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Trauma: S. Rajasekaran, J. Dheenadhayalan, J. N. Babu, S. R. Sundararajan, H. Venkatramani, and S. R. Sabapathy Immediate primary skin closure in type-III A and B open fractures: RESULTS AFTER A MINIMUM OF FIVE YEARS J Bone Joint Surg Br 2009; 91-B: 217-224 [Abstract] [Full text] [PDF]

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Primary skin closure of open fractures

Sharaf B Ibrahim FRCS MS Orth   (2 July 2009)

Role of Ganga Hospital Score in immediate primary skin closure in type-III A and B open fractures

VV NarayanaRao, VenkataSwamy Ch, Sitaramanjaneyulu Y   (17 March 2009)

Classification of Gustilo grade IIIB fractures

Daniel J Rolton, Mr Alan Macleod   (6 March 2009)

Immediate primary skin closure in type-III A and B fractures

Bolarinwa A. Akinola, Ben Davis   (27 February 2009)

Immediate primary skin closure in type-III A and B open fractures

Carlos A. M. F. Carvalho   (5 February 2009)

Primary skin closure of open fractures 2 July 2009
Sharaf B Ibrahim FRCS MS Orth, Paediatric Orthopaedic Surgeon Hospital Univ Kebangsaan Malaysia, Kuala Lumpur, Malaysia. Send letter to journal: Re: Primary skin closure of open fractures sharaf{at}ppukm.ukm.my Sharaf B Ibrahim FRCS MS Orth	Sir, I read this paper with concern. The clinical photograph (Fig. 3e) showed primary skin closure, but this appeared to be under tension and healing resulted in a broad scar. Furthermore, while 143 patients had primary wound healing, 26 patients had marginal wound necrosis not requiring surgical intervention, one had wound necrosis requiring redebridement and secondary suturing, and three required redebridement and flap cover. Is primary skin closure justified considering that 30 patients subsequently had problems with wound necrosis? Although the wounds may have been closed without tension initially, subsequent oedema would have resulted in the sutures constricting the skin edges resulting in ischaemic necrosis. S. Ibrahim FRCS MS Orth, Paediatric Orthopaedic Surgeon, Hospital Univ Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
Role of Ganga Hospital Score in immediate primary skin closure in type-III A and B open fractures 17 March 2009
VV NarayanaRao, Professor of Orthopaedics Guntur Medical College Guntur, AP, India, VenkataSwamy Ch, Sitaramanjaneyulu Y Send letter to journal: Re: Role of Ganga Hospital Score in immediate primary skin closure in type-III A and B open fractures nareshjd{at}yahoo.com VV NarayanaRao, et al.	Sir, We read this paper with great interest. The authors' results have clearly proved the safety of immediate primary skin closure in selected open injuries. However, there are two concerns: 1) We need to know the authors' definition of IIIa and IIIb injuries as it is now commonly believed that IIIb injuries should not be closed. This needs more clarification, as there are many definitions of Gustilo’s classifications in the current literature. 2) The authors state that the "ability to close the wound without tension" is a critical factor. A Ganga Hospital skin score of 1 and 2 would mean that the selected wounds would have no skin loss, irrespective of their size, and hence this would be an inclusion criterion. However, they have also included the total score of less than 10 as additional inclusion criteria. Can we have the logic behind this? This paper has improved our management of open injuries by defining the indications and contra-indications of this controversial procedure. While congratulating the authors for this valuable contribution to literature, we would also be grateful for clarifications regarding the above concerns. V.V. NarayanaRao, MS(Ortho) Professor of Orthopaedics, C. VenkataSwamy, MS(Ortho) Y. Sitaramanjaneyulu, MS(Ortho) Guntur Medical College, Guntur, AP, India.
Classification of Gustilo grade IIIB fractures 6 March 2009
Daniel J Rolton, Specialist Trainee in Trauma and Orthopaedics Mr, Mr Alan Macleod Send letter to journal: Re: Classification of Gustilo grade IIIB fractures danrolton{at}hotmail.com Daniel J Rolton, et al.	Sir, We read this paper with interest in which the authors describe the primary closure of grade-IIIB open fractures. The classification of these fractures is based on the degree of soft tissue injury. The original Gustilo Anderson classification states that grade III injuries are ‘characterized by extensive soft tissue loss, instability, and large areas of exposed bone requiring soft-tissue coverage’.1 Grade III injuries were later subdivided with grade IIIB injuries described as exhibiting extensive soft tissue loss, periosteal stripping and exposure of bone.2 Gustilo has further stated that the treatment of grade IIIB injuries with free or local flaps is essential.3 The high degree of interobserver variation in reporting these types of injuries has been well documented.4 The time at which these injuries are classified is also key as the true degree of soft tissue injury can only be confirmed once an adequate debridement has been performed.3 The authors state that there were difficulties in classifying the injuries into IIIA and IIIB as ‘there is no longer a uniformly accepted definition.’ The study group implemented their own scoring criteria (The Ganga hospital open injury score) for excluding those with large amounts of tissue damage post debridement.5 Whilst there are discrepancies in the current classification the new scoring criteria proposed needs further validation. The published literature supports that grade IIIB injuries are not amenable to primary closure and require additional soft tissue procedures. The findings in the paper would have been more relevant if the authors had detailed separately the individual numbers and outcomes for IIIA and IIIB injuries rather than grouping them together. We would also like to know the authors' own definition for classifying patients as grade IIIB, thereby allowing them to be included in this study. D.J. Rolton, MRCS, Specialist Trainee Trauma and Orthopaedics, A. Macleod, FRCS, Consultant Trauma and Orthopaedic Surgeon, Royal Berkshire Hospital, Reading, UK. 1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg [Am] 1976;58-A:453-8. 2. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984;24:742-6. 3. Gustilo RB. Interobserver agreement in the classification of open fractures of the tibia: the results of a survey of two hundred and forty- five orthopaedic surgeons. J Bone Joint Surg [Am] 1995;77-A:1291-2. [Comment] 4. Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia: the results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg [Am] 1994;76-A:1162-6. 5. Rajasekaran S, Naresh Babu J, Dheenadhayalan J, et al. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. J Bone Joint Surg [Br] 2006;88-B:1351-60.
Immediate primary skin closure in type-III A and B fractures 27 February 2009
Bolarinwa A. Akinola, Core Surgical Trainee Norfolk and Norwich University Hospital, Ben Davis Send letter to journal: Re: Immediate primary skin closure in type-III A and B fractures bolaakinola{at}gmail.com Bolarinwa A. Akinola, et al.	Sir, We read this paper with interest. Primary skin closure of type III open fractures is being undertaken more often, dependent on local conditions, and we commend the authors for their valuable contribution to this issue. We note that their results are equivalent to outcomes for Type IIIA open fractures as reported in the literature. However, we find the title misleading. By classification, a Gustilo and Anderson type IIIB fracture is not amenable to immediate primary closure. The original paper1 classified open fractures into three categories, namely: type I, type II, and type III. The designation of type III was later subdivided, in order of worsening prognosis, into types IIIA, IIIB, and IIIC.2 Type IIIB, by definition, represents extensive soft-tissue injury loss with periosteal stripping and bone exposure.2 Dr Gustilo later clarified a type IIIB injury as one in which the use of local or free vascular flaps is essential.3 It follows then, that strictly speaking, immediate primary closure of open fractures is impossible for a type IIIB injury. Therefore the photographs shown on page 222 can only qualify as a type IIIA injury since there was adequate skin cover left for immediate primary closure following fracture stabilisation. The point was made by Dr Gustilo that their classification system is preliminary at the time of the initial presentation, and final grading should be done only after debridement and irrigation has enabled the surgeon to determine what kind of soft-tissue reconstruction is needed.3 The limitations of the Gustilo-Anderson system have been recognised by others,4,5 and it would be interesting to see whether the authors’ Ganga hospital classification system could be introduced to the orthopaedic world as an alternative. Overall, the paper made for interesting reading, and we once again commend the authors for their contribution. B.A. Akinola, MRCS Ed, Core Surgical Trainee, B. Davis, FRCS(Tr&Orth), SpR, Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Norwich, UK. 1.Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg [Am] 1976;58-A:453–8. 2.Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984;24:742-6. 3.Gustilo RB. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg [Am] 1995;77-A:1291–2. [Letter to the Editor.] 4.Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia: the results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg [Am] 1994;76-A:1162–6. 5.Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg [Am] 1995;77-A:1291–2. [Letter to the Editor: Authors' reply.]
Immediate primary skin closure in type-III A and B open fractures 5 February 2009
Carlos A. M. F. Carvalho, orthopedic trauma surgeon Hospital Geral de Palmas, Palmas, Tocantins, Brazil Send letter to journal: Re: Immediate primary skin closure in type-III A and B open fractures trauma33{at}uol.com.br Carlos A. M. F. Carvalho	Sir, I read this paper with great interest but I do not agree with the authors' statement that G-IIIB are suitable for direct skin suturing, even without tension, because, according to the Gustilo classification of open fractures, such lesions leave a defect that needs a flap to be closed.1 Gustilo and colleagues also wrote that "After debridement and irrigation are completed, a segment of bone is exposed and a local or free skin flap is needed for coverage."2 In my opinion, all cases included in this study must be reclassified as G-IIIA. I would appreciate the authors' comments. C.A.M.F. de Carvalho, MD, SBOT, Orthopaedic Trauma Surgeon, Hospital Geral de Palmas, Palmas, Tocantins, Brazil. 1. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984;24:742-6. 2. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg [Am] 1990;72-A:299-304.