Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 22-28

Can Mangled Extremity Scoring System (MESS) solve the mess of vascular trauma


1 Department of Cardiothoracic Surgery, AIIMS, New Delhi, India
2 Department of Cardiothoracic Surgery, JNMC, AMU, Aligarh, Uttar Pradesh, India
3 Department of General Surgery, JNMC, AMU, Aligarh, Uttar Pradesh, India

Date of Submission23-Jul-2019
Date of Decision16-Aug-2019
Date of Acceptance27-Aug-2019
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Mohd Azam Haseen
Department of Cardiothoracic Surgery, JNMC, AMU, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_44_19

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  Abstract 


Introduction: Trauma is the new scourge of humankind as without utmost and urgent care, it can result in the loss of limb and life. Civilian trauma is mostly caused by road traffic accidents with resultant skeletal, vascular, and neurological injuries. Vascular injuries most commonly involve the extremities and occur in young males. Materials and Methods: Ours is prospective observational study, in which 50 patients of the lower limb vascular injury were included in the study. Results: All of them were male, and mostly, they were in the second and third decades of life. Popliteal artery was the most commonly injured vessel, and road traffic accident was the most common mode of injury. Fifty-six percent (n = 28) had favorable outcomes with 8% mortality (n = 4). Twenty-six (52%) patients had bony involvement, the most commonly injured bone was tibia (n = 16, 32%). The mean warm ischemia time was 15.56 ± 14.03 (range: 3–48) h. Mangled Extremity Severity Score (MESS) scores were significantly different in salvaged and nonsalvaged limbs (P = 0.004). The sensitivity and negative predictive value of MESS were very high (100%), but the specificity and positive predictive value for unfavorable outcomes were low (57.14% and 64.71%). Skeletal injury, neurological involvement, and a blunt mechanism of injury were found to have a significant association with an unfavorable outcome in the patients. Conclusion: We concluded that MESS cannot be completely relied on, and the surgeon's clinical assessment and experience are necessary to decide the plan of management. Warm ischemia time is not the most important factor affecting limb survival, and other factors such as neurological and bony involvement need to be considered. MESS helps to frame the data for the clinician and can help in counseling patients, and their families that poor outcomes are more likely when MESS score is high. Further, large-scale, multicenter randomized trials are necessary for the identification of other risk factors and their incorporation into scoring systems.

Keywords: Femoropopliteal injury, Mangled Extremity Severity Score, vascular trauma


How to cite this article:
Rabbani S, Haseen MA, Rizwi AA, Beg MH. Can Mangled Extremity Scoring System (MESS) solve the mess of vascular trauma. Indian J Vasc Endovasc Surg 2020;7:22-8

How to cite this URL:
Rabbani S, Haseen MA, Rizwi AA, Beg MH. Can Mangled Extremity Scoring System (MESS) solve the mess of vascular trauma. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 10];7:22-8. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/22/280672




  Introduction Top


Trauma today is the leading cause of mortality and disability in the first four decades of life and third in all age groups combined.[1] Although vascular injuries account for only 3% of all civilian trauma,[2] they deserve special attention as without the most urgent and expert care, they result in loss of limb or at times life. These injuries place a huge financial burden not only on the patients and his family but also on society and county as a whole. In more than two-thirds cases, vascular injury involves the extremities.[3] The most common mechanism of injury in military warfare is penetrating type, however, in civilian trauma, the blunt injury is the favored mechanism of vascular injury.[4]

Major developments have taken place in the management of vascular injury, greatly owing to military conflicts in the past 100 years.[5]

The first successful arterial vessel repair with lumen preservation is attributed to Jassinowsky; however, it was Alex Carel who performed the first successful end-to-end anastomosis in 1896. Ten years later, Goyanes used vein graft to bridge an arterial defect in 1906.[6]

Clinical examination still remains the favored method for diagnosing vascular trauma, especially penetrating extremity trauma,[7] however, in patient with soft signs of vascular injury, computed tomography angiography should be done to know the exact nature and site of injury and plan surgical management.[8] Measurement of Ankle–Brachial Pressure Index (ABPI) is also important in patients with soft signs of vascular injury, as ABPI <0.90 is indicative of potential vascular compromise.[9]

