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Open Fractures: Evaluation and Management Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD Abstract Open fractures often result from high-energy trauma and are characterized by variable degrees of soft- tissue and skeletal injury, both of which impair local tissue vascularity. Open fractures communicate with the outside environment, and the resulting contamination of the wound with microorganisms, cou- pled with the compromised vascular supply to the region, leads to an increased risk of infection as well as to complications in healing. In addition, bone, tendons, nerves, and articular cartilage may be exposed and subject to damage. The principles that govern open fracture management include assessment of the patient and classification of the injury, prevention of infection, wound management, and fracture stabilization, including early bone grafting. Management of open fractures can be challenging, and multiple surgical procedures frequently are needed to achieve soft-tissue coverage and fracture union. Assessment and Classification of Open Fractures Patients who present with associated life-threatening injuries should be initially evaluated and resuscitated according to Advanced Trauma Life Support protocols. Injured extremities then should be assessed for neurovas- cular injury and compartment syndrome. The presence of an open fracture wound does not exclude the extremity from the complication of compartment syndrome. 1 In addition, complete assessment of the open fracture includes reviewing the mecha- nism of injury, condition of the soft tissues, degree of bacterial contamination, and characteristics of the fracture. The evaluation of these factors will help to classify the fracture, determine the treatment regimen, and establish the prognosis and potential clinical outcome. In particular, the degree of bacterial contamination and soft-tissue damage is important in classifying an open fracture. Veliskakis 2 proposed a classification system for open fractures that included three types based on in- creasing severity. This concept was refined by Gustilo and Anderson, 3 and their classification system, sub- sequently modified by Gustilo et al, 4 has found widespread application. Type I includes puncture wounds ≤1 cm, with minimal contamination and muscle damage. Type II includes lacerations >1 cm, with moderate soft-tissue injury. Bone coverage is adequate and comminution is minimal. Type III includes three sub- types. Type IIIA involves extensive soft-tissue damage with adequate bone coverage. Usually it is the result of a high-velocity injury with a severe crushing component. Type IIIA also includes heavily contaminated wounds with severe commu- nition and segmental fractures. Type IIIB involves extensive soft-tissue damage, with stripping of the peri- osteum and exposure of the bone. Dr. Zalavras is Assistant Professor, Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA. Dr. Patzakis is Professor and Chairman, The Vincent and Julia Meyer Chair, Chief of Ortho- paedic Surgery Service, University of Southern California University Hospital and Los Angeles County+University of Southern California Med- ical Center, Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine. Reprint requests: Dr. Patzakis, GNH 3900, 2025 Zonal Avenue, Los Angeles, CA 90089-9312. Copyright 2003 by the American Academy of Orthopaedic Surgeons. Open fractures are complex injuries that involve both the bone and surrounding soft tissues. Management goals are prevention of infection, union of the fracture, and restoration of function. Achievement of these goals requires a careful approach based on detailed assessment of the patient and injury. The classification of open fractures is based on type of fracture, associated soft-tissue injury, and bacterial contamination present. Tetanus prophylaxis and intravenous antibiotics should be administered immediately. Local antibiotic administration is a useful adjunct. The open fracture wound should be thoroughly irrigated and débrided, although the optimal method of irrigation remains uncertain. Controversy also exists regarding the optimal timing and technique of wound closure. Extensive soft-tissue damage may necessitate the use of local or free muscle flaps. Techniques of fracture stabilization depend on the anatomic location of the fracture and characteristics of the injury. J Am Acad Orthop Surg 2003;11:212-219 212 Journal of the American Academy of Orthopaedic Surgeons Usually it is associated with heavy contamination and severe comminution of the bone. Coverage using free muscle flaps is necessary. Type IIIC involves any open fracture with ar- terial injury requiring repair, regard- less of the degree of soft-tissue injury. Gustilo et al 5 later classified open fractures more than 8 hours old at presentation as a special category of type III fracture. Despite its wide acceptance, however, the reliability of this classification has been ques- tioned. Brumback and Jones 6 reported that the average