- Email: [email protected]
Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics
The Foot 33 (2017) 44–47
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics
MARK
⁎
Giandavide Ieropolia, Jorge Hugo Villafañeb, , Silvia Chiara Zompic, Umberto Morozzod, Riccardo D’Ambrosie, Federico Giuseppe Usuellie, Pedro Berjanoe a
Istituto Ferrero, Alba, Italy IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy Medicina dello Sport, Turin, Italy d Ospedale San Lazzaro, Turin, Italy e IRCCS Istituto Ortopedico Galeazzi, Milan, Italy b c
A R T I C L E I N F O
A B S T R A C T
Keywords: Osteosynthesis Fractures Foot Tibial pilon Calcaneaus Minimally invasive plate osteosynthesis Infected wound
Objective: The aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures. Methods: Eleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months. Results: The average time of wound closure was 109 ± 60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4–6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living. Conclusion: The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time.
1. Introduction Soft tissues around the distal lower limb (distal leg, ankle and heel) are easily compromised by trauma and subsequent operative fracture treatment; in tibial pilon fractures this rate is about 2%, while in calcaneus fractures this percentage can still occur in up to 25% of patients [1–4]. The coverage of these bones is formed by a thin layer of soft tissue, by integuments and tendons, and lacks a complete muscle girdle that can provide mechanical coverage and vasculature [5–7]. The, poorly vascularised tissue covering these areas, mostly suffer the traumatic insult and therefore badly support the ischemic damage due to surgical ⁎
access, especially if the tissue edema is substantial [8]. Open reduction and internal fixation involve the use of internal fixation devices necessary to stabilize the fracture for a period of time sufficient to allow the consolidation of the bone [9]. In these patients, the fixation device is a foreign body which creates ideal conditions for bacterial contamination. In addition, implants can provide an inert surface prone to induce bacterial adhesion and biofilm production. Previous studies have confirmed that the foreign bodies can complicate effective treatment of infections [10]. As for the infection pathogenesis associated to means of synthesis, these are usually caused by microorganisms growing in biofilms, a strongly hydrated extracellular matrix, which adheres to the surface of implants and fixation devices [11].
Corresponding author at: Piazzale Morandi, 6 (20161), Milan, Italy. E-mail addresses: [email protected] (G. Ieropoli), [email protected] (J.H. Villafañe), [email protected] (S.C. Zompi), [email protected] (U. Morozzo), [email protected] (R. D’Ambrosi), [email protected] (F.G. Usuelli), [email protected] (P. Berjano). http://dx.doi.org/10.1016/j.foot.2017.10.001 Received 8 April 2017; Received in revised form 7 August 2017; Accepted 19 October 2017 0958-2592/ © 2017 Elsevier Ltd. All rights reserved.
The Foot 33 (2017) 44–47
G. Ieropoli et al.
2.2. Intervention
Biofilms grow slowly and can resist a cellular and humoral immune response, and there are different mechanisms to make the bacteria within the biofilm less sensitive to antimicrobial agents: bacterial adhesion and the low rate of bacterial growth [12]. Bacteria present in biofilm resist antibiotic therapy by two mechanisms, the inability of microbial agents to penetrate the biofilm and the presence of a bacterial population that remains in a stationary phase of growth. The elimination of metabolic substances and/or accumulation of waste products in the biofilm causes those microbes to enter into an adynamic state that makes them become 1000 times more resistant to antimicrobial agents compared to their counterparts which do not form parts of a biofilm [13,14]. Infections after internal fixation are classified into early (less than 2 weeks), delayed (2–10 weeks) and late onset (over 10 weeks) [15]. For these reasons, the presence of a foreign body leads to a significant increase of the rate of infection. Soft tissue management, in these cases, is generally oriented to the early removal of fixation devices in order to treat the underlying infection; if bone healing is not reached, serious complications from an orthopedic and rehabilitation point of view may arise. The aim of the current study is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to eradicate infection in patients with tibial pilon or calcaneus fractures.
