Hip disarticulation accounts for only 0.5% of lower limb amputations in the United States.¹³ The patient is positioned in a lateral decubitus position on a well-padded beanbag or in a semisupine position with a support under the pelvis. Split drapes or U-shaped drapes allow for wide exposure to the anterior and posterior hip and buttocks. Prepping should include the abdomen, the groin, the buttock, and the entire lower limb. Current practice is based on the technique described by Boyd¹⁴ and uses a racquet-shaped incision that begins just medial and inferior to the anterior superior iliac spine and descends parallel to the inguinal ligament down to approximately 5 cm distal to the ischial tuberosity and the gluteal crease. The other limb of the incision runs obliquely on the anterior thigh, curving posteriorly approximately 8 cm from the greater trochanter to meet the medial incision (Figure 1). Deep dissection typically begins anteriorly with exposure of the femoral triangle, identification and isolation of the femoral vessels, and meticulous suture ligation and division. The femoral nerve is gently transected under tension and allowed to retract into the pelvis. Following neurovascular control, the muscles are transected in a sequential manner. The sartorius and rectus femoris are detached from their proximal origins, and the pectineus is divided close to the pubis. The external rotators of the hip and the iliopsoas are transected. The obturator vessels should be identified and suture ligated, followed by division of the adductor and the gracilis muscles and a gentle
traction neurectomy of the obturator nerve. Posteriorly, the gluteal muscles are sequentially transected as distally as the disease process will allow to ensure a substantial myocutaneous flap. The sciatic nerve should be transected with a sharp scalpel under tension to minimize symptomatic neuroma formation; when possible, the nerve is either allowed to retract or manually placed inside the pelvis through the sciatic notch. The external rotators of the hip are released from their femoral insertions and the hamstrings from their proximal origins. The hip capsule is released around the acetabulum, the ligamentum teres is transected, and the limb is removed. The muscles of the buttock together with iliopsoas and the obturator externus thus remain attached to the pelvis.

After the limb is removed, the acetabulum is covered by approximating the preserved muscle groups, most frequently the quadratus femoris to the iliopsoas and the obturator externus to the gluteus medius. Deep drains are recommended, followed by closure of the posterior gluteus maximus fascia to the inguinal ligament. This surgical technique allows methodical dissection, avoids weight bearing over the suture lines, divides muscles at their origins or insertions, and provides a viable muscle flap as a weight-bearing surface for sitting and/or prosthetic use. Postoperative care should include strict decubitus ulcer precautions, perioperative antibiotics, and thromboprophylaxis.

Although the previously described approach is most commonly used, alternative surgical approaches may be recommended according to surgeon preference or disease location. One such modification uses a lateral approach¹⁵ and may be more familiar to orthopaedic surgeons. A total adductor myocutaneous flap also has been described when disease precludes using more traditional anterior or posterior flaps.¹⁶ Frey et al¹⁷ described an alternative quadriceps muscle flap, consisting of skin, subcutaneous fat, and the quadriceps muscle. This flap receives its blood supply from the muscular branches of the superficial femoral artery and can cover defects up to the level of the posterior superior iliac spine. Infrequently, when local flaps are not available, free flap or pedicle-based augmentation flaps may be considered.

The approach to surgery begins by positioning the patient in a lateral position, with the ability to modify (as needed) the patient’s position intraoperatively to a more supine or prone inclination, which is commonly described as a “sloppy lateral” position. Such positioning is best achieved with a well-padded beanbag because it allows intraoperative position modifications while simultaneously ensuring adequate patient stability. An axillary roll should be placed beneath the chest wall to avoid pressure or traction on the brachial plexus. All bony prominences must be well padded because the length of the surgical procedure can predispose patients to compressive neuropathy. Prepping the leg into the surgical field allows for easy intraoperative alterations in positioning and is strongly advocated. Hip and knee flexion with hip adduction allows for enhanced exposure posteriorly (Figure 2, A), whereas hip and knee extension with hip external rotation and abduction allow for full anterior exposure (Figure 2, B). A Foley catheter is necessary to monitor fluid balance and facilitate urethra identification and bladder decompression. Preoperative ureteric catheterization and bowel preparations are often advisable to ease the intraoperative identification (or repair in the event of accidental transection) of the ureters and decompress the bowels, which is an important consideration because genitourinary injury and enterotomy are inherent risks of these procedures. When bowel or bladder involvement require visceral resection, a procedure described as a compound hemipelvectomy, including a diverting colostomy and/or ileostomy, is recommended.^23,24

When applying surgical drapes, it is critical to ensure adequate access to the anterior viscera and the posterior structures, including the sacrum. Split drapes are recommended with the limbs of the drapes extending beyond the midline both anteriorly and posteriorly.