MESS≥7在Gustilo Ⅲ型下肢开放性骨折患者保肢治疗应用中的回顾性分析

MESS≥7 in determining limb salvage or amputation among lower limb open fractures:A retrospectively study

目的探讨和评价损伤肢体严重程度评分(mangled extremity severity score,MESS)系统在GustiloⅢ型下肢开放性骨折患者保肢决策中的重要性。方法回顾性分析2015年1月-2020年12月山东第一医科大学附属省立医院收治的75例单侧下肢GustiloⅢ型开放性骨折且MESS≥7分的患者资料,男性54例,女性21例;年龄15~74岁,平均44.3岁;道路交通伤51例,高处坠落伤3例,机器挤压伤11例,重物压砸伤10例。根据Ⅰ期治疗选择,将患者分为保肢组(44例)和截肢组(31例),分别统计其性别、年龄、住院天数、手术次数、休克指数、既往史、MESS及MESS四个亚组评分(致伤暴力评分、伤肢缺血评分、休克评分、年龄评分)、GustiloⅢ分型亚型;并统计保肢组Ⅱ期截肢患者的MESS及MESS四个亚组评分等信息,分析各个变量因素对保肢成功的影响。结果75例患者MESS7~14分,平均8.5分,Ⅰ期截肢率41.3%(31/75),保肢组保肢成功率75.0%(33/44)。两组患者性别、年龄、致伤因素、GustiloⅢ分型亚型等基本资料比较差异无统计学意义(P>0.05),保肢组与截肢组比较,MESS中致伤暴力评分及伤肢缺血评分低[(2.4±0.6)分vs.(2.8±0.9)分、(3.4±1.4)分vs.(5.0±1.4)分,P<0.05];而保肢组最终保肢成功与失败的患者相比,MESS休克评分低(0.5±0.6)分vs.(0.9±0.4)分,年龄评分高(1.3±0.7)分vs.(1.1±0.7)分,组间比较差异有统计学意义(P<0.05)。保肢组成功和失败患者的单因素Logistic回归分析同样表明,MESS中的年龄评分、休克评分是影响保肢成功的危险因素,而致伤暴力评分及伤肢缺血评分比较差异无统计学意义。结论MESS在判断GustiloⅢ型下肢开放性骨折截肢指征时仍具有重要意义,在其4个亚组中,致伤暴力评分和伤肢缺血评分对Ⅰ期截肢指征的判断非常重要,而休克评分和年龄评分则可能影响最终保肢的成功率。

Objective To assess whether the mangled extremity severity score(MESS)still plays a vital role in limb salvage decision-making in patients with Gustilo grade III open fractures of the lower extremities,and to analyze related factors affecting successful limb salvage.Methods A retrospectively analysis was conducted on 75 patients(MESS≥7)with Gustilo grade III open fractures of the lower limbs treated in Shandong Provincial Hospital Affiliated to Shandong First Medical University from Jan.2015 to Dec.2020,including 54 males and 21 females,with the mean age of 44.3 years(range 15-74 years).There were 51 traffic accident injuries,3 falls from height,11 crush injuries by machines and 10 crush injuries by heavy objects.According to the first-stage treatment options,patients were divided into limb salvage group(n=44)and amputation group(n=31).Clinical information was analyzed between two groups,including gender,age,length of hospital stay,number of operations,shock index,past history,Gustilo gradeⅢsubtypes,as well as MESS and its four subgroup scores(injury violence score,injury limb ischemia score,shock score,age score)of amputation patients in stage two.The parameters were further analyzed for their impact on successful limb salvage.Results For the whole study group,the MESS ranged 7-14,mean 8.5.The first-stage amputation rate was 41.3%(31/75),and the success rate of limb salvage was 75.0%(33/44)in the salvage group.There was no significant difference in gender,age,injury mechanisms,and Gustilo gradeⅢsubtypes between the two groups(all P>0.05).Compared with amputation group,the salvage group had a significantly lower MESS injury violence score(2.4±0.6 vs.2.8±0.9)and limb ischemia score(3.4±1.4 vs.5.0±1.4),both P<0.05.In addition,among the limb salvage group,the successful patients had a lower MESS shock score than the failure cases(0.5±0.6 vs.0.9±0.4)and a higher MESS age score(1.3±0.7 vs.1.1±0.7),both P<0.05.Univariate logistic regression analysis also showed that the age and shock scores in MESS were the risk factors affecting limb survival rate,while the violent injury score and injured limb ischemia score showed non-significant differences.Conclusion MESS is still important in determining limb salvage or amputation for patients with Gustilo gradeⅢopen fractures of the lower extremities.It is showed that the MESS trauma violence score and limb ischemia score are of vital sense in first-stage amputation decision-making.Of note,the MESS shock score and age score may affect the success rate of limb salvage.