In 1976, Ramon B. Gustilo and John T. Anderson, two Minnesota-based orthopedic and trauma surgeons, published the seminal study: “Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses” in The Journal of Bone and Joint Surgery.
At the time, while all trauma surgeons understood that open fractures required prompt debridement and irrigation, there was no standard measure for how different patterns of injury responded to the range of treatments available in the mid-1970s.
Gustilo, who’d immigrated to the United States from Manapla, Negros Occidental, Philippines, and his colleague John Anderson collected and evaluated data from 673 long bone open fractures in 602 patients and were able to measure the effect of primary versus secondary closure, use of primary internal fixation, and routine use of antibiotics.
From that data came the foundation of the Gustilo-Anderson treatment algorithm for open long-bone fractures.
Specifically, the two physicians found that primary closure without primary internal fixation and prophylactic antibiotics for Type I and Type II open fractures reduced the risk of infection as much as 84.4% whereas acute internal fixation and primary closure after segmental fractures, extensive lacerations, avulsion, or traumatic amputation resulted in a greater likelihood of subsequent osteomyelitis.
This was a seminal paper and moved the practice of orthopedic trauma care forward significantly.
But the two practicing surgeons did not stop there. They subsequently followed more than 350 patients and organized open injuries into three categories, based on wound size, level of contamination, and osseous injury, as follows:
- Type I = an open fracture with a wound less than 1cm long and clean:
- Type II = an open fracture with a laceration greater than 1cm long without extensive soft tissue damage, flaps, or avulsions; and
- Type III = either an open segmental fracture, an open fracture with extensive soft tissue damage, or a traumatic amputation:
- gunshot injuries,
- any open fracture caused by a farm injury, and
- any open fracture with accompanying vascular injury requiring repair.
Type III open fractures, because of widely varying injury patterns, were the most complex to both classify and treat owing to the varied injury patterns, increased morbidity from associated injuries, massive soft tissue damage or loss over the fracture sites, compromised vascularity, wound contamination, and fracture instability.
Over the ensuing decades, the Gustilo-Anderson classification system was tested repeatedly and was found to correlate well to type of fracture and infection risk. That, in turn, helped physicians refine their surgical protocols, adjust antibiotic recommendations, and determine appropriate timing for interventions including debridement, internal fixation, and soft tissue coverage.
The Gustilo-Anderson system proved to be straightforward to classifying open fractures and became the standard for education of residents and other trainees and treatment of orthopedic trauma patients.
The Life of Ramon Gustilo
On December 19, 2024, at age 94, Ramon Gustilo died at his home in Eden Prairie, Minnesota. The young man who was born in Manapla, Negros Occidental, Philippines, grew up to become one of the most consequential orthopedic and trauma surgeons who ever lived.
Dr. Gustilo earned his medical degree from the University of the Philippines in 1957 and completed his orthopedic training at the University of Minnesota in 1964.
For 25 years Dr. Gustilo served as Chairman of Orthopaedic Surgery at Hennepin County Medical Center and was a founding member of the Philippine Orthopedic Institute in Makati, Manila.
In both public and private practice, for more than 40 years, Dr. Gustilo treated orthopedic patients in the U.S. and after retiring, he continued to operate for 20 more years in the Philippines. Through his international fellowship program, he trained over a hundred hand-picked fellows and residents from the United States, Asia, and Europe.
Dr. Gustilo founded the biomechanics lab at Hennepin County Medical Center. He, of course, published extensively in peer review journals and authored four highly respected orthopedic books. Dr. Gustilo founded several medical societies in the U.S. and the Philippines. He was also granted numerous patents for orthopedic implants and devices, significantly advancing the field of orthopedic surgery, by the United States Patent office.
This past November, Dr. Gustilo was named in the 2024 “World’s Top 2 Percent Scientists” list by Stanford University for his professional achievements.
After retiring, Dr. Gustilo started the first Filipino orthopedics company, Orthopedics International, Inc., in Luzon. On his home island of Negros Occidental, he invested in and rebuilt St. Roch, the church in his hometown of Manapla. He also invested in the housing development of Villa Verde and Northland Town Resort and Hotel.
The project most dear to his heart was a state-of-the art hospital to provide health care to his Manalapan family and friends, the Dr. Ramon B. Gustilo Hospital.
Dr. Gustilo’s warmth, kindness, and dedication to his family, colleagues, and community were felt by all who knew him. He was an extraordinary person who lived an extraordinary life.
