an infected site. Contemporary infectious disease and orthopedic data have suggested that hardware must be removed from a site that becomes infected before resolution of the infection can occur.11 These principles might not hold true for the head and neck region, where the rich vascular supply provides a natural atmosphere for optimal healing. Rigid immobilization of segments has emerged as a key principle in the elimination of infection and promotion of bony union.12 Multiple studies have evaluated protocols for ORIF of infected mandible fractures.6,7,10,13 However, “infected fracture” is a vague statement used interchangeably in the published data to identify both isolated soft tissue infection and osteomyelitis. A definitive diagnosis of osteomyelitis requires bone biopsy, cultures with positive findings, and histologic examination.14 Our study retrospectively evaluated the patient outcomes after RIF of infected mandible fractures in 44 consecutive patients. Each step of the protocol is reviewed independently below.
NUCLEAR SCINTIGRAPHY
Nuclear scintigraphy has been advocated for the identification and management of osteomyelitis. Indium-111–labeled scans are useful to identify inflammation but do not clearly differentiate infection in bone versus in soft tissue.11 We obtained baseline scans to evaluate the effectiveness in diagnosing extension of infection into bone; however, we did not find the results useful. Some of the later patients underwent the “new” technetium-99 –labeled scans to assess the effectiveness of more recent nuclear medicine techniques. However, again, the clinical picture did not always correlate with the official report of the scan. Because of the high cost and inconvenience of obtaining these tests, we believe that nuclear scans have limited utility in routine treatment of infected mandible fractures. A clinically infected fracture requires treatment irrespective of what these scans reveal. However, nuclear scans have some value in determining the duration of antibiotic therapy needed as a negative scan may indicate elimination of infection, and help justify the surgeon’s decision to discontinue antibiotics. ANTIBIOTIC THERAPY
Empirical intravenous antibiotic regimens were instituted for all patients intraoperatively after culture specimens were obtained. The antibiotic of first choice was penicillin G at a dosage of 2 million units intravenously every 4 hours. For penicillin-allergic patients, clindamycin was dosed at 600 mg intravenously every 8 hours. The antibiotic regimen was subsequently modified according to the clinical response and results of culture and sensitivity testing. The observation that 10% of specimens failed to grow any organisms might have reflected poor culture technique or the presence of organisms difficult to grow, such as Eikenella species. The duration of antibiotic therapy, particularly the administration of 4 to 6 weeks of intravenous antibiotics for patients with osteomyelitis, was anecdotally determined from previous successful experience at our institution. It is conceivable that the duration of antibiotic therapy can be shortened, and future studies should focus on this. SURGICAL PROTOCOL
All fractures, with the exception of 1 edentulous patient, were compound.6 Owing to the concerns for greater infection rates, any tooth within the plane of fracture was routinely removed. Although this approach might be considered “aggressive,” we believe that in cases of infected fractures, the removal of dental sources of infection near the fracture site will produce consistently good results.
