Hip Disarticulation and Hemi-Pelvectomy
William Parrish, MD
A mputations through the hip joint or pelvis are most often
indicated for radical treatment of neoplasia when a pri-
mary malignant soft tissue or osseous tumor of the extremity
involves several compartments, the sciatic nerve, or the fem-
oral neurovascular structures. The goal of these procedures
when performed for neoplastic indications is to provide local
disease control. If a primary malignant bone tumor involves
the hip joint or a large portion of the ilium, a hemi-pelvec-
tomy may be indicated. If the tumor involves only a limited
portion of the pelvis but no neurovascular structures, an
internal hemi-pelvectomy may be possible to preserve the
extremity. Amputations through the hip joint or pelvis result
in very similar functional results.
Less often, such amputations may be required in the
setting of vascular catastrophe, such as prosthetic graft
infection or nonhealing of above-knee amputation. Other
indications may include severe trauma with extensive
bone or soft tissue loss and neurovascular injury, or ag-
gressive infectious diseases such as necrotizing fasciitis or
gas gangrene.
Surgical planning for hip disarticulation or hemi-pelvec-
tomy should be based on imaging studies which clearly de-
fine the vascular status of the extremity, the anatomic mar-
gins of a tumor, or the extent of tissue loss or necrosis from
trauma or an infection. CT scan will provide the best images
to define osseous structures. MRI is most useful for defining
soft tissue extension of a tumor, relationship of a tumor to
neurovascular structures, and extent of marrow involvement.
MRI is also helpful in defining the limits of cellulitis or muscle
necrosis that may occur with aggressive infections. Appropri-
ate vascular studies such a doppler ultrasound, digital sub-
traction angiography, or venography may be useful when
evaluating the patient with vascular disease.
Hip Disarticulation:
Surgical Technique
Position
As with all surgical procedures, the operating surgeon must
take primary and personal responsibility for correct identifi-
Department of Orthopedics and Rehabilitation, Penn State Hershey Medical
Center, College of Medicine of the Pennsylvania State University, 500
University Drive, Hershey, PA.
Address reprint requests to Dr. William Parrish, Department of Orthopedics
and Rehabilitation, Penn State Hershey Medical Center, College of Med-
icine of the Pennsylvania State University, 500 University Drive, Her-
shey, PA 17033. E-mail: wparrish@psu.edu
96 1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2005.08.001
cation of the patient and operative site/side. Before position-
ing, a regional anesthetic should be introduced and induc-
tion of the general anesthetic completed. Epidural anesthetics
with an indwelling catheter provide an excellent means of
postoperative pain control. In addition, a regional anesthetic
can be highly beneficial by reducing the incidence of phan-
tom pain postoperatively.
A Foley catheter is placed while the patient is in the
supine position. The patient is then moved into a lateral
decubitus position and stabilized with the aid of a “bean
bag” or other similar apparatus (Fig. 1). The operative
(ipsilateral) side will be facing up. An axillary roll is then
placed beneath the chest wall in the contralateral axilla to
avoid pressure on the brachial plexus and neurovascular
structures. The contralateral arm must be carefully and
naturally positioned on an arm board without unusual
angulation of any joint or pressure against the radial and
ulnar nerves. The ipsilateral arm is often best positioned in
an overhead cradle with generous padding. Foam pads or
blankets should also be used to protect the peroneal nerve
of the contralateral leg and ankle.
It is important to perform the skin preparation and drap-
ing as widely as possible so that the surgical field is not
compromised. Failure to “prep and drape” a wide field may
cause great difficulty in placing correct incisions, and in-
creases the risk of contamination of the surgical field. Patient
positioning, skin preparation, and placement of drapes
should be done under the direct supervision of the operating
surgeon or a very trusted associate.
After antiseptic skin preparation, a U-shaped drape is
placed under the operative leg as close to the midline gluteal
cleft as possible (while excluding the anus). The anterior arm
of the drape is brought along the base of the scrotum, extend-
ing to the umbilicus and ending at the level of the sternum.
The posterior arm of the U-drape extends along the midline
of the spine to the lower margin of the twelth rib. A second
rectangular drape is then used to complete the surgical field
connecting the two ends of the U-drape along the lower
margin of the rib cage.
Incision
See Figs. 1 and 2.
Dissection
The anterior limb of the incision is developed by exposing
the femoral triangle. The femoral triangle is found in the
Hip disarticulation and hemi-pelvectomy 97

Figure 1 Posterior view of patient positioning and placement of incisions for hip disarticulation and hemi-pelvectomy.
