See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/8580344

Hip disarticulation - The evolution of a surgical technique

Article  in  Injury · April 2004

DOI: 10.1016/S0020-1383(03)00063-9 · Source: PubMed

CITATIONS READS

11 11,471

3 authors, including:

Chris Oliver
Edinburgh Napier University
274 PUBLICATIONS   861 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Expeditions View project

Play on Pedals View project

All content following this page was uploaded by Chris Oliver on 20 November 2017.

The user has requested enhancement of the downloaded file.

Injury, Int. J. Care Injured (2004) 35, 299—308

Hip disarticulation–—the evolution of a surgical

technique
Sonia J. Wakelina,*, Christopher W. Oliverb, Matthew H. Kaufmanc

a
Department of Clinical and Surgical Sciences, Royal Infirmary of Edinburgh, Lauriston Place,
Edinburgh EH3 9YW, UK
b
Department of Orthopaedic Surgery, Royal Infirmary 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

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 first 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.
ß 2003 Elsevier Science Ltd. All rights reserved.

Introduction never do it unless it be on a dead body’’ (cited in14).

Pott’s view of this radical procedure echoed that of
First successfully performed in 1774 by Perault, the many surgeons in the pre-anaesthetic era and in
perilous nature of disarticulation of the hip, asso- 1816, John Thomson, Surgeon to the Forces, Regius
ciated with invariably high mortality ensured that it Professor of Military Surgery in the University of
was rarely performed.6 Of the operation, Percival Edinburgh and Professor of Surgery to the Royal
Pott (1714—1788), wrote: ‘‘Amputation in the joint College of Surgeons of Edinburgh, said of it: ‘‘there
of the hip is not an impracticable operation is not, I believe, in the history of surgery, an
(although it may be a dreadful one) I very well example of any operation, the dangers and diffi-
know: I cannot say that I have ever done it, but I culties of which have been so minutely investi-
have seen it done, and am now very sure I shall gated, and so deliberately considered, as those
of amputation at the hip joint; nor of which so
*Corresponding author. many plans had been devised, and so many imita-
E-mail address: sonia.wakelin@btinternet.com (S.J. Wakelin). tions tried on the dead body before an attempt was
0020–1383/$ — see front matter ß 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0020-1383(03)00063-9
300 S.J. Wakelin et al.

