Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 141-144

The validity of the mangled extremity severity score scoring system for lower limb vascular trauma in a tertiary care center


1 Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana, India
2 Department of Orthopaedics, Yashoda Hospital, Hyderabad, Telangana, India
3 Department of Plastic Surgery, Yashoda Hospital, Hyderabad, Telangana, India
4 Department of Anaesthesia, Yashoda Hospital, Hyderabad, Telangana, India

Date of Submission11-Sep-2019
Date of Acceptance21-Oct-2019
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. Aryala Shalini
Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_63_19

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  Abstract 


Purpose: Among all the scoring systems to predict limb salvage versus amputation after a complex trauma, MESS scoring system is considered to have good sensitivity and specificity. MESS scoring system is most widely used scoring system for the last more than 25 years. However when we applied MESS scoring system in our set of patients, it would not correlate with the need of amputation (for MESS score more than 7) and resulting in significant number of limb salvage. Methods: This a prospective study of 60 patients over a period of two years from June 2017-June 2019. All the patients of lower limb vascular trauma were examined and operated by the same team involving vascular surgeon, orthopedic surgeon and plastic surgeon. MESS scoring system was applied for all the patients. Patients with life threatening injuries were excluded in this study. Results: Between June 2017-2019, 60 patients were entered into the study. The majority were male with mean age of 30 years (Range 11-65years). Road traffic accidents with open injuries were the commonest mechanism of injuries (60%) and popliteal artery was involved in majority of injuries. Out of 35 patients of MESS score more than 7, in 28 patients leg was salvaged with the help of vascular,orthopedics and plastic reconstructions and remaining 7 patients underwent secondary amputation. The hospital stay and the finances involved in the treatment was high in patients with MESS score more than 7, where revascularisation was performed. However in the end psychological assessment of these patients and their family members was very encouraging. Conclusions: With the availability of a dedicated trauma team (which include vascular, orthopedic, plastic surgeons & anaesthetist) and improvement in the diagnostic and treatment modalities, the rate of limb salvage has increased significantly, hence reducing the prediction of MESS scoring system for an amputation. We conclude from our study that majority of lower limbs were salvaged in spite of MESS score being more than 7. We suggest with a word of caution for an amputation directly with a MESS score of more than 7 in all patients.

Keywords: Amputation, mangled lower limb, vascular injury, vascular repair


How to cite this article:
Shalini A, Singh D, Dachipalli S, Maddu S, Ram L. The validity of the mangled extremity severity score scoring system for lower limb vascular trauma in a tertiary care center. Indian J Vasc Endovasc Surg 2020;7:141-4

How to cite this URL:
Shalini A, Singh D, Dachipalli S, Maddu S, Ram L. The validity of the mangled extremity severity score scoring system for lower limb vascular trauma in a tertiary care center. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 4];7:141-4. Available from: http://www.indjvascsurg.org/text.asp?2020/7/2/141/286908




  Introduction Top


Trauma has emerged as a major public health problem in developing as well as in developed countries, and vascular trauma is an important component of this problem. The decision on whether to proceed with amputation or reconstruction of a mangled extremity is perhaps one of the most difficult situations for the trauma team, as these types of injuries are seen relatively infrequently and most importantly in young population. Factors considered in the decision-making process include patient age, physiologic condition at presentation, associated injuries, soft-tissue factors, and the potential for salvaging a useful limb. The mangled extremity severity score (MESS) was developed 25 years ago at Harborview Medical Center in Seattle by Johansen et al. in an attempt to create a tool that accurately predicted the need for amputation. The MESS takes into consideration the degree of skeletal and soft-tissue injury, limb ischemia, the presence of shock, patient age, and ischemia time. It has been widely utilized since its inception despite continued questions over its prognostic accuracy. The utility of this scoring system, or any other such scoring system, is further questioned given the major advances that have been made in the management of severely mangled extremities, including increased use of tourniquets in both civilian and military settings, numerous new hemostatic agents, advanced tissue transfer techniques, and novel vascular interventions.

The purpose of this study is to present the magnitude of this important clinical dilemma of amputation versus salvage and the relevance of MESS scoring system in in the present era with the significant advancement in the diagnostic and interventional techniques.