agreement among orthopaedic surgeons on the classification of open tibial fractures was 60% overall, which was deemed to be moderate to poor. Classification systems have the inherent limitation of attempting to classify a continuous variable, such as severity of injury, into distinct cat- egories. Nevertheless, the classification of open fractures is important because it directs the attention of the treating surgeon to the presence and extent of injury variables. Misclassi- fication of an open fracture can oc- cur, especially in a patient with a relatively small skin wound. To im- prove the accuracy of the classification of open fractures, the extent and severity of the injury should be assessed only during surgery, after wound exploration and débride- ment, and not at presentation in the emergency department. Prevention of Infection All open fracture wounds should be considered contaminated because of the communication of the fracture site with the outside environment. A contamination rate of approximately 65% has been reported. 3,7,8 Infection is promoted by the bacterial contamination and colonization of the wound, the presence of dead space with devitalized tissues, foreign material, and the compromised host response resulting from poor vascularity and soft-tissue damage. The risk of infection is related to severity of injury. Infection rates range from 0% to 2% for type I, 2% to 10% for type II, and 10% to 50% for type III. 3,8 Pre- vention of infection is based on im- mediate antibiotic administration and wound débridement. Tetanus prophylaxis should be administered based on the patient’s immunization status. Wound Cultures In the early postfracture period, results of wound cultures may indi- cate the most probable infecting organism and determine the patho- gen’s sensitivity to antibiotics. However, the usefulness of initial cultures (obtained either at patient presentation or intraoperatively before and after débridement of open fracture wounds) has been controversial because they often fail to identify the causative organism. 9,10 In one prospective randomized double-blind trial, only 3 (18%) of 17 infections that developed in a series of 171 open fracture wounds were caused by an organism identified by the initial cultures. 11 The predictive value of wound cultures obtained before wound débri- dement is especially low. This may be attributed to early wide-spectrum antibiotic coverage, multiple wound dé- bridements, and late contamination with nosocomial pathogens. 10 Thus, multiple initial cultures are not recommended. Only postdébridement cultures should be obtained, which can be useful in the management of early infections or in wounds with marine or other unusual environmen- tal contamination. Antibiotics The crucial role of antibiotic administration in the management of open fractures was established in a prospective randomized study by Patzakis et al, 7 who demonstrated a marked reduction in the infection rate when cephalothin was administered (2.4% [2/84 fractures]) compared with no antibiotics (13.9% [11/79]) or with penicillin and strep- tomycin (9.8% [9/92]). The antibiotics were administered before wound débridement. However, further questions regarding administration involve selection of antibiotics, including choice of single or combination therapy; duration of therapy; and usefulness of local administration. It is important that, in the set- ting of an open fracture, antibiotics not be considered prophylactic. This term can be confusing because antibiotics routinely administered in orthopaedic elective procedures are prophylactic. But because infection commonly occurs in open fractures not treated with antibiotics, their administration is better viewed as ther- apeutic. Selection The antibiotics used in the management of open fractures should be selected based on the wound micro- biology. Wound contamination with both gram-positive and gram- negative microorganisms occurs; therefore, the antimicrobial regimen should be effective against both types of pathogens. Currently, systemic combination therapy using a first-generation cephalosporin (eg, cefazolin), which is active against gram-positive organisms, and an aminoglycoside (eg, gentamicin or tobramycin), which is active against gram-negative organisms, appears to be optimal, although other combinations also may be effective. Substitutes for aminoglycosides include quinolones, aztreonam, third- generation cephalosporins, or other antibiotics with coverage for gram- negative organisms. Ampicillin or penicillin should be added to the antibiotic regimen when conditions fa- voring development of anaerobic infections, such as clostridial myonecrosis (gas gangrene), are present, as in farm injuries and vascular injuries (ischemia, low-oxygen ten- Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD Vol 11, No 3, May/June 2003 213 sion, and necrotic tissues). The results of cultures obtained after débridement and of antibiotic- sensitivity testing may help in select- ing the best agents for a subsequent surgical procedure