MESS (Mangled Extremity Severity Score) 25 years on: Time for a reboot?

Contemporary management of open extremity fractures: What you need to know

ABSTRACT

Open extremity fractures are high-risk injuries prone to significant complications, including soft tissue loss, bone defects, infection, infected nonunion, and the necessity for limb amputation. Large-scale multicenter prospective studies from the Lower Extremity Assessment Project and the Major Extremity Trauma Research Consortium have provided novel scientific insights pertinent to the timeliness and appropriateness of specific treatment modalities aimed at improving outcomes of patients with open extremity injuries. These include the imperative for early administration of intravenous antibiotics within 3 hours of injury, preferably within 1 hour of hospital admission. Unlike the proven value of early antibiotics, the time to initial surgical debridement does not appear to affect infection rates and patient outcomes. Recent evidence-based consensus guidelines from the American Academy of Orthopedic Surgeons provide scientific guidance for preventing surgical site infections in patients with open extremity fractures and support the decision making of limb salvage versus amputation in critical open extremity injuries. Patient survival represents the overarching priority in the management of any trauma patient with associated orthopedic injuries. Therefore, the timing and modality of managing open fractures must take into account the patient's physiology, response to resuscitation, and overall injury burden. The present review was designed to provide a state-of-the-art overview on the recommended diagnostic workup and management strategies for patients with open extremity fractures, based on the current scientific evidence.

Risk and prognostic factors of replantation failure in patients with severe traumatic major limb mutilation

Purpose

Traumatic mutilation of major limbs can result in limb loss, motor disability, or death. Patients who had replantation failure needed to undergo additional surgeries (even amputation) and had a longer length of hospital stay. Here, we determined the risk and prognostic factors of replantation failure in patients with traumatic major limb mutilation.

Methods

This retrospective study included adult inpatients with severed traumatic major limb mutilation who underwent replantation from Suzhou Ruixing Medical Group from October 18, 2016 to July 31, 2020. Demographic, and clinical characteristics including traumatic conditions, laboratory findings, mangled extremity severity scores (MESS), treatments, and outcomes of the patients were collected. Data were used to analyze predictors and risk factors for replantation failure.

Results

Among the 66 patients, 48 (72.7%) were males, the median age was 47.0 years old. Replantation failure occurred in 48 patients (72.7%). The area under the curve of the joint prediction of lactic acid on admission, 72-h cumulative fluid balance, and albumin level immediately postoperatively was 0.838 (95% confidence interval [CI], 0.722–0.954; P < 0.001) with a sensitivity of 89.7% and a specificity of 69.2%. Lower limb trauma (odds ratio [OR] 8.65, 95% CI 1.64–45.56, P = 0.011), mangled extremity severity scores (OR 2.24, 95% CI 1.25–4.01, P = 0.007), and first 72-h cumulative fluid balance > 4885.6 mL (OR 10.25, 95% CI 1.37–76.93, P = 0.024) were independent risk factors for replantation failure.

Conclusions

Lower limb trauma, mangled extremity severity scores, and cumulative water balance were associated with replantation failure, implying that fluid management is necessary for major limb salvage. More studies are needed to explore the predictive power of indicators related to tissue oxygenation and wound healing for replantation failure.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01876-w.

Combined Orthopaedic and Vascular Injuries With Ischemia: A Multicenter Analysis

OBJECTIVES

To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation.

DESIGN

Retrospective.

SETTING

Nine trauma centers.

PATIENTS

This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation.

RESULTS

We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant.

CONCLUSIONS

In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Development and Validation of Scoring System to Predict Secondary Amputations in Free Flap Reconstruction

Need for amputation is a potential complication when limb salvage is attempted. The present study aimed to develop a risk assessment tool to predict the risk of future amputation when counseling patients about their reconstructive options.

Methods

All patients undergoing a free flap lower extremity soft tissue reconstruction by the senior author from 2005 to 2019 were retrospectively identified. Patient's demographics, comorbidities, and technical aspects of the operation were extracted. Logistic regressions were used to create a predictive scoring system for future amputation.

Results

A total of 277 patients were identified. Of these patients, two-thirds (183) were used to derive the scoring system and one-third (94) were used to validate the score. In total, 25 of 183 patients (14%) underwent an amputation. A stepwise forward logistic regression identified age > 55 years, smoking, acute wound, aggressive fluid resuscitation intra-operatively, inability to use a superficial vein for drainage, and inability to use the posterior tibialis artery for anastomosis as independent predictors of need for future amputations. The beta co-efficients were used to create the scoring system, and the patients were categorized into mild, moderate, and severe risk based on their cumulative score. The validity of the scoring system was verified by using the one-third validation cohort.

