Reliability of the Mangled Extremity Severity Score in the Management of Peripheral Vascular Injuries in Children: A Retrospective Review

Abstract

This study was aimed to evaluate different management modalities for peripheral vascular trauma in children, with the aid of the Mangled Extremity Severity Score (MESS). A single-center retrospective analysis took place between 2010 and 2017 at University Hospitals, having emergencies and critical care centers. Different types of vascular repair were adopted by skillful vascular experts and highly trained pediatric surgeons. Patients were divided into three different age groups. Group I included those children between 5 and 10 years; group II involved pediatrics between 11 and 15 years; while children between 16 and 21 years participated in group III. We recruited 183 children with peripheral vascular injuries. They were 87% males and 13% females, with the mean age of 14.72 ± 04. Arteriorrhaphy was performed in 32%; end-to-end anastomosis and natural vein graft were adopted in 18% and 29% respectively. On the other hand, 20% underwent bypass surgery. The age groups I and II are highly susceptible to penetrating trauma ( p  = 0.001), while patients with an extreme age (i.e., group III) are more susceptible to blunt injury ( p  = 0.001). The MESS has a significant correlation to both age groups I and II ( p  = 0.001). Vein patch angioplasty and end-to-end primary repair should be adopted as the main treatment options for the repair of extremity vascular injuries in children. Moreover, other treatment modalities, such as repair with autologous vein graft/bypass surgery, may be adopted whenever possible. They are cost-effective, reliable, and simple techniques with fewer postoperative complication, especially in poor/limited resources.

Erratum to: Reliability of the Mangled Extremity Severity Score in the Management of Peripheral Vascular Injuries in Children: A Retrospective Review

Vascular injuries in children stand for approximately 0.6% of trauma in this age group. ¹ Also, it may induce a spectrum of complications, such as defective limb perfusion, claudication, and unequal limb length, leading to a significant impairment of the patients' lifestyle. ² Because the diagnosis of such cases is usually difficult, they still compromise a great channel to the surgeons. This may be attributed to the fact that they usually involve small-diameter vessels that are free of atherosclerosis. Moreover, the growing vessels are vulnerable to vasospasm, together with a limited intravascular volume. The surgical treatment of such injury in children is mainly related to the gathering of data from vascular trauma in adult individuals, yet children may benefit from having good collateral circulation. Furthermore, to support appropriate limb growth, the repair of vascular injuries in pediatric patients needs more than just flow-preserving patency. ^{3 4 5 6 7} Most vascular injuries can be managed by repair with end-to-end primary anastomosis, although an extensive and widespread injury may demand the use of graft interposition. The proper conduit is the natural one, using the great saphenous vein. When absent or unavailable, synthetic material may be used instead. In addition, a vein patch angioplasty may be applied to restore the vessel continuity. ^{8 9} The arterial repair was considered as the most commonly accepted form of treating arterial trauma, where vein ligation is the commonly adopted technique in cases of venous injury. ¹⁰ The current study was performed to evaluate the different treatment modalities for the repair of pediatric extremity vascular injuries in resource-challenged environments.

Methods

A 7-year retrospective analysis was performed between, July 2010 and June 2017 after approval of our institutes' research board (IRB) committee. Registration number (25/08–01/2019) was assigned to the current study. Statistically and according to their ages, the studied patients were divided into three different age groups as follows: 5 to 10 years (group I), 11 to 15 years (group II), while between 16 and 21 years in group III. Patients' records were individually evaluated, and patients were included if they have had acute noniatrogenic peripheral vascular injuries, whether associated with bone/soft tissue injuries or not. Excluded from the study were those who presented with iatrogenic vascular injuries and distal extremity injuries beyond the wrist or ankle. Also, excluded were those children with a preexisting vascular pathology/previous arterial surgical reconstruction. The retrieved data showed patients' sociodemographic, clinical condition on arrival to the emergency department, the mechanisms, types, as well as sites of vascular injury. Moreover, the specific vascular imaging, period between the onset of injury and clinical presentation, duration from the onset of trauma until admission to the operating room, and injured vessel(s) were also reported. In addition, the types and the times of definitive vascular repair, anticoagulation, duration of the hospital stay, as well as the follow-up periods, were also reported. Clinically, all patients were examined for signs of arterial injuries, with special emphasis on the clinical limb status. Furthermore, and to assess the severity of peripheral vascular injuries, we followed the updated guidelines of the Eastern Association for the Surgery of Trauma. ¹¹ For patients who had associated musculoskeletal injuries, the bony fractures were preliminary fixed to favor a subsequent arterial repair. Yet, the arterial repair was preliminarily performed in those patients with absent peripheral pulses, cold limb associated with delayed/absent capillary refill, in addition to the patients who underwent a long period of either warm or cold ischemia. Intraluminal temporary vascular shunt (TVS) was the only available option in some cases. ¹² The adopted operative surgical repair involved several modalities including lateral arteriorrhaphy and end-to-end vascular anastomoses. Alternatively, an autologous vein was used as an interposition graft, rather than synthetic materials. ^{13 14 15} The Mangled Extremity Severity Score (MESS) was the key to predicting limb salvage. ^{16 17} Fasciotomy was performed as a prophylactic measure in all cases to prevent the development of compartment syndrome (CS). Following surgery, most of our patients were given either prophylactic anticoagulants or antiplatelet therapy for 15 to 45 days. ¹⁸ Patients' follow-up included local vascular examination of the limb, in addition to color Doppler ultrasonography (CDUS), computed tomography angiography (CTA)/contrast angiography, to aid in the monitoring of vascular repair and patency. The duration of postoperative follows-up ranged from 1 to 24 months.