or in case of an early infection. The lowest reported infection rate with various systemic antibiotic regimens occurred with combination therapy with a cephalosporin and an aminoglycoside. Patzakis and Wilkins 8 reported that the combination therapy was associated with a 4.6% infection rate (5/109 open tibial fractures), whereas administration of only cephalosporin was associated with a 13% infection rate (25/192). Type I and II open fractures were not analyzed separately, but the distribution of fracture types was comparable between the two groups. Templeman et al 12 proposed administration of a cephalosporin as a single agent in type I and II open fractures. However, cephalosporin does not provide coverage against contaminating gram- negative organisms. Moreover, a potential misclassification of an open fracture because of its small wound size could result in a type IIIA fracture being treated with a single agent. Quinolones are a promising alternative to intravenous antibiotics because they offer broad-spectrum antimicrobial coverage, are bacteri- cidal, can be administered orally with less frequent dosing than intravenous antibiotics, and are well tol- erated clinically. Ciprofloxacin as single-agent therapy is effective in the management of type I and II open fractures. In a randomized prospective study, ciprofloxacin was compared with combination therapy (cefamandole and gentamicin). In- fection rates were similar (6%) in the type I and II fractures; however, in type III open fractures, the ciprofloxacin group had an infection rate of 31% (8/26) compared with 7.7% (2/26) in the combination therapy group. 11 Therefore, in type III open fractures, ciprofloxacin should be used only in combination with a cephalosporin as a substitute for an aminoglycoside. Oral ciprofloxacin can be used for open fracture wounds secondary to low-velocity gunshot injuries because it is as effective as intravenous administration of cephapirin and gentamicin. 13 However, further studies are war- ranted to elucidate the clinical ben- efits of quinolones because their use has been associated with the inhibition of experimental fracture healing and of osteoblasts. 14,15 Duration of Therapy Antibiotics should be started as soon as possible after the injury occurs because a delay >3 hours in- creases the risk of infection. 8 The duration of antibiotic administration is controversial. Dellinger et al 16 demonstrated that a prolonged course of 5-day antibiotic administration was not superior to a 1-day course for prevention of fracture site infections. The duration of therapy should be limited to 3 days, with repeated 3-day administration of antibiotics at wound closure, bone grafting, or any major surgical procedure. 8,12 Local Administration In a series of 1,085 open fractures, Ostermann et al 17 demonstrated that the additional use of local aminoglycoside-impregnated polymethylmethacrylate (PMMA) beads signif- icantly (P < 0.001) reduced the overall infection rate to 3.7%, compared with 12% when only intravenous antibiotics were used. When the types of open fractures were analyzed separately, the reduction of infection was statistically significant (P < 0.001) in only the type III fractures (6.5% versus 20%, respectively, for PMMA beads and intravenous antibiotics). Antibiotic-impregnated PMMA beads are inserted into the open fracture wound, which is subse- quently sealed with a film dressing or similar semipermeable barrier. Commercially available antibiotic- impregnated PMMA beads have not been approved by the Food and Drug Administration for use in the United States, so they must be made by the physician. Forty grams of PMMA beads are mixed with the antibiotic in powder form and are po- lymerized; the beads then are strung onto or incorporated with a bead mold onto a 24-gauge wire. The antibiotic selected should be heat stable, water soluble, and available in powder form and have wide- spectrum antimicrobial activity (for example, 3.6 g of tobramycin mixed with 40 g of PMMA). Vancomycin is not recommended as an initial agent because of concerns regarding resis- tant enterococci. The bead pouch technique is most often used for select type II or type III open fractures. If the anteromedi- al aspect of the tibia is exposed, requiring delayed closure or muscle transfer, the beads are placed inside the bone defect, if present, and on top of the exposed bone. If the soft- tissue coverage is delayed, the bead pouch does not need to be changed because the antibiotics have been shown to elute at levels above the minimum inhibitory concentration for at least 1 month. 18 However, if the patient undergoes repeat dé- bridement, the bead pouch can be changed. The advantages of the bead pouch technique include (1) a high local concentration of antibiotics, often 10 to 20 times higher than that with systemic administration; (2) a low systemic concentration, which protects from the adverse effects of aminoglycosides (although when a tobramycin bead pouch is used, systemic aminoglycoside administration is not needed); (3) a decreased need for the use of systemic aminoglycosides; and (4) sealing of the wound from the external environment with film dressing. This tech- Open Fractures: Evaluation and Management 214 Journal of the American Academy of Orthopaedic Surgeons nique prevents secondary bacterial contamination by nosocomial pathogens, which have been shown to be responsible for many of the infections in type III open fracture wounds. 