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Aims: The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs., Methods: Resource use was measured during the six months that followed open fractures of the lower limb in 748 adults recruited as part of two large clinical trials within the UK Major Trauma Research Network. Resource inputs were valued using unit costs drawn from primary and secondary sources. Economic costs (GBP sterling, 2017 to 2018 prices), estimated from both a NHS and Personal Social Services (PSS) perspective, were related to the degree of complexity of the open fracture based on the OTS classification., Results: Adjusted mean total NHS and PSS costs were £13,785 following treatment of complex fractures and £3,550 following treatment of simple fractures, where the open fracture wound is closed at the end of the first wound debridement, generating a mean difference of £10,235 (95% confidence interval £8,074 to £12,396)., Conclusion: Following previous work correlating clinical outcomes with the OTS classification of open fractures, this study suggests that the new OTS classification also correlates with economic costs estimated from alternative study perspectives. Cite this article: Bone Joint J  2022;104-B(3):408-412.

Aims: To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes., Methods: The proposed classification was investigated within a cohort of adults with open fractures of the lower limb who were recruited as part of two large clinical trials within the UK Major Trauma Network. The classification was correlated with patient-reported Disability Rating Index (DRI) and EuroQol five-dimension questionnaire (EQ-5D) health-related quality of life in the year after injury, and with deep infection at 30 days, according to the Centers for Disease Control and Prevention definition of a deep surgical site infection., Results: A total of 748 participants were included in the analysis. Of these, 288 (38.5%) had a simple open fracture and 460 (61.5%) had a complex fracture as defined by the new classification system. At 12 months, the mean DRI in the simple fracture group was 32.5 (SD 26.8) versus 43.9 (SD 26.1) in the complex fracture group (odds ratio (OR) 8.19; 95% confidence interval (CI) 3.69 to 12.69). At 12 months the mean health-related quality of life (EQ-5D utility) in the simple fracture group was 0.59 (SD 0.29) versus 0.56 (SD 0.32) in the complex fracture group (OR -0.03; 95% CI -0.09 to 0.02). The differences in the rate of deep infection at 30 days was not statistically significant., Conclusion: The Orthopaedic Trauma Society open fracture classification is based upon objective descriptors of the injury and correlates with patient-centred outcomes in a large cohort of open fractures of the lower limb. Cite this article: Bone Joint J 2020;102-B(11):1469-1474.

Purpose: The induced membrane technique (IMT) is a two-stage procedure dedicated to reconstruction of bone defects of the limbs. The objective of this report was to evaluate employment of the IMT for the treatment of open tibia fractures managed in a military trauma center treating both wartime and peacetime injuries., Methods: A retrospective study was performed among the patients treated via IMT for tibial bone defects related to open fractures between 2009 and 2018. The outcomes recorded included bone union, residual infection, amputation and lower limb function., Results: During this period, 15 patients with a mean age of 39 years were included for the treatment of Gustilo II (2 cases) or Gustilo IIIB (13 cases) injuries. A mean number of 2.9 debridements were required before stage 1. Flap coverage was associated in 14 cases. The mean interval between stages was 22 weeks. Five patients were re-operated on after stage 1 due to persistent infection. The mean follow-up was 33 months. Bone union was achieved in 13 of the 15 cases (87%) at a mean time of 10.1 months. However, seven additional bone healing procedures were required, including six inter-tibiofibular grafting. Only one late septic recurrence was found. Most patients returned to work in sedentary jobs., Conclusions: This series is the first to report IMT use in a military setting. The prior eradication of infection constitutes a major challenge in tibial bone defects, especially in high-energy, multi-tissue injuries. An inter-tibiofibular bone reconstruction approach is required when external fixation is chosen.

Introduction: Open fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm., Material and Methods: A literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions., Results: A total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points., Conclusion: The complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database., (Copyright © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. In this patient population, the decision between primary amputation and limb salvage can be challenging. This study aims to evaluate the reconstructive outcomes of patients with Gustilo type IIIC injuries., Methods: A single-center retrospective review of 806 lower extremity free flaps from 1976 to 2016 was performed. Flap loss and salvage rates for patients with Gustilo type IIIC injuries were determined. To determine the utility of performing salvage in this group, outcomes of the IIIC reconstructions were compared to those of similar patients with Gustilo I type IIB injuries with only a single patent vessel., Results: A total of 32 patients with Gustilo type IIIC injuries underwent reconstruction after traumatic injury. Ten patients (31.3 percent) experienced a perioperative complication, including seven unplanned returns to the operating room (21.9 percent), three partial flap losses (9.4 percent), and five complete flap losses (15.6 percent). When type IIIC injuries were compared with single-vessel Gustilo type IIIB injuries, no statistically significant differences were noted with respect to major perioperative complications (p = 0.527), unplanned return to the operating room (p = 0.06), partial flap loss (p = 0.209), complete flap loss (p = 0.596), or salvage rate (p = 0.368). Although this result was not statistically significant, Gustilo type IIIC injuries trended toward lower take-back rates and higher salvage rates compared with single-vessel Gustilo type IIIB injuries., Conclusion: Patients with Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage, as flap loss and reconstruction of these injuries are comparable to those of the routinely reconstructed single-vessel runoff type IIIB injuries., Clinical Question/level of Evidence: Therapeutic, IV.

