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Treatment of Hip Osteomyelitis Using a Modified Disarticulation Closure Method in Paraplegic Patients
Joel B. Durinka, MD1, Rashad G. Choudry, MD1, Nadia Awad, MD1, Sue Y. Lee, MD1, Jack W. Shilling, MD1, H. Hank Simms, MD1, Jeffrey Indes, MD2.
1Albert Einstein Medical Center, Philadelphia, PA, USA, 2Yale University School of Medicine, New Haven, CT, USA.
INTRODUCTION: Historically, hip disarticulation surgery (HDS) is needed for above the knee amputation failure secondary to arterial insufficiency. Patients with spinal cord injury and paraplegia may develop decubitus ulcers and resultant hip osteomyelitis. Classical gluteal muscle flap closure is not an option given the location of necrosis and bone infection. Additionally, HDS may create challenges for upright posture for bed-bound patients with paraplegia.
METHODS: Five HDS (4 patients) were performed in a 60 month period utilizing a quadriceps-based anterior myocutaneous flap for acetabular coverage. All 4 patients presented with putrid hip necrosis and systemic sepsis. Significant comorbidities included severe hypo-albuminemia (2 patients), diabetes mellitus and dialysis-dependency (1 patient). Arterial ultrasound to confirm patency of the ilio-femoral system and superficial femoral artery (SFA) was performed. One patient required pre-operative ipsilateral iliac artery stenting.
RESULTS: In all cases, the myocutaneous flap was based on a patent SFA documented at surgery. All patients healed their primary hip wounds completely and remain alive since surgery. Notably, estimated blood loss was high (>500 mL) and transfusions were required at each operation. All 4 patients required extensive wound care using negative pressure therapy for chronic sacral wounds. One patient received supplemental hyperbaric oxygen therapy. Two patients required soft tissue surgery to promote healing of the sacral ulcers. All 5 procedures maintained SFA patency there was no evidence of flap necrosis necessitating debridement. All 4 patients have been able to sit upright using the muscle mass afforded by the quadriceps muscle group functioning as a “pseudo-stump”.
CONCLUSIONS: We have found that a fully vascularized, anterior thigh myocutaneous flap affords excellent healing of the acetabulum following hip removal in paraplegic patients. Creation of a “pseudo stump” may allow for avoidance of a chronic supine position.
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