Hemipelvectomy and hip disarticulation

Alixsoanne Antazo Gerard Ian A Reyes

Introduction: Hemipelvectomy

So what is hemipelvectomy
Was first performed in 1881
Hemipelvectomy is a an amputation of the pelvis and

the leg on that side Hemipelvectomy may also be life-saving for patients with massive pelvic trauma or uncontrollable sepsis of the lower extremity, and it can provide significant palliation of uncontrollable metastatic lesions of the extremity

Anatomy
The skeletal anatomy and contents of the pelvis are

complex and difficult to visualize without direct experience. Major portions of the gastrointestinal tract, the urinary tract, the reproductive organs, and the neurovascular trunks to the extremities all coexist within the confines of the bony pelvis. Understanding the three-dimensional anatomy is essential to identifying and protecting these structures during a hemipelvectomy

Bony Anatomy
The basic pelvic bony anatomy is best thought of as a ring

running from the posterior sacrum to the anterior pubic symphysis. Major joints include the large, flat sacroiliac joints, the hip joints, and the pubic symphysis. The hip joint is easily located by motion of the extremity; the other joints are easily located and identified by palpation. Other easily palpable bony prominences include the iliac crest, the anterior superior iliac spine, the ischial tuberosity, and the greater trochanter of the femur.

Bony Anatomy continuation

These landmarks are essential in creating rational skin

incisions during the procedure. Likewise, identification of internal bony landmarks helps localize adjacent structures. The lumbosacral plexus is found by palpating the sacroiliac joint, the sciatic nerve and gluteal vessels are found under the sciatic notch, and the urethra is found under the arch of the pubic symphysis.

Pelvic Bones

Vascular anatomy
Ligation of the correct pelvic vessels is crucial to a

successful amputation. The importance of this fact is indicated by the classification scheme, in which the level of ligation determines the type of amputation to be performed. This bifurcation typically occurs at L4, with the lower bifurcation occurring at S1. The left-sided aorta and the iliac and external iliac arteries remain anterior to the major veins throughout the pelvis. The internal iliac artery bifurcates from the posterior surface of the common iliac artery as it travels down toward the sciatic notch.

 The internal iliac vessels supply the pelvic floor,

rectum, bladder, and prostate, as well as the gluteal muscles. Ligation of this vessel will not jeopardize the internal structures because of contralateral blood flow and rich anastomotic vessels; however, it will significantly devascularize the gluteus maximus muscle.

Pelvic Viscera
In addition to the critical vascular structures, major organs

of the gastrointestinal and genitourinary tracts are present and exposed during a hemipelvectomy. In female patients the ovaries, fallopian tubes, uterus, cervix, and vagina require identification and protection. The bladder and urethra, and the prostate in male patients, are located above and under the pubic symphysis. Placement of a Foley catheter with a large inflated balloon makes these structures easier to palpate during surgery. Care must be taken not to injure the urethra during division of the symphysis.

Indications
Unresponsive Sarcomas Involving Multiple

Compartments Contamination of Surrounding Structures Nonviable Extremity Precluding Limb Salvage Failure of Previous Resection Palliation Non oncologic Indications

Hip disarticulation

Hip Disarticulation
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. 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.

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 femoral triangle must be identified to access the

main neurovascular structures encountered in this procedure. 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.

Indications
Proximal tumors not extending above the mid thigh 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 Pathological fractures that are not responsive to induction chemotherapy and immobilization Palliation of extensive tumors

Assesment
A very careful assessment must be made to help

determine if the hip disarticulation amputee will be able to successfully use Prosthesis. The problems of stability control, comfort, and high energy consumption when using hip disarticulation prosthesis must be considered.

Assessment Procedure
Question the patient about the reason for the

amputation, where and when it was performed, what occupation the patient had before and what activities they hope to do after rehabilitation. Assess the general heath condition of the patient. A person who is weakened by illness or disease will have problems with successfully using prosthesis.

 Assess the general condition of the stump. If it is the

possible the prosthetist should look at post operative x-ray to determine whether the amputee has a true hip disarticulation. Carefully palpate the stump. The amputation may have a hemipelvectomy amputation or there may be a very short length of the femur remaining. Also assess the shape of the stump, scar condition, presence of edema, condition of subcutaneous tissue and any problems such as a abrasion, pressure point of pain.

 Test the range of motion (ROM) and muscle strength

of the sound side leg at the hip, the knee, and the ankle. The sound side leg must be very strong to support the patients weight. Finally, test the strength of the muscle of the trunk. These muscle are important for a stabilizing and controlling the prosthesis.

Strength test
Trunk extension test The purpose of this test is to determine the range of motion when the back is arched from the prone position.

Procedure
Lie face down on the floor, with a partner applying

pressure on the back of the thighs. With fingers interlocked behind your neck, gently raise your head and shoulders as far as possible from the floor. This position must be held for 3 seconds.

Components
SOCKETS
HIP JOINTS KNEE JOINTS

FEET

Types of Socket Designs

Single Layer Socket
Double Layer Socket HD/Hemipelvecotomy Complex Socket HD/Hemipelvectomy

Single Layer Socket

In the distant past these were made from reinforced

leather. Laminated or reinforced plastic materials were introduced in the 50's and 60's are still used today. However, the completely rigid plastic sockets are generally no longer in use. The newer reinforced plastics can be made softer in certain areas for comfort according to the clients needs

Single layered socket

Double layered Socket

This type consists of a supportive layer of rigid

material, usually carbon fiber which is strong and light weight. Sometimes it's left in it's original color which is black, but can be painted a flesh color. Inside is a separate layer of various types plastic materials referred to as "bioelastic" or "thermoplastic", which are flexible. The two layers are held together by screws or bolts. The exact trim lines of each layer will depend on body shape and individual needs.

Double Layer Hip Disarticulation

Double layer Hemipelvectomy

Complex Socket
In this type the rigid support system is hidden or

buried inside the socket. Either silicone or synthetic rubber materials are incorporated around the rigid support, both inside and outside the socket. Fabrication is more complex and few prosthetists have the technological skill or equipment necessary.

Complex Hemipelvectomy

Complex Hipdisarticulation

Hip joint
Endo skeletal hip joints
Single axis joint there is a bumper or other mechanics

to act as an extension stop. There is an elastic strap or other mechanism to prevent too much flexion during swing phase. There is usually adjustment for abduction/adduction, flexion/extension and internal/external rotation.

Knee joint
Single axis joint with friction swing control. Like many

joints of this design it is light weight, low cost, and very durable.

Feet
The solid ankle cushion-heel (SACH) foot is often used

with the hip disarticulation prosthesis. It is light weight, low cost, and very durable. The heel cushion must be very soft to help stabilize the knee. Single axis foot is also good choice for the hip disarticulation. A very soft plantar flexion bumper will allow the foot to easily advance from heel strike to foot flat. This will help make the knee stable. Disadvantages are that the foot heavy expensive, and not durable.

 The multi-axis foot can also be use for the hip

disarticulation amputee. The plantar flexion bumper for this foot must also be very soft to increase knee stability. The added advantage of this foot is that is also provides inversion/eversion and transverse rotation. The disadvantages of this foot are that it is also heavy, expensive and not durable.

 The energy recovery feet seen in the TT prosthesis

manual may also be used with hip disarticulation amputee. The push off that these feet provide will affect the action of the knee. These feet may increase the walking speed of the amputee.

Choosing Components
Each component that is used will affect the action of

the others. The foot, the knee joint and the hip joint along with the socket make a complete system. They should be chosen carefully so that they all work well together.

References
oandp.org
Operative Techniques on Orthopedic Surgery icrc.org