BACKGROUND

 

 

Hip disarticulation is an amputation of the lower extremity through the hip joint capsule. Although most tumors of the lower extremities are amenable to limb-sparing techniques, some tumors of the femur and thigh are so extensive that hip disarticulation is needed for adequate tumor resection.5,6,12

 

Disarticulation of the hip for malignant tumors is a rare operation, but it is still needed instead of an aboveknee amputation if the tumor cannot be resected using a limbsalvage procedure due to proximal transosseous skip metastases, pathologic fractures, extensive diaphyseal extension, and large adjacent soft tissue masses

combined with a poor response to chemotherapy.1,11,14

 

With advances in prosthetic design, patients can ambulate with a prosthesis despite the larger energy expenditure needed to ambulate after a hip disarticulation compared to more distal amputations. Even without prosthetic use, most patients are very successful in ambulating and carrying out daily activities.

 

Performing a hip disarticulation may be more preferable in some cases instead of leaving a patient with a very short above-knee amputation stump site, which can make prosthesis fitting difficult.

 

 

Because functional outcome after hip disarticulation is problematic, Jain et al4 published their results of 80 hip disarticulations. Function on the whole was poor, with only one surviving patient regularly using an artificial limb. Patients after hip disarticulation are left without a leg and without a fulcrum to move an artificial limb.

They are likely to suffer loss of self-esteem as well as loss of function and mobility, and they may well suffer from phantom pains.

 

The energy expenditure during mobility after an amputation is much greater than that without an amputation and increases as the amputation level becomes more proximal.13 The energy expenditure after a hip

disarticulation is reported to be 82% greater than that required by a nonamputee.2,3,10 In comparison, the energy expenditure after a long below-knee amputation is only about 10% more than that required by a nonamputee. When a patient with a hip disarticulation attempts to use a prosthesis, the energy requirements can then be as much as twice that of a normal ambulator. Those who cannot overcome these significant energy requirements must adapt to the use of crutches, canes, or a wheelchair. Given these factors, any intervention that can reduce the energy expenditures required of amputees might increase their likelihood of

mobility and improve their overall quality of life.2,3,5,10

 

By preserving the soft tissues of the proximal thigh when amputating the leg at the level of the hip joint, it is possible to reconstruct a functional proximal thigh stump with a proximal femur prosthesis. This requires that the proximal soft tissues of the thigh are without tumor invasion, which is an uncommon situation. This is a rare procedure with only few indications, but it remains an important option due to its benefits over a standard hip disarticulation.

 

Preserving hip function is the main advantage of stump prosthesis over hip disarticulation. The main disadvantages of a hip disarticulation are its unappealing appearance; the discomfort of the basket-shaped

prosthetic socket, which incorporates nearly half of the pelvis; and the 82% increase in energy consumption required for walking compared with that in a normal person.10

 

The stump prosthesis provides a lever arm for hip joint motion. This dramatically lowers the energy consumption of ambulating with a prosthetic limb and thus increases the likelihood of prosthetic use.9

 

The first attempt to improve the functional status of patients requiring hip disarticulation for malignant bone tumors was published in 1979.8

ANATOMY

 

The hip joint region is supplied by several major arteries. Familiarity with these structures can minimize intraoperative bleeding if they can be identified and ligated as needed. These arteries include the profunda artery, the medial and lateral circumflex arteries, and the obturator and superior and inferior gluteal arteries.

 

The tensor fascia lata, gluteus maximus, and iliotibial band form an outer muscular envelope around the hip, and at least one of these structures usually needs to be split to gain access to the hip.

 

The femoral triangle must be identified to access the main neurovascular structures encountered in this procedure. The femoral triangle is bordered superiorly by the inguinal ligament, laterally by the sartorius muscle, and medially by the adductor longus muscle.

 

Hip disarticulation involves amputation through the hip joint capsule. This strong fibrous layer covers the anterior hip to the intertrochanteric line but leaves most of the femoral neck exposed posteriorly.

 

Tumors can often extend to the ischiorectal fossa; this should be determined preoperatively by examining computed tomography (CT) and magnetic resonance imaging (MRI) scans. The ischiorectal fossa is an area bounded medially by the sphincter ani externus and anal fascia, laterally by the tuberosity of the ischium and obturator fascia, anteriorly by the fascia covering the transversus perinei

 

P.260

superficialis, and posteriorly by the gluteus maximus and sacrotuberous ligament. Assessment for tumor extension to this area is particularly important in planning the flaps that will be used.