2.2.1. Surgical technique 2.2.1.1. Pilon fractures. The synthesis of the fibula returns to the correct length at the ankle and provides stability to the synthesis, and it is considered basic if the fibular fracture is at the same level of the tibial fracture. In both cases we performed first fibula reduction and synthesis due to the type of fracture [17]. The plate osteosynthesis of fibula, if deemed necessary, was performed with standard open. In one case of severely comminuted fracture, a LCP 3.5. mm plate, following the principles of MIPO, was used, trying to exclusively reestablish length and alignment. 2.2.1.1.1. Osteosynthesis of the tibia. The choice of fixation for the tibia was based on the typology of the fracture in accordance with AO principles. In comminuted fractures, the fixation was performed with elastic “bridging” technique aiming to a closed fracture alignment and fixation with a 4.5 mm LCP or 3.5–4.5 mm metaphyseal plate, percutaneously. In case of single fractures, a limited access to the fracture site is preferred, in order to place 4.5-mm screws for interfragmentary compression, followed by buttressing with a 4.5 mm LCP or metaphyseal plate, percutaneously inserted [17]. In all cases, closed reduction and minimally antero-medial access were performed. 2.2.1.2. Calcaneus fractures. The calcaneal fracture has been treated with a LCP plate inserted through a minimally invasive lateral approach [16]. 2.2.1.2.1. Treatment of infection. Topical wound treatment was performed as a first step. When it was needed, surgical treatment of the wound was considered. Medical therapy includes measures to maintain a moist environment, reduce infections, pain management, and remove the necrotic material [18]. For these reasons, daily wound care was required for a variable period of time, determined by the site and the extent of the surgical dehiscence injury and the patient’s clinical situation. The choice of antimicrobial agents to reduce or eradicate microorganisms, was made based on the specificity and effectiveness of the agent, its cytotoxicity to human cells, its potential to select resistant strains and its allergenicity. The variety of topical antimicrobials used were chlorhexidine, products containing iodine (cadexomer iodine and povidone iodine) and products made of silver (silver sulfadiazine and silver-impregnated dressings) [19]. Simultaneously, a systemic antibiotic therapy was initiated. The choice of antibiotic was dictated by the result of antibiograms made on every patient. Antibiogram was negative for one patient. See Table 2. Duration of antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. Depending on the situation of the wound and the production of exudate, different dressings were used, consisting of polyurethane sponges for topical use [20,21] which are used in advanced dressings associated with silver-based solutions to create the ideal moist environment and reduce bacterial load. See Table 3. When needed careful surgical debridement was performed by a plastic surgeon [22], performed immediately after the onset of signs and symptoms of infection to avoid the potential formation of biofilms of the pathogen infecting and then the subsequent resistance to antimicrobial therapy. Debridement surgery consisted in removing all the devitalized tissue and debris. Indications for wound revision were local pain, erythema, edema, skin pain, purulent secretion serum and fever for more than 3 days greater than 38.5°.
2. Methods 2.1. Materials and methods Between July 2007 and December 2011, 11 consecutive patients, between 27 and 63 years of age (mean ± SD age: 45 ± 10 years; 27% female), with dehiscence of the surgical wound after MIPO using a Locking Compression Plate (LCP) tibial pilon or calcaneus fractures were recruited from the Department of Traumatology. Patients with type-IIIB or IIIC fractures, according to the Gustilo classification [15], with infection, with old fractures (> 4 weeks), complex pilon fractures (AO 43C3), talar fracture and pathological fractures were excluded from the study. The causes of the injuries were vehicular accidents (n = 2) and falls (n = 9). Nine patients had calcaneal fractures, and 2 of them had pilon tibial fractures. According to the AO classification, the pilon fractures were classified for one patient as AO 43B3, and for the other one as AO 43C2. The calcaneal fractures were classified according to Sanders classification: 3 were type 2A, 1 was 2B, 4 were 2C and 1 was type 3, see Table 1 [16]. Most fractures were closed and only one was exposed and classified as Gustilo type-II fractures. Six patients injured the left side. Open fractures were classified according to the Gustilo & Anderson classification [15]. The 2 patients with pilon tibial fractures had associated fractures of the distal shaft of the ipsilateral fibula (AO type 42A), which were always treated with LCP. Informed consent was obtained from all participants, and all procedures were conducted according to the Declaration of Helsinki.
Table 1 Classication of fractures. Classification of patients fractures Pilon tibial fractures 1 1
AO classification 43B3 43C2
Calcaneal fractures 3 1 4 1
Sanders classification 2A 2B 2C 3
2.3. Study protocol All subjects were treated by the multidisciplinary team formed by the orthopedic surgeon, the plastic surgeon and the infectious disease physician. Each subject underwent MIPO using for tibial pilon or calcaneal fracture. All patients had developed a documented infection of 45
The Foot 33 (2017) 44–47
G. Ieropoli et al.
Table 2 Antibiotic therapy. Pathogenic bacterium
Antibiotic
Dosage
Alpha hemolytic streptococcus Staphylococcus aureus methicillinresistant Staphylococcus aureus Staphylococcus epidermidis Staphylococcus aureus Enterobacter cloacae Enterobacter cloacae
Amoxicillin + clavulanic acid Penicillin + Ciprofloxacin + levofloxacin + rifampicin Ciprofloxacin Teicoplanin/Vancomycin Ciprofloxacin Teicoplanin + Ciprofloxacin Teicoplanin/Vancomycin
4.4 gr × 3/die e.v. Penicellina 4.8 gr die e.v + Ciprofloxacina 400 mg × 2/die e.v + Levofloxacina 1gr die e.v + Rifampicina 600 mg × 2/die 400 mg × 2/die e.v Teicoplanina 10 mg/kg/Vancomicina 1 gr × 2/die e.v Ciprofloxacina 400 mg × 2/die e.v Teicoplanina 10 mg/kg + Ciprofloxacina 400 mg Teicoplanina 10 mg/kg/Vancomicina 1 gr × 2/die e.v
gauzes alternate days, resulting in flap healing. Antibiotics were chosen according to the antibiogram (Table 2). Antibiotic therapy lasted, for every patient, from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration.
