Review Article Open Tibial Shaft Fractures: I. Evaluation and Initial Wound Management

Abstract J. Stuart Melvin, MD Open fractures of the tibial diaphysis are often associated with se- Derek G. Dombroski, MD vere and soft-tissue injury. Contamination of the fracture site and devitalization of the soft-tissue envelope greatly increase the Jesse T. Torbert, MD risk of infection, , and wound complications. Management Stephen J. Kovach, MD of open tibial shaft fractures begins with a thorough patient evalua- John L. Esterhai, MD tion, including assessment of the bone and soft tissue surrounding Samir Mehta, MD the tibial injury. Classification of these injuries according to the sys- tem of Gustilo and Anderson at the time of surgical débridement is useful in guiding treatment and predicting outcomes. Administration of antibiotic prophylaxis as soon as possible after injury as well as urgent and thorough débridement, irrigation, and bony stabilization are done to minimize the risk of infection and improve outcomes. The use of antibiotic bead pouches and negative-pressure wound From the Department of Orthopaedic Surgery (Drs. Melvin, therapy has proved to be efficacious for the acute, temporary man- Dombrowski, Torbert, and Esterhai), agement of severe bone and soft-tissue defects. the Division of Plastic Surgery (Dr. Kovach), and the Orthopaedic Trauma and Fracture Service (Dr. Mehta), University of he subcutaneous location of the Pennsylvania, Philadelphia, PA. Tanteromedial tibial surface is the Epidemiology and Patient Dr. Mehta or an immediate family reason for the high proportion of di- Evaluation member is a member of a speakers’ aphyseal fractures that are open. bureau or has made paid Fractures of the tibial diaphysis are presentations on behalf of AO and These fractures are associated with the most common long bone frac- Smith & Nephew, and has received severe bone and soft-tissue injury. ture, and approximately 24% of nonincome support (such as The often high-energy nature of equipment or services), these fractures are open.1 Road traf- commercially derived honoraria, or these injuries can lead to gross con- fic accidents are the mechanism of other non–research-related funding tamination of the bone and soft tis- (such as paid travel) from Wolters sue, thereby greatly increasing the injury in more than half of all open Kluwer Health–Lippincott Williams & risk of infection, nonunion, and tibial shaft fractures, with most of Wilkins. None of the following the remainder caused by falls, sports- authors or an immediate family wound complications. 1 member has received anything of Appropriate initial management of related injuries, and direct blows. value from or owns stock in a open tibial shaft fractures can pro- The high-energy nature of most of commercial company or institution these fractures contributes to the in- related directly or indirectly to the foundly affect the overall outcome. The subject of this article: Dr. Melvin, first step in treatment is assessment of creased proportion of Gustilo type Dr. Dombroski, Dr. Torbert, the patient and the involved extremity. III (ie, high-energy open) injuries. In Dr. Kovach, and Dr. Esterhai. The goals of initial treatment are to ac- their large epidemiologic study, curately define the extent of the injury Court-Brown et al2 found that nearly J Am Acad Orthop Surg 2010;18: 10-19 and minimize the risk of infection 60% of open tibial shaft fractures through prompt administration of an- were Gustilo type III. Copyright 2010 by the American Academy of Orthopaedic Surgeons. tibiotics as well as urgent débridement Because more than half of patients and copious irrigation. with open tibial shaft fracture present

