Prosthetic Rehabilitation After Hip Disarticulation or Hemipelvectomy

Duration, frequency, and factors related to lower extremity prosthesis use: systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis investigating the duration and frequency of lower extremity prosthesis use and what factors were associated with changes in their use.

MATERIALS AND METHODS

A search of PubMed, CINAHL, and Scopus over 20 years revealed 2409 articles. After review, 29 studies remained, representing 4814 participants with lower limb loss. Quality, funding, publication, and quantitative analyses were addressed.

RESULTS

The mean prosthesis use was 9.6 (5.3) hours/day and 6.4 (1.9) days/week. Distal amputation sites averaged more hours/day of prostheses use than proximal amputations (13.2 [3.2] vs. 10.8 [5.0], p < .001). After hemipelvectomy or hip dislocations, average prostheses use was less hours/day (6.0 [4.7]) than after transfemoral (12.9 [4.8]) or transtibial amputations (14.0 [4.5]) (p < .05). Pooled effects revealed an association between comorbidities and abandonment (OR 0.35, p = .03). The data supported six empirical evidence statements concerning age, sex, social support, amputation proximity, balance, skin condition, comorbidities, pain, falls, and fitness in association with changes in prosthesis utilization.

CONCLUSIONS

The study provided systematic data on lower-extremity prosthesis use, thus helping to inform clinical decision-making and patient education. It also elucidated a path for future studies focused on modifiable factors related to prosthesis use and related outcomes.Implications for rehabilitationLower limb loss can trigger costly and debilitating sequela, which could be mitigated by increased prosthesis use and functionality, but there is no consensus on how often prostheses are being used and what affects changes in their use.When counseling patients on what they can expect after a lower extremity amputation and to set goals, the aggregated means of 9.6 (5.3) hours per day and 6.4 (1.9) days per week can be informative.Individuals who use a lower extremity prosthesis or may have to use one in the future can increase their prosthesis use and mobility by limiting further health deterioration.Rehabilitative care involving the multidisciplinary prioritization of proper socket fit, fitness training, gait training, and social support is associated with increased prosthetic device usage.

Vastus Lateralis Muscle Flap for High-Risk Patients Undergoing Orthopaedic Hip Surgery

INTRODUCTION

Chronic infections and soft-tissue defects are serious complications after total hip arthroplasties (THAs) that may require hip disarticulation (HD). HD is a relatively high-risk procedure with poor long-term outcomes and survival. This is the first study to analyze the effect of an ipsilateral, pedicled vastus lateralis (VL) muscle flap in preventing HD in patients with recurrent complications after THA.

METHODS

This retrospective case review analyzed the 6-month postoperative outcomes of 14 patients who underwent soft-tissue hip reconstruction with a VL muscle flap by a single surgeon.

RESULTS

Most (86%) patients fully recovered after 6 months with preserved hip range of motion, no pain, and no weakness on ambulation. Two (14%) patients ultimately required HD despite introducing a VL flap.

DISCUSSION

A VL muscle flap is an effective treatment of nonhealing THA and prophylactic intervention for patients at high risk for HD. The VL muscle is optimal because of its large size allowing reduction of soft-tissue dead space, its local anatomical location to the hip, and its exceptional vascularity. Additional prospective studies are necessary to determine the most appropriate population for this technique.

Factors affecting successful prosthetic use after hemipelvectomy and hip disarticulation amputations: Five-year experience from a tertiary prosthetic rehabilitation center

BACKGROUND

Rehabilitation after hip disarticulation and hemipelvectomy amputations can be challenging, and many opt to forego prosthetic limb use. There is limited evidence on characteristics that result in successful prosthetic use; therefore, our study aimed to identify these to help guide patient expectations.

METHODS

A retrospective review was performed on patients seen at a UK tertiary prosthetic center in the past 5 years with hip disarticulation or hemipelvectomy amputations. Details and etiology of amputation, length between assessment and delivery of prosthesis, goals, reasons for abandonment, and outcomes were recorded. Successful prosthetic use was defined as the use of a prosthesis at least 3 times a week. Characteristics were compared using odds ratios and Fisher exact test.

RESULTS

Twenty-seven patient notes were analyzed: 42% female, 58% male, and age range 14-90. Thirty percent had a hemipelvectomy, and 70% had a hip disarticulation. Neoplasia accounted for 78% of etiologies followed by trauma 15% and infected endoprosthesis 7%. Sixty-seven percent trialed a walking prosthesis; 33% of these stopped eventually. There were no statistically significant findings of factors increasing odds of successful prosthetic use. However, age significantly increased the odds of being given a trial of a prosthesis.

