J Oral Maxillofac Surg50:434·443, 1992

Rigid Internal Fixation for the Treatmentof Infected Mandibular Fractures

MICHAEL KOURY, DDS,* AND EDWARD ELLIS III, DDS, MSt

A review of the literature is presented that shows that treatment of infectedfractures by rigid internal fixation is biologically sound. A protocol for managinginfected mandibular fractures with plate and screw fixation was developed andused on 11 patients. All patients had osseous union of the fracture and nonerequired removal of the bone plate. This protocol is recommended as a viableoption in the treatment of infected mandibular fractures.

Infected mandibular fractures are common in sur­gical practice because many individuals who sustainfacial trauma fail to seek immediate treatment. Onpresentation, the patient poses a greater problem whenthere is a coexisting infection at the fracture site. Tra­ditionally, such fractures have been treated with max­iIIomandibular (MMF) or external fixation.I However,with the increasing interest in plate and screw fixationin the United States.over the past decade, new methodsoftreating infected mandibular fractures have been de­veloped. Rigid internal fixation offers many advantagesto the patient, including no MMF. In spite ofthe grow­ing interest, most surgeons still.believe that I) metalshould not be used in contaminated wounds'? and 2)once an infection develops in a internally stabilizedfracture, the metal must be removed before resolutionof the infection can occur.6-8 However, others believethat such materials do not need to be removed frominfected sites if rigidity is maintained.v!' Rigid internalfixation has even been called the superior treatmentfor infected mandible fractures. 14

When treating infected mandibular fractures, twogoals exist: 1) resolution of the infection and 2)achievement of bony union. Those advocating MMFor external fixation believe elimination ofthe infectionmust occur before bone union occurs. Those using in-

Received from the Division of Oral and Maxillofacial Surgery,The University ofTexas Southwestern Medical Center, Dallas.

• Resident.t Associate Professor.Address correspondence and reprint requests to Dr Ellis: Division

of Oral and Maxillofacial Surgery, The University of Texas South­western Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235­9031.

© 1992American Association of Oral and Maxillofacial Surgeons0278-2391/92/5005-0002$3.00/0

434

ternal fixation believe that the best manner to eliminatethe infection is to rigidly immobilize the segments andthat, by doing so, bony union will occur irrespectiveof whether an infection is present. Thus, a dichotomyexists in the treatment of such fractures.

When deciding whether to treat a fracture with plateand screw osteosynthesis, the clinician must weigh therisk of exposing the fracture site and placing a plateagainst the benefits ofabsolute rigidity. In the past twodecades, research has provided much informationabout this dispute. To answer the questions about theviability of the treatment options, a review of the bio­logical research is necessary.

Foreign-Body Effect of Implant

In orthopedics and oral and maxillofacial surgery,many have emphasized the "foreign-body effect" of ametal implant.7,10,15 Difficulty exists in accurately de­termining the biological influence of a foreign body,because when an implant is placed, surgical trauma isinevitably inflicted. If an infection then develops, it isdifficult to determine whether the implant or the sur­gical trauma and contamination caused the infection.

Implants Placed Into Clean Wounds

The closest approximation ofthe risk assumed solelyby the addition ofan implant to the body is seen whenplacement occurs with minimal soft tissue and vasculartrauma during a sterile elective procedure. Such is thecase with prosthetic joint replacement. Insall et al re­ported three deep infections in 220 arthroplasties fortotal knee replacements." Similarly, Kaufer and Mat­thews reported three deep infections in 373 total kneereplacements.'? Other orthopedic studies have yieldedsimilar rates of infections when implants are placed

KOURY AND ELLIS

into sterile atraumatic wounds.P:'? showing an ex­tremely low incidence of infection under these con­ditions, in spite of the fact that these implants moveunder function.

In cases of closed long-bone fractures, the infectionrate is not appreciably greater with internal fixationthan with closed reduction. For example, Burri,'? Ole­rod and Karlstrorn." and Allgower" reported infectionrates in closed fractures of 0.18% in 744, l.l% in 91,and 1.4% in 720 fractures, respectively. Comparablerates ofinfection have also been shown between closedtechniques and blind intramedullary nailing.22,23

Implants Placed Into Contaminated Wounds

A difference in the rate ofinfection between implantsplaced in clean and in contaminated wounds was dem­onstrated by Rittmann et al.24 Open and closed tibialfractures were treated with open reduction and internalfixation with compression plates. He found a 1.8% in­fection rate in the closed (noncontaminated) fracturesand a 6.3% in the open (contaminated) fractures. Like­wise, Burri, in a study of 744 fractures, reported aninfection rate of 0.18% in closed and 2.7% in openfractures treated with internal fixation.'? Towers alsonoted an increased rate of infection in open (contam­inated) fractures and believed fewer bacteria wereneeded to produce clinical infection with metal implantplacement."

