ORIGINAL RESEARCH PAPER Volume - 11 | Issue - 03 | March - 2022 | PRINT ISSN No. 2277 - 8179 | DOI : 10.

36106/ijsr

INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH

EVALUATION OF MANAGEMENT OF GUSTILO TYPE IIIB OPEN WOUND

ACCORDING TO GANGA HOSPITAL OPEN INJURY SEVERITY SCORE (GHOISS)

Orthopaedics
Dr Arindam Basu* Dept of Orthopaedics, nrs medical college, Kolkata-700014. *Corresponding Author
(Prof) Dr Sujit Dept of Orthopaedics, Nrs Medical College, Kolkata-700014.
Narayan Nandy
Dr Partha Sarathi Dept of Orthopaedics, nrs medical college, Kolkata-700014.
Sarkar
ABSTRACT
Introduction: In this era of high speedy vehicles road trafc accidents leading to polytrauma and open fractures are very common.There is a lot of
confusion regarding amputation or salvage on day 1, particularly in managing open fractures gustilo type IIIB. So there is an urgent need of a
scoring system which can prognosticate limb salvage or amputation.
Aim: To evaluate the results of open fracture (specially type IIIB) management according to GANGA score and to estimate how successfully it can
prognosticate limb salvage or amputation.
Materials And Methods: In this prospective study for 1.5 years duration ,50 patients were selected randomly with Gustilo type IIIB open wound
from emergency and OPD of ORTHOPAEDICS department (N.R.S.M.C.H) and they were evaluated using GANGA score and MESS score. A
multidisciplinary approach was taken to manage the open fracture with proper and timely consultation of vascular and plastic surgeon.
Results: Sensitivity and specicity of Ganga score is 100% and 97.82% and that of MESS score is 50% and 86.95%. The positive predictive value
of Ganga score is 80% and that of MESS score is 25%. So Ganga score is having greater practical value.
Conclusion: This score acts as a predictable single scoring system for both limb salvage and amputation and it can successfully address the
dilemma of Primary amputation or limb salvage on Day 1 in type IIIB injury.
KEYWORDS
Gustilo type IIIB, open fractures, GANGA score, MESS score.
INTRODUCTION mangled extremity e.g Mangled Extremity Severity Score(MESS),
In this era of high speedy vehicles, road trafc accidents leading to Mangled Extremity Syndrome Index(MESI),Predictive Salvage
polytrauma and open fractures are very common. Expansion in the Index(PSI),Limb Salvage Index(LSI), NISSSA (Nerve Injury,
road network ,a surge in motorization and the rising population in the Ischemia, Soft-tissue contamination, Skeletal injury, Shock and
country contribute towards the increasing number of road accidents, Age),HFS (Hannover Fracture Score).Each of them has their own pros
leading to injuries and fatalities.[1] and cons and some scoring systems are little complicated and not
useful for practical purposes[6][7].
Appropriate management of an open fracture is a major challenge to
any orthopaedician as there is no clear cut guideline available To overcome all these difculties The Ganga Hospital Open Injury
regarding management. There is a lot of confusion regarding Severity Score(GHOISS) was described in 2006 by Rajasekaran et al.
amputation or salvage on day 1, particularly in managing open to specically address the issue of salvage and reconstruction
fractures gustilo type IIIB. 3 outcomes are possible in management of pathways in type IIIB injuries[2].
open fracture…..
1) Successful salvage:-highly desirable
2) Primary amputation:-not desirable but acceptable
3) Failed attempt to salvage ultimately ending amputation:-neither
desirable nor acceptable.

