Limb Salvage Index Research Articles

A Descriptive Study of Concomitant Vascular and Bone Injuries of the Limbs in a Tertiary Care Hospital in South India

Background: We studied patients with concomitant vascular and orthopedic trauma to limbs to assess their outcome and factors that affect the outcome of the limb. Methodology: We conducted a retrospective descriptive study and data from 68 patients was collected. Factors such as demography, mode of injury, and clinical parameters such as pulses, capillary refill time (CRT), sensory-motor function, compartment syndrome, type of bone and vessel injury, and ischemia time were compared and analyzed. Results: Out of 68 patients (n = 68) with concomitant vascular and orthopedic injury included in the study, 63 (92.65%) patients were males, and the mean age in the study was 30.16 ± 16.33 years; 56 (82.35%) patients sustained road traffic accident and 12 (17.65%) patients sustained fall from height, 7 (10.29%) patients were hypertensive, and 2 (2.94%) patients had diabetes mellitus; popliteal (30 patients – 22.06%) and brachial arteries (30 patients – 22.06%) are the most (total 44.12%) followed by femoral artery (seven patients, 10.29%) and radial artery (one patient, 1.47%); sensory function was absent in 20 (29.4%) patients; CRT was more than 3 s in 49 (72.06%) patients. No mortality occurred during the hospital stay in any of the 68 patients. The overall rate of amputation in the study was 20.59% (14 amputations). Significant association of amputation rate was found with increased CRT (P = 0.01), fracture (P = 0.05), open fracture (P = 0.05), transected vessel (P = 0.017), nonextremity injury (P = 0.01), and compartment syndrome (P = 0.002). Fasciotomy was done for 49 (72.06%) patients, and no significant association was found with the amputation rate. Mangled extremity severity score (MESS) was 7 or more than 7 in 23 (33.82%) patients. All the 14 (100%) patients who required amputation in the study had a MESS of 7 or more (P = 0.01), and limb salvage index (LSI) was 6 or more in 17 patients; among the 14 patients who underwent amputation, 13 patients had an LSI of 6 or more than 6 (P = 0.01). The vascular repair was redone in 3 (21.4%) patients, excessive bleeding requiring blood transfusion happened in 2 (14.3%) patients, and hypotension occurred in 4 (28.6%) patients. Intraoperative complications were associated with an increased rate of amputations (P = 0.001). The mean ischemia time was 15 ± 6.5 h with a median of 15 h; the shortest ischemia time was 10 h, and the longest was 19 h. The mean ischemia time was 14 h in the limb salvage group and 18.5 h in the amputation group. Long ischemia time was associated with increased amputation rates (P = 0.03). There was no significant difference in time between the time of injury and presentation to the hospital, the time between presentation and surgery, and the duration of surgery between the two groups (amputated vs. salvaged). Conclusion: The extent of soft-tissue injury and ischemia time are prime determinants of outcome in cases with concomitant vascular and skeletal injury. Early diagnosis, quick referral, addressing compartment syndrome, and proper vascular repair are the critical factors in salvaging a limb.

Vascular Trauma in the Extremities: Factors Associated with the Outcome and Assessment of Amputation Indexes.

Traumatic vascular injury in the extremities may be associated with a low mortality rate but can lead to limb loss that seriously affects patients' functionality. Multiple scoring systems have been designed to evaluate the prognosis, but none are 100% predictive. The management of traumatic vascular injury remains challenging and depends mostly on the surgeon's experience. We identified the risks associated with limb loss and further investigated the utility of current amputation indexes. We retrospectively reviewed 53 cases of traumatic vascular injury in the extremities at a tertiary referral medical center over the past ten years (January 2011-December 2020). The mangled extremity severity score (MESS), limb salvage index (LSI), and predictive salvage index (PSI) were used to assess the traumatized limbs. The injury characteristics and outcomes were evaluated using regression analysis. The incidence of limb loss was 20.8% (n = 11), and open fractures were the most related factor. Extensive involvement of soft tissue, vascular injury combined with tibia or fibula fractures, initial shock status, and the amount of transfusion were associated with limb loss. Our study identified the risk factors and clinical utility of MESS, PSI, and LSI. While both LSI and PSI had acceptable diagnostic accuracy, amputation should be decided based on a variety of criteria and clinical features. Salvaging any limb that has not become apparently futile seems logical, yet the presence of certain factors may suggest a worse outcome.

