Hip disarticulationthe evolution of a surgical

technique
Sonia J. Wakelin
a,
*, Christopher W. Oliver
b
, Matthew H. Kaufman
c
a
Department of Clinical and Surgical Sciences, Royal Inrmary of Edinburgh, Lauriston Place,
Edinburgh EH3 9YW, UK
b
Department of Orthopaedic Surgery, Royal Inrmary of Edinburgh, Lauriston Place,
Edinburgh EH3 9YW, UK
c
Division of Biomedical and Clinical Laboratory Sciences, University of Edinburgh,
Hugh Robson Building, George Square, Edinburgh EH8 9XD, UK
Accepted 4 February 2003
Introduction
First successfully performed in 1774 by Perault, the
perilous nature of disarticulation of the hip, asso-
ciated with invariably high mortality ensured that it
was rarely performed.
6
Of the operation, Percival
Pott (17141788), wrote: Amputation in the joint
of the hip is not an impracticable operation
(although it may be a dreadful one) I very well
know: I cannot say that I have ever done it, but I
have seen it done, and am now very sure I shall
never do it unless it be on a dead body (cited in
14
).
Potts view of this radical procedure echoed that of
many surgeons in the pre-anaesthetic era and in
1816, John Thomson, Surgeon to the Forces, Regius
Professor of Military Surgery in the University of
Edinburgh and Professor of Surgery to the Royal
College of Surgeons of Edinburgh, said of it: there
is not, I believe, in the history of surgery, an
example of any operation, the dangers and dif-
culties of which have been so minutely investi-
gated, and so deliberately considered, as those
of amputation at the hip joint; nor of which so
many plans had been devised, and so many imita-
tions tried on the dead body before an attempt was
Injury, Int. J. Care Injured (2004) 35, 299308
Summary Introduced in the 18th century, hip disarticulation was considered to be one
of the most radical operations performed for trauma or disease of the lower limb. The
high morbidity and mortality associated with it ensured that it was a rarely performed
procedure. It is fortunate that it remains extremely uncommon to the present day.
Since the rst successful hip disarticulation was described, a number of important
advances have occurred. General medical care has improved dramatically and the
development of anaesthesia, analgesics, antibiotics and blood transfusions has
resulted in greatly decreased morbidity associated with this dramatic operation. This
review on the history of hip disarticulation outlines the surgical evolution of the
operation, the indications for its use and the techniques used. It draws on the early
experiences and preferred techniques of the surgeons of the 19th century, with some
discussion on the methods employed to reduce intraoperative haemorrhage. Further
development of techniques in the 20th century is also described together with
discussion on the evolution of hindquarter amputation.
2003 Elsevier Science Ltd. All rights reserved.
*Corresponding author.
E-mail address: sonia.wakelin@btinternet.com(S.J. Wakelin).
00201383/$ see front matter 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0020-1383(03)00063-9
made to perform it upon the living. Whether,
therefore, this operation, which seems to x the
utmost possible limits to the benets that men
wounded in their limbs can ever receive from
operative surgery, shall be adopted as a last but
salutary resource, or rejected as a dangerous and
hopeless remedy, still it must retain in its inten-
tion, plan, and execution, a proposal which reects
honor on all who have been concerned with its
improvements.
40
The aim of this article is to outline the surgical
evolution of hip disarticulation from the early work
of the 19th century through to the present day with
some discussion on the evolution from this techni-
que of hindquarter amputation.
Indications for hip disarticulation
Through the late 18th and the early part of the 19th
century, the high mortality associated with hip
disarticulation ensured that, not only was it prac-
tised infrequently, but also that it remained,
despite its predominantly civilian infancy, under
the remit of the military surgeons. It was only in
the extreme circumstances afforded by the trau-
matic military setting that such a radical procedure
was deemed worthy of consideration.
In the military setting, trauma remains, to the
present day, an important indication for hip disar-
ticulation. Technological advances in ground mili-
tary warfare have led to the increasing use of
maiming devices designed to disable ground troops,
the evacuation of injured soldiers slowing the
advance of the ground forces. Blast injuries and
traumatic amputations therefore continue to be a
signicant cause of morbidity particularly in coun-
tries outside the western world.
