Purpose: We report cancerological and functional outcome in 41 patients who underwent interilioabdominal disarticulation for malignant tumours. Material and methods: This retrospective series included 27 men and 14 women, mean age 49 years, most of whom underwent surgery for chondrosarcoma. In ten patients, the disarticulation followed a resection-reconstruction procedure. In five patients, it followed curettage or contaminated margin resection. For seven patients it was performed after radiotherapy alone. None of the patients had metastatic dissemination prior to surgery. The resection margins were in healthy tissue in 24 cases and contaminated in 17. Mean follow-up was 62 months. Results: Twenty-eight patients died from their disease and one died from pulmonary embolism. At last follow-up, among the 13 living patients, five had local or general relapse. For the 17 patients who had contaminated resection margins, ten developed a recurrent tumour compared with five recurrent tumours among the 25 patients with resection margins in healthy tissue. Mean five-and ten-year survival rates were 30% and 25% respectively. Initial treatment, tumour size and tumour histology did not have any significant effect on prognosis. The only factor with a significant effect on survival was the quality of the resection margins. All patients were able to walk with two crutches. Discussion: Interilioabdominal disarticulation is a very mutilating procedure. Since the development of conservative surgery of the pelvis, indications for interilioabdominal disarticulation are generally limited to very voluminous endopelvic tumours with vessel and nerve invasion. For local recurrence after surgical resection of the pelvis or proximal femur, especially in patients with infection or radiated tissue, interilioabdominal disarticulation may be the only solution providing satisfactory cancerological resection. Careful exploration of the locoregional and general extension is necessary before proposing this mutilating procedure, with its inherent psychological and functional impact, in order to properly select patients free of metastasis who could benefit from the cancerological resection provided by inter-ilioabdominal disarticulation

We have compared the energy expenditure during walking in three patients, aged between 51 and 55 years, with unilateral disarticulation of the hip when using the mechanical-controlled stance-phase control knee (Otto Bock 3R15) and the microprocessor-controlled pneumatic swing-phase control knee (Intelligent Prosthesis, IP). All had an endoskeletal hip disarticulation prosthesis with an Otto Bock 7E7 hip and a single-axis foot. The energy expenditure was measured when walking at speeds of 30, 50, and 70 m/min. Two patients showed a decreased uptake of oxygen (energy expenditure per unit time, ml/kg/min) of between 10.3% and 39.6% when using the IP compared with the Otto Bock 3R15 at the same speeds. One did not show any significant difference in the uptake of oxygen at 30 m/min, but at 50 and 70 m/min, a decrease in uptake of between 10.5% and 11.6% was found when using the IP. The use of the IP decreased the energy expenditure of walking in these patients

1. A prosthesis which is useful in unilateral disarticulations of the hip and highly advantageous in cases of bilateral disarticulation is described. 2. It makes use of the principle of a swing door and makes walking possible with the assistance of elbow crutches in cases of bilateral hip disarticulation and amelia

Purpose: To determine the wound healing rate, perioperative mortality and ambulatory status of patients following knee disarticulation. Method: Retrospective review of all cases performed by one surgeon at tertiary center. Charts reviewed for demographic data, surgical and follow-up data. Ambulatory status preop and postop graded after Volpicelli et al. Descriptive statistics applied. Results: 34 knee disarticulations in 28 patients. 3 perioperative deaths (11%). Report on 31 procedures in 25 patients with mean follow-up of 7 months. 20 males, 5 females. Mean age 73 (55–92). PVD 21/25. Diabetes Mellitus 13/25 (52%). Chronic infection 2, Scleroderma 1 and squamous cell carcinoma 1. Primary wound healing 25 (81%). Delayed healing 6 (19%). Reoperation 1. Revision of amputation 0. Mean ambulatory status preop 2.5/6. Mean ambulatory status postop 1.8/6. Conclusion: Knee disarticulation is a reliable surgical procedure with 81% primary healing in high risk population. Knee disarticulation should be considered as an option to above knee amputation for patients with PVD and complications of diabetes