Historically, the treatment of vascular injury has been primarily surgical, but with rapid advances in technology and instrumentation, endovascular repair can be done in considerable number of cases. Endovascular therapy provides a less invasive alternative to open surgery for critically ill patients with less in-hospital mortality and lower rates of sepsis.[10]

The advancements in the field of surgical revascularization have, in fact, acted as a double-edged sword and overzealous attempts at limb salvage in nonsalvageable limbs have resulted in failed efforts adding heavily to the patient's mortality, morbidity, and hospital costs.[11],[12] In a country like India where health costs are born mainly by patients out of their own pocket, a failed attempt at revascularization leads to heavy monetary burden on patient and his attendants.[13]

The potential to salvage a limb after a vascular injury depends on a number of prognostic factors such as warm ischemia time, associated injuries, damage to other structures (nerves, bones, muscles, etc.), contamination, comorbidity, level of vessel transaction, and blunt/penetrating trauma. An amputation rate of up to 20% has been reported in cases of lower limb vascular injury even though appropriate arterial reconstruction was done.[13] Bony fractures are seen 80% to 100% cases of blunt trauma; however, they drop down to 15% to 40% in cases of penetrating trauma.[14] The high amputation rate in patients with blunt vascular injuries to the extremities can be attributed to the high-energy mechanism of such injuries and the resultant amounts of damage to the bone, nerve, and soft tissue, not typically to the vascular injury itself.[15],[16]

Many scoring systems have been developed to predict the salvageability of the limb after trauma including Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), Limb Salvage Index (LSI), Hannover Fracture Scale-97, and Nerve injury, Ischemia, Soft-tissue injury, Skeletal injury, Shock, and Age of the patient (NISSSA).[11] However, the many different scoring systems proposed until now for the prediction of limb survival have not been properly validated, and different studies have yielded conflicting results.[17],[18] No single score has been found out to be complete until now. The most commonly used score is MESS.[11] MESS involves the use of four parameters, namely skeletal and soft-tissue injury, shock, age, and limb ischemia.[19] The score ranges from 1 to 14. A score ≥7 is predictive for amputation, while a limb with a score <7 can usually be salvaged.

Our study aims to validate the effectiveness of the MESS score in predicting limb salvageability in patients of lower limb vascular trauma in the Indian health-care setting scenario, as only few studies have been done in India to validate it.


  Materials and Methods Top


Ethics

clearance for the study was taken from the Institutional Ethics Committee.

Study design

It was a prospective study conducted in the Departments of Surgery and Cardiothoracic Surgery of Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh.

Duration

The duration of the study was 2 years (November 2014–November 2016). A total of 50 consecutive patients were enrolled in the study who met our inclusion and exclusion criterion.

Inclusion criteria

All patients of vascular trauma (blunt and penetrating) in lower limbs undergoing revascularization procedures were included in our study.

Exclusion criteria

Patients with coexisting injuries in regions other than extremities (abdominal injuries, chest injuries, and head injuries) were excluded from the study.

Diagnosis

Patients were diagnosed by the clinical examination and/or CT angiography performed on 16-slice Siemens Somatom Emotion machine (if needed).

Management

After initial resuscitation, thorough clinical examination was done to assess the amount and nature of injury. A record and diagram was made for all associated injuries, and they were managed as per the standard practice. If needed CT angiography was done apart from the routine blood investigations. The time of injury, presentation, and actual time of revascularization were noted. Anticoagulation was used preoperatively in all patients having acute ischemia if no active bleeding was present. Injection heparin at a dose of 100 IU/Kg was given stat through intravenous route once the patient was stable. His MESS score was calculated and depending on the surgery expected either regional or general anesthesia was used. During the surgery, the type of injuries was noted, and the procedure done was also recorded in case sheet of the patient. Postoperatively, a continuous infusion of unfractionated heparin was given at a dose of 20 IU/Kg/h for 72 h and was monitored using activated partial thromboplastin time. In all patients of vascular repair oral Aspirin was started at dose of 1.5mg/kg, 6-8 hours after surgery and continued for 6 weeks.