5
In civilian practice, the trend in the use of hip
disarticulation has changed. At the time of its intro-
duction, signicant trauma or infection in the upper
femur and hip joint constituted the main indications
for performing the operation. Towards the end of
the 1860s however only 11% of hip amputations were
performed for trauma, with 50% for infection and
39% for malignant tumours.
26
After 1935, 94% of hip
disarticulations were performed for tumours
26
and
to date this remains the most common indication.
Vascular disease and congenital abnormalities are
also amongst the less common indications.
Surgical technique
Since the rst successful amputation through the hip
joint was described, a number of important
advances have occurred. Improvements in front-line
medical care and evacuation have resulted in more
survivors from battleeld trauma. This, coupled
with technological advances in general medical
care, including the use and complexity of anaes-
thetic and analgesic agents, antibiotics and blood
transfusions have resulted in greatly decreased mor-
bidity and mortality from such extensive operative
interventions. Prior to these advances in medical
science, hip disarticulation was associated with
much higher morbidity and mortality than amputa-
tion of any other part of the extremities.
Before the introduction of anaesthesia, speed
was a vital consideration in the practice of surgical
procedures, and was strongly advocated by early
surgeons. Their comments reect the true enormity
of the hip disarticulation procedure. Guthrie said:
I consider the success of the operation to depend
very much upon the quickness with which it is
performed, not on account of haemorrhage, but
to avoid the shock the constitution receives from
the continued exposure and irritation of so large a
surface in the immediate vicinity of the trunk of
the body.
20
Sir Astley Cooper was believed to have said of the
rst hip disarticulation he performed in 1824: The
limb was removed in twenty minutes, the securing
of the arteries in fteen more, the whole was
completed in thirty ve minutes. The patient bore
the operation with extraordinary rmness and for-
titude, and after all was nished said to Sir Astley
that it was the hardest days work he had ever
gone through to which Sir Astley replied that it
was almost the hardest he ever had (cited in
21
).
1
In the military practice of the 18th century,
management of extensive and irreparable trauma
to the extremities involved rapid amputation and
stump formation. In the thigh, distal leg and arm, a
circular technique was employed. Soft tissue dis-
section was rapidly followed by sawing through
bone at a level proximal to that of the skin incision.
The use of this technique in traumatic amputations
led to the coining of the term guillotine amputa-
tion a somewhat misleading term since amputa-
tions through skin, muscle and bone at the same
level were rarely undertaken. Following circular
amputation, traction was applied to the skin,
stretching out a sleeve of skin to allow closure of
the stump. This technique, ideal for amputations of
the distal extremities, was less easy to perform at
1
Sir Astley Coopers patient was a forty-year-old man who had
previously received an above knee amputation on the same side
some years previously since which time the thigh bone had
become diseased from the extremity of the stump up to the
trochanter major and this disease had such an effect on him of
late that he had been rapidly sinking under it.
300 S.J. Wakelin et al.
the level of the hip not least because skin cover
following such a procedure was difcult to achieve
with traction alone. Instead attention turned to ap
methods of amputation for use at the hip. This
technique was rst introduced in the 17th century
by Lowdham for more distal amputations.
35
Asso-
ciated with more complications than the more
commonly used circular method, ap methods
were altogether less popular. They were slower
to perform and had the added complication of ap
necrosis when used in amputations distally. For
amputations at the hip, these ap methods, how-
ever, attracted a great deal of attention not least
because they offered a method of covering the huge
skin and muscle defect left by removal of the limb.
Many of the early ap techniques described liga-
tion of the femoral artery followed by the formation
of a ap from the buttock muscles. Access was
gained posteriorly to the hip joint, the capsule
opened and the round ligament cut. The operation
was then completed by the formation of an internal
ap. Baron Dominique Jean Larrey, Chief Surgeon of
the Grand Army of Napoleon Bonaparte however
rejected this posterior approach to the hip, writing:
This method is extremely painful, difcult and
dangerous. The bleeding from the gluteal, sciatic
and circumex arteries is very difcult to arrest
with the limb still in place. The bone is disarticu-
lated with greatest difculty, and from the differ-
ent positions in which the patient has to be placed
there is a risk of tearing the ligature from the
femoral artery, or that in passing the knife from
the cotyloid cavity to divide the attachments of the
triceps adductor muscles this vessel may be
wounded above the ligature however much care
has been taken to apply this close to the crural
arch (cited in
15
).