1050 All patients were treated using an extraoral approach. Although an extraoral approach is more timeconsuming and carries the risk of facial nerve damage, it allows access to the fracture with minimal periosteal stripping and improved visualization compared with an intraoral approach and safe bicortical screw placement below the inferior alveolar nerve, and provides unsurpassed control of the fracture segments. Moreover, most infected fractures have boggy, swollen, and fragile intraoral tissues, which are not conducive to primary closure over metal plates and might carry a greater risk of wound dehiscence. This approach also allowed for sterile cultures and placement of dependent drains, which were used for local antibiotic (Bacitracin-Polymyxin) and saline solution irrigations. MAXILLOMANDIBULAR FIXATION
The purpose of the 1-week postoperative MMF was 3-fold: first, to help maintain primary closure of the surgical site until formation of an oral seal at the extraction sites; second, to reinforce patient compliance with a soft diet in the initial postoperative period until appropriate dietary habits had been established; finally, to motivate patients to return for postoperative examinations. Most of our patients were part of a local population with a low socioeconomic status. In our experience, this subgroup of patients has historically had a low compliance rate with routine postoperative and dietary instructions. BONE DEBRIDEMENT
Bone debridement was accomplished to bleeding margins, with an effort to maintain the lingual cortex, unless it was grossly infected or necrotic. This lingual cortical preservation eliminates a continuity defect, which would obligate the surgeon and patient to future bone reconstruction. RIGID INTERNAL FIXATION
Once the fracture site was exposed, drained, and debridement accomplished with a rotary instrument, RIF was placed with 2 screws per side and a minimal distance of 1 cm between the fracture site and the first screw. The published data have recommended 3 to 4 screws should be placed on each side of a fracture to secure a plate. However, placing this many screws requires more extensive periosteal stripping, and, in our experience, 2 screws per side have been sufficient to secure plates, especially if no continuity defect was present and 1 week of postoperative MMF used. CRITERIA FOR SUCCESS
The criteria for success in our study included the absence of clinical signs of infection, a normal white
INFECTED MANDIBLE FRACTURES
blood cell count, stable occlusion, a normal range of motion, and radiographic evidence of osseous union. In the present series, the treatment was 100% successful for patients with isolated soft tissue infection and 92% successful for patients with documented osteomyelitis. The combined success rate for all infected fractures was 95%. Of the 44 patients treated with this protocol, the treatment failed in 2. The first case involved a significantly medically compromised, methicillin-resistant S. aureus-positive individual who developed osteomyelitis with a pathologic fracture after a failed surgical procedure at an outside hospital. The patient was treated at our center with the reported protocol, but the infection persisted. She underwent hardware removal, mandibular resection, hyperbaric oxygen therapy, and external pin fixation. The patient underwent successful reconstruction by transport distraction osteogenesis with an intraorally placed internal distraction device. The second patient had initially undergone ORIF of an infected, severely displaced, bilateral edentulous mandible fracture. He did not return for the first follow-up appointment and presented 17 days postoperatively with segmental mobility, frank infection, and loose hardware. He underwent hardware removal, bone debridement, external pin fixation, and 6 weeks of intravenous antibiotic therapy with successful resolution of the infection. He underwent reconstruction 4 months later with iliac crest bone grafts. This protocol has resulted in high success rates with a larger case series than previously published. Koury and Ellis6 provided a protocol for management of infected mandibular fractures with an 11-patient series. Incision and drainage were often accomplished as separate procedures from ORIF, and no cases of osteomyelitis were included. All 11 patients went on to form an osseous union and did not require hardware removal, comparable to our group 1 (isolated soft tissue infection) with a 100% success rate (18 of 18 patients). In a subsequent study, Koury et al7 presented a retrospective report of 7 patients with mandible fractures complicated by osteomyelitis that were successfully managed with rigid internal fixation. However, an extraoral versus intraoral approach was not specified, the reconstruction plates were secured with 4 screws in both proximal and distal segments (rather than 2), and the patients were discharged with longterm oral antibiotics (rather than intravenous antibiotics by way of a percutaneous indwelling catheter line). Their 100% success rate might be attributable to the smaller sample size than in our study. In contrast to the study by Koury et al,7 in which 71% of patients required secondary bone graft reconstruction, none of the 42 patients with successful treatment in our
1051
MEHRA, VAN HEUKELOM, AND COTTRELL
study required bone grafting procedures owing to preservation of the lingual cortex. Viewed in concert with the existing data, the results of the present study have confirmed rigid internal fixation to be predictably successful for the treatment of soft and hard tissue-infected mandibular fractures. Future directions include elucidating the need for long-term antibiotics in cases of osteomyelitis managed using this protocol. At present, 4 to 6 weeks of intravenous antibiotic therapy have been administered with good results. Evidence has suggested that a protocol with long-term oral antibiotics might be sufficient, obviating the need for a percutaneous indwelling catheter line, and decreasing the total treatment cost.7 A protocol consisting of concomitant incision and drainage, intravenous antibiotic therapy, mandibular debridement, removal of high-risk teeth, fracture reduction, and stabilization with rigid internal fixation has provided predictable successful outcomes for management of soft and hard tissue-infected mandible fractures. Nuclear scintigraphy was costly, inconvenient, and of low specificity, with limited utility in the management of infected mandible fractures because it did not modify the clinical treatment decisions. An extraoral approach was key to the successful management of infected fractures using our protocol, because it allowed for sterile cultures, improved access with judicious periosteal stripping, control of segments, and safe placement of bicortical screws below the inferior alveolar nerve. The differentiation of soft tissue infection and osteomyelitis by histopathologic examination and bone culture is necessary. The benefits of this protocol include a decrease in treatment duration, a decreased need for MMF from 6 weeks to 1 week, the promotion of anatomic reduction, and a
decreased reliance on patient compliance for favorable outcomes.