 

INDICATIONS

Proximal tumors not extending above the midthigh

Femoral diaphyseal tumors with proximal intramedullary extension

Soft tissue sarcomas of the thigh with extension to the femur or neurovascular structures Unresectable local recurrences, particularly after radiation therapy has been used Pathologic fractures that are not responsive to induction chemotherapy and immobilization Palliation of extensive tumors

Indications for stump prosthesis reconstructive surgery after hip disarticulation are as follows (FIG 1): Skip metastasis to proximal femur from a primary distal femur osteosarcoma

Inability to achieve safe osseous margins with a typical wide resection or above-knee amputation due to

tumor extension (the most common indication)

 

 

 

 

FIG 1 • Indications for hip disarticulation and reconstruction with a stump prosthesis. A. Proximal skip metastasis without soft tissue extension. B. Plain radiograph of a distal femoral nonunion after a pathologic fracture that was treated with a long retrograde intramedullary nail. C. Corresponding resected pathology gross specimen. D. Distal femoral synovial sarcoma with a proximal femoral head skip metastasis.

 

 

Tumor contamination of the proximal medullary canal after pathologic fracture due to tumor in the distal femur and retrograde intramedullary fixation.

 

A prerequisite for the operation is uncontaminated soft tissues around the hip, retrogluteal region, and proximal thigh.

 

IMAGING AND OTHER STAGING STUDIES

Plain Radiography

 

 

Hip and pelvic imaging to rule out pelvic involvement Radiographic analysis of the entire femur

Computed Tomography and Magnetic Resonance Imaging

 

CT is useful in showing the effect of the tumor on the structural integrity of the bone. It may also show extension into the soft tissues, especially in the ischiorectal fossa, hip joint, and groin.

 

MRI shows the intraosseous spread of the tumor within the marrow and therefore is helpful in determining the level of amputation and the appropriateness of the hip disarticulation.

 

 

 

Bone Scanning

P.261

 

A bone scan is helpful in evaluating the bony involvement of the femur, pelvis, and acetabulum. It will also show any incidence of skip metastases.

 

Acetabular involvement is a contraindication to doing a hip disarticulation.

 

Angiography and Other Studies

 

Angiography can help identify the external iliac, common femoral, and profundus arteries when preparing for surgery.

 

Biopsy

 

A biopsy is warranted before most amputations. Given the potential functional limitations and prosthetic needs of a hip disarticulation, a biopsy is definitely recommended before performing a hip disarticulation.

 

SURGICAL MANAGEMENT

 

Lymph node involvement should be assessed before proceeding with a hip disarticulation. Lymph node involvement is a relative contraindication to performing a hip disarticulation unless the procedure is done for palliation.

 

Hip disarticulations are often required after poor chemotherapy response or tumor aggressiveness. These situations increase the likelihood for close surgical margins, which can lead to local recurrences.

 

All radiographic studies must be reviewed to ensure that there is no suggestion of tumor proximal to the lesser tuberosity. This would increase the risk of having positive or close margins.

 

The development of the flaps is critical for optimal wound closure and healing. It is not uncommon to make flaps of unusual shape in performing a hip disarticulation for tumor of the middle or distal femur or thigh. Previous scars, radiated fields, and the presence of a tumor mass all determine the best skin to be used. If possible, fasciocutaneous flaps should be constructed to promote would healing.

 

Optimizing the patient's overall health and nutritional status preoperatively is essential in promoting wound healing and decreasing perioperative complications. When planning for an amputation stump after disarticulation:

 

 

Arterial blood supply to the soft tissues must be preserved. The superficial femoral artery should be ligated within the sartorial canal as distally as oncologically possible.

 

The prosthesis must be secured to the hip capsule to avoid dislocation aggravated by gravity pulling on the prosthesis. This requires capsular reconstruction and reinforcement.

 

Modular prosthetic design allows use of a large bipolar cup, modular body length with porous coating to aid in soft tissue ingrowth, and a distal rounded tip designed to avoid tissue penetration with distal muscle fixation holes (FIG 2).

 

Muscle groups of the thigh must be connected distally to the prosthesis with tension balanced properly to avoid the excessively strong pull of the hip flexors and abductors.

 

Sufficient soft tissue coverage of all the prosthesis, and specifically its distal part, is critical.

