J Street, D Collins, A Devitt, K Mahalingam

Cork University Hospital.

Hip disarticulation is an uncommon procedure. The indications include en bloc tumour resection, non-salvageable trauma to the lower limb and occasionally vascular disease. We report a recent case of hip disarticulation for severe aortoiliac vascular disease with rest pain. This patient had a previous above knee amputation and had developed a necrotic area in the stump.(fig 1)

This technique was described by Boyd in 1947. ¹ An anterior racquet shaped incision is fashioned beginning at the anterosuperior iliac spine curving distally and medially to a point on the medial aspect of the thigh 5cm distal to the origin of the adductor muscles. (fig 2) The femoral artery and vein are isolated and ligated and the femoral nerve divided and allowed to retract. (fig 3) The incision is continued along the posterior aspect of the thigh approximately 5 cm distal to the ischial tuberosity and continued laterally and anteriorly to leave a generous postero-lateral flap.

Sartorius is detached from the anterior superior iliac spine and rectus femoris from the anterior inferior iliac spine and both are reflected distally. Pectineus is divided 1cm from the pubis, the hip is externally rotated and psoas divided from its insertion into the lesser trochanter. The adductor and gracilis muscles are detached from the pubis together with the origin of adductor magnus from the ischium. A plane is developed between pectineus and obturator externus and the short external rotators of the hip to expose the branches of the obturator artery. These vessels are ligated at this point. (fig 4) Later in the operation, obturator externus is divided close to its insertion on the femur to guard against severing the obturator artery and retraction into the pelvis.

The hip is then internally rotated and gluteus medius and minimus divided from their attachment to the greater trochanter. The fascia lata is incised in line with the skin incision and the tendon of gluteus maximus divided at its insertion into the linea aspera. The sciatic nerve is identified and divided. (fig 5) The short external rotators are divided at their insertions on the femur and the hamstrings released from the ischial tuberosity. The hip capsule and ligamentum teres are then incised to complete the disarticulation. (fig 6)

The gluteal flap is rotated anteriorly and the gluteal muscles sutured to the origin of pectineus and adductor muscles. The skin is closed over a dependent drain.

A description of the Canadian hip disarticulation prosthesis, its mechanism of action and biomechanics can be found at :

Atlanta Case 25, Volume 2, Issue 5.

1. Boyd HB. Anatomic disarticulation of the hip. Surg Gynaecol Obstet 1947; 84: 346.