Purpose: Open tibia fracture is prone to infection, consequently causing significant morbidity and increasing the hospital stay, occupational loss and onset of chronic osteomyelitis. Intramedullary nailing is one choice for treating tibia shaft fractures. To improve the delivery of antibiotics at the tissue-implant interface, many methods have been proposed as a part of prophylaxis against infection. This study was conducted to study the role of gentamicin-impregnated intramedullary interlocking (IMIL) nail in the prevention of infection in Gustilo type I and II open tibia fractures and to compare the results with regular intramedullary nail., Methods: The study included 28 patients with open tibia fractures (Gustilo type 1 or type 2); of them 14 underwent regular IMIL nailing and the other 14 were treated with gentamicin-coated nailing. Randomization was done by alternate allocation of the patients. Follow-up was done postoperatively (day 1), 1 week, 6 weeks, and 6 months for bone union, erythrocyte sedimentation rate (ESR), hemoglobin and C-reactive protein (CRP). Statistical significance was tested using unpaired t-test. A p value less than 0.05 was considered significant., Results: There were 4 cases of infection in controls (regular IMIL nail) and no infection among patients treated with gentamicin-coated nail during the follow up (X 2  = 4.66, p = 0.031). At 6 months postoperatively, CRP (p = 0.031), ESR (p = 0.046) and hemoglobin level (p = 0.016) showed significant difference between two groups. The bone healing rate was better with gentamicin-coated nail in comparison to regular IMIL nail at 6 months follow-up (p = 0.016)., Conclusion: Gentamicin-coated IMIL nail has a positive role in preventing infection in Gustilo type I and II open tibia fractures., (Copyright © 2019 Chinese Medical Association. Production and hosting by Elsevier B.V. All rights reserved.)

Purpose: The aim of this study was to describe complication rates and long-term functional outcomes among patients with amputated versus reconstructed limb after high-energy open tibial fractures., Methods: Patients treated operatively for a high-energy open tibial fracture, classified as Gustilo-Anderson (GA) grade 3, at our hospital in the time period 2004-2013 were invited to a clinical and radiographic follow-up at minimum 2 years after injury. Eighty-two patients with 87 GA grade 3 fractures were included. There were 39 type GA 3A, 34 GA 3B, and 14 GA 3C., Results: The GA 3A reconstruction group had the lowest complication rate and the best long-term outcome scores at mean 5 years (range 2-8 years) after injury. Within the group of GA 3B and 3C fractures, we found no significant differences in long-term outcomes among patients with reconstructed versus amputated limbs. The mean physical component summary score of the SF-36 in the reconstruction versus amputation group was 54.2 (95% CI 46.3-62.1) versus 47.7 (95% CI 32.6-62.2), respectively (p = 0.524), while the mean mental component summary score was 63.7 (95% CI 50.6-71.8) versus 59.2 (95% CI 48.8-68.0), respectively (p = 0.603). On the 6-minute walk test, the reconstruction group walked on average 493 m (95% CI 447-535 m) versus 449 m (95% CI 384-518 m) in the amputation group. The return to work rate was 73% (16 of 22) in the reconstruction group versus 50% (7 of 14) in the amputation group (p = 0.166). The mean patient satisfaction score (VAS 0-100) was 67 (95% CI 67-77) in the reconstruction group versus 65 (95% CI 51-76) in the amputation group (p = 0.795). Regardless of the treatment strategy, the complication rate was high., Conclusions: Amputation should be considered as a viable treatment option, equal to limb salvage, after high-energy open tibial fracture with severe vascular damage or soft tissue loss.

Case: Two patients with open foot and ankle fractures were treated with aggressive irrigation and debridement and acute placement of a dermal regeneration template (DRT) followed by split-thickness skin grafting. Patient 1 was an 82-year-old female with a type IIIB open ankle fracture complexed with 2 significant regions of soft tissue loss. Patient 2 was a 54-year-old male with type IIIB open metatarsal fractures. Both patients healed without complication., Conclusions: Complex open fractures in lower extremities can be managed with acute DRT application. This may be a more cost-effective solution compared to free flaps.