8,9 In addition, this technique allows for the period for soft- tissue transfers to be safely extended. Also, film dressing establishes an aerobic wound environment, which is important for avoiding cata- strophic anaerobic infections; maintains the local antibiotic within the wound; and promotes patient com- fort by avoiding painful changes of wound dressing. Wound Management Irrigation and Débridement Irrigation is an essential part of wound management; however, the optimal volume, delivery method, and irrigation solution have not been determined. 19 Although high- pressure irrigation improves the re- moval of bacteria and debris, it also may damage the bone. 20 Pulsatile flow per se does not add to the effectiveness of irrigation. Antiseptic solutions may be toxic to host cells and should be avoided. Antibiotic solutions have been shown in animal and in vitro studies to be more effective than saline alone, but clinical data on open fracture wounds are lacking. Detergent solutions help re- move bacteria and appear to be a promising alternative. 21 One protocol is a 10-L saline solution delivered to the wound by gravity tubing, with 50,000 U of bacitracin and 1,000,000 U of polymyxin added to the last li- ter of irrigation fluid. After irrigation of the wound, surgical débridement is the most important principle in open fracture management because nonviable tissues and foreign material enhance bacterial growth and hinder the host’s defense mechanisms. The goal is a clean wound with viable tissues and no infection. A sterile tourniquet is applied to the extremity, to be used only when necessary. Débridement without inflating the tourniquet facilitates identification of viable tissues and prevents additional is- chemic damage to the already traumatized tissues. The injury wound may be insufficient for thorough débridement, as in type I and II open fractures, so the wound usually is extended. Skin and subcuta- neous tissues are sharply débrided back to bleeding edges. Viable muscle can be identified by its bleeding, color, consistency, and contractility. Cortical bone fragments without any soft-tissue attachments are avascular and should be débrided, even if this will result in a large bone defect. Ar- ticular fragments, however, should be preserved even when they have no attached blood supply, provided they are large enough and reconstruction of the involved joint is possible. If necessary, a repeat débride- ment can be done after 24 to 48 hours based on the degree of contamination and soft-tissue damage. In injuries requiring muscle flap coverage, débridement also should be repeated at the time of soft-tissue reconstruction. Wound Closure Wound closure is possible when the available soft tissues are adequate; otherwise, soft-tissue reconstruction will be necessary later. The optimal time for wound closure remains controversial. Primary wound closure after a thorough débridement is not associated with an increased rate of infection, may prevent secondary contamination, and may reduce surgical morbidity, hospital stay, and cost. 22 Neverthe- less, it carries the potential for clostridial myonecrosis, which can lead not only to loss of the limb but also to loss of life. 23 Primary wound closure, inadequate débridement, and inadequate antibiotic therapy increase the risk of these complications. 7 We recommend leaving all open fracture wounds open initially. De- layed wound closure (within 3 to 7 days) prevents anaerobic conditions in the wound, facilitates drainage, allows for repeat débridements at 24- to 48-hour intervals, offers the opportunity to reexamine tissues of questionable viability, and permits use of the antibiotic bead pouch technique. Sealing the wound with film dressing prevents secondary contamination and makes delayed wound closure even more preferable. Dressings are not changed in the surgical ward; instead, the wound remains sealed with film dressing. Split-thickness skin grafts are applied on well-vascularized granula- tion tissue. Small wounds, especially in type I open fractures, may be al- lowed to heal secondarily. In type I and II open fractures, the extended wound made to facilitate débridement can be safely closed primarily, leaving the original injury wound open. 24 Part of the injury wound also can be sutured if it is di- rectly over bone, tendons, nerves, or vessels, but the rest of the wound should be left open. Soft-Tissue Reconstruction Severe damage to the soft tissues, as in type IIIB open fractures, pre- cludes adequate bone coverage, and soft-tissue reconstruction is necessary. A well-vascularized soft-tissue envelope is critically important because it enhances vascularity at the fracture site, promotes fracture healing, allows for delivery of antibiotics, and enhances action of the host defense mechanisms. Soft- tissue coverage prevents secondary wound contamination, desiccation, and damage to bone, articular cartilage, tendons, and nerves. The location and magnitude of the soft-tissue defect determine the choice of method of coverage. Re- construction usually is achieved with local or free muscle transfers. 