Mangled Extremity Severity Score Research Articles

Cleaning Up the MESS: Can Machine Learning Be Used to Predict Lower Extremity Amputation after Trauma-Associated Arterial Injury?

Thirty years after the Mangled Extremity Severity Score was developed, advances in vascular, trauma, and orthopaedic surgery have rendered the sensitivity of this score obsolete. A significant number of patients receive amputation during subsequent admissions, which are often missed in the analysis of amputation at the index admission. We aimed to identify risk factors for and predict amputation on initial admission or within 30 days of discharge (peritraumatic amputation [PTA]). The Nationwide Readmission Database for 2016 and 2017 was used in our analysis. Factors associated with PTA were identified. We used XGBoost, random forest, and logistic regression methods to develop a framework for machine learning-based prediction models for PTA. We identified 1,098 adult patients with traumatic lower extremity fracture and arterial injuries; 206 underwent amputation. One hundred and seventy-six patients (85.4%) underwent amputation during the index admission and 30 (14.6%) underwent amputation within a 30-day readmission period. After identifying factors associated with PTA, we constructed machine learning models based on random forest, XGBoost, and logistic regression to predict PTA. We discovered that logistic regression had the most robust predictive ability, with an accuracy of 0.88, sensitivity of 0.47, and specificity of 0.98. We then built on the logistic regression by the NearMiss algorithm, increasing sensitivity to 0.71, but decreasing accuracy to 0.74 and specificity to 0.75. Machine learning-based prediction models combined with sampling algorithms (such as the NearMiss algorithm in this study), can help identify patients with traumatic arterial injuries at high risk for amputation and guide targeted intervention in the modern age of vascular surgery.

Reliability of the Mangled Extremity Severity Score in the Management of Peripheral Vascular Injuries in Children: A Retrospective Cohort Study

Department of Vascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Darrasa, Cairo Division of Vascular Surgery, Department of Surgery, College of Medicine, King Faisal University, Eastern Province, Al-Ahsa

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

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. 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. 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%. 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.

Popliteal artery injuries. Less ischemic time may lead to improved outcomes

BackgroundPopliteal artery injuries are rare. They have high amputation rates. ObjectivesTo report our experience, identify predictors of outcome; mechanism of injury (MOI), Mangled Extremity Severity Score (MESS) score and length of ischemic time. We hypothesized that ischemic time as close to six hours results in improved outcomes. MethodsRetrospective 132-month study. All popliteal artery injuries. Urban Level I Trauma Center. Outcome Measures: MOI, ISS, MESS, ischemic time, risk factors for amputation, role of popliteal venous injuries, and limb salvage. Statistical analysis: univariate and multivariate. Results76 patients – 59 (76.1%) males and 17 (22.4%) females. MOI: penetrating – 54 (71%). MESS for penetrating injuries – 5.8 ± 1.5, blunt injuries – 5.6 ± 1.8. Admission-perfusion restoration (n = 76) – 5.97 hours (358 minutes). Ischemic time was not predictive of outcome (p = 0.79). Ischemic time penetrating (n = 58) 5.9 hours (354 ± 209 minutes), blunt 6.1 hours (371 ± 201 minutes). Popliteal arterial repairs: RSVG 44 (58%), primary repair 21 (26%), PTFE 3 (4%), vein patch 2 (2%), ligation 2 (3%), exsanguinated 4 (6%). No patients underwent stenting. Popliteal Vein: Repair 19 (65%), ligation 10 (35%). Fasciotomies 45 patients (59%). OutcomesLimb salvage – 90% (68/76). Adjusted limb salvage excluding intraoperative deaths – 94% (68/72).Selected patient characteristics; MOI: penetrating vs. blunt – age (p <0.0005). Amputated vs. non-amputated patients, age (p < 0.05). ISS (p < 0.005) predicted amputation, MESS (p = 0.98) did not. Mean ischemic time (p = 0.79) did not predict amputation. Relative risk of amputation, MOI – blunt (p = 0.26, RR 4.67, 95% CI: 1.11 – 14.1), popliteal artery ligation (p = 0.06, RR 3.965, 95% CI: 1.11 – 14.1) as predictors of outcome. Combined artery and vein injuries (p = 0.25) did not predict amputation. ConclusionsDecreasing ischemic time from arrival to restoration of perfusion may lead to improved outcomes and increased limb salvage. MESS is not predictive for amputation. Blunt MOI is a risk factor for amputation. Maintaining ischemic times as close to six hours as possible may lead to improved outcomes.

