Mean Mangled Extremity Severity Score Research Articles

Salvaging mangled upper limbs with early soft tissue cover with flaps- A case series

Mutilating upper limb injuries present complex challenges to both patients and surgeons, necessitating prompt and effective management strategies to achieve favorable outcomes. This retrospective study examines the cases of five consecutive patients with mangled upper limbs resulting from blunt trauma, evaluating demographics, injury mechanisms, injury patterns, and 60-day limb salvage outcomes. Among 2128 admissions between January and December 2022, five patients were identified with mangled upper limbs and open fractures, with an average age of 40.2 years and a notable male predominance (80%). The dominant hand was affected in 60% of cases, primarily due to blunt high-velocity road traffic accidents. The mean Mangled Extremity Severity Score (MESS) was 7.2, and the Ganga Hospital Open Injury Score averaged 16, indicating substantial injury severity without limb ischemia or compartment syndrome. All patients underwent definitive surgery within 48 hours, with various soft tissue reconstruction techniques employed, including free flaps, pedicle flaps, and local muscle mobilization, along with nerve grafting procedures. At the 60-day follow-up, successful limb salvage was achieved in all cases, with no instances of surgical site infection and excellent acceptance of skin grafted areas exceeding 95%. The findings underscore the importance of timely surgical intervention and comprehensive soft tissue coverage in achieving successful limb salvage outcomes in patients with mutilating upper limb injuries, emphasizing the critical role of early intervention and multidisciplinary collaboration.

Hyperbaric oxygen therapy does not change the amputation level in patients with fasciotomy after an earthquake: Our single-center experience after 2023 Kahramanmaras earthquake.

This study aims to evaluate the effect of hyperbaric oxygen therapy (HBOT) on the amputation level in patients undergoing fasciotomy with a Mangled Extremity Severity Score (MESS) score of ≥7 after 2023 Kahramanmaras earthquake. Between February 6th, 2023 and March 10th, 2023, a total of 23 patients (14 males, 9 females; mean age: 36.8±13.2 years; range, 17 to 64 years) who needed amputation with a MESS score of ≥7 and refused amputation were included in the study. All fasciotomies were performed in an external center, and five of them was incomplete. First, incomplete fasciotomies were completed with debridement due to deep muscle necrosis. Daily two HBOT sessions were performed for the first three days. In the following days, daily one HBOT session was performed. The HBOT was terminated for the patients who were decided by the council that they did not benefit from HBOT treatment. Six (26.08%) of the patients had a bone fracture (n=2 forearm, n=1 femur, n=2 tibia, and n=1 ankle fracture). The mean number of HBOT session was 13.24±5.4 (range, 7 to 30) and the mean duration of HBOT was 26.5±10.8 (range, 14 to 60) h. The mean MESS score was 9.96±1.36 (range, 7 to 12). All of the patients were trapped under the rubble with a mean time of 12.3±5.4 (range, 6 to 23) h. All fasciotomies were performed within the first 30 h. Twenty-two of the patients were amputated at the level previously determined by the experienced trauma surgeons. The amputation level changed in only one patient. After 38 h of HBOT, transradial amputation was performed to the patient in whom transhumeral amputation level was determined previously. None of the patients had any adverse event related to HBOT. Our study results suggest that the MESS is a useful scoring system for amputation decision after a high-energy trauma, such as an earthquake, with a high accuracy rate. The outcomes of HBOT are not satisfactory for high-energy traumas, such as earthquakes, in those requiring fasciotomy having more muscle necrosis and a MESS score of ≥7.

Outcomes of severe lower limb injury with Mangled Extremity Severity Score ≥ 7

Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J2021;103-B(4):769-774.

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.

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.

Hip Disarticulation for Severely Injured Lowerlimbs about 11 Cases and Literature Review