25 Fasciocutaneous flaps are useful Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD Vol 11, No 3, May/June 2003 215 when dead space is minimal, when the flaps are pliable, and when they facilitate tendon gliding. They may restore sensibility to the affected area if the flap remains innervated. Local pedicle muscle flaps include the gastrocnemius for fractures in the proximal third of the tibia and the soleus for fractures in the middle third. However, for fractures in the distal third of the tibia, free muscle flaps are necessary; commonly used flaps include the rectus abdominis, gracilis, and latissimus dorsi muscles. In considering local muscle flaps, the condition of the muscle to be transferred must be carefully evaluated. Muscle that is traumatized, crushed, or affected by a compartment syndrome should not be transferred; free muscle transfer should be used instead. Pollak et al 26 reported that in the presence of severe osseous injury, use of rota- tional flaps was notably more likely to lead to wound complications compared with free flaps. Soft-tissue reconstruction should be done early, within the first 7 days. Delays beyond this period have been associated with increased complications related to the flap or infection under the flap. 9 Some have ad- vocated that flap coverage be done within 72 hours. 27,28 Godina 27 reported a failure rate of free muscle flaps in <1% (1/134) when done within 72 hours compared with a failure rate of 12% (20/167) when done from 72 hours to 90 days. In the same series, the infection rate was 1.5% (2/134) in the early surgical group compared with 17.4% (29/167) in the late surgical group. Gopal et al 28 showed that results of an early aggressive protocol in type IIIB and IIIC open fractures also were satisfactory. In their series, deep infection developed in 6% of fractures (4/63) that were covered with a flap within 72 hours compared with 29% of fractures (6/21) covered after 72 hours. However, in these studies, the antibiotic-impregnated bead pouch was not used; therefore, secondary contamination may have played a notable role in contributing to the increased infection rate in patients with delayed flap coverage. 9,27,28 Fracture Stabilization Adequate stabilization protects the soft tissues from further injury by fracture fragments and facilitates the host response to bacteria despite the presence of implants. In addition, stable fixation improves wound care and mobilization of the patient and allows for early motion of adjacent joints, which contributes to function- al rehabilitation. The choice of fracture fixation depends on the fractured bone, the location of the fracture (eg, intra- articular, metaphyseal, diaphyseal), and the extent of soft-tissue injury. Available techniques for fracture stabilization include intramedullary nailing, external fixation, and plate- and-screw fixation. More than one technique may be applicable in a specific injury. Intramedullary Nailing Intramedullary nailing is an effective method of stabilization of diaphyseal fractures of the lower extremity. 29-32 It is a biomechanically advantageous method that does not interfere with soft-tissue management. Static interlocking fixation maintains the length and alignment of the fractured bone and thus has expanded the applicability of nailing to unstable, comminuted fracture patterns. However, it disrupts the endosteal bone circulation to a variable degree, especially when the medullary canal is reamed. Open femoral fractures are best treated with reamed intramedullary nailing: Brumback et al 29 observed no infections in 62 type I, II, and IIIA open fractures, although infection developed in 3 (11%) of 27 type IIIB open femoral fractures. Open tibial fractures have been satisfactorily stabi- lized with unreamed intramedullary nailing, 30-33 but controversies remain regarding the role of external fixation and reamed intramedullary nailing in the stabilization of these fractures. Intramedullary Nailing Versus External Fixation Both unreamed intramedullary nailing and external fixation have been used widely in the management of open tibial fractures, but few prospective randomized studies have compared the two techniques. Tornetta et al 30 evaluated the two methods in 29 type IIIB open tibial fractures.All fractures healed and no difference in the infection rate was found. In a prospective series of 174 open tibial fractures, Henley et al 31 reported no difference between unreamed nailing and external fixation regarding infection and bone healing. They observed that the severity of the soft-tissue injury rather than the choice of implant appeared to be the main factor influencing injury site infection and bone healing. However, half-pin external fixators were associated with malalignment in 31% of cases and with a pin tract infection in 50%. A meta-analysis of the management of open tibial fractures demonstrated that unreamed intramedullary nails reduced the risk of revision surgery, malunion, and superficial infection compared with external fixators. 