Hip fractures are a common source of morbidity and mortality worldwide. Nevertheless, the discovery and development of hip arthroplasty has improved its prognosis, with a high survival rate, and satisfactory functional results (1; 2; 3). Although total hip replacement has been well described in the literature especially for healthy individuals, we found few pieces of information about the technical characteristics and results of this procedure in patients with lower extremity amputation (1; 2; 3; 4; 5; 6)
Lower limb amputees can have many musculoskeletal problems such as osteoporosis, severe osteoarthritis, and muscle deficiency. (1; 2; 3; 4; 5; 6; 7; 8; 9; 10)
Femoral neck fracture on amputated limb is an uncommon lesion and challenging to manage because of technical difficulties such as the patient setup, the surgical approach and the stump manipulation. (2; 8; 11). We report a rare case of femoral neck fracture in a patient with homolateral transtibial amputation, managed by a primary total hip arthroplasty.
A 57 years old female, who underwent at the age of 3 a below-knee amputation of the left lower limb for post traumatic ischemia, was taken to the emergency room for homolateral hip trauma. She tripped and fell from standing height striking the lateral aspect of her left hip on the ground. She was diagnosed with a grade IV femoral neck fracture, according to Garden’s classification (Figure 1).
Physical examination did not reveal any vascular or neurologic complications. No history of vascular or neurological diseases was found.
Under general anesthesia, the patient was positioned on her right side with the spine parallel to the operating table. She underwent a cemented total hip arthroplasty with a trans-gluteal lateral approach: the arthroplasty included a modular metallic femoral implant with a 28mm head, and a polyethylene retentive cup (Figure 2)
Post-operatively, antibio prophylaxis for 72 hours as well as sub cutaneous anticoagulation was prescribed to prevent thrombo-embolic and infectious complications.
The post-operative course was uneventful, and the patient was allowed weight bearing using his prosthesis, and progressive ambulation with two crutches on the third post-operative day.
Physical therapy included isometric strengthening of the hip abductors and flexors, as well as active range-of-motion exercises.
At the last follow-up (thirty-six months), no dislocation episode or infectious complication were noted. The operative wound was healed and dry. The patient had a satisfactory range of motion: her hip flexion was 90°, external and internal rotation was 30°, abduction was 40° and adduction was 20°. The patient was painless, able to walk with only one cane and to undertake all pre-morbid activity independently, using her usual prosthesis (Figures 3 & 4)
The functional outcome was good with a Harris Hips score at 87/100, and a Paustel-Merle-D’Aubigné at 16/18. The left hip radiographs did not reveal any signs of loosening or migration of the femoral and acetabular implants, neither signs of polyethylene wear (Figure 5, 6 & 7).
Total hip replacement is usually preconized to manage displaced femoral neck or sub-capital fracture of the femur. This injury can lead to major morbidity and mortality, especially for elderly patients. Discovery and constant evolution of hip arthroplasty has radically changed the prognosis of femoral neck fractures. (2; 11)
Residual lower limb fracture is a rare entity, with little information available in the previous literature. (2; 8; 11) Its review has shown that below knee amputation may induce osteo-articular as well as muscular modifications (1; 2; 3; 4; 5; 6; 7; 8; 9; 10) :
Some authors have established that amputee patients have a high risk of homolateral fracture because of the lever arm carried by the prosthesis, as well as the high rate of osteoporosis (2; 8; 10; 11). This has been explained by the lack of mechanical stress on the amputated limb, while the unamputated one carries more loads (10).
Analysis of precedent literature showed that most of the surgeons preconize non –operative or conservative treatment for hip fracture in amputees patients, especially for the young ones, such as reduction and fixation or hip arthrodesis (11; 12; 13; 14). Nevertheless, the risk of non-union of the fracture in such patients is higher. This can be explained by the biomechanic changes in the site of fracture: in patients with lower limb amputation, there is lateral shifting of the center of gravity that lead to increase the shearing forces on the fracture (11).
To our knowledge, there have been only two publications reporting a THA in patients with below Knee amputation: Solomon and al (3), Salai.M and al (11).
Solomon (3)described a total hip replacement for severe osteoarthritis for a dysvascular below-knee amputee. Salai (11) reported a small series of five patients with below knee-amputation who underwent total hip arthroplasty for a subcapital femoral fracture. In only two cases, the THA was a primary procedure.
We believe that, up to date, this article is the first case report of a primary THA for a femoral neck fracture in a below-knee amputee, in the same side.
In our case, we chose a total hip replacement because of the relative young age of the patient (fifty-seven years old), the high level of activity and autonomy using her usual prosthesis, as well as the high life expectancy (no medical history of cardio-vascular or respiratory diseases). The surgical management of femoral neck fracture with an amputated lower limb can be very challenging:
-A short stump is difficult to manipulate during hip dislocation and reduction, and especially during implant positioning. Some surgeons resorted to the use of a traction pin with a bone clamp or a bone holder to have a satisfactory rotational and traction control on the stump (1; 2; 8), others opted for a trochanteric osteotomy (7).
-Osteoporosis caused by the amputation can lead to peroperative or post-operative peri prosthetic fractures (2; 4).
-Bone stock loss can cause an early loosening of the implant (4; 5; 7), especially in case of
-Muscular deficiency in the amputated limb increases the risk of hip dislocation (7).
Our patient underwent a total hip arthroplasty through a transgulteal approach, according to Hardinge. This approach was chosen because it offers a better exposure of the implants. It is less traumatic, allows a satisfactory rotation and traction of the stump, and reduces the risk of dislocation. Several techniques have been perfomed by orthopaedic surgeons worldwide to prevent arthroplasty dislocation in patients with neuro-muscular diseases, such as constrained implants. (15; 16; 17)
The arthroplasty included a stainless steel, cemented, femoral implant and a cemented, polyethylene retentive cup. The muscular deficiency due to amputation, which increases the risk of instability, has encouraged us to choose a constrained acetabular implant. We preferred a cemented arthroplasty rather than the cementless one, because of the lower risk of loosening on an osteoporotic field.
Total hip arthroplasty in patients with lower limb amputation is not a common procedure.
The femoral neck fracture in this category is difficult to the patient as well as the physician:
It may have a serious psychological impact on a patient that already suffered from the amputation trauma.
This entity is very challenging for the surgeon because of technical difficulties (patient setup, surgical approach and stump manipulation), and the musculo-skeletal changes in amputee patients (osteoporosis, amyotrophy, contralateral osteo-arthritis).
The high risk of sustaining a fracture in osteoporotic residual stump should be included in the health education of amputee patient.
The patient was informed that the data concerning his case would be submitted for publication, and she consented
Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors thank the patient who was informed that his case will be published in a scientific review, with her full agreement.
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