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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 treatment algorithm of open long-bone fractures. The key findings were that primary closure without primary internal fixation and prophylactic antibiotics for Type I and Type II open fractures reduced the risk of infection as much as 84.4% [16], whereas acute internal fixation and primary closure after segmental fractures, extensive lacerations, avulsion, or traumatic amputation resulted in a greater likelihood of subsequent osteomyelitis.

Gustilo and Anderson then prospectively followed more than 350 patients. They categorized open injuries into the familiar three categories, based on wound size, level of contamination, and osseous injury, as follows: Type I = an open fracture with a wound less than 1 cm long and clean; Type II = an open fracture with a laceration greater than 1 cm long without extensive soft tissue damage, flaps, or avulsions; and Type III = either an open segmental fracture, an open fracture with extensive soft tissue damage, or a traumatic amputation. Special categories in Type III were gunshot injuries, any open fracture caused by a farm injury, and any open fracture with accompanying vascular injury requiring repair [16].

Type III open fractures proved the most difficult to classify and treat owing to the varied injury patterns, increased morbidity from associated injuries, massive soft tissue damage or loss over the fracture sites, compromised vascularity, wound contamination, and fracture instability. Infection in Type III open fractures was observed 10% to 50% of the time [17]. With ranges like that, it became evident that the variation in severity, etiology, and prognosis of Type III injuries made a single classification insufficiently specific for the task at hand; the frequency of these injuries (greater than 60% of open fractures are Type III, according to one epidemiologic study [10]), made that issue even more pressing. In response to that problem, these high-energy open fractures were further subclassified by Gustilo et al. into A, B, and C according to the severity of the soft tissue injury, need for vascular reconstruction, and worsening prognosis, as follows [17]: Type IIIA = open fractures with adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma regardless of the size of the wound; Type IIIB = open fractures with extensive soft tissue injury loss with periosteal stripping and bone exposure. This usually is associated with massive contamination [17]; and Type IIIC = open fractures associated with arterial injury requiring repair [17].

A critical limitation of the Gustilo-Anderson classification is its limited interobserver reliability, shown by Brumback and Jones to be only 60% [5] and Horn and Rettig to have a kappa value of 0.53 [19]. Another critical limitation is that the surface injury does not always reflect the amount of deeper tissue damage and the Gustilo-Anderson classification does not account for tissue viability and tissue necrosis, which tend to evolve with time after more severe injuries. Because open fractures may be underclassified on initial evaluation in the emergency department, many investigators agree that definitive classification (that is, the classification that will drive the eventual treatment decisions) of open fractures is best made in the operating room [3, 13, 22, 23]. Gustilo and Anderson [16] emphasized the importance of debridement but Pollak et al. reported time from injury to debridement was not an independent predictor of infection; rather admission to a definitive trauma center had a significant influence on the incidence of infection [28]. Furthermore, Webb et al., in a cohort study of 156 patients, showed that timing of debridement, timing of soft tissue coverage, and timing of bone graft had no effect on patient outcome [30]. Finally, Bowen and Widmaier found that the number of compromising comorbidities to be significant independent predictors of infection [4]. Studies such as these challenge the true prognostic ability of the Gustilo-Anderson classification.

Another limitation is the two studies [16, 17] were unbalanced in their numbers comparing the retrospective and prospective data without rigid statistical analysis; all long-bone open fractures were included despite different bones inherently having different risks of infection owing to their particular soft tissue envelope [16].

Earlier authors recommended against using internal fixation by plates or intramedullary nails in open fractures given the high infection rate of 19% [16], but this no longer applies to current standards of care.

The Gustilo-Anderson classification laid a foundation for management of open fractures, but the management of open fractures continues to evolve. Dellinger et al., in a prospective randomized study of 248 patients with open fractures, reported that a short course (1 day) of antibiotics was not inferior to prolonged use of antibiotics (5 days) [11]. Ostermann et al. reported that treating 845 compound limb fractures with systemic antibiotics and aminoglycoside-polymethylmethacrylate resulted in an overall infection rate of 3.7% compared with the 12% infection rate in patients treated only with systemic antibiotics [24]. Delayed primary closure historically has been used, especially for Type III fractures, but consideration for earlier closure has been reported. Choudry et al., in a retrospective study of Type IIIB midtibia fractures treated either with acute versus delayed closure, reported delayed soft tissue coverage resulted in 64% to 100% nonunion rates [8]. Finally, adjunctive therapies such as rhBMP-2 have been found to significantly reduce secondary interventions, lower hardware failure, and promote faster fracture healing [15], but more recently Aro et al. observed no significant difference in patients treated with rhBMP-2 with intramedullary fixation compared with patients treated only with intramedullary fixation for Type IIB tibia fractures [1].