made to perform it upon the living. Whether, advances have occurred. Improvements in front-line
therefore, this operation, which seems to fix the medical care and evacuation have resulted in more
utmost possible limits to the benefits that men survivors from battlefield trauma. This, coupled
wounded in their limbs can ever receive from with technological advances in general medical
operative surgery, shall be adopted as a last but care, including the use and complexity of anaes-
salutary resource, or rejected as a dangerous and thetic and analgesic agents, antibiotics and blood
hopeless remedy, still it must retain in its inten- transfusions have resulted in greatly decreased mor-
tion, plan, and execution, a proposal which reflects bidity and mortality from such extensive operative
honor on all who have been concerned with its interventions. Prior to these advances in medical
improvements’’.40 science, hip disarticulation was associated with
The aim of this article is to outline the surgical much higher morbidity and mortality than amputa-
evolution of hip disarticulation from the early work tion of any other part of the extremities.
of the 19th century through to the present day with Before the introduction of anaesthesia, speed
some discussion on the evolution from this techni- was a vital consideration in the practice of surgical
que of hindquarter amputation. procedures, and was strongly advocated by early
surgeons. Their comments reflect the true enormity
of the hip disarticulation procedure. Guthrie said:
Indications for hip disarticulation ‘‘I consider the success of the operation to depend
very much upon the quickness with which it is
Through the late 18th and the early part of the 19th performed, not on account of haemorrhage, but
century, the high mortality associated with hip to avoid the shock the constitution receives from
disarticulation ensured that, not only was it prac- the continued exposure and irritation of so large a
tised infrequently, but also that it remained, surface in the immediate vicinity of the trunk of
despite its predominantly civilian infancy, under the body’’.20
the remit of the military surgeons. It was only in Sir Astley Cooper was believed to have said of the
the extreme circumstances afforded by the trau- first hip disarticulation he performed in 1824: ‘‘The
matic military setting that such a radical procedure limb was removed in twenty minutes, the securing
was deemed worthy of consideration. of the arteries in fifteen more, the whole was
In the military setting, trauma remains, to the completed in thirty five minutes. The patient bore
present day, an important indication for hip disar- the operation with extraordinary firmness and for-
ticulation. Technological advances in ground mili- titude, and after all was finished said to Sir Astley
tary warfare have led to the increasing use of ‘‘that it was the hardest day’s work he had ever
maiming devices designed to disable ground troops, gone through’’ to which Sir Astley replied ‘‘that it
the evacuation of injured soldiers slowing the was almost the hardest he ever had’’’’ (cited in21).1
advance of the ground forces. Blast injuries and In the military practice of the 18th century,
traumatic amputations therefore continue to be a management of extensive and irreparable trauma
significant cause of morbidity particularly in coun- to the extremities involved rapid amputation and
tries outside the western world.5 stump formation. In the thigh, distal leg and arm, a
In civilian practice, the trend in the use of hip circular technique was employed. Soft tissue dis-
disarticulation has changed. At the time of its intro- section was rapidly followed by sawing through
duction, significant trauma or infection in the upper bone at a level proximal to that of the skin incision.
femur and hip joint constituted the main indications The use of this technique in traumatic amputations
for performing the operation. Towards the end of led to the coining of the term ‘‘guillotine amputa-
the 1860s however only 11% of hip amputations were tion’’ a somewhat misleading term since amputa-
performed for trauma, with 50% for infection and tions through skin, muscle and bone at the same
39% for malignant tumours.26 After 1935, 94% of hip level were rarely undertaken. Following circular
disarticulations were performed for tumours26 and amputation, traction was applied to the skin,
to date this remains the most common indication. stretching out a sleeve of skin to allow closure of
Vascular disease and congenital abnormalities are the stump. This technique, ideal for amputations of
also amongst the less common indications. the distal extremities, was less easy to perform at
1
Sir Astley Cooper’s patient was a forty-year-old man who had
Surgical technique 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
Since the first successful amputation through the hip trochanter major and this disease had such an effect on him of
joint was described, a number of important late that he had been rapidly sinking under it’’.
Hip disarticulation–—the evolution of a surgical technique 301

