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Amputations of the Hip and Pelvis
Hip disarticulation and the various forms of hemipelvectomy most often are performed for the treatment of primary bone tumors and rarely for metastases, infection, or trauma. Improved treatments with chemotherapy, radiation, and biologics are increasing survival of patients with malignancies, which has increased the indications for aggressive treatment of these tumors. The dimensions of the amputation vary with oncologic requirements, and nonstandard flaps often are necessary. For patients with such high-level amputations, the energy requirements to use a prosthesis have been estimated to be 250% of normal ambulation. Wheelchair and crutch locomotion are 50% faster and require less energy expenditure; however, especially in younger patients, providing prosthetic walking ability for even short distances may be beneficial to physical and mental health. With new advances in prosthetics, such as polycentric hip joints and microprocessor knees, more patients are increasing their independence and functional mobility. These newer advances provide greater ability to negotiate environmental obstacles such as stairs or inclines and allow variable cadence as well as minimize the need for ambulatory aides. Lighter-weight prostheses also have resulted in less oxygen consumption and more compliance with prosthetic use. The main goals of a prosthesis are to improve function and provide an improved self-body image. Only 43% of patients use a prosthetic device, however, and wear them on average for 5.8 hours per day. Although the only significant metric for unsuccessful prosthetic wear is coronary artery disease, the most common reason that patients do not use a prosthesis is that they were never offered one. We have found that consultation with a prosthetist is most valuable. A multidisciplinary team should be involved in the care of these patients, and thorough preoperative planning is imperative.
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 anatomic method of Boyd and the posterior flap method of Slocum are described here. However, modifications frequently are required based on the location of the pathology.
Anatomic Hip Disarticulation
Technique 17.1
(BOYD)
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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.
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Detach the sartorius muscle from the anterior superior iliac spine and the rectus femoris from the anterior inferior iliac spine. Reflect them both distally.
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Divide the pectineus about 0.6 cm from the pubis.
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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.
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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.
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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.
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Rotate the thigh internally and detach the gluteus medius and minimus muscles from their insertions on the greater trochanter and retract them proximally.
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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.
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Identify, ligate, and divide the sciatic nerve.
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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.
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Incise the hip joint capsule and the ligamentum teres to complete the disarticulation ( Fig. 17.1B ).
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Bring the gluteal flap anteriorly and suture the distal part of the gluteal muscles to the origin of the pectineus and adductor muscles.
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Place a drain in the inferior part of the incision and approximate the skin edges with interrupted nonabsorbable sutures.
Posterior Flap
Technique 17.2
(SLOCUM)
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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.
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Isolate, ligate, and divide the femoral vessels, and section the femoral nerve to fall well proximal to the inguinal ligament.
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Abduct the thigh widely and divide the adductor muscles at their pubic origins.
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Section the two branches of the obturator nerve so that they retract away from pressure areas.
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Free the origins of the sartorius and rectus femoris muscles from the anterior superior and anterior inferior iliac spines. Moderately adduct and internally rotate the thigh and divide the tensor fasciae latae muscle 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.
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Identify, ligate, and divide the sciatic nerve.
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Divide the joint capsule and complete the disarticulation.
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Swing the long posteromedial flap containing the gluteus maximus anteriorly and suture it to the anterior margins of the incision.
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