Limb salvage vs amputation in crush injury due to high energy injury: A case report

Limb injury possesses significant problems, both for the treating physician and patient. Numerous problems ranging from disability, limb amputation or even death can occur to the patient. However, the definitive therapy is still debated. A 50 years old man came to the emergency room with a chief complaint of an open wound of his right leg because of a traffic accident. Subsequently, the repair, secondary closure, and skeletal traction were done following the exploration and debridement. During the next follow up, the surrounding tissues seemed to be non-viable. Therefore, the surgeon decided to do an operation with a urologist to perform hip disarticulation and scrotum necrotomy. The patient undergoes repeated debridement in operating theatre and also using negative pressure wound therapy (NPWT). After three months from the first admission, the patient's condition started to deteriorate, and unfortunately, the patient died. There are several scoring systems that can be used to help determine the management of high energy lower extremity injuries. The most used is Mangled Extremity Severity Score (MESS), Limb Salvage Index (LSI) and Predictive Salvage Index (PSI) scores. Hospital type will surely determine the facility and personnel availability. If the facility and personnel are sufficient, limb reconstruction should be attempted first. However, in the end, the family's consent after considering the risk of the surgery will determine the chosen surgery to perform. The surgeon in charge should consider the decision with high vigilance regarding the patient's clinical condition. The decision between limb salvage and amputation should consider the long-term effect which influences the patient's quality of life.

Is lower limb salvage worthwhile after severe open tibial fractures in a developing country? An analysis of surgical outcomes, quality of life and cost implications.

Open tibial fractures are rare and difficult-to-treat injuries because of the involvement of bony, skin and neuromuscular injury along with co-morbidities. Often, during the management of very severe cases these injuries, the question arises, should we amputate or salvage the limb? This question has been explored previously in civilian and military contexts in the US and UK but remains unstudied in the alternative sociocultural and economic context of the developing world. We studied 78 adult patients with severe open tibial fracture that presented to our institution, a Level 1 trauma center in India, from February 2018 to June 2019. 20 patients underwent above-knee amputation (AKA), 16 underwent below-knee amputation (BKA), and 42 underwent limb salvage. We assessed injury severity using [our institution's] Open Injury Severity Score (GHOISS), which has separate sub-scores for bony injury, skin injury, neuromuscular injury and co-morbidities, and patients were only included with GHOISS > 13. We assessed functional outcome measures as well as economic costs as primary cost levied by our institution and other secondary costs. Salvage (LEFS: mean=51, SF-12 PCS: mean=48, SF-12 MCS: mean=49) provided better outcomes to BKA (LEFS: mean=39, p=0.005, SF-12 PCS: mean=40, p=0.003, SF-12 MCS: mean=43, p=0.052) and AKA (LEFS: mean=31, p<0.001, SF-12 PCS: mean=34, p<0.001, SF-12 MCS: mean=43, p=0.043). Primary costs were higher for limb salvage (index: mean=$3100, total: mean=$4400) than both BKA (index: mean=$2500, p=0.012, total: mean=$2600, p<0.001) and AKA (index: mean=$2800, p=0.020, total: mean=$3200, p<0.001). Secondary costs were higher for limb salvage than both BKA and AKA (p<0.001). Patients who underwent salvage were more likely to return to work at 36 months post-injury compared to below-knee amputees (adjusted OR=0.11, p=0.010). Limb salvage results in better functional outcomes compared with amputation at a higher upfront cost but a likely lower lifetime cost. Unlike other literature on the topic, amputation carries a heavy mental and physical toll in India, likely due to sociocultural differences and stigma. Amputation is a difficult decision for patients to accept and results in poorer outcomes; therefore, we believe that limbs should be aggressively salvaged in our developing country. Therapeutic Level II Prospective Cohort Study.

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

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. 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 twoyears. 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 72hours (1.3%) and six secondary amputations after 72hours from initial debridement (2.7%). Of these, fourpatients died within oneyear 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. 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. GHS has an improved ability to determine amputation in IIIB open tibia fractures.