the level of the hip not least because skin cover external, varied between surgeons. Guthrie, like
following such a procedure was difficult to achieve Larrey preferred to use an internal and external
with traction alone. Instead attention turned to flap flap, while Baudens and Beclard preferred the use
methods of amputation for use at the hip. This of anterior and posterior flaps.8 Cox utilised a mod-
technique was first introduced in the 17th century ification of this method and the three-stage method
by Lowdham for more distal amputations.35 Asso- described by Lisfranc,9 believing the anterior/pos-
ciated with more complications than the more terior flap method to be a faster method of amputa-
commonly used circular method, flap methods tion and thus ‘‘less of a shock to the constitution’’.
were altogether less popular. They were slower Abernethy was one of the minority of surgeons
to perform and had the added complication of flap who preferred to use a circular amputation method
necrosis when used in amputations distally. For at the hip, the method derived from more distal
amputations at the hip, these flap methods, how- amputations (cited in7). It involved a circular inci-
ever, attracted a great deal of attention not least sion proximally in the thigh, about 3 in. below
because they offered a method of covering the huge Poupart’s ligament (i.e. the inguinal ligament).
skin and muscle defect left by removal of the limb. The incision extended through skin and subcuta-
Many of the early flap techniques described liga- neous tissues down to the fascia lata. This tissue
tion of the femoral artery followed by the formation was then reflected and a second circular incision
of a flap from the buttock muscles. Access was used to divide the muscles inserting into the greater
gained posteriorly to the hip joint, the capsule trochanter and those arising from the ischial tuber-
opened and the round ligament cut. The operation osity. The capsule of the joint was finally opened
was then completed by the formation of an internal and the head of the femur disarticulated in order to
flap. Baron Dominique Jean Larrey, Chief Surgeon of complete the operation.
the Grand Army of Napoleon Bonaparte however Although Veitch was said to have performed hip
rejected this posterior approach to the hip, writing: disarticulation by this same circular method, his
‘‘This method is extremely painful, difficult and writings of 180641 rather suggest that he used of
dangerous. The bleeding from the gluteal, sciatic a modification of this technique. He described saw-
and circumflex arteries is very difficult to arrest ing through the femur below the level of the circular
with the limb still in place. The bone is disarticu- skin incision, the aim being to shorten the bone and
lated with greatest difficulty, and from the differ- provide a lever to manoeuvre the femoral head out
ent positions in which the patient has to be placed of the acetabulum. This was different from the
there is a risk of tearing the ligature from the original circular method referred to by Cox, in which
femoral artery, or that in passing the knife from the femoral shaft was left intact to maximise lever-
the cotyloid cavity to divide the attachments of the age and thus aid disarticulation. Using the leverage
triceps adductor muscles this vessel may be afforded by the whole femur, in cases where trau-
wounded above the ligature however much care matic amputation had not already occurred, was
has been taken to apply this close to the crural the approach preferred by a number of surgeons.
arch’’ (cited in15). James Spence, in 1865, wrote: ‘‘rapidity of execu-
Larrey instead advocated the use of a technique tion in this operation is of great importance, as
in which the patient remained supine; the surgeon diminishing the risk from loss of blood; and in the
stood on the inside of the affected thigh and made case of tumours where we have the leverage of the
the first incision anteriorly along the course of the whole limb, the disarticulation may be accom-
femoral vessels whilst the assistant compressed the plished in 10–20 seconds’’.34
femoral artery proximally. The femoral artery and The control of haemorrhage posed a significant
vein once dissected out were ligated above the problem to surgeons performing hip disarticulation
origin of the profunda femoris artery. Two flaps and it is not surprising that a number of different
were then constructed, an inner and an outer. schools of thought existed regarding how best to
The inner flap was retracted medially resulting in control bleeding. Larrey described early ligation of
exposure of smaller vessels, which could be ligated. the femoral artery at a level below Poupart’s liga-
The joint could then be dislocated by dividing the ment. Others, including Langenbeck, Graef, Kri-
round ligament and abducting the thigh. The flaps mer, Colles, Abernethy, Dupuytren, Lisfranc and
were then brought together and sutured. Guthrie, however, argued that: ‘‘tying the artery
Larrey was not alone in his use of a flap operation after passing over the os pubis beneath the crural
at the hip joint and its supporters included a number arch does not avert the danger of haemorrhage,
of other prestigious surgeons including Manec, and that this is further objectionable as superad-
Guthrie, Beclard, Baudens and Larrey. Choice of ding the operation of aneurysm to that of amputa-
flap, either anterior and posterior, or internal and tion’’ (cited in7).
302 S.J. Wakelin et al.

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 d’attente) 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 Figure 2 The anterior and posterior flaps (from12).
obtained. Reproduced with the kind permission of the Royal
For operations at the hip, Cox strongly advocated College of Physicians of Edinburgh.
the use of the horseshoe tourniquet. This device,
believed to have been invented by a Dr. Segnorini of the first incision. Cox related its application: ‘‘Pre-
Padua, was used in Cox’s amputation at the hip viously to the application of the instrument, a
performed in November 1844 on a young woman small piece of wash-leather or sheet caout-chouc
called Elizabeth Powis. The device, illustrated in may be laid upon the integuments to prevent the
Fig. 1 was applied over the femoral artery prior to 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 flaps
and removal of the limb (Figs. 2 and 3). Cox wrote of
his operation: ‘‘The operation was completed under
thirty five seconds. All the vessels were secured
under five minutes; and not more than four ounces
of blood were lost during the operation’’.13
In 1860, Pancoast was the first 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
firmly 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
Figure 1 The compressor applied, the first incision with blood’’. He also recognised that the emptying of the
anterior flap (from11). Reproduced with the kind permis- limb of venous blood prior to surgery helped to
sion of the Royal College of Physicians of Edinburgh. reduce shock: ‘‘The total loss of blood may be still
Hip disarticulation–—the evolution of a surgical technique 303