So there is an urgent need of a scoring system which can prognosticate

limb salvage or amputation.[2]

Grading of open fractures has seen periodical changes over time. Early
attempts by Velaskis[3]at grading open fractures were rened by
Gustilo and Anderson in 1976[4].Gustilo et al subsequently modied
their classication system into it's current form in 1984[5].Gustilo and
Anderson prospectively followed more than 350 patients.They
categorized the injuries into three categories.
Type I Open fracture with wound less than 1 cm long and clean.
Type II Open fracture with wound >1 cm wound but <10cm.
Type IIIa Open fractures with adequate soft tissue
coverage(laceration >10cm)
Type IIIb Open fractures with extensive soft tissue injury
,periosteal stripping and bone exposure.
Type IIIc Open fractures with arterial injury
The major challenge to the trauma surgeon in salvaging type IIIB
injury is it's wide spectrum ranging from easily manageable to barely
salvageable. The interobserver agreement of gustilo's classication
has been found to be only moderate to poor, highly case dependent ,and
varying with the experience of the surgeon. It is well documented that The basis of the scoring system is that the three components of a limb:
we need a better classication to understand these challenging covering tissues(skin),structural tissues(bone) and functional
injuries.[2] tissues(muscles,tendons,nerves).These are injured to different
severity in every type III Injuries. One to ve points are allocated to
Many scoring systems are available to prognosticate limb salvage in each of these three components of the limb, systemic factors which
International Journal of Scientific Research 29
Volume - 11 | Issue - 03 | March - 2022
may inuence the treatment outcome are given two points each and the
nal score is calculated by adding the individual scores together. Now
if the nal score is 14 or less we should consider primary limb salvage
and if the score is 17 or more we should consider primary
amputation.The score 15 ,16 is grey zone and we should consider
primary treatment on case to case basis.
The advantage of Ganga Hospital Open Injury Severity Score is that it
includes a scoring system based on which we can manage open
fractures. In Gustilo's classication there is no such scoring system
and Gustilo's classication is based mainly on the size of wound rather
than the extent of injury to all components of limb.The energy of injury
is dissipated to all the structures of limb and the severity of injury
depends not only on the external size of the wound but also on the
overall involvement of all component of limb i.e. overlying skin,
underlying muscle, bone, joints, comorbid factors. With the help of
this GANGA scoring we can successfully prognosticate limb salvage
and reduce the number of patients in which failed primary salvage has
been done that later on go for amputation. Thus it is evident that Ganga
hospital open injury severity score is much superior and successfully
overcomes the major drawbacks of Gustilo's classication.
MATERIALS AND METHODS
Inclusion criteria –polytrauma patients(both male and female) with
Gustilo type IIIB open wound were selected. Total 50 patients were
s e l e c t e d f r o m e m e rg e n c y / O P D i n t h e d e p a r t m e n t o f
ORTHOPAEDICS, NRSMCH.
Exclusion Criteria
Ÿ Type IIIA and type IIIC open wound
Ÿ Open wound requiring primary vascular repair
Ÿ Peripheral vascular diseases.
Ÿ Moribund patients.
After obtaining ethical clearance ,cases were selected from the patients
visiting the Orthopaedics OPD and Emergency of Orthopaedics
department of N.RS.M.C.H during the time period of January 2017 to
July 2018. Patients meeting the inclusion and exclusion criteria were
included in the study. Patient were classied according to Gustilo
Anderson classication and only type IIIB open injuries were
included. Severity of injury, age of patients, time interval between
injury and operative intervention, overlying skin and soft tissue,
underlying bone joints muscle and other comorbid factors which can
change the management were given special importance and they were
used as parameters for determining management. A multidisciplinary
approach was taken to manage the open fracture. Proper and timely
consultation with the vascular and plastic surgeon was necessary .
Different parameters of GANGA scores were evaluated and followed
up on regular basis. Among the salvaged limbs different parameters
(e.g number of in-patient days, incidence of infection, time for bony
union, requirement of plastic surgical procedure, requirement of
multiple surgery) were evaluated and their relationship with GANGA
scoring (if any) was evaluated. Stastical analysis was done by
appropriate tests.
Management Protocol Of Open Fracture
In our study after stabilisation of the patient we applied GANGA score
and MESS score in each patient to predict nal outcome. The patients
who were included in our study were all type IIIB open fracture.
30 International Journal of Scientific Research
PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr
Appropriate antibiotic therapy was started in the emergency
department or at the latest in the emergency operating room. Wound
swab for culture was sent.
Immediately debride the wound of contaminated and devitalized
tissue, copiously irrigate with normal saline( upto 9 litre) and perform
repeat debridement within 24-72 hours if necessary.
Percutaneous drainage of a Morel –lavallee lesion was done if it was
present.
In our study ,we have used 9L of gravity ow irrigation in most cases.
Additional uid may be necessary in highly contaminated fracture,
whereas lesser amounts (5-6L) were necessary in minimally
contaminated upper extremity injury. Additives such as povidone
iodine, hydrogen peroxide has been used along with the irrigating
solution.
Muscle debridement should remove all non viable muscle that was non
contractile and grossly contaminated. Completely severed tendon ends
that were highly contaminated also may require excision.Care must be
taken to maintain moisture around such structures because once the
tendon becomes dried it is dead and excision was necessary. Early ap
placement or a sealed dressing may prevent desiccation of these
delicate tissue. While dealing with the muscles ; the four “C”s must be
observed: consistency, color, contractility, circulation.
The treatment of bony injury and stabilisation of fractures was one of
the most important step in management of open fractures . Generally
external xation was preferred with occasional plate and screw
xation or k wire xation. Articular congruity restoration was tried as
much possible. Skin should be apposed loosely for wound coverage.
Plastic surgery intervention was needed (ap cover, split thickness
skin grafting ) for denite coverage of wound. The decision of
amputation was taken independently by a consensus of senior
orthopaedic,plastic,vascular surgeon without any bias or consideration
of any score. Retrospective analysis was done to know the
effectiveness of Ganga score to predict slavage or amputation in
Gustilo type IIIB open fractures.
RESULTS AND ANALYSIS
In this study ,we have studied 50 open fractures (Gustilo –Anderson
type IIIB) and the site of injury was both bone leg(tibia-bula) in all
cases.
Among the study group there were 45 male and 5 female patients with
age ranging between (19 -74yrs) and with an average of 41.32 yrs.
The cause of injury was road trafc accident(42) ,fall from height (6),
and farm yard injury in 2 patients.
Comorbid conditions (as per Ganga hospital scoring) was present in 25
patients.
The patients were divided in groups according to Ganga scoring and
MESS scoring. Four groups were made
GANGA score Group
1-5 I
6-10 II
11-15 III
16 and above IV
Two groups according to MESS score[≤6=group I, ≥7=group II).
Volume - 11 | Issue - 03 | March - 2022 PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

