The MESS: is it must?
Background: Massive lower extremity trauma presents an immediate and complex decision making challenge. Significant advancements have made in the field of reconstructive surgery over the past 30 years. Severely traumatised limbs which would have been treated by primary amputation 20 years ago are beginning to be saved. On the contrary, such extensive reconstructive procedures may not always produce the best of results in terms of functional outcomes. Thus the management of a severely crushed extremity presents a therapeutic dilemma as whether to amputate or to attempt salvage.
Methods: All Prospective study of 40 patients with severe crush injury to the lower extremities treated in Sri Ramachandra Medical College, Chennai between June 2012 and June 2014. The inclusion criteria were grade IIIb and grade IIIc open fractures of the lower extremity with a Mangled extremity severity score (MESS) of 7 and above with minimum of 12 months follow up. All the fractures were classified according to the Gustilo and Anderson classification system and Mangled extremity severity score. Out of the 40 patients 18 of them had their limbs salvaged and 22 underwent primary amputation.
Results: The lowest MESS in this study was 7 and highest MESS was 12. The mean score in the limb salvage group was 8 and in the amputated group was 9.7. Complication rates in salvage group were higher. The mean SF score for amputated group for physical component summary was 40.15 and mental component summary was 44.30 while for limb salvage group score for physical component summary was 30.91 and mental component summary was 36.90.Conclusions: The MESS scheme provides excellent guidelines to the treating surgeon when faced with a dilemma of whether to attempt salvage or amputate a severely injured limb. The decision of whether to amputate or salvage an injured limb must be made very early in the course of treatment. This is because immediate amputation is most often viewed by the patient as a result of injury; whereas, delayed amputation is often considered as a failure of treatment.
Sharma S, Devgan A, Marya KM, Rathee N. Critical evaluation of Mangled extremity severity scoring system in Indian patients. Injury. 2003 Jul;34(7):493-6.
Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am. 1990 Feb;72(2):299-304.
Papakostidis C, Kanakaris NK, Pretel J, Faour O, Morell DJ, Giannoudis PV. Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo-Anderson classification. Injury. 2011 Dec;42(12):1408-15.
Charles A. Rockwood, David P. Green. Principles of mangled extremity management. In: Charles A. Rockwood, Robert W. Bucholz, Charles M. Court-Brown, James D. Heckman, Paul Tornetta, eds. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010: 1780-2021.
Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990 May;30(5):568-73.
Caudle RJ, Stern PJ. Severe open fractures of the tibia. J Bone Joint Surg Am. 1987 Jul;69(6):801-7.
Jandrić S, Topić B. Vojnosanit. Effect of primary and secondary below-knee amputation of war injuries on the length of hospitalization and rehabilitation. Pregl. 2002 May-Jun;59(3):261-4.
Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am. 1993 Oct;75(10):1431-41.
Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P, Browner BD. The medical and economic impact of severely injured lower extremities. J Trauma. 1988 Aug;28(8):1270-3.
S. Terry Canale, James H. Beaty. Extremities. In: S. Terry Canale, James H. Beaty, eds. Campbell's Operative Orthopaedics. 10th ed. St. Louis: The C. V. Mosby Company; 2007: 1512.