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A dvances in techn iq ues o f repa ir o f b one , b lo od vesse ls ,ne rves and o the r so ft tissu es m ake po ssib le the p re se rv a-tion o f sev ere ly in ju red low er lim bs, bu t the re su ltan t legm ay func tion le ss w e ll th an a p ro sthesis . P re se rv ativ esu rge ry is cos tly in econom ic an d soc ia l te rm s and th ep ro lon ged p eriod o f rehab ilita tion sign ifican tly reducesthe chances o f th e p atien t eve r re tu rn ing to p ro duc tivew ork (H ansen 1987 ).

The M ang led E x trem ity S ev erity S core (M ESS ) w asd ev elo ped in S eattle (Johansen e t a ! 1 990 ), ba sed on bo th

Table I. M ang led Ex trem ity S eve rity Sco re (M ESS)

re tro sp ec tive and prospec tive ana lysis o f adm ission d atao f pa tien ts w ith seve re low er lim b in ju rie s .

F our v ariab le s d ete rm in in g sk e leta l an d so ft-tissu ein ju ry , lim b ischaem ia, su rg ica l sho ck , and the age of the

Tab le II. D e layed am putatio n for traum a in 65 patien ts

Score

D elay inamputat ion

M ESS(n um be r of p atie n ts )R eas on for am pu tation7 6m on ths 2 21 NecrosisIn fect ionL oss o f fu nctionNo tk n own

I1282

234

23

02

02

81 6 THE JOURNAL OF BONE AND JO INT SURGERY

PRED IC F ION O F AM PUTAT ION AFTERSEV ERE LOW ER L IM B TRAUM A

PETER A . RO BERTSON

F ro m C h ristch u rch P u b lic H o sp ita l, N ew Z ea la n d

The M ang led E x trem ity Sever i ty Score w as ap p lied to 1 52 pa tien ts w ith sev ere ly in jured low er lim bs .A ll cases w ith a sco re of seven or m ore re qu ired am pu ta tio n; s ome w ith sco re s o f le ss th an se ve n e ve ntu allycame t o am p u ta ti on . These ob serva tion s a re discussed.

Sk ele ta l/so f t-tissu e in ju rylow energy (s tab ; s im ple frac tu re ; c iv il ian gu nshot w ound)m edium ene rgy (op en or m u ltip le f ractu re s, d is loc atio n)h ig h ene rgy (sho tgun ; m il itary gu nsh ot w ound , cru sh in jury)very h ig h energy (as ab ov e, p lu s gro ss con tam ina tio n ,s oft-ti ss ue a vu ls io n)

L im b isch aem iapu lse redu ced o r absen t b u t norm a l pe rfus ionpulseless ; paraesthesiae ; red uced cap illary re fillco o l, p ara lysed , insensa te , n um b(score d oub led for is cha em ia lon ger than six h ou rs)

Sh o cksy sto lic BP m a in ta ined above 90 mmH gtr an sie nt h yp ot en sio np ers is te nt h yp ote ns io n

A ge (y ears)5 0

T ab le III. A m puta tio n after vascu larreconstruct ion

N um be rofp atien Is (am pu tate d)< 6hou rs > 6hours

MESS Ischaem ia In ch eem ia7 3(3) 5(5)

P . A . Rober tso n , FRAC S, O r tho paed ic Su rgeonT he Sp ine In sti tu te o f N ew E ng lan d , 2 H urricane L ane , P 0 Box 1043 ,W illis ton , V erm ont 05495 , U SA . 1991 B r itish Ed ito r ia l Soc iety o fB one and Jo in t S urg ery0301-620X /91/5193 $2.0 0JBone lo in tSurg[Br] 1 99 1 ; 7 3-B :8 l6 -8 .

pa tien t a re reco rded on adm ission and a sco re is g iv enfo r each (T ab le I). A ssessm en t o flim b ischaem ia is basedon th e clin ica l a sse ssm en t o f pu ls e, pe rfus ion , tem pera-tu re, s en sa tion and m ov em en t. Th e sco re is do ub led if

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PR ED ICT IO N O F AM PUTAT IO N AFTER SEV ERE LOW ER LIMB TRAUM A 817

VO L . 73-B , N o. 5 , SEPTEM BER 1991

th e tim e to resto ra tion of pe rfusio n ex ceeds six hou rs ,b ecau se o f th e d an ge r o f irrev ers ib le tissu e ch an ge s . B o ththe seve rity o f hy po ten sion and its d u ratio n affec t th esco re. In creased age adv erse ly affec ts th e sco re becauseo f th e g rea te r lik elih ood of o th er d iseases .

