Hip disarticulation and external hemipelvectomy for infectious indications: a systematic review

Hip disarticulation and external hemipelvectomy are radical lower-extremity amputations typically reserved for oncologic, traumatic, or severe infectious indications. Outcome estimates for refractory infectious cases remain sparse, and prior reports mix case reports, small series, and administrative databases with inconsistent mortality windows and limited functional follow-up.

This systematic review was reported in accordance with PRISMA 2020 and prospectively registered in PROSPERO (CRD420261277037). PubMed, Embase, Web of Science, and Cochrane CENTRAL were searched from inception through January 3, 2026. Case reports, case series, and retrospective cohort/database studies were eligible when infectious-indication HD or EH cases were separable. Findings were synthesized narratively. Mortality was summarized primarily at the patient level, with sensitivity analyses separating individual case reports, aggregate studies, and the largest registry cohort. Critical appraisal used JBI checklists for case reports/case series and a modified Newcastle-Ottawa Scale for retrospective cohort/database studies.

Forty-nine studies encompassing 289 infectious-indication patients met inclusion criteria. Periprosthetic joint infection was the most common indication (157/289, 54.3%), followed by necrotizing fasciitis (26/289, 9.0%). One national database study contributed 148 patients, and two patients underwent revision from HD to EH, yielding 291 procedures. Thirty-seven early or in-hospital deaths were explicitly reported; because the largest database study suppressed death counts below 11, the patient-level upper-bound mortality estimate was 37 to < 48 deaths among 289 patients (12.8% to < 16.6%), not a precise pooled rate. Excluding the large registry cohort, early mortality was 37/141 (26.2%). Functional outcome was documented for only 67 survivors; 42/67 (62.7%) remained wheelchair-dependent or bedbound, and 25/67 (37.3%) achieved some degree of ambulation.

Hip disarticulation and external hemipelvectomy performed for infection are associated with substantial early mortality and major functional impairment among survivors. Available evidence does not support a single precise pooled mortality estimate because reporting windows, cohort structures, and follow-up duration vary substantially. Functional results are especially uncertain because they are reported in a minority of survivors.