32 Although no advantages in fracture healing and injury site infection have been established, intramedullary nailing is considered preferable to external fixation. It does not re- quire the same high level of patient compliance, and it is aesthetically more acceptable than external fixation. Unreamed intramedullary nailing can be used for types I to IIIA and for select type IIIB open fractures of the tibial diaphysis. An external fixator may be particularly useful in cases with heavy bacterial Open Fractures: Evaluation and Management 216 Journal of the American Academy of Orthopaedic Surgeons contamination, extensive soft-tissue damage, or vascular injury (ie, types IIIB and IIIC). Unreamed Versus Reamed Intramedullary Nailing Unreamed intramedullary nailing has been widely used in open tibial fractures. 30,31,33 Schemitsch et al 34 showed in a sheep tibia model that endosteal blood flow at comple- tion of the procedure was reduced to 18% of the level prior to nailing when reaming was done whereas it was reduced to only 44% with unreamed nailing. Unreamed nailing preserves endosteal blood supply to a greater degree than does reamed nailing. 34,35 Thus, it may be preferable in open tibial fractures, in which periosteal vascularity may be already compromised by the traumatic insult. Reamed nailing, on the other hand, allows insertion of larger-diameter implants, improves stability at the fracture site, and helps reduce implant failure. More- over, the cortical circulation that was disrupted during reaming is gradu- ally reconstituted, although more slowly than unreamed nailing. 35 Two prospective randomized studies compared reamed with unreamed nailing in open tibial fractures; neither established a significant difference in infection rates. 36,37 Keating et al 36 reported an infection rate of 2.5% (1/40) in fractures treated with the unreamed nailing technique versus 4.4% (2/45) in fractures treated with the reamed nailing technique. Finkemeier et al 37 observed infection rates of 3.8% (1/26) in unreamed nailing and 5.3% (1/19) in reamed nailing. In both studies, a reduced incidence of screw failure was seen in the group undergoing the reamed nailing technique. Choice of technique remains controversial. Interestingly, surgeons who prefer unreamed nailing try to insert a nail of sufficient diameter to accommodate larger locking bolts, whereas surgeons who prefer reamed nailing tend to insert smaller nails, resulting in little difference between the techniques. However, clinical experience with reamed nailing is limited, whereas many investigators have document- ed satisfactory experience with unreamed nailing, including its use with type IIIB open fractures. 30,31,33 The unreamed nailing technique can be used even in type I open tibial fractures to reduce damage to bone vascularity. External Fixation External fixation can be helpful in wounds with severe soft-tissue damage and contamination because it avoids hardware implantation and does not compromise fracture vascularity. External fixation is techni- cally expedient and is associated with minimal blood loss. It is applied at a site distant to the injury and thus does not interfere with wound management. External fixation is suitable for diaphyseal tibial fractures because of the subcutane- ous location of the bone, and it be- comes a more attractive option than intramedullary nailing moving to the proximal or to the distal tibia, if the size of the proximal or distal fragment does not allow for stabilization with a nail. Ring or transartic- ular fixators are useful for periartic- ular fractures. Spanning external fixation is becoming popular and may be safely converted to another method when applied away from the zone of injury. Many authors 38-40 have reported on the effectiveness of external fixation as definitive treatment as well as the value of early bone grafting in severe injuries. 38-40 Marsh et al, 40 in a prospective study of 101 type II and III fractures, reported that 96 fractures (95%) healed, 95% of them with <10° of angulation in any plane, and that 6 fracture sites (6%) were in- fected. To avoid healing complications, early bone grafting should be considered for comminuted fractures without cortical contact and for fractures with bone defects treated with external fixation. External fixation may be accom- panied by pin tract infections and fracture malalignment. These complications can be avoided by the selection of compliant patients; imple- mentation of an external fixation protocol, which includes the use of half-pins inserted after predrilling to avoid thermal necrosis of bone; and meticulous care of the pin tract. A considerable proportion of the complications associated with external fixation can be attributed to the tran- sition to another form of fixation. In- fection has been reported at a rate approaching 50% after conversion of the external fixation to delayed intramedullary nailing. 