 

 

 

FIG 2 • A. The prosthesis body comes in different lengths. B. The distal tip is rounded to avoid penetration of tissues. Distal holes are used to anchor down the distal muscle ends. C. A modular stump prosthesis consists of a proximal bipolar head, porous coating, and holes to reconnect the hip capsule and abductor mechanism.

 

 

Phantom pain and stump pain should be addressed initially by placing an epineural catheter in the transected sciatic nerve and using multimodal analgesia.

 

Preoperative Planning

 

MRI and CT are done to determine the extent of the tumor in the proximal femur.

 

Manipulation of more proximal venous structures can increase the likelihood of the development of deep venous thrombi. Often, these more proximal thrombi can embolize and lead to fatal pulmonary emboli. In patients with a prior history of deep venous thrombosis or pulmonary emboli, the surgeon should consider placing a venous filter before surgery to minimize the risk of pulmonary emboli.

 

An amputation is a life-altering event; both physical and emotional issues need to be addressed. Many patients find psychological counseling helpful, so the surgeon should ensure that these services are available in the

perioperative period.

 

Having patients meet with a prosthetist and a functional amputee can help manage expectations and provide answers about daily activities and function.

 

 

If an amputation stump is to be used, a custom bullet-tip prosthetic extension should be ordered.

 

Positioning

 

Because a hip disarticulation involves both anterior and posterior dissections, a semilateral or lateral position is often best. Some surgeons prefer the patient to be in more of a supine position if an amputation stump is to be created.

 

 

 

Approach

P.262

 

The major portions of the hip disarticulation are done through an anterior approach to the hip and groin. This facilitates exposure of the femoral triangle and muscle origins and allows for anterior flap development.12

 

 

Recently, Lackman et al7 published their technique using the lateral approach for hip disarticulations. This has the advantage of familiarity and provides access to both anterior and posterior structures.

 

TECHNIQUES

• Incision and Initial Exposure

Bony landmarks to be identified include the pubic tubercle, anterior superior iliac spine, anterior inferior iliac spine, ischial tuberosity, and greater trochanter (TECH FIG 1A).

The anterior incision starts 1 cm medial to the anterior superior iliac spine and continues distally to the pubic tubercle and over to the pubic bone to 2 cm distal to the ischial tuberosity and gluteal crease.

If the buttock flap is extremely thick, the anterior portion of the incision should be moved laterally.

The posterior incision starts about 2 cm anterior to the greater trochanter and extends to the back of the leg distal to the gluteal crease.

The distance of the incision beyond the gluteal crease is directly proportional to the anteroposterior diameter of the patient's pelvis.

Skin, subcutaneous fat, and fascia of Scarpa are incised to expose the aponeurosis of the external oblique. Saphenous vein branches are clamped, divided, and ligated.

 

 

 

 

TECH FIG 1 • A. Incision. B. Exposure of the femoral triangle. C. Division of the femoral vessels and nerve.

 

 

A moderate-sized artery, the superficial epigastric, and multiple branches of the external pudendal vessels are secured.

 

The spermatic cord in men or the round ligament in women is identified, and care is taken to avoid injuring these structures.

 

An incision made just below the inguinal ligament into the fossa ovalis exposes the femoral vein, artery, and nerve (TECH FIG 1B).

 

Individual silk ties are placed around the femoral vessels; first the artery and then the vein are tied in continuity. Right angle clamps are placed between the ties, and the vessels are severed. The proximal ends of the vessels are further secured by a silk suture ligature placed proximal to the right angle clamps.

 

 

The femoral nerve is placed on gentle traction and ligated where it exits from beneath the inguinal ligament. When the femoral nerve is severed, it retracts beneath the external oblique aponeurosis, so that if a neuroma forms, it will not be in a weightbearing portion of the stump (TECH FIG 1C).

 

• Division of Anterior Hip and Groin Muscles and Ischial Tuberosity Release

  P.263

   

  The sartorius muscle is located as it arises from the anterior superior iliac spine. It is dissected free from the surrounding fascia and then transected from its origin on the spine by electrocautery. The femoral sheath and fibroareolar tissue posterior to the femoral vessels are also incised by electrocautery. This dissection exposes the hip joint capsule (TECH FIG 2A).