  Materials and Methods Top


Lower extremity injuries named arterial injuries were identified between June 2017 and June 2019. Each component of the MESS was obtained prospectively during data collection using the scoring system shown in [Table 1]. The MESS was calculated for each patient by adding the numerical scores of the skeletal/soft-tissue injury, limb ischemia, shock, and age scores. If there were >6 h of ischemia time, the ischemia score was doubled.
Table 1: MESS scoring system

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All the patients were examined by the emergency physician and a trauma team (vascular, orthopedic, and plastic surgeon), resuscitated, and investigated. Computed tomography angiogram was done in all patients to confirm the level of vascular injuries. Before shifting to the operation theater, the plan of treatment was explained and discussed with the family members in detail in a counseling room having the facility for audio and video recording. The family was also involved in the plan of treatment. Then, this plan was also shared with the patient (those who were fully coherent).

Patients excluded from this study:

  • Patients with upper limb trauma
  • Polytrauma with life-threatening injuries
  • Established cases of irreversible ischemia with gangrene
  • Severely injured limbs with an unreconstructable foot
  • All the patients were examined, operated, and treated by the same team from the vascular surgery department.



  Results Top


Between June 2017 and June 2019, 60 patients with lower extremity arterial injuries were entered into this study. The cohort consisted predominantly of men (87.8%) with an average age of 34 years ± 15.3 (range: 11–65 years). The mechanism of injury was reported as blunt in 25 patients (41.6%) and penetrating in 35 patients (58.3%) [Table 2]. Overall, road traffic accidents were the single most common cause of extremity vascular injury in both the penetrating and blunt trauma. Other forms of trauma in a descending order of frequency were fallen from height, gunshot, and stab injuries. Isolated femoral injuries were found in 5 (8.3%) patients and isolated popliteal injuries in 39 patients (65%). Sixteen injuries (26.6%) to arteries distal to the popliteal artery were identified. The injury to the artery was most often a transection, present in 56.6% of the patients and a contused segment in 43.3% patients. There were 6 (10%) concomitant venous injuries. About 33.3% of these venous injuries were repaired at the time of initial operation and the remainder were ligated (66.6%). There were 56 (93.3%) concomitant orthopedic injuries and 32 (53.3%) severe soft-tissue injuries.
Table 2: Trauma: Mechanism of injuries

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Vascular repair was done prior to orthopedic fixation, as all the patients were referred late with significant ischemia. Majority (90%) of the arterial repair were with the help of an interposition vein graft from the contralateral limb. End-to-end repairs were possible only in tibial arterial injuries and were done in 6 (10%) patients. Most of these patients were subjected for liberal fasciotomies. Orthopedic repairs (mostly an external fixator) and soft-tissue reconstruction with the help of local or free tissue flaps were done by ortho and plastic surgery team.

Application of Mangled Extremity Severity Score scoring system

As per the MESS Scoring System, a MESS score of 7 or more will go for an amputation and a MESS score of <7 would be planned for revascularization.

Of 60 patients, in 25 patients, the MESS score was <7; hence, all planned for revascularization.

In 35 patients, the MESS score was 7 and more than 7. These set of patients were planned for limb salvage, explaining the risk of secondary amputation, infection, multiple surgeries, prolonged hospital stay, and a financial burden to the family members. In 28 (80%) patients, the limb was salvaged, irrespective of MESS score more than 7. Only 7 (20%) patients underwent secondary amputations, following vascular repairs with a MESS score of more than 7. In the salvage group, seven patients continued to have a foot drop and required physiotherapy and splint; however, they are walking without the support and back to work. In the final outcome in both the groups with MESS score less than and more than 7, there is not much significant difference in terms of total hospital stay, cost of treatment, and return to work [Table 3]. Both the group of patients where salvage or amputation was done were subjected for psychological analysis, and it was found to be very encouraging in group where salvage was done in spite of some functional disability [Table 4].
Table 3: Final outcome in salvage group

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Table 4: Psychological assessment

