Management of traumatic hemipelvectomy: an institutional experience on four consecutive cases
© Wu et al.; licensee BioMed Central Ltd. 2013
Received: 25 March 2013
Accepted: 5 August 2013
Published: 16 August 2013
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© Wu et al.; licensee BioMed Central Ltd. 2013
Received: 25 March 2013
Accepted: 5 August 2013
Published: 16 August 2013
The incidence of traumatic hemipelvectomy is rare, but it is a devastating injury. Recently, an increasing number of patients with traumatic hemipelvectomy are admitted to trauma centers alive due to improvements of the pre-hospital care. Successful management requires prompt recognition of the nature of this injury and meticulous surgical technique. We present our successful experiences on four cases of traumatic hemipelvectomy in the past nine years.
Four cases with traumatic hemipelvectomy were admited to our hospital from June 21, 2002 to September 3, 2011. All injuries occurred due to vehicle accident and all patients were in a state of severe hypotension, with two of them having anal lacerations. These four cases were treated immediately with resuscitation, control of hemorrhage, early amputation, repeated debridement and closure of the wounds. An angiographic embolization was given to control hemorrhage in two of the cases preoperatively. One case underwent fecal diversion. Wound infection occurred in all of cases which was successfully controlled by repeated debridements, effective anti-biotic regimen, split-thickness skin grafts.
All four cases were saved successfully with well-healed wounds during follow up from 1 to 7 years. They were able to walk by themself using crutches.
Adhering to the surgery principles of damage control including appropriate resuscitation, hemorrhage control, coagulopathy correction and multiple debridements and closure of the wounds in reasonable period of time can save the life of cases suffering from severe pelvic ring injury.
Traumatic hemipelvectomy is a catastrophic injury. It is rarely seen in clinical practice because only a small number of cases can be survival and are transfered to the hospital. From 1915, when the first case of traumatic hemipelvectomy was successfully treated, there have been increasing numbers of cases were reported to be successfully treated[2–4]. A total of seven cases with traumatic hemipelvectomy were treated in our hospital from June 21, 2002 to September 3, 2011. Two cases died from hemorrhage before and after operation respectively, and one case was transferred to a local hospital two days after amputation and was lost to follow-up. The remaining four cases were successfully treated. Here we report the treatment experience on these four cases and summarize a literature review for the management of traumatic hemipelvectomy.
Traumatic hemipelvectomy is a special type of pelvic fracture that is characterized by the wide separation of the innominate bone from the pubic symphysis and sacrum, the avulsion of the external iliac vessels, and the severe stretch injury or disruption of the femoral and sciatic nerves. The majority of the injuries are open fractures with extensive disruption of the soft tissues in the ipsilateral inguinal and perineal area,and greater than 50% inactivation of the injured limb when still attached to the trunk. In recent years, with the improvement of medical transportation and traumatic care, the number of successfully treated patients of traumatic hemipelvectomy has gradually increased; a total of 10 cases were reported prior to 1977, 19 cases till 1990 and 99 cases prior to 2006.
The most common cause of the injury was a motor vehicle accident involving either pedestrians or cyclists, in which the victim was hit by an oncoming vehicle. Due to the immense external forces involved, the injured limb is usually extremely rotated and dorsiflexed, resulting in complete separation of the pubic symphysis and the sacroiliac joint. Wade first described this mechanism of injury in 1965, and suggested that more than 40% of traumatic hemipelvectomy cases belong to this type of injury. A second mechanism of injury involves the limbs and pelvis were entangled by heavy machinery such as the chassis of a vehicle, harvester combines or conveyor belts. In addition, patients are directly injured by heavy objects, in which the upper body is thrown out of a vehicle while the legs are entangled in the car as well as the direct blow of yacht propeller, which can also result in traumatic hemipelvectomy[3, 6].