Table 3 Different therapies. Dressing
n Patients
Idrogel + Aquacell Ag (on alternate days) Idrocolloids + Aquacell Ag (on alternate days). Spray based on neomycin + gauzes vasellinate Collagen-based dressings (Prism/ PROMOGRAN) + spray based neomycin
9 patients 1 patient 1 patient For all patients when the wound bed seemed clean
4. Discussion This study investigated a multidisciplinary method for the treatment of and infected wound after MIPO for tibial pilon or calcaneal fracture and the 3-month follow-up effects of a MIPO, plastic surgery and antibiotic therapy showed a complete healing in all patients, with a return to normal daily activity. Overall, our results, are consistent with previous work by ours and others groups, showing that the bacterial adhesion on titanium is lower compared to the adhesion on steel used in conventional devices [24,25]. This element, together to the intervention of the infectious diseases specialist, with specific high-dose antibiotic therapy, and specially of plastic surgeon with the use of advanced dressings and cover with flaps, on the basis of the characteristics of dehiscence, helped maintain the synthesis devices within an optimal consolidation cure of the fracture and, in all cases, the presence of infection. All patients reported an immediate wound healing after a multidisciplinary treatment for infection, even if no conclusions can be made about orthopedic consequences such as time for consolidation, post-operative cares, return to weight-bearing and functional or clinical or radiographic outcomes, as they were not the main objective of the study. Various treatment methods have been used for distal tibia and in calcaneus fractures. Good fixation outcomes depend on bone quality, fracture complexity, and surgical techniques. In our series, the patients were relatively young, and the fractures were mainly extraarticular, which are not difficult to treat even with other fixation devices. In the past, the most adopted choice of therapy contemplated the removal of the means of synthesis to allow healing of the infection below [26]. This entailed additional surgery for the removal of the means of synthesis, possibly by applying external fixators to replace the removed plaque and the reconstruction of soft tissue compromises functionally and aesthetically [27]. MIPO has been successful in managing various fractures of the distal tibia, supracondylar femur, proximal tibia, and humeral shaft [28–30]. This thanks to a better biological fixation of the fracture, preservation of fracture haematomas, and better quality of fixation by the angular stable LCP [31]. Infection rates are higher when meta synthesis devices are used, such as in the osteosynthesis of fractures, which interacts with the surrounding soft tissues and may result in an exposure [32,33]. This may be considered a risk in a patient’s normal course of recovery, and is therefore a very serious problem, especially when it concerns the foot and ankle, where a small soft-tissue cover can easily cause a surgical wound dehiscence and therefore exposure of implants. MIPO using a LCP achieves favourable biological fixation for distal tibial and in calcaneus fractures with few complications. In our cohort of patients the removal of the synthesis device was not needed even even if we did not deal with complex fractures. Proper patient selection
the surgical wound. An advanced dressing and topical antibiotic were used, and in case this was not enough, the surgical option could have been chosen. The antibiotic treatment was preceded by antibiogram to identify the microorganisms’ sensitivity. All patients in this cohort were followed up prospectively at regular intervals by the multidisciplinary team. Radiographs were obtained at regular intervals at 40 days, and 90 days from surgical operation. At the end of 2012 final functional outcomes were assessed using the Olerud and Molander scoring system [23]. 3. Results All patients were operated on for fracture reduction and fixation with MIPO for calcaneal or pilon tibial fractures and followed by the plastic surgeon from the moment of exposure until wound closure, while the orthopedic surgeon followed patients until the consolidation of the fracture. All wounds were classified as grade III or IV according with the American College of Surgeons wound classification.The average operating time was 129 ± 32 min (range, 60–170 min). The average length of hospital stay was 15 ± 9 days (range, 3–36). The follow-up intervals were 15 days, 40 days and 3 months. The average time until wound closure was 109 ± 60 days, with a minimum and a maximum of 30–223 days, respectively. At the 3-month follow-up, 11 of the patients had good or excellent outcomes measured with Olerud and Molander scoring system [23], moreover 11 had returned to their normal activity of daily living. The entire sample of patients presented wound dehiscence after the minimally invaisve procedure (mean of 45 ± 17 days post-surgery) with the presence of local infection, diagnosed clinically with local pain, erythema, edema with a barrier to wound healing, skin pain, purulent secretion serum and fever. Ten patients underwent wound care with advanced dressings, 1 patient had coverage with a local dermal-epidermal flap (to cover a defect on the lateral malleolus). The medications that have been used were: Hydrogel + Aquacell Ag on alternate days for 9 patients. Hydrocolloids + Aquacell Ag on alternate days for 1 patient. Subsequently, 5 patients presented a fibrinous deposit covering the wound, treated with collagenase based dressings. When the patients’ wound bed appeared swabbed, collagen dressings (Prism/Promogran) were employed, together with neomycin based spray until wound healing. For 1 patient a local skin flap was required in order to level peri-lateral malleolar with a dermo-epidermal graft; he was then treated for 6 days with neomycin based spray and wet vaseline based 46
