|Year : 2020 | Volume
| Issue : 2 | Page : 151-157
Vetrivel trauma score – An evidence-based scoring system to predict limb salvage and outcomes in gustilo anderson grade III B and C compound fractures of lower extremities
S Vetrivel Chezian Sengodan, V Arun, S Arun
Insitute of Orthopaedics and Traumatology, Coimbatore Medical College and Hospital, Tamil Nadu Dr. MGR Medical University, Tamil Nadu, India
|Date of Submission||28-Feb-2020|
|Date of Decision||10-Mar-2020|
|Date of Acceptance||17-Apr-2020|
|Date of Web Publication||22-Jul-2020|
S Vetrivel Chezian Sengodan
16 H, Housing Unit, Mettupalayam, Coimbatore - 641 301, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Open fractures with severe soft-tissue injuries are clinically challenging to treat. While several scoring systems are available to grade these clinical conditions, the Gustilo Anderson grading system is most commonly used. This grading system neither offers any clue regarding salvaging open fractures of Grade III B and above, nor does it help the surgeon to assess the outcomes in such injuries. Hence, a new system of grading was assessed to address this deficiency. Materials and Methods: Five hundred and twelve open fracture cases were analyzed for this study. Two hundred and twenty-seven patients sustained Grade III injuries according to the Gustilo Anderson classification; Of these, 175 patients had Grade III A open fractures and 52 patients were of Grade III B and above. The 52 patients with open fractures of Grade III B and above were scored using mangled extremity severity score (MESS), Ganga score, and our novel scoring system. The accuracy in deciding amputation and predict outcomes were measured. Results: The scores assessed by the new scoring system were compared with MESS, Gustilo grading, and Ganga score system. Binary logistic regression analysis indicated our scoring system to be more accurate compared to all other scoring systems (P = 0.02). A receiver operating characteristic curve was plotted to compare all other scoring systems. The area under the curve (0.996 ± 0.003) for our scoring system was significantly higher with the less standard error of the mean than other scoring systems compared. Conclusions: Our new scoring system was more accurate in predicting limb salvage and outcomes compared to the existing scoring systems for open fractures of Grade III B and above.
Keywords: Ganga score, Gustilo Anderson classification, Mangled extremity severity score, open fractures
|How to cite this article:|
Chezian Sengodan S V, Arun V, Arun S. Vetrivel trauma score – An evidence-based scoring system to predict limb salvage and outcomes in gustilo anderson grade III B and C compound fractures of lower extremities. J Nat Sc Biol Med 2020;11:151-7
|How to cite this URL:|
Chezian Sengodan S V, Arun V, Arun S. Vetrivel trauma score – An evidence-based scoring system to predict limb salvage and outcomes in gustilo anderson grade III B and C compound fractures of lower extremities. J Nat Sc Biol Med [serial online] 2020 [cited 2021 Mar 4];11:151-7. Available from: http://www.jnsbm.org/text.asp?2020/11/2/151/290493
| Introduction|| |
Gustilo Anderson classification for open fractures is widely used as it allows the clinician to grade them clinically. Injuries of Gustilo Anderson Grade III B and above possess a major challenge in clinical management as they are often associated with a high incidence of infection, nonunion, secondary amputations, secondary procedures, and poor treatment outcomes.,,,,,,, The classification by Gustilo and Anderson is widely used; however, the major drawbacks are that it does not delineate in terms of skin and soft-tissue integrity, predicting limb salvage and outcomes in patients with Grade III B and above.,, It also fails to consider the other systemic illness of the patients, which is necessary to predict outcomes.,, An alternate and detailed scoring system are hence necessary to predict limb salvage as well as to provide guidelines in treating and prognosticating the outcomes.
Mangled extremity severity score (MESS), Hannover trauma score, and Ganga hospital score have been devised for easing surgeons to predict limb salvage in these injuries.,, MESS though widely used does not provide adequate emphasis on prognostic outcomes of salvaged limbs. Hannover trauma score being very elaborate is not widely used. Ganga hospital score is relatively easy and is being popularly used nowadays in predicting limb salvage. However, it does not consider laboratory factors, which provide substantial evidence, and is crucial in deciding amputations versus salvage of affected extremities. Thus, an ideal score, which can identify and evaluate every factor including clinical and laboratory findings in a simple and yet detailed manner to decide on salvaging the limb and as well predict functional outcomes of the complex injuries, is necessary.
