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01.12.2015 | Research article | Ausgabe 1/2015 Open Access

BMC Musculoskeletal Disorders 1/2015

Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system

BMC Musculoskeletal Disorders > Ausgabe 1/2015
Giuseppe Rosario Schirò, Sergio Sessa, Andrea Piccioli, Giulio Maccauro
Wichtige Hinweise

Competing interests

The Authors declare that there is no conflict of interest regarding the publication of this paper.

Authors’ contributions

GRS: partecipate in drafting the article, analyzed all data, give substantial contribution in acquisition of data and conception of the article. SS: participate in drafting the article and give substantial contribution in acquisition of data. AP: give substantial contribution in conception and design of article, participate in drafting the article. GM: participate in drafting the article, give substantial contribution in conception and design of the article, participate in drafting the article and give final approval of the version to be submitted. All authors read and approved the final manuscript.



In the last decades a lot of new reconstructive techniques were developed for the treatment of mangled lower extremity. However failed attempt to limb salvage is related to high risk of mortality for the patient. Several scores were developed to establish guidelines for the decision to amputate or not, however in literature there is no consensus about the reliability of this scores.


The authors focused their attention on the most used score system to provide guidance of the management of a mangled lower limb. The search term used included mangled lower extremity, MESS, PSI, LSI and NISSSA. The inclusion criteria were: studies dealing with mangled lower extremity; articles reporting MESS, PSI, LSI or NISSSA scores; articles published in English in PubMed, Cochrane, Scopus and web of science in the last 30 years, minimum number of cases in study of 15, minimum follow up of 1 year.


According with the criteria described above, we found 134 articles in PubMed, 165 articles in Scopus, 111 articles in the Cochrane Library and 108 articles in Web of Science. The most used score in literature is the MESS. Few results are shown using the other severity scores. There are a lot of controversies in literature about the use of this scale. MESS seems to be more accurate than the LSI in prediction of limb salvage. LSI score shows better results when applied to type III tibial fractures. High sentivity of the PSI score is described when applied to predict successful limb salvage. Low sensitivity and specificity are described for the NISSSA score. The literature is very poor of articles related to mangled lower extremity in children. Higher sensitivity and specificity are described for these scores in children when compared to adult population.


The mangled lower extremity treatment is a challenge for the surgeon. Many scores were developed to help the surgeon, however they cannot be used as the sole criterion by which amputation decision are made and, in case of succesful limb salvage, they are not predictive of the functional recovery. Moreover, undue enthusiasm for new surgical techniques can lead to increased morbidity and mortality in case of secondary amputation.
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