The results of a prospective study of primary bone grafting in a selective group of patients with High energy open fractures (Grade III) of limbs with communition or bone loss are presented. Out of 310 Gustilo Grade III Open injuries managed over a 4 year period, 42 patients with Grade III injuries underwent bonegrafting after satisfying the inclusion criteria (Age <60, Debridement within 12hrs, Stable fracture fixation, wound cover within 72hrs) at or before the time of wound closure or soft tissue cover. Patients with Grade IIIc fractures, farmyard injuries, needing freeflaps, ASA grade of 3 or more, injury severity score > 25 or monomelic polytrauma were excluded. The bone involved was femur in 26 patients, tibia in 4, forearm in 9 and humerus in 3 patients. The injury was Grade IIIA in 11 and Grade IIIB in 31 patients. Wounds were primarily closed immediately after debridement in 28 (66.7%) patients, by split thickness skingrafting in 7 (16.7%) and by suitable regional flaps in 7 (16.7%) patients. Rigid fixation was achieved in all patients with variety of implants depending on the fracture personality. Autologous Cortico-cancellous bonegrafting was done immediately after debridement in 33 (78.6%) and within 72hrs at the time of soft tissue cover in 9 (21.4%) patients.Introduction
Materials and methods
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 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.