The leading causes of death in patients with traumatic hemipelvectomy are blood loss, infections and multiple organ failure. The successful rescue of these patients depends on the following key steps: First, hemorrhage control and vigorous resuscitation. Direct clamping of the large bleeding vessels should be the first step in resuscitation. It has been acknowledged that circumferential compression with a sheet is cost effective method of hemostasis. Wrapping the circumference of the pelvis with sheets and knotting in front of the pelvis can form a wound compression bandage that is effective in controlling bleeding in cases with a complete separation of the injured limb from body. However, this method is sometimes less than ideal for circumstances in which the injured limb is still partially attached to the trunk. In such cases, hemipelvectomy is a life-saving intervention. It has been reported that the early angiography and subsequent embolization should be considered in cases of continued unexplained blood loss.
The hemostatic effect of artery embolization in various pelvic fractures remains controversial. We reviewed 19 cases with traumatic hemipelvectomy reported from 1983 to 2005[1, 3], only four cases underwent arterial embolization before amputation and one case received artery embolization after amputation. Some researchers were of the opinion that only 20% of pelvic fracture bleeding was caused by injury to the small arteries of the pelvis, other sources of bleeding included cancellous bony site and venous plexus in the pelvis[10, 11]. Therefore, it suggested that arterial embolization might not be effective in stopping the majority of hemorrhage. Arterial embolization was given in 2 cases in our study. Though the wounds in the other two cases were large, there was no evidence of active bleeding, arterial embolization was not performed. and amputation surgery was carried out successfully.
The second important factor for the successful rescue of traumatic hemipelvectomy patients is early amputation. Early amputation in these patients can achieve complete hemostasis of the wound, simplify the treatment process and reduce infection and other complications. According to the principle of damage control, severe trauma and bleeding (the first strike) cause a severe inflammation and response syndrome (SIRS). Surgery and blood transfusion can act as a secondary strike which may aggravate the inflammation and result in uncontrolled systemic inflammatory response syndrome, further developing to multiple organ dysfunction syndrome (MODS), which is the main cause of delayed death in severe trauma patients. Amputation is a life-saving surgery and the surgical process should be simplified to minimize the “second hit” to the patients as long as it achieves the aim of amputation and hemostasis. The surgery should be terminated immediately when the trauma triad of death viz. hypothermia (T < 35°C), coagulopathy (PT, APTT > 1.5 times of normal value) and acidosis (pH < 7.2) occur. In our experience, the primary procedure should be limited to 90 min, extensive debridement should not be attempted and the wound should be pressure dressed after surgery. It is often futile to attempt limb salvage. Pohlemann attempted to salvage the limb in four cases of traumatic hemipelvectomy, 3 of them died and the remaining case had to eventually undergo amputation. Up to now, there was only one case of closed traumatic hemipelvectomy, reported by Osti, in which a partial success with limb salvage was achieved. However, this patient underwent below knee amputation as a result of muscle necrosis, and the remaining stump had neither sensory nor motor function. Encouragingly, the patient could wear prosthetics on the stump and walk independently without crutches.
The third most important factor for successful rescue is the treatment of associated injuries. Because the physical forces causing traumatic hemipelvectomy are tremendous, 60% of the patients sustain anorectal lesions, and 85% have genitourinary injury. 48.3% and 13.8% of patiemts had other ipsilateral limb injuries and abdominal organ damage, respectively. Therefore, many researchers suggested that laparotomy should be performed as a routine step of treatment. Moore found missed splenic injury in a case and underwent splenectomy in the laparotomy. Colostomy should be performed in patients with anorectal injury to prevent fecal contamination of the pelvic wound. Many researchers suggested that sigmoid colostomy should also be performed in patients without anorectal injury to prevent the contamination of the pelvic wound with feces. We suggested the stoma of the colostomy should be located in the ipsilateral side of the injured leg, so the contralateral vertical rectus abdominis musculocutaneous(VARM) flap which is a life-boat flap could be used to construct the nonhealing hemipelvectomy wounds. Horst summarized 59 cases of traumatic hemipelvectomy, of which 79.7% underwent sigmoid colostomy. In the four cases reported here, only one patient underwent a routine colostomy, while the remaining three cases, including one with anorectal injury, did not undergo colostomy. Wound infection developed in all four cases, and contamination and existing necrotic tissue were the main source of severe infection rather than the fecal contamination. Retrograde cystourethrogram can be used in the diagnosis of bladder and urethral injury. The treatment option is cystostomy or delayed reconstruction of the urethra, because of the higher failure rate of early reconstruction.