References 1. Fischer-Brandies E, Dielert E: The infected mandibular fracture. Arch Orthop Trauma Surg 103:337, 1984 2. Johannnson B, Krekmanov L, Thomsson M: Miniplate osteosynthesis of infected mandibular fractures. J Craniomaxillofac Surg 16:22, 1988 3. Hoffman W, Barton R: Rigid internal fixation versus traditional techniques for the treatment of infected mandible fractures. J Trauma 30:1032, 1990 4. Dodson T, Perrott D: Fixation of mandible fractures: A comparative analysis of rigid fixation and standard fixation techniques. J Oral Maxillofac Surg 28:362, 1990 5. Iizuka T, Lindqvist C, Hallikainen D, Paukku P: Infection after rigid internal fixation of mandibular fractures: A clinic and radiologic study. J Oral Maxillofac Surg 49:585, 1991 6. Koury M, Ellis E III: Rigid internal fixation for the treatment of infected mandibular fractures. J Oral Maxillofac Surg 50:434, 1992 7. Koury M, Perrott D, Kaban L: Use of rigid internal fixation in mandibular fractures complicated by osteomyelitis. J Oral Maxillofac Surg 52:1114, 1994 8. Schiel H, Hammer B, Ehrenfeld M, et al: Therapy of infected mandibular fractures. Fortschr Kiefer Gesichtschir 41:170, 1996 9. Kirkpatrick D, Gandhi R, Van Sickles JE: Infections associated with locking reconstruction plates: A retrospective review. J Oral Maxillofac Surg 61:462, 2003 10. Benson P, Marshall M, Engelstaad M, et al: The use of immediate bone grafting in reconstruction of clinically infected mandibular fractures: Bone grafts in the presence of pus. J Oral Maxillofac Surg 1:122, 2006 11. Topazian R, Goldberg M, Hupp J: Oral and Maxillofacial Infections (ed 4). Philadelphia, PA, WB Saunders, 2002, pp 65, 214-242, 361-362 12. Beckers H: Treatment of initially infected mandible fractures with bone plates. J Oral Surg 37:310, 1979 13. Buchbinder D, Weber W: Discussion: Rigid internal fixation for the treatment of infected mandibular fractures. J Oral Maxillofac Surg 50:443, 1992 14. Wannfors K, Hammarstrom L: Infectious foci in chronic osteomyelitis of the jaws. Int J Oral Surg 14:493, 1985
Rigid Internal Fixation of Infected Mandibular Fractures Pushkar Mehra, BDS, DMD,* Emily Van Heukelom, DDS,† and David A. Cottrell, DMD‡ Purpose: To evaluate the treatment outcomes of rigid internal fixation for the management of infected
mandible fractures. Patients and Methods: A retrospective chart review of infected mandible fractures managed by a
single oral and maxillofacial surgeon at a level I trauma center during a 7-year period was accomplished by independent examiners. All patients were treated with incision and drainage, culture and sensitivity testing, extraction of nonsalvageable teeth, placement of maxillomandibular fixation when possible, fracture reduction with bone debridement and decortication, rigid internal fixation of the mandible by an extraoral approach, and antibiotic therapy. The medical and social history was contributory in most patients. The analysis was stratified by the differentiation of the fractures into 2 groups: those with soft tissue infections in the fracture region versus those with hard tissue-infected fractures (biopsy-proven osteomyelitis). Results: A total of 44 patients were included in this study, with an average follow-up of 18.2 months from the date of surgery (range 3 to 48). The treatment protocol was successful in all 18 patients (100%) with soft tissue infected mandibular fractures and 24 (92%) of 26 patients with hard tissue-infected fractures. Conclusions: A protocol consisting of concomitant incision and drainage, mandibular debridement, fracture reduction, and stabilization with rigid internal fixation can be effectively used for single-stage management of infected mandible fractures. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:1046-1051, 2009 Treatment of infected mandible fractures remains controversial. The goals for management include restoration of pretrauma function, form, and occlusion; limitation of pain and disability; elimination of infection; preservation of teeth and bone; and restoration of motor and sensory nerve function. Prolonged maxillomandibular fixation (MMF) or external pin fixation has historically been used to manage such cases. However, current practice supports the use of rigid internal fixation (RIF) of mandible fractures with an associated decrease in treatment duration, a decreased