The incision for hip disarticulation (dotted line) begins approximately one fingerbreadth inferior and medial to the
anterior superior iliac spine (ASIS) and proceeds caudally toward the greater trochanter. From there, the incision
courses posteriorly within the gluteal crease and then curves anteriorly within the medial thigh crease to reach the pubic
tubercle. Shown in Fig 2 is the anterior component of the incision, extending from the pubic tubercle to the ASIS. For
hemi-pelvectomy (solid line), the incision passes posteriorly from the ASIS along the iliac crest toward the posterior
superior iliac spine (PSIS). At this point, the incision is directed postero-laterally to the tip of the greater trochanter, and
then posteriorly along the gluteal crease to the ischium. The incision then courses within the thigh crease anteriorly
toward the inferior pubic ramus, continuing on to the pubic symphysis. Figure 2 shows the anterior incision extending
from the pubic symphysis, along the inguinal ligament, to the ASIS.

subfascial space of the proximal thigh. The femoral artery,
vein, and nerve pass through this anatomic area as they
exit the pelvis beneath the inguinal ligament and descend
into the leg. The position of the neurovascular structures
in the femoral canal are nerve, artery, vein, and lymphatics
in a lateral to medial progression (NAVL). The femoral
triangle is bounded by the adductor longus muscle medi-
ally, the sartorius muscle laterally, and the inguinal liga-
ment superiorly. The iliopsoas and pectineus muscles
form the floor of the femoral triangle (Fig. 2).
The most reliable landmark for identification of the femo-
ral vessels is the inguinal ligament, specifically the inferior
“shelving” edge, sometimes referred to as Poupart’s ligament.
Particularly in patients with previous arterial surgery in the
groin, the inguinal ligament can be the only constant struc-
ture. Division of the sartorius muscle at its origin will further
aid in exposing the femoral neurovascular structures in the
femoral triangle. Once exposed, the femoral artery and vein
must be encircled, controlled, and individually suture ligated
with nonabsorbable monofilament suture of 3-0 or larger
size. The femoral nerve is then gently placed under tension,
ligated as it exits beneath the inguinal ligament, divided, and
allowed to retract into the pelvis.
The greater saphenous vein enters the femoral vein very
proximally and may need to be separately ligated. In addi-
tion, the obturator, pudendal, and superficial epigastric ves-
sels may require separate ligation. The lateral femoral cuta-
neous nerve should be identified as it exits the pelvis just
beneath the anterior superior iliac spine. This should be
placed under gentle traction, ligated, and allowed to retract
into the pelvis. The round ligament in a woman or spermatic
cord in a male may be encountered during dissection of the
midline part of the incision. These should be exposed but not
resected with the specimen.
Once these neurovascular structures have been identi-
fied and divided, the dissection continues through the soft
tissues toward the hip joint. Proceeding anterior to poste-
riorly, the iliopsoas muscle is released from its insertion
onto the lesser trochanter of the femur. Circumflex
branches of the femoral vessels may be encountered dur-
ing the dissection. The pectineus and adductor muscles
are transected at their origins on the bony pelvis. Care
must be taken to ligate the obturator vessels during this
part of the dissection.
As the dissection is carried posteriorly, all the muscles
originating on the ischium are released at their origin. This
will include the gracilis and the hamstring muscles. This part
of the dissection is most easily completed with the leg in a
flexed, abducted, and externally rotated position. The poste-
rior limb of the incision is then developed by dividing the
gluteus maximus muscle and releasing the gluteus medius
and minimus muscles from their insertions on the greater
trochanter. This will provide exposure of the deep posterior
thigh including the sciatic nerve and the short external rota-
tors of the hip. The sciatic nerve should be placed under
gentle traction, securely ligated, divided, and allowed to re-
tract proximally beneath the piriformis muscle. The remain-
ing external rotator muscles are then released from their fem-
oral insertion.
Attention is then redirected to the anterior limb of the
incision. The dissection from the greater trochanter to the
ASIS is completed by dividing the tensor fascia lata and re-
98 W. Parrish

Figure 2 Anterior view of the incisions and deep dissection for hip disarticulation and hemi-pelvectomy. Depicted on
the patient’s right side are the incisions for the two procedures. Both begin at the anterior superior iliac spine (ASIS) and
course along the inguinal ligament. For hip disarticulation, the incision turns posteriorly at the pubic tubercle; for
hemi-pelvectomy, it extends to the pubic symphysis before curving posterior along the lateral border of the perineum
and into the medial thigh crease. Posteriorly, both incisions pass within the gluteal crease toward the greater trochanter.