Aims. Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit. Methods. Data were collected retrospectively from a large tertiary referral revision arthroplasty unit’s database. Inclusion criteria included all patients who underwent TFA in our unit. Preoperative demographics, operative factors, and short- and long-term outcomes were collected for analysis. Outcome was defined using the Musculoskeletal Infection Society (MSIS) outcome reporting tool. Results. Overall, 38 TFAs were identified. The mean age was 73 years (42 to 80). All patients underwent TFA for non-oncological indications, most commonly as a consequence of infection (53%) and periprosthetic fracture (26%). The mean follow-up time was ten years (0 to 26); 63% of TFAs were considered a success based upon the MSIS outcome reporting tool. The mean time between TFA and death was 8.5 years (0.2 to 19.2), with two patients dying within one year of surgery. Within the cohort, 66% suffered at least one complication, dislocation being most common (37%); 55% of the total cohort required at least one subsequent operation. In total, 70% of TFAs undertaken for infection were considered infection-free at time of final follow-up. The percentage of mobile patients improved from 52% to 65% between pre- and postoperation, with all patients being able to at least transfer from bed to chair at time of final review. Conclusion. This study is the largest in the UK assessing the use of TFA in patients with bone loss secondary to non-oncological conditions. It demonstrates that TFA has a significant complication profile, however it is favourable in terms of mortality and rehabilitation when compared to amputation and disarticulation. Cite this article: Bone Joint J 2023;105-B(8):888–894

An anterior skin flap taken from the instep can be used to cover the bone ends in disarticulation of the ankle when ulceration or necrosis of the heel prevents the use of the heel flap for a conventional Syme’s amputation. From 1995 to 2003 December, we performed ankle disarticulation by using anterior flap after primary radical debridement in 42 cases with traumatic foot amputation injured by antipersonnel land mines. In all our cases, we observed wound healing in 2 weeks without any problems. The patients were advised to use a cylindrical bootee for indoor walking in third week. After 1–1.5 month, we put plastazote pad on stump end for prosthesis fitting, and for ourdoor walking the patients used prosthesis which would combine partial end-bearing and partial weight bearing on the patellar tendon. Ground contacting and standing without a prosthesis were also acceptable. We observed the advantages of prosthesis fitting. For instance, there is no need to open a window on the prosthesis socket for fitting and it is easier to fit the slender stump into the prosthesis. In early fitting we did not come across any problems about the slipping of the flap from stump as seen in conventional Syme’s amputation. In short and long term follow-ups, we found that the patients did not complain much about their prosthesis. For all these reasons, we think that ankle disarticulation with anterior flap rather than transtibial amputation should be preferred in patients with traumatic foot amputation since conventional Syme’s amputation can not be performed in heel injuries

Eleven patients underwent disarticulation for infected arthroplasty of the hip. Exchange total hip arthroplasty or conversion to a Girdlestone excision arthroplasty had been undertaken previously an average of 2.9 times. The indications for disarticulation were as a life-saving measure, or as a result of severe infection of soft tissue and bone, loss of bone stock, or vascular injury. While the indications for this drastic operation were highly individual, there were instances where disarticulation could have been avoided if repeated exchange operations had been eschewed in deference to a Girdlestone procedure

Disarticulation has been carried out in ten ankles in nine patients in whom it was not possible to use a heel flap. Four patients were able to walk with a prosthesis which gave satisfactory function. In five who were bedridden, healing was achieved and was of sufficient quality to allow transfers. There was no operative morbidity or mortality. This technique can be used instead of a transtibial amputation if necrosis or ischaemia of the heel is a contraindication to conventional Syme’s amputation

Pressure ulcers are a common and recurrent clinical condition in paraplegic patients, requiring specialized equipment and care, as well as surgical interventions in order to treat them. This is especially true whenever and infection is declared, which will delay or impair ulcer epitelization. These surgical interventions require a good use of various myocutaneos flaps to cover all defects. Problem arises whenever there is not enough flap tissue to cover the entire ulcer, or when multiple surgeries to correct previous ulcers have already been performed.

Our goal is to describe the use of a last resort surgical technique for covering infected pressure ulcers.

This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of complementary exams.

We present the case of a 30-years-old man, paraplegic for 10 years due to motor vehicle accident with spinal cord injury. Since the accident, and although he used adapted equipment and pressure relief mattresses and wheelchair cushions, he developed recurrent, infected ulcers in the perineal and sacral area, being operated on for multiple times by the Plastic and Reconstructive Surgery (PRS) department, for surgical debridement and ulcer coverage with tensor faciae latae and hamstrings myocutaneous flaps.

Despite all treatment, patient developed a stage IV perineal ulcer, which ranged from his left great trochanter to the right buttock, and a simultaneous stage IV sacral ulcer. Both ulcers were infected with meticilin-resistent Staphylococcus aureus (MRSA), sensitive to vancomycin. The patient's left hip joint was also infected (due to a direct trajectory to the perineal ulcer) and subluxated (due to absence of soft tissue support).