10 Journal of the American Academy of Orthopaedic Surgeons J. Stuart Melvin, MD, et al with other injuries, the initial evalua- Table 1 tion should follow the guidelines of the AO Classification of Soft-tissue Injury in Open Fractures Advanced Trauma and Life Support protocol.2,3 After initial resuscitation, Type of Injury Description a detailed history of the injury should Skin lesion (open be sought, with a focus on the mechan- fracture) ism and setting. Tetanus immunization IO 1 Skin breakage from inside out status should also be determined. Dur- IO 2 Skin breakage from outside in <5 cm, with contused edges ing physical examination of the injured IO 3 Skin breakage from outside in >5 cm, with increased contusion and devitalized edges extremity, special attention should be IO 4 Considerable, full-thickness contusion, abrasion, extensive open paid to the neurovascular examination, , and skin loss status of the compartments, and the ex- IO 5 Extensive degloving tent of soft-tissue injury and contam- Muscle/tendon ination. It is important to compare MT 1 No muscle injury pulses between legs and to observe for MT 2 Circumscribed muscle injury, one compartment only capillary refill. In all patients with an MT 3 Considerable muscle injury, two compartments abnormal vascular examination, the MT 4 Muscle defect, tendon laceration, and extensive muscle contusion fracture should be reduced and the ex- MT 5 /crush syndrome with a wide zone of tremity evaluated using the ankle- injury brachial index or Doppler ultrasonog- Neurovascular raphy. A patient with an ankle-brachial NV 1 No neurovascular injury index of <0.9 should be evaluated with NV 2 Isolated nerve injury angiography. Absent pulse and clinical NV 3 Localized vascular injury ischemia constitute an emergency and NV 4 Extensive segmental vascular injury should prompt angiographic evaluation NV 5 Combined neurovascular injury, including subtotal or even total in the operating room with emergent vascular surgery consultation. Tempo- rary revascularization should be per- Adapted with permission from Rüedi TP, Murphy WM: Soft-tissue grading system of the AO, in Rüedi TP, Buckley RE, Moran CG, eds: AO Principles of Fracture Management. New formed for all arterial injuries, followed York, NY, Thieme, 2000, pp 72-73. by débridement, irrigation, , fasciotomy, and definitive vas- classified according to the standard wounds (usually <1 cm in length) cular repair. Definitive fracture fixation AO/OTA classification scheme; soft- with minimal contamination. Type II is often best deferred until closure of tissue injury is categorized by the injures have a wound >1 cm in the fasciotomies. Compartment syn- damage imparted to three distinct length but do not present with exten- drome can occur in open fractures. Fol- anatomic structures: integument, sive soft-tissue damage, flaps, or lowing initial assessment and in the ab- muscle and tendon, and neurovascu- avulsions. Generally, type II open sence of vascular injury, the wound lar system. Injury to the skin is fur- fractures are low-energy injuries, but should be cleared of gross debris and ther classified as open or closed (Ta- they have more soft-tissue involve- covered with a sterile permeable dress- ble 1). This framework enables ment than do type I fractures. Type ing, after which the limb should be re- accurate classification of the fracture III injuries are high-energy wounds. aligned and immobilized in a well- and associated soft-tissue injury; These have been subclassified into padded splint. The decision to perform however, it is not commonly used in categories A, B, and C. Type IIIA in- limb salvage or to pursue primary am- the United States.4 juries have extensive soft-tissue dam- putation is made at this time. More commonly, open fractures of age secondary to high-energy trauma the tibial diaphysis are classified ac- but have adequate soft-tissue cover- Classification cording to the system of Gustilo and age. Type IIIB injures exhibit severe Anderson.5 First proposed in 1976, periosteal stripping and bone expo- The AO classification system of open this classification was modified to its sure, often associated with massive fractures offers a comprehensive current form in 19846 (Table 2). contamination. The patient with type method of classifying both bony and Type I injuries are low energy and IIIB injury may require treatment soft-tissue injuries. Bony injury is are associated with small soft-tissue with soft-tissue coverage procedures.

January 2010, Vol 18, No 1 11 Open Tibial Shaft Fractures: I. Evaluation and Initial Wound Management