   

  With the hip slightly flexed, a finger can be placed in a mediolateral direction under the iliopsoas to isolate

  the muscle, which can then be freed from its origin at the lesser trochanter (TECH FIG 2B). If an attempt is made to pass the finger beneath the muscle from lateral to medial, the very intimate attachments between the iliopsoas muscle and the rectus femoris muscle prevent this from being easily done. By sharp and blunt dissection, the entire iliopsoas muscle is dissected until its insertion on the lesser trochanter is clearly defined. Several vessels of prominent size pass from the anterior surface of this muscle, and care should be taken to secure these vessels before their division. The iliopsoas muscle is severed at the level of its insertion onto the lesser trochanter.

   

   

   

  TECH FIG 2 • A. Division of the sartorius muscle and femoral sheath. B. Division of iliopsoas muscle at its insertion. The hip is flexed slightly to relax the iliopsoas muscle. C. Transection of pectineus muscle at its origin. D. Transection of the gracilis, adductor longus, brevis, and magnus muscles from their origin; division of the obturator vessels and nerve. E. Release of the flexor muscles from the ischial tuberosity.

   

   

  Next, the adductor muscles are released from the pelvis in a lateral to medial process. To preserve the obturator externus muscle on the pelvis, the surgeon locates its prominent tendon arising from the lesser trochanter.

   

  P.264

   

  Locating this tendon identifies the plane between the pectineus muscle and the obturator externus; a difference in the direction of the muscle fibers of these two muscles is also apparent. A finger is passed beneath the pectineus muscle, and it is released at the level of its origin from the pubis by electrocautery (TECH FIG 2C).

   

  Beneath the pectineus muscle, numerous branches of the obturator artery, vein, and nerve can now be visualized.

   

  The gracilis, adductor longus, adductor brevis, and adductor magnus are transected at their origins on the symphysis pubis. The obturator vessels and nerves usually bifurcate around the adductor brevis muscle. Branches of the obturator artery must be identified and secured during the dissection to prevent accidental rupture and retraction of the proximal ends up into the pelvis (TECH FIG 2D).

   

  The extremity is hyperabducted to localize the ischial tuberosity and the retracted cut ends of the abductor muscles. The circumflex femoral vessels should be visible and should be avoided. The semimembranosus, semitendinosus, and long head of the biceps are transected from their origin on the ischial tuberosity while preserving the quadratus femoris and sciatic nerve (TECH FIG 2E).

• Hip Joint Capsule Incision and Division of Posterior Muscles

 

All the anterior and posterior muscle groups have been divided. The joint capsule overlying the head of the femur is incised, and the ligamentum teres is transected by electrocautery (TECH FIG 3A).

 

The patient's torso is tilted from posterolateral to anterolateral. The incision is completed posteriorly through gluteal fascia (TECH FIG 3B). The tensor fascia lata and gluteus maximus muscles are divided in the depths of the skin incision. These are the only muscles not divided at either their origin or insertion in the procedure.

 

Directly beneath these muscles is the rectus femoris muscle, which is transected at its origin on the anterior inferior iliac spine by electrocautery (TECH FIG 3C). The common tendon comprising contributions from the gluteus medius, gluteus minimus, piriformis, superior gemellus, obturator internus, inferior gemellus, and quadratus femoris muscles is exposed after the division of the gluteus maximus. All these muscles are divided close to their insertions on the greater trochanter (TECH FIG 3D).

 

 

 

TECH FIG 3 • A. Incision of the anterior portion of the hip joint capsule. B. Completion of the skin incision.

C. Division of the tensor fascia lata, gluteus maximus, and rectus femoris muscles. (continued)

 

 

P.265

 

 

 

TECH FIG 3 • (continued) D. Transection of the muscles inserting into the greater trochanter. E. Release

of specimen. F. Approximation of the obturator externus and gluteus medius over the joint capsule.

 

 

Transection of the hip joint capsule is completed by incising the posterior portion of the capsule. The sciatic nerve is dissected free of surrounding muscle, transected, and allowed to retract beneath the piriformis muscle (TECH FIG 3E).

 

The obturator externus and gluteus medius are sutured together over the acetabulum and joint capsule to help provide soft tissue coverage of the bony prominence (TECH FIG 3F).

Creating a Femoral Stump with a Proximal Femoral Modular Prosthesis

 

The proximal femoral modular prosthesis comprises a proximal bipolar part, a body, and a distal rounded tip. The proximal bipolar part has holes and porous coating around the base of the neck that is intended for reattaching the hip capsule and the greater trochanter. This prevents sliding of the transferred muscles.