CONCLUSION

Although younger patients are more likely to be given the opportunity to trial a walking prosthesis, age does not seem to affect the overall outcome alone. In cases of neoplasia, there is often a delayed start to rehabilitation and prosthetic use, which may affect eventual success. Further studies are required to define the optimum characteristics for successful prosthetic use at higher amputation levels.

Heterotopic Ossification Formation in Military Beneficiaries Following Hip- and Pelvic-Level Amputations

INTRODUCTION

Traumatic hip and pelvic level amputations are uncommon but devastating injuries and associated with numerous complications that can significantly affect quality of life for these patients. While heterotopic ossification (HO) formation has been reported at rates of up to 90% following traumatic, combat-related amputations, previous studies included few patients with more proximal hip and pelvic level amputations.

MATERIALS AND METHODS

We conducted a retrospective review of the Military Health System medical record and identified patients with both traumatic and disease-related hip- and pelvic-level amputations performed between 2001 and 2017. We reviewed the most recent pelvis radiograph at least 3 months following amputation to determine bony resection level and the association between HO formation and reason for amputation (trauma versus disease related).

RESULTS

Of 93 patients with post-amputation pelvis radiographs available, 66% (n = 61) had hip-level amputations and 34% (n = 32) had a hemipelvectomy. The median duration from the initial injury or surgery to the most recent radiograph was 393 days (interquartile range, 73-1,094). HO occurred in 75% of patients. Amputation secondary to trauma was a significant predictor of HO formation (χ2 = 24.58; P < .0001); however, there was no apparent relationship between the severity of HO and traumatic versus non-traumatic etiology (χ2 = 2.92; P = .09).

CONCLUSIONS

Amputations at the hip were more common than pelvic-level amputations in this study population, and three-fourths of hip- and pelvic-level amputation patients had radiographic evidence of HO. The rate of HO formation following blast injuries and other trauma was significantly higher compared with patients with non-traumatic amputations.

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.

Hip disarticulation and hemipelvectomy prostheses: A review of the literature

BACKGROUND

Although the global population of people with a hip disarticulation (HD) or hemipelvectomy (HP) amputation is small, the degree of disability is high, affecting function and independence. A comprehensive literature review is needed to examine the evidence for prostheses in these amputation levels.

METHOD

A scoping literature review was conducted to examine related research documents from 1950 to September 2020, found using Scopus, Web of Science, PubMed, and Google Scholar databases. Studies evaluated (retrospectively or prospectively) HD or HP prostheses and were written in English. Study design and protocol, research instrument, sample size, and outcome measures were reviewed.

RESULTS

In the past 70 years, 53 articles that evaluated HD or HP prostheses were published. Most research was conducted in the United States (24 articles) and Japan (nine articles). In 42 articles, authors prospectively evaluated the effects of prostheses in these amputation levels. On average, prospective studies had four (SD = 5) participants. Since 1950, only five prospective studies evaluated HD or HP prostheses with 10 or more participants. Moreover, sufficient information was often unavailable for research replication.

CONCLUSION

More evidence is needed regarding the effects of HD or HP prosthetic components (i.e. hip, knee, ankle, socket type, and suspension system) on gait, patient satisfaction, prosthetic use, interface pressure, and energy expenditure. Articles mostly have small sample sizes that reduce confidence in the reliability of their findings and limit generalizability. Future investigations are needed with vigorous methodology and larger sample sizes to provide strong statistical conclusions.

Pelvic Osseointegration for Unilateral Hip Disarticulation: A Case Report

CASE

A 24-year-old man with right unilateral hip disarticulation, intolerant of a traditional socket-mounted prosthesis (TSP), underwent pelvic transcutaneous osseointegration and was fit with a prosthetic lower extremity 7 months later. Twenty-four months after osseointegration, he remains pain-free and complication-free, wears his prosthesis all waking hours, walks without assistive devices and can carry 2-handed objects, and works as a livestock farmer.

CONCLUSION

Through 24 months, the world's first patient with pelvic osseointegration has no complications and better mobility than most patients with unilateral hip disarticulation using TSPs. Pelvic osseointegration seems reasonable to further consider in carefully selected patients.

Management of Severe Proximal Femur Bone Loss With a Modular Articulating Antibiotic Spacer

Introduction:

Management of periprosthetic infection in total hip arthroplasties is challenging, especially when there is severe loss of proximal femoral bone stock. When a 2-stage approach is used, either a static or an articulating spacer may be considered. Static spacers leave the patient with a flail leg, which can be very difficult with massive bone loss. The purpose of this study is to report a novel technique for articulating antibiotic spacers and report our results.

