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Limb Salvage is Possible in Select Patients with Arterial Injuries and Elevated Mangled Extremity Severity Scores
Priscilla Tanamal, Sophia Trinh, William Delahoussaye, Claudia Leonardi, Marie Unruh, Amit Chawla, Malachi Sheahan, III, Claudie Sheahan
LSUHSC New Orleans, New Orleans, LA
INTRODUCTION: Lower extremity trauma with vascular compromise is frequently associated with other injuries and requires emergent and complex decision-making. The Mangled Extremity Severity Score (MESS) is widely utilized to predict the need for amputation in these cases. Its creators reported that a MESS of 7 or greater predicted amputation with 100% accuracy. As the tool was developed over 30 years ago, its accuracy in a modern trauma setting is relatively untested. The purpose of this study was to investigate the correlation of an elevated MESS with the need for amputation in patients with traumatic lower extremity arterial injuries.
METHODS: A retrospective chart review was performed on patients ≥18 years old with traumatic lower extremity arterial injuries at a level I trauma center from July 2012 to December 2023. Demographics, injury characteristics, interventions, and outcomes including primary amputation, secondary amputation, and later/eventual amputation following limb salvage attempts were recorded.
RESULTS: Our cohort consisted of a total of 238 limbs with lower extremity arterial injury (233 patients, 5 with bilateral injuries). Average age was 36.8 years (range 18-87 years). The majority of our patients were male (196/238, 84.1%). Mean Injury Severity Score (ISS) was 14.2. The mechanism was predominantly penetrating (155/238, 65.1%), with the majority of these related to gunshot injuries (148/155, 95.5%). Eighty-four lower extremity injures had concomitant injuries (35.3%). The average MESS was 4.87 and median was 5 (IQR 3-6). Vascular repair was performed on 179 lower limbs (75.2%); 168 open repairs (93.9%), nine endovascular interventions (5.0%), and two hybrid interventions (1.1%). All vessel repairs were performed by vascular surgeons. Ninety-two limbs underwent concomitant orthopedic repair (38.7%). Six limbs underwent primary amputation (2.5%) after multidisciplinary consensus, all of which had a MESS of 7 or greater. Of the 179 lower limbs that underwent vascular repair, 8.4% required amputation prior to discharge (15/179), and another 2.8% (5/179) required eventual amputation after discharge. A total of thirty-three lower extremities with a MESS of 7 or greater underwent vascular repair in an attempt at limb salvage. The majority did not require a subsequent amputation (22/33, 66.7%). In the entire cohort, a MESS of greater than or equal to 7 was found to be significantly associated with any amputation (P<.0001), primary amputation (P<.0001), secondary amputation (P<.0001), but not significantly associated with amputation after discharge (P=.1487). Penetrating mechanism of injury was significantly associated with amputation (P<.0001). Each one-point increase in MESS had an odds ratio of 2.117 (95% CI 1.651-2.713) related to any amputation.
CONCLUSIONS: Lower extremity arterial injuries are frequently associated with complex orthopedic and soft tissue trauma. An increasing MESS, penetrating mechanism, and the presence of multiple vascular injuries are significantly associated with the risk of limb loss. While a MESS of 7 or greater is predictive of an increased risk of amputation, excellent limb salvage can still be achieved in many patients with prompt vascular repair.
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