Damage control hip disarticulation: two-stage operation with index creation of a large medial flap for the septic hip

Abstract

BackgroundAlthough rarely performed, hip disarticulation (HD) is usually used for the patient with a non-viable leg who is also in extremis. HD was first used for trauma and infection; however, the technique was perfected during the age of hindquarter amputation for osteosarcomas. The operation performed by most surgeons today is still based on the oncological principles of high vessel control and ligation. When this approach has been used in the overwhelmingly infected or mangled extremity, it has resulted in high mortality rates. During the last 20 years, the concept of damage control operation has been embraced by emergency surgeons in all fields. We sought to extrapolate this concept and to apply it to the non-viable lower extremity.MethodsWe describe a new concept of damage control HD, review the technique and discuss our consecutive series of nine patients who underwent the procedure for trauma or necrotizing infection without flap dehiscence or mortality.ResultsAll patients survived to hospital discharge. At time of discharge or at follow-up, six of the nine patients were able to transfer to a wheelchair.DiscussionProper disarticulations for infection need to address these two operative and postoperative issues: damage control debridement with creation of sufficient flap size and thorough postoperative wound care.Level IV

Double Fillet Flap for End-Stage Pelvic Pressure Injuries in a Paraplegic Patient

“…In most studies, hip disarticulation is indicated as a last resort for infection source control of severe lower extremity infection, such as extensive proximal femoral osteomyelitis, pyoarthritis of hip joint, and severe necrotizing soft tissue infection with hip joint involvement. 8,11,[13][14][15] On the other hand, one case series reported that hip disarticulation with femur removal is performed when the flap size is not sufficient enough for tension-free coverage of the femoral stump. 8 Given our patient's history, we performed the left hip disarticulation and left femur removal in this patient for infection source control.…”

“…Given our patient's history, we performed the left hip disarticulation and left femur removal in this patient for infection source control. However, the literature discussing hip disarticulation in SCI patients with recurrent pelvic injuries are case reports and case series, and the evidence is limited 8,11,13–15 . Further studies are needed to determine the indication of hip disarticulation, and this procedure should be considered depending on patients' clinical condition.…”

Complications after hip disarticulation and hemipelvectomy

“…Veličina režnja kao i temeljna postoperativna nega rane su od velikog značaja za pravilnu dezartikulaciju kuka [14]. Određeni radovi navode starost pacijenta od preko 65 godina i slabije imovinsko stanje kao moguće prediktore za razvoj komplikacija [15].…”

“…Flap size and thorough postoperative wound care are of high importance for proper hip disarticulation [14]. Certain papers note patient age of over 65 years and a lower economic status as possible predictors for the development of complications [15].…”

Impacto da cirurgia de damage control no ano de 2020: uma revisão de literatura / Impact of damage control surgery in 2020: a literature review

“…Nesse contexto, a cirurgia de controle de danos caracteriza-se como um importante avanço no controle da morbimortalidade dos pacientes graves e politraumatizados 3,4 . Entretanto, a falta de protocolos específicos para a sua indicação a torna um importante desafio nos hospitais de todo o Brasil, valorizando-se então a experiência clínica e a capacidade de decisão do cirurgião 1,5,6 .…”