Hip Disarticulation & Forequarter Amputation

• Major neurovascular encasement (not mere abutment) where resection leaves a limb without useful function — e.g. sciatic nerve plus femoral vessel involvement at the hip, brachial plexus encasement at the shoulder
• Fungating, infected or haemorrhagic tumour where wound control and hygiene are otherwise impossible (may be palliative-intent "toilet" amputation)
• Local recurrence after limb salvage, particularly after prior radiotherapy where further salvage would leave an unreconstructable defect
• Massive tumours crossing multiple compartments (proximal femoral or shoulder-girdle sarcoma with skip lesions, extensive skin involvement)
• Pathological fracture through a chemotherapy-unresponsive sarcoma with widespread compartmental contamination
• Note the important negative: metastatic disease is not an automatic contraindication — a forequarter amputation for a fungating recurrent sarcoma can be justified for palliation and quality of life

• Necrotising fasciitis of the thigh/buttock or shoulder girdle failing serial debridement — hip disarticulation can be life-saving; mortality of proximal necrotising infection is high
• Chronic osteomyelitis in a nonfunctional, insensate or chronically painful limb after failed reconstruction
• Unreconstructable trauma: mangled proximal limb with unreconstructable vascular injury, or delayed presentation with a dead limb and systemic toxicity
• Critical ischaemia with non-viable tissue extending above the level of a possible transfemoral amputation (rare; carries very high perioperative mortality in this frail cohort)

• Decision made in a sarcoma/limb-reconstruction MDT: oncologist, radiologist, pathologist, plastic surgeon, rehabilitation physician
• Staging must be current (MRI of the limb, CT chest, plus PET or bone scan as indicated) — do not amputate for a lesion whose systemic burden makes it futile without palliative discussion
• Pre-operative counselling should cover: body image, phantom phenomena (normalise them in advance), realistic prosthetic expectations, sexual function and continence perception after hip disarticulation, return to work
• Involve a clinical psychologist and a peer amputee visitor pre-operatively where possible; pre-operative contact with the prosthetic/rehabilitation team improves adjustment
• Consent explicitly for: haemorrhage and transfusion, wound necrosis, phantom pain, possible pleural breach (forequarter), possible conversion of flap design intra-operatively

• Femoral triangle (inguinal ligament, adductor longus, sartorius): femoral nerve, artery, vein lateral to medial (NAVeL toward the lymphatics) — the site of primary vascular control
• Obturator vessels and nerve exit the obturator foramen deep to pectineus; the corona mortis connects obturator and external iliac/inferior epigastric systems over the superior pubic ramus in roughly 20 to 40 percent of patients
• Sciatic nerve emerges below piriformis with the inferior gluteal vessels; it carries a substantial arterial companion (artery to the sciatic nerve) which must be ligated separately
• Gluteus maximus with its inferior gluteal pedicle is the workhorse posterior flap — its blood supply (superior and inferior gluteal arteries from the internal iliac) is independent of the femoral system, which is why it survives femoral ligation
• Muscle detachment map: iliopsoas from lesser trochanter, abductors and short external rotators from greater trochanter, adductors and hamstrings from ischiopubic origins or divided in bulk depending on margins

• The forequarter specimen comprises the entire upper limb, scapula and lateral two-thirds of the clavicle — the limb is attached to the trunk only by the clavicle (bony strut) and muscular envelopes
• Subclavian vessels and brachial plexus cross the first rib between scalenus anterior (artery behind, vein in front) — resecting or dividing the clavicle unroofs them
• Anterior muscle divisions: pectoralis major and minor, subclavius, omohyoid, latissimus dorsi insertion
• Posterior muscle divisions: trapezius, rhomboids major and minor, levator scapulae, serratus anterior — dividing these "drops" the scapula away from the chest wall
• Structures to protect on the chest wall: pleura and first rib, thoracic duct on the left (chylous leak), phrenic nerve on scalenus anterior, external jugular and transverse cervical vessels

• Position: supine with the ipsilateral buttock elevated on a sandbag (or lateral/semi-lateral if a large posterior flap is needed for a posterior tumour); the whole limb, hemipelvis, flank and perineum are prepped; the perineum is excluded with an adhesive drape; urinary catheter in situ
• Imaging/equipment: cross-matched blood (at least 2 to 4 units), cell salvage where oncologically appropriate (contraindicated with tumour contamination or infection), vascular instruments, warmed fluids; review the MRI to confirm flap territories are tumour-free
• Preparation: prophylactic antibiotics; epidural or regional catheter placed for pre-emptive analgesia; mark the racquet incision with the flaps drawn on the awake or anaesthetised patient and re-checked against imaging

• Racquet incision: starts at the ASIS, passes distally and medially parallel to the inguinal ligament to a point on the medial thigh roughly 5 cm below the origin of adductor longus, then sweeps around the posterior thigh (apex of the posterior flap) and laterally back up over the greater trochanter to the ASIS
• Raise the anterior flap; open the femoral triangle: divide the femoral sheath, isolate the femoral artery and vein individually; doubly ligate and suture-ligate the artery, then ligate the vein — early venous ligation also limits tumour embolisation in oncologic cases
• Divide the femoral nerve sharply under gentle traction after infiltration with long-acting local anaesthetic, allowing it to retract proximally away from the scar