Table 2 the tibial shaft. However, diabetes, HIV status, and smoking, in particu- Gustilo Classification of Open Fractures6 lar, have been associated with de- Type Description layed union as well as a higher rate I Clean wound <1 cm in length and increased severity of infections. II Clean wound >1 cm in length without extensive soft-tissue damage, Aderinto and Keating13 reported flaps, or avulsions deep infection in two of four open IIIA Adequate soft-tissue coverage despite extensive soft-tissue damage, tibial shaft fractures in patients with flaps, or high-energy trauma irrespective of the wound size diabetes. One patient with deep in- IIIB Inadequate soft-tissue coverage with periosteal stripping, often associ- ated with massive contamination fection required transtibial amputa- IIIC Arterial injury requiring repair tion 4 months after intramedullary nailing. Infection rates of 71% to 100% were reported in two series of open fractures in HIV-positive Type IIIC fractures require vascular a series of 1,104 open fractures, Patza- patients.14,15 In addition, a trend to- repair. The full extent of the injury to kis and Wilkins8 showed the tibia to ward nonunion was demonstrated in the deep soft tissue and its viability is be more prone to infection than are HIV-positive persons with open tibia often underestimated on presenta- other long (10.5% [38/363] fracture compared with persons with tion and may not correlate with the versus 5.3% [39/741], respectively). such fracture who were HIV- size of the skin defect. The definitive This is likely because of the large negative. Smoking has been more ex- classification of an open fracture subcutaneous extent of the tibia, tensively evaluated as a factor in should be made in the operating which leads to greater soft-tissue wound healing. Several retrospective room. stripping and increased difficulty in studies have demonstrated decreased Despite the widespread use of the obtaining muscular coverage as well union rates and slower time to heal- Gustilo classification, interobserver as the frequent disruption of signifi- ing as well as increased infection agreement has been reported to be cant portions of the vascular supply. rates and complications in persons only 60%.7 Nevertheless, the Gustilo There is no benefit in obtaining pre- who smoke.16,17 It is important to classification is useful in communi- operative or intraoperative cultures of consider these factors in the treat- cating the severity of open fracture open tibia fracture wounds. In early ment plan and when counseling among surgeons and in helping the studies, routine wound culture indicated patients on their prognosis. Appro- treating physician predict the out- that 8% of predébridement wound cul- priate medical or subspecialist con- come of an open fracture. The tures resulted in infection.10-12 However, sultation to optimize glycemic con- Gustilo classification system also has many subsequent studies have demon- trol or to initiate HIV treatment as prognostic significance; increasing strated that initial wound cultures in well as counseling on smoking cessa- infection rates and worse outcomes the early postfracture setting are inef- tion may improve outcomes in pa- are associated with increasing sever- fective in predicting either infection or tients with open tibia fracture. ity of injury.5,8 Infection rates range the identity of causative organ- from zero to 2% for type I fractures, ism.11,12 Additionally, postdébride- 2% to 10% for type II fractures, and ment wound cultures fail to isolate Antibiotic Prophylaxis 10% to 50% for type III fractures.5,8 the infecting organism in 58% of Antibiotics were long believed to cases.12 Thus, early postfracture prevent infection in open fractures. wound cultures are not routinely rec- However, until publication of the Infection Risk and Wound ommended. In general, wound cul- prospective randomized placebo- Culture ture should be obtained only through controlled study by Patzakis et al10 in sterile technique when clinical signs Infection of an open tibia fracture is 1974, there was no evidence to sup- of infection are present. a serious complication that can lead port this assumption. This series was to significant morbidity, delayed the first to investigate infection rates union or nonunion, and even ampu- Host Factors with respect to specific antibiotic tation. In the absence of antibiotic use. The authors demonstrated a sig- prophylaxis, infection occurs in ap- Many factors contribute to the over- nificant reduction in infection with proximately 24% of open fractures.9 In all outcome of an open fracture of administration of cephalothin (2.4%

12 Journal of the American Academy of Orthopaedic Surgeons J. Stuart Melvin, MD, et al

