DOI: 10.1097/BOT.0b013e31806dba31
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Issn Print: 0890-5339
Publication Date: 2007/07/01
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Excerpt
Congratulations to the authors for an excellent article entitled “The Use of Negative-Pressure Wound Therapy (NPWT) in the Temporary Treatment of Soft Tissue Injuries Associated with High-Energy Open Tibial Shaft Fractures” (J Orthop Trauma. 2007;21:11-17 ).1 This technique is truly an advance in care, and these investigators have been pioneers in its use. However, there is a minor correction needed in an otherwise outstanding article. They have succumbed to a very common error in fracture classification by their definition of a type IIIB open fracture.
The IIIB open fracture was defined in 1984 in an article in the Journal of Trauma by Gustilo and co-authors.2 The definition given is as follows: “Extensive soft tissue injury with periosteal stripping and bony exposure. This is often associated with massive contamination.” Note there is no mention of what treatment may be required. Unfortunately, through common usage, the type IIIB fracture has come to be defined as any open fracture “requiring a flap.” This definition is frequently taught from the podium, promoted in textbooks and research articles, and used by sophisticated trauma surgeons such as these authors. It has even been suggested in print by Dr. Gustilo himself.3
However, defining a fracture classification by what type of treatment is “required” is illogical and invites many problems. Ideally, treatment should be directed by classification, not the other way around. One of the purposes of using any classification is to direct treatment.3 However, using that definition, no fracture could be classified until treatment is completed-or at least until soft tissue closure has been performed. Indeed, in 10 of the authors' 24 “type IIIB” fractures, no flap was performed, and in 7 of the 24 “type IIIA” fractures, flaps were ultimately used. Does that mean that 17 of these 48 fractures were misclassified? How would one classify an open fracture when the initial treating surgeon feels a flap is required, but the consulting soft tissue surgeon does not? What about the massively contaminated and stripped fracture where an amputation, not a flap, is the required procedure? There is a spectrum of techniques for tissue transfer or rearrangement, and it is not clear what constitutes a “flap.” Would it include, for example, a bipedicle fasciocutaneous closure, such as “relaxing” incisions? What about the old technique of “pie-crusting” the skin?
The situation in which a flap is “required” varies tremendously both geographically and temporally, based on factors such as the availability of microvascular surgeons or the use of new technology. Anecdotally, many trauma centers have noticed a decline in the use of flaps but do not note a decrease in the incidence of severe open fractures. Treatment indications change with time.
Dr. Brumback and colleagues have pointed out to us the variability in interobserver classification of open fractures.4,5 That problem is worsened by variability in definition. We need to develop classification systems with less subjectivity and better reliability. In the meantime, I would urge us all to teach that the definition of a type IIIB open fracture is not based on what treatment is felt to be required at some arbitrary point in time, but on characteristics of the injury itself, specifically periosteal stripping and exposed bone.