Larrey instead advocated the use of a technique
in which the patient remained supine; the surgeon
stood on the inside of the affected thigh and made
the rst incision anteriorly along the course of the
femoral vessels whilst the assistant compressed the
femoral artery proximally. The femoral artery and
vein once dissected out were ligated above the
origin of the profunda femoris artery. Two aps
were then constructed, an inner and an outer.
The inner ap was retracted medially resulting in
exposure of smaller vessels, which could be ligated.
The joint could then be dislocated by dividing the
round ligament and abducting the thigh. The aps
were then brought together and sutured.
Larrey was not alone in his use of a ap operation
at the hip joint and its supporters included a number
of other prestigious surgeons including Manec,
Guthrie, Beclard, Baudens and Larrey. Choice of
ap, either anterior and posterior, or internal and
external, varied between surgeons. Guthrie, like
Larrey preferred to use an internal and external
ap, while Baudens and Beclard preferred the use
of anterior and posterior aps.
8
Cox utilised a mod-
ication of this method and the three-stage method
described by Lisfranc,
9
believing the anterior/pos-
terior ap method to be a faster method of amputa-
tion and thus less of a shock to the constitution.
Abernethy was one of the minority of surgeons
who preferred to use a circular amputation method
at the hip, the method derived from more distal
amputations (cited in
7
). It involved a circular inci-
sion proximally in the thigh, about 3 in. below
Pouparts ligament (i.e. the inguinal ligament).
The incision extended through skin and subcuta-
neous tissues down to the fascia lata. This tissue
was then reected and a second circular incision
used to divide the muscles inserting into the greater
trochanter and those arising from the ischial tuber-
osity. The capsule of the joint was nally opened
and the head of the femur disarticulated in order to
complete the operation.
Although Veitch was said to have performed hip
disarticulation by this same circular method, his
writings of 1806
41
rather suggest that he used of
a modication of this technique. He described saw-
ing through the femur belowthe level of the circular
skin incision, the aim being to shorten the bone and
provide a lever to manoeuvre the femoral head out
of the acetabulum. This was different from the
original circular method referred to by Cox, in which
the femoral shaft was left intact to maximise lever-
age and thus aid disarticulation. Using the leverage
afforded by the whole femur, in cases where trau-
matic amputation had not already occurred, was
the approach preferred by a number of surgeons.
James Spence, in 1865, wrote: rapidity of execu-
tion in this operation is of great importance, as
diminishing the risk from loss of blood; and in the
case of tumours where we have the leverage of the
whole limb, the disarticulation may be accom-
plished in 1020 seconds.
34
The control of haemorrhage posed a signicant
problem to surgeons performing hip disarticulation
and it is not surprising that a number of different
schools of thought existed regarding how best to
control bleeding. Larrey described early ligation of
the femoral artery at a level below Pouparts liga-
ment. Others, including Langenbeck, Graef, Kri-
mer, Colles, Abernethy, Dupuytren, Lisfranc and
Guthrie, however, argued that: tying the artery
after passing over the os pubis beneath the crural
arch does not avert the danger of haemorrhage,
and that this is further objectionable as superad-
ding the operation of aneurysm to that of amputa-
tion (cited in
7
).
Hip disarticulationthe evolution of a surgical technique 301
These surgeons preferred to compress the
femoral artery proximally where it passed over
the os pubis. Indeed, Guthrie said of ligating the
vessels primarily: I consider the preliminary steps
of tying the artery and vein unnecessary, by
prolonging the operation; the placing of precau-
tionary ligature above, to be drawn tight if neces-
sary (ligature dattente) is now universally allowed
in England to be extremely dangerous, inducing
rather haemorrhage by causing ulceration of the
coats of the artery, against which it presses, than
preventing it, being therefore itself the cause of
mischief it is intended to suppress.
20
Compression of the artery as a preferred techni-
que was greatly facilitated by the development of
various forms of arterial compressors. The haemor-
rhage associated with amputations of the distal
parts could be dealt with readily by the use of
tourniquets such as those devised by Morel and
Petit.
36
Such tourniquets, however, were less prac-
tical in operations at the hip and shoulder joints
where proximal control of the vessels could not be
obtained.
