Research Article
Management of Open Tibial Shaft
Oscar A. Duyos, MD
David Beaton-Comulada, MD
Ariel Davila-Parrilla, MD
Jose Carlos Perez-Lopez, MD
Krystal Ortiz, BS
Christian Foy-Parrilla, MD
Francisco Lopez-Gonzalez, MD
From the Department of Orthopaedic
Surgery, University of Puerto Rico,
Medical Sciences Campus, San Juan,
Puerto Rico.
Correspondence to Dr. Duyos:
oduyos@gmail.com
Dr. Davila-Parrilla or an immediate
family member is an employee of
Merck. Dr. Lopez-Gonzalez or an
immediate family member is a
member of a speakers bureau or has
made paid presentations on behalf of
Arthrex and serves as a paid
consultant to Arthrex. None of the
following authors or any immediate
family member has received anything
of value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Duyos, Dr. Beaton-Comulada,
Dr. Perez-Lopez, Ms. Ortiz, and
Dr. Foy-Parrilla.
J Am Acad Orthop Surg 2017;25:
230-238
DOI: 10.5435/JAAOS-D-16-00127
Copyright 2017 by the American
Academy of Orthopaedic Surgeons.
230
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Fractures: Does the Timing of
Surgery Affect Outcomes?
Abstract
Background: Open tibial shaft fractures require emergent care.
Treatment with intravenous antibiotics and fracture dbridement
within 6 to 24 hours is recommended. Few studies have examined
outcomes when surgical treatment is performed .24 hours after
occurrence of the fracture.
Methods: This retrospective study included 227 patients aged $18
years with isolated open tibial shaft fractures in whom the time to
initial dbridement was .24 hours. The statistical analysis was
based on time from injury to surgical dbridement, Gustilo-Anderson
classification, method of fixation, union status, and infection status.
Results: Fractures dbrided within 24 to 48 hours and 48 to 96 hours
after injury did not show a statistically significant difference in terms of
infection rates (P = 0.984). External fixation showed significantly
greater infection rates (P = 0.044) and nonunion rates (P = 0.001)
compared with intramedullary nailing.
Conclusion: Open tibial shaft fractures should be dbrided within 24
hours after injury. Our data indicate that after the 24-hour period and
up to 4 days, the risk of infection remains relatively constant
independent of the time to dbridement. Patients treated with
external fixation had more complications than did patients treated
with other methods of fixation. Primary reamed intramedullary nailing
appears to be a reasonable option for the management of Gustilo-
Anderson types 1 and 2 open tibial shaft fractures.
Level of Evidence: Level III retrospective study.
T ibia fractures are the most com-
mon long-bone fractures. Exten-
sive research has been done on the
examination, stabilization, systemic
antibiotics, dbridement and irriga-
tion, temporary or definitive fixation,
clinical management and outcome of and, if needed, soft-tissue coverage
these fractures.1 Open tibial shaft and/or vascular repair.2 Several clas-
fractures are complicated injuries sification systems have been used to
with associated soft-tissue and neu- guide appropriate management and
rovascular damage. Management of outcomes of these fractures. The most
these injuries requires a multidisci- widely recognized and used classifi-
plinary approach involving ortho- cation is the Gustilo-Anderson sys-
paedic surgeons, plastic surgeons, tem, which evaluates open fractures
and vascular surgeons. The manage- on the basis of the size of the wound,
ment of an open tibial shaft fracture the degree of contamination, and the
requires prompt history and physical extent of soft-tissue injury.3 This
Journal of the American Academy of Orthopaedic Surgeons