Received from the Department of Oral and Maxillofacial Surgery, Boston University Medical Center, Boston, MA. *Associate Professor and Director of Residency Training. †Chief Resident. ‡Associate Professor and Chairman. Address correspondence and reprint requests to Dr Mehra: Department of Oral and Maxillofacial Surgery, Boston University Medical Center, 100 East Newton Street, Suite G-407, Boston, MA 02118; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6705-0018$36.00/0 doi:10.1016/j.joms.2008.12.036
need for MMF, promotion of anatomic reduction, and less reliance on patient compliance for a favorable outcome compared with other treatment modalities.1-10 Nonetheless, in acutely infected cases, some current treatment protocols favor other treatment methods such as MMF and external pin fixation with avoidance of plating.11 This report was a retrospective evaluation of the management of soft and hard tissue-infected mandible fractures using antibiotics, surgical debridement, and simultaneous open reduction with rigid internal fixation (ORIF).
Patients and Methods A total of 44 consecutive patients with infected mandible fractures treated by a single surgeon at Boston University Medical Center from 2000 to 2007 were reviewed. The minimal follow-up period for inclusion was 3 months from internal fixation. Data were collected from the inpatient and outpatient clinic records and the radiographic and laboratory results. All patients were treated using the following protocol:
1046
MEHRA, VAN HEUKELOM, AND COTTRELL
1047
FIGURE 1. Panoramic radiograph showing compound fracture of mandible, involving canine and premolar teeth.
FIGURE 3. Adaptation and fixation of large, neutral mandibular fracture plate; first bone screw ⬎1 cm from fracture site.
Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
1. Acquisition of white blood cell-labeled nuclear scans to confirm the presence of inflammation/ infection. 2. Acquisition of purulent specimens for Gram stains, cultures, and sensitivity testing at the initial presentation. 3. Initiation of empirical intravenous antibiotic therapy (penicillin G or clindamycin for penicillin-allergic patients). The first dose of antibiotics was administered intraoperatively after cultures had been obtained. 4. Surgical protocol as follows: A. Incision and drainage of the infected fracture site (Fig 1) using an extraoral approach within 12 hours of presentation. B. Extraction of carious, periodontally involved, or compromised teeth located adjacent to the fracture sites.
C. If osteomyelitis was suspected, debridement and decortication of infected/necrotic bone immediately before placement of RIF. Debridement was accomplished conservatively with the intention to leave the lingual cortex of bone intact whenever possible (Fig 2). D. RIF of the mandible with a noncompression mandibular fracture plate (Stryker-Leibinger). Holes were drilled with a drill guide, and the plates were secured with 2 to 3 2.3-mm diameter screws placed perpendicularly to the plate on either side of the fracture. A minimum of 1 cm was maintained between the fracture site and the first screw (Figs 3, 4). E. Placement of 1 irrigating drain (red rubber catheter) in all patients, and an additional 0.25-in Penrose drain, when indicated for
FIGURE 2. Intraoperative view showing fracture debridement and reduction with lingual cortex preservation.
