Treatment of open injuries and severely mangled limbs represents a major challenge for any trauma surgeon around the world. In the current study, we have identified a simple way to make a classification of open fracture that can give us an idea of prognosis and long of the treatment [2–5, 8, 13]. The main findings were that the inter-observer assessment demonstrated a higher agreement of the Aybar classification compare to Gustilo classification, especially in orthopedic surgeons with a kappa value 0.92 versus 0.18, respectively. Also, the time of bone consolidation was statically different between the classification groups (p = 0.023). Patients under the diagonal have more longer time to recuperation than patients above the diagonal.
Systems of classification of fracture and injury severity scores have been developed to guide the surgeon in making appropriate decisions [4]. Examining the current literature, there are several studies about classification of open fractures, being the Gustilo classification, the most common classification used [2–5, 8, 13]. However, the Gustilo classification had a low inter-observer agreement [6, 7]. We agree with the literature that the main problem in the Gustilo classification is that it only assesses the size of the wound, without assessing the bone fracture. Other classifications have tried to remedy this error but make their classification more complex, with 5 or more variables to analyze. That is why we believe that a classification, like our classification, with only 2 main variables can be useful and simple to use.
In our study, a kappa value demonstrated a high inter-observer agreement in residents and orthopaedic surgeons. Brumback et al, reported in a least experience (residents and fellows) a Gustilo classification agreement of 59 percent [6]. The OTA, 2010 classification demonstrated that the system had high reliability and much improvement compared with that found for the Gustilo–Anderson classification. However, the overall agreement for all categories was 86% (between 52% and 100% agreement for individual categories); and a fair to excellent inter-observer reliability, with Kappa values between 0.21 and 0.9 for individual categories [10]. In the Ganga classification, the intraclass correlation coefficient for the Gustilo classification was only 0.63 compared with 0.95 for the covering tissue score, 0.98 for the functional tissue score, 0.99 for the bone score, 0.99 for the comorbidity score, and 0.97 for the total score and group classification. However, is a classification with 4 variables, each of which has a minimum of 5 categories with different scores. Moreover, in was design to predict the salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures [4]. The new classification performed by OTA in 2020, no intra- and interobserver test reliability were performed [13]. We think a classification is useful, when it simple and have a good level of agreement between residents and surgeons, like our classification.
Other important point of a classification should be that can give us the basic of a treatment, a prognosis of length of the treatment and the prognosis of the outcome. Based on our results we can refer that the fractures that are around the diagonal would be treating according to the preferences of the surgeon. On diaphyseal fractures, patients above the diagonal, in the groups 1-I, 2-I, 3-I and 1-II, and on joint fractures patients in the group 1-I could be treated with one single stage procedure. Patients under the diagonal, in the groups 3-IIII, 4a-III, 4b-II and 4b-III, and on joint fractures patients in the group 2b-III indications will be two-or more stage interventions with initially or definitive treatment with external fixation. Moreover, patients in group of 4a-III and 4b-III of diaphyseal fractures a proposal for early therapeutic amputation should be consider or performed. In a simple explanation, the upper groups are easier to treat, with a better prognosis and the group in the right bottom have poorer prognosis and have a more challenging treatment. The length of treatment was statically different between the groups, been longer in the groups of the right bottom. The length of our treatment is similar to the rates reported. Suksathien et al, in their study reported that the median union time in Type IIIA open fractures of the Gustilo-Anderson classification was 16 weeks (range 20–24), meanwhile for Type IIIB fractures of the Gustilo-Anderson classification, the median union time was 20 weeks (range 20–21) [19]. Rajasekaran et al, in their study of 109 patients showed that the mean time to union was 16 weeks (range 10–28) for patients classified to Group I and 25 weeks (range 8–55) for patients classified to Group II [4]. Tajsic et al, in their study at Cambodian showed a median union of 29 weeks (95% CI, 24–43) for Type IIIA fractures of the Gustilo-Anderson classification and 40 weeks (95% CI, 30–54) for Type IIIB fractures of the Gustilo-Anderson classification [20].
Our study also has its limitations. First, it has intrinsic limitations related to the retrospective study design. We conducted retrospective analyses of radiographic images and skin lesion already stored in our database, which could potentially introduce technique errors. However, all radiographs were performed according to a standardized methodology in our radiology department. Second, the assessment of the classification in this paper was based on tibia open fractures. This is a common factor in other classification, because open tibia fractures are the most common type of open fractures [9]. The OTA classification were also based in open tibia fractures [13]. Third, the number of included patients was relatively low. Hence, the classification has to be validated in larger multicenter studies. Despite we introduce this classification in tibia open fracture, we think that it can also be used in other parts of open fractures in the body and in closed fractures. Also, we think that the novelty of the Aybar classification is that the classification can be represented in a simple understandable draw, that can represent the severe of the injury. We think that this draw makes very understandable the classification for traumatologist, health care professional and inclusive patients and familiar patients. However, about this last point, further research is required.
In summary, we here present a classification of the open fractures. The classification had a good inter-observer and intra-observer agreement and it is presents in a simple and understandable shape for the prognostics of open fracture, through a cross-table diagram.