Retrospective study on predictive scoring system for amputation in open fracture of tibia type III

Made Bramantya Karna


Background: Mangled leg remains a challenge in the surgical treatment. Mangled extremity severity score (MESS) is often used as a predictive scoring system. However MESS considered less sensitive because there are still many patients facing amputation legs should be maintained in the end. For that reason, it is necessary to evaluate the counting system has been used.

Methods: The study design was a retrospective study using medical records of patients with open fractures of the tibia grade III in emergency room of Dr. Soetomo hospital. From the data on patient medical records, MESI, PSI, HFS, LSI, MESS and NISSSA was calculated. Then the results are assessed by sensitivity, specificity, PPV and NPV.

Results: Patients who undergo amputation were 12 people and who successfully maintained limb were 46 people. The sensitivity ranged from 50% (MESI) until 75% (HFS), a specificity ranging from 61% (HFS) until 85% (NISSA). Positive predictive value ranged between 23% (PSI) and 53% (NISSA) and negative predictive value ranged from 81% (PSI) until 91% (NISSA).

Conclusions: This study failed to demonstrate the usefulness of the six counting system because it only shows the sensitivity and specificity in distinguishing limb amputation injuries that require immediate and that allows it to be maintained. Some have incorrectly predicted the counting system, where some patients were successfully maintained limb had been predicted for amputees and vice versa.



Predictive scoring system, Amputation, Open fracture, Tibia

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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 score. Journal Bone & Joint Surgery (Am). 2001;83-A:3-14.

Gaston P, Will E, Elton RA, McQueen MM, Court-Brown CM. Fractures of The Tibia : Can Their Outcome be Predicted? Journal Bone & Joint Surgery (Br). 1999;81:71-6.

Herthel R, Strebel N, Ganz R. Amputation Versus Reconstruction in Traumatic Defects of The Legs Outcome and Costs. Journal of Orthopaedic Trauma. 1996;10:223-9.

McNamara MG, Heckman JD, Corley FG. Severe Open Fractures of The Lower Extremity: A Retrospective Evaluation of The Mangled Extremity Severity Score (MESS). Journal of Orthopaedic Trauma. 1994;8:81-7.

Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P, Browner BD. The Medical and Economis Impact of Severely Injured Lower Extremities. Journal of Trauma. 1988;28:1270-3.

Fairhurst MJ. The Function of Below-Knee Amputee Versus The Patient with Salvage Grade III Tibial Fracture. Clinical Orthopaedic. 1994;301: 227-32.

Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open Tibial Fractures with Severe Soft-Tissue Loss. Journal Bone & Joint Surgery (Am). 1993;75:1431-41.

Gregory RT, Gould RJ, Peclet M, Wagner JS, Gilbert DA, Wheeler JR. The Mangled Extremity Syndrome Index: A Severity Grading System for Multisystem Injury of The Extremity. Journal of Trauma. 1985;25:1147-50.

Hoogendoorn, Jochem M, Chris van der Werken. The Mangled Leg Decision-Making Based on Scoring Systems and Outcome. European Journal of Trauma. 2002;28:1-10.

Howe HR, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, et al. Salvage of Lower Extremities Following Combined Orthopaedic and Vascular Trauma. A Predictive Salvage Index. American Surgery. 1987;53:205-8.

Russel WL, Sailors DM, Whittle TB, Fisher DF Jr, Burns RP. Limb Salvage Versus Traumatic Amputation: A Decision Based on A Seven Part Predictive Index. Annual Surgery. 1991;213:473-80.

Lange RH. Limb Reconstruction Versus Amputation Decision Making in Massive Lower Extremity Trauma. Clinical Orthopaedic. 1989;243: 92-9.