FIGURE 4. Immediate postoperative panoramic radiograph showing stabilization of fracture with rigid internal fixation.
Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
1048
INFECTED MANDIBLE FRACTURES
Table 2. CONTRIBUTORY MEDICAL AND SOCIAL FACTORS
FIGURE 5. Irrigating drain placed. This drain was usually kept in place for average of 2 to 5 days or until purulent drainage ceased. Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
patients with significant infection and purulence (Fig 5). The patients remained in the hospital for 2 to 5 days while the drains were advanced. The drains were discontinued when purulent drainage ceased. MMF was continued for 1 week postoperatively. The patients with isolated soft tissue infections were discharged after drain removal with oral antibiotics prescribed for 1 week. Patients with biopsy-proven osteomyelitis underwent percutaneous indwelling catheter intravenous line placement, and intrave-
Table 1. POSTOPERATIVE FINDINGS
Finding Malocclusion (n) Facial nerve injury (n) Permanent Transient Objectionable scarring (n) Operative time (min) Average Range Permanent inferior alveolar nerve damage† (n) During bone debridement During rigid fixation Treatment failure (n)
Group 1 0
Group 2 0
0 12 (66)* 1
0 17 (65)* 0
177 148-240
247 180-265
0 0 0 0
0 0 0 2
NOTE. Data in parentheses are percentages. *Two patients in group 1 and one in group 2 had progressively improving cranial nerve VII paresis until their last follow-up appointment (range 3 to 5 months) but were then lost to follow-up. †Excluding both patients with treatment failure who underwent resection. Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
Factor
Group 1 (n)
Group 2 (n)
Smoking (⬎1 pack daily) Diabetes mellitus NIDDM IDDM HIV AIDS CD4 ⬍ 200 Polysubstance abuse
11 7 4 3 3 0 1 14
17 4 2 2 4 0 0 20
Abbreviations: NIDDM, noninsulin-dependent diabetes mellitus; IDDM, insulin-dependent diabetes mellitus; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency virus. Mehra, Van Heukelom, and Cottrell. Infected Mandible Fractures. J Oral Maxillofac Surg 2009.
nous antibiotics were continued on an outpatient basis for 4 to 6 weeks. The routine follow-up included examinations at 1, 2, 4, and 6 weeks and the longest point after surgery. At postoperative week 1, the MMF was released, and the patient was placed into guiding elastics, as needed, for a total of 1 to 3 weeks to facilitate correction of minor occlusal discrepancies. MMF was discontinued at postoperative week 6.
Results For the analysis of the results (Table 1), the patients were divided into 2 groups: soft tissue infected fractures (group 1) and hard tissue-infected fractures, biopsy-proven osteomyelitis (group 2). Group 1 included 18 patients with an average age of 44.2 years (range 26 to 62), and group 2 included 26 patents with an average age of 44 years (range 29 to 81). The average follow-up period was 7.7 months (range 3 to 48) after treatment completion. The medical and social history was contributory in 36 of the 44 patients (Table 2). The most common pathogens isolated were alphaor beta-hemolytic streptococcus in 76% of patients. However, 10% of the specimens failed to grow any organism. Methicillin-resistant Staphylococcus aureus was isolated from 3 patients, and 1 case of a fungal infection was documented. Aqueous penicillin G or clindamycin alone was the most frequently used antibiotic (75% of patients). According to the culture and sensitivity data, metronidazole was added in 7 patients for additional anaerobic coverage, vancomycin was used for 3 patients with documented methicillin-resistant S. aureus, and caspofungin was prescribed for the lone fungal infection.
1049
MEHRA, VAN HEUKELOM, AND COTTRELL
Neurosensory disturbance and facial nerve function were evaluated using subjective and objective tests preoperatively and postoperatively. The objective sensory tests included brush stroke, directional discrimination, light touch, 2-point discrimination, and pin-prick sensation. Despite the use of intraoperative facial nerve testing and preservation, transient facial nerve weakness was experienced by one third of the patients in the present series (Table 1). All but 3 cases were fully resolved at the last follow-up visit. The remaining 3 patients had progressively resolving symptoms until their last visit (range 3 to 5 months), but they were subsequently lost to follow-up. This protocol was successful in all 18 patients in group 1 (100%) and in 24 (92%) of 26 patients in group 2. Overall, this represented a 95% success rate for ORIF of infected mandible fractures, comparable to previous studies with a documented success rate of 94% to 100%.