Statistical Analysis

Data were statistically analyzed using Statistical Package for the Social Science (SPSS) version 23, (IBM Corporation, Armonk, NY). Data expressed as the mean ± standard deviation (SD). Categorical variables were presented as number and percentage. These results interpreted in detail the characteristics of the study population and the association between sociodemographic characteristics versus operative procedures, mechanism of injury, and the operative outcome which addressed the study objectives. Age groups were contrasted on continuously distributed outcomes with a t -test and on binary outcomes with Pearson's χ ² test, Fisher's exact test, and Spearman's correlation. Comparison between variables, survival functions, and freedom from reinterventions were analyzed using the Kaplan–Meier survival tests. A p -value of <0.05 was considered to have a statistical significance.

Results

During a 7-year study period, 183 pediatric patients were treated for noniatrogenic extremity vascular injuries. Patients' demographics and age group distribution are shown in ( Table 1 ). The types, the sites, and the methods of injury are represented in ( Table 2 ). The correlations between the different age groups, the types, and mechanisms of trauma are discussed in ( Table 3 ), as well as the operative procedures, where they are illustrated in ( Table 4 ). The operative time ranged from 60 to 165 minutes, with a median of 110 minutes. Intraoperative blood loss occurred in approximately 43.6% ( n  = 79/181) that ranged between 120 and 750 mL), and the mean volume loss is 443 ± 182 mL. Those patients were given either packed red blood cells (PRBCs) or whole blood transfusion. Primary above-knee amputation (AKA) was performed in 1% ( n  = 2) of patients due to severe crushing of the lower limb associated with comminuted bone fractures and massive soft tissue laceration with no hope of either bone fixation or limb revascularization ( Fig. 1 ). Those patients had a MESS score of nine. Bone and soft tissue injuries showed a statistically significant difference between the lower and upper limbs, as most of the injuries were encountered in the lower extremity of the age groups III ( p  = 0.081). The overall technical success for the restoration of the arterial blood flow and to obtain adequate distal limb perfusion was accomplished in 100% of patients. However, among those patients who underwent a reversed interposition saphenous vein graft, they shown a MESS of 7–8, and failure of arterial repair was reported in 6% ( n  = 11/181). They showed severe graft thrombosis and subsequent occlusion due to a massive wound infection that took place on top of anastomotic false aneurysms. These pseudoaneurysms were recognized within the first 24–48 hours postoperatively. This type of infection does not respond well to any antibiotic therapy; yet, culture and sensitivity test was performed. Consequently, the whole leg was nonfunctioning up to the level of the knee joint. Furthermore, a definitive AKA was performed within 2 weeks postoperatively, yet, open guillotine below knee amputation was not performed, as a result of irreversible acute lower limb ischemia. Based on the MESS, most of our patients (97.7%) reported a trauma score ranging between 1 and 6. Initial limb salvage was achieved in 181 patients (98.9%) and definitive limb salvage could be accomplished in 170 patients (93.9%). The number of injured patients and their MESS are listed in Fig. 2 . The median MESS value was 5. However, lower extremity vascular injuries were meaningfully higher than those of the upper extremities ( p  = 0.001). Patients in age groups I and II showed a statistically significant correlation between limb salvage and MESS ( p  = 0.001). On the other hand, there was no correlation between MESS and patients in group III ( p  = 0.873). Apart from amputation, extremity length discrepancy was observed in 10.5% of patients ( n  = 19), 13 of them involved the lower and six in the upper extremity with a contributing factor of bone shortening/limb contractures. Functional impairment was encountered in approximately 13% ( n  = 23). However, sensory/motor neuropathy were reported in 8% ( n  = 16). Vascular patency reached up to 87% ( n  = 158/181) by the end of the follow-up period (i.e., 24 months). As listed in ( Table 5 ), the survival distribution, freedom from reinterventions, as well as the vascular patency, among the different treatment modalities showed satisfactory and promising results for the different types of vascular repair ( p  = 0.001). This is shown and explained by the Kaplan–Meier survival curves for amputation-free and vascular patency ( Fig. 3 ).

