What is the Gustilo (Gustilo classification) for open fractures?

From the Guidelines

The Gustillo classification system is a crucial tool for categorizing open fractures, guiding treatment decisions, and improving patient outcomes, with the most recent and highest quality evidence recommending prompt surgical debridement, irrigation, and appropriate antibiotic therapy, such as cefazolin or clindamycin, with additional gram-negative coverage for Type III open fractures 1.

Key Principles of Gustillo Classification

• The Gustillo classification system categorizes open fractures into three main types: Type I (clean wound less than 1 cm with minimal soft tissue damage), Type II (wound larger than 1 cm with moderate soft tissue injury), and Type III (most severe, subdivided into IIIA, IIIB, and IIIC) 1.
• Treatment generally includes prompt surgical debridement, irrigation, appropriate antibiotic therapy, fracture stabilization, and wound management, with the goal of preventing infection, promoting healing, and minimizing complications 1.
• The classification is important because higher grades correlate with increased risk of infection, delayed union, and other complications, thus requiring more aggressive management approaches 1.

Antibiotic Therapy Recommendations

• For Type I and II open fractures, a first-generation cephalosporin, such as cefazolin, is recommended, while for Type III open fractures, additional gram-negative coverage with an aminoglycoside, such as piperacillin-tazobactam, is preferred 1.
• Local antibiotic prophylactic strategies, such as vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails, may be beneficial, but the evidence is moderate, and the decision should be made on a case-by-case basis 1.

Importance of Early and Appropriate Treatment

• Early and appropriate treatment based on the Gustillo classification significantly improves outcomes in patients with open fractures, reducing the risk of infection, delayed union, and other complications 1.
• Prompt surgical debridement, irrigation, and antibiotic therapy are critical components of treatment, and should be initiated as soon as possible after injury 1.

From the Research

Gustillo Classification

• The Gustillo classification is a system used to classify open fractures based on the type of fracture, associated soft-tissue injury, and bacterial contamination present 2.
• The classification is divided into three types: Type I, Type II, and Type III, with Type III being further subdivided into three subcategories: IIIA, IIIB, and IIIC 3.

Management of Gustillo-Anderson Type III Open Fractures

• The management of Gustillo-Anderson type III open fractures is complex and requires a careful approach based on detailed assessment of the patient and injury 2.
• Recommended antibiotic regimens for Gustillo-Anderson type III fractures include first-, second-, and third-generation cephalosporins, with expanded gram-negative coverage and additional anaerobic coverage if necessary 4.
• A study comparing the efficacy and safety of two antibiotic regimens, cefazolin plus aminoglycoside and ampicillin/sulbactam, found that ampicillin/sulbactam may be an alternative option for managing Gustillo type IIIA open fractures 5.

Treatment of Open Fractures

• The treatment of open fractures involves thorough debridement and irrigation with saline, early soft tissue coverage, and the use of systemic and local antibiotics 6.
• The optimal method of irrigation and the timing and technique of wound closure remain uncertain, with controversy existing regarding the use of vacuum-assisted closure (VAC) and recombinant human bone morphogenetic proteins (rhBMP)-2 6, 2.
• Tetanus prophylaxis and intravenous antibiotics should be administered immediately, with local antibiotic administration being a useful adjunct 2.