Dirschl DR, Dahners LE
Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill.
J Am Acad Orthop Surg. 1996 Jul;4(4):182-190. doi: 10.5435/00124635-199607000-00002.
Amputation of a mangled extremity is repugnant to the patient and the surgeon. However, prolonged unsuccessful attempts at salvage are costly, highly morbid, and sometimes lethal. Much discussion has taken place regarding which criteria predict successful salvage, and predictive indices have been proposed in an attempt to identify limbs for which attempted salvage is unlikely to succeed. The Mangled Extremity Severity Score, or MESS, system is the most thoroughly validated of the various classification systems, but at present there is no predictive scale that can be used with confidence to determine whether to amputate or attempt to salvage a mangled lower extremity. Therefore, these systems should serve only as guides to supplement the surgeon's clinical judgment and experience. Although salvage for severe injuries below the knee can be difficult and the functional outcome unpredictable, prosthetic function after transtibial amputation is generally good. Conversely, prosthetic function after transfemoral or transradial amputation is often poor, while salvage of some useful function for injuries above the knee is often successful. When limb loss is inevitable, immediate amputation is desirable. If obvious criteria for primary amputation are not met, however, it is reasonable to consider an initial salvage attempt, observation, and subsequent early secondary amputation.
对严重毁损的肢体进行截肢，这对患者和外科医生来说都是令人反感的。然而，长时间进行挽救肢体的尝试却未成功，这不仅代价高昂，还会导致严重的病态，有时甚至会危及生命。关于哪些标准能够预测挽救肢体的成功与否，已经进行了大量讨论，并且有人提出了预测指标，试图识别出那些尝试挽救肢体不太可能成功的情况。在各种分类系统中，严重毁损肢体严重程度评分（MESS）系统是经过最全面验证的，但目前还没有一种可以放心使用的预测量表来确定是进行截肢还是尝试挽救严重毁损的下肢。因此，这些系统仅应作为补充外科医生临床判断和经验的指导。虽然对膝下严重损伤进行挽救可能很困难，而且功能结果难以预测，但经胫骨截肢后的假肢功能通常良好。相反，经股骨或经桡骨截肢后的假肢功能往往较差，而对于膝上损伤保留一些有用功能的挽救手术往往是成功的。当肢体丧失不可避免时，应立即进行截肢。然而，如果不符合一期截肢的明显标准，那么考虑进行初步的挽救尝试、观察，随后尽早进行二期截肢是合理的。
