Disarticulation and Total Thigh Flap

This flap is considered a lifesaving procedure especially in the spinal cord–injured patient. This flap is performed as an end-stage procedure for patients with recurrent extensive pressure ulcers when the patient has had a history of many previous flaps to repair the ulcers; as a result, the reserves of muscles and skin become exhausted. Clinically, the patients at this stage have a bowel diversion (colostomy), urinary diversion, and previous bilateral Girdlestone procedure with radiological evidence of destruction of the pelvic bone architect. When the patient is in a sitting position at this stage, the actual location is over the flat thin pelvic floor instead of his/her bilateral ischial bone. These patients unquestionably had many flaps in the past with some being reused twice or three times. The reconstructive surgeon faces a dilemma at this stage when there is no available muscle or skin in the patient’s body to use for repair of this multiple complex ulceration. When the ulcers involve the entire perineum and pelvis, the clinical picture is more complicated; as a result, the patient psychologically feels disturbed and disappointed to lose a leg. Even if the leg has no function for ambulation, it serves for a different purpose which is the psychological and emotional effect on the patient besides stability for sitting in a wheelchair and transferring. In addition to these factors, the patient feels threatened that if he/she loses a leg, this will indicate the end of options available to close future pressure ulcers should they occur, which is a common occurrence in spinal cord injury patients. The author’s clinical practice is to explain to the patient prior to approaching the stage of disarticulation and total thigh flap that if the patient develops future pressure ulcers, the next stage will be losing his/her leg. This will mentally prepare the patient for this extensive surgery. The terminology of disarticulation does not apply literally on the procedure because these patients already lost their hip in a previous Girdlestone procedure. The disarticulation and total thigh flap is not a common procedure like a simple flap which is done on a routine basis. The total thigh procedure was described first by Georgiade in 1956 [1]; at that time, muscle flap was not described and utilized as today. Initially, therefore, this procedure was utilized as a first line to repair multiple ulcers and hip infection, but at present with the utilization of the Girdlestone procedure and various muscle flaps, this has postponed the use of the total thigh procedure for a future time and reserved it as an end-stage procedure. The total thigh flap was reported by Berkas in 1961 [2] to close multiple ulcers; Spira in 1963 [3] described his experience with amputation in spinal cord–injured patients. Steiger in 1968 [4] described the use of total thigh flap procedure to treat chronic infection, and then Royer in 1969 [5] described his 16-year experience in closing extensive pressure ulcers with total thigh flap. The author’s experience in total thigh flap is to reconstruct extensive perineopelvic ulcers when the patient already has lost both ischia secondary to chronic ulceration and infection. The total thigh flap will create a soft tissue padding over whatever bony structure is left in the pelvis. The author’s early experience with total thigh flap is to perform the procedure in two stages because of concerns of infection. The first stage is to debride and remove the entire femur and amputate the thigh within the level of the knee area followed by local wound care to the open total thigh flap. A few weeks later, the second stage is to inset the flap in the large defect; unfortunately, it was found that the insetting of a flap was technically difficult because of the development of immature heterotopic ossification in the muscle group which was very difficult to dissect all the immature heterotopic ossification from the muscles. This procedure is associated with prolonged surgical time and large volume of blood loss. This experience was reported in 1992 [6]. The author’s practice since then has changed into a single-stage total thigh procedure. In addition, the author, in 1994 [7], successfully attempted splitting the total thigh flap into two parts based on the vascularity of the total thigh flap. This procedure is not always easy to perform and poses a risk of flap necrosis. The purpose of the flap division was to cover multiple separate defects. This procedure needs meticulous dissection and accurate identification of the vascular pedicles with a vascular Doppler intraoperatively to identify the superficial femoral artery and the deep femoral artery prior to division of the flap. The author currently utilizes an extended total thigh flap which includes the skin and muscle of the calf. This additional part is used to cover the distal sacrococcygeal area. Boyd in 1947 [8] described the anterior approach to hip disarticulation, and Slocum in 1949 [9] described the posterior approach to disarticulation of the hip joint. Their surgical indications were different from our indications to close multiple recurrent ulcerations, taking into consideration our patients’ condition with previous multiple flaps. As a result of this clinical history, the appearance of the entire thigh flap will show scarring all around the muscle groups and occasional heterotopic ossification formation which will make it very difficult, technically, to identify and utilize anterior or posterior thigh flap. Another important point to mention is that the step of insetting the total thigh flap is more difficult than the dissection of the femoral bone from the muscles because of extensive scarring from previous surgeries. Therefore, folding the flap to accommodate the defect is technically difficult. Release of the scars over the inner surface of the T.T. flap may carry risk of division to a vital blood supply. Minimum amount of scar release should be performed to facilitate the inset of the flap. Another point the surgeon will face when insetting the total thigh flap to cover the sacrococcygeal area is that the anus will be in the pathway of the T.T. flap. For this reason, the patient should be informed regarding the procedure which is to excise the anus and close the rectum in layers, providing the patient has a double-loop colostomy. If not, prior to this procedure, a mucous fistula is performed by bringing the defunctioning bowel loop to the skin surface. In summary, the total thigh flap procedure is a challenge to the reconstructive surgeon and not a rewarding procedure like the flap surgery. On the other hand, it is a procedure to prolong the life of the patient and improve the quality of life of the patient by permitting sitting in a wheelchair and moving around.