classification is a practical system to
guide management, but it has limi-
tations, such as poor interobserver
reliability.4
Open tibia fractures have two major
complications: infection and nonunion.
Infection rates reported in the literature
range between 5% and 50%, and
nonunion rates range between 7% and
60%.5 Because prevention of infection
requires serious consideration in the
management of these fractures, swift
administration of antibiotics and
dbridement are recommended. In
1974, Patzakis et al6 conducted a
prospective study that showed a
statistically significant reduction in
infection rates attributed to the
administration of cephatolin (2.3%)
compared with no antibiotic admin-
istration (13.9%) in the management
of open fractures. Additionally, time
to start of antibiotics is an important
issue. Patzakis and Wilkins7 showed
a considerable reduction in infection
rates when antibiotics were adminis-
tered #3 hours after injury compared
with antibiotic administration .3
hours from the time of injury (4.7%
versus 7.4%).
Irrigation and excisional dbride-
ment is a crucial part of the treatment
algorithm in the management of open
tibial shaft fractures. Established
guidelines clearly state that at least
one dbridement must be performed;
however, the timing of the first
dbridement is still a subject of
debate.2,8-12 The historic recommen-
dation is to perform cleansing and
dbridement within 6 hours after
injury. This recommendation was
based on an 1898 study by Friedrich13
in guinea pigs and was later confirmed
in a study of human wounds by
Robson et al.14 Kindsfater and
Jonassen15 showed a reduction in the
rate of infection of open tibia fractures
when the cleansing and dbridement
occurred within 5 hours. However,
multiple studies have not shown the
same results. Therefore, no definitive
recommendation has been established
March 2017, Vol 25, No 3
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
as to the timing of the first cleansing
and dbridement of open tibia frac-
tures. Pollak et al16 examined 315
patients who sustained high-energy
open lower extremity trauma and
found no statistically significant dif-
ferences in infection rate when surgery
was performed within 24 hours.
Weber et al12 prospectively evaluated
736 patients who sustained open
fractures, and their data showed no
statistically significant difference in
the rate of deep infection when initial
surgical dbridement was performed
within 24 hours of the injury.
The topic of stabilization of an
open tibial shaft fracture is broad.
Multiple factors need to be consid-
ered in the choice of fixation. These
factors include soft-tissue coverage,
gross contamination, mechanism of
injury, and endosteal and periosteal
bone circulation. Hemodynamic sta-
tus and overall risk stratification
based on laboratory studies and
trauma scores are also taken into
account in the choice of fixation. One
of the most important goals in the
management of tibial shaft fractures
is quick stabilization, which is often
attained by means of external fixa-
tion. External fixation has reported
union rates of up to 94% and an
overall infection rate of 16.2%.17
However, the complications of pin
loosening, malunion, nonunion, and
hardware failure have been observed
with the use of external fixation for
.3 months after injury.17,18 For
these reasons, external fixation is
usually used as a temporary method
and, when possible, is converted to
internal fixation, usually in the form
of an intramedullary nail, which can
be placed with or without reaming of
the tibial medullary canal. Intra-
medullary nailing provides superior
alignment and can also be done
relatively quickly, depending on the
surgeons level of expertise. The lit-
erature includes reported union rates
