Gustilo, J Bone Joint Surg Am 1976 - Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones: Retrospective and Prospective Analyses
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Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones: Retrospective and Prospective Analyses
Gustilo, Anderson·J Bone Joint Surg Am·1976·3,211 citations·Retrospective cohort
Gustilo and Anderson set out to settle how open long‑bone fractures should be closed, whether they should be fixed internally at once and how antibiotics should be used to prevent infection.
Retrospective review of 673 open long‑bone fractures (1955 to 1968) plus a prospective protocol series of 352 (1969 to 1973) at Hennepin County Medical Center.
Methods
Design
Retrospective review, 1955 to 1968
Prospective protocol series, 1969 to 1973
Patients
673 retrospective fractures in 602 patients
352 prospective fractures
Tibia and fibula, femur, radius and ulna, humerus
Follow‑up available for 326 of 352 prospective fractures
Basis
Wound length (1 cm cutoff)
Extent of soft‑tissue damage
Segmental fracture or traumatic amputation
Special injury categories (gunshot, farm, vascular repair)
Key Findings
Infection was 2.5% in the prospective protocol series, vs 12% (1955 to 1960) and 5% (1961 to 1968) in the retrospective review.
Type III fractures had a 44% infection rate in the retrospective review vs 9% under the prospective protocol.
70.3% of 158 prospective patients with complete cultures had bacterial growth on admission or at wound closure.
Of 143 prospective isolates, 86 were gram‑positive and 57 were gram‑negative.
Coagulase‑positive Staphylococcus aureus led the retrospective pathogens, isolated in 26 patients.
Based on sensitivity testing, the authors suggested cephalosporin as the preferred prophylactic agent at that time.
Board pearl
Any open fracture from a gunshot or a farm injury, or with vascular injury needing repair, was placed in Type III as a special category.
Gustilo‑Anderson open fracture typesGustilo, J Bone Joint Surg Am 1976
Type I
Wound under 1 cm and clean
Closed primarily under the protocol. Antibiotic: first‑generation cephalosporin.
Type II
Laceration over 1 cm without extensive soft‑tissue damage, flaps or avulsions
Closed primarily under the protocol. Antibiotic: first‑generation cephalosporin.
Type III
Open segmental fracture, extensive soft‑tissue damage or traumatic amputation. Gunshot, farm injury and vascular injury needing repair are special categories.
Left open for delayed closure. Infection fell from 44% to 9% under the protocol. Antibiotic: add an aminoglycoside.
Modified later
Type IIIA
Bone still adequately covered despite extensive laceration or flaps, or any high‑energy injury whatever the wound size
Type IIIB
Soft‑tissue loss with periosteal stripping and exposed bone, usually heavily contaminated
Type IIIC
Arterial injury that needs repair
Authors' conclusion
Sensitivity studies suggested that cephalosporin is currently the prophylactic antibiotic of choice. For the Type III open fractures (severe soft-tissue injury, segmental fracture, or traumatic amputation), the infection rates were 44 per cent in the retrospective study and 9 per cent in the prospective study.
Gustilo and Anderson set out to settle how open long‑bone fractures should be closed, whether they should be fixed internally at once and how antibiotics should be used to prevent infection.
Retrospective review of 673 open long‑bone fractures (1955 to 1968) plus a prospective protocol series of 352 (1969 to 1973) at Hennepin County Medical Center.
Methods
Design
Retrospective review, 1955 to 1968
Prospective protocol series, 1969 to 1973
Patients
673 retrospective fractures in 602 patients
352 prospective fractures
Tibia and fibula, femur, radius and ulna, humerus
Follow‑up available for 326 of 352 prospective fractures
Basis
Wound length (1 cm cutoff)
Extent of soft‑tissue damage
Segmental fracture or traumatic amputation
Special injury categories (gunshot, farm, vascular repair)
Key Findings
Infection was 2.5% in the prospective protocol series, vs 12% (1955 to 1960) and 5% (1961 to 1968) in the retrospective review.
Type III fractures had a 44% infection rate in the retrospective review vs 9% under the prospective protocol.
70.3% of 158 prospective patients with complete cultures had bacterial growth on admission or at wound closure.
Of 143 prospective isolates, 86 were gram‑positive and 57 were gram‑negative.
Coagulase‑positive Staphylococcus aureus led the retrospective pathogens, isolated in 26 patients.
Based on sensitivity testing, the authors suggested cephalosporin as the preferred prophylactic agent at that time.
Board pearl
Any open fracture from a gunshot or a farm injury, or with vascular injury needing repair, was placed in Type III as a special category.
Gustilo‑Anderson open fracture typesGustilo, J Bone Joint Surg Am 1976
Type I
Wound under 1 cm and clean
Closed primarily under the protocol. Antibiotic: first‑generation cephalosporin.
Type II
Laceration over 1 cm without extensive soft‑tissue damage, flaps or avulsions
Closed primarily under the protocol. Antibiotic: first‑generation cephalosporin.
Type III
Open segmental fracture, extensive soft‑tissue damage or traumatic amputation. Gunshot, farm injury and vascular injury needing repair are special categories.
Left open for delayed closure. Infection fell from 44% to 9% under the protocol. Antibiotic: add an aminoglycoside.
Modified later
Type IIIA
Bone still adequately covered despite extensive laceration or flaps, or any high‑energy injury whatever the wound size
Type IIIB
Soft‑tissue loss with periosteal stripping and exposed bone, usually heavily contaminated
Type IIIC
Arterial injury that needs repair
Authors' conclusion
Sensitivity studies suggested that cephalosporin is currently the prophylactic antibiotic of choice. For the Type III open fractures (severe soft-tissue injury, segmental fracture, or traumatic amputation), the infection rates were 44 per cent in the retrospective study and 9 per cent in the prospective study.