Background: Evidence with regard to antibiotic prophylaxis for patients with open fractures of the extremities is limited. We therefore conducted a systematic survey addressing current practice and recommendations., Methods: We included publications from January 2007 to June 2017. We searched Embase, MEDLINE, CINAHL, the Cochrane Central Registry of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews for clinical studies and surveys of surgeons; WorldCat for textbooks; and web sites for guidelines and institutional protocols., Results: We identified 223 eligible publications that reported 100 clinical practice patterns and 276 recommendations with regard to systemic antibiotic administration, and 3 recommendations regarding local antibiotic administration alone. Most publications of clinical practice patterns used regimens with both gram-positive and gram-negative coverage and continued the administration for 2 to 3 days. Most publications recommended prophylactic systemic antibiotics. Most recommendations suggested gram-positive coverage for less severe injuries and administration duration of 3 days or less. For more severe injuries, most recommendations suggested broad antimicrobial coverage continued for 2 to 3 days. Most publications reported intravenous administration of antibiotics immediately., Conclusions: Current practice and recommendations strongly support early systemic antibiotic prophylaxis for patients with open fractures of the extremities. Differences in antibiotic regimens, doses, and durations of administration remain in both practice and recommendations. Consensus with regard to optimal practice will likely require well-designed randomized controlled trials., Clinical Relevance: The current survey of literature systematically provides surgeons' practice and the available expert recommendations from 2007 to 2017 on the use of prophylactic antibiotics in the management of open fractures of extremities.

Purpose: Infectious complications in open lower extremity fractures contribute to significant morbidity. Historically, orthopedic guidelines have recommended Grade III fractures receive a first generation cephalosporin and an aminoglycoside. Despite these guidelines, few studies have evaluated the utility of adding an aminoglycoside in this patient population. At our trauma center, we have a unique trauma service where half of our surgeons treat Grade III open fractures with a cephalosporin alone and half use a cephalosporin + aminoglycoside. We hypothesized that our outcomes were the same between the two groups., Methods: We identified all Grade III fractures of the lower extremity admitted to our urban Level I Trauma Center over the 5-year study period. Charts were retrospectively reviewed to identify demographic information, injury severity score (ISS), fracture location, grade of fracture, type of antibiotic administered, incidence of acute kidney injury (AKI), surgical site infection (SSI), hardware removal, hospital length of stay (HLOS), and disposition. Patients were classified into two groups: those treated with a cephalosporin alone (CEPH) or cephalosporin + an aminoglycoside (CEPH + AG)., Results: A total of 126 grade III fractures of the lower extremity were admitted our Trauma Center during the 5-year study period. There were 65 (52%) patients in the CEPH group and 61 (48%) in the CEPH + AG group. Demographics, ISS, fracture location, grade of fracture, rate of SSI, need for hardware removal, and disposition were not different between the two groups. In contrast, patients in the CEPH group had a 4% incidence of AKI, while the incidence was 10% of patients in the CEPH + AG group (p < 0.05)., Conclusion: The addition of an AG to antibiotic prophylaxis in open lower extremity fractures was associated with a significant increase in AKI with no change in the incidence of wound infection or hardware removal. Cephalosporins alone may be sufficient for prophylaxis in Grade III open fractures of the lower extremity. A large-scale prospective randomized trial is needed to confirm these findings and inform clinical practice.

After presentations of the principles of limb salvage and soft-tissue coverage for Gustilo III open tibia fractures, this third part is dedicated to management of tibial non-unions in low-resource settings. Inter-tibiofibular grafting and the induced membrane technique are preferred because they make it possible to deal with almost all situations. Key technical points of these methods are presented, followed by treatment guidelines based on Catagni's classification and bone defect size.

Background: The Gustilo classification is the most established system for classifying open fractures. Despite this, the classification has changed in how it has been described and interpreted. We have traced how this classification has slowly evolved throughout the literature over the past 4 decades., Methods: A systematic search of the literature was undertaken with the MEDLINE, Embase, and PubMed databases to source relevant articles that have evolved the interpretation of the Gustilo classification. The references from these articles were consecutively hand-searched to find other articles that describe the Gustilo classification., Results: There was a total of 393 results from the Healthcare Databases Advanced Search (HDAS): 95 from MEDLINE, 49 from Embase, and 249 from PubMed. Fifty-six articles were initially selected; an additional 67 articles were retrieved through reference checking and further checking of relevant articles until no additional relevant articles could be found., Conclusions: The original Gustilo and Anderson classification initially was modified by Gustilo before subtle changes were made to the descriptors in the 1990s. Some authors have used the Gustilo classification to create alternative classifications, but these have not gained traction. Other contemporaneous literature has modified the Gustilo-IIIB subtypes to better stratify functional and reconstructive outcomes following vascular injury. The impact and longevity of such recent modifications are yet to be known.