Follow-up

Patients were followed up postoperatively for a period of 3 months. The duration of hospital stay was recorded, and patients were discharged when they met the following criteria:

  • Two consecutive values of total leucocyte counts between 4000 and 11,000/mm 3 atleast 24 h apart
  • No evidence of fever for at least 48 h
  • Patient shifted to oral low-dose aspirin with stoppage of heparin infusion
  • Doppler/clinically-proven distal pulses and no signs of necrosis in salvaged limbs or healthy stump with no signs of wound infection in amputated limbs
  • No other signs or symptoms of sepsis.


Following discharge, the patients were followed up on an outpatient basis. The patients were reassessed at the intervals of 1 week, 1 month, and 3 months.

Statistics

The data were subjected to statistical analysis by the help of IBM ® SPSS23® software (IBM, USA). Statistical significance was accepted when P < 0.05.


  Observations and Results Top


The mean age of the patients in the study was 24.48 ± 9.03 years. The ages ranged from 16 to 48 years. The majority of patients were in the 15–19 years' (n = 18) age group. All the patients were male.

Out of 50 patients enrolled in the study, 20 (40%) patients were injured by penetrating mechanisms, and 30 (60%) had blunt mechanism of the injury. The major cause of vascular injuries was road traffic accidents (n = 22) followed by gunshot injuries (n = 20) [Table 1]. The mean systolic blood pressure of the patients was 104.72 ± 14.2 mmHg. Only four patients presented in shock (systolic blood pressure (SBP) <90 mmHg). Twenty-six (52%) patients had bony involvement, the most commonly injured bone was tibia (n = 16). Majority of the patients had compound fractures (n = 20), and almost all of the fractures were of comminuted pattern.
Table 1: Etiology of vascular trauma

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Thirty-four (68%) patients presented with signs and symptoms of neurological injury characterized by paraesthesia, numbness, and abnormal sensory examination.

The mean warm ischemia time (time from injury to revascularization) was 15.56 ± 14.03 (range: 3–48) h. There was also considerable delay in presentation of the patient to the hospital to actual revascularization. The mean in-hospital delay in revascularization was 3.64 ± 6.02 (range: 1–32) h.

The most commonly involved artery was popliteal artery (n = 26). The most commonly performed procedure was embolectomy (n = 20, 40%) followed by repair with reverse saphenous vein graft (n = 18, 36%) and primary repair in 15 patients (30%). No repairs with prosthetic grafts were performed.

Favorable outcome was seen in 28 (56%) patients. Out of these, four patients had neurological deficit in the form of foot drop. In patients with unfavorable outcomes, there were four deaths [Table 2]. All these patients died in the hospital due to multi-organ dysfunction after secondary amputation.
Table 2: Outcomes of vascular injury patients

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MESS scores showed a mean difference of 3.01 ± 0.93 between salvaged and nonsalvaged limbs at statistically significant (P = 0.004) [Table 3] and [Table 4]. The sensitivity and negative predictive value of MESS (100% each) were very high (which means it can correctly predict favorable outcomes), but the specificity and positive predictive value for unfavorable outcomes were low (57.14% and 64.71%) [Table 5]. The ROC curve was constructed [Figure 1], and MESS showed fair accuracy predicted by the area under ROC curves (0.773) at significant (P = 0.021) [Table 6].
Table 3: Mean scores of Mangled Extremity Severity Score in vascular injury patients

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Table 4: Difference in mean scores of Mangled Extremity Severity Score in patients with different outcomes

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Table 5: The specificity, sensitivity, positive predictive value, and negative predictive value of Mangled Extremity Severity Score

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Figure 1: Receiver operating characteristics curve for Mangled Extremity Severity Score

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Table 6: Characteristics of receiver operating characteristics curve for Mangled Extremity Severity Score

