Bipolar hip hemiarthroplasty in a patient with an above knee amputation: a case report
© Kandel et al; licensee BioMed Central Ltd. 2009
Received: 24 March 2009
Accepted: 31 July 2009
Published: 31 July 2009
The treatment of an above knee amputee who has sustained a fracture of femoral neck is a challenge for both the orthopaedic surgeon and the rehabilitation team. We present a case of such a patient and discuss different difficulties in his treatment.
Hip hemiarthroplasty is a common procedure for the treatment of subcapital femoral fractures. Good postoperative results of hip hemiarthroplasties in patients with below knee amputations have been reported in the past, with a return of the patients to their preoperative level of daily life activity [1, 2]. But, to our knowledge, the use of hip hemiarthroplasty in patients with above knee amputations has not been reported in the literature.
We present a unique case of a bipolar hip hemiarthroplasty for a subcapital femoral fracture in a patient with an above knee amputation of the same extremity. The patient was informed that the case will be submitted for publication.
A 68 year old male patient was admitted to our department suffering from severe pain in his right hip joint caused by an old subcapital fracture of the femur. The patient's right leg had been amputated above the knee after a gun shot wound 58 years ago. Following the amputation he ambulated well using a fitted prosthesis – a quadrilateral socket with a swing control knee and a multiaxis foot. Six months prior to his admission, the patient fell and sustained a subcapital fracture of the right femoral neck.
We presented an ambulating above knee amputee, who had suffered a subcapital femoral fracture. There is no clear epidemiologic data about prevalence of hip fractures in this population. Denton and McClelland stated that incidence of femur and hip fractures in both above and below knee amputees. There is significant bone mass reduction of the femoral neck in amputees, but on the other side, the forces of the fall are lower due to decreased lever arm of the femur.
We assume that the primary treating orthopaedic surgeons expected the fracture to unite, because of the short lever arm, and the patient was treated nonoperatively. Two studies[4, 6] have shown that this an appropriate strategy for most fractures after an amputation, except displaced intertrochanteric and cervical fractures that require surgical fixation. In our case, the fracture did not unite, necessitating surgical intervention.
We believe that an ambulating patient with displaced subcapital fracture will benefit more from hemiarthroplasty than from reduction and fixation of the fracture. The two major problems with this surgery are severe osteoporosis and the length of the proximal femur. The encouraging results obtained on this case were due to the technique of the surgery, especially the emphasis on the difficulties of handling the proximal femur during both the hip dislocation and the prosthesis insertion. Using a bone holder for gently holding the femur in the subtrochanteric area made the dislocation and internal rotation of the femur possible, allowing exposure of the joint and preparing the proximal femur and, if needed, the acetabulum. One should be extremely careful in using this instrument on an osteopenic femur.
Another important factor to be taken into consideration is the prevention of the swelling of the extremity after the procedure, in order to assure a prompt and complication-free return to ambulation with the prosthesis. The surgeon should protect the operating scar from the pressure of the prosthesis.
With these results, we conclude that an ambulating patient with an above knee amputation and a subcapital fracture should be operated on after appropriate planning and preparation with satisfactory results. A patient can return to preoperative level of ambulation and activity after rehabilitation.
'Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.'
- Prickett NM, Scanlon CJ: Total joint replacement in extremities with below-knee amputations. Phys Ther. 1976, 56 (8): 925-7.PubMedGoogle Scholar
- Salai M, Amit Y, Chechik A, Blankstein A, Dudkiewicz I: Total hip arthroplasty in patients with below-knee amputations. J Arthroplasty. 2000, 15 (8): 999-1002. 10.1054/arth.2000.16494.View ArticlePubMedGoogle Scholar
- Carroll K, Baird JC, Binder K: Transfemoral prosthetic designs. Prosthetics and patient management: a comprehensive clinical approach. Edited by: Carroll K, Edelstein JE. 2006, SLACK Incorporated, 93-100.Google Scholar
- Denton JR, McClelland SJ: Stump fractures in lower extremity amputees. J Trauma. 1985, 25 (11): 1074-8.PubMedGoogle Scholar
- Kulkarni J, Adams J, Thomas E, Silman A: Association between amputation, arthritis and osteopenia in British male war veterans with major lower limb amputations. Clin Rehabil. 1998, 12 (4): 348-53. 10.1191/026921598672367610.View ArticlePubMedGoogle Scholar
- Bowker JH, Rills BM, Ledbetter CA, Hunter GA, Holliday P: Fractures in lower limbs with prior amputation. A study of ninety cases. J Bone Joint Surg Am. 1981, 63 (6): 915-20.PubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.