The utility of scores in the decision to salvage or amputation in severely injured limbs

The decision to amputate or salvage a severely injured limb can be very challenging to the trauma surgeon. A misjudgment will result in either an unnecessary amputation of a valuable limb or a secondary amputation after failed salvage. Numerous scores have been proposed to provide guidelines to the treating surgeon, the notable of which are Mangled extremity severity score (MESS); the predictive salvage index (PSI); the Limb Salvage Index (LSI); the Nerve Injury, Ischemia, Soft tissue injury, Skeletal injury, Shock and Age of patient (NISSSA) score; and the Hannover fracture scale-97 (HFS-97). These scores have all been designed to evaluate limbs with combined orthopaedic and vascular injuries and have a poor sensitivity and specificity in evaluating IIIB injuries. Recently the Ganga Hospital Score (GHS) has been proposed which is specifically designed to evaluate a IIIB injury. Another notable feature of GHS is that it offers guidelines in the choice of the appropriate reconstruction protocol. The basis of the commonly used scores with their utility have been discussed in this paper.     

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

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.     

Use of Ganga Hospital Open Injury Severity Scoring for determination of salvage versus amputation in open type IIIB injuries of lower limbs in children—An analysis of 52 type IIIB open fractures

Introduction and aimsOpen injuries in children are rare compared to adults. In children with major open injuries, there is no specific scoring system to guide when to amputate or salvage the limb. The use of available adult scoring systems may lead to errors in management. The role of Ganga Hospital Open Injury Severity Scoring (GHOISS) for open injuries in adults is well established and its applicability for pediatric open injuries has not been studied. This study was done to analyse the usefulness of GHOISS in pediatric open injuries and to compare it with MESS(Mangled Extremity Severity Score).MethodsAll children (0–18 years) who were admitted with Open type IIIB injuries of lower limbs between January 2008 and March 2015 were included. MESS and GHOISS were calculated for all the patients. There were 50 children with 52 type IIIB Open injuries of which 39 had open tibial fractures and 13 had open femur fractures.ResultsOut of 52 type IIIB open injuries, 48 were salvaged and 4 were amputated. A MESS score of 7 and above had sensitivity of 25% for amputation while GHOISS of 17 and above was found to be more accurate for determining amputation with sensitivity of 75% and specificity of 93.75%.ConclusionGHOISS is a reliable predictor of injury severity in type IIIB open fractures in children and can be used as a guide for decision-making. The use of MESS score in children has a lower predictive value compared to GHOISS in deciding amputation versus salvage. A GHOISS of 17 or more has the highest sensitivity and specificity to predict amputation.     

Vascular trauma of the upper extremities

The aim of this study was to evaluate short- and long-term results of the treatment of upper extremities vascular trauma considering aetiology of the lesions, percentage of limb salvage and residual functional disability. The Authors retrospectively evaluated 17 patients accounting for 21 vascular lesions of the upper extremities (16 arterial and 5 venous injuries). Age, sex, modality of trauma, site of the vascular lesions and of the associated injuries, diagnostic procedures at the admission, ischemic time, arterial and venous repair performed were analyzed. The over all peri-operative mortality was 5.8%. Of the 16 arterial injuries long-term reconstruction viability was obtained in 15 patients (93.7%). In all cases limb salvage was obtained. In 3 patients invalidating functional defects due to associated injuries of the major brachial plexus were observed. The Authors believe that associated nervous lesions are the main factor determining invalidating residual disability. In this series ischemic time, technique of vascular repair performed, associated skeletal injuries didn't influence the functional outcome of the reconstruction.     

Prognostic scoring system for peripheral nerve repair in the upper extremity

So far, predictive models with individualized estimates of prognosis for patients with peripheral nerve injuries are lacking. Our group has previously shown the prognostic value of a standardized scoring system by examining the functional outcome after acute, sharp complete laceration and repair of median and/or ulnar nerves at various levels in the forearm. In the present study, we further explore the potential mathematical model in order to devise an effective prognostic scoring system. We retrospectively collected medical record data of 73 cases with a peripheral nerve injury in the upper extremity in order to estimate which patients would return to work, and what time was necessary to return to the pre‐injury work. Postoperative assessment followed the protocol described by Rosén and Lundborg. We found that return to pre‐injury work can be predicted with high sensitivity (100%) and specificity (95%) using the total numerical score of the Rosén and Lundborg protocol at the third follow‐up interval (TS3) as well as the difference between the TS3 and the total score at second follow‐up interval (TS2). In addition, the factors age and type of injured nerve (median, ulnar, or combined) can determine the time of return to work based on a mathematical model. This prognostic protocol can be a useful tool to provide information about the functional and social prospects of the patients with these types of injuries. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Traumatische Extremitätenverletzung mit Knochen- und Gefäßbeteiligung: Prioritätentriage, Interdisziplinäres Management