Discussion Infected mandible fractures have classically been managed with prolonged MMF. Although time tested and effective, this treatment might be contraindicated in some patients because of associated medical or psychiatric conditions, as well as in the presence of fractures better managed by open reduction. Furthermore, MMF is less desirable for many patients and surgeons because of poor oral hygiene, speech and dietary restrictions, and the growing popularity of RIF techniques. Regarding RIF, some clinicians believe that the elimination of infection must precede osseous union and that metal acts as a foreign body and should not be placed into an infected site. Contemporary infectious disease and orthopedic data have suggested that hardware must be removed from a site that becomes infected before resolution of the infection can occur.11 These principles might not hold true for the head and neck region, where the rich vascular supply provides a natural atmosphere for optimal healing. Rigid immobilization of segments has emerged as a key principle in the elimination of infection and promotion of bony union.12 Multiple studies have evaluated protocols for ORIF of infected mandible fractures.6,7,10,13 However, “infected fracture” is a vague statement used interchangeably in the published data to identify both isolated soft tissue infection and osteomyelitis. A definitive diagnosis of osteomyelitis requires bone biopsy, cultures with positive findings, and histologic examination.14 Our study retrospectively evaluated the patient outcomes after RIF of infected mandible fractures in 44 consecutive patients. Each step of the protocol is reviewed independently below.
NUCLEAR SCINTIGRAPHY
Nuclear scintigraphy has been advocated for the identification and management of osteomyelitis. Indium-111–labeled scans are useful to identify inflammation but do not clearly differentiate infection in bone versus in soft tissue.11 We obtained baseline scans to evaluate the effectiveness in diagnosing extension of infection into bone; however, we did not find the results useful. Some of the later patients underwent the “new” technetium-99 –labeled scans to assess the effectiveness of more recent nuclear medicine techniques. However, again, the clinical picture did not always correlate with the official report of the scan. Because of the high cost and inconvenience of obtaining these tests, we believe that nuclear scans have limited utility in routine treatment of infected mandible fractures. A clinically infected fracture requires treatment irrespective of what these scans reveal. However, nuclear scans have some value in determining the duration of antibiotic therapy needed as a negative scan may indicate elimination of infection, and help justify the surgeon’s decision to discontinue antibiotics. ANTIBIOTIC THERAPY
Empirical intravenous antibiotic regimens were instituted for all patients intraoperatively after culture specimens were obtained. The antibiotic of first choice was penicillin G at a dosage of 2 million units intravenously every 4 hours. For penicillin-allergic patients, clindamycin was dosed at 600 mg intravenously every 8 hours. The antibiotic regimen was subsequently modified according to the clinical response and results of culture and sensitivity testing. The observation that 10% of specimens failed to grow any organisms might have reflected poor culture technique or the presence of organisms difficult to grow, such as Eikenella species. The duration of antibiotic therapy, particularly the administration of 4 to 6 weeks of intravenous antibiotics for patients with osteomyelitis, was anecdotally determined from previous successful experience at our institution. It is conceivable that the duration of antibiotic therapy can be shortened, and future studies should focus on this. SURGICAL PROTOCOL
All fractures, with the exception of 1 edentulous patient, were compound.6 Owing to the concerns for greater infection rates, any tooth within the plane of fracture was routinely removed. Although this approach might be considered “aggressive,” we believe that in cases of infected fractures, the removal of dental sources of infection near the fracture site will produce consistently good results.
