Amputation At The Hip-Joint

In amputating at the hip-joint, hemorrhage is especially to be guarded against. This comes from two sources, the femoral artery anteriorly and the branches of the internal iliac posteriorly. The most reliable way of controlling bleeding is probably by the use of the elastic tourniquet held in place by Wyeth's pins. These are two steel pins 5 mm. (3/16 in.) in diameter and 25 cm. (10in.) long. One is entered 6 mm. (1/4 in.) below the anterior superior spine and slightly to its inner side and traverses the tissues on the outer side of the hip for about 7.5 cm. (3 in.) from the point of entrance; the other is entered through the skin and tendon of the adductor magnus 1.25 cm. (1/2 in.) below the perineum and made to emerge 2.5 cm. (1 in.) below the tuber ischii. The elastic tube is to be wound around the hip above the pins, which prevent its slipping down (Fig. 542). The amputation is then performed as desired. Compression of the aorta or common iliac by instrumental means is obsolete. Sometimes the common iliac is compressed laterally by the finger introduced through an incision in the abdominal walls. Another method consists in making lateral flaps with the femoral artery in the angle of the incision - all vessels are then clamped as they are divided.

Fig. 542.   Amputation just above the middle of the thigh, showing insertion of Wyeth's pins.

Fig. 542. - Amputation just above the middle of the thigh, showing insertion of Wyeth's pins.

In some operations the head of the femur is disarticulated before the flaps are made. In this case the first part of the operation is like a resection of the hip by the Langenbeck straight incision.

The bleeding of the posterior flap comes from branches of the gluteal, sciatic, obturator, and internal pudic arteries, derived from the internal iliac.

Amputation Of The Thigh

In amputation of the thigh by the flap method care must be taken to avoid splitting the femoral artery. Its position in the various portions of the thigh should be borne in mind. Anteroposterior flaps are to be preferred to lateral ones, and a short anterior flap is to be avoided because the scar is drawn posteriorly (Fig. 542). The muscles of the posterior part of the thigh, the hamstrings, are not attached to the bone, with the exception of the short head of the biceps, they therefore retract when cut and later pull the scar behind the bone. The crureus and vastus externus and internus anteriorly are attached to the bone, and hence cannot draw back either at the time of the operation or afterwards.

The position of the femoral artery will depend on the point at which the amputation is made. It does not lie close to the bone until the popliteal space is reached. Bleeding from the perforating arteries along the linea aspera should, however, be looked for and the sciatic nerve should be isolated and cut short.