Background: Gustilo-Anderson grade 3B open ankle fracture-dislocations requiring stable fixation and soft tissue coverage are increasingly common in frail populations., Methods: We identified all patients with open ankle fracture-dislocations treated with a tibiotalocalcaneal nail and soft tissue coverage over a five-year period. We retrospectively recorded pre-morbid status, fracture and soft tissue injury pattern, surgical details, post-operative mobility, length of hospital stay, complication and re-operation rate and survival., Results: 21 ankles (20 patients) are included, all grade 3B open fractures. All patients were permitted to mobilise by one to six weeks post-surgery. One patient required further soft tissue surgery. Six patients had superficial wound colonization/infection, none developed deep infections. None of the nails have required removal. We observed a 15% three-month mortality rate., Conclusion: Tibiotalocalcaneal nail fixation and soft tissue coverage of unstable open ankle fractures in frail patients facilitates early return to ambulation with a low complication and re-operation rate., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

After limb salvage based on debridement and external fixation, Gustilo IIIB open tibia fractures must undergo soft-tissue repair within 7 days. In low-resource setting, the coverage is performed with pedicled flaps only, which can be used by any orthopedic surgeon after minimal training. The authors describe here the simplified use of 7 basic flap transfers that can deal with almost all soft tissue defects. The diffusion of these techniques in developing countries is crucial for limiting functional and trophic effects related to prolonged exposure of the fracture site.

In developing countries, road traffic accidents result in many cases of open trauma, especially fractures, with the tibia area at particular risk in motorcycle crashes. Despite a high prevalence of severe leg trauma with multi-tissue injuries, few studies have focused on the challenge of their reconstruction in these limited-resource settings. The first part of this review presents the surgical strategy. Limitations and principles of initial limb salvage are detailed. Orthopedic procedures for early damage control, based on debridement and temporary bone stabilization, are often required. The priority is to shorten the time to initial surgical management to avoid infection, which jeopardizes reconstruction.

Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture., (Copyright © 2017. Published by Elsevier Inc.)

Aims: To evaluate interobserver reliability of the Orthopaedic Trauma Association's open fracture classification system (OTA-OFC)., Patients and Methods: Patients of any age with a first presentation of an open long bone fracture were included. Standard radiographs, wound photographs, and a short clinical description were given to eight orthopaedic surgeons, who independently evaluated the injury using both the Gustilo and Anderson (GA) and OTA-OFC classifications. The responses were compared for variability using Cohen's kappa., Results: The overall interobserver agreement was ĸ = 0.44 for the GA classification and ĸ = 0.49 for OTA-OFC, which reflects moderate agreement (0.41 to 0.60) for both classifications. The agreement in the five categories of OTA-OFC was: for skin, ĸ = 0.55 (moderate); for muscle, ĸ = 0.44 (moderate); for arterial injury, ĸ = 0.74 (substantial); for contamination, ĸ = 0.35 (fair); and for bone loss, ĸ = 0.41 (moderate)., Conclusion: Although the OTA-OFC, with similar interobserver agreement to GA, offers a more detailed description of open fractures, further development may be needed to make it a reliable and robust tool. Cite this article: Bone Joint J 2018;100-B:242-6., (©2018 The British Editorial Society of Bone & Joint Surgery.)

Open distal radius fractures are rare injuries with few studies to guide treatment. Degree of soft tissue injury and contamination may be a primary consideration to dictate timing and operative intervention. Antibiotics should be started as early as possible and include a first-generation cephalosporin. Surgical fixation remains a matter of surgeon preference: although studies support the use of definitive internal fixation, many surgeons address contaminated injuries with external fixation. Although postoperative outcomes are similar to closed injuries for low-grade open distal radius fractures, high-grade injuries with more complex fracture patterns carry a high risk of complications, poor outcomes, and repeat surgical procedures., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Intraarticular fractures of the distal tibia (pilon fractures) are rare injuries and today they occur mostly in traffic accidents and falls from a great height. There are simple fractures in the context of low-energy traumas, as well as complex comminuted fractures in high-energy traumas. Besides the clinical examination, plain radiographs and computed tomographic scans are diagnostic prerequisites. The aim of the diagnostic process is to clearly identify and classify the fracture before appropriate treatment is initiated. The systems used to classify the displaced distal pilon fractures are supposed to ensure the three-dimensional assessment of the fracture and provide high inter- and intra-observer agreement. In addition to the classification of Rüedi and Allgöwer, the classification of pilon fractures has been carried out using the AO classification.

