Prevention of Infection in
the Treatment of One Thousand
and Twenty-Five Open Fractures
of Long Bones. Retrospective
and Prospective Analyses
Gunasekaran Kumar and Badri Narayan
138.1 Authors
Gustilo RB, Anderson JT.
138.2 Reference
J Bone Joint Surg Am. 1976;58:453–458.
138.3 Institute
Hennepin County Medical Center and University of
Minnesota, Minneapolis, Minnesota.
138.4 Abstract
The article compares two groups of patients with open frac-
tures: a retrospective group I (673 patients 1955–1968) and a
prospective study group II (352 patients 1969–1973).
Between 1955 and 1968 673 open fractures of long bones
(tibia and fibula, femur, radius and ulna, and humerus) were
treated at Hennepin County Medical Center and analyzed
retrospectively, the infection rate was 12 % from 1955 to
1960 and 5 % from 1961 to 1968.
The prospective study from 1969 to 1973,352 was char-
acterized by the introduction of a grading or classification of
the open fractures into three groups, I–III. The guidelines of
treatment included routine bacterial cultures, which revealed
that over 70 % of the open wounds were contaminated,
which in turn required antibiotics to be a prophylactic rather
than a therapeutic measure. The emergency debridement had
G. Kumar, FRCS (Tr & Orth) (*)
B. Narayan, MS (Orth), FRCS (Tr & Orth)
Department of Trauma and Orthopaedics,
Royal Liverpool University Hospital, Liverpool, UK
e-mail: gunasekarankumar@hotmail.com
P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics,
DOI 10.1007/978-1-4471-5451-8_138, © Springer-Verlag London 2014
138
to be “thorough” and the irrigation “copious”. The infection
rate was reduced to 2.5 %.
For the prospective study, patients were managed as fol-
lows: debridement and copious irrigation, primary closure
for Type I and II fractures and secondary closure for Type III
fractures, no primary internal fixation except in the presence
of associated vascular injuries, cultures of all wounds, and
oxacillin-ampicillin before surgery and for 3 days
postoperatively.
For the Type III open fractures (severe soft-tissue injury,
segmental fracture, or traumatic amputation), the infection
rates were 44 % in the retrospective study and 9 % in the
prospective study.
138.5 Summary
At the time this article was published there were no accepted
protocols for management of open fractures other than that
they required emergency treatment and irrigation of the
wound. There were no universal agreements on secondary
wound management, timing of fracture stabilisation and
usage of antibiotics.
Based on the retrospective part of the study, the authors
concluded that primary fixation increased infection rates,
primary closure in high energy injuries also increased infec-
tion rates and prophylactic antibiotics were essential in open
fracture management.
Based on the prospective part of the study, the authors
introduced a new classification for open fractures and pro-
vided a protocol for managing these difficult injuries.
• Open fractures require emergency treatment including
adequate debridement and copious irrigation.
• Primary closure is indicated for type I and II fractures.
Delayed primary closure, including split thickness skin
grafts and appropriate flaps, should be used in type III
open fractures.
• Internal fixation by plates or intramedullary nails should
not be used. External skeletal fixation by skeletal traction
527
528
or pins above and below the fracture site incorporated in a
plaster cast were recommended.
• Open fractures associated even with arterial injury
requiring repair should be treated by skeletal traction
whenever possible instead of primary internal
fixation.
• Antibiotics should be administered before and during sur-
gery. If the wound is closed primarily, the antibiotics are
stopped on the third postoperative day. If the wound is
closed secondarily, the antibiotics are continued for
another 3 days after this procedure.
138.6 Citations
1,424
138.7 Related References
1. Giannoudis PV, Papakostidis C, Roberts C. A review of
the management of open fractures of the tibia and femur.
J Bone Joint Surg Br. 2006;88:281–9.
2. Keating JF, O’Brien PJ, Blachut PA, Meek RN,
Broekhuyse HM. Locking intramedullary nailing with
and without reaming for open fractures of the tibial shaft.