Assessment of Patterns of Lower Limb Injuries at a Medical College Hospital of Central India

Introduction: In the recent era of trauma, about one million people get seriously injured annually. Majority of them suffer from lower limb injuries. Due to lack of trauma registry in India, prediction models are not much effective. The aim of our study was to derive basic pattern for lower limb injuries which can be used to develop better prediction models to reduce morbidities and mortalities. Methods: We conducted an observational study on isolated lower limb injuries without any musculoskeletal disorder at a Medical College Hospital in Akola, Maharashtra between January 2012 to December 2013. The lower limb injuries were classified as per the Limb Salvage Index score (LSI) for further management. Results: A total of 1160 patients were included. Mean age was 44.5 years and 75 percent of them were males. Lower limb injuries showed bi-modal age group with first peak between 30 to 40 years and second at 60 to 70 years. Road traffic accidents were the most common cause of injury followed by fall at home. 1.8 percent patients had Limb Salvage Index ranging between 7 to 12 and underwent amputations. Both lower limbs were almost equally affected with left showing a little higher value than right (49 versus 47 percent, p>0.05). Femur was the most commonly affected bone. Conclusion: This study helped us in identifying certain characteristics that may be useful for planning preventive strategies in an attempt to reduce the numbers of accidents and redirect public investment in health.

Epidemiology and patterns of lower limb injuries at a tertiary care hospital in Ahmedabad

Introduction: In the recent era of trauma, about one million people get seriously injured annually. Majority of them suffer from lower limb injuries. Due to lack of trauma registry in India, prediction models are not much effective. The aim of our study was to derive basic epidemiological parameters for lower limb injuries which can be used to develop better prediction models to reduce morbidities and mortalities. Methods: We conducted an observational study on isolated lower limb injuries without any musculoskeletal disorder at a tertiary care institution in Ahmedabad between January 2013 to October 2014. The lower limb injuries were classified as per the Limb Salvage Index score (LSI) for further management. Results: A total of 1160 patients were included. Mean age was 44.5 years and 75 percent of them were males. Lower limb injuries showed bi-modal age group with first peak between 30 to 40 years and second at 60 to 70 years. Road traffic accidents were the most common cause of injury followed by fall at home. 1.8 percent patients had Limb Salvage Index ranging between 7 to 12 and underwent amputations. Both lower limbs were almost equally affected with left showing a little higher value than right (49 versus 47 percent, p>0.05). Femur was the most commonly affected bone. Conclusion: This study helped us in identifying certain characteristics that may be useful for planning preventive strategies in an attempt to reduce the numbers of accidents and redirect public investment in health.

Ganga hospital open injury score in management of open injuries.

Open injuries of the limbs offer challenges in management as there are still many grey zones in decision making regarding salvage, timing and type of reconstruction. As a result, there is still an unacceptable rate of secondary amputations which lead to tremendous waste of resources and psychological devastation of the patient and his family. Gustilo Anderson's classification was a major milestone in grading the severity of injury but however suffers from the disadvantages of imprecise definition, a poor interobserver correlation, inability to address the issue of salvage and inclusion of a wide spectrum of injuries in Type IIIb category. Numerous scores such as Mangled Extremity Severity Score, the Predictive Salvage Index, the Limb Salvage Index, Hannover Fracture Scale-97 etc have been proposed but all have the disadvantage of retrospective evaluation, inadequate sample sizes and poor sensitivity and specificity to amputation, especially in IIIb injuries. The Ganga Hospital Open Injury Score (GHOIS) was proposed in 2004 and is designed to specifically address the outcome in IIIb injuries of the tibia without vascular deficit. It evaluates the severity of injury to the three components of the limb--the skin, the bone and the musculotendinous structures separately on a grade from 0 to 5. Seven comorbid factors which influence the treatment and the outcome are included in the score with two marks each. The application of the total score and the individual tissue scores in management of IIIB injuries is discussed. The total score was shown to predict salvage when the value was 14 or less; amputation when the score was 17 and more. A grey zone of 15 and 16 is provided where the decision making had to be made on a case to case basis. The additional value of GHOIS was its ability to guide the timing and type of reconstruction. A skin score of more than 3 always required a flap and hence it indicated the need for an orthoplastic approach from the index procedure. Bone score of 4 and 5 will require complex reconstruction procedures like bone transport, extensive bone grafting or free fibular graft. Regarding the timing of reconstruction, injuries with a score of 9 or less indicated a low violence trauma and were amenable for early soft tissue reconstruction whereas injuries with a score of 10 or more indicated high violence injuries where a staged reconstruction policy must be followed. Ganga Hospital Open Injury Score was found to be highly useful in decision making regarding salvage in IIIB injuries. The individual tissue scores were also useful to provide guidance regarding the timing and type of bone and soft tissue reconstruction.

