The Problem Of Fitting A Satisfactory Prosthesis Following Hemipelvectomy
Bernte P. Davis, M.D., F.A.C.S. Robert Warner, M.D. Roland Daniel, C.P. William H. Georgi, M.D.
Hemipelvectomy or hindquarter amputation involves removal of the entire lower limb including most, and sometimes all, of one innominate bone. This operation is also known as the interinnominoabdominal amputation or sacral iliac disarticulation. C.A. Theodor Billroth (1829-94) is credited with performing the first hemipelvectomy in 1889. Sir Gordon Gordon-Taylor (1878-1960) established the operation as a safe procedure and reported the results in one of the largest recorded series. He described the hindquarter amputation as, "one of the most colossal mutilations practiced on the human frame".
The necessity for hemipelvectomy is infrequent and for this reason prosthetic replacement for this type of ablation is rarely called for. Survival rate following hemipelvectomy is low because of the gravity of the underlying disease and the need for a prosthesis is not always accepted.
A primary malignant tumor of the innominate bone or upper femur, a primary malignant tumor of the soft tissues of the thigh, and recurrent malignant tumors of the upper thigh are the most common conditions for which a hemipelvectomy is performed. In rare instances hindquarter amputation is required in cases of chronic osteomyelitis of the pelvis or proximal femur, massive cartilaginous tumors of the innominate bone or dissecting aneurysm of the femoral artery.
Desirability of Hemipelvectomy
Despite the uncertainty of the outcome following hemipelvectomy for malignant bone and soft tissue tumors about the upper thigh, the procedure is preferable to allowing a patient to die under so-called "conservative management". The majority of hemipelvectomies are performed for soft tissue tumors; they offer the patient his only real chance for survival.
The literature contains very little information on the subject of prosthetic fitting following hemipelvectomy. Since all of the weight-bearing areas considered essential to a lower-extremity prosthesis are sacrificed, we are left with a twofold problem:
Which areas are to be used for weight-bearing with an ischial tuberosity and a thigh amputation stump missing?
In the absence of an iliac crest, how is the prosthesis to be stabilized?
Three points of weight-bearing are necessary - the axilla, the opposite ischial tuberosity, and the trunk and the lower rib cage. A comfortable pelvic support is needed for fitting of a satisfactory prosthesis and this may be achieved by shifting a part of the weight to the opposite ischium.
In May 1961, the problem of fitting a nine-and-a-half-year-old boy (DE) with a hemipelvectomy prosthesis following surgery from multiple recurrent episodes of a benign soft tissue tumor of the left thigh and buttock was presented to us. When this lad was five years old, his mother placed him over her lap and patted his "fanny", as she put it, when she felt a hard lump in the left buttock. The lump did not protrude, but she could easily feel that it was a solid mass. She noted it again each time she bathed him, and after one month took him to the family physician. The latter observed the mass for some time and then referred the matter to a surgeon.
Under continuing observation further enlargement of the growth was noted and in October of 1956 a mass one inch in diameter overlying the left sciatic nerve was removed. Based on its microscopic appearance, a pathological diagnosis of non-malignant fibroma of the left buttock was made.
About eight months later the mass recurred, and it was again excised. The gluteus maximus muscle was adherent to the entire tumor, which now extended to the sciatic notch and greater trochanter of the left femur. The sciatic nerve was also involved. Interlacing bundles of collagen were seen microscopically but there was no evidence of any malignant change. Recurrence was noted within six months, and before another year a third operation was indicated. Total excision of the tumor was performed at the Roswell Park Memorial Institute and one X-ray treatment was given later.
Nine months later, a total hind-quarter amputation was recommended because of the invasiveness of the lesion into the sacrum, sciatic nerve, buttock, and upper left thigh. The amputation was performed and the patient experienced an uncomplicated convalescence. He had relatively little discomfort, except for temporary phantom sensations which gradually disappeared.
When DE was first seen in our clinic, the results of physical examination indicated normalcy except for the amputation. We found that he had fairly good soft tissue padding and experienced no discomfort ambulating on crutches. He was a bright, normal boy and his parents were sensible, understanding people who faced the situation with equanimity.
A hindquarter prosthesis was fabricated using a hemipelvectomy socket made of leather and plastic with a semiautomatic lock at the hip joint. A standard knee and two-way ankle with a standard wood foot and split felt toe was used. A one-and-one-half inch webbing shoulder strap was added for retention of the prosthesis.
After about 30 hours of gait training, when things seemed to be going well, the patient developed several pressure sores over the amputation stump. The socket was re-padded and re-lined but after several months it was apparent that the boy could no longer wear the prosthesis because of tenderness over the amputation area. In an effort to relieve pressure, his pelvis was "hiked" (elevated) and he was asked to walk with a stiff leg. This proved to be unsuccessful, however, and he discontinued use of the prosthesis a year after it was made. He remained on crutches in the hope that the scarred area would soon become tough enough to withstand the pressure of a prosthesis.
In March 1963, an entirely new socket was made for DE using a new mold. The socket is a tilt table type made of plastic laminate and nylon and is flexible except for the hip joint which has a semiautomatic hip lock. Weight is borne on the opposite ischial tuberosity. A standard knee with inside friction and an e-lastic kick strap, a wood shin, single axis ankle joint, and a wood foot are used.
The wood portion of the limb is finished with plastic laminate and nylon. A cushioned abdominal corset-like cuff, fastened with Velcro straps, is brought high up onto the rib cage (Fig. 1, Fig. 2 , Fig. 3 , and Fig. 4 ).
The patient has gradually become accustomed to this prosthesis and has worn it now for almost a year. He cannot tolerate it all day and can move about much faster without it, but feels that "it is better than nothing". He admits that when he sees his shadow with the prosthesis on, he feels much more satisfied than when it is off. The severe pain he previously experienced has gradually diminished. When he is walking, rigidity of the socket-thigh joint is maintained by the semi-automatic hip lock, but by pressing a small button over the outer side of the hip joint, he can tilt the socket forward and sit in a normal position (Fig. 5 and Fig. 6 ). When he rises to walk, the hip lock engages automatically.
The success achieved thus far in this case is largely due to the determination of the young patient and the perseverance of the prosthetist in cushioning the socket to alleviate all pressure points. Since there has been no evidence of recurrence of the tumor, the results thus far have been quite gratifying.
Amputee Clinic The Children's Hospital Rehabilitation Center Buffalo, New York
Banks, "Hemipelvectomy," Journal of Bone and Joint Surgery. 38A, 1147.
Brittain, H., "Hind Quarter Amputation," Journal of Bone and Joint Surgery, 31B, 1949.
Gordon-Taylor, Sir Gordon, "The Incompatible Faccor in Cancer," British Medical Journal, 1, 1959, 455-462.
Park, "Major Exarticulations for Malignant Neoplasms of the Extremities," Journal of Bone and Joint Surgery. 38A, 249.
Robinson, R.A., "Interinnomino-Abdominal Amputation," Journal of Bone and Joint Surgery, 32A, 446.
Troup, et. al., "Malignant Disease of the Extremities Treated by Exarticulation - 264 Cases with Survival Rates," Journal of Bone and Joint Surgery,42A. 1041.
Wise, R.A., "A Successful Prosthesis for Hemipelvectomy," Journal of Bone and Joint Surgery, 31A, 1949.