The body may have difficulty with bacteria in thepresence ofimplants because biomaterials are a suitablesubstrata for their growth." Removal of fixation ap­pliances from infected wounds unresponsive to anti­biotics has revealed bacterial colonization on their sur­face.26 A bacterial biofilm has also been shown onorthopedic implants." This surface slime, or glycolax,is made from carbohydrates of the bacterial cell wall"and is believed to increase the incidence of infection,to provide a barrier to macrophage and antibiotic pen­etration, as well as to prohibit the culturability of thesebacteria.P Also, spread of bacteria down nonreactivebiomaterials into noncolonized areas has beenshown.29,3o In effect, biomaterials alter the body's de­fense and provide a surface for bacterial adherence andcolonization."

Thus, there is a difference in the rates of infectionbetween placing implants in closed (clean) and in open(contaminated) fractures. A comparison must be made,however, between the use of internal fixation devicesand not using them when treating contaminated (open)fractures. In other words, when a contaminated fracturerequires open reduction, does the use of implants alterthe rate of infection? Answering this question allowsone to weigh the risk of the foreign body versus thebenefit of stabilization of the bony fragments and thesoft-tissue bed in the presence of bacteria.

435

Varying results have been found in comparativestudies. Most studies in the orthopedic literature thathave been performed over the past 30 years show thatwhen similar injuries are compared, no major differ­ences in the rate of infection are found between thosetreated with open reduction with or without internalfixation devices. 31•36 Although some studies have shownincreased rates of infection for open (contaminated)fractures treated with internal fixation when comparedwith open reduction without internal fixation, most ofthese used internal fixation in wounds where the bloodsupply was greatly disturbed.F:"

Soft-tissue injury has been shown to be a primaryfactor in infection rates with internal fixation of con­taminated fractures. Chapman and Mahoney showeda 1.9% infection rate with mild soft-tissue trauma, 8%with moderate trauma, and 41% in severe soft-tissuetrauma of open fractures." Edwards similarly dem­onstrated this point and showed the infection rate ofinternally fixed fractures could be greatly reduced bynot extending the wound when placing the fixation."In dogs, he also found a decrease in the incidence ofosteomyelitis when no soft-tissue damage was producedwhen similar bony fractures were created. These studiesmay indicate that once contaminated, a fracture treatedwith open reduction may be better offwith an internalfixation device as long as the vasculature and soft-tissuebed is not significantly jeopardized by the additionalsurgical exposure during implant placement.

Overall, the fractured mandible should be very sus­ceptible to infection because of their great tendency tobe of the open variety. Mucosal tears and fracturesextending through the periodontal ligament producecontamination of the fracture by the oral flora. 12 Mostfractures that occur through the tooth-bearing area cantherefore be regarded as contaminated. Further, sur­gical intervention through the poorly cleanable oralcavity further contaminates the wound. Of interest,however, is the finding that a foreign body firmly at­tached to bone does not greatly increase the danger ofinfection in the mandible.F:" In fact, Luhr et al foundfewer infections using an intraoral approach (3.2% in­fection) to place fixation devices than when using theextraoral approach (5.6%).42 The explanation for thesefindings is not clear, but P9ssibly rests with the lushvascularity in the maxillofacial region.

Effect of Mobility on Infection

Internal fixation has been called the superior treat­ment for infected mandibular fractures," partly be­cause the biological reaction to mechanical influencesplays an important role in local infection.P Manystudies have shown that instability promotes infection,and stability helps prevent it.9, 11. 13, 19,44-46 Friedrich andKlaue showed a correlation between the presence of

436 RIGID INTERNAL FIXATION FOR INFECTED MANDIBULAR FRACTURES

osteitis and lack of rigidity in rabbit long-bone fracturesby injecting staphylococcus aureus into rigidly or non­rigidly fixed sites.'? The group of mobile fractureswithout bacterial infection did not become infected,showing that even with mobility contamination mustoccur to produce an infection. With mandibular frac­tures, surgeons have made similar suggestions regardingthe effect of mobility on the rate of infection. 12,47.48

Effect of Infection on Bone Healing

Several authors have shown that bone union cantake place in the face of infection both experimentallyand clinically.IO·II,13,44,49,so For instance, all ofMacaus-land and Eaton's 14 postoperative septic long-bonefractures treated with intramedullary rods achievedbony union even though infection was present."? Hebelieved complete immobilization promoted osseousunion. Similarly, Souyris et al reported 25 cases ofmandibular fracture treated with internal fixation thatbecame infected in the early postoperative period."The plates were left in place for several weeks and, onremoval, the bone was found to have healed. Johanssonet al,s2 Prein and Schmoker." and Beckers" haveshown similar results. Johansson et al found primarybone healing in 76% of cases where infection waspresent.V

Experimental verification of bone union in the faceof infection was offered by Rittmann and Perren. IIThey conducted osteosynthesis on sheep femurs andinfected the stable hone-plated fractures with staphy­lococci over a period of8 weeks. All showed bony unionover this period, some of which" was primary, despitethe clinical infections. The study by Friedrich andKIaue ofrabbit long-bone fractures stabilized internallyand infected with Staphylococcus aureus also showedthat primary bone union occurred in the face ofinfec­tion as long as the osteosynthesis was stable.':'

Conversely, mobility of an infected fracture is notwell tolerated. Meyer et al treated 214 cases of osteo­myelitis after operative treatment of fractures; 45 of49 fractures that had unstable fixation resulted in non­union." Furthermore, in the presence of infection,nonsurgical treatment may not be effective because ofthe lack of rigidity, as demonstrated by Nicol1.54 Hetreated 22 infected long-bone fractures nonsurgically,with a resulting 60% incidence of delayed union ornonunion.

