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Trauma: S. Rajasekaran, J. Naresh Babu, J. Dheenadhayalan, A. P. Shetty, S. R. Sundararajan, M. Kumar, and S. Rajasabapathy A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures J Bone Joint Surg Br 2006; 88-B: 1351-1360 [Abstract] [Full text] [PDF]

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S Rajasekaran, J Naresh Babu, J Dheenadhayalan, A.P. Shetty, S.R. Sundararajan, M. Kumar, and S. Rajasabapathy   (18 January 2007)

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

Harish V Kurup   (24 October 2006)

Authors' reply 18 January 2007
S Rajasekaran, Director & Head Dept of Orthopaedic & Spine Surgery, Ganga Hospital, Swarnambika Layout, Ramnagar, Coimbatore:641009, J Naresh Babu, J Dheenadhayalan, A.P. Shetty, S.R. Sundararajan, M. Kumar, and S. Rajasabapathy Send letter to journal: Re: Authors' reply sr{at}gangahospital.com S Rajasekaran, et al.	Sir, We thank Dr Kurup for his interest in our paper. He has raised many relevant points of interest: 1) We agree that degloving of the skin has a higher rate of complication of wound healing and the need for plastic surgical procedures. It is important that every injury with degloved skin be assessed very carefully for viability during debridement. The skin margins of every wound must be debrided until there is evidence of brisk bleeding and the loss assessed. As per the protocol, the scoring for the skin and covering tissue is done after debridement when it would be possible to accurately assess the effects of degloving. If there is loss of skin, the score would be three if the wound is not exposing the fracture, and four if it exposes the fracture. 2) Small butterfly fragments (less than 50%) will attract a score of one only provided contact of the cortex is possible during fracture stabilisation. To attract a score of four or five there must be a circumferential bone loss of either less than or more than 4 cms respectively. Similarly, transverse fractures attract a bone score of one, irrespective of the periosteal stripping. 3) We agree that current evidence suggests that delay in debridement of open fractures is not always associated with a higher risk of infection and the dictum of six hours is no longer valid. However, it is our hospital policy that any open injury must undergo debridement as early as possible unless there is a specific contra-indication for anaesthesia and surgical procedure. We have a dedicated orthopaedic, plastic and anaesthetic team which work on a fixed protocol1of early debridement and cover, irrespective of the time of arrival of the patient. 4) The validity of any score depends not only on the simplicity and the nature of the scoring system, but also on the thorough knowledge the observer has of the scoring system. In our study, six observers rated 25 fractures at the time of the index surgery after debridement. Our aim was to compare the inter-observer agreement between surgeons who were well experienced and those who were less experienced in evaluation of open injuries. It is our opinion that the whole assessment and management of open injuries must be done by surgeons with good knowledge and experience of this type of injury, and hence we did not use blinded observers with no prior knowledge of the classification. 5) Gustilo type-IIIB injuries, by definition, include a wide range of injuries from the easily manageable to the barely salvageable. The overriding factor in the practical assessment of an injury in Gustilo’s classification is obviously the size of the wound. However, a wound which is obviously type-IIIB due to its size may still attract a low score for skin, bone and muscles on careful evaluation if there is no loss.1,2 It is then possible that a IIIB injury can still fall under Group I. 6) Although primary closure of open injuries is against traditional teaching, we firmly believe that good results can be obtained by primary closure of suitable injuries, the results of which have been previously presented.2 The deciding factor for primary closure is not whether it is type-IIIA or B, but whether there is any skin loss either primarily or during debridement, which would involve tension while closing. We have had good results2 with the policy to close wounds primarily if the following criteria are met, irrespective of the size of the wound: (a) Debridement performed within 12 hours and to the satisfaction of the surgeon (b) No loss of primary skin during the injury, or at debridement (skin score of 1 or 2) (c) Skin approximation possible without tension (d) No farmyard or organic contamination. 7) It is true that the apparent rate of infection depends primarily on the definition used,4 and that there can be wide variation in intra-observer reliability in some components of the CDC criteria. The modified CDC definition requires the observation of 16 wound or patient characteristics in order to classify infection and has two subjective criteria, namely a surgeon’s diagnosis of infection and the culture of micro-organisms from the wound included in criterion 3.3 The comparison of CDC criteria with other systems has shown that all or part of criterion 3 for Surgical Site Infection (SSI), as set by the CDC, is subjective with poor inter-observer agreement.5,6,7 Some wounds classified as moderately or severely infected by other systems were classified as not infected or only superficially infected by CDC criteria.4 In order to minimise the subjective nature of the CDC criteria, especially in categorising it as ‘un-infected’, it has been suggested that the ‘requirement for a surgeon’s diagnosis of infection’ be satisfied when a decision is made to start antibiotic treatment or to provide surgical treatment.4 We used the predefined criteria as requirement of antibiotics to avoid the subjectivity and underreporting of superficial infections. 