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Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue 10,
1351-1360.
doi: 10.1302/0301-620X.88B10.17631 Copyright © 2006 by British Editorial Society of Bone and Joint Surgery A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fracturesS. Rajasekaran, MS (Ortho), DNB (Ortho), FRCS (Ed), MChOrth (Liverpool), PhD, Director & Head of Orthopaedics and Spine Surgery1; J. Naresh Babu, MS (Ortho), FNB, Trauma Fellow1; J. Dheenadhayalan, MS (Ortho), Consultant in Trauma Surgery1; A. P. Shetty, MS(Ortho), DNB(Ortho), Consultant Orthopaedic Surgeon1; S. R. Sundararajan, MS (Ortho), Consultant Orthopaedic Surgeon1; M. Kumar, MS (Ortho), Trauma Fellow1; and S. Rajasabapathy, MS, MCh, FRCS, DNB, Director and Head of Plastic and Reconstructive Microsurgery11 Department of Orthopaedics, Ganga Hospital, Ramnagar, Coimbatore 641009, India. Correspondence should be sent to Dr S. Rajasekaran; e-mail: sr{at}gangahospital.com
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. This article has been cited by other articles:
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