Optimizing Outcomes in Mangled Lower Extremity Reconstruction: Insights from a Retrospective Study of 93 Patients and Their Functional Scores

Introduction: Over the past 25 years, advancements in reconstructive techniques and patient management have significantly improved outcomes in mangled lower extremity injuries. Functional results of limb salvage have been demonstrated to surpass those of primary amputations. Developments such as the use of local fasciocutaneous flaps, vacuum-assisted closure, and hyperbaric oxygen therapy have enhanced the reconstructive ladder. Despite progress, the utility of the Mangled Extremity Severity Score (MESS) and Gustilo-Anderson classification remains debated, particularly in their prognostic value for limb salvage decisions. Materials and Methods: This retrospective study analyzed 93 patients treated for mangled lower extremities between January 2015 and October 2022. Patients were assessed for age, gender, injury location, MESS scores, Gustilo-Anderson classifications, surgical methods, and functional outcomes using the Lower Extremity Functional Scale (LEFS). Surgical interventions included internal and external fixation, skin grafts, local flaps, muscle flaps, and free tissue transfer. LEFS scores were categorized into disability levels for functional evaluation. Correlations were drawn between LEFS and variables such as MESS, Gustilo-Anderson types, and nerve injuries. Results: Among the 93 patients, 16 had MESS ≥ 7, and 77 had MESS < 7. Reconstruction methods included local fasciocutaneous and muscle flaps (37 patients), free tissue transfer (29 patients), and skin grafting with vacuum-assisted closure (27 patients). Smoking was associated with delayed union and increased infection rates. LEFS scores were significantly lower in patients with MESS ≥ 7, Gustilo grade 3C fractures, and tibial nerve injuries. Flap failures and higher numbers of surgeries (>3) also correlated with poorer functional outcomes. Average soft tissue healing time was 18 days, and bone union time was 17 weeks. Discussion: Lower extremity reconstruction demands precise surgical planning and execution, prioritizing functional restoration. MESS and Gustilo-Anderson classifications provide useful frameworks but have limitations in predicting long-term functionality. Factors such as joint involvement, nerve injuries, and flap selection significantly influence outcomes. Smoking and delayed healing remain critical challenges. While free flaps are essential for complex defects, simpler methods yield better outcomes in suitable cases. LEFS emerged as a reliable tool.