The hip disarticulation incision then turns superiorly to course directly back to the ASIS. The hemi-pelvectomy incision
travels from the greater trochanter superiorly, posteriorly, and medially toward the posterior superior iliac spine (PSIS).
The posterior component follows the iliac crest back to the ASIS. These relationships are also shown in Fig 1. The left
side of the patient shows the deep dissection for both hip disarticulation and hemi-pelvectomy, as explained in detail
in the chapter text.

leasing the rectus femoris muscle from its origin on the ante-
rior inferior iliac spine. The hip capsule is the incised around
the lip of the acetabulum, and the hip joint dislocated. The
ligamentum teres is divided by electrocautery, completing
the amputation, and allowing removal of the limb from the
surgical field.
Closure
The surgical field is then thoroughly irrigated and in-
spected for hemostasis. The short external rotator muscles
and gluteus medius muscles are then approximated with
the obturator externus and iliopsoas muscles to cover the
acetabulum. One or two large drains are then placed in the
surgical bed and the gluteus maximus flap is mobilized
anteriorly with suturing of the gluteus fascia to the ingui-
nal ligament (Fig. 3). Deep dermal sutures are placed and
the skin is closed with interrupted sutures or staples. A
sterile dressing is placed on the wound and may be se-
cured with a long six inch elastic wrap that is secured
around the waist.
Hip disarticulation and hemi-pelvectomy 99

Figure 3 Hip disarticulation before closure with the gluteal flap. The transected and ligated vessels are seen deep in the
wound. Acetabular coverage is obtained by approximating the short external rotator muscles and gluteus medius muscles
with the obturator externus and iliopsoas muscles. One or two large drains can be placed in the surgical bed if desired. The
gluteus maximus flap is then mobilized anteriorly with suturing of the gluteus fascia to the inguinal ligament.

Postoperative Care
The drains should be left in place until output is minimal.
Removal of the drains too quickly will result in the devel-
opment of a seroma in the large space deep to the gluteal
fascia. The epidural catheter should be left in place for 48
to 72 hours for pain control. Sustained release oral nar-
cotic pain medications should be started while the epi-
dural is in place and should be titrated to the patient’s pain
requirements as the epidural is weaned. Once the incision
line is completely healed, the patient is referred to pros-
thetics to initiate fabrication of prosthesis. A preoperative
visit with a prosthetist can be most helpful for the patient
to understand the concept and process of prosthetic fit-
ting.
100
Hemi-Pelvectomy:
Surgical Technique
Position
Positioning the patient for a hemi-pelvectomy is in many
ways similar to positioning for a hip disarticulation (Fig. 1).
Preoperative preparation for this procedure should include a
mechanical bowel prep on the night before surgery. A beta-
dine-soaked vaginal sponge may be packed into the rectum
to prevent contamination of the surgical field due to manip-
ulation of the retroperitoneum during the surgical proce-
dure. A stent should be placed in the ipsilateral ureter and a
Foley catheter in the urinary bladder while the patient is in
the supine position. This makes it easier to identify the ureter
during surgery and decreases the risk of injury to it.
The patient is moved into a relaxed lateral decubitus position
with placement of an axillary roll and appropriate padding of
pressure points. For a hemi-pelvectomy, the patient is posi-
tioned on the OR table so the flexion break in the table is
centered between the lower ribs and the iliac crest. The bed
is then flexed which opens the space between the ribs and
iliac crest, making the exposure of the retroperitoneum eas-
ier. The patient is placed into a relaxed lateral position so that
the trunk and pelvis can be moved forward or backward to
facilitate surgical exposure. The arms are positioned and pad-
ded as described for hip disarticulation. Skin preparation and
draping is performed in similar fashion. Although these steps
should not be delegated to subordinates, the principles of
positioning and preparation should be familiar to the entire
OR team.
Incision
Posterior flap hemi-pelvectomy is the most common variant
of this procedure. This method utilizes the gluteus maximus
for closure much as was described for a hip disarticulation.
Occasionally, a tumor may involve the posterior aspect of the
pelvis or gluteus maximus, necessitating the use of an ante-
rior flap hemi-pelvectomy. The anterior flap hemi-pelvec-
tomy utilizes an anterior based myocutaneous flap that is
based on the femoral vessels. The incision used will depend
on the type of flap required. This chapter will describe the
posterior flap hemi-pelvectomy. The incisions are outlined
and described in Figs. 1 and 2.