Introduction: Hip disarticulation (HD) consists of a removal of the entire lower limb at the height of the hip-femoral joint. It is an extremely mutilating intervention with a major functional and psychological impact. We report 11 cases of hip disarticulation following severe trauma of the lower limb. The aim of the study is to analyze the frequency, the clinical aspect and present their management results and the patients’ becoming. Patients and methods: A 13-year retrospective study was conducted in our traumatology department. Eleven cases of hip disarticulation were identified. We analyzed the following data: the epidemiological parameters (age, sex, accidentology), Clinico-radiological (gravity injury severity score (ISS), mangled extremity severity score (MESS), associated lesion), admission time, evolutionary aspects and finally the patients’ becoming). Results: The series consisted of 3 males and 8 females, with an average age of 24 years. All experienced a HD following the lower limb severe traumatism due to a road accident. The category of victims was dominated by pedestrians. The average admission time was 13 hours with extremes of 9 and 28 hours. Our series average ISS was 28 with extremes of 15 - 69. The associated lesions were dominated by Gustilo Type III A III B open fractures. The mean MESS at admission was 10 with extremes from 8 to 14. Complications were dominated by infection (at least 72%) with a mortality rate of 36.36%. Algohallucinosis affects all these patients post-operatively at varied degrees. Aggressive components and denial of bereavement were most noticeable. Only one patient was able to honor her Canadian prosthetic equipment. All the victims changed their personal and professional activities. Conclusion: HD is an extremely mutilating surgery with a major functional and psychological impact. Quality of life of the disarticulated patient is taught because of the persistence of the pain, the occurrence of a major motor handicap and the impossibility of apparatus limiting the social and relational life.

Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury: Single center experiences in the Syrian Civil War.

The goal of this retrospective study was to clarify the effect of using temporary vascular shunt (TVS) as a previous intervention. A total of 96 cases with war-related lower extremity arterial injury and surgically treated between October 2013 and March 2016 were included in the study. The patients were divided into two groups: those in which TVS was performed as a previous intervention on admission (TVS group, n=24) and those in which compression, tourniquet, and ligation/clampage were performed as a previous intervention on admission (non-TVS group, n=72). In comparing injury pattern, there was no difference between the two groups. In addition, mean hematocrit level, mean systolic blood pressure, the incidence of concomitant vein injury, nerve injury, soft tissue damage, and bone injury were similar in both groups. The overall amputation rate was 19%. There were a total of 18 amputations, with 1 (4%) in the TVS group and 17 (24%) in the non-TVS group. The difference on amputation rate was statistically significant. The mean values of the mangled extremity severity score (MESS) were 6.45 in the TVS group and 7.44 in the non-TVS group. The overall mean MESS was 7.1. The duration of ischemia (DoI) was 4.84+-1.84 h in the TVS group and 5.95+-1.92 h in the non-TVS group. These differences in MESS and DoI were statistically significant. We think that it may be beneficial for patients to consider a TVS to reduce DoI and gain time for surgical revascularization. As a result, the present study demonstrates that the use of TVS may successfully serve as a bridge between initial injury and definitive repair with a reduction in amputation rates.

Predictors of secondary amputation in patients with grade IIIC lower limb injuries: A retrospective analysis of 35 patients.

The aim of this study was to identify risk factors for failure of limb salvage surgery in grade IIIC lower extremity injuries.A single-institution, retrospective review was performed of all patients with grade IIIC lower limb injuries presenting from January 2009 to April 2014. We gathered the data on each patient who underwent limb salvage and analyzed the final outcome for these patients (limb salvage vs secondary amputation).Grade IIIC lower limb injuries were identified in 41 patients. Primary amputation was performed in 6 patients (15%) as the initial procedure. Thirty-five patients (85%) underwent vascular reconstruction and other surgical procedures to salvage the limb. Limb salvage was successful in 23 patients (66%); 12 patients (34%) ultimately underwent secondary amputation. The median time from injury to secondary amputation was 22.5 days (range 4–380 days). The mean Mangled Extremity Severity Score (MESS) was 7.2 ± 1.5 (range 5–10). The MESS was significantly higher in the secondary amputation group compared with the limb salvage group. Additionally, statistical testing revealed that the limb ischemia time, complex fractures, rate of fasciotomy, and number of vascular reconstruction were significantly higher in the secondary amputation group. Muscle necrosis and extensive soft tissue defect were the main reasons for secondary amputation.The findings indicate that MESS of 7 or greater, complex fractures, limb ischemia time equal to or greater than 6 hours, and osteofascial compartment syndrome were associated with an increased risk of delayed amputation. The MESS is highly prognostic but not perfect; decision-making in patients with an MESS of 7 or greater should be re-evaluated for clinical use.