Table 1. Patients' gender and different age group distribution.

Factor	Result
	n	%	Total %
Gender
Male	159	87	100%
Female	24	13
Age in years (mean)	14.72 ± 04.5
Median (min–max)	16 (5–21)
Age group distribution (y)
05–10	36	20	100%
11–15	53	29
16–21	94	51

Abbreviations: min, minimum; max, maximum.

Table 2. Types, mechanisms, and anatomical sites of extremity injuries.

Factor		Result
Type and mechanism of injury		n	%	n	%
Penetrating	Stab (knife)	69/144	48	144/183	78.7
	Glass/mirror	44/144	30.5
	Gunshot	31/144	21.5
Blunt	RTA	24	61.5	39/183	21.3
	Building collapse	09	23
	Sports injury	06	15.5
Orthopedic injury		76	42
Soft tissue injury		95	52
Peripheral nerve injury		95	52
Anatomical sits of arterial injury
Lower limb	SFA	79/112	70	112/183	61
	PA	21/112	19
	TA	12/112	11
Upper limb	Brachial	51/71	72	71/183	39
	Radial	12/71	17
	Ulnar	08/71	11
Anatomical sites of venous injury
Lower limb	Femoral vein	8/183	4.37	19/183	11
	Popliteal vein	4/183	2.18
	Tibial veins	7/183	3.82
Upper limb	Brachial and antecubital veins	5	2.7	8/183	5
	Cephalic vein	3	1.6

Abbreviations: PA, popliteal artery; RTA, road traffic accident; SFA, superficial femoral artery; TA, tibial arteries.

Table 3. The correlations between mechanisms of injury and different age groups.

Type of trauma	Age groups (y)	p -Value
Penetrating	Age group 1 (05–10)	0.001 a
	Age group 2 (11–15)	0.001 a
	Age group 3 (16–21)	0.979 b
Blunt trauma	Age group 1 (05–10)	0.113 b
	Age group 2 (11–15)	0.185 b
	Age group 3 (16–21)	0.001 a

^aSignificant.

^bNonsignificant.

Table 4. Operative procedures.

Procedures		Result
Operative		n	%
Arteriorrhaphy		58	31.7
Primary repair with end-to-end anastomosis		33	18
Interposition reversed saphenous vein graft		53	29
Bypass surgery using reversed saphenous vein graft		37	20
Repair of associated injuries
Tendon, muscle/ligament direct repair		95	52
Peripheral nerve injury treated by either primary repair, nerve grafting, or secondary repair		95	52
External fixation for associated bone injury		76	42
Venous injury	Repair	12	6.5
	Ligation	15	8
Postoperative
Revision primary repair		11	6
Postoperative AKA		11	6
Temporary vascular shunt		22	12

Abbreviation: AKA, above-knee amputation.

Fig. 1.

Severely crushed lower limb undergoing primary AKA in a patient aged 21 years old. AKA, above-knee amputation.

Fig. 2.

The distribution of the MESS values among injured patients. MESS, Mangled Extremity Severity Score.

Table 5. Limb survival analysis following different types of arterial repair using the Chi-square test.

Overall comparisons
Test	Chi-square	df	p -Value
Log rank (Mantel–Cox)	27.448	3	0.001 a
Breslow (generalized Wilcoxon)	27.211	3	0.001 a
Tarone–Ware	27.392	3	0.001 a

Abbreviation: df, degree of freedom.

^aSignificant.

Fig. 3.

The Kaplan–Meier survival curves for amputation-free and vascular patency.