up to 95% for reamed intra-
medullary nails and up to 97% for
Oscar A. Duyos, MD, et al
unreamed nails.17 Infection rates
ranging from 6% to 7% have been
reported for both reamed and un-
reamed nailing.17 Plate fixation with
screws is another method of fixation,
but the use of this method has
decreased because its complication
rates (osteomyelitis, 19%; implant
failure, 12%) are greater than those
of other methods of fixation.19
Time to dbridement for open tibial
shaft fractures is currently recom-
mended to be within 6 to 8 hours.
Studies taking into consideration the
24-hour period after injury have
shown mixed results. Our literature
review revealed only a few studies of
outcomes in patients with open tibia
fractures dbrided after the 24-hour
mark. In a level IV retrospective
outcome study of 58 patients who
underwent initial dbridement of
open tibia fractures after 24 hours, the
average time to dbridement was 29.7
hours, and deep infection developed
in 29% of patients.20 A retrospective
study consisting of 6,099 patients
evaluated whether delays .24 hours
could occur and, if so, what factors
may contribute to these delays. In this
study, 24% of patients with open
tibia fractures underwent initial sur-
gical dbridement beyond 24 hours.11
Delayed management of open tibial
shaft fractures may be more common
than is thought and is a topic worthy
of discussion.
Our study aimed to present clinical
data on the management and out-
comes of open tibial shaft fractures
whose initial dbridement could not
be performed within the first 24
hours after injury. The primary
outcomes measured in our study are
infection and nonunion rates ac-
cording to the time to dbridement
and fixation type, with the Gustilo-
Anderson classification status taken
into account. We aspired to con-
tribute information and recommen-
dations on the management of open
tibial shaft fractures when the time to
surgical dbridement is .24 hours.
231
Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?
Methods
After Institutional Review Board
approval was obtained, we per-
formed a retrospective chart review
of all open tibial shaft fractures
managed at the Puerto Rico Medical
Center between December 1993 and
May 2012. Specifically, the cases
came from patient records at the
University District Hospital for
Adults, a University of Puerto Rico
School of Medicine teaching hospital
and currently the only major trauma
center in Puerto Rico and the
Caribbean islands. We identified a
total of 227 patients aged $18 years
who sustained an isolated open tibial
shaft fracture (Gustilo-Anderson
type 1 to 3A) and in whom the time
to initial dbridement was .24
hours. Information gathered from
patient charts included time from
injury to initial antibiotic manage-
ment, time from injury to surgical
dbridement and fixation, fracture
classification by Gustilo-Anderson
type, method of fixation, union sta-
tus, and infection/overall complication
status. Time periods were divided into
24-hour intervals and ranged from 24
to 96 hours. Complications were
analyzed across time to dbridement,
mode of fixation, and Gustilo-
Anderson fracture classification.
On arrival at the emergency depart-
ment, patients were treated per estab-
lished Advanced Trauma Life Support
protocol guidelines and basic ortho-
paedic fracture management protocol,
including complete imaging studies.
Initial fracture management consisted
of a focused history and comprehen-
sive physical examination, intrave-
nous antibiotics (given to all patients
within 3 hours of injury), and tetanus
prophylaxis. Antibiotic selection and
dosage was based on established
guidelines. Specifically, patients with
Gustilo-Anderson type 1 or 2 fractures
were given a first-generation cephalo-