Validation of mangled extremity severity score in assessing the need for extremity amputation

INTRODUCTION: The decision to either salvage or amputate a mangled extremity poses great challenge to a surgeon.Different scoring systems were therefore developed to aid orthopaedic surgeons in this decision,eitherto contemplate amputation or proceed to salvage a mangled extremity. Of these scoring systems, the mangled extremity severity score (MESS) is mostly used.However,the high predictive accuracy reported by its developers has not been replicated by other authors. This study was carried out to validate the use of this scoring system in Nigeria and by extension, Africa.PATIENTS MATERIALS AND METHOD:The study was a hospital based prospective descriptive one which studied all patients with mangled extremities that were admitted into the Accident and Emergency room of the Lagos University Teaching Hospital (LUTH), Idi- Araba, from April 2014 to March 2015. Injured patients with mangled extremities were resuscitated and relevant investigations conducted. The MESS was calculated at presentation in the emergency room by two senior doctors in orthopaedic and trauma units (not lower than senior registrar cadres) independently and an average score calculated, rounded up to the nearest positive integer and documented.Type of treatment offered was based on the experience of the managing consultants. Patients' progresses were monitored and functional outcomes documented. All data generated during the study were analysed using Statistical Package for the Social Sciences (SPSS inc. Chicago, Illinois. version 21.0.Year of release - 2012).RESULTS: Twenty-nine mangled extremities in 27 patients were studied.The male: female ratio was 3.5:1.Age of patients ranged between 21-70 years with a mean age of 39.9 ±12.3years. Nineteen (65.5%) extremities were salvaged while 10(34.5%) were primarily amputated. Average MESS of all mangled limbs reviewed was 8.1+ 2.6 with scores that ranged from 3 to 13. The mean MESS for limb salvage was 7.0 +2.2while that for primary amputation was 10.1+2.0(P value- 0.01).MESS in this study had a sensitivity of 90%,specificity of 47.4%,positive predictive value of 47.4%, negative predictive value of 90%.AUROC in this study was 0.853.The cost of treatment, number of surgeries, and duration of hospital stay were higher in those with Salvaged limbs.The functional outcome for salvaged upper and lower extremities were better than for those whose limbs were amputated.Level of satisfaction was better in the limbs salvaged group than for those who had ablative surgery with statistical significance (P value- .000).CONCLUSION: This study validated the clinical utility of MESS in predicting the need for amputation in patients with mangled extremity injuries but it had a low predictive accuracy for extremities that would eventually enter the limb salvage pathway.Therefore,when contemplating limb salvage for a patient with mangled extremity,in addition to the result of the MESS score,the surgeons experience cannot be overemphasized.KEY WORDS: Open fracture,mangled limb,amputation,MESS score,classification

Reliability of the mangled extremity severity score in combat-related upper and lower extremity injuries.

Background:Decision of limb salvage or amputation is generally aided with several trauma scoring systems such as the mangled extremity severity score (MESS). However, the reliability of the injury scores in the settling of open fractures due to explosives and missiles is challenging. Mortality and morbidity of the extremity trauma due to firearms are generally associated with time delay in revascularization, injury mechanism, anatomy of the injured site, associated injuries, age and the environmental circumstance. The purpose of the retrospective study was to evaluate the extent of extremity injuries due to ballistic missiles and to detect the reliability of mangled extremity severity score (MESS) in both upper and lower extremities.Materials and Methods:Between 2004 and 2014, 139 Gustillo Anderson Type III open fractures of both the upper and lower extremities were enrolled in the study. Data for patient age, fire arm type, transporting time from the field to the hospital (and the method), injury severity scores, MESS scores, fracture types, amputation levels, bone fixation methods and postoperative infections and complications retrieved from the two level-2 trauma center's data base. Sensitivity, specificity, positive and negative predictive values of the MESS were calculated to detect the ability in deciding amputation in the mangled limb.Results:Amputation was performed in 39 extremities and limb salvage attempted in 100 extremities. The mean followup time was 14.6 months (range 6–32 months). In the amputated group, the mean MESS scores for upper and lower extremity were 8.8 (range 6–11) and 9.24 (range 6–11), respectively. In the limb salvage group, the mean MESS scores for upper and lower extremities were 5.29 (range 4–7) and 5.19 (range 3–8), respectively. Sensitivity of MESS in upper and lower extremities were calculated as 80% and 79.4% and positive predictive values detected as 55.55% and 83.3%, respectively. Specificity of MESS score for upper and lower extremities was 84% and 86.6%; negative predictive values were calculated as 95.45% and 90.2%, respectively.Conclusion:MESS is not predictive in combat related extremity injuries especially if between a score of 6–8. Limb ischemia and presence or absence of shock can be used in initial decision-making for amputation.

