Third degree open fractures and traumatic sub-/total amputations of the upper extremity: Outcome and relevance of the Mangled Extremity Severity Score

Optimizing Outcomes in Mangled Lower Extremity Reconstruction: Insights from a Retrospective Study of 93 Patients and Their Functional Scores

Background/Objectives: Over the past 25 years, reconstructive techniques and patient management advancements have significantly improved outcomes in mangled lower extremity injuries. Functional results of limb salvage have been demonstrated to surpass those of primary amputations. Developments such as local fasciocutaneous flaps, vacuum-assisted closure, and hyperbaric oxygen therapy have enhanced the reconstructive ladder. Despite progress, the utility of the Mangled Extremity Severity Score (MESS) and Gustilo-Anderson classification remains debated, particularly in their prognostic value for limb salvage decisions. In the study, we aimed to evaluate the outcomes of optimizing mangled lower extremity reconstruction in 93 patients, focusing on their functional scores retrospectively. Methods: This retrospective study analyzed 93 patients treated for mangled lower extremities between January 2015 and October 2022. Patients were assessed for age, gender, injury location, MESSs, Gustilo-Anderson classifications, surgical methods, and functional outcomes using the Lower Extremity Functional Scale (LEFS). Surgical interventions included internal and external fixation, skin grafts, local flaps, muscle flaps, and free tissue transfer. LEFS scores were categorized into disability levels for functional evaluation. Correlations were drawn between LEFS and variables such as MESS, Gustilo-Anderson types, and nerve injuries. Results: Among the 93 patients, 16 had MESSs ≥ 7, and 77 had MESSs < 7. Reconstruction methods included local fasciocutaneous and muscle flaps (37 patients), free tissue transfer (29 patients), and skin grafting with vacuum-assisted closure (27 patients). Smoking was associated with delayed union and increased infection rates. LEFS scores were significantly lower in patients with MESSs ≥ 7, Gustilo grade 3C fractures, and tibial nerve injuries. Flap failures and a higher number of surgeries (>3) also correlated with poorer functional outcomes. The average soft tissue healing time was 18 days, and bone union time was 17 weeks. Conclusions: Lower extremity reconstruction demands precise surgical planning and execution, prioritizing functional restoration. MESSs and Gustilo-Anderson classifications provide practical frameworks but have limitations in predicting long-term functionality. Factors such as joint involvement, nerve injuries, and flap selection significantly influence outcomes. Smoking and delayed healing remain critical challenges. While free flaps are essential for complex defects, more straightforward methods yield better outcomes in suitable cases. LEFS emerged as a reliable tool.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.

METHODS

The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence.

RESULTS

A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed.

CONCLUSION

The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.

Comparison of epidemiologic features between upper and lower limb injuries and risk factors for intensive care unit admission in a university hospital affiliated with the National Trauma Registry of Iran

PURPOSE

Upper extremity injuries (UEIs) and lower extremity injuries (LEIs) constitute a considerable component of traumas. However, their epidemiologic differences and short-term in-hospital outcomes are not fully elucidated. This study aims to compare such discrepancies in a large-scale study.

METHODS

In this retrospective study, all patients with UEIs and/or LEIs hospitalized from 24th July 2016 to 16th May 2020 in Sina Hospital, Tehran, Iran, and registered at the National Trauma Registry of Iran were enrolled in the study. Relevant demographic and clinical characteristics were extracted from the National Trauma Registry of Iran database. Patients were grouped into either UEI or LEI. For those with concomitant UEIs and LEIs, the more severe one based on the abbreviated injury scale was defined as the principal diagnosis. In addition, cases with the abbreviated injury scale > 3 for both UEI and LEI or concomitant injuries to body areas other than the limbs were excluded. Independent samples t-test, Mann-Whitney U test, Chi-square test, quintile regression models, and logistic regression models with "margins" command were used for statistical analyses, as indicated.

