Staged reconstruction of severe perineal destruction with open pelvic and femoral fractures: a 5-year follow-up case report
Kehai Mei, Ye Xu, Lizhi Yu, Jinzhan SunIntroduction and importance:
Open pelvic fracture with perineal destruction and an open femoral fracture is uncommon and carries a high risk of infection and functional loss. Concurrent management of the pelvic ring, femur, and perineal soft tissues is particularly demanding.
Presentation of case:
A 36-year-old man sustained a high-energy industrial crush injury with an open pelvic fracture, an open femoral shaft fracture, and a heavily contaminated perineal wound. After resuscitation, external fixation, and exploration, colostomy and urinary diversion were omitted. Infection was controlled with serial debridement and anus-sparing negative-pressure wound therapy with instillation (NPWTi), followed by skin grafting. The pelvic ring remained stable after external fixation. Femoral reconstruction with internal fixation and an external fixator was performed on day 84. Delayed union at 14 months was managed with staged dynamization. At 51 months, he had returned to work; the Harris Hip Score was 87 and the Majeed Pelvic Score was 86. Radiographs at 60 months showed maintained fracture union and bone remodeling.
Clinical discussion:
With an intact anorectum, anus-sparing NPWTi was used without fecal diversion. Staged fixation balanced infection risk and stability. Dynamization for delayed union was followed by callus formation and union. This approach does not replace fecal diversion when the anorectum is injured.
Conclusion:
A staged approach to damage control, infection control, and delayed reconstruction may help selected patients with severely contaminated open pelvic and femoral fractures to achieve favorable outcomes.