Surgical and Prosthetic Management of Hip Disarticulation Patients

This report provides a comprehensive overview of the evolution of surgical and prosthetic management for hip disarticulation patients, primarily focusing on the UK. It begins by establishing the prevalence and indications for hip disarticulation, highlighting its historical context, from the pre-anaesthetic era to the present day. The report details the significant advancements in surgical techniques, including the shift from high-mortality procedures to modern approaches like Harold Boyd’s disarticulation amputation and semi-oval incisions, emphasizing efforts to minimize blood loss and improve stump shaping. Furthermore, the report explores the progression of prosthetic designs, starting with the "tilting table prosthesis" and the US Navy hydraulic prosthesis, and then delves into the biomechanical innovations of the "Canadian" socket type and the latest advancements with the Otto Bock Helix Hip, outlining their respective advantages, limitations, and impact on patient mobility and energy expenditure. The report concludes by emphasizing the importance of continued advancements in prosthetic technology and the need for affordable solutions to improve the quality of life for hip disarticulation patients, considering the challenges in the UK healthcare system.

Evolution of Surgical and Prosthetic Management of
Hip Disarticulation Patients
In the UK in 2006/07 there were 4574 patients referred to a prosthetic service
centre. Of this just 1% were hip disarticulation patients (1).This type of
amputation is associated with severe increases in energy consumption for
walking and is performed today commonly for patients with severe vascular
problems or for patients who suffered severe trauma. However the most
common indication for a hip disarticulation amputation is as a result of a tumour.
During the 1960s – 1970s there were a lot of these amputation performed due to
osteo-sarcomas and the belief at that time that it was better to remove the
entire affected bone. Today the vast majority of lower limb osteo-sarcoma
patients are treatable using other methods with those unable to keep their limb
having trans-femoral amputations (2).
The hip-disarticulation amputation is not favoured and is considered to be a poor
choice with patients having severely affected gait and vastly increased energy
expenditure with some figures putting the energy increase as high as 200% for
patients (3).
The hip disarticulation amputation was first performed successfully in 1774 by
Perault. However in this era of pre-anaesthetic it was associated with a very high
mortality rate and so was rarely undertaken usually as a last resort (4). It was
namely done to military patients who had been shot or had blast wounds from
explosions. In the civilian realms this type of amputation was at that time mostly
performed as a result of infection and to a lesser extent tumours (5).
Since that time there have been vast improvements in medical care with the
discovery of anaesthetics and the use of blood transfusions helping to vastly
improve the survival rates of patients. Initially mortality rates were as high as
91%. One of the main reasons for this was due to hemorrhagic shock. This was
very problematic to treat as the femur contains a major blood supply with
several branches making it difficult to control blood loss. A tourniquet is also
difficult to fit, so there have been several, perhaps radical, methods designed.
One such innovative method was Wyeth’s system which used pins to hold rubber
tubing in place. Other radical ideas for minimising blood loss included the
suppression of the aorta (5). Nowadays a modified version of Harold Boyd’s dis-
articulation amputation is used by many surgeons as it utilises racket shaped
incision on the anterior portion of the leg to help the surgeon access the blood
vessels and to help prevent blood loss. Boyd also tried to minimise this blood
loss by cutting the muscles at either their origin or their insertion. This racket
shaped incision also leaves a large posterior flap which then in turn allows for an
anterior scar which can help isolate any pressure sensitive areas (6). There is
also another form of incision known as the semi-oval incision which is perhaps
preferred due to the decrease risk of causing a pressure point under the
prosthesis that can occur with the racket shape if the shape is too long (6).

There have also been drastic changes to the shaping of the stump since the
original amputations two centuries ago. During the early history of hip-
disarticulation surgery, leaving a large soft tissue stump was quite popular
amongst surgeons. Another version of this was devised by Lyons in 1859 which
left some periosteal tissue. However this procedure was difficult to perform
although it did have some merits, with some surgeons claiming that this
procedure allowed the residual tissue to be flexed, extended, adducted and
abducted powerfully.
One of the main pitfalls with this operation was that it was quite common for
undesirable growths to occur with bony spurs. It was also the case that this
operation could not be performed for patients with malignancies. Today the
stump shape tends to be a compact one where soft tissues are removed
wherever possible (5).
Ever since the first successful hip disarticulation surgery there has been a need
for prostheses for patients. However even today a lot of patients choose to use
crutches or a wheelchair rather than try and use a prosthesis. There have been a
few different types of sockets designed for hip disarticulation patients. One of
the first of these was the “tilting table prosthesis”, this was quite a heavy
prosthesis and utilised a leather socket and was attached by a belt around the
pelvis. This prosthesis then had metal bars attached to the lateral side. This was
then attached to the components of the prosthetic leg. This socket type often
had a semi-automatic lock which afforded the patient some control and stability
during stance phase (8).
Figure 1 Tilting table prosthesis (8) Fig.2 US Navy Hydraulic Prosthesis
(8)
This socket type was, however, quite cumbersome and so difficult for patients to
utilise effectively and efficiently. The tilting table prosthesis also required the
patient to thrust their pelvis quite forcefully to propel it forward, thus vaulting
was quite a common occurrence amongst tilting table users.
The tilting table prosthesis was quite common until around 1954 when the
“Canadian” socket type was introduced. There were however other socket