A multidisciplinary team assembled and decision was made to disarticulate the patient's left hip, debride and irrigate extensively the surgical site, and use a double gastrocnemius myocutaneous fillet flap in-continuity, in a surgical collaboration between the Orthopaedics and PRS department. This should provide satisfactory soft tissue ulcer coverage as well as facilitate antibiotics penetrance and infection eradication.

Surgery went without complications and the patient healed uneventfully. He resumed unrestricted positioning for sitting and wheelchair mobilization. Now, at two years follow-up, the patient still has no recurrence of either the ulcer or the infection.

This surgical technique provided robust soft tissue coverage for the ulcers, as well as an important aid for infection control. It proved to be a viable option in a paraplegic patient, when more traditional flap techniques can no longer be used and with a recurrent infection.

There is a paucity of data available for the use of Total Femoral Arthroplasty (TFA) for joint reconstruction in the non-oncological setting. The aim of this study was to evaluate TFA outcomes with minimum 5-year follow-up. This was a retrospective database study of TFAs performed at a UK tertiary referral revision arthroplasty unit. Inclusion criteria were patients undergoing TFA for non-oncological indications. We report demographics, indications for TFA, implant survivorship, clinical outcomes, and indications for re-operation. A total of 39 TFAs were performed in 38 patients between 2015–2018 (median age 68 years, IQR 17, range 46–86), with 5.3 years’ (IQR 1.2, 4.1–18.8) follow-up; 3 patients had died. The most common indication (30/39, 77%) for TFA was periprosthetic joint infection (PJI) or fracture-related infection (FRI); and 23/39 (59%) had a prior periprosthetic fracture (PPF). TFA was performed with dual-mobility or constrained cups in 31/39 (79%) patients. Within the cohort, 12 TFAs (31%) required subsequent revision surgery: infection (7 TFAs, 18%) and instability (5 TFAs, 13%) were the most common indications. 90% of patients were ambulatory post-TFA; 2 patients required disarticulation due to recurrent PJI. While 31/39 (79%) were infection free at last follow-up, the remainder required long-term suppressive antibiotics. This is the largest series of TFA for non-oncological indications. Though TFA has inherent risks of instability and infection, most patients are ambulant after surgery. Patients should be counselled on the risk of life-long antibiotics, or disarticulation when TFA fails

Aim. Repeat revision surgery of total hip or knee replacement may lead to massive bone loss of the femur. If these defects exceed a critical amount a stable fixation of a proximal or distal femur replacement may not be possible. In these extraordinary cases a total femur replacement (TFR) may be used as an option for limb salvage. In this retrospective study we examined complications, revision free survival (RFS), amputation free survival (AFS) and risk factors for decreased RFS and AFS following a TRF in cases of revision arthroplasty with a special focus on periprosthetic joint infection (PJI). Method. We included all implantations of a TFR in revision surgery from 2006–2018. Patients with a primary implantation of a TFR for oncological indications were not included. Complications were classified using the Henderson Classification. Primary endpoints were revision of the TFR or disarticulation of the hip. The minimum follow up was 24 month. RFS and AFS were analyzed using Kaplan-Meier method, patients´ medical history was analyzed for possible risk factors for decreased RFS and AFS. Results. After applying the inclusion criteria 58 cases of a TFR in revision surgery were included with a median follow-up of 48.5 month. The median age at surgery was 68 years and the median amount of prior surgeries was 3. A soft tissue failure (Henderson Type I) appeared in 16 cases (28%) of which 13 (22%) needed revision surgery. A PJI of the TFR (Henderson Type IV) appeared in 32 cases (55%) resulting in 18 (31%) removals of the TFR and implantation of a total femur spacer. Disarticulation of the hip following a therapy resistant PJI was performed in 17 cases (29%). The overall 2-year RFS was 36% (95% confidence interval(CI) 24–48%). Patients with a Body mass Index (BMI) >30kg/m² had a decreased RFS after 24 month (>30kg/m² 11% (95%CI 0–25%) vs. <30kg/m² 50% (95%CI 34–66%)p<0.01). The overall AFS after 5 years was 68% (95%CI 54–83%). A PJI of the TFR and a BMI >30kg/m² was significantly correlated with a lower 5-year AFS (PJI 46% (95%CI 27–66%) vs no PJI 100%p<0.001) (BMI >30kg/m² 30% (95% KI 3–57%) vs. <30km/m² 85% (95% KI 73–98%)p<0.01). Conclusions. A TFR in revision arthroplasty is a valuable option for limb salvage but complications in need of further revision surgery are common. Patients with a BMI >30kg/m² should be informed regarding the increased risk for revision surgery and loss of extremity before operation