The fourth important factor for the rescue of these patients is repeated debridement and control of infection. Wound infection, which may result from incomplete debridement or contamination with feces and urine, is a most common cause of delayed death after traumatic hemipelvectomy. The best way to prevent and treat infection is repeated debridement. Patients with serious trauma cannot tolerate long periods of extensive debridement. In addition, injured soft tissue which appears normally at early stages may become necrotic gradually. For these two reasons, repeated debridement is unavoidable. Horst’s results indicated that 86% of patients underwent debridement on an average of 3.2 times, ranging from 1 to 10 times. Only in small number of cases, the wound can be closed at the primary stage followed amputation, and did not need repeated debridement. All four cases reported here developed infection and presented with sustained high fever. The fever gradually decreased to normal and the wound eventually healed after repeated debridements (at least one debridement and up to eight times, the average times of debridement were five) and treatment with specific antibiotics. The timing of debridement is very important as well. The interval of debridement ranged from 3–4 day following the primary surgery. For patients whose general condition was relatively stable with normal coagulation, debridement should be more thoroughly for less bleeding. In addition, the systemic inflammatory response caused by first-strike was decreasing gradually, therefore debridement on the third or fourth postoperative day should avoid overlap of first strike with the “second hit” to prevent an excessive systemic inflammatory response. The duration of the first and second debridements should generally be limited to 90 min. Active bleeding should be stemmed before wound dressing. Hemostasis with gauze packing in this condition was unreliable, due to the extent of the wounds, the pressure dressings were unreliable and prone to loosen, resulting in incomplete hemostasis and persistent postoperative bleeding.
Particular attention should be paid to the necrosis of iliopsoas muscle during debridement. The level of iliopsoas muscle necrosis gradually rose in two patients of this group following debridement, and ultimately the iliopsoas had to be completely resected below the diaphragm. Several researchers have previously noted this phenomenon of delayed necrosis of the iliopsoas muscle[3, 14]. It has been suggested that the iliopsoas undergoes strong contraction during the incident, and its blood supply was impacted significantly, which was followed by gradual necrosis. Therefore, many experts have advocated that the iliopsoas should be resected completely if there is any question about the viability of the muscle. The wound should be best covered by the myocutaneous gluteus flap after debridement. Split-thickness skin grafting can be used to cover the remaining wound if it cannot be completely covered by the gluteal flap. A free flap can also be used to cover the wound, however, this requires excellent microsurgical technique.
A patient described in another study developed Gram-negative meningitis. The authors estimated that meningitis was secondary to ascending infection along the course of the avulsed lumbar and sacral nerve roots. The patient had a high fever and suffered from delirium. Gram-negative bacteria were cultured from cerebrospinal fluid. Therefore, cerebrospinal fluid culture should be considered for patients with unexplained fever and consciousness disorders after injury.
Furthermore, nutritional support, early psychiatric consultation, management of depression and phantom limb pain and timely physiotherapy contributed significantly to the functional rehabilitation of these patients. It is noteworthy that the treatment of traumatic hemipelvectomy is a very complex procedure associated with a high cost burden, which the patients and their families must be aware of.
In summary, the successful management of patients with traumatic hemipelvectomy is challenging. The principles of damage control should be adhered to in the treatment procedure. Resuscitation, hemorrhage control and amputation should be the priorities, followed by repeated debridements and wound closure. The cooperation and dedication of a multi-disciplinary team of medical staff is a prerequisite for successful treatment.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Red blood cells
Severe inflammation and response syndrome
Multiple organ dysfunction syndrome
Disseminated intravascular coagulation.
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