Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain a therapeutic challenge with varying levels of evidence to support some of the most commonly used practices. Additionally, a significant number of studies on this topic have focused on open tibial fractures. A systematic approach to evaluation and management should begin as soon as immediate life-threatening conditions have been stabilized. The Gustilo classification is arguably the most widely used method for characterizing open fractures. A first-generation cephalosporin should be administered as soon as possible. The optimal duration of antibiotics has not been well defined, but they should be continued for 24 hours. There is inconclusive evidence to support either extending the duration or broadening the antibiotic prophylaxis for type Gustilo type III wounds. Urgent surgical irrigation and debridement remains the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure. Wound sampling has a poor predictive value in determining subsequent infections. Early wound closure is recommended to minimize the risk of infection and cannot be substituted by negative-pressure wound therapy. Antibiotic-impregnated devices can be important adjuncts to systemic antibiotics in highly contaminated or comminuted injuries. Multiple fixation techniques are available, each having advantages and disadvantages. It is extremely important to maintain a high index of suspicion for compartment syndrome, especially in the setting of high-energy trauma.

Objectives: To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique. Design: Retrospective cohort study. Setting: Four Level 1 Academic Trauma Centers. Patients/Participants: All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018. Intervention: Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6–8 weeks. Main Outcome Measurements: Time to union, number/reason for reoperations, time to full weight-bearing, and any complications. Results: One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12–148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN.” Conclusions: This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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Objectives: To determine whether immediate weightbearing after intramedullary (IM) fixation of extra-articular distal tibial fractures (OTA/AO 43-A) results in a change in alignment before healing. Design: Retrospective review. Setting: Level 1 trauma center. Intervention: IM nailing of distal tibial fractures. Patients/Participants: Fifty-three patients with 54 fractures, all of whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 43-A1, 20 OTA/AO 43-A2, and 16 OTA/AO 43-A3; 20 fractures were open. Main Outcome Measurements: Change in fracture alignment or loss of position. Results: Average change from initial angulation at final follow-up was 0.52 ± 1.49 degrees of valgus and 0.48 ± 3.14 degrees of extension. Final alignment was excellent in 14, acceptable in 28, and poor in 12; 2 fractures went from acceptable initial alignment to poor final alignment; and 2 fractures went from excellent to acceptable alignment. Seven fractures had an improvement in alignment over time. Two fractures required free-flap coverage and 4 required staged grafting because of bone loss. Ten fractures had an unplanned return to the operating room (5 for infected nonunion requiring implant exchange, 3 for infection requiring debridement without implant revision, and 2 for aseptic nonunion). No patient had revision for implant failure. Conclusions: Immediate weightbearing after IM fixation of extra-articular distal tibial fractures (OTA/AO 43-A) led to minimal change in alignment and seems to be safe for most patients. Complications were consistent with those reported in previous non-weightbearing cohorts. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.