Multiple systems currently exist for classifying open fractures,of which the Gustilo and Anderson (GA)1 system is probably the most popular.Since its introduction in 1976,1 ithas been adopted worldwide, not least due to its use in stratifyingthe risk of infection based on the classification. In their originalstudy, Gustilo et al1 reportedinfection rates of 44% in their retrospective series and 9% in their prospectiveseries for Type III open fractures. A further study by Gustilo etal2 recommendedsubdivision of Type III fractures into three subtypes, in orderof worsening prognosis, based on the varied severity and prognosisof Type III open fractures. They reported infection rates of 0%for Type I fractures, 2.5% for Type II fractures and up to 52% forType IIIb and IIIc fractures.1,2,3 Although the classification originallydescribed only open tibial fractures, it has since been appliedto other anatomical sites. Despite its clinical use, the definitionsof injury characteristics in the system are imprecise and can leadto variability in interpretation, resulting in suboptimal reliabilityand reproducibility.4 As aresult, over time the classification has been modified without validation,thereby creating even more inherent variability.

To be scientifically sound and justify widespread use, fractureclassifications need to be reliable, reproducible, responsive, clinicallyrelevant, and valid. In 2010, the Classification Committee of theOrthopaedic Trauma Association (CCOTA) therefore proposed a newclassification system for open fractures, in order to overcome someof the shortcomings of the GA classification.5 The Orthopaedic TraumaAssociation Open Fracture Classification (OTA-OFC) comprises fivefactors (Fig. 1): injury to skin, muscle or arteries, bone loss,and contamination.5 Eachof these may be rated mild, moderate, or severe.

The Orthopaedic Trauma Association Open Fracture Classification. This figure was first published in the following study: Evans AR, Agel J, DeSilva GL, et al. A new classification scheme for open fractures. J Orthop Trauma 2010;24:457-464. Reproduced with the permission of Wolters Kluwer Health, Inc.

Although the OTA-OFC offers a more detailed description of openfractures, it must be noted that the classification was originallydeveloped out of expert consensus opinion and is yet to be fullyvalidated. Hao et al8 therefore advisedcaution in the interpretation of their results. The study by Joneset al6 onlyinvestigated the OTA-OFC in the lower limb. Agel et al9 also presented onlya small number of cases, mainly in the lower limb (three tibialshaft, one distal tibia pilon, one distal humerus, and one anklemalleolar fracture), and reported limitations with their video presentationmethodology. The videos were recorded at the time of the initialdebridement, six hours post-injury, and so gave little informationon whether the system is an accurate or useful tool for classifyingopen fractures at the time of initial presentation to the EmergencyDepartment. A comparative inclusion of the corresponding GA classificationscore would have been useful. As the main authors were members ofthe CCOTA, they were likely to have contributed to the developmentof the OTA-OFC. This might have led to some unintended bias in fractureselection and classification and thereby limit the general applicabilityof the OTA-OFC system.

Other novel classification systems have also been proposed previouslyto overcome the well-reported limitations of the GA classification.Rajasekaran et al10,11 published theGanga hospital score in 2006, reporting superior inter- and intraobserverreliability for prediction of amputation, nonunion, and infectionwhen compared with the GA classification. It failed to gain widespreadpopularity due to its limited applicability to only GA IIIa andIIIb open tibial fractures. Garnavos et al12 claimed improved inter- and intraobserveragreement over the AO/Müller long bone fracture classification system13 using the newGarnavos Classification System. Although the system proved simple, reliable,and memorable for classification of tibial fractures, no comparisonwith the GA system is available in the published literature andits use in other long-bone fractures remains unclear. 2b1af7f3a8