sporin (1 g cefazolin intravenously
232
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
every 6 hours). Patients with
Gustilo-Anderson type 3 fractures
were given a combination of a
first-generation cephalosporin (1 g
cefazolin intravenously every 6
hours) and an aminoglycoside (80 mg
gentamicin intravenously every 8
hours). Patients with penicillin allergies
were given vancomycin or clindamycin
and/or an aminoglycoside if indicated.
All patients underwent initial fracture
irrigation at the time of evaluation in
the emergency department with sterile
normal saline (1 to 3 L, with or without
povidone iodine 30 mL per liter).
Fractures were then stabilized with
long posterior splints. Medical optimi-
zation was undertaken as needed, and
patients were admitted to the hospital
by either the orthopaedic service or the
trauma service before surgical man-
agement. After patients were medically
optimized and cleared for surgical
treatment, they were taken to the
operating room for cleansing, dbride-
ment, and surgical stabilization.
The fractures were classified intra-
operatively on the basis of the Gustilo-
Anderson classification system.
The methods of fracture fixation
used in our institution during the time
frame of this study were external
fixators, intramedullary nails with
and without reaming, and plates. The
choice of fixation was based on the
preference of the treating physician.
After surgical treatment, patients
underwent close follow-up in both
the inpatient setting and outpatient
clinics. Clinical improvements and
complications were evaluated and
properly documented.
The complications included deep
infection, which was defined pri-
marily on the basis of clinical signs
and symptoms, laboratory workup,
plain radiographs, and other imaging
studies that can indicate the possibil-
ity of an active infection. Clinical
signs and symptoms suggestive of
infection included fever, chills, ery-
thema, warmth, swelling of the limb,
and purulent accumulation or an
Journal of the American Academy of Orthopaedic Surgeons
active draining sinus at or near the
site of the open fracture wound and/
or the surgical wound. At our insti-
tution, we consider the laboratory
values of C-reactive protein level .14
mg/dL, erythrocyte sedimentation
rate .67 mm/h, and white blood cell
count of 14 109 as threshold
markers for infection; however, these
values are used as an adjunct to
imaging studies and observation of
clinical presentation. Another com-
plication documented in our follow-
up clinical notes was nonunion,
which was defined as a fracture with
no signs of bone healing or callus
formation 9 months after initial
management, or a fracture 6 months
after initial management with no
signs or progression of radiographic
bone healing during 3 consecutive
months.
Data collected in this study included
the patients age, sex, Gustilo-
Anderson classification (based on
intraoperative findings), mechanism
of injury, time of accident/injury, time
to initial antibiotic management, and
time to cleansing and dbridement.
Also, we documented the type of
initial fixation (temporary or defini-
tive) used to manage the fracture, as
well as any complications that
developed thereafter. Comparisons
between categorical variables were
made using a chi-square analysis. The
results were considered significant if
the P value was ,0.05. All statistical
analyses were performed using IBM
SPSS statistics version 24 (IBM).
Results
For fractures dbrided in the 24- to
48-hour period, the overall infection
rates were 9%, 15%, and 27% for
Gustilo-Anderson type 1, 2, and 3
injuries, respectively. For fractures
dbrided in the 48- to 72-hour period,
the overall infection rates were 11%,
20%, and 29% for Gustilo-Anderson
type 1, 2, and 3 injuries, respectively.

