MESS: Mangled Extremity Severity Scores - Lucy Dennell 18/11/2003

Authors             Johansen K, et al Harborview Medical Centre, Seattle , Tampa General Hospital , South Florida

Title                  Objective Criteria Accurately Predict Amputation following lower extremity Trauma

Reference        The Journal of Trauma, 30; 5 pp568-573 1990

Summary         Aim; to establish a simple, accurate scoring system based on objective clinical criteria. Retrospective followed by a prospective study, N= 26 limbs in each part. Results Mess = 4.88 and 4.0 for salvaged limbs, and Mess= 9.11 and 8.83 for ultimately amputated limbs. Therefore with the threshold of 7, 100% accuracy claimed.

Critique             the prospective part did not actually use the score to determine initial management therefore did not really make an advance on the retrospective part. No mention at all of length of follow up or the timing of the “secondary amputation” in the prospective group. They acknowledge that severe nerve injury or severe trauma elsewhere may alter decision making process.

Authors             Lin ch et al Chang Gung Memorial Hospital , Taiwan

Title                  The functional outcome of lower extremity fractures with vascular injury

Reference:       The Journal of Trauma (I,I + CC)43(3),Sept 1997 480-485

Summary         retrospective, 36 limbs all Gustilo IIIC, over 3 years,

                        All underwent revascularization procedures. Aim was to find evidence to support using a level of MESS score of < or = to 10 instead of 7 for attempting salvage. 2 year min follow up. Results, overall 75% salvage rate at 2 years 27/36. 9/36 (19%)underwent 2ndary amputation by the first week. A further 2; one at 34 days, one at 18 months for neurotrophic ulcers. Minimal Functional Recovery, MESS 5-7; 94%, MESS<or= 9; 90%. MESS 10 all failed.

Critique             Retrospective, small n, multiple surgeons, multiple operative procedures, level one trauma centre. Admitted that the choice between amputation and reconstruction is always individualized ie scores are not ideal for decision making. Makes it clear that functional salvage is possible even with vascular injury and provides evidence that would allow one to justify attempted salvage of limbs with MESS= 9.

Authors             Bosse MJ et al part of LEAP at 8 level1 trauma centres in USA

Title                  A prospective evaluation of the clinical utility if the lower extremity injury-severity scores

Reference        JBJS Am 83 A(1)January 2001 pp3-14:

Summary         Aim to preoperatively evaluate 5 different scoring systems. 556 high energy lower extremity injuries for 6 months.

Looked at the sensitivity- probability that limbs requiring amputation will have scores at or above the threshold level = total no of limbs amputated with scores >or = to the threshold/ total no of amputations in 6 months. Specificity,the reverse. A measure of the index discrimination 0.5 equivalent to chance, up t 1.0 = perfect ability to discriminate.

                        Results Specificity MESS 91%, LSI 97%, PSI,87%, when the immediate amputations excluded dropped to 27%, 26% and 36% respectively. LSI had 0.85 area under the receiver operating characteristic curve for all open tibial fractures in the group.

Critique             large, independent, prospective, well-defined inclusion and exclusion criteria. Level 1 trauma centres therefore not generalisable