Open tibial shaft fractures: a historical perspective

Over the past century, the approach to open tibial shaft fracture management has undergone a drastic transformation. As stated by Decoulx et al in 1969, "Hardly more than 10 years ago, the dogma was the following one: an open fracture of the tibial shaft always means infection […] It is therefore necessary to trim and excise the inoculated tissues as thoroughly as possible and to avoid introducing any metal into the fracture site. Osteosynthesis of open fractures was considered by many as imprudent and almost a therapeutic mistake. Progressively, it was realized that strict immobilizing of the fracture site was the best way of [eradicating] the infection and that osteosynthesis was not an audacious attempt, but a superior therapeutic method."1 Given the significant evolution in the treatment strategies for open tibial shaft fractures and the spectrum of injury that these fracture patterns represent, it is important to review and understand the current principles for this complex injury pattern. During the American Civil War (1861–1865), there was an uptick in the severity of injuries to soldiers due to new developments of rifled musket and bullet.2 Civil War surgeons quickly realized that amputation was the most reliable form of treatment for severe injuries of the extremities and amputation became the most common surgical procedure performed, with an estimated 50,000 amputations performed on both Confederate and Union soldiers throughout the course of the war.2 Shortly after the war, Joseph Lister, influenced by the work of Louis Pasteur, began to experiment with using carbolic acid on wounds and published multiple reports of successfully treated compound fractures with carbolic acid that did not develop infection.3 He eventually began applying carbolic acid as a lotion directly to raw wounds in surgery, as an antiseptic paste to closed wounds, as a spray to decontaminate operating rooms, and advocated that surgeons wear clean gloves and wash their hands and instruments before and after procedures with a 5% carbolic acid solution.3 When World War I (1914–1918) began, not only were antiseptics more routinely used but surgeons also developed a newfound appreciation for the importance of a good debridement of nonviable tissues based on the work of German surgeon P.L. Friedrich.4 In addition, with the use of antiseptics and wound debridement, surgeons were able to treat open tibia fractures with plaster immobilization as opposed to ambulation.4 After World War I, Alexander Fleming revolutionized medicine with the introduction of penicillin, which lead to the discovery of many other antibiotics (sulfa drugs, streptomycin, erythromycin, vancomycin, etc.) throughout the 1940s and 1950s.5,6 The introduction of antibiotics further improved open fracture treatment, with multiple studies between 1948 and 1975 demonstrating decreased infection rates with cephalothin.7–10 The Gustilo–Anderson classification was first described in 1976 and was based on the sentiment that the extent of the soft tissue injury is a critical factor in open fracture management.7,11 The framework of the Gustilo–Anderson classification seems to derive from Konstatin P. Veliskakis, who also recognized the importance of soft tissue injury in open tibial shaft fractures and published on a series of 80 open tibia fractures in 1959 in which he proposed classifying open fractures into 3 "grades" based on the appearance of the wound.12 While Veliskakis is cited in the 1976 Gustilo paper, his contributions are not specifically discussed.11 However, after Gustilo's 1976 publication, the Gustilo–Anderson classification provided a common language for orthopaedic surgeons to use and also helped establish guidelines on appropriate antibiotics based on the degree of soft tissue injury.7 This seminal paper demonstrated that when open fractures were treated with antibiotics before and for 3 days after surgery, the infections rates dropped significantly and recommended a cephalosporin as the standard of care for open fractures based on sensitivity studies.11 The Gustilo–Anderson classification was further modified for type III open fractures in 1984 to better describe the clinical presentation of type III fractures and recommended that type III open fractures receive an aminoglycoside in addition to a cephalosporin or a third generation cephalosporin alone, given the high incidence of gram-negative bacteria in type III open fractures.7,13 Although these guidelines are still considered the standard of care, modifications to the algorithm of open fractures have continued to evolve in the past 50 years.7,8,11,13–15 The second half of the 20th century also brought a huge change in the paradigm of fracture treatment with the inception of the AO group. At the start of the 20th century, tibial shaft fractures were managed similar to other long bone injuries—casting and non–weight-bearing.16 Yet in the early 1900s, Delbet began to advocate for early ambulation after tibial shaft fractures, which was eventually adopted by army hospitals between 1950 and 1960.17,18 The patellar tendon–bearing cast as described by Sarmiento also became popular to encourage early mobilization and knee range of motion.19,20 Open tibial shaft fractures were treated with the same plaster casts and weight-bearing precautions as their closed fracture counterparts, as the belief was still that management with any type of osteosynthesis would lead to infection. However, with the establishment of the AO Foundation in 1958, as well as the development of Kuntscher's nailing techniques after World War II, the use of external fixators, plates, and intramedullary nails gradually became more common.10,21–23 Although some had early success with using dynamic compression plating for the treatment of open tibial shaft fractures, especially in comparison with nonoperative management, it soon became clear that plating open tibial shaft fractures lead to more complications, including an increased infection rate, which only worsened with the severity of the open fracture, likely due to soft tissue stripping in an already sensitive soft tissue bed.24–27 Surgeons subsequently turned to flexible and then rigid intramedullary nailing. When flexible intramedullary fixation (ie, Ender or Lottes nails) was used, type III open tibial shaft fractures experienced the worst outcomes, and although external fixators performed superior to casting, when external fixation was used as a bridge to intramedullary fixation, the results were also poor.10,23,28–30 As nail designs evolved and improved, unreamed then reamed intramedullary nails became increasingly used.31–34 However, it was not until the SPRINT trial, a multicenter blinded randomized trial that included 1319 patients, and was published in 2008 that reamed intramedullary nailing became the standard of care for both closed and open tibial shaft fractures. Yet the difficulty in treating open tibial shaft fractures lies not in the fixation selection, but in the soft tissue management, the degree of soft tissue injury significantly correlates with the risk and incidence of infection.9,23,31,35,36 As early as 1958, there have been proponents for immediate soft tissue coverage for open tibial shaft fractures.37 Although the introduction of timely antibiotics has significantly reduced infection rates, authors have cautioned that "antibiotics, here as elsewhere, may not be substituted for sound surgery," and "the use of antibiotics does not replace adequate toilet of the wound, however, which is the most important prophylactic measure against infection."9,37,38 Subsequent studies have demonstrated superior results when soft tissue coverage is obtained within 7 days of injury, with a delay of coverage beyond 7 days leads to 16% increased risk of infection for every day that coverage is delayed.39,40 In addition, coverage and fixation techniques have evolved to the point where outcomes after limb salvage are equivalent to those following amputation based on the results of the LEAP study.41 Despite all the advances in the past century, there is no perfect algorithm for this complex injury pattern. The purpose of this series was to provide an in-depth review of the many nuances in treatment of open tibial shaft fractures, including soft tissue coverage, fixation strategies, and tools for dealing with complications such as bone loss, osteomyelitis, and nonsalvageable tibias. Although the field has overall improved outcomes, there are still areas for improvement in open tibial shaft fracture management.