The Foot 33 (2017) 44–47
G. Ieropoli et al.
2008;121:2010–9. [11] Trampuz A, Osmon DR, Hanssen AD, Steckelberg JM, Patel R. Molecular and antibiofilm approaches to prosthetic joint infection. Clin Orthop Rel Res 2003:69–88. [12] Khoury AE, Lam K, Ellis B, Costerton JW. Prevention and control of bacterial infections associated with medical devices. ASAIO J 1992;38:M174–8. [13] Donlan RM. Biofilms: microbial life on surfaces. Emerg Infect Dis 2002;8:881–90. [14] Stewart PS, Costerton JW. Antibiotic resistance of bacteria in biofilms. Lancet 2001;358:135–8. [15] Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am Vol 1990;72:299–304. [16] Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Rel Res 1993:87–95. [17] Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of internal fixation. 3rd ed. 1991. [18] Doughty DB. Preventing and managing surgical wound dehiscence. Adv Skin Wound Care 2005;18:319–22. [19] Wihlborg O. The effect of washing with chlorhexidine soap on wound infection rate in general surgery: a controlled clinical study. Ann Chir Gynaecol 1987;76:263–5. [20] Dumville JC, Walter CJ, Sharp CA, Page T. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev 2011;7. CD003091. [21] Palfreyman S, Nelson EA, Michaels JA. Dressings for venous leg ulcers: systematic review and meta-analysis. BMJ 2007;335:244. [22] Chambers L, Woodrow S, Brown AP, Harris PD, Phillips D, Hall M, et al. Degradation of extracellular matrix components by defined proteinases from the greenbottle larva Lucilia sericata used for the clinical debridement of non-healing wounds. Br J Dermatol 2003;148:14–23. [23] Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch Orthop Trauma Surg 1984;103:190–4. [24] Metsemakers WJ, Schmid T, Zeiter S, Ernst M, Keller I, Cosmelli N, et al. Titanium and steel fracture fixation plates with different surface topographies: influence on infection rate in a rabbit fracture model. Injury 2016;47:633–9. [25] Ribeiro M, Monteiro FJ, Ferraz MP. Infection of orthopedic implants with emphasis on bacterial adhesion process and techniques used in studying bacterial–material interactions. Biomatter 2012;2:176–94. [26] Budny PJ, Fix RJ. Salvage of prosthetic grafts and joints in the lower extremity. Clin Plast Surg 1991;18:583–91. [27] Nieminen H, Kuokkanen H, Tukiainen E, Asko-Seljavaara S. Free flap reconstructions of tibial fractures complicated after internal fixation. J Trauma 1995;38:660–4. [28] Zhiquan A, Bingfang Z, Yeming W, Chi Z, Peiyan H. Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures. J Orthop Trauma 2007;21:628–33. [29] Apivatthakakul T, Arpornchayanon O, Bavornratanavech S. Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report. Injury 2005;36:530–8. [30] Cole PA, Miclau 3rd T, Ly TV, Switzer JA, Li M, Morgan RA, et al. What's new in orthopaedic trauma. J Bone Joint Surg Am Vol 2008;90:2804–22. [31] Bottlang M, Doornink J, Lujan TJ, Fitzpatrick DC, Marsh JL, Augat P, et al. Effects of construct stiffness on healing of fractures stabilized with locking plates. J Bone Joint Surg Am Vol 2010;92(Suppl. 2):12–22. [32] Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004;350:1422–9. [33] Murray CK. Infectious disease complications of combat-related injuries. Crit Care Med 2008;36:S358–64.
and preoperative planning are essential to prevent complications. The limitations of our study were a small cohort, relatively few complex fracture patterns, the absence of a control group, wide variability of fracture pattern, lack of homogeneity in patients’ population and follow-up period. 5. Conclusion The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisciplinary treatment in association with titanium devices are able to eradicate infection in a short time. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Lau TW, Leung F, Chan CF, Chow SP. Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Int Orthop 2008;32:697–703. [2] Usuelli FG, D'Ambrosi R, Maccario C, Boga M, de Girolamo L. All-arthroscopic AMIC(R) (AT-AMIC(R)) technique with autologous bone graft for talar osteochondral defects: clinical and radiological results. Knee Surg Sports Traumatol Arthrosc 2016. Epub ahead of print. [3] Clare MP, Crawford WS. Managing complications of calcaneus fractures. Foot Ankle Clin 2017;22:105–16. [4] Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Deutsches Arzteblatt Int 2014;111:377–88. [5] D'Ambrosi R, Maccario C, Serra N, Liuni F, Usuelli FG. Osteochondral lesions of the talus and autologous matrix-induced chondrogenesis: is age a negative predictor outcome? Arthroscopy 2017;33:428–35. [6] D'Ambrosi R, Maccario C, Ursino C, Serra N, Usuelli FG. Combining microfractures autologous bone graft, and autologous matrix-induced chondrogenesis for the treatment of juvenile osteochondral talar lesions. Foot Ankle Int 2017. http://dx. doi.org/10.1177/1071100716687367. Epub ahead of print. [7] Guelfi M, Pantalone A, Mirapeix RM, Vanni D, Usuelli FG, Guelfi M, et al. Anatomy, pathophysiology and classification of posterior tibial tendon dysfunction. Eur Rev Med Pharmacol Sci 2017;21:13–9. [8] Borrelli Jr. J, Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma 2002;16:691–5. [9] Malerba F, Benedetti MG, Usuelli FG, Milani R, Berti L, Champlon C, et al. Functional and clinical assessment of two ankle arthrodesis techniques. J Foot Ankle Surg 2015;54:399–405. [10] Ulusal AE, Lin CH, Lin YT, Ulusal BG, Yazar S. The use of free flaps in the management of type IIIB open calcaneal fractures. Plast Reconstr Surg
47
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics
MARK
⁎
Giandavide Ieropolia, Jorge Hugo Villafañeb, , Silvia Chiara Zompic, Umberto Morozzod, Riccardo D’Ambrosie, Federico Giuseppe Usuellie, Pedro Berjanoe a
Istituto Ferrero, Alba, Italy IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy Medicina dello Sport, Turin, Italy d Ospedale San Lazzaro, Turin, Italy e IRCCS Istituto Ortopedico Galeazzi, Milan, Italy b c
A R T I C L E I N F O
A B S T R A C T
Keywords: Osteosynthesis Fractures Foot Tibial pilon Calcaneaus Minimally invasive plate osteosynthesis Infected wound
Objective: The aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures. Methods: Eleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months. Results: The average time of wound closure was 109 ± 60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4–6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living. Conclusion: The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time.
