New scoring system helps surgeons predict outcomes for open tibial fractures

Indian investigator said the tool effectively helped him focus salvage measures.

Issue: Issue 6 2007

Korea flag

SEOUL — Researchers from Ganga Hospital in India devised a trauma score to grade the severity of damage made to covering tissues, bones and functional tissues from open tibia fractures.

Although orthopaedic surgeons can use a number of other scoring methods, the current limb injury severity scores “have poor sensitivity and specificity to predict salvage or outcome,” S. Rajasekaran, PhD, FRCS, MS(Orth) said. Furthermore, “If you have an injury that isn’t ischemic in nature, it can score you low on these scales,” leading to a futile attempt to salvage and secondary amputations.

He presented his team’s findings at the 15th Triennial Congress of the Asia Pacific Orthopaedic Association, here.

Ranking tibial fracture severity

Using the new scale in a retrospective study, Rajasekaran and colleagues ranked the severity of tibial fractures from 1 to 5 (least to most severe). Seven comorbid conditions were assigned a score of 2 each.

The scoring system was prospectively validated in 109 consecutive open tibial injuries, including 42 Gustilo type IIIA and 67 Gustilo type IIIB, he said.

Salvage and outcome can be measured by dividing injuries into four groups, with group IV associated with the most severe and disabling injuries. Scoring is performed at the end of debridement, he said.

In the recent comparison study in which patients were followed for more than 6 months, the investigators’ trauma score compared favorably with the Mangled Extremity Severity Score (MESS) in terms of sensitivity (98% and 99%, respectively), specificity (100% and 17%), positive predictor value (100% and 97.5%) and negative predictive value (70% and 50%), he said.

A receiver-operating characteristic curve also showed that the area under the curve for this score was better [0.988 (0.013 SEM)] than the MESS [0.938 (0.039 SEM)].

A better curve

“Having the scale makes it easy to discuss treatment plans with the patient and his or her family, because we can show why we made certain care decisions,” he said. “The final decision is still the patient’s, but the scale helps guide the patient in that decision-making process.”

Rajasekaran said he hopes to answer other questions as he gathers more data, including determining when the wounds can be primarily closed, and how to sequence orthopaedic and plastic reconstruction procedures for obtaining best functional outcomes.

All the above injuries are Gustilo Type IIIb injuries; however, they vary significantly in their severity, from “easily manageable” (far left) to “barely salvageable” (far right). These injuries are graded by the Ganga Hospital Open Injury Severity Score so that a proper management protocol can be planned, according to Rajasekaran.

Images: Rajasekaran S

For more information:
S. Rajasekaran, PhD, FRCS, MS(Orth), director and head of the department of orthopaedics and spine surgery, can be reached at Ganga Hospital, Swarnambika Layout, Ramnagar, Coimbatore: 641009, Tamilnadu, India; +91-(0)422-2235050; sr@gangahospital.com.
Reference:
Rajasekaran S. A score for predicting salvage and outcome in Gustilo type IIIA and type IIIB open tibia fractures. F048-2. Presented at the 15th Triennial Congress of the Asia Pacific Orthopaedic Association. Sept. 9-13, 2007. Seoul.