Predicting the Outcome of Limb Revascularization in Patients With Lower-extremity Arterial Trauma: Development and External Validation of a Supervised Machine-learning Algorithm to Support Surgical Decisions.

Estimating the likely success of limb revascularization in patients with lower-extremity arterial trauma is central to decisions between attempting limb salvage and amputation. However, the projected outcome is often unclear at the time these decisions need to be made, making them difficult and threatening sound judgement. The objective of this study was to develop and validate a prediction model that can quantify an individual patient's risk of failed revascularization. A BN prognostic model was developed using domain knowledge and data from the US joint trauma system. Performance (discrimination, calibration, and accuracy) was tested using ten-fold cross validation and externally validated on data from the UK Joint Theatre Trauma Registry. BN performance was compared to the mangled extremity severity score. Rates of amputation performed because of nonviable limb tissue were 12.2% and 19.6% in the US joint trauma system (n = 508) and UK Joint Theatre Trauma Registry (n = 51) populations respectively. A 10-predictor BN accurately predicted failed revascularization: area under the receiver operating characteristic curve (AUROC) 0.95, calibration slope 1.96, Brier score (BS) 0.05, and Brier skill score 0.50. The model maintained excellent performance in an external validation population: AUROC 0.97, calibration slope 1.72, Brier score 0.08, Brier skill score 0.58, and had significantly better performance than mangled extremity severity score at predicting the need for amputation [AUROC 0.95 (0.92-0.98) vs 0.74 (0.67-0.80); P < 0.0001]. A BN (https://www.traumamodels.com) can accurately predict the outcome of limb revascularization at the time of initial wound evaluation. This information may complement clinical judgement, support rational and shared treatment decisions, and establish sensible treatment expectations.

Vetrivel trauma score – An evidence-based scoring system to predict limb salvage and outcomes in gustilo anderson grade III B and C compound fractures of lower extremities

Background: Open fractures with severe soft-tissue injuries are clinically challenging to treat. While several scoring systems are available to grade these clinical conditions, the Gustilo Anderson grading system is most commonly used. This grading system neither offers any clue regarding salvaging open fractures of Grade III B and above, nor does it help the surgeon to assess the outcomes in such injuries. Hence, a new system of grading was assessed to address this deficiency. Materials and Methods: Five hundred and twelve open fracture cases were analyzed for this study. Two hundred and twenty-seven patients sustained Grade III injuries according to the Gustilo Anderson classification; Of these, 175 patients had Grade III A open fractures and 52 patients were of Grade III B and above. The 52 patients with open fractures of Grade III B and above were scored using mangled extremity severity score (MESS), Ganga score, and our novel scoring system. The accuracy in deciding amputation and predict outcomes were measured. Results: The scores assessed by the new scoring system were compared with MESS, Gustilo grading, and Ganga score system. Binary logistic regression analysis indicated our scoring system to be more accurate compared to all other scoring systems (P = 0.02). A receiver operating characteristic curve was plotted to compare all other scoring systems. The area under the curve (0.996 ± 0.003) for our scoring system was significantly higher with the less standard error of the mean than other scoring systems compared. Conclusions: Our new scoring system was more accurate in predicting limb salvage and outcomes compared to the existing scoring systems for open fractures of Grade III B and above.

