Where Are We in 2022? A Summary of 11,000 Open Tibia Fractures Over 4 Decades

Abstract

Objectives: To determine the infection and nonunion rates for open tibia fracture treatment over the past 4 decades since the introduction of the Gustilo–Anderson (GA) open fracture classification. Data Sources: PubMed, Scopus, CINAHL, and Cochrane databases were reviewed using the PRISMA checklist for articles between 1977 and September 2018. Study Selection: One hundred sixty-one articles meeting the following inclusion criteria: English language, published between 1977 and 2018, reported infection rates, reported nonunion rates, and fractures classified by the GA open fracture criteria were selected. Data Extraction: All articles were thoroughly evaluated to extract infection and nonunion data for open tibia fractures. Data Synthesis: Due to variability in the data reviewed, statistical evaluation could not be reliably done. Results: 11,326 open tibia fractures were reported with 17% type I, 25.2% type II, 25.3% type IIIA, and 32.5% type IIIB/C. The average infection rate over 4 decades was 18.3%, with 24.3% superficial, 11.2% deep, and 14.7% pin tract. The infection rate by decade was 14% for 1977–1986, 16.2% for 1987–1996, 20.5% for 1997%–2006%, and 18.1% from 2007 to 2017. The overall nonunion rate was 14.1%. The nonunion rate was 13% for 1977–1986, 17% for 1987–1996, 12.8% for 1997%–2006%, and 12.3% for 2007–2017. Conclusions: This in-depth summary has demonstrated that the percentage rate for infections and nonunion has remained similar over the past 40 years. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A meta-analysis of the incidence of infections following open tibia fractures and the microorganisms that cause them in high-, middle- and low-income countries

“…The highest incidence of infection amongst these trials was conducted in Uganda 37 which included a higher rate of patients with Gustilo Anderson III fractures, which are known to be associated with higher rates of infection. 38,39 Large prospective observational studies in LMICs have shown a low rate of infection following operative management of people with fractures. 18 The high incidence of infection reported in our one selected article may be due to the increasing incidence of severe fractures, delays in operative management or availability of plastic surgeons.…”

Classification of open tibia fractures: the rationale for a new classification system

“…Despite advances in antibiotic therapy, debridement, and fixation strategies, the numbers remain largely unchanged. 5 Gustilo et al 6 A progressively worsening prognosis was seen within these subtypes as IIIA injuries had a 4.4% infection rate with no amputations, IIIB injuries had a 52% infection rate with 16% leading to amputation, and IIIC injuries had a 42% infection rate with a 42% amputation rate. Over time, there have been numerous attempts to modify the Gustilo classification.…”

“…Despite advances in antibiotic therapy, debridement, and fixation strategies, the numbers remain largely unchanged. 5 Gustilo et al 6 further subclassified type III open fractures into 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; IIIB: open fractures with extensive soft-tissue injury loss with periosteal stripping and bone exposure, which are usually associated with massive contamination; and IIIC: open fractures associated with arterial injury requiring repair. A progressively worsening prognosis was seen within these subtypes as IIIA injuries had a 4.4% infection rate with no amputations, IIIB injuries had a 52% infection rate with 16% leading to amputation, and IIIC injuries had a 42% infection rate with a 42% amputation rate.…”

Prevention and treatment of osteomyelitis after open tibia fractures

“…Advances in fracture fixation, soft-tissue management, and antimicrobial therapy have significantly improved treatment options for patients. 14 Institutional algorithms and protocols for treating open tibia fractures, and open fractures in general, should be developed on evidence-based recommendations. We aim to briefly summarize the key, evidence-based interventions, which improve outcomes and prevent infection and osteomyelitis after open tibia fractures.…”