Arterial Reconstruction after Mangled Extremity: Injury Severity Scoring Systems Are Not Predictive of Limb Salvage

Abstract

The Vascular Unit at Suez Canal University Hospital in Egypt covers a wide area with high rates of severe injuries. This is a prospective study of mangled extremities to identify risk factors associated with limb loss in these patients. Between December 2000 and August 2003, a prospective study on all patients with arterial injuries in mangled extremities was undertaken. All patients were scored using the Mangled Extremity Severity Score (MESS) and the Mangled Extremity Severity Index (MESI). During this period, arterial reconstruction was performed in 62 patients. Primary patency, secondary patency, and limb salvage rates were 81%, 85.5%, and 93.5%, respectively. The only factor affecting limb salvage (statistical trend) was the site of trauma (upper limb 100% vs lower limb 89%; p = .08%). There was no significant effect related to the mechanism of trauma (blunt 90% vs stab 100%; p = .125), MESS (< 7, 100% vs > 7, 91%; p = .22), and MESI (< 20, 100% vs > 20, 90.5%; p = .154). Upper limb injuries were the least likely to lead to amputation. We recommend that all injuries, whatever their score, should be surgically explored before treatment decisions are made.

Predictors of secondary amputation in patients with grade IIIC lower limb injuries

“…Amputation was recommended for patients having an MESS score equal to or greater than 7. MESS has been widely used and analyzed, with some studies revealing a good correlation between an MESS higher than 7 and amputation, [15,24–26] while others did not. [18,27,28] In our study, MESS in the secondary amputation group was higher than in the limb salvage group, revealing that MESS was a stronger predictor for secondary amputation.…”

Difficult Decisions in Surgery: An Evidence-Based Approach Limb Salvage for the Mangled Extremity

“…<Insert Table 2> Many issues arise when using these scores. First, since all scores (except the MESS) were retrospectively investigated in a small subset of patients with different inclusion criteria and different outcome parameters, many authors questioned the importance, predictive utility, and predictive potential of these scores for long-term functional recovery (1,(35)(36)(37)(38)(39)(40)(41). Most of the scores are specific in helping to predict limb salvage potential, but not sensitive.…”

“…The scores must be used with caution and interpreted carefully since upper limb anatomy (especially vascularity), function, and treatment goals are different (95). Upper limb injuries are less likely to be amputated (35) since the critical time of ischemia is usually longer (up to 10 hours), the prostheses are not as functional, and the loss of the upper extremity may also be much more emotional (8). In addition, shortenings are much better tolerated in the upper body than shortenings of the lower leg.…”

Management of Major Limb Injuries

“…Poor predictors of limb salvage are delayed revascularization (beyond 6–8 hours), presence of associated fractures, arterial ligation, and location of injury (popliteal). However, in some recent studies, it has been seen that successful limb salvage in patients with an MESS of ≥7 is possible with good functional outcomes [28–30]. MESS of ≥7 is not a good predictor for the need for amputation in patients especially with upper limb vascular injury, although an MESS of <7 remains a good predictor for patients who do not require amputation [30].…”