Now person in each group is as such surgical intervention was required in 10 patients out of 24(41.66%).
Group acc to GANGA scoring No. Of patients Among the 3 patients were treated with ap cover and 7 patients were
I 0 treated with STSG. In group III (Ganga score group) plastic surgical
II 24 intervention is required in 18 patients out of 22(81.81%) indicating the
higher need of plastic surgical intervention. Among them 6 patient
III 22
required ap cover and 8 skin grafting and rest 4 required both
IV 4 procedure. In group IV (Ganga score group) 2 patient(50%) required
Group ACC to MESS No. Of patients plastic surgical intervention and among them in 1 patient ,there was
I 48 failure of ap. The other 2 patients underwent primary amputation.
II 2
Now the decision of amputation was taken independently by a
consensus of senior orthopaedic,plastic,vascular surgeon without any
bias or consideration of any score. Total 4 patients were amputated in
our study among them 3 were primary and 1 was secondary
amputation. Amputation was considered primary if they were
performed during initial procedure and secondary if they were carried
out at any time after that.

Now the 4 patients who have undergone amputation,all of them have

Ganga score of more than 14. One patient is having score of
15,another one is having score of 16 ,the rest 2 have score of 17 and 18
resepectively.

Now in MESS scoring, of the four amputations only 2 have score of 7or
more the rest 2 have score of 6. One patient with a score of 8 has
undergone limb salvage procedure.

The details of 4 patient is

GANGA score MESS score Primary Secondary
amputation amputation
15 6 Done -
16 6 - Done
17 9 Done -
18 8 Done -
Now the patient who had undergone secondary amputation after 1
month is due to secondary loss of soft tissue and muscle necrosis and
failure of ap. Amputation was not advised primarily with the
expectation of limb salvage. Now in that particular case,MESS score
was 6 and GANGA score was 16. So the predictive value of GANGA
scoring was more towards amputation than Mangled extremity
severity score.