Total and subtotal amputation of lower limbs treated by acute shortening, revascularization and early limb lengthening with ilizarov ring fixation – A retrospective study

We present the results of 15 patients who sustained total or subtotal traumatic amputation of the lower limbs who were treated by acute limb shortening and stabilisation with external fixator, revascularization and early lengthening with Ilizarov ring fixator. The mean age of the patients was 28 years [5–38]. There were three females and 12 males. The mean Mangled Extremity Severity Score was 8.5 [range 6–11]. The mean amount of shortening done was 6.9cm [range 3–12.5] to enable revascularization and soft tissue repair. Three cases had to be amputated early because of failure of vascular repair. In the remaining 12 patients who were followed up the mean interval between revascularization and application of Ilizarov ring fixator was 4.7 weeks [range 3–10]. The mean follow up was 6.5 years [3–16 years]. Union occurred in all patients. Ten of the 12 patients returned to work and residual shortening was present in two cases. We conclude that whenever possible lower limb salvage should be undertaken.

Evaluation of the Mangled Extremity Severity Score in Combat-Related Type III Open Tibia Fracture

The purpose of this study was to determine the extent to which the Mangled Extremity Severity Score (MESS) predicted outcomes for soldiers sustaining combat-related Gustilo-Anderson type III open tibia fractures. Retrospective cohort study. Tertiary trauma center. Service Members with combat-related type III open tibia fractures occurring between 2003 and 2007 treated definitively in a US military medical center. Amputation or limb salvage. MESS, amputation or limb salvage. Complete data were available for 155 patients treated for type III open tibia fractures. One hundred ten patients had salvaged limbs, and 45 patients had lower extremity amputations. The mean MESS values for amputees and patients treated with limb salvage were 5.8 and 5.3 (P = 0.057), respectively. The sensitivity and specificity of a MESS ≥7 predicting amputation was 35% and 87.8%, respectively. A MESS value of ≥7 was found to have a positive predictive value on 50%. Thirty-three percent of patients treated with amputation had an associated vascular injury versus 12.7% of patients treated with limb salvage (P < 0.0026). There was no significant difference between MESS values of amputees and those treated with limb salvage. Moreover, these data demonstrate that the MESS is neither sensitive nor accurate in predicting amputation.

Vehicle factors and outcomes associated with hand-out-window motor vehicle collisions

Patients can experience devastating injuries when an upper extremity travels out of a window during a motor vehicle collision. These injuries are typically very severe and may even result in loss of the affected limb. The purposes of this retrospective study were to determine the clinical fate of these extremities and analyze for common factors during the collisions. A retrospective chart review of 20 patients between 2003 and 2010, evaluating the patient's age, arm involvement, number and types of surgeries, as well as the Mangled Extremity Severity Score (MESS) was conducted. In addition, patients were contacted to survey them about accident and vehicle factors and to complete the Quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) survey. The data were then analyzed for common factors. The mean age of the 20 patients involved was 28.8 years. There were 11 men and 9 women. The mean MESS was 5.4. Two patients required amputation of some form. Fifteen patients were wearing a seatbelt at time of collision, four were not, and the restraint status of one patient is unknown. The closest extremity to the window was involved in 18 (90%) of 20 patients. Vehicle rollover was the most common mechanism of injury with 16 patients (80%) involved, while 4 patients (20%) were involved in head-on or side-impact type collisions. The average quickDASH score was 24 (range, 5-91). The hand-out-of-the-window phenomenon during motor vehicle crashes results in very serious injury to the affected extremity. Most patients were involved in rollover accidents, and most were wearing a seatbelt. The arm closest to the window was nearly always involved. The mean MESS is high in these patients but did not necessarily correlate with amputation. Therapeutic, level IV.

Evaluation of Mangled Extremity Severity Score (MESS) as a Predictor of Lower Limb Amputation in Children with Trauma

Management of the severely injured lower limb in children remains a challenge despite advances in surgical techniques. Models that predict the risk of lower limb trauma patients are designed to provide an estimation of the probability of limb salvage. In this study, we validate Mangled Extremity Syndrome Index (Mangled Extremity Severity Score [MESS]) by measurement of its discrimination in children. From September 2009 to 2010, we collected the hospital records of all children who presented with lower extremity long bone open fractures. The inclusion criteria were I grade, II B, III C open fractures, severe injury to three of four organ systems, and severe injury to two of four organ systems with minor injury to two of four systems that require surgical interventions. Severity of limb injury was measured using MESS. Patients were followed up for 1 year. The discrimination of MESS model in differentiating of outcome in patients was assessed by calculating the area under the receiver operator characteristic plot. We evaluated 200 children referred consecutively to our center. The mean MESS in the amputation group was 7.5 ± 1.59 versus 6.4 ± 2.02 in the limb salvage group (p = 0.04). Amputation rate was 7.5% (n = 15). Percentages of skeletal/soft-tissue injury was different between groups (p = 0.0001). Children in the amputation group showed more tissue injury compared with limb salvage group. The best clinical discriminator power was calculated as MESS ≥ 6.5 (sensitivity = 73%, specificity = 54%). We assumed that patients with a high risk of amputation can be identified early, and specific measures can be implemented immediately by using MESS with threshold of 6.5.