Discussion

Management of pediatric extremity vascular injuries still represents a significant challenge for most of the surgeons. The desirable goal is not only salvaging the limb, but also avoidance of any functional disability. ¹⁹ Improvements in vascular, orthopaedic, and musculoskeletal reconstructions have added to the improved outcomes and tangled the process of decision making for severe limb injury. ^{20 21 22} In the current study, the male gender prevailed, mounting to 89% with a median age of 16 years old. These data are in accordance with the previously published reports. ^{23 24 25 26} Male predominance and the younger age group may be explained by the fact that children in this age group are hyperactive, thus more vulnerable to this type of injury. ²⁷ However, the dominant cause of extremity trauma was penetrating injuries, where it affects approximately 79% of children. These findings are supported by what has been previously reported. ^{1 24 25 28} The high incidence of penetrating injuries in our study may be attributed to the poor socioeconomic status and could be considered as a risk factor for ill health in patients of these susceptible age groups. ²⁹ Moreover, trauma to the superficial femoral artery (SFA) was the most commonly affected pathology in our series, whereas it accounts for 70% of injuries. These data coincide with the previously published reports. ^{1 20 22 23 24 25 26 30 31} Open surgical repair was adopted as a standard treatment option. It included lateral arteriorrhaphy with vein patch angioplasty and end-to-end vascular anastomosis. Moreover, interposition graft ( Fig. 4 ) and surgical bypass ( Fig. 5 ) were adopted for the treatment of some patients using the reversed saphenous vein graft. Initial operative technical success was achieved in 100% of patients. Graft thrombosis and occlusions were developed in 6% ( n  = 11) of our treated patients that necessitated revision repair. It was previously reported that an MESS score of ≥7 had a 100% incidence rate for amputation. ³² This may coincide with what we have reported in our series, where 13 patients having a score of ≥7. However, among those patients who underwent a reversed saphenous vein interposition graft, severe postoperative infection ending up with graft thrombosis and subsequently complete graft occlusion. This was recorded in 6% ( n  = 11) of the whole treated patients. This obliged revision repair was subsequently failed with extensive tissue death of the whole leg up to the knee level. Moreover, this happened as a result of a massive wound infection that took place on top of anastomotic false aneurysms. The severe infection did not positively respond to any antibiotic therapy, despite the performed culture and sensitivity. Consequently, the whole leg was nonfunctioning up to the level of the knee joint. Therefore, those patients underwent a definitive AKA amputation without delayed secondary skin closure within 10–15 days postoperatively. As they had a MESS value of 7–8 and their limbs showed fixed color changes associated with a picture of irreversible acute severe ischemia of the whole leg, associated with major tissue loss and permanent nerve damage ( Fig. 6 ). Graft failure was mainly attributed to graft thrombosis and occlusion because of a massive wound infection that does not respond to antibiotic treatment. Moreover, the MESS of ≥7 was reported for those patients. Furthermore, a two-stage amputation (i.e., guillotine below knee amputation (BKA)) was not performed, because of severe limb infection that reached a higher level (i.e., up to the knee joint). For that reason, there is no role for guillotine BKA to take place. The MESS has a critical score that, when reached, it was preferred that the patient was better served with definitive amputation rather than limb salvage with two-stage guillotine amputation. ³³ In addition to the more severe and extensive infection, that extended up to the knee level. So, we do not perform preliminary guillotine BKA but, AKA took place from the start as a final and definitive treatment option. Moreover, most of our patients 93% had a low injury severity score ranged from 1 to 6. This was supported by the literature that reported a significantly low injury severity score in pediatric patients. ¹ Therefore, MESS looks to be an accurate tool in distinguishing between salvageable and nonsalvageable limbs. ^{16 17 34} In the current study, we reported two patients (1%), having a score of 9. Those patients underwent a primary AKA due to severe crushing of the limb. Despite the limitations of our resources, the incidence of morbidity and mortality rates were very low. As it approaching nearly 7% in contrast to the previous literature reports. ^{1 20 22 23 24 25 26 30 31} This may be referred to the fact that most of the treated children were evaluated and treated either by vascular surgeon/well-trained pediatric and general surgeons. Fasciotomy was performed as a prophylactic measure in all patients. This goes in accordance with that reported in the literature. ³⁵ It has been postulated that following limb revascularization, prompt fasciotomy was accompanied by a four-fold decrease in both the rate of amputation and other relevant complications. ^{35 36} In our series, the amputation rate is much common in older children, as it was performed in patients above the age of 15 years. These results are similar to that reported in the literature. ^{1 20 23 24 25 26 30 31} The summary of our results in comparison to that reported in some literature reports are represented in ( Table 6 ). ^{1 20 22 23 24 25 26 30 31 35} Despite acceptable vascular patency rate; a long-term functional outcome was developed in 23% of our treated patients during the 24-month follow-up period. This functional disability may be considered as the most important and vexing aspect of pediatric vascular injuries. This result coinciding with previously published reports. ^{37 38}

Fig. 4.