1. Introduction Soft tissues around the distal lower limb (distal leg, ankle and heel) are easily compromised by trauma and subsequent operative fracture treatment; in tibial pilon fractures this rate is about 2%, while in calcaneus fractures this percentage can still occur in up to 25% of patients [1–4]. The coverage of these bones is formed by a thin layer of soft tissue, by integuments and tendons, and lacks a complete muscle girdle that can provide mechanical coverage and vasculature [5–7]. The, poorly vascularised tissue covering these areas, mostly suffer the traumatic insult and therefore badly support the ischemic damage due to surgical ⁎
access, especially if the tissue edema is substantial [8]. Open reduction and internal fixation involve the use of internal fixation devices necessary to stabilize the fracture for a period of time sufficient to allow the consolidation of the bone [9]. In these patients, the fixation device is a foreign body which creates ideal conditions for bacterial contamination. In addition, implants can provide an inert surface prone to induce bacterial adhesion and biofilm production. Previous studies have confirmed that the foreign bodies can complicate effective treatment of infections [10]. As for the infection pathogenesis associated to means of synthesis, these are usually caused by microorganisms growing in biofilms, a strongly hydrated extracellular matrix, which adheres to the surface of implants and fixation devices [11].
Corresponding author at: Piazzale Morandi, 6 (20161), Milan, Italy. E-mail addresses: [email protected] (G. Ieropoli), [email protected] (J.H. Villafañe), [email protected] (S.C. Zompi), [email protected] (U. Morozzo), [email protected] (R. D’Ambrosi), [email protected] (F.G. Usuelli), [email protected] (P. Berjano). http://dx.doi.org/10.1016/j.foot.2017.10.001 Received 8 April 2017; Received in revised form 7 August 2017; Accepted 19 October 2017 0958-2592/ © 2017 Elsevier Ltd. All rights reserved.
The Foot 33 (2017) 44–47
G. Ieropoli et al.
2.2. Intervention
Biofilms grow slowly and can resist a cellular and humoral immune response, and there are different mechanisms to make the bacteria within the biofilm less sensitive to antimicrobial agents: bacterial adhesion and the low rate of bacterial growth [12]. Bacteria present in biofilm resist antibiotic therapy by two mechanisms, the inability of microbial agents to penetrate the biofilm and the presence of a bacterial population that remains in a stationary phase of growth. The elimination of metabolic substances and/or accumulation of waste products in the biofilm causes those microbes to enter into an adynamic state that makes them become 1000 times more resistant to antimicrobial agents compared to their counterparts which do not form parts of a biofilm [13,14]. Infections after internal fixation are classified into early (less than 2 weeks), delayed (2–10 weeks) and late onset (over 10 weeks) [15]. For these reasons, the presence of a foreign body leads to a significant increase of the rate of infection. Soft tissue management, in these cases, is generally oriented to the early removal of fixation devices in order to treat the underlying infection; if bone healing is not reached, serious complications from an orthopedic and rehabilitation point of view may arise. The aim of the current study is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to eradicate infection in patients with tibial pilon or calcaneus fractures.