[2/84 fractures]) compared with no ing single-agent ciprofloxacin with a tinely administered. However, it is antibiotics (13.9% [11/79]) or a regi- combination of cefamandole and important to consider the available men of and streptomycin . Both regimens provided data and avoid the use of broad- (9.8% [9/92]) (P ≤ 0.05). Coagulase- similar rates of infection prevention spectrum antibiotics because their positive Staphylococcus aureus and in type I and II open fractures. How- use has been shown to increase the β-hemolytic streptococci were the ever, for type III open fractures, the risk of nosocomial infections in gen- most common pathogens isolated, infection rate with ciprofloxacin eral as well as the risk of death re- accounting for 14 of the 22 infected alone was 31%, compared with sulting from nosocomial pneumo- 18 wounds. Only two of these infections 7.7% for combined prophylaxis with nia. There is evidence to support a occurred in the cephalothin group. cefamandole and gentamicin. Ap- short course of first-generation ceph- Open tibia fracture was the most alosporin or a similar agent active proximately one third of the frac- common fracture studied in this against gram-positive bacteria as tures in this study involved the tibia. group. This and subsequent series es- prophylaxis for all types of open Based on these results, the authors tablished strong evidence for the effi- tibia fractures.18 Alternatively, a quin- recommended that ciprofloxacin not cacy of first-generation cephalospo- olone can be considered for treat- be used alone as prophylaxis for type rins in the management of open ment in type I and II fractures.20 We III open fractures. The benefits of fractures.10,18 However, investigators recommend that the duration of ini- prophylaxis with fluoroquinolones also concluded that antibiotic pro- tial wound prophylaxis be limited to must be weighed against experimen- phylaxis should include gram- a 24- to 72-hour course.8,22 There is tal evidence suggesting that fluoro- negative coverage as well, which is no clear evidence supporting or op- quinolones adversely affect the early suggested but not directly supported posing the recommendation to ad- phases of bone healing.21 by data. Currently, there are insuffi- minister subsequent 24- to 48-hour cient data to conclude that gram- courses of antibiotic prophylaxis for negative prophylaxis is beneficial in Timing and Duration of each additional surgical procedure the management of open fractures.18 Prophylaxis until definitive wound closure; thus, Penicillin G is commonly recom- this decision must be made at the mended for prophylaxis against Antibiotic prophylaxis should be ini- surgeon’s discretion.18 clostridial myonecrosis.18 However, tiated as soon as possible after in- data are insufficient to support this jury. The benefit of early antibiotic recommendation. Moreover, it is rare prophylaxis was demonstrated by Wound Management for to be re- Patzakis and Wilkins,8 who showed sistant to antibiotics typically used a significantly increased rate of infec- Timing of Débridement and for open fracture prophylaxis.19 Nev- tion in fractures managed with anti- Irrigation ertheless, the importance of adequate biotic prophylaxis >3 hours after in- The timing of initial surgical débride- débridement and delayed closure for jury compared with <3 hours after ment of open tibia fractures is con- wounds thought to be at high risk injury (7.4% versus 4.7%, respec- troversial. Most current guidelines for clostridial myonecrosis (eg, farm tively). However, the appropriate du- recommend that débridement be per- injuries, prolonged ischemia) cannot ration of antibiotic prophylaxis is formed within 6 hours of injury.23 be overemphasized. less clear. There is evidence that However, few recent data exist to Quinolones have been evaluated as shorter courses of antibiotics are as support this recommendation, which an alternative to intravenous cepha- effective as longer courses, but the is believed to stem from Friedrich’s losporins for infection prophylaxis.20 most appropriate duration has not 1898 study of guinea pigs.24 Most of This class of drugs is attractive for been determined. Dellinger et al22 the current literature is unable to several reasons. These drugs offer found no difference in infection rates demonstrate a decreased infection broad-spectrum bactericidal cover- between a 1-day course of cefonicid rate for open tibia fractures that are age, they can be administered orally, sodium (12.7% [10/79]), a 5-day initially débrided within 6 hours of they require less frequent administra- course of cefonicid (11.8% [10/85]), injury compared with those débrided tion, they achieve good bone pene- and a 5-day course of cefamandole later.25 We feel that surgical manage- tration, and can provide prophylaxis (13.1% [11/84]). ment of low-energy, type I open frac- for patients who are allergic to peni- It is clear that antibiotic prophy- tures may be delayed until the fol- cillin. In 2000, Patzakis et al20 pub- laxis reduces the rate of infection in lowing morning; however, although lished the results of a study compar- open fractures and should be rou- the evidence does not mandate the