W hen th ese fo u r va riab le s w ere asse ssed an d a to ta lsco re g iv en , the exp erience in S ea ttle w as tha t a sco re o fseven o r m ore p red icted the n eed fo r am pu ta tion o f th el imb .

PA T IENTS AND M ETHODSDu ring the last ten yea rs adequ ate in fo rm a tion w asav ailab le fo r 1 52 pa tien ts w ho h ad su ffe red seve re in ju r iesto 16 4 low er lim bs. T hey h ad requ ired e ith e r vascu la rrecon stru ctio n , so ft-tis sue reconstruc tion by p las tic su r-geon s, o r had had m a jo r open frac tu res com bined w itho th er se riou s in ju rie s ; som e had unde rgon e traum a ticam pu ta tion a t the tim e o f in ju ry , o r im m ed ia te am pu ta-tion o n adm issio n to hosp ita l.

T he M ESS w as ca lcu lated from the ir s ta tu s o nadm ission as ou tlined in T ab le I. A sses sm en t o f ske le ta land so ft-tis sue in ju ry is c lea r-cu t fo r low and m ed iumen ergy in ju rie s . F o r the h igh e r en e rgy in ju r ies a c rushin ju ry m ean t th at a sig n if ican t ope rativ e debridem en t o fd ev italis ed m u sc le w as requ ired , and an avu ls ion in ju ryim p lied th at at lea st an en tire m u sc le com partm en t w aslost .

T h e su bsequ en t course o ftreatm en t and the o u tcom efo r the lim b w ere reco rd ed .

R E SULTSO f the 1 6 4 sev ere ly in ju red lim b s in th is stud y , 1 21ev en tua lly cam e to am pu tatio n . Tw en ty -six leg s w eream pu ta ted by th e traum a , 30 pa tien ts had an im m edia team pu ta tion on adm issio n to hosp ita l, becau se o f thesev erity o f th e traum a , and d elayed am pu tatio n w asca rr ied o u t in 65 .

T he M ESS for the pa tien ts w ho suffe red traum a ticam pu ta tion w as sev en or m o re excep t in one pa tien t w ithsev ere v iscera l in ju rie s . In th is ca se, a v iab le fo o t w asam pu tated on site to allow the pa tien t to be rem ov edfrom a veh ic le .

O f th e 3 0 pa tien ts w ho had im m edia te am pu tatio no n a rr iva l a t h osp ital, 2 5 had a M ESS of seven or m ore ,fo u r sco red six an d one h ad a sco re o f fou r.

O f th e 65 p atien ts und e rgo ing de lay ed am puta tion ,16 h ad a M ESS score o f seven o r m ore and the rem a ind ersco red le ss than sev en (T ab le II) . N ecrosis o r isch aem iaw as the usu al cause fo r d elay ed am puta tion in th e firs tm on th fo llow in g in ju ry . In th ose pa tien ts und ergo ingam puta tion a fter tw o m onth s, in fectio n and u sele ssn esso f the lim b w ere the usu al causes (T ab le II).

F o rty - th ree lim bs w ere salv ag ed or avo ided am pu-tatio n , and in these case s, n o pa tien t had a M ESS o fseven or more.

Vascu la r reconstruc tion w as req u ired in 18 pa tien ts .E igh t had a M ESS of seven o r m ore and a ll cam e toam pu ta tion (T ab le III) . O f the ten pa tien ts in w hom th etim e to re -es tab lishm en t o f a r ter ia l sup p ly w as greate rthan s ix h ours , s ix cam e to am pu ta tion . T he fo ur inw hom the lim b surv ived h ad ad eq ua te co lla te ra l circu la -tion and sco red on ly tw o po in ts fo r is ch aem ia (d ou b ledto fou r b ecause it w as p ro lon ged b ey ond s ix h ou rs). T h eyw e re a ll yo ung , sh ow ed an absence o f sho ck , an d h adsu ffe red from e ithe r low or m ed ium ene rg y in ju rie s ,k eep ing the M ESS be low seven . O f th e tw o sys tem icp aram e te rs , the M ESS w as in flu enced by hypo tension in5 0 cases (41 .3% ), and by age in 46 cases (3 8% ).

D ISCUSS IONThe advan tag es o fan accu ra te sys tem ofo b je c tive sco rin gfo r seve re ly in ju red lim bs w hich w ou ld de term in eou tcom e a re o bv iou s. W hen the lo ss o fa lim b is p red ic ted ,imm ed ia te am pu ta tion w ou ld a llow rehab ilita tion tobeg in a t an early stage , w ith a sh orten ed pe rio d o fd isab ility . B u t an y sco rin g system tha t is a p red ic to r o fou tcom e , w h e re one o f th e p rop osed trea tm en ts isam pu tation , m ust have a h ig h deg ree o f sp ec ific ity .