9,41 However, in these series, infection was associated with a prior pin tract infection in the majority of patients. Blachut et al 42 showed that by early (mean, 17 days) conversion of the fixator to a nail in the absence of pin tract infections, infection developed in only 5% of patients. Loss of alignment frequently occurs when the fixator is prematurely removed and the patient is transferred to a brace. 38 In heavily contaminated open fractures, temporary external fixation can be a useful option. Howev- er, to minimize the chance of bacterial colonization of the pin tracts, conversion to intramedullary nailing should be done in the absence of pin tract infections and when the fixator has been present for only a short time. 42 Otherwise, the fixator should be maintained until fracture healing. Plate Fixation Plate fixation is useful in intra- articular and metaphyseal fractures because it stabilizes an accurate restoration of joint congruency and ori- entation. In diaphyseal fractures of the upper extremity, plate fixation is often the method of choice. Plate fixation in open tibial fractures has been associated with an increased Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD Vol 11, No 3, May/June 2003 217 incidence of infection and hardware failure. 43,44 Bach and Hansen 43 reported wound infection in 35% (9/ 26) and fixation failure in 12% (3/26) of type II and III open tibial fractures. Clifford et al 44 observed implant failure in 7 of 97 open tibial fractures and infection in 4 of 9 type III fractures. New plating techniques using fixed-angle plate screw devic- es are characterized by minimally in- vasive insertion and preservation of bone vascularity, and they may prove to be a useful alternative for metaphyseal fractures, especially when intra-articular extension is present. However, to date, no pub- lished data are available to support their use. Early Secondary Procedures to Stimulate Healing In the presence of bone defects or delayed healing, early bone grafting can expedite healing. With bone defects, the preferred timing for bone grafting ranges from 2 to 6 weeks after soft-tissue coverage. 38,45 Waiting for 6 weeks after a soft-tissue transfer ensures the absence of infection and restoration of the soft-tissue envelope. Then the existing defect is bone grafted. Depending on the fracture pattern, grafts are applied either at the fracture site beneath a flap or posterolaterally away from the site of injury. Early bone grafting in the absence of a bone defect also may be necessary when healing is delayed and no callus is apparent on radio- graphs at 8 to 12 weeks. Autogenous bone graft remains the method of choice. The usefulness of graft substitutes in the management of defects associated with open fractures has not been shown to be effective. Exchange nailing is another option to stimulate healing in cases of delayed union, provided no infection or bone defect is present. Infec- tion necessitates additional débride- ment, whereas bone defects should be managed with bone grafting. Summary Assessment and classification of open fractures should be done intraoperatively based on the degree of bacterial contamination, soft-tissue damage, and fracture characteristics. To avoid the complication of clostridial myonecrosis, the wound should be thoroughly irrigated and débrided and not closed primarily. Early, systemic, wide-spectrum antibiotic therapy is necessary to cover both gram-positive and gram- negative organisms. A 3-day administration of a first-generation cephalosporin and an aminoglycoside, supplemented with ampicillin or penicillin for injuries occurring on a farm and for vascular injuries, is a critically important part of effective treatment. Local antibiotic delivery with the bead pouch technique can prevent secondary wound contamination. In the presence of extensive soft-tissue loss and exposed bone, coverage is accomplished with early transfer of local or free muscle flaps. Stable fracture fixation is important; the method chosen depends on the bone and soft-tissue characteristics. Early bone grafting is indicated for bone defects, unstable fractures treated with external fixation, and delayed union. References 1. Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim NA: Compartment syndrome in open tibial fractures. J Bone Joint Surg Am 1986;68:1348-1353. 2. Veliskakis KP: Primary internal fixation in open fractures of the tibial shaft: The problem of wound healing. J Bone Joint Surg Br 1959;41:342-354. 3. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thou- sand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976; 58:453-458. 4. 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