JBJS Classics: Open Fracture Infection Prevention
Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
The common knowledge applied in managing open fractures (asepsis, irrigation and debridement, immobilization, and wound protection against infection) was obtained from the surgical experience accrued during World War I. Despite the overall improvement in outcomes from applying that knowledge, the varying severity of associated soft-tissue injuries created considerable ambiguity regarding optimal treatments during the years that followed.
”Prevention of Infection in the Treatment of 1,025 Open Fractures of Long Bones” by Ramon Gustilo and John Anderson in the June 1976 edition of JBJS classified open fractures into three types of increasing severity based on wound size, level of contamination, and osseous/soft-tissue injury. In general, more severe open fractures have a worse clinical prognosis for infection, nonunion, and other complications, although actual outcomes vary depending on numerous additional clinical factors. Also, high-energy Type III open fractures are not homogeneous, and in response to that variation, in 1984 Gustilo et al. further classified Type III open fractures into A, B, and C subtypes according to the severity of soft-tissue injury, the need for vascular reconstruction, and worsening prognosis.
However, the reliability of the Gustilo classification has been questioned in recent years. Clinical researchers have observed that the assessment of surface injuries does not always reflect deeper damage and does not account for tissue viability and tissue necrosis, which tends to develop with time after high-energy injuries. Also, a 1993 study found only moderate interobserver agreement among users of the classification. The limitless variety of injury patterns, mechanisms, and severities is almost impossible to be contained in a limited number of discrete categories.
As the management of open fractures continues to evolve, the 1976 Gustilo and Anderson treatment recommendation against primary internal fracture fixation for most Type III injuries due to high infection rates no longer represents the standard of care. Stabilization, even with internal fixation, for many of these fractures promotes healing, allows early rehabilitation, restores function, and reduces the risk of infection and malunion.
While “best practices” may have changed, the Gustilo-Anderson classification still correlates well with the risk of infection in patients with comorbid medical illnesses and other complications. It remains an easy-to-use classification system that has formed the foundation for open fracture management during the last four decades, with good but imperfect prognostic and therapeutic implications. It remains widely accepted for research and training purposes, and it provides the preferred basic language for communicating about open fractures.
Konstantinos Malizos, MD, PhD
JBJS Deputy Editor