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 figure most quoted for his contribution
to the technique of hip disarticulation, from which
a number of contemporary methods are derived. A
surgeon from Tennessee, Boyd described, in 1947, a
technique in which dissection was performed along
Figure 3 The second incision, with the anterior flap fascial planes, his so-called ‘‘anatomic disarticula-
carried back and the vessels compressed (from12). tion of the hip’’.2 This was based on the principles
Reproduced with the kind permission of the Royal previously described by Callander and Kirk. Call-
College of Physicians of Edinburgh. ander had observed that division of muscles near
their insertions around the knee resulted in less
further diminished in many cases by carefully ban- blood loss than when muscles were divided through
daging the limb, and raising it above the level of their bulk in the above knee amputation.4 Kirk
the trunk for a few hours before the operation’’.1 subsequently reported on the hip disarticulation,
In 1873, the introduction of the Esmarch bandage, writing: ‘‘All muscles except those normally
an elastic compression bandage rolled up the limb belonging in the buttocks are removed from the
and secured proximally to exsanguinate the limb stump, saving one muscle flap, which is conserved
further helped to conserve venous blood loss.37 to fill up the acetabulum if a disarticulation is
Other surgeons directed their attention to alter- elected. The muscles on the whole are cut at their
native forms of proximal haemorrhage control. Davy origins’’.25
devised a rod (Davy’s lever) with which the iliac Boyd’s technique (Figs. 4 and 5) involves, like
artery could be compressed against the pelvic that originally described by Larrey, the use of an
brim.37 Others including surgeons Gross, Woodbury anterior racket-shaped incision used to allow satis-
and Van Buren advocated the use of digital manual factory access to all the structures of the proximal
compression of the aorta or external iliac artery by thigh and groin. With this approach and using the
an assistant believing it to be less harmful than principles of Callander and Kirk, sartorius and rectus
methods previously described. In 1876, Trendelen- femoris are detached from their proximal origins
berg developed a technique involving the tunnelling and reflected distally. Pectineus is divided close to
of a rod anterior to the hip joint. A rubber tube was the pubis and then following external rotation of the
then wound around the protruding ends of the rod hip, psoas is detached from its lesser trochanter
thus constricting the vessels anterior to the hip insertion. The adductors and gracilus are divided at
joint.37 their proximal insertions. Gluteus medius and mini-
In 1890, Wyeth devised a technique, which may mus are divided distally as too are the most distal
have had some foundation in Trendelenberg’s fibres of gluteus maximus at their insertion on the
single rod technique. Wyeth used two rods inserted linea aspera. The external rotators of the hip are
through the soft tissues: the first passing poster- also separated from their femoral insertions and the
olaterally from just below the anterior superior hamstrings from their proximal insertions. The mus-
iliac spine to emerge posterior to the greater cles of the buttock together with iliopsoas and the
trochanter, and the second passing posteromedially obturator externus thus remain attached to the
from a point on the anteromedial aspect of the most pelvis. Consequently, a flap is created by the gluteal
304 S.J. Wakelin et al.