The development of trauma surgery, especially vascular reconstruction in limb-threatening vascular and bone injuries, is closely related to the multiple military conflicts over the past 50 years. In civilians, such trauma surgery is an infrequent but difficult management problem.The aim of an interdisciplinary procedure – with adequate bone stabilization, arterial and venous revascularization (autologous) and soft tissue reconstruction – should be a functional extremity. The time taken for diagnosis, transport and bone stabilization should be as short as possible as time is of predictive value for limb salvage. Our experience with 120 patients who underwent simultaneous bone and vascular surgery for traumatic extremity injuries is reported.The incidence of arterial injury was lower than 1%, limb salvage after bone and arterial reconstruction was between 89 and 95%. The repair rather than the ligation of complex vascular injuries in severe extremity trauma is recommended for limb salvage.An interdisciplinary approach should be used, taking into account soft tissue management (debridement, fasciotomy, soft tissue reconstruction, monitoring). Our trauma management procedure is described.The extremity injury severity scores proved to be of little clinical value.Thus limb-threatening vascular injuries will always be a challenge for interdisciplinary management as well as for the vascular and trauma surgeon!     

Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol

BACKGROUND: Prompt identification of cervical spine injuries has been a critical issue in trauma management. In 1998, the authors developed a new protocol to evaluate cervical spines in blunt trauma. This protocol relies on clinical clearance for appropriate patients and helical computed tomography instead of plain radiographs for patients who cannot be clinically cleared. The authors then prospectively collected data on all cervical spine evaluations to assess the sensitivity and specificity of their approach. METHODS: Any patient without clinical evidence of neurologic injury, alcohol or drug intoxication, or distracting injury underwent cervical spine evaluation by clinical examination. Patients who did not meet these criteria underwent helical computed tomographic scanning of the entire cervical spine. For patients who had neurologic deficits, a magnetic resonance image was obtained. If the patient was not evaluable secondary to coma, the computed tomographic scan was without abnormality, and the patient was moving all four extremities at arrival in the emergency department, the cervical spine was cleared, and spinal precautions were removed. Data were collected for all patients admitted to Santa Barbara Cottage Hospital trauma service between 1999 and 2002. The authors selected for analysis patients with blunt trauma and further identified those with closed head injuries (Glasgow Coma Scale score < 15 and loss of consciousness). In addition, all blunt cervical spine injuries were reviewed. RESULTS: During the period of study, 2,854 trauma patients were admitted, of whom 2,603 (91%) had blunt trauma. Of these, 1,462 (56%) had closed head injuries. One hundred patients (7% of patients admitted for blunt trauma) had cervical spine or spinal cord injuries, of which 99 were identified by the authors' protocol. Only one injury was not appreciated in a patient with syringomyelia. Fifteen percent of patients with spinal cord injury had no radiographic abnormality; all of these patients presented with neurologic deficits. The sensitivity for detecting cervical spine injury was thus 99%, and the specificity was 100%. The risk of missing a cervical spine injury in these blunt trauma patients was 0.04%. The authors missed no spine injuries in patients with head injuries. CONCLUSION: The use of the authors' protocol resulted in excellent sensitivity and specificity in detecting cervical spine injuries. In addition, it allowed early removal of spinal precautions.     

Flap reconstruction following high pressure injection injuries of the hand: a report of three cases.

High pressure injection injuries are well known to cause significant injury to the hand, with high amputation rates and poor functional outcome. Surgical treatment consists of early aggressive debridement followed by secondary closure. Flap reconstruction is a reconstruction option which can increase the chance of digit salvage, as well as give an acceptable functional and cosmetic result. We review three cases of flap reconstruction following high pressure injection injuries, and discuss their role in the treatment of these injuries.     