The sensitivity, specicity, positive predictive value,negative

predictive value was calculated for Ganga hospital score with a
threshold value of 15 for amputation and a threshold value of 7 for
Mangled extremity severity score. Now among the 50 patients,limb
salvage was possible in all patients with Ganga score of 14 or less(total
45 patients). Limb salvage was possible in one patient with a score of
16(Ganga score) and a MESS score of 8 indicating a better prognostic
value of Ganga score in detecting limb salvage . 2 patient with Ganga
score of 17 and above had undergone primary amputation.

Sensitivity and specicity of Ganga score was 100% and 97.82% and
that of MESS score was 50% and 86.95%. The positive predictive Deep tissue infection is present in 2 cases among the 24 patients of
value of Ganga score was 80% and that of MESS score was 25% group II Ganga score(6-10). The percentage of infection in this group
indicating that even with patient scoring 7 or more in MESS, the limb is 8.33%. The same is present in 8 patients among the 22 patients of
can be salvaged. So Ganga score is having greater practical value. The group III Ganga score (11-15) and the percentage is 36.36%.
negative predictive value of Ganga score is 100% and that of MESS
score is 95.23%.
Ganga score MESS score
Sensitivity 100% 50%
Specicity 97.82% 86.95%
Positive predictive value 80% 25%
Negative predictive value 100% 95.23%
Now if we calculate the outcome measures, the mean no. of Surgical
procedures done in group II(Ganga score between 6-10) is 3 and that
of group III( Ganga score between 11-15) is 5. The average number of
surgical procedure done in group IV (Ganga score over 16) is 5.

The mean no. of inpatient days in group II Ganga score(score between

6-10) is 18.62 days(6-35days) compared with 52 days in group III
[score between 11-15](28-66 days). Group IV Ganga score[score
between 16 or above] has an average value of 50.5 days(29-50.5) days.