Amputation of an unsalvageable post-traumatic limb in a young Haemophiliac: A multi-faceted clinical dilemma

A twenty-nine-year-old male presented to the emergency ward of our institute with a history of having been involved in a road traffic accident with a heavy motor vehicle (HMV), 18 hours ago, with trauma to his left lower limb. Arteriovenous Doppler evaluation of the affected limb confirmed devascularization, and radiographs showed fracture of the femur in supracondylar region and tibial diaphysis with significant soft tissue injury (Letts and Vincent type D floating knee). Due to the prolonged ischemia time of 18 hours, the Mangled Extremity Severity Score (MESS) of 10, and the contaminated nature of the wound, it was decided to proceed with Guillotine above-knee amputation. However, a detailed history-taking revealed the patient to be a sufferer of Hemophilia Type A (Coagulation factor VIII deficiency). The patient was stabilized hemodynamically, and supplemented with Factor VIII following which the amputation was done successfully. This case report documents his perioperative and postoperative course in the hospital, ending with his discharge with a small wound healing by secondary intention. Surgical procedures in hemophiliacs have always presented as clinical dilemmas, with increased blood loss, poor tissue perfusion, and infective events adding to the postoperative complications. Lower limb amputations in sufferers of hemophilia are very rare, with less that fifty cases being found in the global medical literature. A meta-analysis of said cases reveals the vast majority to have been due to infective indications or for management of hemophilic pseudo-tumours, and post-traumatic above knee amputations are virtually unheard of in such a clinical scenario. The presence of a traumatic vascular insult in this case, provided a rare clinical predicament, and the successful management of this Catch-22 situation makes for a unique situation.

Peripheral Arterial Injuries in Children: An Audit at a University Hospital in Developing Country.

Objectives: To review the prevalence, pattern, management, outcome, and predictive factors for limb loss of pediatric peripheral arterial injuries (PAIs) at a university hospital in Pakistan.Methods: Medical records of children (age <18 years) managed for PAIs at the university hospital between Jan 2008 and Dec 2018 were reviewed for demographic data; mechanism, type, and severity of injury; management; and outcome.Results: During the study period, of the 1718 children managed for trauma, 75 (67 males and 8 females) had PAI secondary to glass cut (33.3%), gunshot (28.0%), and road traffic accidents (24.0%). Forty-nine patients (65.3%) presented to the emergency room within 6 h of injury. Brachial (28.0%), superficial femoral (20.0%), and radial (20.0%) arteries were the frequently injured vessels. At presentation, the mean revised trauma score and Mangled Extremity Severity Score (MESS) were 3.86±0.55 and 3.4±1.92, respectively. Sixty-eight patients (90.66%) underwent vascular procedures: interposition saphenous vein bypass graft or PTFE graft in 38.7% and primary repair in 29.3%. Limb salvage was achieved in 92.65% of the patients. Late presentation (>6 h) was a risk factor for limb loss (p=0.014).Conclusion: Of the 23 children who presented with trauma, 1 had major PAI. Early presentation (<6 h) and appropriate vascular interventions can salvage limbs in most of the patients.

Outcomes of Popliteal Artery Injuries Repair: Autologous Vein versus Prosthetic Interposition Grafts

The aim of this study is to compare wound infection, graft infection, and secondary amputation rates in patients who had popliteal artery injury repair with interposition vein versus prosthetic grafts. This retrospective comparative study included all adult patients (>18years) who had interposition grafting for popliteal artery injuries between January 2008 and August 2018 at a university hospital. Patients were divided into 2 groups. Popliteal arteries were repaired with venous graft in Group "A" and with prosthetic graft in Group "B." The outcome measures were wound infection, graft infection, and secondary amputation rates. Forty patients fulfilled the inclusion criteria. Twenty-two patients had arterial repair with venous while 18 with polytetrafluoroethylene grafts. All were male with median age of 32 (interquartile range [IQR] 19.5) years. Both groups were comparable in terms of median age (32.5 [19] vs. 30.5 [23]), Mangled Extremity Severity Score (6 [5] vs. 7 [7]), median hospital stay (7 [5] vs. 7 [9] days), and perioperative complications (2/22 vs. 3/18). In Group "A," no patient had graft infection or secondary amputation while in Group "B," 1 patient had secondary amputation and another had graft infection (P>0.99). There is no statistical difference in secondary amputation rate, wound infection, or graft infection in patients undergoing popliteal artery repair with interposition vein versus prosthetic grafts in trauma setting.