January 2010, Vol 18, No 1 13 Open Tibial Shaft Fractures: I. Evaluation and Initial Wound Management emergent débridement and irrigation All necrotic tissue is excised, and tiseptic solutions such as povidone- of open tibia fractures within 6 muscle viability is determined by the iodine, Dakin solution, and chlor- hours of injury, treatment should not four Cs: contractility, color, consis- hexidine disrupt the bacterial cell be delayed until the end of an elec- tency, and capacity to bleed.26 Com- wall or membrane; these solutions tive schedule the following evening. pletely free, large cortical bone frag- have not been shown conclusively to 27 Most surgeons agree that highly con- ments may be preserved in a sterile lower infection rates. Additionally, taminated type III open tibia frac- fashion to aid in determining length there exists substantial in vitro evi- tures are best treated with urgent and rotation at the time of fracture dence that these solutions adversely surgical débridement and irrigation. stabilization. However, these frag- affect the viability of host cells ments should be removed before de- grown in cell culture and, thus, that Débridement and Irrigation finitive fixation and closure. Signifi- they should be avoided as additives cant articular fragments should be for irrigation.27 Débridement and irrigation are vi- thoroughly cleansed and retained Antibiotics differ from antiseptics tally important to the successful when possible. In high-energy inju- mechanistically in that antibiotics in- management of open tibia fractures. ries, it is often difficult to fully deter- terfere with bacterial physiology. Although the details and methods of mine the viability of all tissues within Most animal studies have shown an- irrigation are debated, the role of the zone of injury at the time of ini- tibiotic irrigation (typically, bacitra- careful and complete débridement is tial débridement. Repeat débride- cin) to be superior to saline irrigation clear. Gustilo stated that adequate ment at 48- to 72-hour intervals alone at preventing infection in con- débridement is the single most im- should be done to eliminate devital- taminated soft-tissue wound mod- portant factor in the attainment of a ized tissue that subsequently devel- els.27 However, human studies in the good result in the treatment of an ops. orthopaedic literature have failed to open fracture26 (Figure 1). Irrigation is used to supplement demonstrate the superiority of anti- Systematic débridement, beginning systematic and thorough débride- biotic irrigation compared with stan- with removal of gross contamination ment in removing foreign material dard irrigation.27 Moreover, although and debris, should be done as soon and decreasing bacterial load. De- the risk of antibiotic irrigation is as possible in the operating room. spite its importance and the fre- low, it adds cost, may promote resis- However, if the patient is too ob- quency with which irrigation is em- tance, and carries a small risk of ana- tunded for urgent surgical interven- ployed, there is a relative paucity of phylaxis.27 Thus, in the absence of a tion, removing the gross contamina- high-quality literature pertaining to proven benefit in humans, the poten- tion can begin in the resuscitation the optimal solution, volume, addi- tial risks and additional costs of anti- bay or the emergency department. A tive, and method of irrigation for biotic additives should be carefully tourniquet should be applied before open tibia fractures. considered in regard to the irrigation prepping and draping, but it should There are scant animal data sug- of open fractures. not be inflated. Tourniquet use gesting that increasing the volume of Surfactants or soaps have been should be minimized because it is irrigation improves the removal of used in wound irrigation since the more difficult to assess the viability bacteria and debris; however, the op- preantibiotic era. Surfactants work of tissues in the presence of an in- timal volume has not been deter- by disrupting the hydrophobic forces flated tourniquet. Furthermore, an mined.27 Based on the widespread that function in bacterial surface ad- elevated tourniquet may cause addi- availability of 3-L bags of normal sa- hesion. In an in vitro study, Anglen tional ischemic damage to an already line, Anglen27 recommended using et al28 demonstrated that a castile compromised region. The injury 3 L of irrigation for type I fracture, soap solution was several orders of shock wave can devitalize tissues be- 6 L for type II fracture, and9Lfor magnitude more effective than an yond the extent of the skin defect. type III fracture. antibiotic solution in removing a Often, it is necessary to extend the Some surgeons use sterile saline glycocalyx-producing bacteria from traumatic wound to adequately eval- alone for irrigation. The use of anti- stainless steel screws. Bhandari et al29 uate the nature of the soft-tissue in- septics, antibiotics, and surfactants studied the effects of several irrigat- jury and to address bony contamina- in combination with saline has been ing solutions on canine that had tion. Extension of the traumatic studied in an attempt to determine been inoculated with S aureus for 6 wound should be longitudinal and the efficacy of these agents in reduc- hours. They found that a soap solution carefully planned, with consideration ing bacterial load and their effects on best preserved the number and activity made for future rotational flaps. local tissue viability and healing. An- of osteoblasts and removed the great-