| Materials and Methods|| |
This study was conducted in the Institute of Orthopaedics and Traumatology, Government Coimbatore Medical College Hospital after ethical committee clearance, which is a tertiary care teaching hospital. The hospital serves as an apex referral center for a population of around seven million people spanning over four major districts of Tamil Nadu and adjacent states (Kerala and Karnataka). The hospital has separate plastic surgery and vascular surgery department working round the clock. The entire treatment is provided free of cost by the Government of Tamil Nadu, which is the reason for the very high caseload. The huge number of open fractures of the lower limb led us to use the numerous other features unused in routine classifications, which were collectively organized and evaluated to device a new scoring system for deciding limb salvage and determine the prognosis. We have named our scoring scheme as Vetrivel trauma score (VTS) for the lower extremity open fractures of Grade III B and above.
A prospective study was conducted from December 2017 to August 2019 involving 512 open fractures cases, of which 227 patients sustained Grade III injuries according to the Gustilo Anderson classification. One hundred and seventy-five patients had Grade III A open fractures and 52 patients were of Grade III B and above according to the Gustilo Anderson classification. Among the 52 patients, 46 patients belong to Grade III B and six patients belong to Grade III C (Gustilo Anderson classification). Patients with Grade I and Grade II open fractures, according to the Gustilo Anderson classification, were excluded from our study. The patients with Grade III A fractures had a good functional outcome; hence, we excluded them from our study. Patients with only lower limb injuries of Grade III B and above were included in this study. For patients with a suspected case of vascular injury, the vascular surgeon's opinion was obtained immediately, which was supported by investigations including computed tomography angiogram. Patients with irreparable vascular injury, as decided by the vascular surgeon at the time of admission, were excluded from our study. Nerve injuries were not considered in our scoring system, as it cannot be taken as definitive criteria for amputation.
A total of 52 patients were included in the study group with lower limb injuries of Grade III B and above. The age group of the study subjects ranged from 19 to 73 years, with 41 male and 11 female patients. The mode of injury was predominantly by road traffic accidents (44 patients), followed by train traffic accidents (four patients) and work spot injuries (four patients). In this study, the Gustilo Anderson Grade III B and above injuries were scored as per the existing MESS and Ganga scoring system as well as our new scoring system VTS. The role of the VTS system was also evaluated in relation to the duration of hospital stay, wound infection, and the need for secondary procedures.
Our score comprises of two fixed categories, namely: preoperative– nonlaboratory clinical parameters and preoperative– laboratory parameters. Each component was given separate weightage, and a total score ranging from 6 to 55 (minimum and maximum respectively) was obtained. Our scoring system is very objective and single time based, unlike the Gustilo Anderson classification, which changes with relook procedures or after serial debridement.
The preoperative nonlaboratory clinical parameters in VTS include numerous factors that were collected through various available literature, and a preliminary weightage was given by a team of five expert traumatologists on the identified factors. The rank order of mean was calculated for each factor, and the first 12 factors were taken into account and graded according to their role in previously amputated crush injury patients similar to the methodology used to devise Orthopaedic Trauma Association classification. Scoring was done preoperatively in the emergency room [Figure 1]. The preoperative nonlaboratory parameters in VTS are elaborated in [Table 1].
|Figure 1: Preoperative clinical picture showing type of injury, extent of injury, colour, viability, injury location and degree of contamination. (Reproduction size at column width)|
Click here to view
The preoperative laboratory parameters in VTS include three main sub-categories. Rhabdomyolysis following major soft-tissue injury may lead to serious life-threatening complications, including arrhythmias, electrolyte abnormalities, acute renal failure, acidosis, volume depletion, compartment syndrome, and eventually leading to death. Hence, in our scoring system, we included the following three simple and cost-effective biochemical markers(serum creatine kinase, serum lactate dehydrogenase (LDH), and oxygen saturation) that play a vital role in prognosticating ongoing rhabdomyolysis and predicting limb salvage, as elaborated in [Table 2].
Serum creatine kinase is the most sensitive indicator of damage to muscles. A sudden persistently elevated creatine kinase levels suggest continuing muscle injury, development of compartment syndrome, and myoischemia. Values over 1000 indicated crush syndrome, with the normal range being 40–170 iu/l. Although CK-mm is the most sensitive isoform of creatine kinase, in our study, we measured total serum creatine kinase levels as it is available in all tertiary care hospitals.