Application of lower extremity injury severity scores in children

Severe lower extremity trauma presents challenges in decision-making in terms of reconstruction or amputation. While injury severity scores have been developed to aid decision-making in adults, evaluation of their use in children is limited. Children presenting with severe lower limb trauma from 2000 to 2010 in a major trauma centre were identified from a trauma registry. Records were reviewed for details of the injury, surgical intervention, amputation and scores for the Mangled Extremity Severity Score, Limb Salvage Index, Predictive Salvage Index, Nerve injury, Ischaemia, Soft tissue injury, Skeletal injury, Shock, Age System and the Hanover Fracture Scale 1998. Twenty children (average age 8.7 years) were eligible for inclusion. There were three primary amputations and no secondary amputations. All of the scoring systems had poor specificity and would have recommended amputation in several limbs that were successfully reconstructed. Currently available injury severity scores behave differently in children and adults. In their current format, these scores should not be used as an absolute indication for early amputation in children.

Comparison of three grading systems for mangled extremity syndrome: amputation versus salvage

Objective To compare the values of the mangled extremity syndrome index （MESI）, the mangled extremity severity score （MESS） and the limb salvage index （LSI） in deciding amputation or salvage in the management of the mangled extremity syndrome （MES）. Methods Clinical data of 353 MES patients including 95 with amputation and 258 with salvage admitted in recent eight years were retrospectively evaluated by using MESI, MESS and LSI, the value of which in deciding amputation or salvage was assessed with receiver operating characteristic （ ROC ）. Results There was statistical difference in aspect of mean scores of three grading systems between patients with amputation or salvage （P〈0. 01）. For MESI, MESS and LSI, the sensitivities was 89.47%, 85.26% and 83.15% respectively, the specificities was 100%, 96.89% and 96.12% respectively, the coincidence was 97.16%,93.76% and 92.63% respectively, the areas under ROC curves was 0. 924, 0905 and 0. 861 respectively and the cut-off points were equal or over 20, 7 and 6 respectively. Conclusions Three scoring systems are all highly capable of predicting early amputation or not in MES management. The MESI is recommended as a quantitative criterion for determining amputation or salvage. Key words: Amputation, traumatic ; Extremities ; Wounds and injuries

Orthoplastic Classification Systems

Over the last few decades, there have been many important advances in the treatment of severe lower limb injuries. This article looks at a few of the more widely used classification systems and Injury Severity Scores to examine their utility in a practical setting. Gustilo and Anderson formulated their landmark classification system in 1976 (J Bone Joint Surg Am. 1976;58:453-458). For the Gustilo classification system to serve any useful purpose, it is necessary to include supplemental information, whenever discussing these injuries, that includes the mechanism and energy of the injury and the presence of any other concomitant injuries or comorbidities. Byrd et al (Plast Reconstr Surg. 1985;76:719-728) recognized some of the shortcomings of the Gustilo-Anderson system and proposed a classification system of their own in 1985. The Byrd-Spicer classification is less commonly used, mainly because of a large degree of interobserver variability, but it includes energy and presence of devitalized tissue. The Predictive Salvage Index, devised in 1987, recognized the importance of vascular injury as a prognostic indicator and was formulated in an attempt to avoid not only unnecessary amputations, but also to avoid protracted attempts at salvage that might eventually be converted into a delayed amputation. The Mangled Extremity Severity Score looked at 4 variables: patient age; the presence and duration of shock; ischemia time; and the energy of the injury. Critics question the relevance of its parameters. The 7 components of the Limb Salvage Index include injury to an artery, deep vein, nerve, bone, skin, and muscle as well as warm ischemia time. However, predictive results have not been reproduced. The Hanover Fracture Scale was initially developed on the basis of 13 weighted variables to quantify risk factors for amputation and complications in high-energy trauma to a limb. This included index bacteriology, and was weighted heavily toward the presence of vascular injury. Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score attempted to address criticized weaknesses of the Mangled Extremity Severity Score. These scores can be useful tools in the decision-making process when used cautiously, but should not be used as the principal means for reaching difficult decisions.