14 Journal of the American Academy of Orthopaedic Surgeons J. Stuart Melvin, MD, et al

Figure 1

Treatment algorithm for open tibial shaft fracture. ATLS = Advanced Trauma and Life Support, BMP-2 = bone morphogenetic protein-2, NPWT = negative-pressure wound therapy

January 2010, Vol 18, No 1 15 Open Tibial Shaft Fractures: I. Evaluation and Initial Wound Management

Figure 2 believe that soap added to irrigation Immediate Primary is most useful for all fractures with Wound Closure visible contamination and for those Immediate primary closure of an fractures for which initial débride- open wound is possible when an ade- ment and irrigation is delayed >12 quate amount of viable soft tissue is hours. available to allow closure of an open The effect of irrigation pressure wound without tension. With mod- has also been evaluated. Evidence in- ern antibiotic prophylaxis and surgi- dicates that high-pressure pulsatile cal techniques, immediate primary lavage (HPPL) (nozzle pressure ≥50 wound closure is safe and may psi) is effective in removing bacteria decrease nosocomial infection by 31 and debris from wounds. However, sealing open wounds and providing recent animal studies have suggested biologic coverage. DeLong et al35 that HPPL may be detrimental to managed 87 of 119 open fractures bone and soft-tissue structure as well with immediate primary wound clo- as bone healing and that it may drive sure after irrigation and débride- 27,31-33 The Donati-Allgöwer suture pattern. bacteria into wounds. Has- ment. The authors found no differ- The suture does not exit the singer et al32 evaluated fresh ovine ence in infection or nonunion rates epidermis; instead, it anchors muscle specimens contaminated with compared with delayed closure. No vertically in the dermis on the far bacteria and demonstrated deeper side of the wound. Increasing cases of gas were reported. tension pulls the far side into bacteria penetration and greater bac- Hohmann et al36 found no difference opposition with the near side of the terial retention with HPPL compared in infection rates among type I, II, wound, but this does not seem to with low-pressure lavage. In a simi- and IIIA open tibia fractures man- result in kinking or folding of the 33 skin and, thus, does not lar model, Boyd and Wongworawat aged with primary versus delayed compromise blood flow. (Adapted showed that HPPL penetrates and wound closure. with permission from Sagi HC, disrupts soft tissues to greater a de- In the setting of timely antibiotic pro- Papp S, Dipasquale T: The effect of gree than does low-pressure lavage. phylaxis and thorough débridement suture pattern and tension on 31 cutaneous blood flow as assessed Dirschl et al demonstrated a detri- and irrigation in a healthy host, we rec- by the laser Doppler flowmetry in a mental effect of HPPL on early new ommend that type I through type IIIA pig model. J Orthop Trauma bone formation in New Zealand fracture be closed primarily at the time 2008;22:171-175.) white rabbits that underwent osteot- of initial débridement provided that it omy of the medial femoral condyle is possible to achieve a tension-free clo- est number of bacteria. and subsequent HPPL. In that study, sure. We advocate the use of Donati- More recently, Anglen30 prospec- HPPL was compared with control Allgöwer sutures to minimize the tively randomized patients with open and bulb syringe irrigation groups. A amount of cutaneous vascular compro- fracture of the lower extremity to ei- follow-up study showed that early mise. The Allgöwer modification of the ther irrigation with a solu- new bone formation is inhibited by Donati vertical mattress suture tech- tion or a nonsterile castile soap solu- HPPL pressure ≥50 psi.34 nique was shown in a porcine model to tion. Infection developed in 18% of We have found that continuous have the least effect on cutaneous blood patients irrigated with bacitracin and gravity irrigation via cystoscopy flow compared with simple, horizon- in 13% of patients irrigated with the tubing using 6 to9Lofnormal sa- tal mattress and vertical mattress su- 37 castile soap solution. This difference line (with a soap solution for heavy tures (Figure 2). In wounds with was not statistically significant. Sig- contamination) provides excellent limited soft-tissue viability, lack of nificantly increased wound healing wound irrigation without the poten- soft-tissue coverage, or severe con- problems were reported in the antibi- tial detrimental effects of HPPL, an- tamination, other methods of wound otic irrigation group (P = 0.03). tiseptic, or antibiotics. A prospective coverage should be considered, such Anglen30 concluded that antibiotic multicenter international study is un- as a bead pouch or vacuum-assisted solutions offer no advantage over der way to examine the effects of closure. nonsterile castile soap in the irriga- both fluid pressure (high versus low) tion of open fractures and that anti- and solution type (normal saline ver- Local Antibiotics biotic solutions may, in fact, ad- sus normal saline with soap) on the Local antibiotic-impregnated deliv- versely affect wound healing. We infection rate of open fractures. ery vehicles can be a useful adjunct