For operations at the hip, Cox strongly advocated
the use of the horseshoe tourniquet. This device,
believed to have been invented by a Dr. Segnorini of
Padua, was used in Coxs amputation at the hip
performed in November 1844 on a young woman
called Elizabeth Powis. The device, illustrated in
Fig. 1 was applied over the femoral artery prior to
the rst incision. Cox related its application: Pre-
viously to the application of the instrument, a
small piece of wash-leather or sheet caout-chouc
may be laid upon the integuments to prevent the
injurious effects of pressure on the skin; and still
more effectually to perform the compression,
either a piece of perfectly smooth, soft cork, about
two inches in length and an inch wide, with its
under surface slightly grooved, or a pad of soft
linen may be placed beneath the pad of the com-
pressor.
10
The arterial compressor was then left in place
until completion of the anterior and posterior aps
and removal of the limb (Figs. 2 and 3). Cox wrote of
his operation: The operation was completed under
thirty ve seconds. All the vessels were secured
under ve minutes; and not more than four ounces
of blood were lost during the operation.
13
In 1860, Pancoast was the rst to turn his atten-
tion to compression of the aorta against the verteb-
ral column using an abdominal aortic tourniquet.
38
Subsequent to this, several instruments of a similar
nature were devised including those of Lister, Skey
and Esmarch. The use of the abdominal clamp was
rmly advocated by Annandale who wrote there
can be no doubt also that with the assistance of the
abdominal clamp, amputation at the hip joint may
be performed with the loss of only 2 or 3 ounces of
blood. He also recognised that the emptying of the
limb of venous blood prior to surgery helped to
reduce shock: The total loss of blood may be still
Figure 1 The compressor applied, the rst incision with
anterior ap (from
11
). Reproduced with the kind permis-
sion of the Royal College of Physicians of Edinburgh.
Figure 2 The anterior and posterior aps (from
12
).
Reproduced with the kind permission of the Royal
College of Physicians of Edinburgh.
302 S.J. Wakelin et al.
further diminished in many cases by carefully ban-
daging the limb, and raising it above the level of
the trunk for a few hours before the operation.
1
In 1873, the introduction of the Esmarch bandage,
an elastic compression bandage rolled up the limb
and secured proximally to exsanguinate the limb
further helped to conserve venous blood loss.
37
Other surgeons directed their attention to alter-
native forms of proximal haemorrhage control. Davy
devised a rod (Davys lever) with which the iliac
artery could be compressed against the pelvic
brim.
37
Others including surgeons Gross, Woodbury
and Van Buren advocated the use of digital manual
compression of the aorta or external iliac artery by
an assistant believing it to be less harmful than
methods previously described. In 1876, Trendelen-
berg developed a technique involving the tunnelling
of a rod anterior to the hip joint. A rubber tube was
then wound around the protruding ends of the rod
thus constricting the vessels anterior to the hip
joint.
37
In 1890, Wyeth devised a technique, which may
have had some foundation in Trendelenbergs
single rod technique. Wyeth used two rods inserted
through the soft tissues: the rst passing poster-
olaterally from just below the anterior superior
iliac spine to emerge posterior to the greater
trochanter, and the second passing posteromedially
from a point on the anteromedial aspect of the most
proximal part of the thigh. Once in position an
Esmarch limb bandage was applied to the leg to
effect exsanguination. A rubber tourniquet was then
applied proximal to the rods and the Esmarch ban-
dage removed. This technique permitted the opera-
tion to be performed with minimal blood loss without
the danger of the tourniquet slipping distally into the
wound.
37
Contemporary methods of hip
disarticulation
Attention to the principles of shock management
and in particular the minimising of intraoperative
blood loss have remained, to the present day,
important in surgical technique. Harold Boyd is
probably the gure most quotedfor his contribution
to the technique of hip disarticulation, from which
a number of contemporary methods are derived. A
surgeon fromTennessee, Boyd described, in 1947, a
technique in which dissection was performed along
fascial planes, his so-called anatomic disarticula-
tion of the hip.
2
This was based on the principles
previously described by Callander and Kirk. Call-
ander had observed that division of muscles near
their insertions around the knee resulted in less
blood loss than when muscles were divided through
their bulk in the above knee amputation.
