Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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1052 Section XIII • Amputations

Line of incision

FIGURE 95 –2

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ General, spinal, or regional anesthesia may be selected when appropriate.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The proposed incision is mapped on the foot. Dorsally, the incision is slightly curved just

distal to the midshaft of the metatarsal bones. The plantar ﬂ ap extends to the metatarsopha-

langeal crease (Figure 95-2).

CHAPTER 95 • Transmetatarsal Amputation 1053

2. DISSECTION

◆ The incision is begun on the dorsal surface of the foot directly down to the level of the

bone without undermining the ﬂ aps. As the medial and lateral extents of the dorsal ﬂ ap are

reached, the plantar incision is begun, leaving an acute angulation to avoid dog ears with

closure. Soft tissue coverage of the metatarsals will be provided by the long plantar ﬂ ap.

◆ Once hemostasis has been achieved, the small-bladed oscillating saw is used to divide the

metatarsal bones approximately 1 cm proximal to the dorsal skin ﬂ ap, starting with the ﬁ rst

metatarsal (Figure 95-3). The second metatarsal shaft is cut at the same level as the ﬁ rst,

and the remaining metatarsals are cut 3 mm shorter than the ﬁ rst two. The oscillating saw

is used to avoid splintering of the bones. The cut edges are smoothed with a rasp.

Incision through skin

and deep tissue

FIGURE 95 –3

1054 Section XIII • Amputations

◆ The plantar soft tissues are divided to release the amputated segment. The tendons are

placed on stretch and cut short so that they retract into the stump (Figure 95-4).

◆ Redundant and devitalized soft tissues of the planter ﬂ ap are trimmed and hemostasis is

ensured. An estimation of the tension on the closed ﬂ ap is made, and if necessary, the

metatarsal bones are trimmed further (Figure 95-5).

3. CLOSING

◆ The superﬁ cial fascia may be approximated with 2-0 interrupted absorbable sutures.

◆ Skin staples or 2-0 vertical mattress permanent sutures are placed to close the wound and

are left in place until complete healing is certain (Figure 95-6).

FIGURE 95 –4

CHAPTER 95 • Transmetatarsal Amputation 1055

Superficial fascia approximated

with interrupted absorbable sutures

Flexor tendons

FIGURE 95 –5

FIGURE 95 –6

1056 Section XIII • Amputations

STEP 4: POSTOPERATIVE CARE

◆ A sturdy dressing such as a well-padded cast will help limit postoperative edema and

protect the stump. The stump should be inspected at least weekly to assess for viability and

infection.

◆ The patient should avoid weight bearing on the extremity until the wound is safely healed.

STEP 5: PEARLS AND PITFALLS

◆ Careful attention to hemostasis, debridement of devitalized tissue, and tension-free closure

will help ensure the optimal outcome.

◆ In the setting of a contaminated wound, the stump may be left open to heal by secondary

intention or subsequent grafting. Premature closure of a contaminated stump will likely

result in further soft tissue loss and necessitate a higher level of amputation.

SELECTED REFERENCES

1. Durham JR, McCoy DM, Sawchuk AP, et al: Open transmetatarsal amputation in the treatment of severe

foot infections. Am J Surg 1989;158:127-130.

2. Dwars BJ, van den Broek TA, Rauwerda JA, Bakker FC: Criteria for reliable selection of the lowest possible

level of amputation in peripheral vascular disease. J Vasc Surg 1992;15:536-542.

3. McKittrick LS, McKittrick JB, Risley TS: Transmetatarsal amputation for infection or gangrene in patients

with diabetes mellitus. Ann Surg 1949;130:826-842.

4. Effeney DJ, Lim RC, Schecter WP: Transmetatarsal amputation. Arch Surg 1977;112:1366-1370.

1057

INDICATION

◆ Hip disarticulation is performed for malignant soft tissue or bony tumors of the proximal

thigh region (below the lesser trochanter of the femur) in which negative margins cannot be

achieved without a less radical operation. Most sarcomas can be treated with limb-sparing

procedures and the use of adjuvant or neoadjuvant therapies. In general, bone and vessels

can be resected and replaced with grafts. Sacriﬁ ce of a single nerve, either the femoral nerve

or the sciatic nerve, would result in some neuromuscular dysfunction but is preferable to

amputation. This operation may be appropriate in locally recurrent cases of extensive

(unresectable) tumor involvement (usually when adjuvant radiotherapy options have

already been exhausted).

