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Chapter 21A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles Hip Disarticulation and Transpelvic Amputation: Surgical Procedures
Robert E. Tooms, M.D.
Frederick L. Hampton, C.P.
Hip disarticulation is the surgical removal of the entire lower limb by transection through the hip joint. Transpelvic amputation is the surgical removal of the entire lower limb plus all or a major portion of the ilium. Ablative surgery of this magnitude is indicated most often to eradicate a malignant tumor of the bone or soft tissues about the thigh, hip, or pelvic region. Less frequent indications are extensive trauma or uncontrolled infections, especially gas gangrene. On rare occasions, the function and prosthetic fit of a congenital limb anomaly may be improved by surgical conversion to a hip disarticulation.
SURGICAL TECHNIQUES
The basic surgical techniques outlined here may require selective modification because of limb scarring, draining sinus tracts, or the location of a tumor. In most instances, however, the techniques are followed as presented.
Hip Disarticulation
The technique of hip disarticulation as described by Boyd is the basic procedure in general use. In developing his technique, Boyd attempted to minimize blood loss by transecting muscles at either their origin or insertion, these areas being relatively avascular. The resultant stump is well padded and provides an excellent weight-bearing surface for prosthetic use.
Placement of the incision may be varied to avoid large areas of scarring or to provide access to the retroperitoneal lymph nodes when excision of this tissue is indicated in certain malignancies. The standard incision is an anterior racquet incision, which begins just inferior to the antero superior iliac spine and curves medially about the upper portion of the thigh just inferior to the inguinal ligament (Fig 21A-1.,A). Posteriorly, the incision passes distal to the ischial tuberosity and then curves laterally to pass about 8 cm distal to the base of the greater trochanter. From this point, the incision swings anteriorly and proximally to join the beginning of the incision. After ligation and division of the femoral vessels and transection of the femoral nerve, the superficial muscles about the anteromedial aspect of the hip are transected at their origin on the pelvis. The iliopsoas and the short external rotator muscles are divided at their insertions on the femur. The obturator artery is carefully ligated and divided, and the obturator nerve is transected (Fig 21A-1.,A). The hip abductors are then divided at their insertion on the greater trochanter, and the gluteus maximus is detached from its insertion on the femur. The hamstring muscles are detached from their origin on the ischial tuberosity, and the sciatic nerve is ligated and divided. The hip joint capsule is then circumferentially incised and the liga-mentum teres divided to complete the disarticulation (Fig 21A-1.,B). The wound is closed by suturing the gluteus maximus to the remnants of the adductor muscles and approximating the skin edges (Fig 21A-1.,B).
Transpelvic Amputation
This formidable procedure is performed almost exclusively for treatment of malignant tumors about the hip and pelvis. Numerous methods have been described, but the operative technique follows the same general pattern in each of the various methods. For purposes of this chapter, the technique as described by King and Steelquist will be outlined.
The patient is positioned on the operating table in the lateral position with the sound side down. In this position the abdominal contents fall away from the part of the pelvis to be removed, thus eliminating the need for excessive retraction of the abdominal viscera. The operation is divided into three parts: anterior, perineal, and posterior, performed in that order. The initial incision begins at the pubic tubercle and is extended laterally along the inguinal ligament and then posteriorly along the iliac crest (Fig 21A-2.,A). The abdominal muscles and the inguinal ligament are detached from the iliac crest, and the fossa between the iliacus muscle and the peritoneum is dissected. The inguinal ligament and rectus abdominis muscle are severed from the pubis and retracted medially along with the spermatic cord and the bladder. This provides exposure of the external iliac artery and vein, which are ligated and divided, and the femoral nerve, which is divided (Fig 21A-2.,B). The limb is then widely abducted and the skin incision extended from the pubic tubercle along the pubic and ischial rami to the ischial tuberosity. After stripping the perineal muscles from the rami, the ligaments and fibrocartilage of the pubic symphysis are completely divided (Fig 21A-2.,C). After the anterior and perineal portions of the procedure are completed, the initial anterior incision is continued posteriorly along the iliac crest to the posterosuperior iliac spine. From this point the incision swings laterally to the greater trochanter and then follows the gluteal crease into the perineum to join the perineal part of the incision. The aponeurosis of the gluteus maximus is divided in line with the skin incision, and this muscle is elevated with the overlying fat and skin as a large flap. The sciatic nerve is then identified, ligated, and divided. The ilium is then divided adjacent to the sacroiliac joint and rotated laterally to expose the intrapelvic structures (Fig 21A-2.,D). After ligating and dividing the obturator vessels and nerves, the psoas and the levator ani muscles are transected, completely freeing the ilium and entire lower limb (Fig 21A-2.,E). The wound is closed by suturing the gluteal flap to the abdominal muscles and approximating the skin edges (Fig 21A-2.,F).
Postoperative Treatment
After surgery the soft tissues of the amputation site should be firmly supported. This can be accomplished by using a soft compression dressing in the conventional manner or by applying a rigid dressing of plaster of paris according to the immediate postsurgical prosthetic fitting technique. Resolution of edema from the surgical site is quite rapid after treatment by either of these postoperative management techniques.
After an initial enthusiastic application of an immediate postsurgical prosthetic fitting to hip disarticulations and transpelvic amputations, many surgeons discovered that the available prosthetic components of this system do not permit comfortable sitting, nor do they provide a satisfactory gait. Furthermore, suspension of the temporary prosthesis is rather cumbersome. These problems, plus rapid maturation of these amputation stumps when treated in the conventional manner, have led most surgeons to discontinue using the immediate postsurgical prosthetic fitting technique for amputations at the hip disarticulation and transpelvic levels.
When a soft compression dressing is used, the patient is mobilized from bed as soon as comfort allows- usually on the third or fourth postoperative day. In younger individuals, standing in parallel bars can be instituted at this time and rapidly followed by crutch ambulation. Stump wrapping is continued until a definitive prosthesis is fit, often at 6 to 8 weeks after surgery.
References:
- Boyd HB: Anatomic disarticulation of the hip. Surg Gynecol Obstet 1947; 84:346-349.
- Gordon-Taylor G, Munro RS: Technique and management of "hindquarter" amputation. Br J Surg 1952; 39:536-541.
- King D, Steelquist J: Transiliac amputation. J Bone Joint Surg 1943; 25:351-367.
- Lazarri JH, Rack FJ: Method of hemipelvectomy with abdominal exploration and temporary ligation of common iliac artery. Ann Surg 1951; 133:267-269.
- Pack GT, Ehrlich HE: Exarticulation of the lower extremities for malignant tumors; hip joint disarticulation (with and without deep iliac dissection) and sacroiliac disarticulation (hemipelvectomy). Ann Surg 1946; 123:965-985.
- Sarondo JP, Ferre RL: Amputacion interilio-abdominal. Ann Orthop Traumatol 1948; 1:143.
Chapter 21A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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