Ability of Lower-Extremity Injury Severity Scores to Predict Functional Outcome After Limb Salvage

Lower-extremity injury severity scoring systems were developed to assist surgeons in decision-making regarding whether to amputate or perform limb salvage after high-energy trauma to the lower extremity. These scoring systems have been shown to not be good predictors of limb amputation or salvage. This study was performed to evaluate the clinical utility of the five commonly used lower-extremity injury severity scoring systems as predictors of final functional outcome. We analyzed data from a cohort of patients who participated in a multicenter prospective study of clinical and functional outcomes after high-energy lower-extremity trauma. Injury severity was assessed with use of the Mangled Extremity Severity Score; 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-98. Functional outcomes were measured with use of the physical and psychosocial domains of the Sickness Impact Profile at both six months and two years following hospital discharge. Four hundred and seven subjects for whom the reconstruction regimen was considered successful at six months were included in the analysis. We used partial correlation statistics and multiple linear regression models to quantify the association between injury severity scores and Sickness Impact Profile outcomes with the subjects' ages held constant. The mean age of the patients was thirty-six years (interquartile range, twenty-six to forty-four years); 75.2% were male and 24.8% were female. The median Sickness Impact Profile scores were 15.2 and 6.0 points at six and twenty-four months, respectively. The analysis showed that none of the scoring systems were predictive of the Sickness Impact Profile outcomes at six or twenty-four months to any reasonable degree. Likewise, none were predictive of patient recovery between six and twenty-four months postoperatively as measured by a change in the scores in either the physical or the psychosocial domain of the Sickness Impact Profile. Currently available injury severity scores are not predictive of the functional recovery of patients who undergo successful limb reconstruction.

The utility of scores in the decision to salvage or amputation in severely injured limbs

The decision to amputate or salvage a severely injured limb can be very challenging to the trauma surgeon. A misjudgment will result in either an unnecessary amputation of a valuable limb or a secondary amputation after failed salvage. Numerous scores have been proposed to provide guidelines to the treating surgeon, the notable of which are Mangled extremity severity score (MESS); the predictive salvage index (PSI); the Limb Salvage Index (LSI); the Nerve Injury, Ischemia, Soft tissue injury, Skeletal injury, Shock and Age of patient (NISSSA) score; and the Hannover fracture scale-97 (HFS-97). These scores have all been designed to evaluate limbs with combined orthopaedic and vascular injuries and have a poor sensitivity and specificity in evaluating IIIB injuries. Recently the Ganga Hospital Score (GHS) has been proposed which is specifically designed to evaluate a IIIB injury. Another notable feature of GHS is that it offers guidelines in the choice of the appropriate reconstruction protocol. The basis of the commonly used scores with their utility have been discussed in this paper.

Results of reconstruction in major pelvic and extremity venous injuries

Purpose: Outcome and venous patency after reconstruction in major pelvic and extremity venous injuries was studied. Methods: We retrospectively reviewed 46 patients with 47 venous injuries. Results: Injuries were caused by penetrating trauma in 37 extremities, blunt trauma in 6 patients, and were iatrogenic in 4 patients. Pelvic veins were injured in 4 patients, lower-extremity veins were injured in 39 limbs in 38 patients, and upper-extremity veins were injured in 4 patients. Concomitant arterial injuries occurred in 37 patients. Venous repairs were mostly of the complex type and included spiral or panel grafts in 15 (32%) reconstructions, interposition grafts or patch venoplasty in 19 (40%) reconstructions, end-to-end and lateral repair in 11 patients, and ligation in 2 patients. Two patients underwent early amputation. Early transient limb edema occurred in 2 patients, and postoperative venous occlusions were documented in 4 patients. Full function was regained in 39 (81%) extremities. No variable, including 4 retrospectively applied extremity injury scores (mangled extremity severity score [MESS], limb salvage index [LSI], mangled extremity syndrome index [MESI], predictive salvage index [PSI]), correlated with outcome. High values on all 4 scores were significantly associated with reexplorations ( P < .02), which were done in 8 patients for debridement (5), arrest of bleeding (2), and repair of a missed arterial injury (1). Follow-up of 28 ± 6 months on 27 patients (57%; duplex scan in 18, continuous-wave Doppler and plethysmography in 9, and venography in 3) showed 1 occlusion 6 weeks after the injury and patency of all other venous reconstructions. Conclusion: Reconstructions of major venous injuries with a high rate of complex repairs result in a large proportion of fully functional limbs and a high patency rate. A high extremity injury score predicts the need for reexploration of the extremity. Mostocclusions occur within weeks of injury, and the subsequent delayed occlusion rate is very low. (J Vasc Surg 1998;28:901-8.)

