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A Prospective Evaluation of the Clinical Utility of the Lower-Extremity Injury-Severity Scores
Michael J. Bosse, MD; Ellen J. MacKenzie, PhD; James F. Kellam, MD; Andrew R. Burgess, MD; Lawrence X. Webb, MD; Marc F. Swiontkowski, MD; Roy W. Sanders, MD; Alan L. Jones, MD; Mark P. McAndrew, MD; Brendan M. Patterson, MD; Melissa L. McCarthy, ScD; Juliana K. Cyril, MPH
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Investigation performed as part of a larger study (the Lower Extremity Assessment Project) at eight level-I trauma centers in the United States
Michael J. Bosse, MD
James F. Kellam, MD
Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232-2861
Ellen J. MacKenzie, PhD
Melissa L. McCarthy, ScD
Juliana K. Cyril, MPH
Center for Injury Research and Policy, Johns Hopkins University School of Hygiene and Public Health, 624 North Broadway, Baltimore, MD 21205
Andrew R. Burgess, MD
Alan L. Jones, MD
The R Adams Cowley Shock Trauma Center, University of Maryland at Baltimore, 22 South Green Street, T3R59, Baltimore, MD 21201-1595
Lawrence X. Webb, MD
Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157
Marc F. Swiontkowski, MD
Department of Orthopaedic Surgery, University of Minnesota Medical School, 420 Delaware Street S.E., Box 492, Minneapolis, MN 55455
Roy W. Sanders, MD
Orthopaedic Trauma Service, 4 Columbia Drive, Suite 710, Tampa, FL 33606
Mark P. McAndrew, MD
Department of Orthopaedics and Rehabilitation, Vanderbilt University School of Medicine, 1161 21st Avenue South, Medical Center North, T-4311, Nashville, TN 37232
Brendan M. Patterson, MD
Department of Orthopaedic Surgery, Cleveland MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was Grant RO1-AR42659 from the National Institutes of Arthritis and Musculoskeletal and Skin Diseases, the National Institutes of Health.

J Bone Joint Surg Am, 2001 Jan 01;83(1):3-3
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Background: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems.

Methods: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation.

Results: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation.

Conclusions: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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