• Detach sartorius from the ASIS and rectus femoris from the AIIS; divide iliopsoas at the lesser trochanter
• Divide pectineus near the pubis to expose the obturator externus and obturator neurovascular bundle; ligate the obturator vessels deliberately near the foramen — do not avulse them (retraction into the pelvis via the corona mortis causes haemorrhage that is very difficult to control)
• Release adductors from the pubis (or divide in bulk distally if margins demand muscle on the specimen); divide gracilis and hamstring origins from the ischial tuberosity
• Externally rotate the limb: divide abductors from the greater trochanter, then the short external rotators; ligate the branches of the medial and lateral circumflex vessels and the cruciate anastomosis as encountered
• Identify the sciatic nerve below piriformis: ligate its accompanying artery, infiltrate with local anaesthetic, apply gentle traction and divide sharply so it retracts under gluteus maximus

• Capsulotomy: circumferential division of the hip capsule; divide the ligamentum teres (flexion-adduction-external rotation opens the joint and delivers the head), completing the disarticulation; remove the specimen, orientate and ink for pathology
• Haemostasis; irrigate copiously
• Coverage: bring the posterior gluteus maximus myofasciocutaneous flap forward and perform a myodesis to the pubis, inguinal ligament and adductor origins — this converts the buttock into a durable, weight-distributing end-bearing pad over the ischium and acetabulum and obliterates the dead space; consider tacking the flap into the acetabulum or covering the acetabulum with residual capsule
• Large-bore suction drains; layered closure without tension; light compressive spica-type dressing
• Aftercare: drains until output settles, early sitting balance and trunk work, oedema control, phantom pain protocol from day zero; prosthetic assessment once the wound is sound (typically 6 to 12 weeks)

Many surgeons use a combined approach: anterior first stage for vascular control, then reposition or roll the patient to complete the posterior release.

• Position: supine with the shoulder elevated, limb draped free; anaesthetist warned about pleural breach and vessel control; blood cross-matched
• Incision: along the clavicle from the sternoclavicular joint, curving over the deltopectoral groove into the axilla anteriorly, with a posterior limb along the scapular spine and lateral scapular border to meet in the axilla
• Detach pectoralis major from the clavicle; divide or resect the middle third of the clavicle (osteotomy or claviculectomy at the medial extent) — this unroofs the subclavian vessels
• Divide subclavius and pectoralis minor; identify and ligate the subclavian artery first (double ligation plus suture-ligation), then the subclavian vein separately — never together
• Divide the trunks of the brachial plexus sharply proximally after local anaesthetic infiltration, allowing retraction behind scalenus anterior; protect the phrenic nerve and, on the left, the thoracic duct
• Divide latissimus dorsi and remaining axillary soft tissue, then pass posteriorly: divide trapezius, omohyoid, levator scapulae, rhomboids and finally serratus anterior, freeing the scapula from the chest wall and delivering the specimen

• Position: lateral, tumour side up, entire quarter prepped
• Posterior incision along the vertebral border of the scapula and scapular spine; divide trapezius, rhomboids, levator scapulae and serratus anterior, hinging the scapula laterally and forward off the chest wall ("open-book")
• Retract the specimen anteriorly; identify the neurovascular bundle at the apex of the axilla/first rib from behind; ligate subclavian artery, then vein, divide the plexus as above
• Complete the anterior musculocutaneous division (pectorales, clavicular osteotomy) and remove the specimen

• Keep the dissection superficial to the ribs and intercostal fascia except where the tumour dictates en bloc chest-wall resection (plan this pre-operatively with thoracic colleagues — rib resection needs mesh/flap chest-wall reconstruction)
• Check for pleural breach: fill the wound with saline and give a Valsalva breath; if breached, insert a chest drain
• Haemostasis, drains, and closure by advancing the posterior/medial skin flap over the chest-wall defect; in tumour cases where skin must go with the specimen, a fillet forearm free flap from the amputated limb is the elegant spare-parts solution for coverage
• Post-operative chest radiograph is mandatory

• The standard device is the Canadian-type hip disarticulation prosthesis (Colin McLaurin's design): a moulded socket embracing the hemipelvis and bearing weight on the ischium and gluteal pad, with an anteriorly placed free hip joint, a stance-stable knee and a dynamic foot; the hip joint anterior placement gives inherent alignment stability in stance
• Gait is a stiff, tilting, step-to or slow step-through pattern; energy cost of walking rises by well over 80 percent compared with normal gait, and self-selected walking speed is markedly reduced
• Honest counselling: many patients ultimately abandon the prosthesis in favour of elbow crutches or a wheelchair, because crutch gait is faster and less exhausting; younger, fitter patients and those with strong motivation do best
• Rehabilitation sequence: sitting balance and trunk strengthening from day one, oedema control and stump shaping, standing frame, casting for the socket once wounds are sound and volume stable, then gait training with the rehabilitation team

• Functional prostheses (body-powered or myoelectric) at this level have almost no useful control sources and are very rarely used functionally; the practical prescription is a lightweight cosmetic shoulder cap that restores shoulder contour, allows clothing to hang normally and improves body image
• The dominant rehabilitation goals are one-handed independence training (dominance transfer if needed), shoulder-girdle asymmetry and neck pain management (physiotherapy, sometimes a counterweight), and psychological adjustment
• Occupational therapy and driving/work adaptations matter more to outcome than any device

• Oncologic outcome is determined by tumour biology and margin status, not by the amputation itself; survival after amputation for high-grade sarcoma parallels stage-matched limb salvage
• Quality-of-life studies show amputees adapt substantially over time; pain control and psychological support are stronger determinants of reported quality of life than prosthetic sophistication
• Emergency hip disarticulation for necrotising infection or ischaemia carries markedly higher perioperative mortality than elective oncologic disarticulation — reflect this in consent