RESULTS

In this research, 3170 eligible cases were identified. For the LEI group, there was a much higher proportion of male patients (86.7% vs. 82.0%) and higher mean age (years, 42.9 vs. 35.3) compared to the UEI group (both p < 0.001). Patients with an injury severity score (ISS) of 9 - 15 were outnumbered in the LEI group (22.9% vs. 1.6%, p < 0.001), while the proportion of those with an ISS < 9 was higher in the UEI group (98.1% vs. 76.8%, p < 0.001). The multiple logistic regression model showed a statistically significant association between intensive care unit (ICU) admission and ISS (odds ratio (OR) = 4.01 for ISS 9 - 15 vs. ISS < 9, 95% confidence interval (CI)): 3.01 - 5.35; OR = 17.65 for ISS ≥ 16 vs. ISS < 9, 95% CI: 4.03 - 77.27), age (OR = 1.02, 95% CI: 1.01 - 1.03), cause of injury (OR = 0.27 for blunt trauma vs. road traffic crash, 95% CI: 0.08 - 0.90; OR = 0.49 for cut/stab injuries vs. road traffic crash, 95% CI: 0.28 - 0.84) and body region (OR = 1.65 for lower extremity, 95% CI: 1.19 - 2.29). Having adjusted for other covariates, the odds of ICU admission in patients with LEIs was 1.65 times the odds in patients with UEIs.

CONCLUSIONS

Patients with LEIs were older and suffered from more severe injuries. In addition, the age- and ISS-adjusted ICU admission and length of hospital stay were significantly higher in LEI patients. The chance of ICU admission was associated with age, cause of injury, ISS, and body region. The findings of this study can aid in the meticulous selection of ICU-candidate patients. In addition, the role of factors other than ISS and age in ICU admission and prolongation of hospitalization should be addressed by prospective studies.

Utility of severity scoring systems for mangled upper limb salvage: A systematic review and meta-analysis

BACKGROUND

The purpose of scoring systems is to aid in the decision-making process of whether to salvage or amputate mangled extremities, but their efficacy for upper limbs is uncertain. In this study, we examined the predictive potential of scoring systems for upper limb salvage.

METHODS

Two investigators undertook a systematic search of 3 leading databases for English or Japanese literature from 1985, when the first scoring system to evaluate mangled extremities was proposed, until January 2022. To be eligible, studies must have had upper extremity limb salvage or amputation as an outcome, and identified the scoring system used and treatment outcome in individual cases.

RESULTS

Ten studies (N = 338) of the Mangled Extremity Scoring System (MESS) were ultimately included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95 % CI = 0.69-0.99) and 0.81 (0.65-0.91), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.95 (0.93-0.97). A subgroup analysis showed lower specificity in isolated vascular injuries. Scoring systems other than MESS were ineligible for the quantitative synthesis because none were examined in an adequate number of publications.

CONCLUSION

The pooled sensitivity and specificity for MESS were comparable to those reported for the lower extremities. The specificity suggests that limb salvage was achieved in at least 20 % of the patients whose MESS was above the threshold beyond which amputation is indicated. Given the likelihood of upper extremity functional limitations following amputation and the drawbacks of prostheses, we conclude that current scoring systems poorly predict salvageability of a mangled upper extremity and should not be used to justify amputation.

Limb salvage results of Gustilo IIIC fractures of the lower extremity

This study aims to present our results for limb salvage in Gustilo IIIC open fractures of the femur and tibia. 92 patients with Gustilo IIIC fractures operated in our clinic between January 2000 and March 2016 were retrospectively evaluated. Demographic data, ischemia time, method of arterial repair, means of primary and secondary fixation, time to amputation, complications, and final VAS scores were recorded. The difference between the primary amputation rates of tibia and femur fractures was not statisti- cally significant (18% vs 21%, p>0.05). The difference between the secondary amputation rates of tibia and femur fractures was not significant (16% vs 27%, p>0.05). All secondary amputations were done within the first month during the initial hospital stay. Overall limb salvage rate was 69% for Gustilo IIIC fractures of the femur and 58% for Gustilo IIIC fractures of the tibia. The overall limb salvage rate was not significantly different between the two groups (p>0.05). At the final follow-up, patients in the limb salvage group had average VAS scores of 4.3 (femur) and 4.7 (tibia). The decision between amputation versus limb salvage remains a difficult decision that should be jointly made by the treating physicians and the patient.