In th is s tu dy th e re w ere no fa lse-p os it ive resu lts ,ind icatin g 100% spec ific ity . H ow eve r , the fac t th at m anyp atien ts w ith a M ESS of less than seven even tua llyu nde rw en t am pu ta tio n , sugg es ts tha t the m eth od lack ssensitivity.

The g rad in g sys tem fo r sk ele ta l an d so ft-tissu e in ju ryw as sim p le to ap p ly w hen sco rin g e ith e r one o r tw o po in tsbu t w ith h igh ene rg y in ju rie s , w he re th ree p o in ts a resco red fo r a sho tg un , m ilita ry g unsh o t w ound or c ru shin ju ry , and fo ur p o in ts fo r add itiona l g ros s co n tam ina tiono r so ft-tis su e av u lsion , the de fin itio ns a re m o re su b je c t toobse rve r e rro r , pa rticu la r ly w hen they a re b ein g usedretrosp ectiv ely , a s in th is stud y . So ft- tissu e av u lsio n ,w h ich sco re s fo u r po in ts , w as o n ly d iagno sed w hen a tlea st an en tire m u sc le com partm en t w as invo lved .T raum atic am pu tatio n sco re s a M ESS of seven byde fin ition , d ue to the avu ls ion so ft- tissu e in ju ry an d toth e vascu la r in ju ry w ith its re su ltan t ex trem ity ischaem ia .

The m any re fe ren ce s to fire arm in ju rie s re flec t theN orth Am erican orig in o f M ESS . In o ur N ew Z ealandstu dy , o n ly tw o p atien ts su ffe red such in ju r ies . Th esco ring oflim b ischaem ia from a com bina tion of clin ica ls ig ns g iv es a rea son ab le ind ica tion o f ou tcom e , b u t ita lon e is n o t an accu rate p red ic to r. Y oung p atien ts m ayund erg o p erio ds o f ischaem ia exceed ing six h ou rs andrequ ire va scu la r re co ns tru ction , ye t in th e p resence o fgood co lla te ra l b loo d su pp ly , an d a low or m ed ium ene rgyin ju ry , th e leg can be saved .

The im po rtance o f re-e s tab lish ing pe rfus io n w ith ins ix h ou rs in the ischaem ic , traum a tised , low e r l im bw here v ascu la r recon struc tion is req u ired , c ann o t b eov e remph as i s ed .

The m easu re s o f sy s tem ic sh ock an d the ag e o f the

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81 8 P . A . R OB ER TS ON

THE JOURNAL O F BONE AND JO INT SURGERY

pa tien t bo th add specif ic ity to the m ang led ex trem itysev erity sco re . Th is stu dy con firm s th e sig n if icance o fthese v a riab le s in th e ou tcom e ofth e sev ere ly in ju red leg .

In m anag in g tib ia ! fractu re s w ith concu rren t so ft-tissue in ju r ies o f such seve rity tha t v ascu la r reconstruc -tion w as requ ired , C aud le and S te rn (1 987 ) fo und tha tthe lo ng-te rm resu lts w ere p oor. M ost lim b s even tua llyeith e r requ ired am pu ta tion , o r func tion ed far le sssucces sfu lly th an w ou ld a p rosthesis . M ESS p rov idesclea r gu ide line s fo r th e m anagem en t o f these seve re lytraum atis ed lim b s. A bso lu te re liab ility is v ita l w he re one

trea tm en t op tion is am pu ta tio n , an d th at sp ecif icity h asb een confirm ed in our stud y .N o bene fits in an y fo rm have b een rece ived o r w ill be rece ived f rom acomm erc ial p arty re la te d d ire ctly or in d irect ly to the su b je ct o f th isar t ic le .

REFERENCESCaudle RJ, Stern PJ. S ev ere o pen frac tu res o f the tib ia . J B on e J o in t

S u rg [A m] 1987 ; 6 9-A :8 01-7 .Han sen ST Jr. E dito ria l. T he type -II IC tib ia l fra ctu re : sa lv age o ramputat ion . J B one Jo in t Su rg [A m ] 1987 ; 6 9-A :7 99-80 0 .Joh ansen K , Dam es M , H ow ey T , H e lfe t D , H an sen ST Jr . O b ject iv e

c rite ria ac curate ly pred ict am putatio n fo llow in g low er ex trem ityt r a uma . I T raum a 1 99 0; 3 0: 56 8-7 3.