 

The prosthesis body has variable length options. The correct length is chosen according to trial measurements.

 

The distal conical tip is custom-made to fit the prosthetic body. It has a rounded bullet-shaped tip to avoid penetrating the soft tissue and includes two sets of four holes each for reattaching the distal ends of the quadriceps, hamstrings, and adductor muscles.

 

A trial proximal femoral prosthesis can be assembled based on an approximation of the required length. The resected femoral head should be measured to help approximate the head cup size that is required. The trial prosthesis should be placed into the acetabulum and the soft tissues should be released from their retracted positions to simulate closure and demonstrate whether the trial prosthesis will allow adequate soft tissue closure (TECH FIG 4).

 

Once the desired prosthesis is determined, the prosthesis is assembled and the Morse tapers are impacted.

Reconstruction of the Hip Joint Capsule

 

To strengthen the capsular closure, we use 3-mm Dacron tape, which acts as a noose around the prosthesis to prevent dislocation. This step is often easier if done just before the actual prosthesis placement.

 

 

 

TECH FIG 4 • Trial measurements of the stump prosthesis. Bipolar cup size may be adjusted to fit the acetabular diameter. Body length is measured so that when muscle groups (quadriceps, hamstrings, and adductors) are reconnected distally, even tension and a neutral position of the limb are achieved.

 

 

P.266

 

 

 

TECH FIG 5 • A,B. The hip capsule that had been tagged at the time of resection is reconstructed and attached to the proximal part of the prosthesis. The psoas muscle is reattached on the anterior aspect of the capsule and the external rotators are reattached to the posterior capsule.

 

 

The Dacron tape is sewn circumferentially around the cut capsule (TECH FIG 5). Putting too much tension on the Dacron tape may cause difficulty in reducing the prosthesis. Once the Dacron is in place, the assembled prosthesis is reduced into the acetabulum and the Dacron is snugly tightened and tied, forming a noose around the femoral neck. In our experience, this has helped to prevent dislocations.

 

The hip joint should be put through functional range of motion to ensure a successful outcome.

 

Once the surgeon is satisfied with the prosthesis and range of motion, the previously detached iliopsoas muscle is pulled over the anterior hip capsule and sutured to it with Ethibond. The short external hip rotators are pulled anteriorly and sutured to the posterior capsule.

 

 

 

TECH FIG 6 • A-C. The abductors and greater trochanter are reattached with a cable system. The adductors are reconnected to the prosthesis body.

Reconstruction of the Adductor and Abductor Mechanism

 

The hip abductors with the osteotomized greater trochanter are repositioned and reconnected with cables and a greater trochanter grip (TECH FIG 6A). The adductors are reconnected to the stump stem (TECH FIG 6B,C).

 

P.267

 

The remaining proximal portion of the sciatic nerve is identified. Its epineural sheath is opened carefully using a fine right angle clamp, and a standard epidural catheter is placed and threaded proximally for at least 5 to 10 cm within the sheath. The catheter is then sutured to nearby adipose or muscular tissue to help secure it using a 4-0 chromic suture. A 14-gauge angiocatheter is placed at the desired exit point for the catheter, with the needle passing beneath the subcutaneous and muscular layers. The epineural catheter is threaded through the angiocatheter to its desired position at the skin level and the angiocatheter is removed with the epineural catheter now outside the skin. The catheter should be infused with 4 to 8 mL 0.25% bupivacaine without epinephrine to aid in postoperative pain control.

Soft Tissue Reconstruction and Wound Closure

 

Dacron tapes are sutured into all cut distal stumps of the quadriceps, adductors, and hamstrings (TECH FIG 7).

 

 

 

TECH FIG 7 • The distal muscle ends are tagged at the time of resection. Reconstruction consists of balancing between flexor and extensor muscles and between the abductors and the adductors. These are all reconnected to the distal end of the prosthesis and to each other. Technically, this is done with the prosthesis in neutral position. A,B. The quadriceps, hamstrings, and adductor muscle groups are pulled and attached to the prosthesis with even tension. The muscle ends are then connected to one another at their distal ends. C,D. When connected correctly, the prosthesis remains in neutral position as the patient awakens on the operating table.

