In 2009, the guidelines on the management of open tibial fractures from the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) were modified to change the recommended timing of debridement from within 6 h of injury to within 24 h of injury [15]. In fact, the historical cutoff of 6 h was based on scarce evidence.

More recently, new clinical evidence has arisen supporting the change in practice from emergent debridement to debridement within 24 h. Patzakis and Wilkins looked at the relation between infection rate and timing of debridement. Seven percent was the rate of infection in both groups treated within 12 h of injury or more than 12 h after their open fracture [16]. Other authors confirmed the lack of correlation between urgent debridement and reduced infection rates both in humans [17–19] and in animal models [20].

It appears that the most important aspect of management of open fractures in reducing the risk of infection is by the early initiation of prophylactic intravenous antibiotics. The timing of debridement does not appear to relate to the development of deep infection if performed within 24 h.

In 2010, the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) working party on the management of open tibial fractures [15] agreed on a protocol that is now followed nationwide across the United Kingdom. This includes antibiotic prophylaxis but also a well-defined step-by-step approach for initial wound debridement that includes:

It is only following this radical and systematic approach that the injury can be classified and a multidisciplinary treatment plan be elaborated by the orthopedic and microvascular surgery teams.

When closing the tissue defect created by an open fracture, the surgeon much choose whether to close it soon after the injury or wait and close it later as a means to control potential infection. Primary closure, defined as approximation of wound edges immediately following debridement or cleaning within 6 h of injury, has the benefit of rapid wound healing but presents the threat of increased wound infection. Delayed closure, defined as approximation of wound edges more than 48 h after debridement or cleaning, is often used for wounds judged to be “dirty” or contaminated—i.e., with a risk of infection perceived to be higher due to the environment and circumstances surrounding the injury. However, no good evidence exists to guide this decision; as of July 2011, a review of the Cochrane Database by Eliya and Banda indicated there were no randomized controlled trials comparing primary versus delayed wound closure [21].

Negative pressure wound therapy, in which vacuum suction is applied across an airtight topical dressing, has been used in the treatment of chronic and surgical wounds. The negative pressure is thought to aid the drainage of excess fluid, reduce infection rates, and increase localized blood flow. It is also known as topical negative pressure (TNP) therapy, vacuum-assisted closure (VAC), and sealed surface wound suction (Fig. 9.2). A systematic review in 2008 by Ubbink et al. found only a small number of flawed trials and thus little evidence to support the use of negative pressure wound therapy in the treatment of wounds [22].

The use of antibiotic beads is advocated by Ostermann and Seligson in a paper reviewing 1,085 consecutive cases of severe open fractures [23]. The first group was managed solely with systemic antibiotics and debridement at the time of presentation, while the second group was supplemented with local aminoglycoside-polymethylmethacrylate (PMMA) beads. The difference between the overall infection rates in both groups was shown to be statistically significant (p < 0.001), with a 12 % infection rate in patients managed with IV antibiotics and debridement only versus a 3.7 % infection rate in the group managed with additional placement of antibiotic beads. The authors also analyzed fracture subtypes and concluded that while both acute infection and osteomyelitis were reduced in the second group for all fractures types overall, the reduction reached the level of statistical significance only for type IIIB and IIIC fractures for acute infection and type II and IIIB fractures for chronic osteomyelitis (Fig. 9.3).

Other papers have shown similar results. Henry et al. treated 404 open fractures, with similar distributions of fracture types. Around two thirds of patients were treated with IV antibiotics and tobramycin antibiotic bead chains, while the remaining third was treated with IV antibiotics only. The group supplemented with antibiotic beads had a statistically significant lower rate of infection (4.2 %) than the group that did not receive beads (21.4 %) [24, 25].