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 (from2).
Reproduced with kind permission of the Journal of the American College of Surgeons.

muscles that can be moved anteriorly to provide a Such techniques have been further modified and
good weight-bearing surface. improved and, more recently, Sugarbaker and
Perhaps owing to the relative infrequency with Chretien described a technique that incorporated
which this operation is performed, very few mod- many of the advantages of those previously
ifications of Boyd’s technique have since been described. As in Boyd’s method, the patient is
proposed. Those modifications that have evolved placed in a lateral position and a racket-shaped
have concentrated on the provision of adequate incision made with its apex medial to the anterior
stump provision to allow prosthetic limbs to be superior iliac spine. The femoral triangle is
used if desired. In the early years of hip disarticu- exposed and the vessels secured and divided. Sar-
lation, prostheses were not available and early torius and iliopsoas are divided at their origins and
stumps were bulky. At the time of the American the adductors released from the pelvis. Tensor
civil war the provision of large amounts of soft fascia lata and gluteus maximus are then divided,
tissue in the stump was the preferred operative though not through their origins or insertions as for
technique. With time the excision of increasing the other muscle divisions. The muscles inserting
amounts of soft tissue slimmed the stumps down into the greater trochanter are removed allowing
and, following the Second World War, the proximal exposure of the joint capsule and disarticulation of
femoral shaft was left intact wherever possible to the joint. Following removal of the limb, the acet-
provide a bony stump to aid the fitting of a pros- abulum is covered by approximating preserved
thesis. Later still, however, with the introduction muscles, namely quadratus femoris with ilopsoas
of McLaurin’s Canadian prosthesis27 this technique and obturator externus with gluteus medius. This
fell from favour as the wearing of a prosthesis was technique so described allows methodical dissec-
made more difficult by the presence of a short tion, avoids weight-bearing over the suture lines,
mobile bony stump. divides muscles at their origins or insertions and
Hip disarticulation–—the evolution of a surgical technique 305

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 (from2). Reproduced with the kind permission of the
Journal of the American College of Surgeons.

provides a viable muscle flap as a weight-bearing wrote in his 1934 paper on the interinnomino-
surface.39 abdominal amputation: ‘‘Hemipelvectomy’ evokes
a shudder, and a sigh of regret that some knowledge
of Latin and Greek is no longer considered necessary
Hindquarter amputation for those who claim to have received more than a
kindergarten education’’.19
The various techniques of hip disarticulation also The complicated nature of hindquarter amputa-
formed the basis for a number of the various hind- tion probably explains why it was not performed for
quarter amputations performed for pathology of the some 120 years following the first hip disarticula-
pelvis. This radical procedure involving the disarti- tion. Christian Albert Theodor Bilroth (1829—1894)
culation of the sacroiliac joint and the symphysis was credited with having performed the first trans-
pubis, followed by removal of the limb was described pelvic amputation in Vienna in 1891, although this
by Gordon-Taylor and Wiles as ‘‘one of the most resulted in early death of the patient. Charles
colossal mutilations practised on the human Girard in Bern probably performed the first success-
frame’’.19 Throughout the life of this extended pro- ful hindquarter amputation in 1895.23 This two-
cedure, the terminologies proposed include wordy stage procedure was undertaken on a 17-year-old
but accurate terms such as interinnomino-abdominal girl with osteosarcoma. She underwent hip disarti-
amputation32 and interpelvi-abdominal amputa- culation in 1894 and then had a hemipelvectomy
tion35 and also other less accurate but eminently when she later developed recurrence of tumour in
more popular terms such as hindquarter amputation the scar. This right-sided disarticulation at the
as used here3,28 and hemipelvectomy. Gordon-Tay- sacroiliac joint was performed under ether anaes-
lor was scathing of the use of the latter term. He thesia and she was able to resume a relatively
306 S.J. Wakelin et al.

