Background The Mangled Extremity Severity Score (MESS) was developed 25 years ago in an attempt to utilize 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 utility 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 (PROOVIT) 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 PROOVIT registry. The majority were male with a mean age of 34 years (range 4–92) 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 ICU (median 6 (2, 13) vs 3 (1, 6), p=0.03). 81.3% of limbs 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 Level III evidence, prospective study, prognostic.

Background Racial/ethnic disparities in treatment outcomes of peripheral arterial disease (PAD) are well documented. Compared to non-Hispanic (NH) whites, blacks and Hispanics are more likely to undergo amputation and less likely to undergo bypass surgery for limb salvage. Endovascular procedures are being increasingly performed as first line of therapy for PAD. In this study, we examined the outcomes of endovascular PAD treatments based on race/ethnicity in a contemporary large population-based study. Methods We used Patient Discharge Data (PDD) from California’s Office of Statewide Health Planning and Development (OSHPD) to identify all patients over the age of 35 who underwent a lower extremity arterial intervention from 2005 to 2009. A look-back period of five years was used to exclude all patients with prior lower extremity arterial revascularization procedures or major amputation. Cox proportional hazards regression was used to compare amputation-free survival and time to death within 365 days. Logistic regression was used for comparison of 1-month myocardial infarction (MI), 1-month major amputation, 1-month all-cause mortality, 12-month major amputation, 12-month reintervention, and 12-month all-cause mortality rates among NH white, black, and Hispanic patients. These analyses were adjusted for age, gender, insurance status, severity of PAD, comorbidities, history of coronary artery angioplasty or bypass surgery, or history of carotid endarterectomy. Results Between 2005 and 2009, a total of 41,507 individuals underwent PAD interventions, 25,635 (61.7%) of whom underwent endovascular procedures. There were 17,433 (68%) NH whites, 4,417 (17.2%) Hispanics, 1,979 (7.7%) blacks, 1,163 (4.5%) Asian/Native Hawaiians, and 643 (2.5%) others in this group. There was a statistically significant difference in the amputation-free survival within 365 days among the NH white, Hispanic and black groups (P < 0.0001); the hazard ratio for amputation within 365 days was 1.69 in Hispanics (95% CI 1.51–1.90; P <0.0001) and 1.68 in blacks (95% CI 1.44–1.96; P <0.001) compared to NH whites following endovascular procedures after adjusting for age, gender, insurance status, comorbidities, severity of PAD, history of coronary artery angioplasty or bypass surgery, or history of carotid endarterectomy. After adjusting for the aforementioned confounders, the first reintervention within 12 months was also significantly associated with race/ethnicity (P=0.002). Odds ratio for reintervention was 1.17 in blacks (95% CI 1.06–1.30, P=0.002) and 1.084 in Hispanics (95% CI 1.00–1.16, P=0.04) compared to NH whites. Conclusions In this contemporary large population-based study, we demonstrated that even among matched cohorts Hispanics and blacks have worse amputation-free survival than NH whites following endovascular therapy. Our study also found that Hispanics and blacks are more likely to undergo lower extremity arterial reinterventions than NH whites. Further research is crucial in understanding if higher reintervention rates in ...

III, Therapeutic/care management.