A prospective, randomized study. J Bone Joint Surg Am.
1997;79:334–41.
3. Ostermann PA, Seligson D, Henry SL. Local antibiotic
therapy for severe open fractures. A review of 1085
consecutive cases. J Bone Joint Surg Br. 1995;77(1):
93–7.
4. Kim PH, Leopold SS. Gustilo-Anderson classification.
Clin Orthop Relat Res. 2012;470(11):3270–4.
138.8 Key Message
The system of Gustilo and Anderson is the most commonly
and widely used classification grade of the severity of open
fractures. It describes three grades of increasing severity
based on the size of the open wound, the degree of its con-
tamination and the extent of soft-tissue injury. Type III inju-
ries were later subdivided into Types IIIA, IIIB and IIIC
according to the severity of the soft tissue injury and the need
for vascular reconstruction [1].
The authors stressed the high risk of infection with Type
III injuries and recommended against primary closure of
these wounds.
Routine bacterial cultures on admission (50.7 %) or at
wound closure (20 %) revealed that over 70 % of all open
wounds were contaminated. The article emphasized the
importance of prophylatic antibiotics to treat these contami-
nated wounds.
G. Kumar and B. Narayan
138.9 Why Is It Important
Early attempts by Veliskakis [2] at grading open fractures
were refined by Gustilo and Anderson in 1976. The Gustilo
and Anderson system provided a practical classification of
open fracture wounds that could be used as a basis for treat-
ment decisions. It could allow for comparisons of the results
of treatment among different series and facilitates communi-
cation among surgeons and scientists.
Several treatment principles outlined by Gustilo in this
article have become firmly established, such as emergency
debridement and washout even with jet lavage, as well as the
use of prophylactic antibiotics due to an over 70 % rate of
wound contamination.
The strict management of open fractures with thorough
debridement and copious irrigation as an emergency proce-
dure and the routine therapeutic use of antibiotics remains
today’s gold standard.
138.10 Strengths
The study included a large number of cases from a single
institution with both a retrospective and prospective analysis
on the management of open fractures.
Based on the findings of their retrospective study the
authors undertook a prospective study with standardised pro-
tocols on managing these injuries. During the retrospective
part of the study, antibiotic prophylaxis was changed accord-
ing to microbiology results, which brought down the infec-
tion rates by 50 %. The authors created a classification of
open fractures based on their observations that is still a valid
classification used today.
As a widely known and relatively straightforward system
that has become the standard for classifying open fractures,
the Gustilo-Anderson classification is also useful for educat-
ing residents and other trainees in the treatment of patients
with open injuries [3]
138.11 Weaknesses
During the retrospective study period there were no criteria
to decide on primary internal fixation. There were three dif-
ferent antibiotics protocols and different types of antibiotics
were prescribed during the retrospective study period.
However, the changes in protocols were due to sensitivities
based on the organisms identified in the infected cases.
Unmatched comparisons between primary fixation and
non-operated open fractures were performed that showed
increased infections in primary fixations. Similarly,
unmatched comparisons in the retrospective study between
primary wound closure versus secondary closure showed
higher infection rates in secondary closure group. However
138 Prevention of Infection in the Treatment of One Thousand
primary closure after segmental fractures, extensive lacera-
tions, avulsion, or traumatic amputation resulted in a greater
likelihood of subsequent osteomyelitis.
Only 56 % of patients in the prospective group were fol-
lowed up for 6 months. A substantial number of cases were
lost to follow up. There were no statistical analyses other
than percentages. The authors were unable to recommend an
antibiotic regimen based upon the study findings. It seems
unlikely that the reduction in infection rates was sorely due
to the change in antibiotic regimen alone. No mention is
made when the primary surgery was performed.
The major disadvantage of the original classification was
that the type-III category included a broad spectrum of open
injuries of differing severity and, subsequently, of variable
prognosis. Therefore in 1984 Gustilo, Mendoza and Williams
reclassified the type III injuries into three subgroups based
on the size of the open wound, the degree of contamination
and the extent of soft tissue injury [1]. This was a very
important amendment as it allows for subsequent upward
revision for a wound which demonstrates progressive soft
tissue necrosis following initial evaluation.