Serum LDH is another marker for rhabdomyolysis and is constantly elevated in skeletal trauma and muscle ischemia. In our study, the values were increased several-fold in Grade III B injuries from a normal range of 225–450 iu/l. Although LDH-5 is the most sensitive isoform of LDH, in our study, we measured total serum LDH levels due to its cost-effectiveness and as it could be widely used in developing countries all over the world.
Oxygen saturation (SPo2) monitoring of distal extremity provided a valuable information on tissue perfusion and vascular integrity and measured easily using a pulse oximeter [Figure 2].
|Figure 2: Shows preoperative laboratory value of oxygen saturation. (Reproduction size at column width)|
Click here to view
Thus this novel scoring system had an overall maximum score of 55 and a minimum score of 6. All the 52 patients in the study group were categorized into the following four major groups. i.e.,) Group I: Comprising scores (5–16), Group II: Comprising scores (17–28), Group III: Scores (29–38), and Group IV: Scores 39 and above.
| Results|| |
Of 52 patients studied, 39 patients underwent limb salvage, 12 patients underwent primary amputation, and one patient underwent secondary amputation after 1 week, as the patient was not willing for primary amputation [Figure 3]. Of the 39 salvaged patients, 31 patients underwent plastic intervention with flap cover, and the remaining eight patients were managed with split skin grafting [Figure 4]. In our study, eighteen patients were in Group I, twelve patients in Group II, nine patients in Group III, and 13 patients in Group IV. All patients in Group IV underwent amputation (12-primary, 1-secondary).
|Figure 3: Pie diagram showing limb salvage versus amputation in 52 patients (Reproduction size at column width)|
Click here to view
|Figure 4: Pie diagram showing plastic intervention versus no intervention in salvaged limbs (Reproduction size at column width)|
Click here to view
In all 52 patients, MESS, Gustilo grading and Ganga hospital score was calculated and compared with VTS. All patients with VTS of 39 and above went for amputation while there were discrepancies in MESS and Ganga scores. Two patients with MESS score of eight and nine had their limbs salvaged, while one patient with Ganga score of 13 went for amputation while another patient with a Ganga score of 17 had his leg salvaged.
A binary logistic regression analysis was performed for salvage with amputation as dependant value and the MESS, Ganga score, Gustilo, or VTS as independent variables. VTS was observed to significantly influence amputation with (P < 0.01), Ganga score (P = 0.045) being next while both MESS (P = 0.048) and Gustilo (P = 0.09) being nonsignificant. The inter-observer reliability was calculated. Using Kappa analysis by a team of five orthopedic consultants and the average agreement to scores was as high as 98.1% (range: 96.4–99.8).
The accuracy of VTS to predict limb salvage compared with that of MESS and Ganga score was determined by constructing a receiver operating characteristic (ROC) curve and the area under this curve was calculated. A ROC curve plots the sensitivity of an index by its false-positive fraction (1-specificity) over the entire range of possible scores. First, we have used Ganga score as cutoff against VTS as well as the Ganga score [Figure 5]. Then another ROC curve was constructed with VTS as cutoff against Ganga score as well as VTS [Figure 6]. In comparing these scoring systems against each other's classification, when we plot a ROC, then the area under the curve for VTS was 0.974 compared to 0.964 for the Ganga score system. In this way, VTS was identified as a better predictor of limb salvage than the Ganga score system. On the other hand, if MESS was used as the common cutoff for plotting against the VTS and Ganga score, then it was observed that VTS is a better predictor of limb salvage when compared to both Ganga score and MESS [Figure 7].
|Figure 5: Receiver operating characteristic curve with Ganga score as cut-off against Vetrivel trauma score as well as Ganga score (Reproduction size at column width)|
Click here to view
|Figure 6: Receiver operating characteristic curve with Vetrivel score as cut-off against Vetrivel trauma score as well as Ganga score (Reproduction size at column width)|
Click here to view
|Figure 7: Receiver operating characteristic curve with Mangled Extremity Severity Score as the common cut-off plotted against the Vetrivel trauma score and Ganga score (Reproduction size at column width)|
Click here to view
The area under the curve for VTS was 0.974 ± 0.024, the Ganga score was 0.964 ± 0.025, and the MESS was 0.960 ± 0.028. Hence, VTS was superior and more accurate in predicting limb salvage with less standard error mean compared with other scores.
