Amputations of Pelvis &

Acetabulum
Dr. UMER SHAFIQUE
PGT Orthopaedics
BBH, Rawalpindi
• Hip disarticulation and the various forms of
hemipelvectomy most often are performed
for the treatment of
 primary bone tumors
 rarely for metastases
 infection
 trauma
• Energy requirements to use a prosthesis have
been estimated to be 250% of normal
ambulation
 Hip disarticulation
• Hip disarticulation occasionally is indicated
after
 massive trauma
 arterial insufficiency
 severe infections
 certain congenital limb deficiencies.
• Accounts for 0.5% of lower extremity
amputations.
• Mortality rates vary in studies from 0% to
44%.
 Methods

• The anatomic method of Boyd

• the posterior flap method of Slocum
 ANATOMIC HIP DISARTICULATION
• Patient in the lateral decubitus position,
• anterior racquet-shaped incision,
• 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
• 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
• Detach the sartorius muscle from the anterior
superior iliac spine and the rectus femoris from
the anterior inferior iliac spine. Reflect them both
distally.
• Divide the pectineus about 0.6 cm from the
pubis.
• 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.
• 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.
• 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.
• Rotate the thigh internally and detach the
gluteus medius and minimus muscles from
their insertions
• Divide the fascia lata and the most distal fibers
of the gluteus maximus muscle.
• Identify, ligate, and divide the sciatic nerve.
• Divide the short external rotators of the hip
• Incise the hip joint capsule and the
ligamentum teres
• Bring the gluteal flap anteriorly and suture the
distal part of the gluteal muscles to the origin
of the pectineus and adductor muscles.
• Place a drain in the inferior part of the incision
and approximate the skin edges with
interrupted nonabsorbable sutures.
 POSTERIOR FLAP
• Begin the incision at the level of the inguinal
ligament
• Isolate, ligate, and divide the femoral vessels
• section the femoral nerve
• Abduct the thigh widely and divide the
adductor muscles at their pubic origins.
• Section the two branches of the obturator
nerve
• Free the origins of the sartorius and rectus
femoris muscles from the anterior superior
and anterior inferior iliac spines.
• divide the tensor fasciae latae muscle at the
level of the proximal end of the greater
trochanter.
• Identify, ligate, and divide the sciatic nerve.
• Divide the joint capsule and complete the
disarticulation.
 HEMIPELVECTOMY
(HINDQUARTER AMPUTATION)
• Indications
 tumors that cannot be adequately resected by
limb-sparing techniques
 life-threatening infection
 arterial insufficiency
 STANDARD HEMIPELVECTOMY
• Place the patient in a lateral decubitus
position
• Perform the anterior dissection first, making
an incision extending from 5 cm above the
anterior superior iliac spine to the pubic
tubercle
• Retract the spermatic cord medially.
• Expose the iliac fossa by blunt dissection.
• Elevate the parietal peritoneum off the iliac
vessels
• Ligate the inferior epigastric vessels.
• Release the rectus muscle and sheath from
the pubis.
• Identify the iliac vessels, retract the ureter
medially, and ligate and divide the common
iliac artery and vein.
• Pack the anterior wound with warm, moist
gauze packs
• Make a posterior skin incision, extending from
5 cm above the anterior superior iliac spine,
coursing over the anterior aspect of the
greater trochanter, paralleling the
glutealcrease posteriorly around the thigh,
and connecting with the inferior end of the
anterior incision
• Raise the posterior flap by dissecting the
gluteal fascia directly off the gluteus maximus.
• Divide the external oblique, sacrospinalis,
latissimus dorsi, and quadratus lumborum
from the crest of the ilium
• Reflect the gluteus maximus from the
sacrotuberous ligament, coccyx, and sacrum
• Divide the iliopsoas muscle; genitofemoral,
obturator, and femoral nerves; and
lumbosacral nerve trunk at the level of the
iliac crest.
• Abduct the hip, placing tension on the soft
tissues around the symphysis pubis. Pass a
long right-angle clamp around the symphysis,
and divide it with a scalpel
• Divide the sacral nerve roots, preserving the
nervi erigentes if possible.
• Divide the joint anteriorly with a scalpel or
osteotome and divide the iliolumbar ligament
• Place considerable traction on the extremity,
separating the pelvic side wall from the
viscera.
• Place considerable traction on the extremity,
separating the pelvic side wall from the
viscera.
• Proceeding from anterior to posterior, divide
the following from the pelvic side wall:
urogenital diaphragm, pubococcygeus,
ischiococcygeus, iliococcygeus, piriformis,
sacrotuberous ligament, and sacrospinous
ligaments
• Move the extremity anteriorly and divide the
posterior aspect of the sacroiliac joint to
complete the dissection.
• Place suction drains in the wound and suture
the gluteal fascia to the fascia of the
abdominal wall.
• Close the skin.
ANTERIOR FLAP HEMIPELVECTOMY
• Anterior flap hemipelvectomy is indicated for
lesions of the buttock or posterior proximal
thigh that cannot be adequately treated by
limb-sparing methods.
CONSERVATIVE HEMIPELVECTOMY
• Indicated for the tumors around the proximal
thigh and hip that cannot be resected
adequately by limb-sparing techniques
• The operation is a supraacetabular
amputation that divides the ilium through the
greater sciatic notch.
THANK YOU