The Mangled Extremity: When Should It Be Amputated?

Amputation of a mangled extremity is repugnant to the patient and the surgeon. However, prolonged unsuccessful attempts at salvage are costly, highly morbid, and sometimes lethal. Much discussion has taken place regarding which criteria predict successful salvage, and predictive indices have been proposed in an attempt to identify limbs for which attempted salvage is unlikely to succeed. The Mangled Extremity Severity Score, or MESS, system is the most thoroughly validated of the various classification systems, but at present there is no predictive scale that can be used with confidence to determine whether to amputate or attempt to salvage a mangled lower extremity. Therefore, these systems should serve only as guides to supplement the surgeon's clinical judgment and experience. Although salvage for severe injuries below the knee can be difficult and the functional outcome unpredictable, prosthetic function after transtibial amputation is generally good. Conversely, prosthetic function after transfemoral or transradial amputation is often poor, while salvage of some useful function for injuries above the knee is often successful. When limb loss is inevitable, immediate amputation is desirable. If obvious criteria for primary amputation are not met, however, it is reasonable to consider an initial salvage attempt, observation, and subsequent early secondary amputation.