 

 

The posterior muscle groups are tenodesed to the stump prosthesis using the holes made into the distal portion of the prosthesis with the hip in complete extension. The quadriceps muscle is tenodesed to the anterior portion of the stump prosthesis in a similar fashion through the preformed holes, also with the hip in extension. The adductor group is connected in a similar fashion. By setting the prosthesis in neutral position and pulling all three groups and tenodesing them at once, muscle balance is achieved.

 

The surgeon should avoid hip flexion and adduction.

 

The ends of the muscles are sutured to each other, forming a continuous fascial border covering the distal stump. Appropriate muscle tensioning and balancing are imperative to prevent muscle contractures, particularly abduction and adduction or flexion contractures.

 

 

The reconstructed stump should lie in neutral position. The origin of the vastus lateralis is reattached to the greater trochanter proximally. The vastus lateralis fascia is tenodesed to the fascia lata.

 

• Release of Specimen and Closure if a Stump Is Not Created

P.268

 

The gluteal fascia is elevated and secured to the inguinal ligament and the pubic ramus. Multiple stitches are placed bisecting the fascial edge that gather the gluteal fascia as it is secured to the inguinal ligament.

Sutures are individually placed and then tied. Before closure of this posterior myocutaneous flap, suction catheters are placed beneath the gluteal fascia.

 

The skin is closed with interrupted sutures. Again, care is taken to make sure that there is equal distribution of the excess tissue of the posterior flap. Not infrequently, additional suction catheters must be used to obliterate space within the subcutaneous tissue when the buttock flap is thick (TECH FIG 8).

 

Patency of the suction catheters must be maintained until drainage is diminished. Ambulation may proceed if the patient's hemodynamic status permits on the first postoperative day.

 

 

 

TECH FIG 8 • Skin closure and drainage catheters.

 

 

PEARLS AND PITFALLS

Sparing the abductor

mechanism with a greater trochanter osteotomy

• As long as no disease involves the area of the greater trochanter, this should be osteotomized and used in

reconnecting the abductor mechanism.

Trial prosthesis

• Measurements should be made intraoperatively for the bipolar head size and body length of the prosthesis.

Hip capsule

• Hip joint capsule should be preserved and tagged. After resection, the capsule should be reconnected to the

prosthesis around the base of the neck. The hip capsule is then reinforced by connecting the distal end of the psoas muscle to the anterior capsule and the short external rotators to the posterior capsule.

Muscle tension

• The quadriceps, hamstrings, and adductor muscles should be reconnected at equal tension while the prosthesis is in

neutral position.

Bony prominences

• Closure of the remaining obturator externus to the gluteus medius provides good soft tissue coverage over bony

prominences, which facilitates prosthetic use.

Wounds and incisional ▪ The remaining flap tissue should be distributed equally and carefully to eliminate irritated redundant tissue, which

areas could cause asymmetry of the incisional area and discomfort with prosthetic use or problems with prosthesis use.

 

Dead space closure

• Approximating the remaining iliopsoas and quadratus femoris provides good soft tissue closure over the joint capsule

and closes some of the dead space created by the amputation.

Phantom pain

• Postoperative analgesia is crucial. We believe pain should be treated perioperatively by inserting an epineural catheter

  into the transected tip of the sciatic nerve.

• The use of epineural catheters in the remnants of the femoral and sciatic nerves decreases the incidence and severity of phantom pain and sensations and can decrease overall narcotic needs.

 

 

POSTOPERATIVE CARE

 

A compressive dressing should be maintained for 3 to 5 days to minimize swelling. After this time, the wound should be inspected and redressed.

 

Drains should remain until the total daily output is minimal, usually about 3 to 4 days following surgery. Compressive dressings are used for the first few weeks after surgery. A prosthesis may be fitted as soon as the wound has healed. Full weight bearing is permitted.

 

 

Physiotherapy may begin promptly after surgery and should focus on achieving good range of motion.

 

 

Prosthesis fitting can begin when the wound swelling has decreased and the wound is completely healed. Usually, this takes at least 4 to 6 weeks after surgery.

 

OUTCOMES

The 5-year survival of patients after hip disarticulation done as the primary treatment is 32%. When done for local recurrence, the 5-year survival is 25%.

Hip disarticulation has been shown to be very effective as a means of palliation for extensive tumors without other treatment options. It thus improves the quality of life of these patients.