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  Discussion Top


The original MESS was developed in 1990 by a retrospective review of 25 consecutive patients with lower extremity injuries.[1] The same authors subsequently applied the scoring system to a group of 26 comparable patients studied prospectively. In the original study, the MESS for salvaged limbs ranged from 3 to 6, whereas the amputated limbs ranged from 7 to 12. These authors concluded that in their hands, a MESS of 7 or greater predicted amputation with 100% accuracy. Subsequent authors were unable to obtain this degree of accuracy and developed alternative scoring systems. These systems include the limb salvage index; the predictive salvage index; the nerve injury, ischemia, soft-tissue injury, skeletal injury, shock, and age of patient score; and the Hannover Fracture Scale.[2] Each contain various elements of patient characteristics at presentation (e.g., age and presence of shock), structural injury (e.g., concomitant bone, muscle, skin, nerve, vascular, injury, and degree of contamination), and treatment factors (e.g., warm ischemia time and time to treatment).[3],[4],[5],[6] These five scoring systems were prospectively evaluated in 2001 by Bosse et al. as part of the Lower Extremity Assessment Project (LEAP) study group.[7] A total of 556 high-energy injuries were evaluated including ischemic limbs; Type III-A, III-B, and III-C tibial fractures; severe distal tibial fractures (open pilon fractures or Type III-B ankle fractures), hindfoot fractures; and isolated soft-tissue injuries of the lower extremities. This extensive analysis could not validate the clinical utility of any of these scoring systems. The scores did have high specificity in predicting limb-salvage potential but had a low sensitivity in predicting the need for amputation. A subsequent study by the LEAP group showed that none of these scoring systems were predictive of functional recovery in patients who underwent successful limb reconstruction.[8]

Recent reevaluations of the MESS have continued to question its validity. Menakuru et al. found that of 148 patients, a MESS of >7 had a sensitivity of only 44% and a specificity of 70% in predicting amputation.[9] Recent systematic reviews further confirm the unreliability of the MESS. Fodor et al. concluded that MESS correctly identified the need for amputation in only 25% of cases,[10] whereas Schirò et al. found the range of reported accuracy of a MESS >7 to be anywhere between 0% and 93.4% in the literature.[11] The MESS has also been evaluated in combat-related injuries. Sheean et al. reported on 155 patients treated for Type III open tibia fractures in US military service personnel, involving primarily blast injuries.[12] One hundred one patients had successful limb salvage and 45 underwent primary amputation. The mean MESS value for amputees was 5.8 and for those that were salvaged was 5.3 (P = 0.057). The sensitivity and specificity of a MESS ≥7 in predicting the need for amputation in the combat setting were 35% and 87.8%, respectively (positive predictive value of 50%). These military surgeons concluded that the MESS was not useful in battlefield-related injuries. Additional studies on battlefield-related extremity vascular injuries did find that those with preserved limbs but high MESS scores (≥7) had higher levels of dysfunction as rated with the Short Musculoskeletal Function Assessment tool.[13]

In another contemporary analysis of the mangled lower extremity, de Mestral et al. retrospectively examined a cohort of patients entered into the National Trauma Data Bank (NTDB) between 2007 and 2009. A total of 1354 patients were identified, with a 21% amputation rate.[14] These authors found that the presence of a severe head injury, shock in the emergency room, and a high-energy mechanism of injury were associated with early amputation. Unfortunately, the NTDB does not contain sufficient data to accurately calculate the MESS score. A recent study from Austria looked at early failed attempts at salvage in open lower limb fractures demonstrating that in addition to MESS, other important predictors of secondary amputations included complex fractures, severe soft-tissue damage, and the need for fasciotomy.[15] In 60% of these patients, failed limb salvage resulted from infectious complications and 40% from a failed vascular reconstruction.

In 2015, Aarabi et al. from Seattle presented their data on the utility of MESS 25 years after its creation. In their series of 48 patients with mangled extremities complicated by acute arterial insufficiency, 81% were salvaged (MESS mean of 4.8) and 19% required amputation (MESS mean of 9.1).[16] In their series, 77% of those who went onto secondary amputation had a popliteal artery injury. These authors also reported that MESS independently predicted the cost and length of hospitalization; on average for every 1-point increase in MESS, the hospital cost increased by almost $6000.

