A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures

Abstract

Limb-injury severity scores are designed to assess orthopaedic and vascular injuries. In Gustilo type-IIIA and type-IIIB injuries they have poor sensitivity and specificity to predict salvage or outcome. We have designed a trauma score to grade the severity of injury to the covering tissues, the bones and the functional tissues, grading the three components from one to five. Seven comorbid conditions known to influence the management and prognosis have been given a score of two each. The score was validated in 109 consecutive open injuries of the tibia, 42 type-IIIA and 67 type-IIIB. The total score was used to assess the possibilities of salvage and the outcome was measured by dividing the injuries into four groups according to their scores as follows: group I scored less than 5, group II 6 to 10, group III 11 to 15 and group IV 16 or more. A score of 14 to indicate amputation had the highest sensitivity and specificity. Our trauma score compared favourably with the Mangled Extremity Severity score in sensitivity (98% and 99%), specificity (100% and 17%), positive predictive value (100% and 97.5%) and negative predictive value (70% and 50%), respectively. A receiver-operating characteristic curve constructed for 67 type-IIIB injuries to assess the efficiency of the scores to predict salvage, showed that the area under the curve for this score was better (0.988 (+/- 0.013 SEM)) than the Mangled Extremity Severity score (0.938 (+/- 0.039 SEM)). All limbs in group IV and one in group III underwent amputation. Of the salvaged limbs, there was a significant difference in the three groups for the requirement of a flap for wound cover, the time to union, the number of surgical procedures required, the total days as an in-patient and the incidence of deep infection (p < 0.001 for all). The individual scores for covering and functional tissues were also found to offer specific guidelines in the management of these complex injuries. The scoring system was found to be simple in application and reliable in prognosis for both limb-salvage and outcome measures in type-IIIA and type-IIIB open injuries of the tibia.

Infectious Complications of Open Type III Tibial Fractures among Combat Casualties

“…Overall, there was a higher prevalence of wound infection (77%) in this series of patients than that reported for other combat-associated open fracture injuries or for civilian type III tibial injuries [10][11][12][13][14]. Despite this high rate of early infection, patients generally cleared the initial infection.…”

“…With aggressive surgical intervention and treatment of local infections, most cases of delayed union eventually result in a functional limb. Type III tibial fractures have a reported infection rate of 6%-39%, whereas the associated amputation rate has historically been !10% [9][10][11][12].…”

Early versus Late Flap Coverage for Open Tibial Fractures

“…Factors affecting the decision to perform early or late flap coverage were not known. The definition of Gustilo grade-IIIB fractures is not as specific as described in newer classifications, 24,25 but it remains the most commonly used classification. The relatively small cohort of patients in the early flap coverage group may have been underpowered to detect differences in clinically important outcomes.…”

Does accelerated bone healing associated with traumatic brain injury (TBI) occur in open fractures

“…Tibial fractures which belonged to 42 A, B and 43 A, B were included. Open fractures were classified and managed based on the Ganga Hospital Open Injury Severity Score (GHOISS) proposed by Rajasekaran et al which specifically addresses the issue of salvage and reconstruction pathways in open injuries [5,6] . In closed fractures with TBI (group IA), there were 34 patients (femur-19 and tibia-15).…”