Microsurgical reconstruction of opposable digits in mutilating hand injuries

Multilating hand injuries with multiple digital amputations require a cooperative patient, a highly skilled hand/microsurgical team, and a continuum of hand rehabilitation therapy for optimal functional salvage. A systematic approach for assessing a patient's functional deficit and reconstructive requirements contributes to a coordinated reconstruction and rehabilitation plan designed to optimize functional gains. Today's sophisticated microsurgical reconstruction coupled with comprehensive hand therapy generally represents the best option for patients with mutilating hand injuries. Throughout reconstruction and rehabilitation the ultimate goal of multilating hand injury care, that of restoring a functional extremity that is useful in a patient's daily life must be remembered.     

Early Microvascular Reconstruction of Gustilo Type III-C Lower Extremity Wound: Case Report

Current algorithms for lower limb injuries recommend amputation for most Gustilo type III-C injuries with a limb salvage index score of 6–8 or more. Recent improvements in the timing and technique of microvascular flaps with the reduction in bone healing time as a result of better fixation devices and early bone grafting make the option of limb salvage after such severe injuries a valid and acceptable therapeutic approach. We present a case of severe shot gun injury to the leg with a limb salvage index score of 9 that was successfully salvaged by vascular reconstruction followed three days later with a microvascular osteocutaneous scapular flap anastomosed to the divided limbs of a preliminary arterio-venous fistule that had been constructed at the time of the initial vascular repair. The patient was able to walk unaided one year after the injury.     

Multiple High-Energy Open Injuries in the Same Limb: Comparison of Outcomes Between Salvage and Amputation Groups

AimTo analyze the functional outcomes between limb salvage and amputation patients who had multiple open injuries in the same lower limb.Materials and MethodsThis observational study analyzed 21 patients who were admitted with multiple open injuries in the same lower limb between January 2012 and December 2015 in our unit. Twelve patients underwent limb salvage and nine patients underwent amputation. The total number of surgeries, duration of hospital stays, ICU admission, complications, time to return to work and costs of inpatient treatment were analyzed. The functional outcome was assessed by using the lower extremity functional scale (LEFS) in both groups, SF-12 score was done for both groups and amputation specific scoring was done by using locomotors capabilities index (LCI).ResultsThe LEFS was lower in salvage group than amputation group. The SF-12 score was close to normal population in the amputation group and was higher than salvage group. The duration of hospital stays, total number of surgeries and the costs of inpatient admission were higher in salvage group. The time to return to work was earlier in amputation group. Sixty-seven percentage of patients in the salvage group developed complications.ConclusionThe functional outcome and SF-12 score was better in amputation group. Patients who had amputation returned to work earlier, had smaller number of secondary hospitalization and has less complications and incurred less expenditure for treatment. The treatment decision should be periodically reviewed when an initial choice of salvage is made. Amputation must be looked at as a treatment for early rehabilitation.     

Percutaneous fixation of Lisfranc joint injuries: A systematic review of the literature

ObjectiveThe aim of this systematic review was to present the outcome of Lisfranc joint injuries treated with closed reduction and screw percutaneous fixation.MethodsWe searched in Pubmed and Google Scholar Databases for articles regarding screw percutaneous fixation of Lisfranc injuries. Seven studies in total were found to be compatible to our search, according to PRISMA guidelines. Four of those met the criteria of the review and they were included in the meta-analysis. A total number of 106 patients were separated into five groups according to the type of injury and the mean AOFAS score of each group was calculated. Cases in which percutaneous fixation was converted to open treatment due to poor reduction were not included in the study. In addition we compared the outcome score between types of injury according to Myerson classification as well as between purely ligamentous and osseoligamentous injuries. The characteristics of all seven selected studies, such as kind of screw used for fixation, post operative protocol, complications and outcome are mentioned as well.ResultsAverage AOFAS score was 86,2 for type A, 87,54 for type B, and 85 for type C injuries respectively. In pure dislocation group the average AOFAS score was 86,43 and in fracture dislocation group was 87,36. Good to excellent outcome can be expected in patients with different types of injury according to Myerson classification following percutaneous fixation of lisfranc joint injury. Patients with type B injury or a fracture dislocation injury might have better outcome, although this difference was not found to be statistically significant.ConclusionPercutaneous fixation of tarsometatarsal joint injuries is a relatively simple and safe method of treatment, leading to a good functional outcome, especially for Myerson type B as well as for fracture dislocation type of injuries, provided that an anatomical reduction has been achieved.Level of EvidenceLevel III, Therapeutic Study.     