The requirement of specialised plastic surgery procedure was well Thus it clearly shows that the incidence of infection increases with
predicted by Ganga scoring. In group II( Ganga score group) plastic increase in Ganga score.
International Journal of Scientific Research 31
Volume - 11 | Issue - 03 | March - 2022
The statistical analysis was done using SPSS software. So the p value
of the study is .000(<0.05) and it is statistically signicant.So the
prediction of limb salvage or amputation with Ganga Hospital Score
has a statistical signicance. ROC (Receiver Operating Characteristic)
curve was drawn for Ganga Score and MESS score to assess the
efciency of score to predict limb salvage and the area under the curve
for Ganga score(.992) was better than MESS score(.761).
DISCUSSION
Major advances have been achieved in the last couple of decades in the
management of open injuries of limbs, which has helped us to achieve
restoration of function to the patients. Improvements in intensive care
management of the patients with polytrauma, the availability of
powerful antibiotics, aggressive management by radical debridement,
immediate bony stabilization and early soft tissue cover have largely
improved the rate of salvage of limbs and improved the functional
outcome. However these injuries continue to remain as a major
challenge in management with a high potential for loss of limb or life
and a poor functional outcome even after adequate treatment[1],[2],[3].
Although multi-factorial, the outcome in Type IIIB injuries of limbs
depend mainly on the severity of the injury to the various components
of the limb. [4],[5],[6],[7] Gustilo and Anderson made a land mark
contribution when they described in 1976 a classication for open
fractures that was based on the size of the wound . Type III open
[8]
fractures, which had extensive soft tissue damage and crushing was
shown to have worse prognosis due to a higher rate of infection,
nonunion, and secondary amputations compared to type I and II. In
1984, Gustilo et al reported a sub-classication of Type III open
fractures . Type IIIA injuries had adequate coverage of soft tissue of a
[9]
fractured bone despite aps or extensive laceration of the soft tissue;
Type IIIB injuries had extensive soft tissue injury with periosteal
stripping and exposure of bone, and usually with massive
contamination; and Type IIIC injuries had an open fracture with an
arterial injury requiring repair for salvage of the limb. This
classication has since then gained wide popularity and is widely used.
While Type IIIA and IIIC injuries do not pose any problems in
evaluation, Type IIIB injuries include a wide spectrum of injuries,
from the easily manageable to the barely salvageable making this
classication inefcient in providing guidelines in management or
prognostication. There are many problems specic to Type IIIB
injuries which become obvious when a large number of such injuries
are managed[4],[5].
The Gustilo classication is based more on the nature and size of the
wound and does not address specically the severity of injuries of the
musculotendinous structures and skeletal structures[10],[11].
Injury to the muscles, nerves and bone can often be more crucial than
the nature of the wound. The system also does not consider comorbid
factors and does not address the question of salvage. There is a high
degree of subjectivity leading to poor inter-observer reliability.
Gustilo's grading can change with debridement and again if the wound
requires redebridement [12],[13] . This undermines the value of the
classication as an initial guide to treatment. Although the classication
was initially proposed as an assessment before debridement, at a later
date, Gustilo agreed that the classication done at the time of initial
presentation is often inaccurate and the nal grading must be done only
after the debridement has enabled the surgeon to determine what kind
of soft tissue reconstruction is needed. . He also agreed that the grading
may need revision after each debridement.
The rst decision in the management of a severely injured lower limb
is the question of salvage. While it would be a disaster to amputate a
salvageable limb, failed reconstructions leading to secondary
amputations are unacceptable and frustrating to the patient[14],[15].
Many injury severity scores for the lower limb have been developed,
the more important of which are the Mangled Extremity Severity score
,the limb salvage Index ,the predictive salvage index, the nerve injury,
ischaemia, soft-tissue injury, skeletal injury, shock and age of patient
(NISSA) score and the Hannover fracture scale-97 .These scores,
however, have been designed to assess limbs with combined
orthopaedic and vascular injuries and are poor predictors for type-IIIB
injuries.[16],[17].[18]
In our study sensitivity and specicity of Ganga score is 100% and
32 International Journal of Scientific Research
PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr
97.82% and that of MESS score is 50% and 86.95%. The positive
predictive value of Ganga score is 80% and that of MESS score is 25%
indicating that even with patient scoring 7 or more in MESS ,the limb
can be salvaged. So Ganga score is having greater practical value. The
negative predictive value of Ganga score is 100% and that of MESS
score is 95.23%. The area under the ROC curve is also greater in Ganga
score than MESS score indicating a better prognostic value of Ganga
score in predicting amputation.
It is important to have an intermediate 'grey zone' rather than a single
threshold score since there are many other inuencing factors such as
the expertise of the treating team, the social and cultural background of
the patient, the cost and the personality of the patient.
Ganga hospital scoring system also has a statistical signicance and
positive correlation with number of inpatient days, number of surgical
procedures, and plastic surgical intervention(p value<0.05 for all) . So
there is a higher need of plastic surgical intervention,greater in-patient
days, multiple surgical procedures in patient with higher Ganga score.
Thus it can actually predict the outcome of a the salvaged limb
properly.[19][20][21][22][23]
Ganga Hospital Scoring system also gives importance to the co-
morbid condition. Previously used scoring system do not have co
morbid condition in their scoring system and thus neglecting an
important aspect of open wound management.
The Ganga hospital score is of practical value in helping the surgeon to
make appropriate decisions and forecast the outcome. It has higher
sensitivity and specicity for predicting amputation, even when
vascularity is not affected, than the presently available lower-limb
injury severity scores. It is superior to the modied Gustilo
classication of type-III injuries since it addresses the question of
salvage and also provides a more accurate assessment of the injury to
the limb. It has a better inter-observer agreement rate and is practical
for routine clinical use.
Photographs of three injuries which are by denition Gustilo-
Anderson type-IIIB. The management and prognosis for the three
injuries are completely different.
CONCLUSION
From our study we can conclude that Ganga hospital open injury
severity score acts as a predictable single scoring system for both limb
salvage and amputation and it can successfully address the dilemma of
Primary amputation or limb salvage on Day 1 in type IIIB injury.
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International Journal of Scientific Research 33