Total hip arthroplasty after lower extremity amputation

Simultaneous above-knee amputation and ipsilateral total hip arthroplasty in a neglected neck of femur fracture with an insensate limb

Total hip arthroplasty (THA) in patients with ipsilateral mid-thigh amputation is surgically challenging. We report a case of same setting THA and ipsilateral above-knee amputation in a male patient. The patient had 8 months old neglected neck femur fracture and ipsilateral femur shaft fracture with 14 cm bone loss. There was an associated neurovascular (femoral artery injury and sciatic nerve palsy) deficit at the initial insult; however, the limb survived because of well-formed collaterals. The limb was insensate at the time of presentation because of complete sciatic nerve palsy. The decision to undergo amputation was taken based on insensate limb, compromised circulation and huge bone loss with healed open fracture. After 10 months follow-up, the patient was walking with prosthesis limb fitted to the amputated mid-thigh stump and there were no incidences of osteolysis, subsidence or infection in the THA site.

Total hip and knee arthroplasty after lower extremity amputation in a military population

INTRODUCTION

The military includes lower extremity amputees requiring arthroplasty; however, there is little literature on this population. The primary aim of this study was to report demographics and clinical factors in amputees who undergo total hip or knee arthroplasty (THA/TKA) in the Military Health System (MHS). Second, patient-reported outcome measures (PROMs) are reported.

METHODS

The Military Data Repository was queried for patients with lower extremity amputations and TKA or THA between 1 October 2014 and 12 October 2020. The medical records were reviewed and patients were contacted to complete PROMs. Mean follow-up for TKA and THA was 5.5 and 2.5 years, respectively.

RESULTS

Nineteen TKAs (76%) and eight THAs (28%) were performed in 25 patients. Mean age of TKA and THA patients at the time of arthroplasty was 57 years old. A majority of TKA (68%) and THA (57%) patients underwent amputations secondary to trauma. Nearly all TKAs were performed on the contralateral side to the amputation (95%), while half of THAs were performed on the ipsilateral side (50%). Two THAs (29%) were revised due to periprosthetic fractures, whereas six TKAs (32%) were revised or reoperated on due to infection. Ten TKA patients completed PROMs. The mean score on Knee Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) was 41.8 and Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) was 41.6 (Global Physical Health) and 49.6 (Global Mental Health).

CONCLUSIONS

Most TKAs were performed on the contralateral limb, suggesting increased demand on the joint. The most common indication for amputation and post-TKA complication was trauma and infection, respectively. KOOS JR may not accurately capture the outcomes of this population, or they simply do worse. However, PROMIS-10 scores were similar to the non-amputee population, suggesting that the PROMIS-10 may be more useful than the KOOS JR.

Modular megaprostheses in the treatment of periprosthetic fractures of the femur

Background

Periprosthetic fractures (PPF) of the femur remain challenging, especially in patients with previous multiple revisions. Modular megaprostheses (mMPs) are rarely used in this indication; however, in some cases mMPs seem to be the last chance for limb salvage. We aimed to evaluate the clinical outcome of PPFs of the femur treated by modular mMPs at our institution.

Patients and methods

In this study 33 patients (27 female; mean age 79 years) with a PPF after total hip or total knee arthroplasty (no tumor indications) were treated using modular proximal (mPFR; n = 12), distal (mDFR; n = 14) or total (mTFR; n = 7) femur replacement. A retrospective evaluation regarding mortality and revision rates was performed. Failures with need for revision were classified.

Results

At a mean follow up of 60 months (range 0–178 months), the total mortality rate as well as total revision rate were both found to be 39%. At 1 year follow-up the mortality rate was highest within the mDFR group, and less revisions were necessary in the mPFR group, however both findings were not significantly. Those patients, who had revision surgery before PPF, were found to have higher revision rate after implantation of mMP. In the mPFR group, dislocation was the most frequent failure, within the mDFR and the mTFR group infection. In one case amputation of the lower limb was necessary.

Conclusion

mMPs represent a valuable option in PPFs of the femur. Infection and dislocation remain the most frequent complications. Prospective clinical studies are required to further define the outcome of mMPs in PPFs of the femur.

