Management of Partial Traumatic Hemipelvectomy

Abstract

Partial traumatic hemipelvectomy is a devastating condition. Although by definition the affected limb is not totally transected from the trunk because of retained soft tissue, the reported mortality rate is actually higher than in complete traumatic hemipelvectomy. Between January 2000 and December 2011, a total of 917 patients were admitted to the authors' institution for pelvic fracture. Seven of these patients met the criteria for partial traumatic hemipelvectomy. All 7 patients had multiple associated injuries and met the criteria for Baskett class IV hypovolemic shock on arrival at the emergency department. The amount of bleeding was the greatest issue, and control of hemorrhage and rapid blood transfusion were the initial goals. Abdominal aorta balloon occlusion, laparotomy and packing, and pelvic external fixation were useful to control bleeding. Two patients died during the initial resuscitation phase. Angiography (digital subtraction or computed tomographic) was performed in 4 patients but did not provide any treatment-altering information. Limb preservation was attempted in 2 patients; both of these patients eventually required hindquarter amputation. One patient died, and the second patient survived after a difficult postoperative course. The best results were obtained in 3 patients who underwent completion of the hindquarter amputation within 24 hours of trauma. All patients became wheelchair dependent, and no patient was able to return to work. Early completion of hindquarter amputation after hemorrhaging has been controlled is recommended in patients with partial traumatic hemipelvectomy. Angiography did not prove useful in decision making.

A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination

“…REBOA balloon occlusion times were adequately reported in 35 studies [ 10 , 12 , 23 , 25 , 26 , 29 – 34 , 36 , 38 – 41 , 43 – 45 , 47 , 48 , 55 , 58 , 62 , 66 , 68 – 71 , 82 , 83 , 97 , 101 , 104 , 105 ]. Occlusion times within the zones of occlusion were described in 15 studies examining Zone I occlusion times, where 196 patients had a median occlusion time of 58.4 min.…”

Partial Zone II Resuscitative Endovascular Balloon Occlusion of the Aorta in Management of Multiple Trauma with Combined Abdominal and Pelvic Injury

“…Partial inflation with controlled hypotensive target allowed benefits overcome risks of a defective procedure. REBOA adoption, even in a potentially dangerous position, gave authors time to move patient from OR to angiographic room (not available at the moment in our hospital a hybrid surgical angiographic suite) [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] and time to find the primary source in a severe and multiple hemorrhagic trauma, with good clinical outcome.…”

Traumatic Hemipelvectomy: Surgical and Medical-Legal Aspects

“…In fact, studies show that even in cases where the limb remains connected to the pelvis with residues of structures (skin, muscles, tendons, etc. ), before proceeding with any reparative surgical operations of any harmed internal organs, the general recommendation is to complete the hemipelvectomy, as hemostasis (control of hemorrhage is the initial and primary goal) and an adequate debridement are easier to realize, leading to fewer complications [24][25][26][27]. The limb of our patient was completely amputated, lying about 12 feet from the subject, so after drug therapy exploratory laparotomy was immediately carried out, which allowed us to safely perform hemostasis and then, once damage of internal organs was accurately identified, to rapidly proceed to repair them.…”