Dissection
The dissection begins at the posterior superior iliac spine and
extends anteriorly along the iliac crest and the inguinal liga-
ment to the pubic symphysis. The retroperitoneal space is
exposed by releasing the insertion of the abdominal muscles
on the iliac crest and inguinal ligament. The peritoneal sac
and contents are retracted medially with the ureter. The com-
mon iliac artery and vein are identified as well as the internal
and external iliac vessels. The level of ligation of these vessels
may be determined by the position of the tumor. For a pos-
terior flap hemi-pelvectomy, preservation of the internal iliac
vessel or at least the first branch (the superior gluteal artery)
will result in better flap viability because the superior gluteal
artery supplies the gluteus maximus. Once the level of liga-
tion is determined, the appropriate vessels are suture ligated
with monofilament nonabsorbable suture no smaller than
W. Parrish
4-0. Surgeons not familiar with handling of large vessels
should obtain assistance from a vascular surgeon, especially if
the vessels are heavily calcified or aneurysmal. The iliopsoas
muscle is divided near the inguinal ligament. In most cases,
the iliacus will be included in the surgical specimen and the
majority of the psoas muscle preserved. The femoral nerve is
finally identified, ligated, and divided (Fig. 2).
The perineal dissection is then performed. The bladder is
retracted along with the urethra and protected with a broad
malleable retractor. The ischiorectal space is the exposed as
the dissection is extended along the inferior pubic ramus and
the ischium by releasing the muscles of the pelvic floor as
they insert on the boney pelvis. The bladder, urethra, and
spermatic cord should be protected during this part of the
dissection. An osteotome is then used to divide the pubic
symphysis.
The posterior segment of the dissection is then completed
by extending the incision from the PSIS to the greater tro-
chanter, then along the inferior border of the gluteus maxi-
mus, connecting to the perineal incision and region of dis-
section. If possible, the gluteus maximus muscle is preserved
with the posterior flap; however, it may be necessary with
some tumors to sacrifice the gluteus maximus to achieve an
acceptable surgical margin. This myocutaneous or fasciocu-
taneous flap is then developed in an anterior to posterior
direction.
As the flap is developed posteriorly, the superior gluteal
artery should be preserved in those cases using a myocuta-
neous gluteus flap. The superior gluteal artery will exit the
pelvis through the greater sciatic notch and is tightly adher-
ent to the bone in this location. Once the posterior flap is
developed, the deep posterior hip musculature and sciatic
nerve will be visible. The piriformis muscle is divided to
reveal the sciatic nerve as it exits the pelvis. The very large
nerve must be firmly ligated, divided, and allowed to retract
into the pelvis. The inferior gluteal artery will exit the pelvis
inferior to the piriformis muscle. This artery should be iden-
tified and ligated to avoid bleeding. The thick broad sacro-
tuberous ligament will then be encountered extending from
the lateral border of the sacrum to the ischial tuberosity, and
must be divided.
Once division of the soft tissues and neurovascular struc-
tures are completed, attention is then directed to final step:
sacral osteotomy. The standard hemi-pelvectomy is com-
pleted by passing a series of osteotomes through the sacro-
iliac joint. A blunt ribbon retractor is placed through the
sciatic notch into the pelvis along the anterior margin of the
sacro-iliac joint to protect the anterior structures. The sur-
geon then directs the osteotomes serially through the joint to
complete the amputation. The amputation specimen is
passed from the surgical field and hemostasis obtained. The
presacral area is highly vascular with great potential for ve-
nous bleeding, which must be controlled with suture liga-
tures or electrocautery.
Closure
The surgical field should then be irrigated with several liters
of fluid and closed over large drains. Closure is accomplished
by bringing the gluteus maximus flap forward and suturing
the gluteus fascia to the external oblique and rectus abdomi-
Hip disarticulation and hemi-pelvectomy
nus fasciae of the abdominal wall. Scarpa’s fascia may be
re-approximated according to the surgeon’s preference,
along with the desired method of skin closure. The rectal
packing should be removed and a bulky dressing placed on
the wound, secured with a large elastic bandage around the
waist.
Conclusion
Hip disarticulation and hemi-pelvectomy procedures result
in major functional disabilities, but do not preclude the re-
101
sumption of an acceptable quality of life. Aggressive rehabil-
itation enables most of these patients to ambulate with fore-
arm crutches, which many patients choose in preference to a
large unwieldly prosthesis. Amputation support groups can
be instrumental in helping patients make both emotional and
physical adjustments to their disability.
Suggested Reading
Clark MA, Thomas JM: Major amputation for soft-tissue sarcoma. Br J Surg
90:102-107, 2003
Paz IB: Major palliative amputations. Surg Clin N Am 13:543-547, 2004