8) The GHS score does not aim to predict or recommend an appropriate fracture fixation device or technique. S. RAJASEKARAN, J. NARESH BABU, J. DHEENADHAYALAN, A.P. SHETTY, S.R. SUNDARARAJAN, M. KUMAR, S. RAJASABAPATHY, Department of Orthopaedic and Spine Surgery, Ganga Hospital, Coimbatore, India. 1. Rajasekaran S, Sabapathy SR. A philosophy of care of open injuries based on the Ganga hospital score. Injury 2007;38:137-46. 2. Rajasekaran S. The Safety of Primary Closure in Open Injuries of Limbs [abstract]. AAOS Meeting, March 2006. 3. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606-8. 4. Wilson AP, Helder N, Theminimulle SK, Scott GM. Comparison of wound scoring methods for use in audit. J Hosp Infect 1998;39:119-26. 5. [No authors listed] National prevalence survey of hospital acquired infections: definitions. A preliminary report of the Steering Group of the Second National Prevalence Survey. J Hosp Infect 1993;24:69-76. 6. Bailey IS, Karran SE, Toyn K, et al. Community surveillance of complications after hernia surgery. BMJ 1992; 304:469-71. 7. Wilson AP. Surveillance of wound infections. J Hosp Infect 1995;29:81-6.
A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures 24 October 2006
Harish V Kurup, Specialist Registrar in Orthopaedics Royal Glamorgan Hospital, Llantrisant, United Kingdom Send letter to journal: Re: A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures harishvk{at}yahoo.com Harish V Kurup	Sir, I read this paper with great interest. The proposed ‘Ganga Hospital Score’ appears to give a reproducible and reliable scoring system to be used for type-III open fractures of the tibia without arterial injury. I have a few queries for the authors. 1. Regarding the score for covering tissues, degloving of skin despite a small external wound usually denotes a more severe injury and should not be overlooked.1 Is it necessary to give a wound without skin loss, but with degloving, a higher score? 2. With regard to fracture configuration, a common scenario is a small butterfly fragment (<50%) which is either lost or removed at surgery because of absence of soft tissue attachments. Will this count as a score of 1 or 4? If there is extensive periosteal stripping in a transverse fracture, without significant functional tissue damage, what score should it receive? 3. Current evidence suggests that delay in initial debridement of open fractures does not influence the risk of infection.2 Do the authors perform initial debridement and fracture stabilisation of all open fractures immediately after presentation or wait until the next morning? Being a referral hospital, do they operate on all open fractures within the first 12 hours after trauma? 4. In the initial validation of the score, if all six observers rated all 25 fractures at the time of surgery, is there not a high degree of bias possible? Using blinded observers with no prior knowledge of the classification might have been more appropriate. 5. In Table 2, a Gustilo type-IIIB fracture has been listed as GHS group 1. From the scoring system, it seems unlikely that a Gustilo IIIB can have a score of less than GHS 6. 6. Of the 102 fractures, 42 were managed with wound management and primary closure in this series. Even though traditional orthopaedic teaching does not recommend primary closure in open fractures,3 there is growing evidence to support this.4 With available evidence it appears acceptable to close Gustilo type-I and type-II wounds primarily, but is it advisable in type-IIIA injuries, especially if they are not operated on within six hours? 7. Requirement of antibiotics for wound healing as a criterion to diagnose infection does not appear to reflect current practice.5 How did the authors differentiate between superficial and deep infection? 8. The method of fracture fixation has not been commented on in the article. Did the Ganga Hospital Score (GHS) have any predictive value on the choice of fixation technique? H.V. KURUP, MS, MRCS, Specialist Registrar in Orthopaedics, Royal Glamorgan Hospital, Llantrisant, Wales, UK. 1. Gregory P, Sanders R. The management of severe fractures of the lower extremities. Clin Orthop Relat Res 1995;318:95-105. 2. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg [Br] 2006;88-B:351-7. 3. Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J Bone Joint Surg [Br] 1990;72-B:125-8. 4. Hohmann E, Tetsworth K, Radziejowski MJ, Wiesniewski TF. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Arch Orthop Trauma Surg 2006 Aug 31. 5. Allami MK, Jamil W, Fourie B, Ashton V, Gregg PJ. Superficial incisional infection in arthroplasty of the lower limb. Interobserver reliability of the current diagnostic criteria. J Bone Joint Surg [Br] 2005;87-B:1267-71.