Infection Following Osteosynthesis

Once an infection develops in a fracture stabilizedwith internal fixation, can one obtain complete reso­lution of the infection with the implant in place? Manyclinicians in orthopedics and maxillofacial surgery havestated that implants must be removed to resolve infec-

tion under these circumstances.Y Insall et al16 andKaufer and Matthews'? each had three deep infectionswith 220 and 373 arthroplasties, respectively, that re­quired implant removal for resolution, but many inorthopedics believe metal implants that provide sta­bility should be left in place and only the unstable onesshould be removed. I1.19.20 Hicks believed infection waseasy to overcome with rigid internal fixation."

Although several authors have stated that implantsmust be removed to resolve infection in the mandible,clinicians have shown resolution without removal aslong as the fixation was stable. Johansson et al reported42 infected mandibular fractures treated with mini­plates." Twenty-four percent of the infections persistedpostoperatively. Six of nine resolved, whereas in theremaining three the fixation devices were removed be­cause of instability. Beckers showed resolution of all19 infected mandibular fractures he treated with in­ternal fixation." Others also have found resolution ofinfection with plates in place when the fractures re­mained stable. 12,52,53,s6-s8 On the other hand, whenplates or screws were loose, infections persisted untilthe loose implants were removed.s2,s3,57,59,60

Overview

The findings from the short review presented ledto the following conclusions regarding placement offixation devices into contaminated wounds: 1) the riskofinfection following open reduction may be no greaterthan when a device is not placed; 2) bony union canoccur in the face ofinfection as long as immobilizationof the fractured segments is maintained; 3) resolutionof infection can occur even when a plate is present; 4)if resolution ofan infection does not occur in a fracturetreated with internal fixation, one must verify that thefixation is rigid; 5) if resolution of an infection doesnot occur in a fracture treated with stable internal fix­ation, one can usually leave the plate for 8 to 12 weeksto achieve bone union, and then remove it to allowrapid resolution of the infection.

Given these findings, we developed a simple protocolfor treating infected fractures with internal fixation in­tending not to remove the plates. Choice of treatmentis predicated on the extent of the infection. If a patientpresents with a mild to moderate cellulitis or a spon­taneously draining abscess, the patient is treated byopen reduction and internal fixation, with placementofa drain for postsurgical irrigation with saline. Intra­venous antibiotics are given in the perioperative period.If a patient presents with a severe cellulitis or closed(nondraining) abscess, the patient is treated as any pa­tient with an infection, with intravenous antibioticsand incision and drainage in the case of an abscess.After 3 to 4 days, the patient is taken to surgery foropen reduction and internal fixation of the fracture. A

KOURY AND ELLIS

drain is left following surgery for continued saline ir­rigation. In either of the preceding courses oftreatment,any other potential cause for the infection, such as adevitalized tooth, is eliminated as soon as possible.

We have used this protocol for the past 2 years andhave found it to be effective. Frequently, owing toscheduling difficulties, the timing of surgical interven­tion may be expedited or delayed, but we generallyattempt to institute the protocol described. Two casesrepresentative ofour experience with placement of rigidinternal fixation in infected mandibular fractures arepresented. Nine additional cases are presented in TableI. Contrary to previously reported cases, the fixationdevices were not removed.

Report of Cases

Case 1

A 31-year-old woman was struck in the face several daysprior to seeking care. The patient had poor oral hygiene,malocclusion (Fig IA), submental space abscess (Fig IB),mobility between the first premolar and canine, and an in­terincisal opening of 30 mm. Radiographic evaluation re­vealed a minimally displaced left body fracture and a mod­erately displaced right subcondylar fracture (Fig IC). Thepatient was admitted to the hospital and treated with intra­venous penicillin G (2 million units four times hourly). Twodays later, she was taken to the operating room, where anincision and drainage of the' submental abscess was per­formed, followed by application ofarch bars and MMF. Thefracture in the mandibular body was opened transorally andrigidlysecured with the placement ofa six-hole reconstructionplate at the inferior border of the mandible after the removalofa small sequestrum (Fig ID). A Penrose drain was placedthrough the extraoral incision and drainage incision into thesubperiosteal space (Fig IE). No postsurgical MMF was used.Two days later, with the patient progressing well and withno purulent drainage, the drain was removed and she wasdischarged with a prescription for cephalexin (500 mg fourtimes daily). At this time, the patient had moderate swellingaround the chin. By the following week the swelling had re­solved. Eight weeks later, the patient had an interincisalopening of45 mm and was without complaint. The arch barswere subsequently removed and 55 weeks after injury shewas doing well without further complications (Figs IF,IG).

