The use of the Ganga Hospital Score to predict the treatment and outcome of open fractures of the tibia

Abstract

Aims Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. Methods We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman’s correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting. Results The mean follow-up was 11.4 months (3 to 31). The mean time to union was 9.7 months (3 to 21), the mean number of operations was 2.8 (1 to 11), the mean time in hospital was 17.7 days (5 to 84), the mean length of treatment was 92.7 days (5 to 730), the mean number of admissions was 1.7 (1 to 6), and the mean functional score (Lower Extremity Functional Score (LEFS)) was 60.13 (33 to 80). There was a significant correlation between the GHS and each of the outcome measures. A predictive model was generated from which the GHS could be used to predict the various outcome measures. Conclusion The GHS can be used to predict the outcome of patients who present with an open fracture of the tibia. Our model generates a numerical value for each outcome measure that can be used in clinical practice to inform the treating team and to advise patients. Cite this article: Bone Joint J 2020;102-B(1):26–32

Clinical effectiveness of the Ganga Hospital Open Injury Severity Score for limb salvage versus amputation in patients with complex limb injuries

“…Limb salvage was associated with better LEFS than amputations. 15 Similarly, patients with amputations scored significantly lower on both 12-Item Short Form Health Survey (SF-12) 24 composite physical and mental health scores and had lower EuroQol five-dimension health questionnaire (EQ-5D) 25 quality of life indices than those with salvaged limbs. 14 Messner et al 16 showed that despite good clinical outcomes, open fractures in children had lasting impact on function and quality of life, and potential for long-term psychological problems.…”

“…One study totally excluded patients who underwent amputation, raising high concerns that the reference standard did not match the review question, and another excluded an unspecified number of patients and did not report on amputations. 15 Diagnostic meta-analysis for Ganga Hospital Open Injury Severity Score in detecting the need for secondary and primary amputations in lower limbs. The solid square represents the pooled value of sensitivity and specificity.…”

“…Heterogeneity among studies was visually inspected employing forest plots, and three studies that were primarily designed to investigate specific secondary outcomes were outliers due to patient selection bias. [14][15][16] One study did not report amputations and excluded an unspecified number of patients, the second study excluded amputations, and the third only included patients who had attended follow-up appointments. The remaining five studies evaluated patients with severe complex limb injuries, presenting directly to a tertiary centre, within the first 24 hours of injury after traditional resuscitation.…”

Open tibial fractures: An overview

“…Furthermore, the covering tissue score yields suggestions on the soft tissue closure approach, ranging from primary closure to delayed flap. 38,39 Finally, it generates estimates in 6 treatment outcomes: total length of treatment, number of surgeries required, number of hospital admissions, length of hospital stay, final functional outcomes, and bony union time. GHOISS has been described to be superior in assessing Gustilo-Anderson IIIb injuries, where other scoring systems have demonstrated poor intraand inter-observer reliability and inability to predict limb salvage and functional outcomes.…”

“…40 Since its inception, GHOISS has demonstrated a high sensitivity and specificity for amputation and good predictability of surgical outcomes in type IIIb open tibial fractures in both adults and children. 39,41,42…”