1050 All patients were treated using an extraoral approach. Although an extraoral approach is more timeconsuming and carries the risk of facial nerve damage, it allows access to the fracture with minimal periosteal stripping and improved visualization compared with an intraoral approach and safe bicortical screw placement below the inferior alveolar nerve, and provides unsurpassed control of the fracture segments. Moreover, most infected fractures have boggy, swollen, and fragile intraoral tissues, which are not conducive to primary closure over metal plates and might carry a greater risk of wound dehiscence. This approach also allowed for sterile cultures and placement of dependent drains, which were used for local antibiotic (Bacitracin-Polymyxin) and saline solution irrigations. MAXILLOMANDIBULAR FIXATION
The purpose of the 1-week postoperative MMF was 3-fold: first, to help maintain primary closure of the surgical site until formation of an oral seal at the extraction sites; second, to reinforce patient compliance with a soft diet in the initial postoperative period until appropriate dietary habits had been established; finally, to motivate patients to return for postoperative examinations. Most of our patients were part of a local population with a low socioeconomic status. In our experience, this subgroup of patients has historically had a low compliance rate with routine postoperative and dietary instructions. BONE DEBRIDEMENT
Bone debridement was accomplished to bleeding margins, with an effort to maintain the lingual cortex, unless it was grossly infected or necrotic. This lingual cortical preservation eliminates a continuity defect, which would obligate the surgeon and patient to future bone reconstruction. RIGID INTERNAL FIXATION
Once the fracture site was exposed, drained, and debridement accomplished with a rotary instrument, RIF was placed with 2 screws per side and a minimal distance of 1 cm between the fracture site and the first screw. The published data have recommended 3 to 4 screws should be placed on each side of a fracture to secure a plate. However, placing this many screws requires more extensive periosteal stripping, and, in our experience, 2 screws per side have been sufficient to secure plates, especially if no continuity defect was present and 1 week of postoperative MMF used. CRITERIA FOR SUCCESS
The criteria for success in our study included the absence of clinical signs of infection, a normal white
INFECTED MANDIBLE FRACTURES
blood cell count, stable occlusion, a normal range of motion, and radiographic evidence of osseous union. In the present series, the treatment was 100% successful for patients with isolated soft tissue infection and 92% successful for patients with documented osteomyelitis. The combined success rate for all infected fractures was 95%. Of the 44 patients treated with this protocol, the treatment failed in 2. The first case involved a significantly medically compromised, methicillin-resistant S. aureus-positive individual who developed osteomyelitis with a pathologic fracture after a failed surgical procedure at an outside hospital. The patient was treated at our center with the reported protocol, but the infection persisted. She underwent hardware removal, mandibular resection, hyperbaric oxygen therapy, and external pin fixation. The patient underwent successful reconstruction by transport distraction osteogenesis with an intraorally placed internal distraction device. The second patient had initially undergone ORIF of an infected, severely displaced, bilateral edentulous mandible fracture. He did not return for the first follow-up appointment and presented 17 days postoperatively with segmental mobility, frank infection, and loose hardware. He underwent hardware removal, bone debridement, external pin fixation, and 6 weeks of intravenous antibiotic therapy with successful resolution of the infection. He underwent reconstruction 4 months later with iliac crest bone grafts. This protocol has resulted in high success rates with a larger case series than previously published. Koury and Ellis6 provided a protocol for management of infected mandibular fractures with an 11-patient series. Incision and drainage were often accomplished as separate procedures from ORIF, and no cases of osteomyelitis were included. All 11 patients went on to form an osseous union and did not require hardware removal, comparable to our group 1 (isolated soft tissue infection) with a 100% success rate (18 of 18 patients). In a subsequent study, Koury et al7 presented a retrospective report of 7 patients with mandible fractures complicated by osteomyelitis that were successfully managed with rigid internal fixation. However, an extraoral versus intraoral approach was not specified, the reconstruction plates were secured with 4 screws in both proximal and distal segments (rather than 2), and the patients were discharged with longterm oral antibiotics (rather than intravenous antibiotics by way of a percutaneous indwelling catheter line). Their 100% success rate might be attributable to the smaller sample size than in our study. In contrast to the study by Koury et al,7 in which 71% of patients required secondary bone graft reconstruction, none of the 42 patients with successful treatment in our