designs that existed at this time, such as the U.S Navy hydraulic prosthesis
which was developed at the close of the Second World War. This used a manually
controlled valve and hydraulic piston about the knee which gave the patient
some shock absorption as well as the patient having the ability to lock the valve
in any position. The valve also had some automation, for instance if there was
fast movement around the hip the valve would close giving the patient knee
stability. This prosthesis design was lighter and relatively cost effective when
compared with the tilting table due to its use of an aluminium alloy as a base
material. However there were problems with the technology involved such as the
noise of the pistons and its maintenance (8).
The Canadian socket type itself was designed by McLaurin in 1954 and used a
different approach. Instead of having a lock hip for stability, his socket type used
simple biomechanical principles to achieve stability in stance whilst also
achieving flexion during the swing phase of gait.
On the path to the design of this prosthesis were other experimental
mechanisms, such as a four bar link (of equal length) between the socket and
thigh section. The thinking behind this was to avoid the stresses involved in
conventional locking systems. However this design was found to be unstable for
the patient as their hip centre was too far forward of the ground reaction forces.
The principles behind this socket were, however, sound and so some
modification was needed. The forward link was replaced by a much longer and
stronger bar, with the intention of this bar being to withstand all the body forces.
The rear bars were removed and replaced with a bumper which prevented
hyperextention of the prosthesis. The final modification was to add elastic
webbing to help prevent excessive hip flexion and the Canadian socket was
created. This socket type is still used commonly today with locking joints rarely
being needed (8).
The actual socket of the Canadian socket was designed to encompass the ischial
tuberosity for weight bearing and the iliac crest for suspension whilst also
providing trunk stability. There is also good stability during stance due to the
anterior position of the hip joint. However there are limitations to this design, for
example the need for the prosthetic length to be much shorter than the sound
side. This is to prevent vaulting as the prosthesis is at its maximum length during
mid-swing as the patient cannot control flexion of the prosthetic knee. There
have been a couple of relatively successful attempts to bypass this issue, by
using a spring to push the prosthetic leg forward quickly at push off. However
due to the nature of the spring a knee with a friction brake would be needed in
order to ensure the patient does not fall during stance. All in all this prosthesis
type is a strong, relatively efficient and light weight (9).
The latest advancement in hip disarticulation prostheses is the Otto Bock Helix
Hip since its release in 2008. It boasts a 3 dimensional hip joint that can aid and
compensate for pelvic rotation and as well as promoting a more natural and
symmetrical gait. In addition it is easier for the patient during swing phase due to
springs in the hip joint that extend it. The Helix hip also allows for leg length

reduction during swing phase which can aid amputees as they will be more
secure and the risk of falling will be reduced. The hip allows also for individual
stride length so the patient will be able to walk or even run at varying speeds.
However in order to use this hip joint, it requires a knee with stance extension
and swing flexion damping. This means that the patient will be limited to a very
few types of knees such as the C-Leg which is also manufactured by Otto Bock
(10).
Together with the hip joint and knee this prosthesis will be very expensive and so
in the UK would probably only ever be made available to the higher end user of
amputee. But it could well be the future of Hip disarticulation prostheses.
To conclude, in terms of surgery, there has been significant advances since the
first hip-disarticulation surgeries which has greatly improved the survival rates of
hip-disarticulation patients such as the introduction of blood transfusions as wells
as antibiotics and antiseptic techniques. Despite these improvements it
continues to be the case that surgeons would only perform this type of surgery
as a last resort due to not only the risk involved but also the loss of function
associated with this level of amputation.
Although there are not significant numbers of hip disarticulation amputees in
Britain when compared with other levels of amputation. It is important that they
are not neglected as until recently there have not been any major advances in
terms of socket design or prosthetic hips. Currently the latest one, the Helix Hip
is not the most affordable nor is it likely to be available to the majority of NHS
patients. So for most patients with a hip disarticulation amputation they will be
faced vastly increased energy expenditure to try and use a prosthesis as a result
many will reject it and instead opt for a wheelchair or crutches.
References:
1. NASDAB. The Amputee Statistical Database for the United Kingdom 2006/07.
Edinburgh : NHSScotland, 2009.
2. Malawer, P Sugarbaker and M. Chapter 21 Hip Disarticulation.
Musculoskeletal Cancer Surgery Treatment of Sarcomas and Allied Diseases.
Washington : Kluwer Academic Publishers, 2001.
3. Overview of Hip Disarticulation Prostheses. Stark, Gerald. Texas : American
Academy of Orthotists and Prosthetists, 2001.
4. Hip disarticulation—the evolution of a surgical technique. S Wakelin, C
Oliver, M Kaufman. 3, Edinburgh : Elsevier Science Ltd, 2004, Vol. 35.

5. The Past and Present Medical Significance of Hip Disarticulation. Loon, H. 28,
Berkeley : University of California, 1957, Vol. 11.
6. Anatomic disarticulation of the hip. Boyd, H. s.l. : Surg Gynecol Obstet, 1947,
Vol. 84.
7. Hip Disarticulation and Transpelvic Amputation: Surgical Procedures. Tooms,
R. Washington : s.n., 2001.
8. The Evolution of the Canadian-Type Hip-Disarticulation Prosthesis. McLaurin,
C. Hampton : s.n., 1957.
9. Experiences of the Hipdisarticulation Prosthesis in the Juvenile. Raiford, R. 1,
Washington : Howard University, 1957, Vol. 66.
10. Bock, Otto. 7E10 | Helix3D Hip Joint System. Otto Bock: Quality for Life.
[Online] 2008. [Cited: 16 11 2010.]
http://www.ottobock.com/cps/rde/xchg/ob_com_en/hs.xsl/7307.html.