Introduction: Third degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20 years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb., Material and Methods: A retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of trauma surgery (level I trauma center) and the Clinical division of plastic and reconstructive surgery at the general hospital of Vienna between 1994 and 2014., Results: Fifty-four out of 606 patients (9%) suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson, type IIIA, n=30; Gustilo-Anderson, type IIIB, n=15; Gustilo-Anderson, type IIIC, n=9; traumatic sub-/total amputations, n=7). Thirty-seven out of 54 patients (69%) suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range: 3-10) and 9 (range: 4-50), respectively. Seventeen out of 54 patients (31%) were diagnosed with a MESS≥7. Twenty-one out of 54 patients (39%) suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7., Discussion: It became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study, limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs., Level of Evidence: IV: retrospective or historical series., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Purpose: Type III B and C open tibia fractures in children pose a challenge to the orthopaedic surgeon. Limb salvage is the initial goal for the majority of patients, but managing soft-tissue defects and bone loss can be a challenge. The purpose of this study was to evaluate the use of circular external fixation in the management of these injuries., Methods: In this retrospective review, we examined children with type IIIB and IIIC open tibial fractures treated with circular external fixation and soft-tissue coverage between 1990 and 2010. Chart review included: mechanism and severity of injury, degree of bone and soft-tissue loss, technique and duration of external fixation, additional procedures, clinical and radiographic outcomes, and complications., Results: Eight patients were identified whose average age at the time of injury was 10.4 years (range, 3.8 to 15.3 y). There were 7 type IIIB and 1 type IIIC fractures. All patients received free or rotational soft-tissue flaps. Average bone loss was 5.4 cm (range, 0 to 12 cm). Three techniques of circular external fixation were used, including: (1) static stabilization to allow for soft-tissue coverage and fracture healing, (2) acute shortening with plan for later limb lengthening, and (3) stabilization of the extremity for soft-tissue coverage and intended bone transport. Seven of 8 limbs were salvaged. Of those 7, all were followed to skeletal maturity and ambulating without assistive devices at final follow-up. Three patients had a clinically relevant leg-length discrepancy (≥2 cm). Four of 8 patients required secondary or contralateral procedures., Conclusions: Pediatric type IIIB and IIIC tibia fractures are limb-threatening injuries that require dynamic thinking and management as the bone and soft-tissue injuries evolve. We have proposed a general algorithm to guide the treatment of these severe injuries. In our experience, circular external fixation, in conjunction with this algorithm, provides the appropriate stability and environment for managing soft tissue and bone loss and can facilitate limb salvage., Level of Evidence: Level IV.

Open fractures in children are rare and are typically associated with better prognoses compared with their adult equivalents. Regardless, open fractures pose a challenge because of the risk of healing complications and infection, leading to significant morbidity even in the pediatric population. Therefore, the management of pediatric open fractures requires special consideration. This article comprehensively reviews the initial evaluation, classification, treatment, outcomes, and controversies of open fractures in children., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Open lower leg fractures are the most common open fractures of the locomotor system and their treatment is associated with a number of complications., Objective: The aim of the paper was to present the results of the treatment of 68 patients with open lower leg fractures, as well as the complications that accompany the treatment of these fractures., Methods: In the analyzed group, there were 45 (66.18%) men and 23 (33.82%) women. The majority of patients – 33 (48.53%) of them – were injured in motor vehicle accidents, whereas 24 (35.29%) patients sustained injuries due to falls from heights. In two (2.94%) patients the cause of open tibial fractures was gunshot injuries. In the analyzed group, there were 18 (26.47%) type I open fractures, 21 (30.88%) type II open fractures, 19 (27.94%) type IIIA open fractures, seven (10.29%) type IIIB open fractures, and three (4.41%) type IIIC open fractures., Results: The tibial shaft fracture healed without serious complications in 50 (73.53%) patients, whereas in 18 (26.47%) patients we observed some complications. Nonunion was found in 10 (14.71%) patients, osteitis in four (5.88), malunion in two (2.94%) patients. Milder complications such as soft tissue pin tract infection developed in 13 (19.12%) patients, infection of the open fracture wound soft tissue was observed in four (5.88%) patients., Conclusion: Basic principles in the treatment of open lower leg fractures in this study are thorough primary open fracture wound treatment followed by the delayed wound closure, stable fracture fixation using unilateral external skeletal device, proper antibiotic treatment and tetanus prophylaxis. The results correlate with similar studies.

Background: Most open malleolar ankle fracture wounds can be closed primarily after meticulous debridement. However, the development of wound necrosis following operative treatment of open malleolar ankle fractures can have catastrophic consequences. The aim of this study was to identify risk factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures., Methods: A total of 137 patients with open malleolar ankle fractures were identified. The open fracture wound was primarily closed in 110 of 137 (80%) patients, and postoperative wound necrosis occurred in 18 (16%) of these patients. These patients were compared to the open fracture patients without wound necrosis. Twenty possible risk factors for the development of wound necrosis were studied with logistic regression analysis., Results: The variables that were independently associated with an increased risk for postoperative wound necrosis included ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery., Conclusions: Our study showed that ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery were the most important factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. The findings warrant a further study specifically comparing primary and delayed wound closure in patients with Gustilo grade III open malleolar ankle fractures and different ASA classes. Also, the role of pulsatile lavage should be re-evaluated., Level of Evidence: Level III, retrospective comparative series., (© The Author(s) 2016.)

Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain a therapeutic challenge with varying levels of evidence to support some of the most commonly used practices. Additionally, a significant number of studies on this topic have focused on open tibial fractures. A systematic approach to evaluation and management should begin as soon as immediate life-threatening conditions have been stabilized. The Gustilo classification is arguably the most widely used method for characterizing open fractures. A first-generation cephalosporin should be administered as soon as possible. The optimal duration of antibiotics has not been well defined, but they should be continued for 24 hours. There is inconclusive evidence to support either extending the duration or broadening the antibiotic prophylaxis for type Gustilo type III wounds. Urgent surgical irrigation and debridement remains the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure. Wound sampling has a poor predictive value in determining subsequent infections. Early wound closure is recommended to minimize the risk of infection and cannot be substituted by negative-pressure wound therapy. Antibiotic-impregnated devices can be important adjuncts to systemic antibiotics in highly contaminated or comminuted injuries. Multiple fixation techniques are available, each having advantages and disadvantages. It is extremely important to maintain a high index of suspicion for compartment syndrome, especially in the setting of high-energy trauma., (Copyright 2015, SLACK Incorporated.)

In this study we quantified and characterised the return of functional mobility following open tibial fracture using the Hamlyn Mobility Score. A total of 20 patients who had undergone reconstruction following this fracture were reviewed at three-month intervals for one year. An ear-worn movement sensor was used to assess their mobility and gait. The Hamlyn Mobility Score and its constituent kinematic features were calculated longitudinally, allowing analysis of mobility during recovery and between patients with varying grades of fracture. The mean score improved throughout the study period. Patients with more severe fractures recovered at a slower rate; those with a grade I Gustilo-Anderson fracture completing most of their recovery within three months, those with a grade II fracture within six months and those with a grade III fracture within nine months. Analysis of gait showed that the quality of walking continued to improve up to 12 months post-operatively, whereas the capacity to walk, as measured by the six-minute walking test, plateaued after six months. Late complications occurred in two patients, in whom the trajectory of recovery deviated by > 0.5 standard deviations below that of the remaining patients. This is the first objective, longitudinal assessment of functional recovery in patients with an open tibial fracture, providing some clarification of the differences in prognosis and recovery associated with different grades of fracture., (©2015 The British Editorial Society of Bone & Joint Surgery.)

Background: This study describes a modified classification and management protocol for perineal soft tissue injuries associated with pelvic fractures., Methods: A total of 11 patients with perineal soft tissue injuries associated with open pelvic fractures were studied retrospectively. The patients were classified into three types based on the area of defect: type A (urogenital zone), type B (anal zone), and type C (both urogenital and anal zones). Each type included the following subclasses: A1 (without urethra injuries), A2 (with urethra injuries), B1 (without anorectal injuries), B2 (with anorectal injuries), C1 (with types A1 and B1), C2 (with types A2 and B1), C3 (with types A1 and B2), and C4 (with types A2 and B2). The management protocol was planned according to the individual classifications. Protocol A1 (for type A1) involved skin graft or myocutaneous flap transplantation. Protocol A2 (for type A2) involved the same protocol combined with urine diversion. Protocol B1 (for type B1) involved skin graft or myocutaneous flap transplantation. Protocol B2 (for type B2) involved the same management combined with fecal diversion. Protocol C involved the correspondent protocol used for each subtype of type C., Results: Out of the 11 patients, there were 5, 3, and 3 cases of types A, B, and C, respectively. One patient died due to sepsis, and the wounds of the remaining patients healed well. No anal incontinence had occurred., Conclusions: Perineal soft tissue injuries associated with pelvic fractures can be classified into three types, and the management protocol can be planned according to the classification., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

This study is a single center retrospective chart and radiographic review of patients with open tibia fractures under the age of 16 years of age over past 10 years. The purpose of this study is to investigate the treatment of open pediatric tibia fractures with plating in regards to time to ambulation, time to union, and deformity in comparison to other treatment options. We found that plating open pediatric tibia fractures is a safe treatment option that can lead to excellent results with low risk of complications.