Patients who have limb amputation for musculoskeletal tumours are a rare group of cancer survivors. This was a prospective cross-sectional survey of patients from five specialist centres for sarcoma surgery in England. Physical function, pain and quality of life (QOL) outcomes were collected after lower extremity amputation for bone or soft-tissue tumours to evaluate the survivorship experience and inform service provision. Of 250 patients, 105 (42%) responded between September 2012 and June 2013. From these, completed questionnaires were received from 100 patients with a mean age of 53.6 years (19 to 91). In total 60 (62%) were male and 37 (38%) were female (three not specified). The diagnosis was primary bone sarcoma in 63 and soft-tissue tumour in 37. A total of 20 tumours were located in the hip or pelvis, 31 above the knee, 32 between the knee and ankle and 17 in the ankle or foot. In total 22 had hemipelvectomy, nine hip disarticulation, 35 transfemoral amputation, one knee disarticulation, 30 transtibial amputation, two toe amputations and one rotationplasty. The Toronto Extremity Salvage Score (TESS) differed by amputation level, with poorer scores at higher levels (p < 0.001). Many reported significant pain. In addition, TESS was negatively associated with increasing age, and pain interference scores. QOL for Cancer Survivors was significantly correlated with TESS (p < 0.001). This relationship appeared driven by pain interference scores. . This unprecedented national survey confirms amputation level is linked to physical function, but not QOL or pain measures. Pain and physical function significantly impact on QOL. These results are helpful in managing the expectations of patients about treatment and addressing their complex needs. Cite this article: Bone Joint J 2015;97-B:1284–90

Introduction. Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning. Materials and Methods. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons. Results. Ten boys and ten girls, with an average age of 18 months and average follow up of 70 months were included in the study. The most common indication was fibular hemimelia. Wound complications were reported in three children, phantom pain in one, heel pad migration in two. None had wound dehiscence, flap necrosis, stump overgrowth, or calcaneal regrowth. None of this required surgical intervention. One child required an amputation at a higher-level secondary to a congenital malformation of nervous tissue in the affected leg. Prosthetic compatibility was 94.7 % and none used mobility aids. Six children participated in sports. Conclusions. Syme amputation is a safe and potentially advantageous procedure in children, with a low incidence of complications to offer patients with non-salvageable foot conditions. It offers good prosthetic use with minimal risk of complications and can offer patients a functional solution with only one surgical intervention throughout their childhood

1. The question whether amputation for lower femoral osteosarcoma should be by disarticulation of the hip or through the upper femur to leave a stump is discussed. 2. Sixty-eight such patients are reviewed. Thirty were treated by disarticulation and thirty-eight by through-femur amputation. 3. There was a 16 per cent incidence of stump recurrence after through-femur amputation, but none after disarticulation. Comparison of survival was not conclusive. 4. Disarticulation of the hip is advised

This work examines the Upper limb (UL) blast-mediated traumatic amputation (TA) significance from recent operations in Afghanistan. It is hypothesized that the presence of an UL amputation at any level is an independent predictor of torso injury. A joint theatre trauma registry search was performed to determine the number of British casualties with TA and their associated injuries. UL TA accounted for 15.7% of all amputations; distributed: shoulder disarticulation 2.5%, trans-humeral 30%, elbow disarticulation 10%, trans-radial 20% and hand 37.5%. The presence of an UL amputation was more likely in dismounted casualties (P=0.015) and is a predictor of an increased number of total body regions injured and thoracic injuries (P 0.001 and P 0.026 respectively). An increased Injury Severity Score (ISS) was seen in patients with multiple amputations involving the UL (UL TA present ISS=30, no UL TA ISS=21; P=0.000) and the ISS was not significantly different whether mounted or dismounted (P=0.806). The presence of an upper limb amputation at any level should insight in the receiving clinician a high index of suspicion of concomitant internal injury; especially thoracic injury. Therefore with regards to blast mediated TA the injury patterns observed reflect a primary and tertiary blast mechanism of injury