For fractures dbrided in the 72- to
96-hour period, the overall infection
rates were 10%, 15%, and 25% for
Gustilo-Anderson type 1, 2, and 3
injuries, respectively (Figures 1 to 4).
When we compared the infection rate
for patients who underwent dbride-
ment between 24 and 48 hours after
injury with that of patients who
underwent dbridement later (48 to
96 hours after injury), no statistically
significant differences were found
(P = 0.984). Chi-square analysis of
the relationship of Gustilo-Anderson
fracture type and infection rate re-
vealed a statistically significant asso-
ciation of higher Gustilo-Anderson
type with increased rate of infection
(P = 0.013; 95% confidence interval
[CI], 1.80-1.94).
In patients with Gustilo-Anderson
type 1 or 2 fractures, regardless of the
time to dbridement, reamed intra-
medullary nails had a 14.9% infection
rate (18 of 121 patients), none of the
22 patients with unreamed intra-
medullary nails had infection, external
fixation had a 26.8% infection rate
(11 of 41 patients), and plates had a
0.05% infection rate (1 of 22 patients).
Chi-square analysis of external fixa-
tion versus intramedullary nailing
(reamed and unreamed) for Gustilo-
Anderson type 1 and 2 fractures
demonstrated that external fixation
was twice as likely to result in an
infection. This result was statistically
significant (P = 0.027; 95% CI, 0.168-
0.918).
In patients with Gustilo-Anderson
type 3 fractures, regardless of the time
to dbridement, reamed intra-
medullary nails had a 50% infection
rate (3 of 6 patients), neither of the 2
patients with unreamed intramedullary
nails had infection, external fixation
had a 23% infection rate (3 of 13
patients), and the 1 patient who
underwent plating did not have infec-
tion. In patients with Gustilo-
Anderson type 3 fractures, we found
that external fixation was less likely
than intramedullary nailing (reamed or
March 2017, Vol 25, No 3
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
unreamed) to result in an infection
(23% for external fixation versus
37.5% for intramedullary nailing);
however, this result was not statisti-
cally significant (P = 0.477; 95% CI,
0.291-13.738).
In the comparison of nonunion
rates among types of fixation, we
found that external fixation resulted
in a 40.7% nonunion rate (22 of 54
patients), reamed intramedullary
nails resulted in a 16.5% nonunion
rate (21 of 127 patients), unreamed
intramedullary nails resulted in a
29.2% nonunion rate (7 of 24
patients), and plates resulted in a
13.6% nonunion rate (3 of 22
patients). Chi-square analysis com-
paring nonunion rates of external
fixation with those of definitive fixa-
tion (intramedullary nailing with or
without reaming, or plate fixation)
demonstrated that external fixation
was twice as likely as definitive fixa-
tion to result in nonunion. Specifi-
cally, we observed nonunion rates of
40.7% for external fixation and
17.9% for all types of definitive fix-
ation as a group. This result was sta-
tistically significant (P = 0.001; 95%
CI, 1.615-6.139). When external
fixation was compared with intra-
medullary nailing (with or without
reaming), we found that external
fixation was twice as likely to result
in nonunion (40.7% for external
fixation versus 18.5% for intra-
medullary nailing). This result was
also statistically significant (P =
0.001; 95% CI, 1.529-5.964).
Discussion
During the time frame of our study,
Puerto Rico had a population of
approximately 3.6 to 4 million people
and had approximately 100 active
orthopaedic surgeons, not all of
whom managed orthopaedic trauma.
Additionally, the island has only one
orthopaedic surgery residency. Cur-
rent treatment guidelines indicate that
Oscar A. Duyos, MD, et al
open tibial shaft fractures should be
dbrided within 24 hours after injury.
However, the management of these
fractures, specifically the time to the
first surgical dbridement, is some-
times delayed. Reasons for delayed
surgical dbridement include lack of
transportation in rural areas, distance
to a trauma center, and initial treat-
ment at smaller medical centers,
where the lack of adequately trained
personnel (ie, orthopaedic and/or
trauma surgeons) and resources can
lead to delays in transfer to a trauma
center. Other delays in surgical
management can occur because of the
need for medical optimization and/or
clearance for surgical treatment,
which at times may not be granted
immediately on arrival because
of multiple medical comorbidities,
hemodynamic/resuscitative status
problems, other injuries that take
priority and must be addressed first,
and the overall complexity of the
case.
Through the years, we have treated
several patients with open tibial shaft
fracture whose treatment deviated
from the standard management in
terms of time to dbridement. We
decided to conduct the present study
with the aim of establishing treatment
recommendations for patients whose
open tibial shaft fracture was man-
aged after the 24-hour mark. Despite
the delayed surgical treatment, it is
important to note that all patients
with open tibial shaft fractures
included in this study were given their
first intravenous antibiotic dose
within 3 hours of the injury.
As noted previously, our data
showed that, for Gustilo-Anderson
fracture types 1, 2, and 3, respec-
tively, the overall infection rates were
9%, 15%, and 27% in the 24- to 48-
hour period; 11%, 20%, and 29% in
the 48- to 72-hour period; and 10%,
15%, and 25% in the 72- to 96-hour
period. As expected, when we com-
pare these infection rates with those
found in previous studies in which the
233
Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?