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores

BACKGROUND: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems. METHODS: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation. RESULTS: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation. CONCLUSIONS: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.     

Hyperbaric oxygen therapy facilitates surgery on complex open elbow injuries: preliminary results

Complex open elbow injuries present a significant challenge to orthopaedic surgeons because of the poor potential for achieving a good functional level, even given good anatomic realignment. Associated massive soft-tissue damage impedes surgical fixation, delays rehabilitation, and therefore, further deteriorates the functional outcome. We studied a prospective, consecutive series of 16 patients with complex open elbow injuries who were treated with a combination of treatment modalities including early bony stabilization, debridement of soft tissue, and early coverage. The treatment protocol also used hyperbaric oxygen therapy to facilitate immediate internal fixation. The median value of the Mangled Extremity Severity Score was 5.5 (range, 3-10). Successful reconstruction was achieved in all 16 patients. No deep infection occurred, but there were 3 self-limited superficial infections. The average elbow functional result at 12 months after surgery, based on the Mayo score system, was good (mean value, 80.9; range, 55-100). Of the patients, 75% achieved satisfactory functional results for the elbow. The results of this study demonstrate that the studied treatment protocol provides a promising alternative for managing these complex open elbow injuries.     

Similar functional outcomes of arthroscopic reconstruction in patients with isolated Posterior Cruciate Ligament (PCL) and combined Anterior Cruciate Ligament (ACL) and PCL tears

BackgroundPosterior Cruciate Ligament (PCL) injuries seldom occur in isolation and majority occurs in conjugation with other ligament injuries. Posterior Cruciate Ligament (PCL) reconstruction continues to be taken into consideration as a complicated surgical procedure, with heterogeneity in literature regarding clinical and functional outcomes in isolated PCL and combined ACL and PCL injuries.MethodsThe retrospective evaluation of patients with isolated PCL reconstruction (group 1) and combined Anterior Cruciate Ligament (ACL) and PCL reconstruction (group 2) was performed. A total of 66 patients with either isolated PCL or combined ACL and PCL reconstruction surgeries that met the inclusion criteria, were included in the study. These patients were assessed for functional outcome scores including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Lysholm score, International Knee Documentation Committee (IKDC) and Tegner activity score at a minimum follow-up of 5 years.ResultsThe mean follow-up of patients was 82.09 ± 12.43 months in group 1 and 79.36 ± 11.24 months in group 2, with a total of 29 patients in group 1 and 21 patients in group 2. Both the groups were found to be comparable in terms of age, gender, duration of injury and pre-injury Tegner activity level. Post-surgical functional outcome scores (WOMAC score, Lysholm score and Tegner score) were found to be comparable between 2 groups at a mean follow-up of 5 years. Further, 22 patients in group 1 and 16 patients in group 2 had normal or near normal objective IKDC outcome scores at a mean follow-up of 5 years.ConclusionsNo differences were observed in functional outcome scores (WOMAC score, Lysholm score, Tegner score and IKDC score) between isolated reconstructed PCL and combined ACL and PCL reconstructed patients.     

Distally Based Pedicled Fibula Flap for Reconstruction of Infected Charcot’s Midtarsal Collapse—Diabetic Rocker Bottom Foot

Introduction and Methods  Diabetic rocker bottom foot with secondary infection exacts the expertise of a reconstructive surgeon to salvage the foot. The author selected 28 diabetic patients with secondarily infected Charcot’s degenerated rocker bottom feet and reconstructed their feet using distally based pedicled fibula flap. Reconstruction was done in a staged manner. Stage 1 surgery involved external fixation following debridement. In stage 2, struts were activated for distraction and arthroereisis. In stage 3, the distally based pedicled fibula was used for reconstruction and beaming of the arches. Results  In this retrospective study, the author analyzed the outcome of all 28 patients using the Musculoskeletal Tumor Society Rating (MSTSR) score. The average MSTSR score was 27.536 in an average follow-up of 30.5 months. The limb salvage rate with the author’s procedure was 96.4% ( p = 0.045). Conclusion  Author’s protocol for the staged reconstruction and salvage of the infected diabetic rocker bottom foot, using the pedicled fibula flap, will be a new addendum in the reconstructive armamentarium of the orthoplastic approach.     