normal lifestyle following her discharge from hos- and posterior stages. With the patient in a lateral
pital 6 weeks after the operation. She subsequently position, the procedure is commenced anteriorly,
developed further recurrence of tumour in the scar with detachment of the abdominal muscles and
and died 7 months later. Five years later in 1900, inguinal ligament from the iliac crest. The bladder
Hogarth Pringle was the first British surgeon to is retracted medially and the external iliac vessels
successfully perform the procedure. He performed ligated and divided. This stage is followed by a
hindquarter amputation in a 10-year-old girl with medial stage in which the perineal muscles are
tuberculosis of the hip which had spread to the detached from the pelvis and the symphysis pubis
pelvis. This operation was performed in three is divided. The final part of the operation is per-
stages: excision of the hip joint in 1899 followed formed posteriorly and involves the formation of a
by disarticulation and then excision of the ilium and large myocutaneous flap from gluteus maximus, the
pubic ramus at a later stage. The patient recovered division of piriformis, the sciatic nerve, ilium,
well from all three procedures and lived until her sacrotuberous and sacrospinous ligaments, obtura-
early 20s. Pringle reported further hindquarter tor vessels and nerves and finally levator ani.
amputations, and is credited with having performed Sorondo and Ferré described their procedure in
the first single-stage procedure.30 He operated on 1948.33 Involving two surgeons operating simulta-
two patients: the first a 34-year-old man and the neously and the patient in a lateral position, the
second on a 46-year-old woman, both with sarcomas affected leg is held in 308 abduction. Dissection is
of the thigh. He published a review in 1916 on 19 performed anteriorly with division of the external
hindquarter amputations performed for thigh sar- iliac vessels, psoas, femoral and obturator nerves
comas and reported in this series an early mortality and iliolumbar vessels, thus allowing exposure of
of 68%.31 The operation he described took between the sacroiliac joint. Further anterior dissection
55 and 60 min to perform. Later, in 1934, Gordon- allows exposure and division of the symphysis pubis.
Taylor reported with Phillip Wiles on three success- The operation is continued posteriorly with forma-
ful cases out of five single-stage operations per- tion of a posterior flap. Division of the sacrum near
formed.19 Gordon-Taylor had first attempted this the sacroiliac joint is performed using a Giglie saw
procedure in 1922 but his first successful operation by two surgeons standing either side of the patient.
was performed in 1929. Gordon-Taylor and Monroe developed a techni-
que incorporating anterior and posterior stages and
described this in 1952.18 This method was success-
Contemporary methods of hindquarter fully used by Gordon-Taylor on a number of occa-
amputation sions and, by 1957, he was reported to have had a
personal series of 108 cases.17 Commencing ante-
Various techniques for performing hindquarter riorly with the patient in a lateral position but with
amputation have since been described. The tech- some backward tilt, the abdominal muscles are
niques of King and Steelquist,24 Sorondo and Ferré33 freed from the iliac crest. The spermatic cord,
and Gordon-Taylor and Monroe18 are among the bladder and peritoneum are retracted medially
methods most commonly used today. The methods allowing division of the external iliac vessels and
vary mainly in their positioning of the patient on the iliolumbar vein and division of the symphysis pubis.
table and the number of stages into which the The patient is moved into a full lateral position to
operation is divided. The procedures share a com- allow dissection posteriorly. The posterior flap,
mon starting point with a first incision along the consisting only of skin and subcutaneous tissue is
inguinal ligament and division of the rectus abdo- reflected to allow exposure of the posterior iliac
minis to allow inspection of the vessels and lymph spines and erector spinae sheath. Following division
nodes. As the majority of these operations are of the erector spinae aponeurosis the gluteus max-
performed for malignancy, this allows a further imus is divided in the line of its fibres inferior to the
assessment to determine whether there is evidence posteroinferior iliac spine. Division through the
of local spread of the malignancy prior to proceed- sacroiliac joint and removal of the limb follows
ing with the operation. Following this preliminary and the posterior flap drawn forward to allow clo-
exploration and biopsy to exclude advanced malig- sure.
nancy, further dissection allows division of the
symphysis pubis and the lateral movement of the
hemipelvis before division of the musculature and Conclusion
sacroiliac joint posteriorly.
King and Steelquist24 described a three-part Hip disarticulation and hindquarter amputation are
operation comprising anterior, medial/perineal still considered to be major insults to the human
Hip disarticulation–—the evolution of a surgical technique 307

