Amputations of the Hip and Pelvis

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Chapter 17 Amputations of the Hip and Pelvis

Marc J. Mihalko

DISARTICULATION OF THE HIP 

HEMIPELVECTOMY 

Hip disarticulation and the various forms of hemipelvectomy most often are performed for the treatment of tumors. The dimensions of the amputation vary with oncological requirements, and nonstandard flaps often are necessary. Although satisfactory prostheses are available, few patients find them to be useful. For patients with such high-level amputations, the energy requirements to use a prosthesis have been estimated to be 200% of normal ambulation; wheelchair locomotion is faster and requires less energy expenditure; however, especially in younger patients, providing prosthetic walking ability for even short distances may be beneficial to physical and mental health.

Disarticulation of the Hip

Hip disarticulation occasionally is indicated after massive trauma, for arterial insufficiency, for severe infections, for massive decubitus ulcers, or for certain congenital limb deficiencies. Most frequently, however, hip disarticulation is necessary for treatment of bone or soft tissue sarcomas of the femur or thigh that cannot be resected adequately by limb-sparing methods. Hip disarticulation accounts for 0.5% of lower extremity amputations. Mortality rates vary in studies from 0% to 44%. The inguinal or iliac lymph nodes are not routinely removed with hip disarticulation. The anatomical method of Boyd and the posterior flap method of Slocum are described here; however, modifications frequently are required based on location of pathology.

Anatomical Hip Disarticulation

Technique 17-1

(BOYD)

image With the patient in the lateral decubitus position, make an anterior racquet-shaped incision (Fig. 17-1A), beginning the incision at the anterior superior iliac spine and curving it distally and medially almost parallel with the inguinal ligament to a point on the medial aspect of the thigh 5 cm distal to the origin of the adductor muscles. Isolate and ligate the femoral artery and vein, and divide the femoral nerve; continue the incision around the posterior aspect of the thigh about 5 cm distal to the ischial tuberosity and along the lateral aspect of the thigh about 8 cm distal to the base of the greater trochanter. From this point, curve the incision proximally to join the beginning of the incision just inferior to the anterior superior iliac spine.

image Detach the sartorius muscle from the anterior superior iliac spine and the rectus femoris from the anterior inferior iliac spine, and reflect them both distally.

image Divide the pectineus about 0.6 cm from the pubis.

image Rotate the thigh externally to bring the lesser trochanter and the iliopsoas tendon into view; divide the latter at its insertion and reflect it proximally.

image Detach the adductor and gracilis muscles from the pubis, and divide at its origin that part of the adductor magnus that arises from the ischium.

image Develop the muscle plane between the pectineus and obturator externus and short external rotators of the hip to expose the branches of the obturator artery. Clamp, ligate, and divide the branches at this point. Later in the operation the obturator externus muscle is divided at its insertion on the femur instead of at its origin on the pelvis because otherwise the obturator artery may be severed and might retract into the pelvis, leading to hemorrhage that could be difficult to control.

image Rotate the thigh internally, and detach the gluteus medius and minimus muscles from their insertions on the greater trochanter and retract them proximally.

image Divide the fascia lata and the most distal fibers of the gluteus maximus muscle distal to the insertion of the tensor fasciae latae muscle in the line of the skin incision, and separate the tendon of the gluteus maximus from its insertion on the linea aspera. Reflect this muscle mass proximally.

image Identify, ligate, and divide the sciatic nerve.

image Divide the short external rotators of the hip (i.e., the piriformis, gemelli, obturator internus, obturator externus, and quadratus femoris) at their insertions on the femur, and sever the hamstring muscles from the ischial tuberosity.

image Incise the hip joint capsule and the ligamentum teres to complete the disarticulation (Fig. 17-1B).

image Bring the gluteal flap anteriorly, and suture the distal part of the gluteal muscles to the origin of the pectineus and adductor muscles.

image Place a drain in the inferior part of the incision, and approximate the skin edges with interrupted nonabsorbable sutures.

image

FIGURE 17-1 Boyd disarticulation of hip. A, Femoral vessels and nerve have been ligated, and sartorius, rectus femoris, pectineus, and iliopsoas muscles have been detached. Inset, Line of skin incision. B, Gluteal muscles have been separated from insertions, sciatic nerve and short external rotators have been divided, and hamstring muscles have been detached from ischial tuberosity. Inset, Final closure of stump. SEE TECHNIQUE 17-1.

(Redrawn from Boyd HB: Anatomic disarticulation of the hip, Surg Gynecol Obstet 84:346, 1947.)

Posterior Flap

Technique 17-2

(SLOCUM)

image Begin the incision at the level of the inguinal ligament, carry it distally over the femoral artery for 10 cm, curve it along the medial aspect of the thigh, continue it laterally and proximally over the greater trochanter, and swing it anteriorly to the starting point. A posteromedial flap long enough to cover the end of the stump is formed.

image Isolate, ligate, and divide the femoral vessels, and section the femoral nerve to fall well proximal to the inguinal ligament.

image Abduct the thigh widely, and divide the adductor muscles at their pubic origins.

image Section the two branches of the obturator nerve so that they retract away from pressure areas.

image Free the origins of the sartorius and rectus femoris from the anterior superior and anterior inferior iliac spines. Moderately adduct and internally rotate the thigh, and divide the tensor fasciae latae at the level of the proximal end of the greater trochanter; at the same level, divide close to bone the muscles attached to the trochanter. Next, abduct the thigh markedly and divide the gluteus maximus at the distal end of the posterior skin flap.

image Identify, ligate, and divide the sciatic nerve.

image Divide the joint capsule, and complete the disarticulation.

image Swing the long posteromedial flap containing the gluteus maximus anteriorly, and suture it to the anterior margins of the incision.

Hemipelvectomy

Hemipelvectomy most often is performed for tumors that cannot be adequately resected by limb-sparing techniques or hip disarticulation. Other indications for hemipelvectomy include life-threatening infection and arterial insufficiency. Chan et al. reported hemipelvectomy for decubitus ulcers in patients with spinal cord injury. In contrast to hip disarticulation, all types of hemipelvectomy remove the inguinal and iliac lymph nodes.

The standard hemipelvectomy employs a posterior or gluteal flap and disarticulates the symphysis pubis and sacroiliac joint and the ipsilateral limb. An extended hemipelvectomy includes resection of adjacent musculoskeletal structures, such as the sacrum or parts of the lumbar spine. In a conservative hemipelvectomy, the bony section divides the ilium above the acetabulum, preserving the crest of the ilium. Internal hemipelvectomy is a limb-sparing resection, often achieving proximal and medial margins equal to the corresponding amputation. This procedure is discussed in Chapter 24.

All types of hemipelvectomy are extremely invasive and mutilating procedures. They require optimizing the patient’s nutritional status, preparing for blood replacement, and adequate monitoring during surgery. Many patients have significant phantom pain in the early postoperative course. Flap necrosis and wound sloughs are common complications. In their review of 160 external hemipelvectomies, Senchenkov et al. reported a morbidity rate of 54%, including intraoperative genitourinary (18%) and gastrointestinal injuries (3%). Wound complications were the most common postoperative complications, including infection and flap necrosis. Patients with a posterior flap, who had ligation of the common iliac vessels, were 2.7 times more likely to have flap necrosis than those patients who had ligation of the external iliac vessels. Appropriate emotional and psychological support is an important part of rehabilitation. Although good prostheses are available for patients after hemipelvectomy, few find them useful. Techniques for the standard, anterior flap and conservative hemipelvectomy are described.

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