All the 52 patients in the study group were categorized into four major groups. i.e.,) Group I: Comprising scores (5–16), Group II: Comprising scores (17–28), Group III: Scores (29–38), and Group IV: Scores 39 and above as per VTS.
The outcomes were measured among the four groups based on the occurrence of wound infection, need for secondary procedures, and the duration of hospital stay.
Wound infection was diagnosed if the patient met the criteria of superficial or deep surgical site infection. Of 52 patients, two out of eighteen patients in Group I, three out of 12 patients in Group II, and four out of nine patients in Group III had wound infection. Out of 13 patients who underwent amputation in Group IV, three patients had stump site infection [Figure 8].
|Figure 8: Bar diagram showing occurrence of wound infection (Reproduction size at column width)|
Click here to view
The secondary procedures include flap cover, split skin grafting, arterial reconstruction, bone plating, and intramedullary interlocking nailing. Eleven out of 18 patients in Group I, 11 out of 12 patients in Group II, and all nine patients in Group III had intervention by the plastic surgeon. Two out of 9 in Group III had intervention by the vascular surgeon [Figure 9].
|Figure 9: Bar diagram showing the need for secondary procedures (Reproduction size at column width)|
Click here to view
The mean duration of hospital stay in Group I, II, II, and IV was 13.9, 31.6, 47.4, and 28.1 days, respectively [Figure 10].
|Figure 10: Pie diagram showing duration of hospital stay. (Reproduction size at column width)|
Click here to view
In all the three outcome measures, the differences between Group I, II, and III were statistically significant (Chi-square test; P < 0.001). Thus VTS was directly proportional to the occurrence of wound infection, need for secondary procedures, and the duration of hospital stay. Hence, we believe VTS will be helpful to the surgeon in explaining the prognosis of the affected limb even before surgery to the patient and their families.
| Discussion|| |
Numerous classification systems are developed to help the surgeon in clinical decision making to treat open fractures and salvage injured limbs., The management of severe lower-extremity trauma with vascular compromise possess a difficult situation for both the surgeon and the patient. In the last decade, surgeons have had the technical ability to salvage viability in most, if not all, tibial fractures with vascular compromise. However, this is often “technique over reason,” and the result is a physical, psychological, financial, and social cripple with a useless salvaged limb. Many patients, as a result of this protracted experience, continue to experience physical, psychological, social, and financial problems. Studies have also shown that the chances for rapid rehabilitation and recovery from injury for patients who have multiple procedures and prolonged hospitalization are poorer than the chances for those who have primary amputation. In addition, futile attempts at limb salvage place an incredible financial burden on patients.
The most commonly and widely accepted classification systems include Gustilo Anderson classification, MESS, and Ganga score., Gustilo Anderson system although it is most popular, it has poor inter-observer reliability and lacks uniformity.,,,,, Injuries with the major crushing component, lack of soft tissue cover, bone loss, disrupted tendons, co-morbidities, requiring aggressive management were all included broadly under Grade III B in Gustilo's classification, which doesn't help the surgeons in deciding amputation or predict functional outcomes in such injuries along with its poor inter-observer reliability., Hence, a more precise, detailed, and objective comprehensive scoring system is necessary for acute traumatic injury settings.,,,,,
The MESS doesn't delineate much about the fore-mentioned factors and is helpful only in limb injury with normal perfusion. The score doesn't consider a variety of factors that separately assess the limb in terms of survival, need for further procedures, and predicting the prognosis of these severe injuries. According to the Mangled extremity severity scoring system, the cumulative value of seven or more was considered the cutoff value for amputation. In many prospective studies, it was found that the sensitivity and positive predictive value of the score depend solely on the ischemic status of the limb.,,,
Ganga score was developed, and the fallacies of previous scoring systems were rectified with good sensitivity and specificity for a cutoff score of 17 and above to decide amputation. Although the classification has been widely recognized, it does not consider the laboratory factors that predict and determine the ongoing rhabdomyolysis and tissue necrosis at the injured segment of the limb. The Ganga scoring is solely based on preoperative factors that do not consider the evidence-based biochemical markers that will be universally accepted in the era of evidence-based medicine.