frame. It is fortunate then that their use remains so 6. Cox WS. A memoir on amputation of the thigh at the
hip-joint. London: Reeve & J. Churchill; 1845. p. 7.
uncommon. Figures from the House of Commons
7. Cox WS. A memoir on amputation of the thigh at the
Hansard Debates for July 1991 suggested that of hip-joint. London: Reeve & J. Churchill; 1845. p. 19.
5335 leg amputations performed in England during 8. Cox WS. A memoir on amputation of the thigh at the
1988—1989, only 25 (0.5%) were disarticulations at hip-joint. London: Reeve & J. Churchill; 1845. p. 21.
the hip and a further 40 (0.7%) were hindquarter 9. Cox WS. A memoir on amputation of the thigh at the
amputations.22 Figures from the Amputee Statisti- hip-joint. London: Reeve & J. Churchill; 1845. p. 22.
10. Cox WS. A memoir on amputation of the thigh at the
cal Database for the United Kingdom 1999—2000 hip-joint. London: Reeve & J. Churchill; 1845. p. 26—7.
report confirm continuing low prevalence of these 11. Cox WS. A memoir on amputation of the thigh at the
procedures.29 Eighteen hip disarticulations and 11 hip-joint. London: Reeve & J. Churchill; 1845. p. 27.
hemipelvectomies were reported to the database 12. Cox WS. A memoir on amputation of the thigh at the
during this period, most of which were performed hip-joint. London: Reeve & J. Churchill; 1845. p. 28.
13. Cox WS. A memoir on amputation of the thigh at the
for neoplasia. Only 3 of the 18 hip disarticulations hip-joint. London: Reeve & J. Churchill; 1845. p. 32.
and none of the hemipelvectomies were performed 14. Dible JH. Napoleon’s surgeon. London: Heinemann Medical;
for trauma. Similarly, in the United States, Dilling- 1970. p. 130.
ham et al.16 reviewed limb amputations performed 15. Dible JH. Napoleon’s surgeon. London: Heinemann Medical;
over an 8-year period between 1988 and 1996. Of 1970. p. 132.
16. Dillingham TR, Pezzin LE, McKenzie EJ. Limb amputation
lower limb amputations, 0.5% were hip disarticula- and limb deficiency: epidemiology and recent trends in the
tions. Four hundred and eighteen hip disarticula- United States. South Med J 2002;95:875—83.
tions and 52 pelvic amputations were performed for 17. Gordon-Taylor G. On malignant disease in the region of the
trauma during this period constituting 0.23% of all hip-joint. J Roy Coll Surg Edin 1959;5:1—21 [Third John
amputations. Fraser Memorial Lecture, delivered in the University of
Edinburgh, 6 June 1957].
Although these operations are rarely performed, 18. Gordon-Taylor G, Monroe RS. Technique and management
the advent and development of anaesthesia, trans- of hindquarter amputation. Br J Surg 1952;39:536—5541.
fusion medicine, antibiosis and analgesia have 19. Gordon-Taylor G, Wiles P. Interinnomino-abdominal (hind-
meant that for those unfortunate individuals where quarter) amputation. Br J Surg 1934;22:671—95.
20. Guthrie GJ. On gun-shot wounds of the extremities requiring
such procedures are deemed appropriate, their
the different operations of amputations with their after-
perioperative morbidity and mortality have been treatment: establishing the advantages of amputation on
dramatically reduced. The operations themselves the field of battle to the delay usually recommended.
have changed little since they were first described London: Longman, Hurst, Rees, Orme & Brown; 1815. p. 177.
and one can only have admiration for the pioneers 21. Hospital Reports. Guy’s Hospital, January 16. Amputation at
who were responsible for their introduction into the hip joint. Lancet 1824;2:96—7.
22. House of Commons Hansard Debates, 18 July 1991 (http://
surgical practice. www.parliament.the-stationery-office.co.uk/pa/cm199091/
cmhansrd/1991-07-18/Writtens-7.html), last accessed 22
December 2002.
Acknowledgements 23. Jones P. Hindquarter amputations: review of a personal
series. Aust N Z J Surg 1974;44:1—11.
We would like to thank the library staff at the Royal 24. King D, Steelquist J. Trans-iliac amputation. J Bone Joint
Surg 1943;25:351—67.
College of Physicians, Edinburgh and the Wellcome 25. Kirk NT. Amputations. Hagerstown: WF Pryor; 1943. p. 84.
History of Medicine Library, London. Thanks are also 26. Loon HE. The past and present significance of hip
due to Miss Jean Archibald and her staff in the disarticulation. Artif Limbs 1957;4:4—21.
Special Collections Section, Edinburgh University 27. McLaurin CA. The Canadian hip disarticulation prosthesis.
Library. Artif Limbs 1957;4:22—8.
28. McPherson JHT. Traumatic hindquarter amputation. J Med
Assoc Georgia 1960;49:494—5.
29. National Amputee Statistical Database (NASDAB), 1999—
References 2000 (http://www.show.scot.nhs.uk/isd/amputee), last ac-
cessed 22 December 2002.
1. Annandale T. Observations on amputation at the hip-joint. 30. Pringle JH. The interpelvi-abdominal amputation. Lancet
Edin Med J 1870;15:881. 1909;1:530—1.
2. Boyd HB. Anatomic disarticulation of the hip. Surg Gynecol 31. Pringle JH. The interpelvi-abdominal amputation, with
Obstet 1947;84:346—9. notes on two cases. Br J Surg 1916;4:283—96.
3. Brittain HA. Hindquarter amputation. J Bone Joint Surg 32. Robinson RA. Interinnomino-abdominal amputation. J Bone
1949;31B:404—9. Joint Surg 1950;32A:446—8.
4. Callander CL. Tendoplastic amputation through the femur 33. Sorondo JP, Ferré RL. Amputation interilioabdominal. Ann
at the knee. J Am Med Assoc 1938;110:113—8. Orthop Traumatol 1948;1:143.
5. Coupland RM, Korver A. Injuries from antipersonnel mines: 34. Spence J. Case of successful amputation at the hip-joint on
the experience of the International Committee of the Red account of malignant tumour of the femur. Edin Med J
Cross. Br Med J 1991;303:1509—12. 1865;11:400.
 308 S.J. Wakelin et al.