The classification system has been criticized because of its
subjective nature. Brumback et al. [4] in a study in which sur-
geons reviewed videotapes of initial wound management and
then classified the open tibia fractures according to fracture
type, found a general agreement among the 245 orthopaedic
surgeons of 60 %. The agreement was case dependent rang-
ing from 42 to 94 %. Horn and Retting found the classifica-
tion to have a kappa value of 0.53 [5]. In defence Gustilo
states the classification system is preliminary at the time of
the initial presentation, and final grading should be done only
after debridement and irrigation has enabled the surgeon to
determine what kind of soft tissue reconstruction is needed
[6]. In addition Gustilo believed open fractures represent a
continuous spectrum of injury and it is somewhat artificial to
classify injuries into specific subsets [7]. Ideally assessment
of all open fractures should include the mechanism of injury,
the appearance of the soft tissue envelope and its condition in
the operating room, the level of likely bacterial contamina-
tion, and the specific characteristics of the fracture [3].
The broad nature of Class III injuries is a definite weak-
ness of the paper, which was subsequently addressed.
The classification system and treatment is based sorely on
the soft tissue injury and essentially ignores the fracture pat-
tern or fracture classification.
One final issue for residents sitting advanced orthopedic
exams is that you can get dragged into semantics with this
classification system. The Gustilo open fracture classifica-
tion was published as two separate articles. The first article,
in 1976, was authored by Gustilo and Anderson but did not
include any subtype for type III open fractures. The second
article, in which type III open fractures were analyzed and
subdivided, was written by Gustilo, Mendoza, and Williams
in 1984. Thus, to quote the Gustilo classification using
529
subtypes for a type III open fracture, the correct reference
would be related to the two articles or to any of the reviews
subsequently written by Gustilo [8].
138.12 Relevance
Open fractures are uncommon injuries. The commonest
open fractures are tibial and are often part of multiple inju-
ries. In the study presented, observations on infections in the
primary closure group showed that majority of them were
high-energy injuries (segmental fractures, extensive soft tis-
sue injuries and primary closure in traumatic amputations).
The retrospective part of the study evaluated 673 open
fractures of long bones in 602 patients to determine the
impact of primary versus secondary closure, use of primary
internal fixation, and routine use of antibiotics in the treat-
ment algorithm of open long-bone fractures. The key find-
ings were that primary closure without primary internal
fixation and with prophylactic antibiotics for Type I and
Type II open fractures reduced the risk of infection as much
as 84.4 %, whereas acute internal fixation and primary clo-
sure after segmental fractures, extensive lacerations, avul-
sion, or traumatic amputation resulted in a greater likelihood
of subsequent osteomyelitis
During the prospective study (1969–1973), the authors fol-
lowed more than 350 patients and classified open fractures
into the familiar three categories based on wound size, level of
contamination, and osseous injury, as follows: Type I (clean
and <1 cm wounds), Type II (>1 cm lacerations without exten-
sive soft tissue damage) and Type III (high energy injuries,
gunshot wounds, farm yard injuries, vascular injuries).
During the prospective part of the study the infection rate
was 2.4 % (previously at 11.4 %). Seventy percent of open
fractures cultured were positive for micro-organisms. The
authors advocate short term use of antibiotics until wound
cover was obtained. Any delay in wound closure provided
opportunity for gram negative organisms to flourish.
The authors observed the poor prognosis for Type III inju-
ries, especially associated with vascular injury that were pre-
viously treated with primary internal fixation that invariably
ended in infection. Therefore because of the high risk of
infection their recommendation was skeletal traction as initial
management of these fractures. They argued strongly against
internal fixation of open fractures with plates or intramedul-
lary nails. This view is not shared by today’s trauma surgeons
and no longer applies to current standards of care [9–11]. The
availability of better intramedullary devices and improved
external fixation techniques has radically changed our atti-
tude towards our management of the osseous injury [12].
