Factors Influencing Need for Hip Disarticulation after Heroic Vascular Intervention

Hip disarticulation is a rare major lower extremity amputation that is usually performed after trauma or severe infection by orthopedic and plastic surgeons. Rarely, vascular surgery patients require this type of amputation for progressive ischemia or necrosis above the mid femur level of the leg. The purpose of this study is to evaluate the factors influencing this type of procedure as well as the indications and outcomes of hip disarticulations performed by vascular surgery at our institution. Retrospective review of a prospectively collected computerized surgery management system for a single academic institution was queried for hip disarticulations performed by the vascular surgery service. Procedures were performed by vascular surgeons with variable flaps and closures depending on extent of tissue necrosis and ischemia. Demographics, risk factors, operative details, and outcomes were recorded from de-identified data. From January 1, 2003 to July 31, 2022, 25 hip disarticulations were performed. The mean age was 58.8 years (range, 21-79 years) and 17 (68%) were males. Risk factors were: smoking (n = 13; 52%), hypertension (n = 13; 52%), coronary disease (n = 8; 32%), hypercholesterolemia (n = 8; 32%), diabetes (n = 4; 16%), renal failure (n = 2; 8%), and chronic obstructive pulmonary disease (n = 2; 8%). Indications were gangrene/wound (n = 18; 72%), infection (n = 6; 24%), and arterial thrombosis (n = 1; 4%). Twenty patients (80%) had prior lower extremity revascularizations, of which two (8%) were inflow only, five (20%) were infrainguinal bypasses, and 13 (52%) had inflow and outflow bypasses. Twenty-eight (88%) had prior ipsilateral major amputations with 12 undergoing subsequent debridement of the prior amputation site. Mean follow-up was 21 months (range, 1-79 months). 30-day mortality was 12% (n = 3) and 32% (n = 8) at 90 days. Seventeen (68%) required further debridement and revision. No patients were ambulatory at follow-up. Hip disarticulation is an extreme lower extremity amputation performed for massive tissue loss and ischemia. The majority of these patients had undergone aggressive revascularization procedures and mid-femur amputations in an attempt to limit the need for disarticulation. This type of amputation can be performed with moderate operative mortality rates and have successful healing with diligent wound care and debridement, but postoperative ambulation is most likely not possible.