Osteosynthesis of acute femoral neck fracture in a young adult with ipsilateral transfemoral amputation

Suresh Ezhuhachan; KR Renjith; S Sanju

doi:10.4103/joasis.joasis_31_22

CASE REPORT

Year : 2022 | Volume : 19 | Issue : 2 | Page : 85-87

Osteosynthesis of acute femoral neck fracture in a young adult with ipsilateral transfemoral amputation

Suresh Ezhuhachan, KR Renjith, S Sanju
Department of Orthopedics, Aswini Hospital, Thrissur, Kerala, India

Date of Submission	28-Sep-2022
Date of Acceptance	01-Oct-2022
Date of Web Publication	09-Feb-2023

Correspondence Address:
K R Renjith
Department of Orthopedics, Aswini Hospital, Karunakaran Nambiar Road, Aswini Junction, Patturaikkal, Opposite to Big Bazaar, Thrissur - 680 020, Kerala
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joasis.joasis_31_22

Abstract

Management of fracture neck of the femur in young adults with above-knee amputation is a challenging scenario for even the most experienced orthopedic surgeon owing to the short lever arm possessed by the residual limb to perform a closed reduction. We report a unique case of fracture neck of the right femur successfully managed by closed reduction and percutaneous screw fixation in a 43-year-old male who had undergone an ipsilateral transfemoral amputation 15 years back.

Keywords: Above-knee amputee, closed reduction, fracture neck of femur, percutaneous screw fixation, young adults

How to cite this article:
Ezhuhachan S, Renjith K R, Sanju S. Osteosynthesis of acute femoral neck fracture in a young adult with ipsilateral transfemoral amputation. J Orthop Assoc South Indian States 2022;19:85-7

How to cite this URL:
Ezhuhachan S, Renjith K R, Sanju S. Osteosynthesis of acute femoral neck fracture in a young adult with ipsilateral transfemoral amputation. J Orthop Assoc South Indian States [serial online] 2022 [cited 2023 Mar 27];19:85-7. Available from: https://www.joasis.org/text.asp?2022/19/2/85/369405

Introduction

Treatment of fracture neck of the femur in young patients is always challenging owing to the high technical expertise required and the risk for nonunion as well as avascular necrosis associated with internal fixation. Management of these injuries in an ipsilateral lower limb amputee becomes even more challenging considering the difficulties in closed reduction with regard to a short lever arm, they possess especially with transfemoral amputations. Moreover, the residual limb osteopenia, as described by Bowker et al. in 1981 in their series of 90 fractures in a residual limb, can add on to the reasons for fixation failure seen in these patients.^[1]

We report a unique case of fracture neck of the right femur successfully managed by closed reduction and percutaneous screw fixation in a 43-year-old male who had undergone an ipsilateral transfemoral amputation 15 years back.

Case Report

A 46-year-old, male bank executive manager, presented to our emergency department with right hip pain following an accidental fall at home. He had undergone an above-knee amputation on the same side 15 years back for chondrosarcoma of the lower femur and was using an ischial weight-bearing, prosthetic limb on a full-time basis. The patient reported that following the fall, he had difficulty moving the residual limb and increased pain on weight-bearing with a prosthesis. Initial radiographs revealed a fracture neck of the femur with significant osteopenia when compared with the unaffected hip [Figure 1]. In view of his younger age and high demand for mobility, he was offered operative treatment in the form of closed reduction and screw fixation after discussing in detail regarding the pros and cons of the same as well as alternative management options. A short residual limb, measuring 10 cm was the major challenge for us in obtaining closed reduction due to the inability to attach to a traction apparatus [Figure 2]. On the operative table, we used a 4.5-mm Schanz pin inserted at the distal end of the residual limb mediolaterally, as a joystick to attain closed reduction. One assistant held the Schanz pin firmly whereas the primary surgeon completed percutaneous fixation with the aid of three 6.5-mm cannulated cancellous screws [Figure 3]. On account of his low bone mass, he was started on injection teriparatide 20 μg daily subcutaneous dose for 1 year postoperatively. The patient was advised a passive range of motion exercises as soon as the pain subsided on a postoperative day 4. Follow-up X-rays at 6 weeks and 3 months showed a good healing response with no signs of implant loosening, breakage, or loss of reduction. He was started on bilateral crutch walking initially followed by unilateral crutches and he was back on to his preinjury pattern of walking with a prosthesis at 6-month follow-up [Figure 4]. On the final follow-up at 1 year, his radiographs revealed complete healing without any features of avascular necrosis [Figure 5].