Case 2

A 32-year-old man sustained a fracture of the mandibularsymphysis 3 weeks prior to coming to the emergency de­partment. He complained of swelling and draining pus. liewas afebrile, had submental swelling with extensive overlyingerythema, and had a sinus tract in the submental area thatoccasionally drained spontaneously. Intraorally, the mucosawas open, with exposed bone. An occlusal step was apparenton the left side, and the left lower lip was anesthetic. A di­agnosis of open, infected, minimally displaced mandibularsymphysis fracture was made (Fig 2A). The patient was ad­mitted to the hospital, treated with intravenous penicillin G(2 million units every 4 hours) and a submental incision anddrainage was done. Initial cultures revealed coagulase-positivestaphylococcus, clostridium, peptostreptococcus, and fuso-

437

bacterium. Two days later, with gross purulence absent, thedrain was removed and the patient was taken to the operatingroom and given cefazolin (I g every 6 hours). Under generalanaesthesia, an intraoral incision was made and granulationtissue was removed from the fracture site. Arch bars wereplaced, MMF secured, and a bone clamp was used to reducethe fracture. A six-hole reconstruction plate was placed in­traorally in a noncornpressive manner along with a Penrosedrain; the MMF was then released (Fig IB). Four days later,the antibiotic was changed to ticarcillin/clavulonate (3.1 gevery 6 hours). Slight purulence was noted at this time, butstable fracture segments and occlusion were present. The fol­lowing day, an intraoral communication was noted but thewound was free of purulence and granulation tissue wasforming at the wound site. After drain removal the followingday, the patient was given amoxicillin/clavulonate (500 mgevery 8 hrs) and discharged. Ten days later the patient re­turned to the clinic without complaint. At this time he hada good range of motion, normal sensation in his lower lip,and resolution of the swelling. The arch bars were removedthat day. The patient was seen 26 weeks following fractureand was found to be doing well. His occlusion was normal(Fig IC), and the fracture had healed completely with nosigns of residual infection (Fig ID).

Additional Cases

Nine additional cases are presented in Table l. Allof these cases were treated by 2.7-mm bone platingsystems. Follow-up in all cases showed resolution ofinfection, stability across the fracture to bimanual pal­pation, good occlusal relationships, and no clinical orradiographic signs of nonunion.

Discussion

The cases presented support the findings of otherauthors in orthopedics9,I1,2o,46,49 and oral/maxillofacialsurgeryl2,14,52,58 where internal fixation has been usedto treat infected fractures. The majority ofthese authorsremoved the fixation appliance after bony union oc­curred. We have found that fracture union and reso­lution of infection can be accomplished without re­moval of the plate. Using our experience in thetreatment of infected fractures with rigid internal fix­ation and those fractures that had become infected fol­lowing application of rigid internal fixation, we devel­oped a protocol for treating infected mandibularfractures.

As with any patient, a careful history and physicalexamination are performed. After the diagnosis ismade, the patient is given antibiotics, preferably intra­venous, and is usually admitted to the hospital. A de­cision must then be made whether to treat the infectionbefore reduction and internal fixation of the fracture.This decision is predicated largely on the basis of thevascularity of the region and severity of the infection.The vascularity of the tissue has been found to be ex­tremely important for preventing and overcoming aninfection, especially in the presence of an avascular

~(j.)ex>

Table 1. Cases of Infected Mandibular Fractures Treated With Rigid Internal Fixation

Age Infected Duration of Previous Treatment Rendered forPatient Sex (yr) Fracture Infection Treatment Type of Infection Infected Mandibular Fracture Follow-up (wk)

3 F 29 Symphysis 1 wk Oral PCN X I wk Nondraining abscess IV PCN, simultaneous I/O I & 17prior to with overlying D and ORIF with four-holepresentation cellulitis in compression bone plate, E/ ;;0

submental space o drain; drain removed 2 d spostop; DC 2 d postop; at 7 Sd, readmission with ~submental infection; IV mamoxieillin, E/O I & D, E/O ;;0

zdrain placed;drain removed >

[""

2 d postop; DC 3 d postop :!l4 M 3\ Rt angle >1 mo Closed reduction Spontaneously draining 6 d of IV PCN; simultaneous 74 X

of same (I/O) submandibular E/O I & Dand >-l

fracture 5 mo space abscess, debridement, ORIF with 0before; no sequestra formation eight-hole noncornpression Z

follow-up reconstructivebone plate,.,.,0

extr no. 31, E/O drains; ~

drains removed 5 d postop; ZDC6 d postop ril

5 M 27 Lt angle 3 wk Oral PCN X I wk Spontaneously draining IV ccphazolin, E/O I & D and 21 ::Jprior to (I/O) subperiosteal ORIF with noncompression tn