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.

Surgical timing for open fractures

Controversy exists over the optimal management of open fractures as new clinical studies question open fracture management dogma. Open fractures are complex injuries requiring the orthopaedic surgeon to consider both the bone injury as well as associated soft tissue injury. Early intravenous antibiotics and tetanus prophylaxis remain instrumental in infection prevention. However, the “six-hour rule” for initial open fracture debridement and revascularization has come into question. New evidence supports initial debridement within 24 hours with the appropriate surgical team. Additionally, orthopaedic surgeons and vascular surgeons should collaborate on the sequence of management of open fractures with associated vascular injury. Whereas debates on the optimal irrigation pressure and solution have been answered by multicenter randomized controlled trials, further research is required to determine the optimal irrigation volume and timing of wound closure. With advances in management of open fractures, the utility of well-known classification systems including the Gustilo-Anderson classification and Mangled Extremity Severity Score need to be re-evaluated in favor of up-to-date classification systems which better guide management and predict prognosis.

Utility of The Mangled Extremity Severity Score In Predicting Amputation In Military Lower Extremity Arterial Injury

Utility of The Mangled Extremity Severity Score In Predicting Amputation In Military Lower Extremity Arterial Injury

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

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.

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

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.

Blunt Handlebar Injury of the Common Femoral Artery in a Pediatric Patient: Case Report

Introduction - Vascular non-iatrogenic trauma in pediatric population is rare. Generally, they are associated to bone fractures, stab or cut wounds. Less common is the blunt trauma as a cause of a vascular lesion. There are implications in the treatment of this kind of lesion associated to the pediatric anatomy, physiology and the growth potential of the pediatric patient. Mainly by the small size of the vessels, thickness of the veins wall or the vascular spasm of the arteries. It’s still controversial which is the best treatment option in these cases, with a wide range of options from medical treatment, direct repair, autogenous saphenous vein graft, ligation and endovascular stenting. Methods - We describe a case of a 9-year-old boy with a very small groin hematoma and an acute left limb ischemia grade IIa after a handle bike trauma 24 hours ago. Ultrasound and CT scan showed a common femoral artery occlusion as well as an absence of femoral vein thrombosis. Results - A surgical treatment was chosen. A common femoral artery approach showed a focal contained artery transection with thrombosis. An autologous panel saphenous vein graft interposition was performed to avoid graft size mismatch. An uneventful postoperative course was developed, and he was discharged 72 hours later. Conclusion - Blunt vascular trauma is a rare condition in pediatric population and clinical suspicion is necessary to avoid a diagnosis delay. The handlebar pressure on the femoral artery against femur or pubis bone may be a traumatic weapon even in not severe bike trauma. Special considerations and technical difficulties should be considerate in the surgical and medical pediatric treatment. There are different options of treatment that depends on the type of injury and the clinical situation. References1Sarfati MR, Galt SW, Treiman GS, Kraiss LW. Common femoral artery injury secondary to bicycle handlebar trauma. J Vasc Surg. 2002 Mar;35(3):589-91.2Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, Krettek C, Probst C. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res. 2010 Apr 15;5:25. doi: 10.1186/1749-799X-5-25.

In a Mid-European Country the Mangled Extremity Severity Score is Up To Date not a Good Tool to Decide Whether to Go for Primary Limb Amputation or not in cases of Limb Trauma with Vascular Reconstruction

In a Mid-European Country the Mangled Extremity Severity Score is Up To Date not a Good Tool to Decide Whether to Go for Primary Limb Amputation or not in cases of Limb Trauma with Vascular Reconstruction

The Mangled Extremity Severity Score Fails to be a Good Predictor for Secondary Limb Amputation After Trauma with Vascular Injury in Central Europe.