Primary amputation versus limb salvage in upper limb major trauma: a systematic review

PURPOSE

Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage.

METHODS

A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO.

RESULTS

A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities.

CONCLUSIONS

Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.

Roles of Trauma CT and CTA in Salvaging the Threatened or Mangled Extremity

Extremity arterial injuries account for up to 50% of all arterial traumas. The speed, accuracy, reproducibility, and close proximity of modern CT scanners to the trauma bay have led to the liberal use of CT angiography (CTA) when a limb is in ischemic jeopardy or is a potential source of life-threatening hemorrhage. The radiologist plays a critical role in the rapid communication of findings related to vessel transection and occlusion. Another role of CT that is often overlooked involves adding value to surgical planning. The following are some of the key questions addressed in this review: How does CTA help determine whether a limb is salvageable? How do concurrent multisystem injuries affect decision making? Which arterial injuries can be safely managed with observation alone? What damage control techniques are used to address compartment syndrome and hemorrhage? What options are available for definitive revascularization? Ideally, the radiologist should be familiar with the widely used Gustilo-Anderson open-fracture classification system, which was developed to prognosticate the likelihood of a functional limb salvage on the basis of soft-tissue and bone loss. When functional salvage is feasible or urgent hemorrhage control is required, communication with trauma surgeon colleagues is augmented by an understanding of the unique surgical, endovascular, and hybrid approaches available for each anatomic region of the upper and lower extremities. The radiologist should also be familiar with the common postoperative appearances of staged vascular, orthopedic, and plastic reconstructions for efficient clinically relevant reporting of potential down-range complications. Online supplemental material is available for this article. ^©RSNA, 2022.

Mangled extremity- Modern concepts in treatment

A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain.

Correlation of HISS and Strickland Score with the Michigan Hand Outcome Questionnaire in hand injuries

BACKGROUND

The widely used Hand Injury Severity Score (HISS) has intrinsic drawbacks like inability to score vascular status and questionable correlation with Disability of Arm, shoulder and Hand. We compared it with the Strickland score which is easier to calculate and has provision for evaluation of vascular status. We assessed correlation of both the scores with the Michigan Hand Outcome Questionnaire (MHQ).

METHODS

In a prospective study of 1574 patients admitted with hand injuries, we recorded their HISS and Strickland scores and followed them up for a year and later interviewed for MHQ score. Statistical correlation was done comparing the HISS and Strickland score with the MHQ using the SPSS package.

RESULTS

Majority of these injuries were in manual labourers (47.5%) with agricultural or industrial background with a mean age of 25 years (18-26 years). Using the One-way ANOVA test we found a significant correlation between the HISS and MHQ (P Value < 0.001). Using the Unpaired T-test, statistically significant association (P < 0.001) was seen between the Strickland score and MHQ. The correlation between HISS and Strickland Score done by One-way ANOVA Test was also found to be significant (P Value < 0.001). On evaluating the group of patients with a Strickland score >10, we observed that the MHQ was almost similar between those who underwent amputation with those who underwent a successful salvage, though not statistically significant.

CONCLUSION

HISS and Strickland score correlated significantly with each other and with the MHQ. Strickland score was easy and quicker to determine the salvagability of hand injury. However, small group of patients who may benefit from salvage in spite of a high Strickland score where factors like patient's age, occupation, comorbid health condition, motivation, expenses, and social environment needs to be taken into account in decision making.