Classification of open fractures: the need to modernize

Abstract

classification -the need to modernise IntroductionIt is well known that the clinical outcome of open fractures is, in part, dependent on the injury severity and specifically on the extent of any soft tissue disruption. In order to collect meaningful data, and to offer guidance that is easy to follow, there must be reproducible means of classifying these injuries. With a robust classification system, there should come a sensible management algorithm that is user friendly and not open to misinterpretation. Accuracy of such data supports meaningful research and allows evolution in fracture care. Currently, the most commonly (mis)quoted classification system for open fractures is that of Gustilo and Anderson 1 2 . However, there has been some loss in translation from the original articles 3 . Furthermore, the original Gustilo-Anderson system has several limitations when applied to open fracture management in the current clinical era.Many healthcare systems around the world have algorithms and recommendations for treatment of open fractures. These serve to help achieve predictable outcomes for patients and to set standards against which performance can be measured, often with financial incentives. These algorithms suggest management strategies dependent on the grade of the open fracture as defined in the original Gustilo-Anderson classification.Here, we challenge the validity of the original grading systems and discuss the concept of an ideal system, based on patient reported outcomes and resource consumption in the 21 st century.

Association between the Orthopaedic Trauma Society classification of open fractures and economic costs

“…Theoretically, resource use and economic cost could be associated with the severity of the open fracture and the subsequent risk of complications. Our study confirms this assumption, 21 demonstrating that the OTS classification, which separates simple open fractures, where the wound can be closed primarily at the end of the first surgical debridement, from complex open fractures, where a reconstructive procedure is required, correlates with overall resource use and hence economic cost. The initial hospital admission, including wound and fracture management and inpatient care, was identified as the main cost driver.…”

In response

“…entailing type 2 muscle injury), skin injury domain, and contamination domain. 1,3 Finally, within the arterial injury domain, differentiating between no arterial injury (type 1) and arterial injury without distal ischemia (type 2) may be difficult in cases where an angiogram or CT angiogram is not performed, which would be a critical detail within our study.…”

“…Moderate Artery injury without distal ischemia 3. Severe:Artery injury with distal ischemia" 2,3 Apparently, the authors and reviewers were not aware of this component of the OTA OFC because it was not mentioned in the article. In my opinion, the findings of this article are further support for the utilization of the OTA OFC.…”

Implementing predictive tools in surgery: A narrative review in the context of orthopaedic surgery

“…Using the example of the Gustilo‐Anderson classification, this was first described in 1976 as a prognostic tool to guide surgical treatment of open fractures 68 . Two recent developments significantly increased its implementation in general clinical practice 69 . The first occurred in 2016 with the incorporation of Gustilo‐Anderson concepts into the National Institute for Health and Care Excellence (NICE) guidelines for complex fracture management 70 .…”