Gustilo IIIC fractures in the lower limb

Controversy continues to surround the management of patients with an open fracture of the lower limb and an associated vascular injury (Gustilo type IIIC). This study reports our 15-year experience with these fractures and their outcome in 18 patients (15 male and three female). Their mean age was 30.7 years (8 to 54) and mean Mangled Extremity Severity Score (MESS) at presentation was 6.9 (3 to 10). A total of 15 lower limbs were salvaged and three underwent amputation (two immediate and one delayed). Four patients underwent stabilisation of the fracture by external fixation and 12 with an internal device. A total of 11patients had damage to multiple arteries and eight had a vein graft. Wound cover was achieved with a pedicled flap in three and a free flap in six. Seven patients developed a wound infection and four developed nonunion requiring further surgery. At a mean follow-up of five years (4.1 to 6.6) the mean visual analogue scale for pain was 64 (10 to 90). Depression and anxiety were common. Activities were limited mainly because of pain, and the MESS was a valid predictor of the functional outcome. Distal tibial fractures had an increased rate of nonunion when associated with posterior tibial artery damage, and seven patients (39%) were not able to return to their previous occupation.

Treatment of Compartment Syndrome of the Thigh Associated With Acute Renal Failure After the Wenchuan Earthquake

Compartment syndrome of the thigh is a rare emergency often treated operatively. The purpose of this study was to evaluate the effects of nonoperative treatment for compartment syndrome of the thigh associated with acute renal failure after the 2008 Wenchuan earthquake. Nonoperative treatment, which primarily involves continuous renal replacement therapy, was performed in 6 patients (3 men and 3 women) who presented with compartment syndrome of the thigh associated with acute renal failure. The mean mangled extremity severity score (MESS) and laboratory data regarding renal function were analyzed before and after treatment, and the clinical outcome was evaluated at 17-month follow-up. Laboratory data regarding renal function showed improvements. All 6 patients survived with the affected lower limbs intact after nonoperative treatment. Follow-up revealed active knee range of motion and increased muscle strength, as well as a recovery of sensation. A positive linear correlation was found between MESS and the time required to achieve a reduction in swelling, as well as the time required for the recovery of sensation and knee range of motion (r>0.8; P<.05). Satisfactory clinical outcomes were obtained in patients with compartment syndrome of the thigh associated with acute renal failure.Urine alkalization, electrolyte and water balance, and continuous renal replacement therapy have played an important role in saving lives and extremities. Nonoperative treatment should be considered in the treatment of compartment syndrome of the thigh associated with acute renal failure.

Temporary Vascular Shunts as Initial Treatment of Proximal Extremity Vascular Injuries During Combat Operations: The New Standard of Care at Echelon II Facilities?

Historically, penetrating injuries to the extremities account for up to 75% of wounds sustained during combat and 10% of deaths. Rapid vascular control and perfusion of injured extremities at forward deployed Echelon II surgical facilities is essential to limit loss of life and maximize limb preservation. We review our experience with the management of extremity vascular trauma and report the largest single Echelon II experience to date on temporary vascular shunting (TVS) for proximal extremity vascular injuries. Data on combat trauma patients presenting to a US Navy Echelon II forward surgical facility in Iraq were prospectively recorded during a 7-month period. Patients with suspected vascular injuries underwent exploration in the operating room. After vessel control, thrombectomy and instillation of heparinized saline, vascular injuries in the proximal extremity were temporarily shunted in a standardized fashion. Vascular injuries in the distal extremity were routinely ligated. After shunting, patients were transported to an Echelon III facility in the Iraqi Theater and underwent vascular reconstruction. They were followed through transfer to the Continental United States or discharge into the civilian Iraqi medical system. Shunt patency, limb salvage, and survival data were obtained by retrospective review of electronic medical records. Six hundred ten combat trauma patients were treated from August 16, 2006 to February 25, 2007. Thirty-seven patients (6.1%) sustained 73 injuries to major extremity vascular structures. Twenty-three proximal vascular shunts were placed in 16 patients with mean Injury Severity Score of 25 (range, 17-43) and mean mangled extremity severity score (MESS) of 8 (range, 5-10). Twenty-two of 23 shunts (95.6%) were patent upon arrival to the Echelon III facility and underwent successful autologous vein reconstruction. All shunt patients survived their injuries with 100% early limb preservation as followed through their first 30 days of medical care or discharge into the local medical community. Complex combat injuries to proximal extremity vessels should be routinely shunted at forward-deployed Echelon II facilities as part of the resuscitative, damage control process.