Sideswipe injuries around the elbow: Management and functional evaluation

Introduction:

Sideswipe injuries constitute a subgroup of complex elbow trauma. Almost all of these are high energy open injuries. There is no fixed protocol that is followed in the earlier studies. The injury pattern is grotesque and ill managed with poor functional outcome. We report the functional outcome in our series of patients who sustained sideswipe injuries.

Materials and Methods:

Thirty four patients presenting with sideswipe injuries around the elbow were managed and functional results evaluated. The patients were followed for 15-94 months (mean 74 months). 32 of these were males and two were females. The injuries were sustained between 8 years and 48 years age group (mean 30 years). The right side was affected in 20 and left side was injured in 14 patients. Road traffic accident was the cause in all patients. Principles of management followed were (1) debridement and stabilization of fractures, (2) vascular repair, (3) redebridement, (4) nerve repair and (5) soft tissue cover. An external fixator was used for fracture stabilization in 20 patients with open fractures. Internal fixation was used as a stabilization modality in 12 patients. Primary nerve repair was carried out in 4 cases. In case of segmental loss, tendon transfers or nerve grafting was carried out at a later date once softtissue healing was complete. Soft tissue coverage was provided within 24-48 h of injury. Results were evaluated using the Mayo elbow performance score.

Results:

The average Mayo elbow performance score was 70. Excellent results (score > 90) in accordance with Mayo elbow score were seen in 30% of the patients. Good results (score 75-89) were seen in 33% of the patients.

Conclusion:

Sideswipe injuries should be managed timely, aggressively and an algorithmic protocol should be followed to achieve best results. The injury pattern is distinct for which a multispecialty approach is needed and an orthopedic, vascular and plastic surgeon must be involved. Limb salvage is possible in most cases.     

Improved results in the treatment of civilian vascular injuries associated with fractures and dislocations

Patients with vascular injuries associated with fractures or dislocations of the extremities were managed according to a standard protocol, which included the liberal use of preoperative arteriography, early fasciotomy when indicated, individualization of timing and type of orthopedic procedures, arterial reconstruction primarily with interposition reversed saphenous vein grafts, repair of major venous injuries, routine completion arteriography, and regular postoperative monitoring of Doppler-derived ankle/brachial indices. Adherence to these principles led to a limb salvage rate of 97% in 38 patients with such injuries.     

Functional Reconstruction of Hindfoot With Total Calcaneus and Talus Loss by Ilizarov Technique: A Case Report

Total calcaneus and talus loss in the hindfoot is an unusual but severe condition encountered in clinical settings. This condition affects lower-extremity function and poses a significant challenge to limb salvage. We present a case of a 43-year-old man with total calcaneus and talus loss in the right foot treated by Ilizarov technique. A staged treatment protocol was planned to reconstruct and optimize the heel for weightbearing and walking. During the 15-month postoperative follow-up, the patient reported no significant discomfort in the targeted foot and regained satisfactory function, including shoe wearing, walking, driving, and climbing stairs. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 71, which was an improvement from a preoperative score of 40. This case is the first reported on the functional reconstruction by Ilizarov technique of hindfoot with total calcaneus and talus loss. This treatment protocol provides an effective approach to reconstructing the hindfoot with massive bone loss, although the long-term outcome remains unknown.     

Limb reconstruction versus amputation decision making in massive lower extremity trauma

Massive lower extremity trauma, in particular open tibial fractures with associated vascular injuries, presents an immediate and complex decision-making challenge between a limb salvage attempt and primary amputation. Unfortunately, the literature to date is deficient in providing sound and defensible guidelines for primary amputation. Individual patient variables, specific extremity injury characteristics, and associated injuries must all be weighed before a decision can be reached. Further prospective studies are necessary before a well-defined protocol for primary amputation can be properly developed.