2.2.1. Surgical technique 2.2.1.1. Pilon fractures. The synthesis of the fibula returns to the correct length at the ankle and provides stability to the synthesis, and it is considered basic if the fibular fracture is at the same level of the tibial fracture. In both cases we performed first fibula reduction and synthesis due to the type of fracture [17]. The plate osteosynthesis of fibula, if deemed necessary, was performed with standard open. In one case of severely comminuted fracture, a LCP 3.5. mm plate, following the principles of MIPO, was used, trying to exclusively reestablish length and alignment. 2.2.1.1.1. Osteosynthesis of the tibia. The choice of fixation for the tibia was based on the typology of the fracture in accordance with AO principles. In comminuted fractures, the fixation was performed with elastic “bridging” technique aiming to a closed fracture alignment and fixation with a 4.5 mm LCP or 3.5–4.5 mm metaphyseal plate, percutaneously. In case of single fractures, a limited access to the fracture site is preferred, in order to place 4.5-mm screws for interfragmentary compression, followed by buttressing with a 4.5 mm LCP or metaphyseal plate, percutaneously inserted [17]. In all cases, closed reduction and minimally antero-medial access were performed. 2.2.1.2. Calcaneus fractures. The calcaneal fracture has been treated with a LCP plate inserted through a minimally invasive lateral approach [16]. 2.2.1.2.1. Treatment of infection. Topical wound treatment was performed as a first step. When it was needed, surgical treatment of the wound was considered. Medical therapy includes measures to maintain a moist environment, reduce infections, pain management, and remove the necrotic material [18]. For these reasons, daily wound care was required for a variable period of time, determined by the site and the extent of the surgical dehiscence injury and the patient’s clinical situation. The choice of antimicrobial agents to reduce or eradicate microorganisms, was made based on the specificity and effectiveness of the agent, its cytotoxicity to human cells, its potential to select resistant strains and its allergenicity. The variety of topical antimicrobials used were chlorhexidine, products containing iodine (cadexomer iodine and povidone iodine) and products made of silver (silver sulfadiazine and silver-impregnated dressings) [19]. Simultaneously, a systemic antibiotic therapy was initiated. The choice of antibiotic was dictated by the result of antibiograms made on every patient. Antibiogram was negative for one patient. See Table 2. Duration of antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. Depending on the situation of the wound and the production of exudate, different dressings were used, consisting of polyurethane sponges for topical use [20,21] which are used in advanced dressings associated with silver-based solutions to create the ideal moist environment and reduce bacterial load. See Table 3. When needed careful surgical debridement was performed by a plastic surgeon [22], performed immediately after the onset of signs and symptoms of infection to avoid the potential formation of biofilms of the pathogen infecting and then the subsequent resistance to antimicrobial therapy. Debridement surgery consisted in removing all the devitalized tissue and debris. Indications for wound revision were local pain, erythema, edema, skin pain, purulent secretion serum and fever for more than 3 days greater than 38.5°.
2. Methods 2.1. Materials and methods Between July 2007 and December 2011, 11 consecutive patients, between 27 and 63 years of age (mean ± SD age: 45 ± 10 years; 27% female), with dehiscence of the surgical wound after MIPO using a Locking Compression Plate (LCP) tibial pilon or calcaneus fractures were recruited from the Department of Traumatology. Patients with type-IIIB or IIIC fractures, according to the Gustilo classification [15], with infection, with old fractures (> 4 weeks), complex pilon fractures (AO 43C3), talar fracture and pathological fractures were excluded from the study. The causes of the injuries were vehicular accidents (n = 2) and falls (n = 9). Nine patients had calcaneal fractures, and 2 of them had pilon tibial fractures. According to the AO classification, the pilon fractures were classified for one patient as AO 43B3, and for the other one as AO 43C2. The calcaneal fractures were classified according to Sanders classification: 3 were type 2A, 1 was 2B, 4 were 2C and 1 was type 3, see Table 1 [16]. Most fractures were closed and only one was exposed and classified as Gustilo type-II fractures. Six patients injured the left side. Open fractures were classified according to the Gustilo & Anderson classification [15]. The 2 patients with pilon tibial fractures had associated fractures of the distal shaft of the ipsilateral fibula (AO type 42A), which were always treated with LCP. Informed consent was obtained from all participants, and all procedures were conducted according to the Declaration of Helsinki.
Table 1 Classication of fractures. Classification of patients fractures Pilon tibial fractures 1 1
AO classification 43B3 43C2
Calcaneal fractures 3 1 4 1
Sanders classification 2A 2B 2C 3
2.3. Study protocol All subjects were treated by the multidisciplinary team formed by the orthopedic surgeon, the plastic surgeon and the infectious disease physician. Each subject underwent MIPO using for tibial pilon or calcaneal fracture. All patients had developed a documented infection of 45
The Foot 33 (2017) 44–47
G. Ieropoli et al.
Table 2 Antibiotic therapy. Pathogenic bacterium
Antibiotic
Dosage
Alpha hemolytic streptococcus Staphylococcus aureus methicillinresistant Staphylococcus aureus Staphylococcus epidermidis Staphylococcus aureus Enterobacter cloacae Enterobacter cloacae
Amoxicillin + clavulanic acid Penicillin + Ciprofloxacin + levofloxacin + rifampicin Ciprofloxacin Teicoplanin/Vancomycin Ciprofloxacin Teicoplanin + Ciprofloxacin Teicoplanin/Vancomycin
4.4 gr × 3/die e.v. Penicellina 4.8 gr die e.v + Ciprofloxacina 400 mg × 2/die e.v + Levofloxacina 1gr die e.v + Rifampicina 600 mg × 2/die 400 mg × 2/die e.v Teicoplanina 10 mg/kg/Vancomicina 1 gr × 2/die e.v Ciprofloxacina 400 mg × 2/die e.v Teicoplanina 10 mg/kg + Ciprofloxacina 400 mg Teicoplanina 10 mg/kg/Vancomicina 1 gr × 2/die e.v
gauzes alternate days, resulting in flap healing. Antibiotics were chosen according to the antibiogram (Table 2). Antibiotic therapy lasted, for every patient, from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration.