Application of the Mangled Extremity Severity Score in a Combat Setting

The aim of this study was to examine the Mangled Extremity Severity Score (MESS) in a combat setting. Data on extremity injuries were collected from a forward surgical team. MESS and Revised Trauma Score values were retrospectively calculated for each patient. Student's t test was used to compare amputated and salvaged limbs. A total of 60 extremities was identified in 49 patients. There were 10 major vascular repairs (20%). MESS values differed significantly for the eight amputations performed (mean MESS, 7.87 +/- 1.91) and 50 salvaged extremities (mean MESS, 2.44 +/-_ 0.438; p = 0.001). A MESS of >7 correlated with amputation, thus validating the MESS in a combat setting. A young average patient age and high-energy injury mechanism on the battlefield leave ischemic time and shock as the most important factors in dictating whether a MESS is >7 or <7.

Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs

Background:The purpose of the present study was to evaluate the clinical utility of Mangled extremity severity score (MESS) in severely injured lower limbs.Materials and Methods:Retrospectively 25 and prospectively 36 lower limbs in 58 patients with high-energy injuries were evaluated with the use of MESS, to assist in the decision-making process for the care of patients with such injuries. Difference between the mean MESS scores for amputated and salvaged limbs was analyzed.Results:In the retrospective study 4.65 (4.65 ± 1.32) was the mean score for the salvaged limbs and 8.80 (8.8 ± 1.4) for the amputated limbs. In the prospective study 4.53 (4.53 ± 2.44) was the mean score for the salvaged limbs and 8.83 (8.83 ± 2.34) for the amputated limbs. There was a significant difference in the mean scores for salvaged and amputated limbs. Retrospective 21 (84%) and prospective 29 (80.5%) limbs remained in the salvage pathway six months after the injury.Conclusion:MESS could predict amputation of severely injured lower limbs, having score of equal or more than 7 with 91% sensitivity and 98% specificity. There was a significant difference in the mean MESS scores in the prospective study (n=36), 4.53 (4.53 ± 2.44) in thirty salvaged limbs (83.33%) and 8.83 (8.83 ± 2.34) in six amputated limbs (16.66%) with a P-value 0.002 (P-value < 0.01). Similarly there was a significant difference in the mean MESS score in the retrospective study (n=25), 4.65 (4.65 ± 1.32) in twenty salvaged limbs (80%) and 8.80 (8.8 ± 1.4) in five amputated limbs (20%) with a P-value 0.00005 (P-value < 0.01). MESS is a simple and relatively easy and readily available scoring system which can help the surgeon to decide the fate of the lower extremity with a high-energy injury.

Tactical Surgical Intervention With Temporary Shunting of Peripheral Vascular Trauma Sustained During Operation Iraqi Freedom: One Unit??s Experience

Rapidly restoring perfusion to injured extremities is one of the primary missions of forward military surgical teams. The austere setting, limited resources, and grossly contaminated nature of wounds encountered complicates early definitive repair of complex combat vascular injuries. Temporary vascular shunting of these injuries in the forward area facilitates rapid restoration of perfusion while allowing for deferment of definitive repair until after transport to units with greater resources and expertise. Standard Javid or Sundt shunts were placed to temporarily bypass complex peripheral vascular injuries encountered by a forward US Navy surgical unit during a six month interval of Operation Iraqi Freedom. Data from the time of injury through transfer out of Iraq were prospectively recorded. Each patient's subsequent course at Continental US medical centers was retrospectively reviewed once the operating surgeons had returned from deployment. Twenty-seven vascular shunts were used to bypass complex vascular injuries in twenty combat casualties with a mean injury severity score of 18 (range 9-34) and mean mangled extremity severity score of 9 (range 6-11). All patients survived although three (15%) ultimately required amputation for nonvascular complications. Six (22%) shunts clotted during transport but an effective perfusion window was provided even in these cases. Temporary vascular shunting appears to provide simple and effective means of restoring limb perfusion to combat casualties at the forward level.