16 Journal of the American Academy of Orthopaedic Surgeons J. Stuart Melvin, MD, et al to systemic antibiotic prophylaxis in bead pouch technique at the time of fection in animal models.43,44 These managing large open tibial wounds. reamed intramedullary nailing with delivery vehicles eliminate the need Polymethylmethacrylate (PMMA) delayed wound closure. A notably for removal of PMMA cement and cement is the most commonly used lower rate of deep infection was may reduce the number or volume of antibiotic delivery vehicle. Commer- found in the group managed with a autografts while providing osteocon- cially prepared PMMA beads are not bead pouch and delayed primary clo- ductive and/or osteoinductive mate- available in the United States, so they sure than in the group managed with rial to aid in fracture healing. Beard- must be made by the surgeon. Typi- no bead pouch and with delayed more et al43 created in a goat model a cally, 40 g PMMA is mixed with 3.6 wound closure (4% versus 16%, 12-mm–diameter unicortical defect g , molded into 5- to respectively). The bead pouch tech- in the proximal tibial metaphysis and 10-mm spheres, and strung on suture nique appears to be a useful tempo- contaminated the defect with an in- or wire. Alternatively, a cement rizing option for severely contami- fecting dose of S aureus. Tobra- block spacer may be formed for nated open fractures of the tibial mycin-impregnated calcium sulfate placement in a segmental defect. shaft with inadequate tissue for im- pellets combined with demineralized Most often, are mediate closure. bone matrix was found to be as ef- used because of their broad spectrum Local antibiotics have also been used fective as tobramycin-impregnated of activity and heat stability; how- successfully in the management of large ever, vancomycin and segmental bone loss in open tibia PMMA cement beads in preventing have also been employed. With the fractures. Masquelet et al40 and Pelis- infection. support of the hospital pharmacy, sier et al41 used a two-stage proto- these beads can be prepared sterile col in which antibiotic-impregnated Negative-pressure Wound and peel-packed for immediate use. PMMA cement spacers were inserted Therapy For wounds with inadequate soft- into segmental defects to maintain The Vacuum-Assisted Closure device tissue coverage, local antibiotics are of- length and induce a synovium-like (VAC; Kinetic Concepts, San Antonio, ten administered through the creation foreign-body membrane. This mem- TX) uses continuous subatmospheric of a bead pouch. The area is débrided brane provides a contained space for pressure (typically, 125 mm Hg) applied and irrigated, the antibiotic-im- future cancellous and through an open-cell foam dressing pregnated PMMA beads are placed into has been shown to secrete transform- sealed over a wound to decrease edema, an open fracture defect, and the defect ing growth factor-β1, vascular endo- rapidly increase the amount of granu- is sealed with a semipermeable sterile thelial growth factor, and bone mor- lation tissue, and reduce wound covering. Use of a bead pouch allows phogenetic protein-2. Ristiniemi size.45 The popularity of the VAC de- for high local concentrations of antibi- et al42 used a similar two-stage tech- vice has increased tremendously otic (10 to 20 times higher than sys- nique in the management of 23 open since its introduction, and the device temic administration) and reduces the tibia fractures with substantial bone appears to be a versatile tool in potential for nosocomial contamina- loss (mean, 52 mm). Septopal beads wound management. Parrett et al46 tion. The use of drains in addition to a (Merck, Damstadt, Germany) were observed a shift in their treatment bead pouch is controversial. We prefer placed at the time of wound cover- patterns for open fractures of the not to use drains in combination with age and bone stabilization to pre- lower extremity over a 12-year pe- the bead pouch so as to maintain higher serve the volume of the bone loss riod. Significantly fewer free flaps levels of antibiotics locally. In addition, and to induce a foreign-body mem- were placed in the last 4 years of the frequency of surgical intervention brane. They were removed at a mean their series than in the first 4 years in a patient with an open tibia fracture of 8 weeks after the soft-tissue cover (5% versus 20%, respectively). Ad- may minimize the impact of drains. procedure and were replaced with ditionally, there was an increase in In a series of 1,085 open fractures, iliac crest bone graft within the the use of negative-pressure wound Ostermann et al38 found an infection foreign-body membrane. Twenty- therapy (NPWT), from 7% during rate of 3.7% for those treated with two of the 23 fractures healed after a the middle 4 years (when NPWT was the bead pouch technique and sys- mean of 40 weeks. introduced) to 49% during the final temic antibiotics compared with a More recently, delivery of local an- 4-year period, even though there was 12% infection rate for fractures tibiotics through bioabsorbable vehi- no change in the severity of open managed with systemic antibiotics cles such as calcium sulfate, deminer- fracture. With this shift in wound alone (P < 0.001). Keating et al39 ret- alized bone matrix, and fibrin clots management, a decrease in reopera- rospectively compared the use of the has shown promise in preventing in- tion rates was noted, from 19% in