Arterial repair using an interposition reversed saphenous vein graft.

Fig. 5.

Femorodistal bypass for gunshot injury of the popliteal artery.

Fig. 6.

An irreversible acute limb ischemia in a 19-year-old patient that occurs within 15 days of revision repair using an interposition reversed saphenous vein graft, because of graft infection and thrombosis. This patient underwent definitive above-knee amputation.

Table 6. Summary of our results in relation to some literature reports.

		Current study	Barmparas et al (2010) 1	Wahlgren and Kragsterman (2015) 20	Allen et al (2015) 22	Sciarretta et al (2014) 23	Gurien et al (2017) 24	Klinkner et al (2007) 25	Kayssi et al (2018) 26	Corneille et al (2011) 30	Villamaria et al (2014) 31
n		183	1.138	222	1,928	2,844	94	102	106	116	155
Age (mean ± SD)		14.7 (4.5)	10.7 (4.4)	9.6 (4.1)	11 (6)	14.7 (2.6)	12.1 (5)	10.7 (4.3)	9 (5)	12.7 (4.1)	12 (7)
Sex (male/female)		159/24	838/300	148/47	1,350/578	17/1	62/32	75/27	80/26	82/34	122/33
Type of injury	Blunt trauma	26.5% (39)	58% (660)	66% (146)	76% (1465)	18% (3)	44% (41)	31% (32)	38% (40)	42% (49)	5% (5)
	Penetrating trauma	78.5% (144)	42% (478)	23% (51)	24% (463)	78% (14)	56% (53)	68% (70)	72% (76)	58% (67)	95% (148)
Site of injury	Upper limb	39% (71)	36% (406)	60% (134)	58% (30)	NA	37% (35)	36% (37)	34% (36)	37% (43)	28% (52)
	Lower limb	61% (112)	19% (212)	29% (65)	42% (21)	94% (17)	32% (31)	30% (31)	13% (14)	25% (29)	38% (70)
Operative treatment	Primary repair	40% (73)	NA	12% (27) a	17% (13) a	6% (1) a	27% (25) a	20% (21) a	49% (52) a	25% (26) a	56% (78)
	Interposition graft	48.5% (89)	NA	24% (54) a	24% (18) a	39% (7) a	33% (31) a	1% (1) a	14% (15) a	26% (27) a
Reoperation		6% (11)	NA	22.2% (10)	NA	NA	NA	NA	NA	NA	NA
Fasciotomy		100% (183)	NA	23% (51)	NA	39% (7)	NA	NA	NA	NA	10% (15)
Amputation		7% (13)	1.4% (16)	7% (3)	NA	6% (1)	3% (3)	7% (7)	1% (1)	2.6% (3)	6% (9)

Abbreviations: NA, not available; SD, standard deviation.

^aOther modalities for treatment of vascular injuries rather than our used techniques were excluded from this table.

Limitations

Due to the restriction and limitations of our resources, synthetic materials were not used in our series. This might pave the road for a broad range of vascular surgeons in addition to most of the general and pediatric professions to adopt the use of primary repair with end-to-end vascular anastomosis, lateral vein patch angioplasty, and interposition reversed saphenous vein graft. Bypass surgery may also be performed in certain situations. Therefore, these different treatment strategies, if adequately performed, may result in an acceptable rate of morbidity and mortality.

Conclusion

Vascular injuries in children are challenging regarding their diagnosis, perioperative assessment, and operative technical procedures. Although pediatric vascular trauma is uncommon, it must be taken into consideration that, it is a well-known cause of morbidity, disability, and mortality among these different ages. Many techniques for limb salvage have been adopted. Therefore, it is strongly recommended that using the standard vascular repair with vein patch angioplasty adopted by lateral arteriorrhaphy and end-to-end primary vascular repair. Moreover, a reversed interposition saphenous vein graft, in addition to the surgical bypass for selected cases may be used whenever necessary, especially in the areas with poor/limited-resources. Furthermore, it is highly recommended that using the MESS system in all types of pediatric trauma patients to thoroughly estimate and stratify limb viability following extremity vascular injuries, and hence to ascertain the probability of salvaging the limb versus empirical amputation.

Funding Statement

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.