Cpresentation abscess at eight-hole reconstructive z

mandibular angle bone plate + four-hole 2- >.mm plate at superior Z

Cborder, E/O drains; drains tiiremoved I d postop; DC 2 ed postop !;:

;;06 M 33 Symphysis 2wk None Localized cellulitis and IV PCN,I/O I & D and ORIF 15

~swelling with with seven-holeerythema of noneompression ::Jsubmental skin reconstructivebone plate, c

no drain placed;DC same ~

day I3l

7 M 28 Lt body 3d ORI F with lag Localized alveolar IV PCN, I/O I & D, hard ware 20 ~

screw and 2· swelling, removal (hardware was 0c:mm bone plate spontaneous- loose), sequestrectomy, and :;0

-<of fractur e 5 draining (I/O ) ORIF with six-hole >wk earlier submandibular space noncompression Z

abscess, non union of reconstructive bone plate, 1/ 0tTl

fx o drain; drain removed 2 d r-postop; DC 4 d postop r-

Vi8 M 33 Rt body 2 wk Non e Spontaneous-drainin g IV PCN, E/O I & D and ORI F 13

(I/O ) submandibular with eight-holespace abscess noncompression

reconstructive bone plate,E/O drains; drain remo ved2 d postop; DC 3 d postop

9 F 34 Rt body 5 wk Closed reduction Spontaneous-draining IV PeN, E/O I & D and 14of fracture 6 (I/O ) subm and ibular sequestrectomy. ORIF withwk earlier space abscess, seven-hole noncomprcssion

sequestra formation reconstructive bone plate.E/O drains; drain removed2 d postop; DC 3 d postop

10 M 32 Rt angle 3 wk ORI Fof same Spon taneous-draining IV PCN, E/O I & D and 31fracture 5 wk (I/O) subm andi bular sequestrectomy, ORIF withprior with two space abscess, eight-hole noncompression2-mm plates sequest ra format ion reconstructive bone plate,

E/O drains; drain removed3 d postop ; DC 4 d postop

II M 28 Lt angle 1 wk None Submandibular/ IV PeN. E/O I & D and ORI F 16subperiosteal abscess with eight-holelateral mand ible. noncompressionfluctuant reconstructive bone plate.

E/O drains; drains remo ved2 d postop; DC 3 d postop

All bone plates were appli ed with 2.7-mm bone screws.Abbreviations: E/O. extraoral ; I/O , intraoral; I & D. incision and drainage; PCN, penicillin G ; ORIF, open reduction and internal fixat ion; DC, discharge.

.j:Io.c.:l<0

440 RIGID INTERNAL FIXATION FOR INFECTED MANDIBULAR FRACTURES

B

FIGURE I. Patient with infected mandibular symphysis fracture. A. Malocclusion. B. Submental abscess. C, Panoramic radiograph ofpatientshowing symphyseal fracture and right subcondylar fracture. E, Six-hole reconstruction bone plate used to stabilize the fracture. Note smallpiece of bony sequestrum in forceps (below). D, Immediately postsurgery, showing Penrose drain in place. F. Occlusal relationship at 55 weekspostsurgery. G, Panoramic radiograph at 55 weeks postsurgery.

KOURY AND ELLIS 441

AGURE 2. Patient with infected mandibular symphysis fracture. A. Panoramic radiograph showing fracture. B. Intraoperative photographshowingfracturereducedwith a reconstructionbone plate. C.Occlusionat 26 weekspostsurgery. D, Panoramic radiograph26 weekspostsurgery.

implant.33,38,4o,61,62 If there is only a mild to moderatecellulitis or a spontaneously draining abscess, we per­form the open reduction and internal fixation as soonas our operating room schedule permits. Drains areplaced if gross purulence is noted intraoperatively. Ifsevere cellulitis is present, intravenous antibiotics aregiven until the tissue pressure has decreased to allowimproved perfusion of the area for better healing andresolution of the infection. Likewise, if copious purul­ence has caused extensive tissue dissection and abscessloculations, implant placement may be best accom­plished a fewdays after incision and drainage to relievethe tissue tension. Any devitalized teeth are removedas early as possible. In such cases, the drains are irri­gated four times daily. Once the swelling and purulencehave decreased, the patient is taken back to the oper­ating room for open reduction and rigid fixation. Sim­ilarly, infected wounds with a large area of necroticand avascular tissue and comminuted fragments, suchas infected gunshot wounds, may be better treatedwithout extensive surgical intervention until the infec­tion begins to resolve and viability of the soft tissuesis established. Typically, when surgery is delayed, it isusually performed approximately 3 to 4 days followingincision and drainage.