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A univariate analysis of all the associated factors was done using Pearson's Chi-square test for categorical covariates and independent t-test for continuous covariates. Odds ratio with 95% confidence intervals was calculated. Out of bony involvement, neurological involvement, presence of shock (SBP <90 mmHg) at presentation, mechanism of injury and fasciotomy, only fracture (P = 0.0349), neurological involvement (P = 0.027), and a blunt mechanism of injury (P = 0.015) were found to have a significant association with an unfavorable outcome in the patients [Table 7]. The means of age and warm ischemia time were not significantly (0.309 and 0.805) different [Table 8]. These three covariates with significant independent associations were subsequently subjected to binomial logistic regression, but none was found to be an independent predictor of unfavorable outcome.
Table 7: Analysis of categorical variables using Pearson's Chi-square test

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Table 8: Independent t-test results for continuous variables

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  Discussion Top


Gender distribution

Similar to our study, in most of the other studies also vascular injury patients are mostly males.[6] This could be attributed to outdoor nature of work of males and their involvement in conflicts.

Age distribution

Vascular trauma affects individuals in the young age group and so was evident in our study as the mean age of the patients was 24.48 ± 9.03 (range: 16–48 years). Our observation was comparable to many other studies.[16],[21]

Mechanism of injury

Vascular injury has traditionally been associated with penetrating trauma like in studies by Singh and Pinjala [22] However, the trends have been changing lately, and extremity vascular injuries result from blunt and penetrating mechanisms with almost equal frequency in most of the modern studies.[21] Gupta et al.[23] also concluded that the ratio of injuries by blunt mechanism to that of penetrating was on a rise.

In our study also, the most common mode of injury was blunt (60%). The changing pattern may be attributed to the increasing number of vascular injuries being caused by high-energy road traffic accidents in the civilian settings. Furthermore, many of the older studies represented wartime data which consisted of injuries, mainly due to assault penetrating mechanisms. Blunt mechanism is common in lower limb vascular trauma as compared to upper extremities,[24] and this could also be one of the reasons for higher proportion of blunt mechanisms in our study.

Artery involved

in our study, popliteal artery was the most commonly involved artery. Other studies also show that femoropopliteal artery injury (FPAI) is the most common injury occurring in the arteries of the lower extremity.[25]

Delay in revascularization

The mean warm ischemia time to actual revascularization was 15.56 ± 14.03 (range: 3–48) h. Guraya [26] reported a mean of 9.3 h (range: 3–19 years) in their study. Khan et al.[27] observed a range of 30 min to 28 h in reporting to the hospital and a range of 1–32 h for actual warm ischemia time. The mean time is higher in studies from the Indian subcontinent probably due to poor transport facilities and less number of centers capable of managing vascular trauma.

A significant finding in our study was a 3.64 ± 6.02 (1–32) h of in-hospital delay. The probable reasons are lack of integrated trauma teams and unavailability of dedicated operation theatres (OTs) at our center.

Mangled Extremity Severity Score

Similar to findings of our study, other studies have also recorded a statistically significant (P < 0.01) difference between MESS values of salvaged and amputated limbs.[28] In another study by Pimple et al.[29] showed that the mean MESS score in salvaged extremities was 6.94 ± 1.46, and for the amputated extremities was 9.4 ± 1.5 (P < 0.01).

Like other studies, our study also showed a high sensitivity and a low specificity for MESS score implying that its ability to predict amputation was less but could identify salvageable limbs adequately.[17],[29],[30]

Another important aspect is that in patients with MESS score ≥7, even if the limb survived they had a poor functional outcomes.[31] In our study also, the long-term functional outcomes of patient with elevated MESS score were poor, as they had neurological deficit at 3 months [Table 2]. Hence, undue enthusiasm in preserving the limb can lead unnecessary morbidity and mortality in case of secondary amputation.[32]

Studies have also found MESS score less reliable for predicting outcomes of the upper limb vascular injury.[33] MESS seems to be more accurate than the LSI in prediction of limb salvage. PSI score also has high sensitivity but suffers from low specificity when applied to predict successful limb salvage. Low sensitivity and specificity are described for the NISSSA score.[32]

In a study by Kim et al., a MESS score of >7 and orthopedic fixation were statistically significant factors associated with amputation. They concluded that in cases of femoropopliteal artery injuries with Injury severity Score of >20, MESS of >7, and orthopedic fixation, amputations should be considered.[25]