Figure 1

Bar graphs demonstrating infection rates in patients with Gustilo-Anderson type 1 fractures, according to fixation method
and time to initial dbridement at 24 to 48 hours (A), 48 to 72 hours (B), and 72 to 96 hours (C). IM = intramedullary

data were based on surgical dbride-
ment at ,24 hours after injury, we
see a considerable increase in the rate
of infection across Gustilo-Anderson
types past the 24-hour mark. Spe-
cifically, previous studies show
infection rates of none to 2%, 2%
to 10%, and 10% to 50% for
Gustilo-Anderson types 1, 2, and 3,
respectively.7,21 Our data show that
the infection rates nearly doubled
when the first dbridement is past the
24-hour mark. However, after 24
hours and up to 4 days (96 hours),
the rate of infection remains rela-
tively constant within each Gustilo-
Anderson type, independent of the
time to dbridement.
When we analyzed our data across
types of fixation past the 24-hour
mark, we found several clinically
pertinent findings. Compared with
intramedullary nailing, external fix-
ation was found to be twice as likely
to result in a deep wound infection,
specifically in patients with Gustilo-
Anderson type 1 and 2 fractures. This

234 Journal of the American Academy of Orthopaedic Surgeons

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Oscar A. Duyos, MD, et al

Figure 2

Infection rates in patients with Gustilo-Anderson type 2 fractures, according to fixation method and time to initial dbridement
at 24 to 48 hours (A), 48 to 72 hours (B), and 72 to 96 hours (C). IM = intramedullary

finding was statistically significant
(P = 0.027). However, the finding for
Gustilo-Anderson type 3 fractures
was not statistically significant and
was deemed inconclusive. We also
compared external fixation versus all
definitive fixation methods (intra-
medullary nails with or without
reaming, and plates) and versus in-
tramedullary nailing alone. Our data
showed that external fixation was
twice as likely to result in nonunion,
compared with definitive fixation
methods as a group and compared
with intramedullary nailing alone.
These outcomes were found to be
statistically significant (P = 0.001 for
both comparisons).
On the basis of this study, we rec-
ommend that patients with open tib-
ial shaft fractures undergo their initial
dbridement as soon as medically
possible. However, if dbridement of
an open tibial shaft fracture ends up
being delayed past the 24-hour
mark, we recommend that medical
optimization take precedence over
surgical management. This recom-
mendation is backed by our data,
which showed that although infec-
tion rates double after the 24-hour
mark, they stabilize and plateau
between 24 and 96 hours within

March 2017, Vol 25, No 3 235

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?

Figure 3

Infection rates in patients with Gustilo-Anderson type 3 fractures, according to fixation method and time to initial dbridement
at 24 to 48 hours (A), 48 to 72 hours (B), and 72 to 96 hours (C). IM = intramedullary

each Gustilo-Anderson fracture type.
Additionally, taking into consider-
ation the risk of infection versus the
risk of nonunion, our opinion, based
on the data, is that primary intra-
medullary nailing is a reasonable
option for patients with Gustilo-
Anderson fracture types 1 and 2.
For Gustilo-Anderson type 3 frac-
tures, many confounding variables
were involved, and our data were
inconclusive. At our institution, we
have previously used intramedullary
nailing as the initial management of
Gustilo-Anderson type 3 fractures
regardless of time to dbridement
and have obtained good outcomes.
However, we currently perform
staged fixation (external fixation
with later conversion to intra-
medullary nailing) of Gustilo-
Anderson type 3 fractures when the
initial dbridement cannot be per-
formed within 24 hours after injury,

236 Journal of the American Academy of Orthopaedic Surgeons

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Oscar A. Duyos, MD, et al

Figure 4

Overall infection rates according to Gustilo-Anderson fracture type and time to initial dbridement at 24 to 48 hours (A), 48 to
72 hours (B), and 72 to 96 hours (C).

as well as in patients who are med-
ically unstable and need rapid
orthopaedic treatment for damage
control.
Conclusions
This level III retrospective study
addresses a controversial topic and
may open the door for surgeons
in other centers to evaluate their
experience with these fractures. It
raises the possibility of a level I pro-
spective randomized study; however,
such a study may be ethically chal-
lenging. For now, the fixation method
remains a personal choice of the treat-
ing physician and the patient. The
decision should not be based on an
algorithm but should be made on a
case-by-case basis, with medical
optimization and trauma resuscitation
always taking precedence over ortho-
paedic fixation. The time to the
administration of the first antibiotic
dose and the quality of the initial
dbridement and/or subsequent
dbridement are of utmost importance.
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March 2017, Vol 25, No 3 237

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Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?
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