Hip disarticulation - case series analysis and literature review

Peripheral Arterial Disease and Prosthetic Joint Infection Resulting in Hip Disarticulation: A Case Report

Introduction

The aim of this study was to report a patient with refractory prosthetic joint infection (PJI) and severe peripheral arterial disease that necessitated hip disarticulation (HD), a rare and aggressive procedure. While this is not the first HD performed due to PJI, this is the first reported incidence that deals with profound infection burden along with immense vascular disease that has failed all other treatment options.

Case Report

We report a case of an elderly patient with a prior history of the left total hip arthroplasty, PJI, and severe peripheral arterial disease who underwent a rare HD procedure and was discharged with minimal complications. Before this major surgery, several surgical revisions and antibiotic regimens were attempted. The patient had also failed a revascularization procedure to treat an occlusion stemming from the peripheral arterial disease and had developed a necrotic wound at the surgical site. Irrigation and debridement of associated necrotic tissue was unsuccessful and due to concerns such as cellulitis, HD was performed with patient consent.

Conclusion

HD is a rare procedure that comprises only 1-3% of all lower limb amputations and is reserved for extremely deleterious indications such as infection, ischemia, and trauma. Complication and 5 year mortality rates have been reported to be as high as 60% and 55%, respectively. Despite these rates, the patient case illustrates a situation, in which early detection of indications for HD prevented further negative outcomes. Based on this case, we believe that HD is a reasonable treatment of choice in patients with severe peripheral arterial disease who fail revascularization and prior moderate treatment options. However, the limited availability of data involving HD and variety of comorbid conditions necessitate further analysis in terms of outcomes.

A hip disarticulation prostheses test system to simulate gait for prostheses evaluation

BACKGROUND

The limited number of hip prostheses users makes it less feasible to conduct amputee tests for prosthesis development in the clinic, which restricts the development efficiency of the intelligent prostheses.

OBJECTIVE

This study proposes a hip disarticulation prostheses test system (HDPTS) to supplement the amputee tests for hip disarticulation prosthesis (HDP) evaluation, which would potentially facilitate the prosthesis evaluation safety and development efficiency.

METHODS

The hip trajectory of an individual with normal gait was acquired and reproduced by calculating the corresponding movement joint angle of a manipulator. Then, an HDP was fit on an amputee and on the HDPTS respectively to obtain the hip and knee joint angles of the HDP during walking. Comparing the root mean square error (RMSE) of the expected and planned trajectory, the joint angles between the amputee test and HDPTS test, to verify the feasibility and accuracy of the HDPTS for prosthesis evaluation.

RESULTS

The RMSE between the expected and planned trajectory value was less than 1.20 mm (< 0.19%). The RMSE of the joint angles between the amputee test and HDPTS test were 2.18∘ (1.8%) and 3.13∘ (5.92%) for hip and knee joint respectively.

CONCLUSION

The HDPTS was found accurate in hip trajectory reproduction and feasible in gait simulation for the prosthesis evaluation, which could potentially supplement the amputee test for prosthesis design thus improving prosthesis test safety and development efficiency.

Hip Disarticulation in Wound Care: A Case Series

BACKGROUND

Hip disarticulation (HD) is a radical lower extremity amputation performed by carefully transecting all muscles and nerves surrounding the hip joint and separating the leg at the joint capsule. It is considered a last resort to be used as a life-preserving measure under emergent circumstances due to high rates of morbidity and mortality.

METHODS

This case series presents 4 patients who underwent HD. The procedure was performed due to various indications including necrotizing fasciitis, gangrene, stump necrosis from previous above-the-knee amputation, and septic joint secondary to chronic osteomyelitis, 3 of which were planned and 1 was emergent.

RESULTS

The procedure was performed successfully in all 4 patients. Furthermore, all patients were eventually discharged to home or to a long-term care facility for wound care or rehabilitation.

CONCLUSIONS

Overall, HD should be reserved as a life-saving treatment for various indications including infections that fail other modalities, limb ischemia, trauma, and malignancy. Ideally, this procedure would be planned and performed on proper candidates; however, HD should still be a consideration in the emergent setting regardless of most optimal patients due to its life-saving potential.