4
Kirk
subsequently reported on the hip disarticulation,
writing: All muscles except those normally
belonging in the buttocks are removed from the
stump, saving one muscle ap, which is conserved
to ll up the acetabulum if a disarticulation is
elected. The muscles on the whole are cut at their
origins.
25
Boyds technique (Figs. 4 and 5) involves, like
that originally described by Larrey, the use of an
anterior racket-shaped incision used to allow satis-
factory access to all the structures of the proximal
thigh and groin. With this approach and using the
principles of Callander and Kirk, sartorius and rectus
femoris are detached from their proximal origins
and reected distally. Pectineus is divided close to
the pubis and then following external rotation of the
hip, psoas is detached from its lesser trochanter
insertion. The adductors and gracilus are divided at
their proximal insertions. Gluteus medius and mini-
mus are divided distally as too are the most distal
bres of gluteus maximus at their insertion on the
linea aspera. The external rotators of the hip are
also separated fromtheir femoral insertions and the
hamstrings from their proximal insertions. The mus-
cles of the buttock together with iliopsoas and the
obturator externus thus remain attached to the
pelvis. Consequently, a ap is created by the gluteal
Figure 3 The second incision, with the anterior ap
carried back and the vessels compressed (from
12
).
Reproduced with the kind permission of the Royal
College of Physicians of Edinburgh.
Hip disarticulationthe evolution of a surgical technique 303
muscles that can be moved anteriorly to provide a
good weight-bearing surface.
Perhaps owing to the relative infrequency with
which this operation is performed, very few mod-
ications of Boyds technique have since been
proposed. Those modications that have evolved
have concentrated on the provision of adequate
stump provision to allow prosthetic limbs to be
used if desired. In the early years of hip disarticu-
lation, prostheses were not available and early
stumps were bulky. At the time of the American
civil war the provision of large amounts of soft
tissue in the stump was the preferred operative
technique. With time the excision of increasing
amounts of soft tissue slimmed the stumps down
and, following the Second World War, the proximal
femoral shaft was left intact wherever possible to
provide a bony stump to aid the tting of a pros-
thesis. Later still, however, with the introduction
of McLaurins Canadian prosthesis
27
this technique
fell from favour as the wearing of a prosthesis was
made more difcult by the presence of a short
mobile bony stump.
Such techniques have been further modied and
improved and, more recently, Sugarbaker and
Chretien described a technique that incorporated
many of the advantages of those previously
described. As in Boyds method, the patient is
placed in a lateral position and a racket-shaped
incision made with its apex medial to the anterior
superior iliac spine. The femoral triangle is
exposed and the vessels secured and divided. Sar-
torius and iliopsoas are divided at their origins and
the adductors released from the pelvis. Tensor
fascia lata and gluteus maximus are then divided,
though not through their origins or insertions as for
the other muscle divisions. The muscles inserting
into the greater trochanter are removed allowing
exposure of the joint capsule and disarticulation of
the joint. Following removal of the limb, the acet-
abulum is covered by approximating preserved
muscles, namely quadratus femoris with ilopsoas
and obturator externus with gluteus medius. This
technique so described allows methodical dissec-
tion, avoids weight-bearing over the suture lines,
divides muscles at their origins or insertions and
Figure 4 The stage of the anatomic disarticulation following ligation of the femoral vessels and nerves, and
detachment of the sartorius, rectus femoris, pectineus, and iliopsoas muscles. Inset shows the line of incision (from
2
).
Reproduced with kind permission of the Journal of the American College of Surgeons.
304 S.J. Wakelin et al.
provides a viable muscle ap as a weight-bearing
surface.
39
Hindquarter amputation
The various techniques of hip disarticulation also
formed the basis for a number of the various hind-
quarter amputations performed for pathology of the
pelvis. This radical procedure involving the disarti-
culation of the sacroiliac joint and the symphysis
pubis, followed by removal of the limb was described
by Gordon-Taylor and Wiles as one of the most
colossal mutilations practised on the human
frame.