Figure 1: Plain radiograph AP and lateral view showing fracture neck of right femur with decreased bone density on the same side. AP: Anteroposterior

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Figure 2: Plain radiograph and patient photograph showing a significantly short residual limb

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Figure 3: Intraoperative C-arm images showing good reduction with percutaneous fixation of 3 mm × 6.5 mm cannulated cancellous screws

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Figure 4: Patient weight bearing with prosthesis at 6-month follow-up

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Figure 5: Plain radiograph AP and lateral views right hip joint showing well-fixed implants with good fracture healing at 1-year follow-up. AP: Anteroposterior

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Discussion

Femoral neck fractures in young adults are not as common as they occur in the elderly. These injuries are very rarely encountered in an above-knee amputee and therefore, creates a challenging situation both for the treating orthopedic surgeon and the rehabilitation team. Whether to go for internal fixation or to do a replacement arthroplasty continues to be a matter of debate due to the rarity of these injuries as well as the scarcity of literature in this regard.

The existing largest series of fracture neck of femur in lower limb amputees was by Bowker et al. where 10 out of 90 patients in his study had an above-the-knee amputation.^[1] They pointed out that decreased bone mineral density due to disuse atrophy was the reason for the failure of fixation in this group of patients. Replacement arthroplasty has also been suggested as a successful option by some of the authors when the patient is elderly or when there was associated arthritis of the hip joint. Even there were supporters for nonoperative management of these injuries especially when the fracture is undisplaced and intertrochanteric in location. Since our patient was a young, healthy adult with good preinjury mobility, we had no dilemma in opting for surgical fixation. Internal fixation of fracture neck of the femur demands precise positioning of the affected limb in axial traction along with rotational control, at the same time, allowing adequate fluoroscopic exposure. A short residual stump in above-knee amputees thus creates a challenging situation where the surgeon has to adopt an improvised positioning technique. Various methods have been described for below-knee amputees including radiolucent thigh support, connecting the prosthesis foot to the traction boot, and attaching the below-knee stump to an inverted traction boot.^[2],[3] However, none of these were applicable in the above-knee amputees. Another report on surgical fixation of intertrochanteric fracture in residual limb had utilized radiolucent thigh support on the affected side and gutter support on the contralateral side; however, it did not gain much popularity due to the lack of rotational control.^[4] A modified technique has been proposed by Berg AJ et al. where they used a distal Steinmann pin attached to a traction hoop for traction.^[5] We adopted our technique from Freitas et al. who managed a similar injury using a distally inserted Schanz pin as a joystick to attain and hold the reduction.^[6] We found this technique as simple and effective without the need for any complicated traction apparatus setup. We could achieve a good reduction of the fracture by closed means and completed percutaneous fixation using three 6.5-mm cannulated cancellous screws.

Conclusion

Osteosynthesis remains a safe and effective technique for the management of fracture neck of femur in above-knee amputees, especially in young adults with good preoperative mobility status. Schanz pin inserted into the distal aspect of the residual limb can be a useful tool in intraoperative fracture reduction.

Ethical standard statement and consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from the patient for being included in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	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;63:915-20.
2.	Rethnam U, Yesupalan RS, Shoaib A, Ratnam TK. Hip fracture fixation in a patient with below-knee amputation presents a surgical dilemma: A case report. J Med Case Rep 2008;2:296.
3.	Al-Harthy A, Abed R, Campbell AC. Manipulation of hip fracture in the below-knee amputee. Injury 1997;28:570.
4.	Aqil A, Desai A, Dramis A, Hossain S. A simple technique to position patients with bilateral above-knee amputations for operative fixation of intertrochanteric fractures of the femur: A case report. J Med Case Rep 2010;4:390.
5.	Berg AJ, Bhatia C. Neck of femur fracture fixation in a bilateral amputee: An uncommon condition requiring an improvised fracture table positioning technique. Case Reports 2014;2014:bcr2013203504.
6.	Freitas A, Souto DR, da Silva JF, Dantas BR, de Paula AP. Treatment of an acute fracture of the femoral neck in a young female adult with a transfemoral amputation: A case report. JBJS Case Connect 2015;5:e58.