Disarticulation of the hip in patients with high-grade tumours in the upper thigh results in significant morbidity. In patients with no disease of the proximal soft tissue a femoral stump may be preserved, leaving a fulcrum for movement and weight-bearing. We reviewed nine patients in whom the oncological decision would normally be to disarticulate, but who were treated by implantation of an endoprosthesis in order to create a functioning femoral stump. The surgery was undertaken for chondrosarcoma in four patients, pleomorphic sarcoma in three, osteosarcoma in one and fibrous dysplasia in one. At follow-up at a mean of 80 months (34 to 132), seven patients were alive and free from disease, one had died from lung metastases and another from a myocardial infarction. The mean functional outcome assessment was 50 (musculoskeletal tumor society), 50 and 60 (physical and mental Short-form 36 scores). Implantation of an endoprosthesis into the stump in carefully selected patients allows fitting of an above-knee prosthesis and improves wellbeing and the functional outcome

We report a variant of tibial hemimelia in a six-year-old boy that did not comply with recognised classification systems. The femur and knee were normal, but the fibula was displaced proximally and there was severe diastasis of the proximal and distal tibiofibular joints to the extent that a grossly deformed foot articulated with the fibula and there was separate soft-tissue cover for the distal tibia and fibula. Although it would have been preferable to create a one-bone leg, amputate the foot and use the fibula as the stump for a below-knee prosthesis, local circumstances resulted in the choice of a disarticulation through the knee. This was undertaken without complications, and six months post-operatively the child was walking comfortably with a prosthesis

We present a patient who underwent delayed sub-periosteal hemipelvectomy for control of infection and to enable soft-tissue cover after trauma. At four months after amputation, clinical examination and radiographs demonstrated almost complete re-ossification of the hemipelvis. This has allowed the patient to regain sitting balance and to use a walking prosthesis designed for patients following disarticulation of the hip. After 14 months from injury, no perineal hernia has developed, and no dysfunction of pelvic organs is attributable to heterotopic bone formation or adhesions. The patient’s mobility with a prosthesis is similar to that expected of a through-hip amputee

Background. Extendable proximal femoral replacements(PFR) are used in children with bone tumours in proximity to the proximal femoral physis, previously treated by hip disarticulation. Long-axis growth is preserved, allowing limb salvage. Since 1986, survival outcomes after limb salvage and amputation have been known to be equal. Method. Retrospective review of all patients <16years undergoing extendable PFR at Royal National Orthopaedic Hospital (UK) between 04/1996 and 01/2006, recording complications, failures, procedures undertaken and patient outcomes. Results. 8 patients (mean age 8.9±3 years) underwent extendable PFR for Ewing's Sarcoma(5), Osteosarcoma(1), Chondrosarcoma(1) and rhabdomyosarcoma(1). 2 primary PFRs failed (infection of unknown source & local recurrence, both at 26months); 2 required revision for full extension (1 became infected at revision, requiring 2 stage revision). 3 patients had the original prosthesis in situ at last follow-up (mean 7.2;range 3–10.5years). 1 patient had no implant complications, but died (neutropaenic sepsis) 63 days after implant insertion. 2 were treated for recurrence but disease free at last review. 5 were continuously disease free. 5 patients were lengthened a mean 3.7cm; 2 were not lengthened.1 had incomplete data. 5 patients suffered subluxation/dislocation (mean 15.6months), 3 recurrently. Each underwent a mean 1.6 open & 1.4 closed procedures for the displaced joint. 3 patients had 4 open reductions and acetabuloplasties and 2 patients were converted to THR, with 3 major complications: 2 sciatic nerve palsies and 1 (THR) infection. The 5th patient was due for acetabuloplasty but had hip disarticulation for recurrence. Acetabular erosion occurred in 3; 2 were revised to THR (3.5 & 6.8years). 3 patients suffered peri-prosthetic supracondylar fracture (treated conservatively). 5 patients were revised to THR (mean 5.9years): 2 for dislocation, 2 for acetabular erosion & 1 for infection. 1 underwent amputation and another died. Only 1 surviving implant was not converted to THR: this patient had progressive acetabular erosion at 10.5 years & will eventually require THR. The amputee had poor hip function prior to disarticulation but went on to become an international Paralympic sportsman and had very good function 11.4 years post-disarticulation. 3 patients had fixed hip adduction deformity. 1 was isolated and treated with adductor tenotomy, whilst 2 were associated with knee flexion deformity (one required in-patient physiotherapy; the other prosthetic shortening). Conclusions. Extendable PFR permits limb salvage with psychological & functional benefits, but complications are common and some are specific to PFR. Surgery for these may result in further complications. Patients should be warned of the high conversion rate to THR. All the above should be borne in mind when selecting patients. As illustrated above, functional outcome is sometimes better with amputation