Table 3 Different therapies. Dressing
n Patients
Idrogel + Aquacell Ag (on alternate days) Idrocolloids + Aquacell Ag (on alternate days). Spray based on neomycin + gauzes vasellinate Collagen-based dressings (Prism/ PROMOGRAN) + spray based neomycin
9 patients 1 patient 1 patient For all patients when the wound bed seemed clean
4. Discussion This study investigated a multidisciplinary method for the treatment of and infected wound after MIPO for tibial pilon or calcaneal fracture and the 3-month follow-up effects of a MIPO, plastic surgery and antibiotic therapy showed a complete healing in all patients, with a return to normal daily activity. Overall, our results, are consistent with previous work by ours and others groups, showing that the bacterial adhesion on titanium is lower compared to the adhesion on steel used in conventional devices [24,25]. This element, together to the intervention of the infectious diseases specialist, with specific high-dose antibiotic therapy, and specially of plastic surgeon with the use of advanced dressings and cover with flaps, on the basis of the characteristics of dehiscence, helped maintain the synthesis devices within an optimal consolidation cure of the fracture and, in all cases, the presence of infection. All patients reported an immediate wound healing after a multidisciplinary treatment for infection, even if no conclusions can be made about orthopedic consequences such as time for consolidation, post-operative cares, return to weight-bearing and functional or clinical or radiographic outcomes, as they were not the main objective of the study. Various treatment methods have been used for distal tibia and in calcaneus fractures. Good fixation outcomes depend on bone quality, fracture complexity, and surgical techniques. In our series, the patients were relatively young, and the fractures were mainly extraarticular, which are not difficult to treat even with other fixation devices. In the past, the most adopted choice of therapy contemplated the removal of the means of synthesis to allow healing of the infection below [26]. This entailed additional surgery for the removal of the means of synthesis, possibly by applying external fixators to replace the removed plaque and the reconstruction of soft tissue compromises functionally and aesthetically [27]. MIPO has been successful in managing various fractures of the distal tibia, supracondylar femur, proximal tibia, and humeral shaft [28–30]. This thanks to a better biological fixation of the fracture, preservation of fracture haematomas, and better quality of fixation by the angular stable LCP [31]. Infection rates are higher when meta synthesis devices are used, such as in the osteosynthesis of fractures, which interacts with the surrounding soft tissues and may result in an exposure [32,33]. This may be considered a risk in a patient’s normal course of recovery, and is therefore a very serious problem, especially when it concerns the foot and ankle, where a small soft-tissue cover can easily cause a surgical wound dehiscence and therefore exposure of implants. MIPO using a LCP achieves favourable biological fixation for distal tibial and in calcaneus fractures with few complications. In our cohort of patients the removal of the synthesis device was not needed even even if we did not deal with complex fractures. Proper patient selection
the surgical wound. An advanced dressing and topical antibiotic were used, and in case this was not enough, the surgical option could have been chosen. The antibiotic treatment was preceded by antibiogram to identify the microorganisms’ sensitivity. All patients in this cohort were followed up prospectively at regular intervals by the multidisciplinary team. Radiographs were obtained at regular intervals at 40 days, and 90 days from surgical operation. At the end of 2012 final functional outcomes were assessed using the Olerud and Molander scoring system [23]. 3. Results All patients were operated on for fracture reduction and fixation with MIPO for calcaneal or pilon tibial fractures and followed by the plastic surgeon from the moment of exposure until wound closure, while the orthopedic surgeon followed patients until the consolidation of the fracture. All wounds were classified as grade III or IV according with the American College of Surgeons wound classification.The average operating time was 129 ± 32 min (range, 60–170 min). The average length of hospital stay was 15 ± 9 days (range, 3–36). The follow-up intervals were 15 days, 40 days and 3 months. The average time until wound closure was 109 ± 60 days, with a minimum and a maximum of 30–223 days, respectively. At the 3-month follow-up, 11 of the patients had good or excellent outcomes measured with Olerud and Molander scoring system [23], moreover 11 had returned to their normal activity of daily living. The entire sample of patients presented wound dehiscence after the minimally invaisve procedure (mean of 45 ± 17 days post-surgery) with the presence of local infection, diagnosed clinically with local pain, erythema, edema with a barrier to wound healing, skin pain, purulent secretion serum and fever. Ten patients underwent wound care with advanced dressings, 1 patient had coverage with a local dermal-epidermal flap (to cover a defect on the lateral malleolus). The medications that have been used were: Hydrogel + Aquacell Ag on alternate days for 9 patients. Hydrocolloids + Aquacell Ag on alternate days for 1 patient. Subsequently, 5 patients presented a fibrinous deposit covering the wound, treated with collagenase based dressings. When the patients’ wound bed appeared swabbed, collagen dressings (Prism/Promogran) were employed, together with neomycin based spray until wound healing. For 1 patient a local skin flap was required in order to level peri-lateral malleolar with a dermo-epidermal graft; he was then treated for 6 days with neomycin based spray and wet vaseline based 46