Mid-to long-term results of total hip arthroplasty after contralateral lower extremity amputation

Objective

There is limited literature concerning the outcomes and role of THA as a surgical option for amputee patients. The aim of this study is to determine the mid-to long-term survival and complication rates of cementless total hip arthroplasty (THA) in patients with contralateral below knee amputations.

Methods

A retrospective review of 54 patients with below knee amputation were perfomed who underwent THA for osteoarthritis of the contralateral hip over a 5-year period between 1999 and 2014. Patients were monitored for at least 5 years and assessed with the Harris Hip Score and activities of daily living scale and by evaluating migration or osteolysis around the acetabular cup and femoral stems (amputee group). The amputee group was compared with a control group (non-amputee group) with the same number of patients.

Results

Differences in the Harris Hip Score (p = 0.021) and activities of daily living scale (p = 0.043) between the two groups were statistically significant lower in the amputee group at 3 months after surgery. However, no differences were found between the groups from 6 months postoperatively to the last follow-up (Harris Hip Score p = 0.812, activities of daily living scale p = 0.885). Radiologically, any cups or stems showed no signs of migration or osteolysis. In the amputee group, dislocation was found in 1 patient 2 months after arthroplasty (p = 0.315) and long stem revision surgery were performed on two patients due to periprosthetic fracture (p = 0.153).

Conclusions

THA performed on the contralateral side of patients with below knee amputation is considered to be an effective treatment with good clinical and radiological results at mid-to long-term follow-up.

Level of evidence

Level IV, therapeutic study.

Minimally invasive treatment for fractures of lower extremity amputees using a rapid reductor

PURPOSE

A traction table is recommended for lower limb fractures, while it is unavailable for amputees to immobilize the ipsilateral foot to remain stationary and reduce the fracture. For these patients, our rapid reductor can be applied to guarantee stable fixation and optimal reduction, allowing satisfactory implant positioning. This study aims to evaluate the prognosis of amputee patients with lower limb fractures treated by minimally invasive techniques that employ a rapid reductor to reduce the fracture.

METHODS

Between 2013 and 2014, 11 cases of amputees suffering from a lower limb fracture were enrolled in the study, including four transtibial amputees with a tibial plateau fracture, three transtibial amputees with a femoral shaft fracture, and four transfemoral amputees with a femoral neck fracture. All fractures involved the amputated ipsilateral lower limbs, which were all reduced in a closed fashion using a rapid reductor. During the operation, the rapid reductor was connected to the injured limb for skeleton traction to reduce the fracture and then used to maintain the reduction for subsequent minimally invasive fixation. The operation time, reduction time, fluoroscopy time, and intra-operative blood loss were recorded. Follow-ups were conducted to evaluate the union of the fractures and the functional recovery.

RESULTS

All 11 cases were treated successfully using this minimally invasive technique, with anatomical or nearly anatomical reduction reached in all fractures. The average operative time, reduction time, fluoroscopy time, and intra-operative blood loss were 60 minutes (range, 46-90 minutes), 13.2 minutes (range, 7-20 minutes), 19.8 seconds (range, 6-65 seconds), and 95 mL (range, 80-170 mL), respectively. No incidents of reductor-induced complications occurred during the operation. Patients were followed up for an average of 20.8 months (range, 18-24 months). All fractures healed well on an average of six months. At the latest follow-up, all 11 cases reported satisfactory functional recovery of the fixed limbs, which were similar to that before the fractures.

CONCLUSIONS

The rapid reductor can be used to efficiently reduce and maintain ipsilateral fractures of the amputated lower extremity in a closed fashion, which can facilitate minimally invasive fixation of the fractures. The patients can achieve excellent outcomes.

Safety and function of a prototype microprocessor-controlled knee prosthesis for low active transfemoral amputees switching from a mechanic knee prosthesis: a pilot study

PURPOSE

Aim of this pilot study was to assess safety and functioning of a microprocessor-controlled knee prosthesis (MPK) after a short familiarization time and no structured physical therapy.

MATERIALS AND METHODS

Five elderly, low-active transfemoral amputees who were fitted with a standard non-microprocessor controlled knee prosthesis (NMPK) performed a baseline measurement consisting of a 3 D gait analysis, functional tests and questionnaires. The first follow-up consisted of the same test procedure and was performed with the MPK after 4 to 6 weeks of familiarization. After being refitted to their standard NMPK again, the subjects undertook the second follow-up which consisted of solely questionnaires 4 weeks later.