When using rigid internal fixation devices for in­fected mandibular fractures, three points should beborne in mind. First, adequate debridement of infectedtissue is essential for resolution of the infection. to This

step necessitates the removal of teeth in the line of thefracture that are indicated for extraction,52,53.63 curet­tage of granulation and infected soft tissue, sauceri­zation and sequestrectomy of dead bone, and the re­moval of nonfunctional foreign bodies. 7.9,44,46,64

Second, if drains are deemed necessary due to the pres­ence of purulence in the wound at the time ofsurgery,they must be kept in place until the wound stops pro­ducing such drainage.46,52 The drains allow the woundto be irrigated and also prevent the build-up ofabscesscavities that the body is unable to fight efficiently. Oneshould not be too quick to remove the drains in suchpatients. Third, absolute rigidity is essential. Rigidityhas been shown to produce a stable foundation for soft­tissue growth " so that vascularity to the area can im­prove and the wound can heal." Avascularity has beenshown to be one of the primary risk factors for infec­tion. 37,39 Rigidity has also been shown to prevent bac­teria from being continually pumped through the frac­ture site, thereby decreasing the chance of osteitis.'?One must remember that osteolysis occurs in the pres­ence of infection, which can weaken the bone sur­rounding the screws.I 1,13 This increases the possibilityof fragment mobility and delayed bone healing. Be­cause of these considerations, greater rigidity is nec­essary. We most commonly employ heavy reconstruc­tion bone plates with 2.7-mm bone screws to securesuch fractures. In the mandibular angle region, andusually elsewhere in the mandible, three screws are

442 RIGID INTERNAL FIXATION FOR INFECTED MANDIBULAR FRACTURES

placed on each side of the fracture to assure firm fix­ation. When the bone fragments have not been erodedby the infective process, we may employ the use ofcompression osteosynthesis. Compressing the bonefragments provides more rigidity for a given numberof bone screws." Compression also helps reduce thefracture gap,65 thus decreasing the chance of osteitisand the progression of the infection.I':'? In 1979,Beckers" reported 14 infected fractures in which fourof five treated without compression developed post­operative infections, whereas only one of nine withcompression became infected. Reduction of the bonegap and absolute rigidity also promoted primary boneunion;,,1J·52 expediting the healing time.'?

During the course of healing, resolution of the in­fection and stability of the fracture must be assessed.Usually both will proceed uneventfully.lv'? but if pu­rulent drainage continues after drain removal, surgicaltreatment is indicated. The usual causes of persistentdrainage are I) an odontogenic infection;5,47.52.62 2)sequestra, or 3) loose fixation.52,53,63 Treatment of thelatter two usually cannot be accomplished under localanesthesia. Iflarge sequestra are seen radiographically,or if the fracture is mobile, the patient will most likelyneed to be taken back to the operating room for de­bridement in the former case and restabilization in thelatter. '9,52 Correction of these conditions normally re­sults in resolution of the infection, but occasionallyminor purulence will remain. If drainage is still oc­curring after a period in which union is likely, the platecan be removed." Usually, as long as the fixation hasremained stable, union will occur even if an infectionwas present. II,13,14,51 Often, it is found that loose fixa­tion propagated the infection.51,53,57,59 Resolution ofthe infection usually proceeds rapidly after the non­functional foreign body is removed.f

If during the course of healing the implant becomesexposed, the treatment decision is again predicated onwhether the fracture is mobile.58.6o If the fracture isstable, the bone is allowed to achieve union and thenthe plate is removed." Removal is frequently necessarybecause soft tissue does not always cover an exposedplate."

Conclusion

Our experience and that of others in both orthope­dics and oral/maxillofacial surgery indicates the use ofinternal fixation is a plausible treatment for infectedmandible fractures. The following reasons are note­worthy: l) fracture union and resolution of infectionare predictably achievable; 2) if, after using rigid fixa­tion the infection is prolonged, bone union can stilloccur; 3) if resolution of infection is delayed, the im­plant can be kept in place until after bone union; un­eventful wound healing will then occur following im­plant removal.

This treatment is not proposed as a replacement formore traditional methods. Both external fixation andMMF have stood the test of time and proved theireffectiveness. Rather, plate and screw fixation is a viableoption that allows the patient the same benefits thatits use in noninfected fractures provides. It is very usefulin the noncompliant patient who frequently will nottolerate MMF.

References

I. Topazian RG, Goldberg MH: Oral and Maxillofacial Infections.Philadelphia, PA, Saunders, 1977 pp 216-218

2. Soto-lIiII R, Horwitz T: The treatment of compound fractureof the femur. JAMA 130:128, 1946

3. Watson-Jones SR: Primary internal fixation of compound frac­tures. J Bone Joint Surg IBr] 35:147, 1953

4. TowersAG: Wound infection in an orthopaedic hospital. Lancet2:380,1965

5. Ketenjan AY, Shelton ML: Primary internal fixation of openfractures: a retrospective study of the use of metallic internalfixation in fresh open wounds. J Trauma 12:756, 1972

6. Dahl-Iverson E: On the frequency and the duration of osteitisafter osteosynthesis illustratedby 274casesand re-examinationof 66 cases of operatively treated fractures. Acta Chir Scand63:41, 1928

7. Reynolds FC, Zaepfel F: Management of chronic osteomyelitissecondary to compound fractures. J Bone Joint Surg [Am]30:331, 1948

