严重肢体损伤评分与截肢：修订时机
The mangled extremity score and amputation: Time for a revision.
作者信息
Loja Melissa N, Sammann Amanda, DuBose Joseph, Li Chin-Shang, Liu Yu, Savage Stephanie, Scalea Thomas, Holcomb John B, Rasmussen Todd E, Knudson M Margaret
机构信息
From the Department of Surgery (M.N.L., J.D.), Divisions of Vascular and Trauma Surgery, University of California, Davis, Sacramento, California; Department of Surgery (A.S., M.M.K.), University of California, San Francisco, San Francisco, California; Department of Public Health Sciences, Division of Biostatistics (C-S.L.), University of California, Davis, Sacramento, California, Department of Statistics (Y.L.), University of California, Davis, Sacramento, California; Department of Surgery (S.S.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery (T.S., T.E.R.), R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland; Department of Surgery (J.B.H.), Center for Translational Injury Research, University of Texas Health Sciences Center Houston, Houston, Texas.
出版信息
J Trauma Acute Care Surg. 2017 Mar;82(3):518-523. doi: 10.1097/TA.0000000000001339.
BACKGROUND
The Mangled Extremity Severity Score (MESS) was developed 25 years ago in an attempt to use the extent of skeletal and soft tissue injury, limb ischemia, shock, and age to predict the need for amputation after extremity injury. Subsequently, there have been mixed reviews as to the use of this score. We hypothesized that the MESS, when applied to a data set collected prospectively in modern times, would not correlate with the need for amputation.
METHODS
We applied the MESS to patient data collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment registry. This registry contains prospectively collected demographic, diagnostic, treatment, and outcome data.
RESULTS
Between 2013 and 2015, 230 patients with lower extremity arterial injuries were entered into the PROspective Vascular Injury Treatment registry. Most were male with a mean age of 34 years (range, 4-92 years) and a blunt mechanism of injury at a rate of 47.4%. A MESS of 8 or greater was associated with a longer stay in the hospital (median, 22.5 (15, 29) vs 12 (6, 21); p = 0.006) and intensive care unit (median, 6 (2, 13) vs 3 (1, 6); p = 0.03). Of the patients' limbs, 81.3% were ultimately salvaged (median MESS, 4 (3, 5)), and 18.7% required primary or secondary amputation (median MESS, 6 (4, 8); p < 0.001). However, after controlling for confounding variables including mechanism of injury, degree of arterial injury, injury severity score, arterial location, and concomitant injuries, the MESS between salvaged and amputated limbs was no longer significantly different. Importantly, a MESS of 8 predicted in-hospital amputation in only 43.2% of patients.
CONCLUSION
Therapeutic advances in the treatment of vascular, orthopedic, neurologic, and soft tissue injuries have reduced the diagnostic accuracy of the MESS in predicting the need for amputation. There remains a significant need to examine additional predictors of amputation following severe extremity injury.
LEVEL OF EVIDENCE
Prospective, prognostic study, level III.
背景
肢体严重损伤评分（MESS）于25年前制定，旨在利用骨骼和软组织损伤程度、肢体缺血、休克及年龄来预测肢体损伤后截肢的必要性。随后，对于该评分的应用评价不一。我们推测，将MESS应用于现代前瞻性收集的数据集时，其与截肢必要性不相关。
方法
我们将MESS应用于美国创伤外科协会前瞻性血管损伤治疗登记处收集的患者数据。该登记处包含前瞻性收集的人口统计学、诊断、治疗及结局数据。
结果
2013年至2015年期间，230例下肢动脉损伤患者被纳入前瞻性血管损伤治疗登记处。大多数为男性，平均年龄34岁（范围4 - 92岁），钝性损伤机制发生率为47.4%。MESS为8或更高与住院时间延长相关（中位数，22.5（15，29）对12（6，21）；p = 0.006）以及重症监护病房住院时间延长相关（中位数，6（2，13）对3（1，6）；p = 0.03）。患者的肢体中，81.3%最终得以挽救（MESS中位数，4（3，5）），18.7%需要一期或二期截肢（MESS中位数，6（4，8）；p < 0.001）。然而，在控制包括损伤机制、动脉损伤程度、损伤严重程度评分、动脉位置及合并伤等混杂变量后，挽救肢体与截肢肢体之间的MESS不再有显著差异。重要的是，MESS为8仅在43.2%的患者中预测了院内截肢。
结论
血管、骨科、神经及软组织损伤治疗方面的进展降低了MESS在预测截肢必要性方面的诊断准确性。严重肢体损伤后截肢的其他预测因素仍有很大研究需求。
证据水平
前瞻性、预后研究，III级。
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