However, the management of the soft tissue injury as outlined
by Gustilo in this article is essentially unchanged [13].
Although the Gustilo-Anderson classification laid a foun-
dation for management of open fractures it still continues to
530
evolve. Many of the questions raised by Gustilo’s research
remain unanswered today.
In 2009, the British Orthopaedic Association and the British
Association of Plastic, Reconstructive and Aesthetic Surgeons
modified the guidelines on debridement timing of open tibia
fractures from within 6 h to within 24 h from injury. Several con-
founding factors were present in Gustilo’s original study and it
was difficult to reach definitive conclusions as to which factors
reduced infection rates. A number of studies emerged in support
of debridement within 24 h [14]. The general consensus is that
thoroughness of debridement is more important than its timing:
a well-done debridement by an experienced surgeon is better
than an inadequate debridement performed within 6 h. There is
now a national agreed U.K. protocol for radical and systematic
approach to the management of open tibial fractures.
This paper was a seminal paper in identifying the issues in
managing open fractures and based on the observations, both
retrospectively and prospectively, the authors provide an
excellent protocol for managing open fractures. The principles
of aggressive managing open fractures outlined in this paper
have withstood the test of time and are still valid today [15].
Although many better written articles on open fractures
have been published since Gustilo’s article, they have usually
used a different, less pragmatic approach and therefore cannot
be directly compared. The concern in treating open fractures
still remains high, as the management of open injuries is one of
the biggest and most rewarding challenges in skeletal trauma.
In summary the Gustilo-Anderson classification system
remains the preferred system for categorizing open fractures.
Despite its limited interobserver agreement, good but imper-
fect prognostic ability, and somewhat dated treatment algo-
rithms, no other classification is superior in terms of its
popularity and common use, also correlating well with the
risk of infection and other complications [3]
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III open fractures. J Trauma. 1984;24(8):742–6.
G. Kumar and B. Narayan
2. Veliskakis KP. Primary internal fixation in open fractures of the
tibial shaft the problem of wound healing. J Bone Joint Surg Br.
1959;41(2):342–54.
3. Kim PH, Leopold SS. Gustilo-Anderson classification. Clinical
Orthop Relat Res. 2012;470(11):3270–4.
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tion of open fractures of the tibia. The results of a survey of two
hundred and forty-five orthopaedic surgeons. J Bone Joint Surg
Am. 1994;76:1162.
5. Horn BD, Rettig ME. Interobserver reliability in the Gustilo and
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1993;7:357–60.
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fractures of the tibia. The results of a survey of two hundred and
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7. Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on
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fication. J Shoulder Elbow Surg. 2009;18(4):e32.
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Schemitsch EH, Leece P, et al. Interobserver agreement in the
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Swiontkowski MF. Treatment of type II, IIIA, and IIIB open frac-
tures of the tibial shaft: a prospective comparison of unreamed
interlocking intramedullary nails and half-pin external fixators. J
Orthop Trauma. 1998;12(1):1–7.
11. Lange RH, Bach AW, Hansen Jr ST, Johansen KH. Open tibial frac-
tures with associated vascular injuries: prognosis for limb salvage.
J Trauma. 1985;25:203–8.
12. Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith
RM. Fix and flap: the radical orthopaedic and plastic treatment of
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13. Fischer M, Gustilo R, Varecka T. The timing of flap coverage,
bone-grafting, and intramedullary nailing inpatients who have a
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Joint Surg Am. 2006;73(9):1316–22.
14. Mauffrey C, Bailey JR, Bowles RJ, Price C, Hasson D, Hak DJ,
et al. Acute management of open fractures: proposal of a new mul-
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15. Tornetta P, Bergman M, Watnik N, Berkowitz G, Steuer J. Treatment
of grade-IIIb open tibial fractures. A prospective randomised com-
parison of external fixation and non-reamed locked nailing. J Bone
Joint Surg Br. 1994;76:13–9.