Is it possible to predict limb viability in complex Gustilo IIIB and IIIC tibial fractures? A comparison of two predictive indices

The patient with severe lower limb trauma presents a management dilemma; whether to amputate primarily or to attempt limb salvage. In recent years, many predictive indices have been published which purport to identify limbs which are non-viable. We retrospectively applied two recently described indices, the Mangled Extremity Severity Score (MESS) and the Limb Salvage Index (LSI), to 54 limbs in 50 patients with either Gustilo IIIB or IIIC complex tibial fractures. There were 22 amputations (40.7 per cent) in the series. The mean MESS score in the limb salvage group was 3.8 (range 2-10), and the mean MESS score in the amputation group was 7.7 (range 4-13) (P < 0.0001). The mean LSI score in the limb salvage group was 3.6 (range 3-8), and the mean LSI score in the amputation group was 6.9 (P < 0.01). However, in the group with MESS scores > 7 (which recommends amputation), there were three limbs which were salvaged with acceptable functional outcome. Similarly, in those with LSI scores > 6 (which recommends amputation), there were seven limbs successfully salvaged. A MESS > 7 offered a greater relative risk of amputation (9.2) than a LSI score > 6 (5.3). We found both indices of use in predicting limb salvage and functional outcome. However, neither is sufficiently accurate to be considered absolutely reliable in clinical practice.

Outcome and utility of scoring systems in the management of the mangled extremity

The role of scoring systems as predictors of amputation and functional outcome in severe blunt extremity trauma was examined. All severe extremity injuries treated over a 10-year period were scored retrospectively using four scoring systems: Mangled Extremity Syndrome Index (MESI), Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), and Limb Salvage Index (LSI). Twenty-three upper (UE) and 51 lower extremity (LE) injuries were evaluated. Sensitivity and specificity, respectively, were MESI 100% and 50%, MESS 79% and 83%, PSI 96% and 50%, and LSI 83% and 83%. For each system, there were no differences between patients with good and poor functional outcomes. All of the scoring systems were able to identify the majority of patients who required amputation. However, prediction in individual patients was problematic. None of the scoring systems were able to predict functional outcome.

THE FUTILITY OF PREDICTIVE SCORING OF MANGLED LOWER EXTREMITIES

Fifty-eight lower limb salvage attempts over a 10-year period were retrospectively scored using the Mangled Extremity Syndrome Index (MESI), Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), and the Limb Salvage Index (LSI). Primary amputations were excluded. Limb salvage failure was defined at four levels, including functional failure 2 years postinjury. Cross-validational sensitivity and specificity analyses revealed no predictive utility in any of the four indices. Although most failed limb salvage attempts could be identified early in the course of management, a significant percentage of our patients suffered prolonged reconstructive efforts. We conclude that efforts must be directed at more precisely determining the factors that aid in the decisions to terminate futile salvage efforts.

Limb Salvage Versus Traumatic Amputation A Decision Based on a Seven-part Predictive Index

In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. To answer this question, the authors performed a 5-year review of 70 limbs in 67 patients. Patients were identified as presenting with major lower extremity trauma and an associated arterial injury. Nineteen (27%) of the 70 limbs were amputated. Limb salvage was not related to the presence or absence of shock and order of repair (orthopedic or vascular). No statistical difference was noted between the time of injury to operative repair in either the amputated or limb salvage group. Limb salvage was related to warm ischemia time and the quantitative degree of arterial, nerve, bone, muscle, skin, and venous injury. A limb salvage index (LSI) was formulated based on the degree of injury to these systems. All 51 patients with an LSI score of less than 6 had successful limb salvage (p less than 0.001). All 19 patients with an LSI score of 6 or greater had amputations (p less than 0.001). Although statistics cannot replace clinical judgment, this index can be a valuable objective tool in the evaluation of the patient with a severely traumatized extremity.