Materials and Methods:

We describe a technique for an articulating hip spacer in the setting of a large amount of proximal femoral bone loss using a locked intramedullary nail, modular femoral body, and an all-polyethylene constrained acetabular component. This technique allowed for mobilization of the patient without a flail leg. Four patients underwent 2-stage reconstruction, and the case series is reported here.

Results:

No complications occurred due to the spacer, and in all cases, a second reconstruction was later carried out after treatment with intravenous antibiotics. Three of 4 patients did well after 2-stage reconstruction, with 1 patient ultimately requiring an amputation.

Discussion:

We feel this technique improves upon previously reported large spacers due to the stability and maintenance of leg length.

Conclusion:

This technique offers a modular solution to address massive bone loss of the proximal femur in the face of periprosthetic joint infection.

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.

COMPLICATIONS AND COST ANALYSIS OF HEMIPELVECTOMY FOR THE TREATMENT OF PELVIC TUMORS

Objective:

Hemipelvectomy is a complex surgery with a high complication rate. Here, we aimed to identify factors related to the onset of complications and calculate their impacts on hospital costs.

Methods:

We evaluated 31 consecutive patients who underwent hemipelvectomy between 1999 and 2015. We assessed the clinical and radiographic data to determine the patients’ demographic factors, tumor and surgical characteristics, and complications. The individual hospital stays and financial balances were assessed up to 6 months following the index surgery.

Results:

The overall complication rate was 61% (19/31). Infection was the most prevalent complication (36%). Immediate postoperative death occurred in 5/31 patients (16%); another 5 (16%) died after hospital discharge due to disease progression. Histological grade, previous surgery, and previous radiotherapy were not associated with complications or infection. Acetabular resections, bone reconstruction, and longer operative times were associated with infection, whereas older age, pelvic organ involvement, and comorbidities were associated with immediate postoperative death. Complications and infection were associated with 4.8- and 5.9-fold increases in hospital costs, respectively.

Conclusions:

Acetabular resection and bone reconstruction are important factors that increase short-term complication rates, infection rates, and hospital costs. Mortality was associated with older age and adjacent pelvic tumor progression. Level of Evidence: IV, case series.

Health concerns of veterans with high-level lower extremity amputations

BACKGROUND

The aim of the study was to identify health concerns of veterans with high-level lower extremity amputations.

METHODS

Through a cross-sectional study, general practitioners, an orthopedic specialist, psychologists, psychiatrists, physiotherapist and prosthetists examined 100 veterans using a short-form health-related quality of life questionnaire (SF-36) that assessed their ability to perform activities of daily living (ADL), instrumental activities of daily living (IADL) and life satisfaction (SWLS) after hip disarticulation or hemi-pelvectomy amputations. The assessment tool was designed to gather statistically useful information about their health needs.

RESULTS

The means of the Physical Component Summary (PCS), Mental Component Summary (MCS), SWLS, ADL and IADL were 48.58 ± 29.6, 33.33 ± 22.0, 19.30 ± 7.7, 48.10 ± 10.5 and 5.08 ± 1.8, respectively. Somatization, depression, and anxiety were the most prevalent disorders; among the veterans who were visited by psychiatrists, 11.6% had a history of hospitalization in a psychiatry section, and 53.2% had a psychiatric visit. Regardless of their injury in battle, 34% of veterans were hospitalized. Hearing problems were common, and about four-fifths of the participants suffered from at least one orthopedic condition. Neuroma (49%) was the most common stump-related complication during orthopedic evaluations, though the prevalence of phantom pain was 81% during the pain assessment. A total of 87% of the participants had a history of wearing a prosthesis, but only 29% wore a prosthesis at the time of the present study. The Canadian-type of prosthesis was uncomfortable and not useful (27%) and excessively heavy (10%) according to the amputees.

CONCLUSIONS

Understanding veterans' characteristics and special needs are important to make sure that enough facilities and services are afforded to them. These findings emphasize the importance of paying close attention to different dimensions of health in veterans and can help health providers identify health needs and make regular assessments.

Traumatic Hemipelvectomy with a Contralateral Unstable Pelvis and Acetabular Fracture: A Case Report and Review of the Literature

CASE

A traumatic hemipelvectomy (THP) is a rare life-threatening injury, with limited reports in the civilian population. We present the case of a patient who sustained a massive pelvic injury with an incomplete unilateral THP, a contralateral unstable pelvis, and a fracture of the acetabulum.

CONCLUSION

With advancements in resuscitative techniques, carefully timed and planned surgical interventions, and a coordinated multidisciplinary approach, a greater number of patients may be able to survive a massive pelvic injury.