The senior authors have used the technique of creating an above-knee amputation stump after hip disarticulation in six patients—osteosarcoma (n = 2), malignant fibrous histiocytoma (n = 2), and synovial sarcoma (n = 2)—with very good results. There were no infections, dislocations, and local recurrences nor were secondary procedures required in any of those patients.

P.269

 

 

 

 

FIG 3 • Patient after hip disarticulation and proximal thigh stump reconstruction after being fitted with an above-knee prosthesis.

 

 

Prosthetic use in this population is usually lower than that seen in groups with more distal amputations. Use ranges from 5% to 60% of amputees. Problems with artificial limb use and reasons for the lack of limb use have included limb weight and inconvenience with toileting. Despite this, all patients should be offered an artificial limb.

 

Many patients with hip disarticulations are very functional (FIG 3), and one study found that most were even able to drive whether or not they used a prosthesis.

 

COMPLICATIONS

The local recurrence rate is 2% to 12% and is usually higher in patients whose amputation was done for local recurrences or if there were close margins.

A possible complication is deep infection involving the prosthesis. Stump reconstruction should be

 

undertaken only when it is evident that there is no infection of the limb. If there is any doubt about

infection, a two-stage procedure is recommended.

To avoid hip dislocation when an amputation stump is created, the hip joint capsule must be reconstructed. The reconstructed hip is then reinforced with the psoas anteriorly and the short external rotators posteriorly. Stability should be assessed intraoperatively.

There is a natural tendency for the stump to migrate toward flexion and abduction due to the muscle strength of the quadriceps and abductors. It is therefore crucial to achieve muscle balance of the quadriceps, adductors, hamstrings, and abductors during reconstruction.

Wound healing problems can arise from seroma or hematoma development. The use of drains can help decrease the risk of seromas and hematomas.

 

 

REFERENCES

1. Abudu A, Sferopoulos NK, Tillman RM, et al. The surgical treatment and outcome of pathological fractures in localised osteosarcoma. J Bone Joint Surg Br 1996;78B:694-698.

    

    

2. Chin T, Kuroda R, Akisue T, et al. Energy consumption during prosthetic walking and physical fitness in older hip disarticulation amputees. J Rehabil Res Dev 2012;49(8):1255-1260.

    

    

3. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J 2002;95:875-883.

    

    

4. Jain R, Grimer RJ, Carter SR, et al. Outcome after disarticulation of the hip for sarcomas. Eur J Surg Oncol 2005;31:1025-1028.

    

    

5. Jeans KA, Browne RH, Karol LA. Effect of amputation level on energy expenditure during overground walking by children with an amputation. J Bone Joint Surg Am 2011;93(1):49-56.

    

    

6. Kalson NS, Gikas PD, Aston W, et al. Custom-made endoprostheses for the femoral amputation stump: an alternative to hip disarticulation in tumour surgery. J Bone Joint Surgery Br 2010;92(8): 1134-1137.

    

    

7. Lackman RD, Quartararo LG, Farrell ED, et al. Hip disarticulation using the lateral approach: a new technique. Clin Orthop Relat Res 2001;392:372-376.

    

    

8. Marcove RC, McMillian RD, Nasr E. Preservation of the functional above-knee stump following hip disarticulation by means of an Austin-Moore prosthesis. Clin Orthop Relat Res 1979;141: 217-222.

    

    

9. Merimsky O, Kollender Y, Inbar M, et al. Palliative major amputation and quality of life in cancer patients. Acta Oncol 1997;36: 151-157.

    

    

10. Nowroozi F, Salvanelli ML, Gerber LH. Energy expenditure in hip disarticulation and hemipelvectomy amputees. Arch Phys Med Rehabil 1983;64:300-303.

     

     

11. Rougraff BT, Simon MA, Kneisl JS, et al. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur: a longterm oncological, functional, and quality-of-life study. J Bone Joint Surg Am

    1994;76A:649-656.

     

     

12. Sugarbaker P, Malawer M. Hip disarticulation. In: Malawer MM, Sugarbaker PH. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Boston: Kluwer, 2001:337-349.

     

     

13. Van der Windt DA, Pieterson I, van der Eijken JW, et al. Energy expenditure during walking in subjects with tibial rotationplasty, aboveknee amputation, or hip disarticulation. Arch Phys Med Rehabil 1992;73:1174-1180.

     

     

14. Westbury G. Hindquarter and hip amputation. Ann R Coll Surg Engl 1967;40:226-234.