Conclusions

In patients undergoing free flap reconstruction of the lower extremity, the need for future amputation is 14%. The use of a scoring system can guide the surgeon's and patient's decision regarding limb salvage.

Utility of the Mangled Extremity Severity Score in Predicting Amputation in Military Lower Extremity Arterial Injury

BACKGROUND

Effective amputation prediction may help inform appropriate early limb salvage efforts in military lower extremity (LE) arterial injury. The Mangled Extremity Severity Score (MESS) is the most commonly applied system for early amputation prediction but its utility in military trauma is unknown.

METHODS

Retrospective cohort study of Iraq and Afghanistan casualties with LE arterial injury who underwent a vascular limb salvage attempt. Retrospectively assessed MESS was statistically explored as an amputation predictor and MESS component surrogates (mechanism, vascular injury characteristics, tourniquet use, and transfusion volume) were used to characterize limb injuries by presenting characteristics and evaluated for amputation prediction.

RESULTS

A total of 439 limbs were included with 99 (23%) amputations, 29 (7%) within 48 hr of injury. Median MESS was 5 (interquartile range 4-6) among salvaged limbs and 7 (5-9) among amputations (P < 0.0001). An MESS cutoff of ≥7 had a better receiver operating characteristic sensitivity/specificity profile (area under the curve 0.696 overall, 0.765 amputation within 48 hr) than MESS ≥8 (0.593, 0.621), but amputation rates were only 43% for MESS ≥7 and 50% for ≥8. MESS ≥7 was significantly associated with age, polytrauma, blast or crush mechanism, fracture, tourniquet use, distal (popliteal/tibial) and multiple arterial injuries, and massive transfusion. Amputation was significantly associated with polytrauma, blast or crush mechanism, fracture, and massive transfusion; however, 83 casualties had all 4 characteristics with an amputation rate of only 46%.

CONCLUSIONS

In combat casualties with arterial injury, LE amputation after attempted vascular limb salvage is inadequately predicted by existing scoring systems or the presenting characteristics available in this registry. Limb loss is predominantly late and likely because of factors not projectable at initial presentation.

Comparing the performance of different open injury scores in predicting salvage and amputation in type IIIB open tibia fractures

BACKGROUND

Various open injury scores have been devised to aid the difficult decision of salvage or amputation following open fractures of the lower limb. Our aim of the study was to compare the performance of mangled extremity severity score (MESS), limb salvage index (LSI), orthopaedic trauma association-open fracture classification (OTA-OFC) and Ganga hospital score (GHS) in our population of type IIIB injuries.

MATERIALS AND METHODS

A total of 219 patients with 225 type IIIB open fractures of the tibia were studied prospectively between July 2016 and June 2017. The decision of salvage or amputation was taken by a combined consensus of senior orthopaedic and plastic surgeons, blinded to the scores. All four open injury scores were calculated by an independent reviewer following initial debridement. The follow-up period was one to two  years.

RESULTS

After final follow-up, there were 193 (85.7%) successfully salvaged limbs, 19 primary amputations without attempt of debridement (8.4%), three primary delayed amputations within 72 hours (1.3%) and six secondary amputations after 72 hours from initial debridement (2.7%). Of these, four patients died within one  year and were excluded. All four scores performed well for salvage, while GHS was superior when considering amputation. MESS, LSI and OTA-OFC underscored amputations, since these scoring systems award more points for vascular injuries. There were both salvaged and amputated patients around the threshold value of amputation for all scores, which was only acknowledged by GHS in its unique 'grey zone'. It includes patients who are neither easily salvageable nor definitely requiring amputation.

CONCLUSION

The performance of the GHS was superior to MESS, LSI and OTA-OFC in our study, since it was developed for type IIIB injuries and includes the 'grey zone', where decisions need to be undertaken on a case to case basis.

CLINICAL RELEVANCE

GHS has an improved ability to determine amputation in IIIB open tibia fractures.

Establishing an Evaluation System and Limb-Salvage Protocol for Mangled Lower Extremities in China

Road traffic accident-related severely injured extremities account for the majority of disabilities in young people in China. Limb-salvage concepts and techniques vary greatly from physician to physician and from district to district in China. Current severity-scoring systems for lower-extremity injuries lack sensitivity and cannot be used as the sole criterion by which amputation decisions are made. China lacks a national database of mangled lower extremities, which is a priority for both limb-salvage protocols and scoring system development.