Objective: Is the OTA open fracture classification (OTA-OFC) potentially predictive of early amputation and specific clinical treatments?, Design: Retrospective chart review of prospectively collected data., Setting: Level I trauma center, Seattle, WA., Patients/participants: Three hundred fifty-six patients with open fractures of the femur, tibia, malleoli, humerus, radius/ulna, pelvis, acetabulum, foot, or clavicle., Intervention: No intervention., Main Outcome Measurements: Vacuum-assisted closure placement, 3+ irrigation and debridements, antibiotic bead placement, and early amputation., Results: The OTA-OFC is related to the type of treatment used to treat an open fracture. The model demonstrated that the strongest potential predictor of vacuum-assisted closure use is the severity of the skin injury; multiple debridements (≥ 2) is best predicted by the severity of the skin injury and muscle injury; bone loss was the strongest potential predictor of antibiotic bead placement; and the strongest predictors of early amputation are skin injury, contamination, and arterial injury., Conclusions: Exploratory analysis of these data demonstrates that variations in muscle damage, skin injury, bone loss, arterial injury, and contamination sustained in an open fracture are related to different treatments in the total study population and for anatomical regions. The information provided by this study demonstrates that the OTA-OFC may have predictive abilities relative to how an open fracture is treated., Level of Evidence: Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Radiology-based classifications of pelvic ring injuries and their relevance for the prognosis of morbidity and mortality are disputed in the literature. The purpose of this study was to evaluate potential differences between the pelvic ring injury classification systems by Tile and by Young and Burgess with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries., Patients and Methods: Two-hundred-and-eighty-five consecutive patients with pelvic ring fractures were analyzed for mortality within 30 days after admission, number of blood units and total volume of fluid infused during the first 24h after trauma, the Abbreviated Injury Severity (AIS) scores for head, chest, spine, abdomen and extremities as a function of the Tile and the Young-Burgess classifications., Results: There was no significant relationship between occurrence of death and fracture pattern but a significant relationship between fracture pattern and need for blood units/total fluid volume for Tile (p<.001/p<.001) and Young-Burgess (p<.001/p<.001). In both classifications, open book fractures were associated with more fluid requirement and more severe injuries of the abdomen, spine and extremities (p<.05). When divided into the larger subgroups "partially stable" and "unstable", unstable fractures were associated with a higher mortality rate in the Young-Burgess system (p=.036). In both classifications, patients with unstable fractures required significantly more blood transfusions (p<.001) and total fluid infusion (p<.001) and higher AIS scores., Conclusions: In this first direct comparison of both classifications, we found no clinical relevant differences with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Primary closure of skin wounds after debridement of open fractures is controversial. The purpose of the present study was to determine whether primary skin closure for grade-IIIA or lower-grade open extremity fractures is associated with a lower deep-infection rate., Methods: We identified 349 Gustilo-Anderson grade-I, II, or IIIA fractures treated at our level-I academic trauma center from 2003 to 2007. Eighty-seven injuries were treated with delayed primary closure, and 262 were treated with immediate closure after surgical debridement. After application of a propensity score-matching algorithm to balance prognostic factors, 146 open fractures (seventy-three matched pairs) were analyzed., Results: After application of a propensity score-matching algorithm with adjustment for age, sex, time to debridement, American Society of Anesthesiologists (ASA) class, fracture grade, evidence of gross contamination, and a tibial fracture rather than a fracture at another anatomic site, the two treatment groups were compared with respect to the prevalence of infection. Deep infection developed at the sites of three of the seventy-three fractures treated with immediate closure (infection rate, 4.1%; 95% confidence interval [CI], 0.86 to 11.5) compared with thirteen in the matched group of seventy-three fractures treated with delayed primary closure (infection rate, 17.8%; 95% CI, 9.8 to 28.5) (McNemar test, p = 0.0001)., Conclusions: Immediate closure of carefully selected wounds by experienced surgeons treating grade-I, II, and IIIA open fractures is safe and is associated with a lower infection rate compared with delayed primary closure.

Complete fractures of the tibial pilon are rare and their treatment difficult. The pathophysiology includes three groups: (A) high-energy trauma (motor vehicle injuries), with severe articular and soft tissue lesions, (B) rotation trauma, (skiing accidents), with modest articular and soft tissue damage, and (C) low-energy trauma in elderly people. These three groups occasion very different problems and complications. In emergency situations, these fractures should be stabilized, most often using external fixation to restore length and prepare definitive fixation. The second stage can be applied once soft tissue healing is achieved. Two methods are discussed: internal plating and definitive external fixation. The first goal of treatment is to restore the articular surface, although this does not always prevent secondary arthritis. The second is to restore correct positioning of the foot as regard to the leg. The complication rate is high. Neither of the two fixation techniques has proven to be more effective. In group B, the two methods are similar, but external fixation seems to be safer in group A., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Fractures of the distal tibia are often very severe injuries that generally occur in the context of high-energy trauma and present with significant concomitant soft tissue involvement. Open fractures and extensive destruction of the articular surfaces are important challenges to the treating surgeon. In consequence the outcome for distal meta- and epiphyseal tibial fractures depends largely on the severity of the soft tissue injury and its management. Conventionally, tibial pilon fractures require surgical intervention. Conservative treatment would only be considered in some exceptional cases, for example, inoperability of the patient. Controversial discussion of optimal surgical technique and optimal timing of surgery is ongoing. There is broad consensus that soft tissue consolidation must have first priority as this is the basis for both fracture healing and good long-term outcomes. Surgical intervention can be managed as a one-stage or multi-stage procedure to achieve internal or external fracture fixation.

