Abstract
BackgroundIn the last decades a lot of new reconstructive techniques were developed for the treatment of mangled lower extremity. However failed attempt to limb salvage is related to high risk of mortality for the patient. Several scores were developed to establish guidelines for the decision to amputate or not, however in literature there is no consensus about the reliability of this scores.MethodsThe authors focused their attention on the most used score system to provide guidance of the management of a mangled lower limb. The search term used included mangled lower extremity, MESS, PSI, LSI and NISSSA. The inclusion criteria were: studies dealing with mangled lower extremity; articles reporting MESS, PSI, LSI or NISSSA scores; articles published in English in PubMed, Cochrane, Scopus and web of science in the last 30 years, minimum number of cases in study of 15, minimum follow up of 1 year.ResultsAccording with the criteria described above, we found 134 articles in PubMed, 165 articles in Scopus, 111 articles in the Cochrane Library and 108 articles in Web of Science. The most used score in literature is the MESS. Few results are shown using the other severity scores. There are a lot of controversies in literature about the use of this scale. MESS seems to be more accurate than the LSI in prediction of limb salvage. LSI score shows better results when applied to type III tibial fractures. High sentivity of the PSI score is described when applied to predict successful limb salvage. Low sensitivity and specificity are described for the NISSSA score. The literature is very poor of articles related to mangled lower extremity in children. Higher sensitivity and specificity are described for these scores in children when compared to adult population.ConclusionThe mangled lower extremity treatment is a challenge for the surgeon. Many scores were developed to help the surgeon, however they cannot be used as the sole criterion by which amputation decision are made and, in case of succesful limb salvage, they are not predictive of the functional recovery. Moreover, undue enthusiasm for new surgical techniques can lead to increased morbidity and mortality in case of secondary amputation.
Highlights
In the last decades a lot of new reconstructive techniques were developed for the treatment of mangled lower extremity
In literature there is no consensus about the reliability to predict functional outcome and secondary amputation of these scores
Principle variables considered by the developers are: soft tissue, time of ischemia, bone and nerve injury, blood loss (Table 1) [6]
Summary
In the last decades a lot of new reconstructive techniques were developed for the treatment of mangled lower extremity. Bosse et al [7] evaluated prospectively 556 high energy lower extremity injuries with the use of data collected as a part of a multicenter study (LEAP: Lower Extremity Assessment Project) developed to compare clinical outcome of lower mangled limb after salvage or amputation; the Authors did not support the utility of any of these scores to make a decision to amputate or not. In their study the authors described different specifity and sensibility for each of these scores: regarding PSI the sensitivity and specificity were 56 and 79 % considering ischemic limb injury; while the sensitivity of the MESS was 46 % considering all limbs and 72 % if only ischemic limb were considered, this score demostred high specificity to predict limbs amputation. The goals of this study is to analyze the most used scoring systems described in literature for the assessment of mangled
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