19
Throughout the life of this extended pro-
cedure, the terminologies proposed include wordy
but accurate terms such as interinnomino-abdominal
amputation
32
and interpelvi-abdominal amputa-
tion
35
and also other less accurate but eminently
more popular terms such as hindquarter amputation
as used here
3,28
and hemipelvectomy. Gordon-Tay-
lor was scathing of the use of the latter term. He
wrote in his 1934 paper on the interinnomino-
abdominal amputation: Hemipelvectomy evokes
a shudder, and a sigh of regret that some knowledge
of Latin and Greek is no longer considered necessary
for those who claim to have received more than a
kindergarten education.
19
The complicated nature of hindquarter amputa-
tion probably explains why it was not performed for
some 120 years following the rst hip disarticula-
tion. Christian Albert Theodor Bilroth (18291894)
was credited with having performed the rst trans-
pelvic amputation in Vienna in 1891, although this
resulted in early death of the patient. Charles
Girard in Bern probably performed the rst success-
ful hindquarter amputation in 1895.
23
This two-
stage procedure was undertaken on a 17-year-old
girl with osteosarcoma. She underwent hip disarti-
culation in 1894 and then had a hemipelvectomy
when she later developed recurrence of tumour in
the scar. This right-sided disarticulation at the
sacroiliac joint was performed under ether anaes-
thesia and she was able to resume a relatively
Figure 5 The stage of the anatomic disarticulation following separation of the glutei from their insertions, division of
the sciatic nerve, severance of the short rotators, and detachment of the hamstring muscles from the ischial
tuberosity. Inset shows the stump after closure of the wound (from
2
). Reproduced with the kind permission of the
Journal of the American College of Surgeons.
Hip disarticulationthe evolution of a surgical technique 305
normal lifestyle following her discharge from hos-
pital 6 weeks after the operation. She subsequently
developed further recurrence of tumour in the scar
and died 7 months later. Five years later in 1900,
Hogarth Pringle was the rst British surgeon to
successfully perform the procedure. He performed
hindquarter amputation in a 10-year-old girl with
tuberculosis of the hip which had spread to the
pelvis. This operation was performed in three
stages: excision of the hip joint in 1899 followed
by disarticulation and then excision of the ilium and
pubic ramus at a later stage. The patient recovered
well from all three procedures and lived until her
early 20s. Pringle reported further hindquarter
amputations, and is credited with having performed
the rst single-stage procedure.
30
He operated on
two patients: the rst a 34-year-old man and the
second on a 46-year-old woman, both with sarcomas
of the thigh. He published a review in 1916 on 19
hindquarter amputations performed for thigh sar-
comas and reported in this series an early mortality
of 68%.
31
The operation he described took between
55 and 60 min to perform. Later, in 1934, Gordon-
Taylor reported with Phillip Wiles on three success-
ful cases out of ve single-stage operations per-
formed.
19
Gordon-Taylor had rst attempted this
procedure in 1922 but his rst successful operation
was performed in 1929.
Contemporary methods of hindquarter
amputation
Various techniques for performing hindquarter
amputation have since been described. The tech-
niques of King and Steelquist,
24
Sorondo and Ferre
33
and Gordon-Taylor and Monroe
18
are among the
methods most commonly used today. The methods
vary mainly in their positioning of the patient on the
table and the number of stages into which the
operation is divided. The procedures share a com-
mon starting point with a rst incision along the
inguinal ligament and division of the rectus abdo-
minis to allow inspection of the vessels and lymph
nodes. As the majority of these operations are
performed for malignancy, this allows a further
assessment to determine whether there is evidence
of local spread of the malignancy prior to proceed-
ing with the operation. Following this preliminary
exploration and biopsy to exclude advanced malig-
nancy, further dissection allows division of the
symphysis pubis and the lateral movement of the
hemipelvis before division of the musculature and
sacroiliac joint posteriorly.
King and Steelquist
24
described a three-part
operation comprising anterior, medial/perineal
and posterior stages. With the patient in a lateral
position, the procedure is commenced anteriorly,
with detachment of the abdominal muscles and
inguinal ligament from the iliac crest. The bladder
is retracted medially and the external iliac vessels
ligated and divided. This stage is followed by a
medial stage in which the perineal muscles are
detached from the pelvis and the symphysis pubis
is divided. The nal part of the operation is per-
formed posteriorly and involves the formation of a
large myocutaneous ap from gluteus maximus, the
division of piriformis, the sciatic nerve, ilium,
sacrotuberous and sacrospinous ligaments, obtura-
tor vessels and nerves and nally levator ani.
