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Mangled Extremity Severity Score in Foot and Ankle Free Flap Reconstruction

Knobloch, Karsten M.D., Ph.D.; Steiert, Andreas M.D.; Busche, Marc N. M.D.; Redeker, Joern M.D.; Vogt, Peter M. M.D., Ph.D.

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Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 685-686
doi: 10.1097/PRS.0b013e3181e096cb
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We read with great interest the recent report by Dr. Hollenbeck et al. highlighting a subunit approach to address foot and ankle defects.1 We would like to comment on some issues raised by the authors in detail. The authors state that “the decision to amputate or salvage a mangled limb is difficult and should be postponed until after the first débridement.” Besides the clinical assessment, the Mangled Extremity Severity Score has proven valid to aid guidance in this regard based on skeletal and soft-tissue damage, limb ischemia, shock, and age.2 A Mangled Extremity Severity Score greater than or equal to 7 predicted an amputation with 100 percent accuracy in the initial aforementioned study. In a combat setting, a Mangled Extremity Severity Score greater than 7 correlated with amputation,3 whereas in ballistic combat trauma, the Mangled Extremity Severity Score did not help to decide about an amputation.4 However, the use of such a score should be performed with caution by a surgeon, given the fact that he or she decides the fate of a lower extremity injury.5 In our view, it would be interesting if the authors could reevaluate the patients' charts to determine the Mangled Extremity Severity Score that led to the free flap soft-tissue reconstruction in their cohort study. To the best of our knowledge, no such data have been reported on a larger cohort undergoing free flap foot and ankle reconstruction. It might be the case that patients with even higher Mangled Extremity Severity Scores greater than 7 might have been managed successfully with free flap surgery, which would be notable.

The authors stress that “reconstructions should be performed as soon as possible (within 72 hours).” Although retrospective by nature, we reviewed our free flaps with later or prolonged reconstruction and found no inferior results in contrast to early reconstruction within 72 hours after trauma.6 Depending on concomitant injuries such as in a patient with multiple injuries with Injury Severity Scores well above 16, damage control surgery is recommended as first-line therapy with consecutive prolonged soft-tissue reconstruction. We would appreciate if the authors could report the time between the trauma and the soft-tissue free flap reconstruction in more detail.

As far as free flap decision is concerned, we would like to consider not only “pliable tissues” but also the thickness of a given free flap regarding the specific foot and ankle subunits to achieve appropriate shoe fitting. For us, it would be interesting if the authors could comment on their strategy for debulking—excision only, liposuction only, or a combination of both—and how they make decisions regarding further debulking procedures.

Notably, the authors found late ulceration in plantar free flaps to be more likely if a skin paddle is incorporated, especially at the free flap/native plantar skin interface. It would be interesting if the authors adjust the flap and pedicle design based on this observation to minimize the free flap/native skin interface.


The authors have no financial interest to disclose.

Karsten Knobloch, M.D., Ph.D.

Andreas Steiert, M.D.

Marc N. Busche, M.D.

Joern Redeker, M.D.

Peter M. Vogt, M.D., Ph.D.

Plastic, Hand, and Reconstructive Surgery

Hannover Medical School

Hannover, Germany


1. Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg. 2010;125:924–934.
2. Johanesen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568–572.
3. Rush RM Jr, Kjorstad R, Starnes BW, Arrington E, Devine JD, Andersen CA. Application of the Mangled Extremity Severity Score in a combat setting. Mil Med. 2007;172:777–781.
4. Brown KV, Ramasamy A, McLeod J, Stapley S, Clasper JC. Predicting the need for early amputation in ballistic mangled extremity injuries. J Trauma 2009;66(4 Suppl):S93–S97.
5. Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury severity scores. J Bone Joint Surg (Am.) 2001;83:3–14.
6. Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy: Worse of worth? J Plast Reconstr Aesthet Surg. 2009;62:675–683.

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