The Foot 33 (2017) 44–47
G. Ieropoli et al.
2008;121:2010–9. [11] Trampuz A, Osmon DR, Hanssen AD, Steckelberg JM, Patel R. Molecular and antibiofilm approaches to prosthetic joint infection. Clin Orthop Rel Res 2003:69–88. [12] Khoury AE, Lam K, Ellis B, Costerton JW. Prevention and control of bacterial infections associated with medical devices. ASAIO J 1992;38:M174–8. [13] Donlan RM. Biofilms: microbial life on surfaces. Emerg Infect Dis 2002;8:881–90. [14] Stewart PS, Costerton JW. Antibiotic resistance of bacteria in biofilms. Lancet 2001;358:135–8. [15] Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am Vol 1990;72:299–304. [16] Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Rel Res 1993:87–95. [17] Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of internal fixation. 3rd ed. 1991. [18] Doughty DB. Preventing and managing surgical wound dehiscence. Adv Skin Wound Care 2005;18:319–22. [19] Wihlborg O. The effect of washing with chlorhexidine soap on wound infection rate in general surgery: a controlled clinical study. Ann Chir Gynaecol 1987;76:263–5. [20] Dumville JC, Walter CJ, Sharp CA, Page T. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev 2011;7. CD003091. [21] Palfreyman S, Nelson EA, Michaels JA. Dressings for venous leg ulcers: systematic review and meta-analysis. BMJ 2007;335:244. [22] Chambers L, Woodrow S, Brown AP, Harris PD, Phillips D, Hall M, et al. Degradation of extracellular matrix components by defined proteinases from the greenbottle larva Lucilia sericata used for the clinical debridement of non-healing wounds. Br J Dermatol 2003;148:14–23. [23] Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch Orthop Trauma Surg 1984;103:190–4. [24] Metsemakers WJ, Schmid T, Zeiter S, Ernst M, Keller I, Cosmelli N, et al. Titanium and steel fracture fixation plates with different surface topographies: influence on infection rate in a rabbit fracture model. Injury 2016;47:633–9. [25] Ribeiro M, Monteiro FJ, Ferraz MP. Infection of orthopedic implants with emphasis on bacterial adhesion process and techniques used in studying bacterial–material interactions. Biomatter 2012;2:176–94. [26] Budny PJ, Fix RJ. Salvage of prosthetic grafts and joints in the lower extremity. Clin Plast Surg 1991;18:583–91. [27] Nieminen H, Kuokkanen H, Tukiainen E, Asko-Seljavaara S. Free flap reconstructions of tibial fractures complicated after internal fixation. J Trauma 1995;38:660–4. [28] Zhiquan A, Bingfang Z, Yeming W, Chi Z, Peiyan H. Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures. J Orthop Trauma 2007;21:628–33. [29] Apivatthakakul T, Arpornchayanon O, Bavornratanavech S. Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report. Injury 2005;36:530–8. [30] Cole PA, Miclau 3rd T, Ly TV, Switzer JA, Li M, Morgan RA, et al. What's new in orthopaedic trauma. J Bone Joint Surg Am Vol 2008;90:2804–22. [31] Bottlang M, Doornink J, Lujan TJ, Fitzpatrick DC, Marsh JL, Augat P, et al. Effects of construct stiffness on healing of fractures stabilized with locking plates. J Bone Joint Surg Am Vol 2010;92(Suppl. 2):12–22. [32] Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004;350:1422–9. [33] Murray CK. Infectious disease complications of combat-related injuries. Crit Care Med 2008;36:S358–64.
and preoperative planning are essential to prevent complications. The limitations of our study were a small cohort, relatively few complex fracture patterns, the absence of a control group, wide variability of fracture pattern, lack of homogeneity in patients’ population and follow-up period. 5. Conclusion The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisciplinary treatment in association with titanium devices are able to eradicate infection in a short time. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Lau TW, Leung F, Chan CF, Chow SP. Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Int Orthop 2008;32:697–703. [2] Usuelli FG, D'Ambrosi R, Maccario C, Boga M, de Girolamo L. All-arthroscopic AMIC(R) (AT-AMIC(R)) technique with autologous bone graft for talar osteochondral defects: clinical and radiological results. Knee Surg Sports Traumatol Arthrosc 2016. Epub ahead of print. [3] Clare MP, Crawford WS. Managing complications of calcaneus fractures. Foot Ankle Clin 2017;22:105–16. [4] Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Deutsches Arzteblatt Int 2014;111:377–88. [5] D'Ambrosi R, Maccario C, Serra N, Liuni F, Usuelli FG. Osteochondral lesions of the talus and autologous matrix-induced chondrogenesis: is age a negative predictor outcome? Arthroscopy 2017;33:428–35. [6] D'Ambrosi R, Maccario C, Ursino C, Serra N, Usuelli FG. Combining microfractures autologous bone graft, and autologous matrix-induced chondrogenesis for the treatment of juvenile osteochondral talar lesions. Foot Ankle Int 2017. http://dx. doi.org/10.1177/1071100716687367. Epub ahead of print. [7] Guelfi M, Pantalone A, Mirapeix RM, Vanni D, Usuelli FG, Guelfi M, et al. Anatomy, pathophysiology and classification of posterior tibial tendon dysfunction. Eur Rev Med Pharmacol Sci 2017;21:13–9. [8] Borrelli Jr. J, Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma 2002;16:691–5. [9] Malerba F, Benedetti MG, Usuelli FG, Milani R, Berti L, Champlon C, et al. Functional and clinical assessment of two ankle arthrodesis techniques. J Foot Ankle Surg 2015;54:399–405. [10] Ulusal AE, Lin CH, Lin YT, Ulusal BG, Yazar S. The use of free flaps in the management of type IIIB open calcaneal fractures. Plast Reconstr Surg
47