Any fracture of a bone which communicates with the outside environment via a wound in the skin is classified as an open fracture. This may be from penetration by sharp objects from the exterior, laceration caused by the fracture fragments, or shearing forces that tear or de-glove soft tissue from a limb. These injuries vary in mechanism and severity, ranging from a broken finger caught in a bulkhead door to a catastrophic lower limb fracture suffered from an improvised explosive device (IED). We address the management principles that can be applied to all open fractures regardless of cause.

Objectives: To determine the reliability of the Orthopaedic Trauma Association (OTA) Open Fracture Classification., Design: Video-based reliability study., Setting: Orthopedic meetings and grand rounds., Patients/participants: Orthopedic surgeons., Intervention: None., Main Outcome Measurements: Interobserver reliability assessment classification., Results: The results demonstrate the system to have high reliability and much improvement compared with published Gustilo-Anderson classification reliability studies. Overall interrater reliability (κ) values were highest for arterial injury, with near perfect agreement across all raters and within each value. Skin injury, bone loss, and contamination demonstrated moderate to substantial levels of agreement. Muscle injury had the most disagreement between raters but still demonstrating a fair level of interrater agreement, which is a level of agreement superior to the literature related to the Gustilo-Anderson classification. Levels of agreement were similar between attending surgeons and residents for all categories., Conclusions: This study, which included a diverse multicenter multinational cohort of orthopaedic surgeons and residents, of the OTA Open Fracture Classification demonstrated moderate to excellent interobserver reliability.

The present study is aimed to understand the meaning of living with an external fixation device for grade III open fractures of the lower limbs from the perspective of the patient. The data were collected with six young adults who were undergoing outpatient orthopedic treatment in a public hospital in the city of São Paulo, through semi-structured interviews with open questions, between June and August 2010. Seeking to understand the meaning of this experience, we have maintained a phenomenological attitude during the analysis, which made it possible to reveal the phenomenon "try to live in spite of feeling trapped in a cage." Patients said that their personal desire and support from others helped them reorganize their lives, despite the several challenges they had to overcome to adapt to the fastener attached to their body and the fear of the future and doubts about the success of treatment.

Background: Historically, open pelvic fractures have a high mortality rate. The Jones-Powell Classification system was developed to assist with morbidity and mortality prediction.The purposes of our study were twofold: 1. Apply the Jones-Powell Classification to mortality rates of open pelvic fractures; 2. Because the original article published on the Jones-Powell Classification was from 1997, there have been advances in the early treatment of pelvic fractures to include the use of the pelvic binder, early diverting colostomies, and emergent angiography. We wanted to examine if any of those acute interventions affected mortality rate., Methods: This is a retrospective review of all patients presenting with open pelvic fractures at six Level I trauma centers between 2000 and 2006., Results: There were 64 patients with an average age of 34 years (range, 17-57 years). Fourteen had stable pelvic fracture patterns, and 50 had unstable fracture patterns. The overall mortality rate in our study was 15 patients (23%). All patients who died had an unstable pelvic fracture and/or rectal laceration. Sixteen patients had diverting colostomies within 48 hours of injury. There were four patients with rectal lacerations and no patients with diverting colostomies who died., Discussion: In our population group, there was an overall mortality rate of 23%. A Jones-Powell Class 3 injury had a 38% mortality rate. The presence of a rectal laceration may serve as a marker for the severity of the patient's injuries and increased risk of mortality., Level of Evidence: Epidemiologic study, level IV.

Background: Management of the severely injured lower limb in children remains a challenge despite advances in surgical techniques. Models that predict the risk of lower limb trauma patients are designed to provide an estimation of the probability of limb salvage. In this study, we validate Mangled Extremity Syndrome Index (Mangled Extremity Severity Score [MESS]) by measurement of its discrimination in children., Materials and Methods: From September 2009 to 2010, we collected the hospital records of all children who presented with lower extremity long bone open fractures. The inclusion criteria were I grade, II B, III C open fractures, severe injury to three of four organ systems, and severe injury to two of four organ systems with minor injury to two of four systems that require surgical interventions. Severity of limb injury was measured using MESS. Patients were followed up for 1 year. The discrimination of MESS model in differentiating of outcome in patients was assessed by calculating the area under the receiver operator characteristic plot., Results: We evaluated 200 children referred consecutively to our center. The mean MESS in the amputation group was 7.5 ± 1.59 versus 6.4 ± 2.02 in the limb salvage group (p = 0.04). Amputation rate was 7.5% (n = 15). Percentages of skeletal/soft-tissue injury was different between groups (p = 0.0001). Children in the amputation group showed more tissue injury compared with limb salvage group. The best clinical discriminator power was calculated as MESS ≥ 6.5 (sensitivity = 73%, specificity = 54%)., Conclusion: We assumed that patients with a high risk of amputation can be identified early, and specific measures can be implemented immediately by using MESS with threshold of 6.5., (Georg Thieme Verlag KG Stuttgart · New York.)