In our study, we found that blunt injuries, vessel transection, popliteal injuries, and concomitant severe extensive soft-tissue injuries were associated with a higher risk for amputation and were more predictive than an isolated MESS score. Limb salvaged was 80%, irrespective of MESS score of 7 or more than 7 and with acceptable final outcome. MESS was a very poor predictor of amputation in this cohort, predicting only 20% of amputations.


  Conclusion Top


As majority of cases represent a “gray zone” of unpredictable prognosis and borderline cases are a dilemma, the decision to amputate or not amputate should not always be made during the initial evaluation. Although scoring systems and “cutoff points” are useful, the final decision for limb salvage should be based on the team experience, technical skills, multidisciplinary consultation, tertiary care facility, and the profile of the patient. Scoring systems should be used only as guides to supplement the surgeon's clinical judgment and experience.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568-72.  Back to cited text no. 1
    
2.
Scalea TM, DuBose J, Moore EE, West M, Moore FA, McIntyre R, et al. Western trauma association critical decisions in trauma: Management of the mangled extremity. J Trauma Acute Care Surg 2012;72:86-93.  Back to cited text no. 2
    
3.
Howe HR Jr., Poole GV Jr., Hansen KJ, Clark T, Plonk GW, Koman LA, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg 1987;53:205-8.  Back to cited text no. 3
    
4.
McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the mangled extremity severity score (MESS) J Orthop Trauma 1994;8:81-7.  Back to cited text no. 4
    
5.
Russell WL, Sailors DM, Whittle TB, Fisher DF Jr., Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991;213:473-80.  Back to cited text no. 5
    
6.
Tscherne H, Oestern HJ. A new classification of soft-tissue damage in open and closed fractures (author's transl). Unfallheilkunde 1982;85:111-5.  Back to cited text no. 6
    
7.
Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. Aprospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 2001;83:3-14.  Back to cited text no. 7
    
8.
Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ, LEAP Study Group. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg Am 2008;90:1738-43.  Back to cited text no. 8
    
9.
Menakuru SR, Behera A, Jindal R, Kaman L, Doley R, Venkatesan R. Extremity vascular trauma in civilian population: A seven-year review from North India. Injury 2005;36:400-6.  Back to cited text no. 9
    
10.
Fodor L, Sobec R, Sita-Alb L, Fodor M, Ciuce C. Mangled lower extremity: Can we trust the amputation scores? Int J Burns Trauma 2012;2:51-8.  Back to cited text no. 10
    
11.
Schirò GR, Sessa S, Piccioli A, Maccauro G. Primary amputation vs limb salvage in mangled extremity: A systematic review of the current scoring system. BMC Musculoskelet Disord 2015;16:372.  Back to cited text no. 11
    
12.
Sheean AJ, Krueger CA, Napierala MA, Stinner DJ, Hsu JR, Skeletal Trauma and Research Consortium (STReC). et al. Evaluation of the mangled extremity severity score in combat-related type III open tibia fracture. J Orthop Trauma 2014;28:523-6.  Back to cited text no. 12
    
13.
Scott DJ, Watson JD, Heafner TA, Clemens MS, Propper BW, Arthurs ZM. Validation of the short musculoskeletal function assessment in patients with battlefield-related extremity vascular injuries. J Vasc Surg 2014;60:1620-6.  Back to cited text no. 13
    
14.
de Mestral C, Sharma S, Haas B, Gomez D, Nathens AB. A contemporary analysis of the management of the mangled lower extremity. J Trauma Acute Care Surg 2013;74:597-603.  Back to cited text no. 14
    
15.
Fochtmann A, Mittlböck M, Binder H, Köttstorfer J, Hajdu S. Potential prognostic factors predicting secondary amputation in third-degree open lower limb fractures. J Trauma Acute Care Surg 2014;76:1076-81.  Back to cited text no. 15
    
16.
Aarabi S, Kavousi Y, Friedrich J, Singh N, Bulger E. Severe Lower Extremity Injury: Mess (Mangled Extremity Severity Score) Twenty-Five Years Later. J Trauma Acute Care Surg 2016.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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