35. Stedman TL. A reference handbook of the medical sciences 38. Stedman TL. A reference handbook of the medical sciences
embracing the entire range of scientific and practical embracing the entire range of scientific and practical
medicine and allied science, vol. 1. 4th ed. New York: medicine and allied science, vol. 1. 4th ed. New York:
Williams, Wood & Co.; 1923. p. 264. Williams, Wood & Co.; 1923. p. 296.
36. Stedman TL. A reference handbook of the medical sciences 39. Sugarbaker PH, Chretien PB. A surgical technique for hip
embracing the entire range of scientific and practical disarticulation. Surgery 1981;90:546—53.
medicine and allied science, vol. 1. 4th ed. New York: 40. Thomson J. Report of observations made in the British
Williams, Wood & Co.; 1923. p. 269. Military Hospitals in Belgium, after the Battle of Waterloo
37. Stedman TL. A reference handbook of the medical sciences with some remarks upon amputation. Edinburgh/London:
embracing the entire range of scientific and practical Blackwood/T. Cadell & W. Davies; 1816. p. 258.
medicine and allied science, vol. 1. 4th ed. New York: 41. Veitch J. Observations on amputation at the hip-joint. Edin
Williams, Wood & Co.; 1923. p. 270. Med Surg J 1807;3:129—34.

View publication stats