Periprosthetic Fungal Infections in Severe Endoprosthetic Infections of the Hip and Knee Joint-A Retrospective Analysis of a Certified Arthroplasty Centre of Excellence

The treatment of periprosthetic joint infections (PJI), and especially of re-infections, poses a highly complex problem in orthopaedic surgery. While fungal infections are rare, they present a special challenge. The therapy is often protracted and based on limited evidence. A total of 510 hip and knee revision surgeries were analysed for the occurrence of bacterial and fungal PJI. In patients with PJI, the duration of the hospital stay and the incidence of disarticulation of the infected joint were recorded. Out of the analysed revision arthroplasties, 43.5% were due to PJI. Monomicrobial infection occurred in 55.2%, dual microbial infection in 21.4%, and polymicrobial (≥3 different bacterial or fungal species) infection in 17.2% of the cases. Overall, Candida species were detected in 12.4% cases. Candida albicans was the main fungal pathogen. In 6.9% of cases, disarticulation of the joint was the only option to control PJI. The detection of polymicrobial infection more than doubled in follow-up revisions and there was a strong association between detection of Candida infection and disarticulation (OR 9.39). The majority of fungal infections were mixed infections of bacteria and Candida albicans. The choice of a biofilm penetrating antimycotic, e.g., caspofungin, together with a sufficient standard procedure for detection and surgical treatment can help to control the infection situation. Fungal infection often proves to be more difficult to treat than anticipated and is more frequent than expected.

Regaining Gait Using an Early Postoperative Hip Prosthesis: A Case Report of an Elderly Woman

Background:

Hip prostheses are generally avoided in elderly patients because of cognitive decline and/or reduced muscle strength. The present report describes the case of an elderly woman who regained gait using a prosthesis prescribed during the early postoperative phase following hip disarticulation.

Case:

A 78-year-old woman suffered from a pathological fracture caused by liposarcoma of the left thigh. Before hospitalization, the patient was fully independent in her activities of daily living, including gait. The right and left handgrip strengths were 12.9 and 14.2 kg, respectively, and the patient had no signs of cognitive decline. Radical treatment involving hip disarticulation was scheduled. Before surgery, the possibility of fitting a hip prothesis that would allow the patient to walk was discussed, to which she consented. On postoperative day 23, the patient was fitted with a hip prosthesis and began gait training. On day 31, she was able to walk using a fixed walker and, eventually, using a crutch.

Discussion:

The present case demonstrated the successful reacquisition of gait using a hip prothesis prescribed during the early postoperative phase after amputation, suggesting that the applicability of hip prostheses may be widely considered even for elderly patients.

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

Background

Although 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.

Methods

We 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.

Results

All 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.

Discussion

Proper 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.

A case of an elderly hip disarticulation amputee with rheumatoid arthritis who regained the ability to walk using a hip prosthesis

[Purpose] We report a case of an elderly patient with rheumatoid arthritis who underwent hip disarticulation because of necrotizing fasciitis and regained the ability to walk independently with a prosthetic limb. [Participant and Methods] A 61-year-old female patient underwent right hip disarticulation due to severe necrotizing fasciitis of the right lower limb. Her chief complaint was that she was not able to walk inside her house or outdoors to perform instrumental activities of daily living. We applied a Canadian-type hip disarticulation prosthesis to the stump. The patient received in-hospital physical therapy, occupational therapy, and clinical psychology counselling for 145 days. As her hands and fingers were weakened by rheumatism, we made several modifications to the prosthesis to enable the patient to attach and detach it independently. [Results] The patient was able to use the prosthesis to walk continuously for 45 m, perform various housework duties, drive a car, and go out, thus accomplishing the desired daily activities. [Conclusion] Our patient, an elderly hip disarticulation amputee with rheumatoid arthritis, was able to walk independently using a prosthetic limb. The application of prosthetic limbs may be appropriate even for hip disarticulation amputees with comorbidities that make it difficult to acquire a prosthetic gait.