The Mangled Extremity Severity Score (MESS) was constructed as an objective quantification criterion for limb trauma. A MESS of or greater than 7 was proposed as a cut-off point for primary limb amputation. Opinions concerning the predictive value of the MESS vary broadly in the literature. The aim of this study was to evaluate the applicability of the MESS in a contemporary civilian Central European cohort. All patients treated for extremity injuries with arterial reconstruction at two centres between January 2005 and December 2014 were assessed. The MESS and the amputation rate were determined. Seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. The mean MESS was 4.97 (CI 4.4-5.6). Seventy-three per cent of all patients (52/71) had a MESS < 7 and 27% (19/71) of ≥7. Eight patients (11%) underwent secondary amputation. Patients with a MESS ≥ 7 showed a higher, but statistically not significant secondary amputation rate (21.1%; 4/19) than those with a MESS < 7 (7.7%; 4/52; p = 0.20). The area under the ROC curve was 0.57 (95% CI 0.41; 0.73). Based on these results, the MESS appears to be an inappropriate predictor for amputation in civilian settings in Central Europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft-tissue traumas.

Impact of Staged Vascular Management on Limb Outcomes in Wartime Femoropopliteal Arterial Injury

By necessity, wartime arterial injuries undergo staged management. Initial procedures may occur at a forward surgical team (role 2), where temporary shunts can be placed before transfer to a larger field hospital (role 3) for definitive reconstruction. Our objective was to evaluate the impact of staging femoropopliteal injury care on limb outcomes. A military vascular injury database was queried for Iraq/Afghanistan casualties with femoropopliteal arterial injuries undergoing attempted reconstruction (2004-2012). Cases were grouped by initial arterial management: shunt placed at role 2 (R2SHUNT), reconstruction at role 2 (R2RECON), and initial management at role 3 (R3MGT). The primary outcome was limb salvage; secondary outcomes were limb-specific complications. Descriptive and intergroup comparative statistics were performed with significance defined at P≤0.05. Of 257 cases, all but 4 had definitive reconstruction before evacuation to Germany (median, 2days): 46 R2SHUNT, 84 R2RECON, and 127 R3MGT; median Mangled Extremity Severity Score was 6 for all groups. R2SHUNT had median extremity Abbreviated Injury Scale--vascular of 4 (other groups, 3; P<0.05) and was more likely to have concomitant venous injury and to undergo fasciotomy. Shunts were used for 5±3hr. About 24% of R2RECON repairs were revised at role 3. Limb salvage rate of 80% was similar between groups, and 62% of amputations performed within 48hr of injury. Rates of limb and composite graft complications were similar between groups. Thrombosis was more common in R2SHUNT (22%) than R2RECONST (6%) or R3MGT (12%) (P=0.03). Late (>48 hr) thrombosis rates were similar, whereas 60% of R2SHUNT thromboses occurred on day of injury (P=0.003 vs. 25% and 0%). Staged femoropopliteal injury care is associated with similar limb salvage to initial role 3 management. Early thrombosis is likely because of shunt failure but does not lead to limb loss. Current military practice guidelines are appropriate and may inform civilian vascular injury management protocols.