Beginning with a report by Winquist et al. in 1984, early intramedullary nailing has been shown to be effective in the treatment of femoral shaft fractures [27]. Okike and Bhattacharyya identified several articles studying early intramedullary nailing with reaming for open femoral shaft fractures. A prospective, randomized, controlled trial by Bone et al. in 1989 compared early (within 24 h) and late (after 48 h) stabilization of 178 femoral fractures, which demonstrated no differences for patients with isolated injuries but decreased complications for poly-trauma patients. Specifically, these patients, when undergoing stabilization within 24 h, were shown to have a decreased rate of pulmonary complications, shorter hospital stays, and less time in the ICU [28]. In 1988, Lhowe and Hansen concluded that immediate intramedullary nailing could be accomplished safely with an acceptable rate of complications after their series of 67 patients with open femoral shaft fractures. Only 2 of 67 patients suffered a wound infection, and all fractures healed within 4 months of injury [29]. Brumback et al. published a series of 89 open femoral fractures stabilized by intramedullary nailing with reaming and reported no infections among 62 type I, II, and IIIA fractures. Of the 27 type IIIB fractures, only 3 became infected, and the rate of infection did not differ for patients treated early (within 24 h) or late (after 48 h) [30]. More recently, 2009 study by Taitsman et al. identified open fractures as a risk factor for nonunion for fractures treated by intramedullary nailing [31], but the preponderance of evidence still supports early reamed intramedullary nailing as the preferred method for treatment of open femoral shaft fractures.

The current literature favors intramedullary nailing for fixation of open tibia fractures. In their 2006 paper, Okike and Bhattacharyya chronicle the evolution of opinion regarding treatment for open tibia fractures. They list two articles written in the 1980s that addressed external fixation in tibia fractures: Edwards et al. concluded that external fixation was successful for treatment of severe open tibia fractures [32], and Bach and Hansen [33] reported fewer complications with external fixation than with internal plate fixation. The 1990s saw a shift away from external fixation toward intramedullary nailing, and Okike and Bhattacharyya point out several studies making this argument. Henley et al. found fewer incidences of malalignment (8 % vs. 31 %, p < 0.001), fewer subsequent procedures (mean 1.7 vs. 2.7, p = 0.001), and lower rate of infection (13 % vs. 21 %, not significant) comparing 104 patients treated with unreamed intramedullary nailing to 70 patients treated with external fixation [34]. Schandelmaier et al. reported a retrospective study of 114 patients with fresh tibial shaft fractures with severe soft tissue injury; 48 were treated with unreamed tibia nails and 66 were treated with external fixators. The unreamed tibia nail group underwent fewer subsequent procedures and achieved better functional outcomes, though the authors articulate that this result may not hold true for patients with less severe injuries [35]. Similarly, in 1994 Tornetta et al. compared intramedullary nailing with external fixation in a randomized, controlled trial of 29 patients with severe (grade IIIB) open tibia fractures. Though they detected no significant differences in healing or range of motion, they considered intramedullary nailing superior due to patient preference and easier fracture management [36]. More recently, the usefulness of external fixation for “damage control orthopedics” has been described by Lebel et al. following their experiences in the aftermath of the 2010 Haiti earthquake [37]. Furthermore, a review by Bhandari et al. has shown that intramedullary nailing after external fixation achieves good union and infection rates and may be superior to casting for definitive treatment, as casting has similar rates of infection but significantly higher rates of nonunion. Removal of the external fixator within 28 days may reduce the risk of infection by 83 % [38].

There has been some controversy as to whether intramedullary nails should be inserted reamed or unreamed, and several smaller trials were inconclusive [39–41]. A meta-analysis by Bhandari et al. in 2001 presented strong evidence in favor of intramedullary nailing over external fixation but failed to find any definitive evidence for reamed versus unreamed nailing, suggesting a much larger study was necessary to analyze the question [42].

Accordingly, the SPRINT trial, a multicenter, blinded randomized trial completed in 2007 and reported in 2008, studies reamed versus unreamed nails in both closed and open tibia fractures on a much larger scale. One of the largest orthopedic studies ever conducted, over 1,226 patients with 1,248 fractures of the tibial shaft were included. Of these, 400 patients with 406 open fractures (108 [26.6 %] Gustilo type I, 161 [39.7 %] Gustilo type II, 107 [26.4 %] Gustilo type IIIA, 30 [7.4 %] Gustilo type IIIB) were treated with reamed (210 total) and unreamed (196 total) intramedullary nails. As its primary outcome, the study evaluated reoperation and/or autodynamization within 1 year. A total of 106 patients experienced a primary event (reoperation)—60 from the reamed group and 46 from the unreamed group. There was no statistically significant difference between these two groups (p = 0.16), and the study concludes that the optimal nailing technique for open fractures remains uncertain [43].