Hindquarter Amputation

Indications

  • Pelvic or proximal femoral sarcoma not suitable for limb salvage
  • Tumour involving the femoral vessels, sciatic nerve or femoral nerve together with hip joint
  • Fungating or recurrent tumour, and intractable pelvic osteomyelitis with sepsis
  • Internal hemipelvectomy spares the limb when vessels and sciatic nerve are free
  • Enneking and Dunham types are I iliac, II periacetabular, III pubis and ischium
  • External hindquarter amputation removes the limb with the hemipelvis

Position

  • Lateral decubitus with the whole hemipelvis, abdomen and limb in the field
  • Table can be rolled supine or prone during the case
  • Urinary catheter, ureteric stents and bowel preparation. Plan with plastic, urology and vascular surgeons

Operative Steps

  1. Choose the flap. Posterior gluteal flap relies on the superior gluteal vessels from the internal iliac artery
  2. Anterior flap, from the quadriceps and thigh, relies on the femoral vessels. Use it when gluteal vessels are compromised
  3. Incise along the inguinal ligament to the anterior superior iliac spine and iliac crest
  4. Enter the retroperitoneum and identify the ureter, then ligate the external iliac artery and vein
  5. Divide the spermatic cord or round ligament, rectus abdominis, and the symphysis pubis, protecting the bladder and urethra
  6. Divide the femoral, obturator and sciatic nerves high
  7. Divide the sacroiliac joint or perform an iliac osteotomy, then detach the gluteal muscles and pelvic floor
  8. Rotate the flap, suture the abdominal wall to it and close over drains, using mesh if deficient
  9. Reconstruct the internal hemipelvectomy with iliofemoral arthrodesis, saddle prosthesis, allograft or custom implant

Postoperative Care

  • Intensive care monitoring, flap perfusion checks and large volume transfusion readiness
  • Drains until output falls, with venous thromboembolism prophylaxis
  • Stoma and urinary care, then rehabilitation with tilting table prosthesis or crutches
  • Multimodal analgesia for phantom pain, with psychological support

Complications

  • Flap necrosis, especially when the gluteal vessels were ligated or the tumour was resected near them
  • Wound infection and dehiscence
  • Haemorrhage and haematoma from the iliac vessels
  • Bladder, ureteric or bowel injury, and abdominal wall hernia
  • Phantom pain, local recurrence and venous thromboembolism

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 12 October 2026.