Predictors of poor outcome in infrainguinal bypass for trauma

BackgroundTrauma remains a leading cause of morbidity and mortality worldwide. Vascular injuries are present in approximately 1% to 2% of trauma patients, with the majority of injuries occurring to the extremities. Trauma patients with vascular injuries have been shown to have increased morbidity and mortality as well as the need for increased resources compared with those without vascular injuries. This study aimed to determine predictors of poor outcomes in infrainguinal bypasses performed for traumatic arterial injury. MethodsAll patients admitted between September 1999 and July 2015 who underwent infrainguinal arterial bypass for trauma at a single level I trauma center were included for analysis. The primary outcome was a composite of thrombosis leading to graft abandonment, revision, amputation, or death. Data were analyzed by univariate descriptive and multiple logistic regression analyses. Long-term data were analyzed by Kaplan-Meier method. ResultsDuring the study period, 108 patients presented with and underwent infrainguinal arterial bypass for traumatic arterial injury. The cohort had a mean age of 35.8 years (16/108 female [15%]). The average Injury Severity Score was 15.2; admission glomerular filtration rate, 79.3 mL/min/1.73 m2; Mangled Extremity Severity Score (MESS), 6; and injury to operating room time, 5.1 hours. Of 108 patients, 37 (34%) had penetrating injury, 71 (66%) had blunt injury, 10 (9.3%) had diabetes mellitus, and 76 (70.4%) had a below-knee target for bypass. Univariate risk factors for poor outcome included age >40 years (odds ratio [OR], 3.27 [1.40-7.65]; P < .01), MESS ≥7 (OR, 5.19 [2.08-19.97]; P < .01), blunt mechanism (OR, 3.35 [1.24-9.07]; P = .02), popliteal artery injury (OR, 3.04 [1.22-7.6]; P = .02), and below-knee target vessel (OR, 4.32 [1.37-13.58]; P = .01). Concomitant orthopedic injuries (P = .08) were not associated with poor outcome. Baseline renal function, type of repair performed (end-to-side vs interposition bypass), injury to surgery time, surgeon's specialty, and associated venous injuries were not significantly predictive of poor outcome. MESS was strongly predictive of poor outcome, with probability rising as high as 95% when MESS reached 12. A score ≥7 (high MESS) was 73% sensitive and 70% specific to predict poor outcomes. Age (OR, 1.03/y; P < .05) and MESS ≥7 (OR, 3.6; P < .03) were persistent predictors of poor outcome in multivariable analysis. ConclusionsPoor outcomes in infrainguinal bypass for trauma are significantly predicted by the MESS, with poor outcomes occurring >50% of the time when MESS is ≥9 and >75% of the time when MESS is ≥11. Whereas amputation vs revascularization is a decision that also depends on nerve and soft tissue damage and other comorbidities, the MESS helps frame the data for the clinician and can aid in decision-making. Patients and family should understand that poor outcomes are more likely when MESS is ≥9. For patients with MESS ≥11, primary amputation can be considered.

Risk Factors of Amputation in Lower Extremity Trauma with Combined Femoropopliteal Arterial Injury.

PurposeThe clinical characteristics and results of femoropopliteal artery injury (FPAI) remain unclear. In this study, we evaluated the outcomes and risk factors of limb loss in patients treated for FPAI.Materials and MethodsWe retrospectively reviewed data from a database of patients who underwent revascularization for an FPAI at a single institution between January 2013 and December 2017. We reviewed and analyzed the characteristics, postoperative results, and factors that influence amputation rates.ResultsTwenty-four femoropopliteal arterial reconstructions in 24 patients were included in this study. Among the patients were 20 (83.3%) male with a first-quartile age of 28 years and a third-quartile age of 45 years (range, 15–68 years). The mean injury severity score (ISS) was 16 (range, 4–55), and 5 patients (20.8%) had ISSs of >20 points. The mean mangled extremity severity score (MESS) was 3.8 (range, 1–11), and 8 patients (33.3%) had MESSs of >5 points. In terms of arterial reconstruction methods, autogenous saphenous vein grafting, vein patching, and primary closure were performed in 9 patients (37.5%), 4 patients (16.7%), and 11 patients (45.8%), respectively. Despite arterial reconstruction, 5 patients (20.8%) underwent above-knee amputation. ISSs of >20, MESSs of >7, and orthopedic fixation were statistically significant factors associated with amputation.ConclusionIn cases of FPAI with ISSs of >20, MESSs of >7, and orthopedic fixation, amputations should be considered. We were also careful to attempt limb salvage in such cases.