MESS score is less specific for predicting amputation when the score is between 7 and 9, however, MESS predicts poor outcomes correctly >50% of the times when MESS is ≥9 and >75% of the time when MESS is ≥11. For patients with MESS ≥11, even primary amputation can be considered.[34]

Risk factors for amputation

Our study showed a strong association of amputation with bony involvement, neurological involvement, and blunt mechanism of injury on univariate analysis. It implies that bony involvement, neurological involvement and blunt mechanism of injury were associated with poor prognosis on applying univariate analysis (statistical test). However on applying binomial logistic regression analysis (statistical test) it didn't show correlation with poor prognosis probably because of small number of patients. There was no significant association of shock, age, performance of fasciotomy, and warm ischemia time with amputation.

Russell et al.[35] also in their study observed that no significant association of amputation with shock or time to operative injury. They did find a significant association of amputation to severe injuries to soft tissue, bone, and nerves. Shabbir [36] found a significant association of skeletal trauma and warm ischemia time with amputation.

de Silva et al.[37] concluded that condemning limbs as unsalvageable purely on the basis of ischemia time needs to be reconsidered. The decreasing role of warm ischemia time in the prediction of amputation may be explained on the basis of changing pattern of mechanism of injuries. The older pattern of injuries commonly included isolated vascular injuries due to low-energy penetrating trauma, wherein the role of ischemia time was of major importance. However, the rising incidence of blunt injuries suggests more diffuse and high-energy impacts cause skeletal and neurological injuries that are associated with bad outcomes. Furthermore, the presence of neurological symptoms is suggestive of prolonged ischemia. Thus, warm ischemia time considered to be the most important predictor conventionally needs to be reconsidered and tested for its validity as other factors appear to play a more important role.[38]

Mortality and morbidity

Similar to our finding, mortality was around 5%–8% in other studies also in patients of lower extremity vascular trauma.[39],[40] All our patients died because of multiorgan dysfunction following a failed attempt at revascularization. Our limb salvage rate (56%) is low as compared to other studies.[41] It could be because of several factors such as long warm ischemia, higher number of patients who had skeletal injuries, high percentage of patients with blunt trauma, recruitment of patients with high MESS scores, and higher number of patients with popliteal artery injury. Other studies corroborate our finding of high-amputation rate in case of FPAI even after revascularization.[25] Another important aspect is fixation of orthopedic fractures along with vascular repair in patients of FPAI for optimal results.

Other prognostic factors

Our study did not find any correlation of age with poor prognosis; however, few studies show strong correlation of amputation with age >40. In another study, the authors found correlation between increased risk of nonhealing of bones and amputation with age.[41]

Chronic pain after vascular repair is again associated with adverse outcomes as most of these patients land up with amputation. Even after 5 years of vascular injury, these patients continue to have lower quality of life measures as compared to normal population.[31]

Our study did not show any correlation of fasciotomy with amputation rates, however, a study found a correlation between early fasciotomy with lower amputation rate, lower infection rate, and shorter total hospital stay than those in the late fasciotomy group.[42]

The limitation of our study is small sample size and even when MESS score was high, we went for vascular repair and did not go for amputation outrightly that is the reason for our high amputation rate and mortality.


  Conclusion Top


In Indian subcontinent, where health resources are meager and vascular specialists are hard to find, vascular repair is usually delayed and poorly managed. Since most of the times the cost of treatment is borne by the patient/relatives, a failed attempt at revascularization drains the patient financially, so if we can develop a full proof scoring system which can truly identify patients who need amputation, we can decrease the vascular work load and manage the patients better.

We concluded that MESS cannot be completely relied upon, and the surgeon's clinical assessment and experience are necessary to decide the plan of management. Warm ischemia time is not the most important factor affecting limb survival, and other factors such as neurological and bony involvement need to be considered. MESS helps to frame the data for the clinician and can help in counseling patients and their families that poor outcomes are more likely when MESS score is high. Further large scale, multicenter randomized trials are necessary for the identification of other risk factors and their incorporation into scoring systems.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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