8. Gustilo RB, Simpson L, Nixon R, et al: Analysis of 511 openfractures. C1in Orthop 6:148, 1969

9. KeyJA, ReynoldsFC:The treatment of infectionafter medullarynailing. Surgery 35:749, 1954

10. Rowe CR, Sakellarides lIT: Recent advances in the treatmentof osteomyelitis following fracture of the long bones. SurgC1in North Am 41:1593, 1961

I I. Rittmann WW, Perren SM: Cortical Bone HealingAfter InternalFixationand Infection.New York, NY, SpringerVerlag. 1974

12. SchilliW:Compression osteosynthesis.J Oral Surg 35:802, 197713. Friedrich B, Klaue P: Mechanical stability and post-traumatic

osteitis: An experimental evaluation of the relation betweeninfection of bone and internal fixation. Injury 9:23, 1977

14. Beckers HL: Treatment of initially infected mandible fractureswith bone plates. J Oral Surg 37:310, 1979

15. StrelzowVV, StrclzowAG: Osteosynthesis of mandible fracturesin the angle region. Arch Otolaryngol 109:403, 1983

16. Insall J, Scott WN, Ranawat CS: The total condylar knee pros­thesis. J Bone Joint Surg [Am] 61:173, 1979

17. Kaufer H, Matthews LS:Spherocentric arthroplasty of the knee.J Bone Joint Surg [Am] 63:545, 1981

18. Sheehan JM: Arthroplasty of the knee. J Bone Joint Surg [Br]60:333, 1978

19. Burri C: Post-TraumaticOsteomyelitis. Bern, Hans Huber, 1975,pp 19-125

20. OIerud S, Karlstrorn G: Tibial fractures treated by AO compres­sion osteosynthesis.Acta Orthop Scand 140:1, 1972 (suppl)

2 I. AllgowerM: Weichteilprobleme und infektionsrisike dcr osteo­synthese, Langenbecks Arch Klin Chir 329:1127, 1971

22. Lottes JO, llill U, Key JA: Closed reduction, plate fixation andmedullary nailing of fractures of both bones of the leg.J BoneJoint Surg [Am] 34:861, 1952

23. D'Aubigne RM, Maurer P, Zucman J, et al; Blind intramedullarynailing for tibial fractures. Clin Orthop 105:267, 1974

24. Rittmann WW, Schibli M, Matter P, ct al: Open fractures: long­term results of 200 consecutive cases. Clin Orthop 138:132,1979

25. Gristina AG, CostertonJW, Leake E, et al: Bacterial colonizationof biornatcrials. C1inLab Stud Orthop Trans 4:355, 1980

26. Nishioka GJ, Jones JK, Triplett RG, et al: The role of bacteria­laden biolilmsin infection of maxillofacial biomaterials, J OralMaxillofacSurg46:19,1988

BUCHDINDER AND WEBER

27. Costerton JW, Geesey GG, Cheng KJ: 1I0w bacteria stick. SciAm 238:86,1978

28. Gristina AG, Kolkin J: Current concepts review-Total jointreplacementand sepsis. J BoneJoint Surg[Am] 65:128, 1983

29. Gristina AG, Rovere GO: An in vitro study of the effects ofmetals used in internal fixation on bacterial growth and dis­semination. J BoneJoint Surg [Am] 45:1104, 1963

30. Gristina AG, Revere GO, Shoji II, et al: An in vitro study ofbacterial response to inert and reactive metals and to methylmethacrylate. J Biomed Mater Res 10:273, 1976

31. Holstad HA: Primary osteosynthesis versus conservative treat­ment of compound fractures of long tubular bones. J OsloCity Hosp 12:225, 1962

32. WadePA, Campbell RD: Open versusclosedmethodsin treatingfractures of the leg. Am J Surg 95:599, 1958

33. Solheim K: Fracturesof the lowerleg.Acta Chir Scand 119:268,1960

34. Bauer GC, Edwards P, Windmark PII: Shaft fractures of thetibia: Etiologyof poor results in a consecutive series of 173fractures. Acta Chir Scand 124:386, 1962

35. Edwards P: Fracture of the shaft of the tibia: 492 consecutivecases in adults. Acta Orthop Scand 76:I, 1965(suppl)

36. Wehner W: Wandlung in der behandlung komplizierter langersehaftknocjenfrakturen.Z Artz FortbiId 62:1313, 1968

37. GustiIo RB, Anderson JT: Prevention of infection in the treat­ment of 1025open fracturesof longbones. J BoneJoint Surg[Am] 58:453, 1976

38. Gallinaro P, Grova M, Dcnicolai F: Complications in 64 openfracturesof the tibia. Injury 5:157, 1974

39. Chapman MW, Mahoney M: The role of early internal fixationin the management of open fractures. Clin Orthop 138:120,1979

40. Edwards P: The effect of crush injury to the skin on healing offracturesof the shaft of the tibia in dogs. Acta Orthop Scand36:89, 1965

41. Niederdellrnann II, Akuarnon-Boatcng E: Internal fixation offractures. Int J Oral Surg 7:252, 1978

42. Luhr IIG: Comparative studies between the extraoral and in­traoralapproach in compression-osteosynthesisof mandibularfractures, ill Hjorting-Hansen E (cd): Oral and MaxillofacialSurgery. Proc 8th Inti Conf Oral Maxillofac Surg. Chicago,IL, Quintessence, 1985,pp 133-137 .