◆ This procedure can also be considered for massive trauma and crush injury to the lower

extremity or following multiple failed vascular procedures and distal amputations.

STEP 1: SURGICAL ANATOMY

◆ See Figure 96-2 for illustration of key anterior structures. See Figures 96-4 and 96-5 for the

posterior lateral anatomy, which must be considered with hip disarticulation.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Magnetic resonance imaging of soft tissue tumors of the proximal thigh can delineate the

extent of tumor involvement relative to muscular compartments, neurovascular bundles,

and bony structures. A bone scan is useful to ensure that the acetabulum and pelvis are

not involved with tumor. A Tru-Cut needle biopsy or an open biopsy should have already

been performed to conﬁ rm the malignant nature of the tumor and the necessity of such a

radical operation.

◆ A complete neurologic examination of the involved extremity may reveal signiﬁ cant loss of

function and intractable pain preoperatively.

◆ General anesthesia is used.

Hip Disarticulation

Celia Chao and Courtney M. Townsend, Jr.

CHAPTER

1058 Section XIII • Amputations

STEP 3: OPERATIVE STEPS

1. INCISION

◆ A Foley catheter is placed in the bladder. The patient is positioned in the lateral decubitus

position to provide adequate exposure for both anterior and posterior aspects of the thigh

(Figure 96-1). A bean bag may be used to help maintain this position. The skin is prepped

from midchest down to the toes. The extremity below the thigh can be covered with a

stockinette, such that the entire leg can be manipulated and repositioned intraoperatively to

facilitate the resection.

Incision line

FIGURE 96 –1

CHAPTER 96 • Hip Disarticulation 1059

◆ Anteriorly, a skin incision is made approximately 3 cm below the inguinal ligament. The

posterior skin ﬂ ap is much longer. It is approximately 6 to 8 cm below the anterior incision

to facilitate a ﬁ sh-mouth closure at the lateral and medial corners (Figure 96-2; see also

Figure 96-1).

Iliopsoas muscle

incision

Posterior

incision

Sartorius muscle

Tensor fasciae latae muscle

Rectus femoris muscle

Pectineus muscle

Femoral nerve, artery, and vein

Adductor longus muscle

FIGURE 96 –2

1060 Section XIII • Amputations

2. DISSECTION

◆ After dissecting past Scarpa’s fascia, the surgeon creates the anterior ﬂ ap. The femoral ves-

sels are identiﬁ ed below the inguinal ligament and are serially divided and suture ligated.

The femoral nerve and the sartorius muscles, lateral to the vessels, are also divided. The

femoral nerve should be on gentle traction and ligated just as it exits the inguinal ligament.

The residual nerve will retract beneath the external oblique aponeurosis. If a neuroma

forms, it should be well away from the weight-bearing portion of the stump. Muscles lateral

to the vessels are identiﬁ ed and include the iliopsoas and the rectus femoris. The insertion

of the iliopsoas onto the less trochanter is divided with electrocautery, preserving most of

the proximal aspects of the muscle (Figure 96-3).

◆ Medially, a ﬁ nger is passed beneath the pectineus muscle, and the muscle can be released

from its origin on the pubis using electrocautery. Continuing medially, the surgeon transects

the adductor magnus and brevis muscles and the gracilis muscles at their origin on the

symphysis pubis, exposing the obturator externus muscle (Figures 96-4 and 96-5).

Beneath the pectineus and adductor muscles, branches of the obturator nerve and vessels

are identiﬁ ed and ligated. The tendinous insertion of the obturator externus muscle is cut

at its insertion into the lesser trochanter.

Sartorius muscle

Iliopsoas muscle

Tensor fasciae

latae muscle

Rectus femoris muscle

Adductor longus muscle

Pectineus muscle

Gracilis muscle

FIGURE 96 –3

CHAPTER 96 • Hip Disarticulation 1061

Gluteus maximus muscle

Gluteus medius muscle and

Gluteus minimus muscle

Sartorius muscle

Sciatic nerve

Inferior gemellus muscle

Quadratus femoris muscle

Biceps femoris muscle

Semimembranosus muscle

Semitendinosus muscle

Adductor magnus muscle

Superior gemellus muscle

Obturator internus muscle

Piriformis muscle

Tensor fasciae latae muscle

FIGURE 96 –5

Gracilis muscle

Piriformis muscle

Gluteus minimus muscle

Gluteus medius muscle

Obturator internus muscle

Superior gemellus muscle

FIGURE 96 –4