Sorondo and Ferre described their procedure in
1948.
33
Involving two surgeons operating simulta-
neously and the patient in a lateral position, the
affected leg is held in 308 abduction. Dissection is
performed anteriorly with division of the external
iliac vessels, psoas, femoral and obturator nerves
and iliolumbar vessels, thus allowing exposure of
the sacroiliac joint. Further anterior dissection
allows exposure and division of the symphysis pubis.
The operation is continued posteriorly with forma-
tion of a posterior ap. Division of the sacrum near
the sacroiliac joint is performed using a Giglie saw
by two surgeons standing either side of the patient.
Gordon-Taylor and Monroe developed a techni-
que incorporating anterior and posterior stages and
described this in 1952.
18
This method was success-
fully used by Gordon-Taylor on a number of occa-
sions and, by 1957, he was reported to have had a
personal series of 108 cases.
17
Commencing ante-
riorly with the patient in a lateral position but with
some backward tilt, the abdominal muscles are
freed from the iliac crest. The spermatic cord,
bladder and peritoneum are retracted medially
allowing division of the external iliac vessels and
iliolumbar vein and division of the symphysis pubis.
The patient is moved into a full lateral position to
allow dissection posteriorly. The posterior ap,
consisting only of skin and subcutaneous tissue is
reected to allow exposure of the posterior iliac
spines and erector spinae sheath. Following division
of the erector spinae aponeurosis the gluteus max-
imus is divided in the line of its bres inferior to the
posteroinferior iliac spine. Division through the
sacroiliac joint and removal of the limb follows
and the posterior ap drawn forward to allow clo-
sure.
Conclusion
Hip disarticulation and hindquarter amputation are
still considered to be major insults to the human
306 S.J. Wakelin et al.
frame. It is fortunate then that their use remains so
uncommon. Figures from the House of Commons
Hansard Debates for July 1991 suggested that of
5335 leg amputations performed in England during
19881989, only 25 (0.5%) were disarticulations at
the hip and a further 40 (0.7%) were hindquarter
amputations.
22
Figures from the Amputee Statisti-
cal Database for the United Kingdom 19992000
report conrm continuing low prevalence of these
procedures.
29
Eighteen hip disarticulations and 11
hemipelvectomies were reported to the database
during this period, most of which were performed
for neoplasia. Only 3 of the 18 hip disarticulations
and none of the hemipelvectomies were performed
for trauma. Similarly, in the United States, Dilling-
ham et al.
16
reviewed limb amputations performed
over an 8-year period between 1988 and 1996. Of
lower limb amputations, 0.5% were hip disarticula-
tions. Four hundred and eighteen hip disarticula-
tions and 52 pelvic amputations were performed for
trauma during this period constituting 0.23% of all
amputations.
Although these operations are rarely performed,
the advent and development of anaesthesia, trans-
fusion medicine, antibiosis and analgesia have
meant that for those unfortunate individuals where
such procedures are deemed appropriate, their
perioperative morbidity and mortality have been
dramatically reduced. The operations themselves
have changed little since they were rst described
and one can only have admiration for the pioneers
who were responsible for their introduction into
surgical practice.
Acknowledgements
We would like to thank the library staff at the Royal
College of Physicians, Edinburgh and the Wellcome
History of Medicine Library, London. Thanks are also
due to Miss Jean Archibald and her staff in the
Special Collections Section, Edinburgh University
Library.
References
1. Annandale T. Observations on amputation at the hip-joint.
Edin Med J 1870;15:881.
2. Boyd HB. Anatomic disarticulation of the hip. Surg Gynecol
Obstet 1947;84:3469.
3. Brittain HA. Hindquarter amputation. J Bone Joint Surg
1949;31B:4049.
4. Callander CL. Tendoplastic amputation through the femur
at the knee. J Am Med Assoc 1938;110:1138.
5. Coupland RM, Korver A. Injuries from antipersonnel mines:
the experience of the International Committee of the Red
Cross. Br Med J 1991;303:150912.
6. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 7.
7. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 19.
8. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 21.
9. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 22.
10. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 267.
11. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 27.
12. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 28.
13. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 32.
14. Dible JH. Napoleons surgeon. London: Heinemann Medical;
1970. p. 130.