43. Muller ME, Allgowcr M, Schneider R, et al: Manual oflnternalFixation (ed 2). Berlin, Springer-Verlag, 1979, pp 152,306

44. BravEA,Jeffress VH: Intramedullary nailing in recent gunshotfractures of the femoral shaft. J Bone Joint Surg [Am] 35:141,1953

45. Rush ilL, Fills \VT, Gibbons J, et al: Intramedullary nailing inthe presenceof infection. Surg Gynecol Obstet 94:727, 1952

46. MeyerS, Weiland AJ, Willenegger H: The treatment of infected

J Oral Maxillofac Surg50:443-444. 1992

443

non-union of fractures of long bones. J Bone Joint Surg 57:836, 1975

47. Kellman RM: Repair of mandibular fractures via compressionplatingand more traditional techniques: A comparison of re­sults, Laryngoscope 94:1560, 1984

48. KlotchOW, Bilger JR: Platefixation foropen mandiblefractures.Laryngoscope 95:1374, 1985

49. Macausland WR, EatonRG:The managementofsepsis followingintramedullary fixation for fractureof the femur.J BoneJointSurg [Am] 45:1643, 1979

50. Carr CR, Turnipseed CD: Experience with intramedullary fix­ation of compound femoral fractures in war wounds.J BoneJoint Surg [Am] 35:153.1953

51. SouyrisF, LamarcheJP, Mirfakhrai AM:Treatment of mandiblefractures by intraoral placement of bone plates. J Oral Surg38:33, 1980

52. Johansson B, Krekmanov L, Thomasson M: Miniplate osteo­synthesis of infected mandibularfractures. J Cranio MaxillofacSurg 16:22, 1988

53. Prein J, Schmoker R: Treatment of infected fracturesand pseu­doarthrosis of the mandible, IIISpicssl B(ed): New Conceptsin Maxillofacial BoneSurgery. NewYork, NY,Springer, 1976,pp 169-174

54. Nicoll EA: Fracture of the tibial shaft. J Bone Joint Surg [Br]46:373, 1964

55. Hicks HI: Amputations in fractures of the tibia. J Bone JointSurg [Br]46:388, 1964

56. Frost DE, EI·AtlarA, Moos KF: Evaluation of metacarpal boneplates in the mandible fracture. BrJ Oral Surg 21:214, 1983

57. Tu 11K, Tenhulzen D: Compression osteosynthesis of mandiblefractures: A retrospective study. J Oral Maxillofae Surg 43:585, 1985

58. Prcin J, Beyer M: Management of infection and nonunion inmandibular fractures. Oral MaxillofacSurg Clin North Am2:187, 1990

59. Cawood J1: Small plate osteosynthesis of mandibular fractures.Br J Oral MaxillofacSurg 23:77, 1985

60. Assael LA:Complications of rigid internal fixation of the facialskeleton. Oral Maxillofae Surg Clin North Am 2:615, 1990

61. Hicks JH: High rigidity in fractures of the tibia. Injury 3:121,1971

62. StrelzowVV,Friedman W: Dynamiccompression platingin thetreatment of mandibular fractures. Arch Otolaryngol 108:583,1982

63. Buchbinder D: Use of rigid internal fixation in the treatment ofmandible fractures. Oral MaxillofacSurg Clin North Am 2:41,1990

64. Dramula JO, AjagbcHA:Chronic osteomyelitisof the mandiblein adults: A clinical study of 34 cases. Br J Oral Surg 20:58,1981

DiscussionRigid Internal Fixation for the Treatment

of Infected Mandibular Fractures

Daniel Buchbinder, D/lfD, andWilliam Weber, DMDThe Mount Sinai School ofMedicine and Medical Center,Nell' York

The authors' presentation of II cases of open reductionand rigid inlernal fixation (RIF) of infected mandibular frac­tures using their treatment protocol further shows the use­fulness and, when properly performed, efficacy of RIF inmaxillofacial traumatology. The benefits of absolute rigid

fixation applied according to established biomechanicalprinciples have been well documented.' Early, pain-free mo­bilization of the mandible without jeopardizing healing hascome to include application of these techniques in recon­structivc and orthognathic procedures as well as in the treat­ment of infected fractures'" and delayed treatmcnr'" ofnon­infected fractures. Reports of early immobilization as aprerequisite for considering RIF have been unconvincing.t

Cases for rigid internal fixat ion, like any other treatment;must be carefully selected. As the authors suggest, it shouldbe strongly considered in the treatment of noncompliant pa­tients who will not tolerate MMF. Although many cases ofinfected fractures may involve a noncompliant patient pop­ulation, some infected cases are the result oftreatment delayed