RESULTS

Questionnaires and functional tests showed an increase in the perception of safety. Moreover, gait analysis revealed more physiologic knee and hip extension/flexion patterns when using the MPK.

CONCLUSION

Our results showed that although the Genium with Cenior-Leg ruleset-MPK (GCL-MPK) might help to improve several safety-related outcomes as well as gait biomechanics the functional potential of the GCL-MPK may have been limited without specific training and a sufficient acclimation period. Implications for Rehabilitation Elderly transfemoral amputees are often limited in their activity by safety issues as well as insufficient functioning regarding the non microprocessor-controlled knee prostheses (NMPK), thing that could be eliminated with the use of suitable microprocessor-controlled prostheses (MPK). The safety and functioning of a prototype MPK (GCL-MPK) specifically designed for the needs of older and low-active transfemoral amputees was assessed in this pilot study. The GCL-MPK showed indicators of increased safety and more natural walking patterns in older and low-active transfemoral amputees in comparison to the standard NMPK already after a short acclimatisation time and no structured physical therapy. Regarding functional performance it seems as if providing older and low-active transfemoral amputees with the GCL-MPK alone without prescribing structured prosthesis training might be insufficient to achieve improvements over the standard NMPKs.

Reverse Shoulder Arthroplasty in Patients With Amputation or Paralysis of the Contralateral Upper Extremity (One-Arm Patients)

BACKGROUND

Theoretically, patients with only one functional arm secondary to contralateral amputation or paralysis will subject their only functional upper extremity to increased loads. This could become an issue after reverse shoulder arthroplasty (RSA). However, there are no reported data on the implant survival or function for patients with a nonfunctional contralateral upper extremity.

OBJECTIVE

To report the outcomes of RSA in patients with contralateral upper extremity amputation or paralysis.

DESIGN

Retrospective case series.

SETTING

Tertiary university hospital.

PATIENTS

All patients who underwent RSA between January 2004 and December 2013.

METHODS

Of 1335 RSA procedures performed, 5 patients had a minimum 2-year follow-up and nonfunctional contralateral upper extremity. There were 3 men and 2 women, with a mean (standard deviation) age and length of follow-up of 72.4 (7.5) years and 56.4 (24-132) months. Two of the patients had a contralateral upper extremity amputation, and the other 3 had contralateral upper extremity paralysis as a result of stroke, traumatic brain injury, and traumatic brachial plexus injury at birth.

MAIN OUTCOMES

Pain, range of motion, functional scores (Simple Shoulder Test, American Shoulder and Elbow Society and Quick-Disability of the Arm, Shoulder and Hand), satisfaction, complications/reoperations, and radiographic loosening.

RESULTS

RSA resulted in substantial improvement in pain (P = .008), forward flexion (P = .02), and external range of motion (P = .01). The mean (standard deviation) Simple Shoulder Test, American Shoulder and Elbow Society, and Quick-Disability of the Arm, Shoulder, and Hand scores were 9.8 (1.3), 82 (13), and 17.8 (13.4), respectively. The results were excellent in 3, satisfactory in 1, and unsatisfactory in 1 patient (due only to external rotation limited to 10°). Subjectively, all 5 patients felt greatly improved and stated they would undergo RSA again. There were no complications or reoperations. There were no shoulders with component loosening.

CONCLUSIONS

RSA seems to be a safe, effective, and successful surgical procedure for patients with a nonfunctional contralateral upper extremity. Studies with larger sample sizes and longer follow-up will hopefully validate the present findings.

LEVEL OF EVIDENCE

IV.

Primary Total Hip Replacement for a Femoral Neck Fracture in a Below-Knee Amputee

INTRODUCTION

Femoral neck fracture on amputated limb is an uncommon lesion and challenging to manage.

CASE REPORT

We report a case of a displaced neck fracture of the left femur in a 57-year-old female. She underwent at the age of the three a below-knee amputation of the ipsilateral limb for post traumatic ischemia. The fracture was managed by a total hip arthroplasty (THA), as a primary procedure. In this article we describe our experience of this unusual entity.

CONCLUSION

Total hip arthroplasty in patients with lower limb amputation is a challenging and uncommon intervention, especially when it's a primary procedure. It may provide satisfactory outcome, and allows early rehabilitation.