Hence, the need for a more elaborate, universally accepted and evidence-based scoring system is necessary to help the surgeon take the most judicial decision in deciding amputation or limb salvage as well as to predict prognosis in terms of occurrence of wound infection, need for secondary procedures and duration of hospital stay. The two broad categories, namely preoperative clinical and preoperative laboratory parameters, were developed comprising numerous components, which led to the development of a new scoring system with very high specificity and sensitivity for predicting amputation and predicting outcomes. We refer to this scoring system as the VTS. In the VTS system, a score of 39 or more predicted 100% need for amputation and scores 29–38 categorized the patients into a grey zone prognosticating the outcomes. Further, the VTS system was also useful as a predictor of proposed hospital stay, chances of wound infection, and the need for secondary procedures.
| Conclusions|| |
The VTS is a very useful tool for the surgeon to decide either to amputate or salvage open lower limb fractures of Gustilo Anderson Grade III B and above. This new score system also helps the surgeon to predict the outcomes on hospital stay, chances of wound infection, and the need for secondary procedures by orthopedic as well as plastic surgeons. Even though the Vetrivel scoring system has been very accurate in predicting and prognosticating these injuries in our hospital, our sample size is small. A large multi-centric trial may be necessary to further validate our study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453-8.
Copeland CS Jr., Enneking WF. Incidence of osteomyelitis in compound fractures. Am Surg 1965;31:156.
Patzakis MJ, Wilkins J, Moore TM. Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res 1983;178:36-41.
McGraw JM, Lim EV. Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing. J Bone Joint Surg Am 1988;70:900-11.
Blick SS, Brumback RJ, Lakatos R, Poka A, Burgess AR. Early prophylactic bone grafting of high-energy tibial fractures. Clin Orthop Relat Res 1989;240:21-41.
Rosenthal RE, MacPhail JA, Oritz JE. Non-union in open tibial fractures. J Bone Joint Surg Am 1977;59:244-8.
Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am 1993;75:1431-41.
Olson SA. Instructional course lectures, the American academy of orthopaedic surgeons-open fractures of the tibial shaft. Current treatment. J Bone Joint Surg Am 1996;78:1428-37.
Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am 1991;73:1316-22.
Sanders R, Swiontkowski M, Nunley J, Spiegel P, Florida T. The management of fractures with soft tissue disruptions. An instructional course lecture, the American academy of orthopaedics surgeons. J Bone Joint Surg Am 1993;75:778-89.
, Bergman M, Watnik N, Berkowitz G, Steuer J. Treatment of grade III-B open tibial fractures. J Bone Joint Surg Br 1994;76:13-9.
Walton RL, Rothkopf DM. Judgment and approach for management of severe lower extremity injuries. Clin Plast Surg 1991;18:525-43.
Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568-72.
Südkamp N, Haas N, Flory PJ, Tscherne H, Berger A. Criteria for amputation, reconstruction and replantation of extremities in multiple trauma patients. Chirurg 1989;60:774-81.
Rajasekaran S. Ganga hospital open injury severity score-A score to prognosticate limb salvage and outcome measures in type III B open tibialfractures. Indian J Orthop 2005;39:4-13. [Full text]
Evans AR, Agel J, DeSilva GL, DeCoster TA, Dirschl DR, Jones CB, et al
. A new classification scheme for open fractures. J Orthop Trauma 2010;24:457-64.
Brancaccio P, Lippi G, Maffulli N. Biochemical markers of muscular damage. Clin Chem Lab Med 2010;48:757-67.
Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin 2004;20:171-92.
Burstein AH. Fracture classification systems: Do they work and are they useful? J Bone Joint Surg Am 1993;75-A:1743-4.
Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742-6.
Rockwood CA, Green SP. Fractures in Adults. 4th
ed., Vol. 1. Philadelphia: Lippincott-Raven; 1996. p. 309-11.
Chapman MW. The role of intramedullary fixation in open fractures. Clin Orthop 1986;212:26-34.
Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia: The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am 1994;76-A:1162-6.
Horn BD, Rettig ME. Interobserver reliability in the gustilo and anderson classification of open fractures. J Orthop Trauma 1993;7:357-60.
DeLong WG Jr., Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW. Aggressive treatment of 119 open fracture wounds. J Trauma 1999;46:1049-54.
Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al
. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 2001;83:3-14.
Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the mangled extremity severity score. Clin Orthop Relat Res 1990;256:80-6.
Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. J Trauma 1993;34:99-104.
Durham RM, Mistry BM, Mazuski JE, Shapiro M, Jacobs D. Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg 1996;172:569-73.
Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop Relat Res 1989;243:92-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2]