January 2010, Vol 18, No 1 17 Open Tibial Shaft Fractures: I. Evaluation and Initial Wound Management the first 4 years to 4% in the final 4 extent of damage to the bone and 1. Court-Brown CM, McBirnie J: The years. During this time there was no soft tissues. This is best accom- epidemiology of tibial fractures. J Bone Joint Surg Br 1995;77:417-421. change in infection, amputation, plished at the time of surgical dé- bridement, when classification of the 2. Court-Brown CM, Rimmer S, Prakash malunion, or nonunion rates. These U, McQueen MM: The epidemiology of results were attributed to the intro- fracture according to the system of open long bone fractures. Injury 1998; duction of NPWT and improved lo- Gustilo and Anderson will guide 29:529-534. cal flap techniques. Dedmond et al47 treatment and predict outcome. To 3. American College of Surgeons minimize the risk of infection, anti- Committee on Trauma: ATLS: Advanced came to similar conclusions when Trauma Life Support for Doctors. they reported on the use of the VAC biotic prophylaxis with a first- Student Course Manual, ed 8. Chicago, device for high-energy open tibial generation , along with IL, American College of Surgeons, 2008. appropriate tetanus prophylaxis, shaft fractures in adults, concluding 4. Rüedi TP, Murphy WM: Soft-tissue should be administered as soon as grading system of the AO, in Rüedi TP, that the VAC device likely decreases possible, preferably within 3 hours. Buckley RE, Moran CG, eds: AO the need for free-tissue transfer. Principles of Fracture Management. New Débridement and copious low- Despite the apparent effect of York, NY, Thieme, 2000, pp 72-74. pressure irrigation should begin as NPWT on the method of soft-tissue 5. Gustilo RB, Anderson JT: Prevention of soon after that as is feasible. The an- infection in the treatment of one coverage required, the use of NPWT tibiotic bead pouch technique offers thousand and twenty-five open fractures does not appear to affect the infec- of long bones: Retrospective and additional protection from infection tion rate for wounds that need soft- prospective analyses. J Bone Joint Surg for severely contaminated fractures, Am 1976;58:453-458. tissue coverage. Most infections of and NPWT provides excellent initial open tibia shaft fractures occur sec- 6. Gustilo RB, Mendoza RM, Williams coverage for severe soft-tissue de- DN: Problems in the management of ondary to nosocomial pathogens.18 type III (severe) open fractures: A new fects. Adherence to these guidelines Thus, it has been hypothesized that classification of type III open fractures. will provide the best opportunity for J Trauma 1984;24:742-746. early coverage of the wound with a optimal functional outcomes. 7. Brumback RJ, Jones AL: Interobserver VAC device would lessen the rate of agreement in the classification of open infection. However, Bhattacharyya fractures of the tibia: The results of a et al48 showed that VAC therapy did survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg not allow delay of soft-tissue cover- The second part of this article, Am 1994;76:1162-1166. age >7 days without a significant in- “Open Tibial Shaft Fractures: II. 8. Patzakis MJ, Wilkins J: Factors crease in infection rate. In their se- Definitive Management and Limb influencing infection rate in open ries, type IIIB open wounds were fracture wounds. Clin Orthop Relat Res Salvage,” will be published in the 1989;243:36-40. covered with a VAC device at the February 2010 issue of the Jour- time of initial débridement. The au- 9. Patzakis MJ, Wilkins J, Moore TM: Use nal of the American Academy of of antibiotics in open tibial fractures. thors reported an infection rate of Orthopaedic Surgeons. Clin Orthop Relat Res 1983;178:31-35. 12.5% for wounds that underwent 10. Patzakis MJ, Harvey JP Jr, Ivler D: The definitive coverage at ≤7 days com- role of antibiotics in the management of pared with an infection rate of 57% open fractures. J Bone Joint Surg Am 1974;56:532-541. for those that underwent definitive References 11. Valenziano CP, Chattar-Cora D, O’Neill coverage at >7 days (P < 0.008). A, Hubli EH, Cudjoe EA: Efficacy of Evidence-based Medicine: Levels of primary wound cultures in long bone open extremity fractures: Are they of any evidence are described in the table of Summary value? Arch Orthop Trauma Surg 2002; contents. In this article, level I studies 122:259-261. Open fracture of the tibial shaft can include references 7, 14, 20, and 30. 12. Lee J: Efficacy of cultures in the References 1-3, 11, 12, 17, 18, and 38 management of open fractures. Clin be devastating, involving severe bone Orthop Relat Res 1997;339:71-75. and soft-tissue injury. Contamination are level II studies. Level III studies include references 5, 6, 8, 10, 25, and 13. Aderinto J, Keating JF: Intramedullary of the fracture site as well as devital- nailing of fractures of the tibia in ization of the soft-tissue envelope 35. References 9, 13, 15, 16, 22, 31, diabetics. J Bone Joint Surg Br 2008;90: 638-642. greatly increases the risk of compli- 39, 42, and 48 are level IV studies. cations. The initial assessment and Reference 40 is a level V study. 14. Harrison WJ, Lewis CP, Lavy CB: Open fractures of the tibia in HIV positive management of these fractures can Citation numbers printed in bold type patients: A prospective controlled single- affect functional outcome. It is im- indicate references published within blind study. Injury 2004;35:852-856. portant to accurately assess the full the past 5 years. 15. O’Brien ED, Denton JR: Open tibial

18 Journal of the American Academy of Orthopaedic Surgeons J. Stuart Melvin, MD, et al

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Ann Chir Patterson BM, LEAP Study Group: different irrigating solutions to remove Plast Esthet 2000;45:346-353. Impact of smoking on fracture healing adherent bacteria from bone. J Bone 41. Pelissier P, Masquelet AC, Bareille R, and risk of complications in limb- Joint Surg Am 2001;83:412-419. Pelissier SM, Amedee J: Induced threatening open tibia fractures. membranes secrete growth factors J Orthop Trauma 2005;19:151-157. 30. Anglen JO: Comparison of soap and antibiotic solutions for irrigation of including vascular and osteoinductive factors and could stimulate bone 18. Hauser CJ, Adams CA Jr, Eachempati lower-limb open fracture wounds: A regeneration. J Orthop Res 2004;22:73- SR, Council of the Surgical Infection So- prospective, randomized study. J Bone 79. ciety: Surgical Infection Society guide- Joint Surg Am 2005;87:1415-1422. line: Prophylactic antibiotic use in open 42. Ristiniemi J, Lakovaara M, Flinkkilä T, fractures. An evidence-based guideline. 31. 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