15. Dible JH. Napoleons surgeon. London: Heinemann Medical;
1970. p. 132.
16. Dillingham TR, Pezzin LE, McKenzie EJ. Limb amputation
and limb deciency: epidemiology and recent trends in the
United States. South Med J 2002;95:87583.
17. Gordon-Taylor G. On malignant disease in the region of the
hip-joint. J Roy Coll Surg Edin 1959;5:121 [Third John
Fraser Memorial Lecture, delivered in the University of
Edinburgh, 6 June 1957].
18. Gordon-Taylor G, Monroe RS. Technique and management
of hindquarter amputation. Br J Surg 1952;39:5365541.
19. Gordon-Taylor G, Wiles P. Interinnomino-abdominal (hind-
quarter) amputation. Br J Surg 1934;22:67195.
20. Guthrie GJ. On gun-shot wounds of the extremities requiring
the different operations of amputations with their after-
treatment: establishing the advantages of amputation on
the eld of battle to the delay usually recommended.
London: Longman, Hurst, Rees, Orme & Brown; 1815. p. 177.
21. Hospital Reports. Guys Hospital, January 16. Amputation at
the hip joint. Lancet 1824;2:967.
22. House of Commons Hansard Debates, 18 July 1991 (http://
www.parliament.the-stationery-ofce.co.uk/pa/cm199091/
cmhansrd/1991-07-18/Writtens-7.html), last accessed 22
December 2002.
23. Jones P. Hindquarter amputations: review of a personal
series. Aust N Z J Surg 1974;44:111.
24. King D, Steelquist J. Trans-iliac amputation. J Bone Joint
Surg 1943;25:35167.
25. Kirk NT. Amputations. Hagerstown: WF Pryor; 1943. p. 84.
26. Loon HE. The past and present signicance of hip
disarticulation. Artif Limbs 1957;4:421.
27. McLaurin CA. The Canadian hip disarticulation prosthesis.
Artif Limbs 1957;4:228.
28. McPherson JHT. Traumatic hindquarter amputation. J Med
Assoc Georgia 1960;49:4945.
29. National Amputee Statistical Database (NASDAB), 1999
2000 (http://www.show.scot.nhs.uk/isd/amputee), last ac-
cessed 22 December 2002.
30. Pringle JH. The interpelvi-abdominal amputation. Lancet
1909;1:5301.
31. Pringle JH. The interpelvi-abdominal amputation, with
notes on two cases. Br J Surg 1916;4:28396.
32. Robinson RA. Interinnomino-abdominal amputation. J Bone
Joint Surg 1950;32A:4468.
33. Sorondo JP, Ferre RL. Amputation interilioabdominal. Ann
Orthop Traumatol 1948;1:143.
34. Spence J. Case of successful amputation at the hip-joint on
account of malignant tumour of the femur. Edin Med J
1865;11:400.
Hip disarticulationthe evolution of a surgical technique 307
35. Stedman TL. A reference handbook of the medical sciences
embracing the entire range of scientic and practical
medicine and allied science, vol. 1. 4th ed. New York:
Williams, Wood & Co.; 1923. p. 264.
36. Stedman TL. A reference handbook of the medical sciences
embracing the entire range of scientic and practical
medicine and allied science, vol. 1. 4th ed. New York:
Williams, Wood & Co.; 1923. p. 269.
37. Stedman TL. A reference handbook of the medical sciences
embracing the entire range of scientic and practical
medicine and allied science, vol. 1. 4th ed. New York:
Williams, Wood & Co.; 1923. p. 270.
38. Stedman TL. A reference handbook of the medical sciences
embracing the entire range of scientic and practical
medicine and allied science, vol. 1. 4th ed. New York:
Williams, Wood & Co.; 1923. p. 296.
39. Sugarbaker PH, Chretien PB. A surgical technique for hip
disarticulation. Surgery 1981;90:54653.
40. Thomson J. Report of observations made in the British
Military Hospitals in Belgium, after the Battle of Waterloo
with some remarks upon amputation. Edinburgh/London:
Blackwood/T. Cadell & W. Davies; 1816. p. 258.
41. Veitch J. Observations on amputation at the hip-joint. Edin
Med Surg J 1807;3:12934.
308 S.J. Wakelin et al.