1051
MEHRA, VAN HEUKELOM, AND COTTRELL
study required bone grafting procedures owing to preservation of the lingual cortex. Viewed in concert with the existing data, the results of the present study have confirmed rigid internal fixation to be predictably successful for the treatment of soft and hard tissue-infected mandibular fractures. Future directions include elucidating the need for long-term antibiotics in cases of osteomyelitis managed using this protocol. At present, 4 to 6 weeks of intravenous antibiotic therapy have been administered with good results. Evidence has suggested that a protocol with long-term oral antibiotics might be sufficient, obviating the need for a percutaneous indwelling catheter line, and decreasing the total treatment cost.7 A protocol consisting of concomitant incision and drainage, intravenous antibiotic therapy, mandibular debridement, removal of high-risk teeth, fracture reduction, and stabilization with rigid internal fixation has provided predictable successful outcomes for management of soft and hard tissue-infected mandible fractures. Nuclear scintigraphy was costly, inconvenient, and of low specificity, with limited utility in the management of infected mandible fractures because it did not modify the clinical treatment decisions. An extraoral approach was key to the successful management of infected fractures using our protocol, because it allowed for sterile cultures, improved access with judicious periosteal stripping, control of segments, and safe placement of bicortical screws below the inferior alveolar nerve. The differentiation of soft tissue infection and osteomyelitis by histopathologic examination and bone culture is necessary. The benefits of this protocol include a decrease in treatment duration, a decreased need for MMF from 6 weeks to 1 week, the promotion of anatomic reduction, and a
decreased reliance on patient compliance for favorable outcomes.
References 1. Fischer-Brandies E, Dielert E: The infected mandibular fracture. Arch Orthop Trauma Surg 103:337, 1984 2. Johannnson B, Krekmanov L, Thomsson M: Miniplate osteosynthesis of infected mandibular fractures. J Craniomaxillofac Surg 16:22, 1988 3. Hoffman W, Barton R: Rigid internal fixation versus traditional techniques for the treatment of infected mandible fractures. J Trauma 30:1032, 1990 4. Dodson T, Perrott D: Fixation of mandible fractures: A comparative analysis of rigid fixation and standard fixation techniques. J Oral Maxillofac Surg 28:362, 1990 5. Iizuka T, Lindqvist C, Hallikainen D, Paukku P: Infection after rigid internal fixation of mandibular fractures: A clinic and radiologic study. J Oral Maxillofac Surg 49:585, 1991 6. Koury M, Ellis E III: Rigid internal fixation for the treatment of infected mandibular fractures. J Oral Maxillofac Surg 50:434, 1992 7. Koury M, Perrott D, Kaban L: Use of rigid internal fixation in mandibular fractures complicated by osteomyelitis. J Oral Maxillofac Surg 52:1114, 1994 8. Schiel H, Hammer B, Ehrenfeld M, et al: Therapy of infected mandibular fractures. Fortschr Kiefer Gesichtschir 41:170, 1996 9. Kirkpatrick D, Gandhi R, Van Sickles JE: Infections associated with locking reconstruction plates: A retrospective review. J Oral Maxillofac Surg 61:462, 2003 10. Benson P, Marshall M, Engelstaad M, et al: The use of immediate bone grafting in reconstruction of clinically infected mandibular fractures: Bone grafts in the presence of pus. J Oral Maxillofac Surg 1:122, 2006 11. Topazian R, Goldberg M, Hupp J: Oral and Maxillofacial Infections (ed 4). Philadelphia, PA, WB Saunders, 2002, pp 65, 214-242, 361-362 12. Beckers H: Treatment of initially infected mandible fractures with bone plates. J Oral Surg 37:310, 1979 13. Buchbinder D, Weber W: Discussion: Rigid internal fixation for the treatment of infected mandibular fractures. J Oral Maxillofac Surg 50:443, 1992 14. Wannfors K, Hammarstrom L: Infectious foci in chronic osteomyelitis of the jaws. Int J Oral Surg 14:493, 1985