The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 12

Case Reports | December 01, 2007

Traumatic Transfemoral Amputation with Concomitant Ipsilateral Proximal Femoral Fracture: A Report of Two Cases

Second Lieutenant C. Jesse Pickard-Gabriel, BA¹; Major Cheryl L. Ledford, MD²; Lieutenant Colonel Donald A. Gajewski, MD²; Colonel Robert R. Granville, MD²; Lieutenant Colonel Romney C. Andersen, MD²

¹ Medical Service Corps, United States Air Force Reserve, 6608 14th Street N.W. #201, Washington, DC 20012. E-mail address: S8CPickardGabriel@USUHS.mil
² United States Army Medical Corps, Orthopaedic Surgery Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Air Force, Department of the Army, Department of the Navy, Department of Defense, nor the U.S. Government.

Investigation performed at Walter Reed National Military Medical Center, Bethesda, Maryland and Washington, D.C.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2007 Dec 01;89(12):2764-2768. doi: 10.2106/JBJS.G.00229

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Extract

In contrast to civilian amputations, military amputations today are almost entirely due to trauma^1-6. The current conflicts in Afghanistan and Iraq have resulted in more than 700 major limb amputations⁷. We present the cases of two patients who sustained traumatic transfemoral amputations with concomitant ipsilateral femoral fractures. The injuries in these two patients represent particularly complex injuries that are rarely, if ever, seen in the civilian trauma setting. These patients represent a different segment of the population than do traditional civilian amputees because of their young age, excellent physical conditioning prior to injury, high capacity for healing, and long life expectancy following amputation^8-11.

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Introduction

Introduction | Case Reports | Discussion | References

When a traumatic lower-limb amputation occurs in a young healthy adult, the best outcome is attained with use of a prosthetic limb to restore as much function and mobility as possible¹². More distal levels of amputation (e.g., transtibial compared with transfemoral) allow more efficient walking^{8,10,11,13-16} and better overall function^14,17. It is therefore important to maintain as much skeletal length as possible to optimize outcome. The current standard suggests that a minimum length of 5 to 10 cm distal to the lesser trochanter (approximately one-third of the original femoral length) is necessary to fit a patient with a transfemoral total-contact ischial-containment narrow-medial-lateral socket prosthesis rather than a hip-disarticulation total-contact ischial-containment prosthesis. Ideally, the residual length should be approximately 20 cm distal to the lesser trochanter (approximately two-thirds of the original femoral length).

Evolution of Surgical Technique

Historically, according to the Department of the Army, "Only in the very occasional case was it found expedient to amputate through a long bone which was the site of a proximal fracture."^4,6 Technical challenges, risk of infection, and the limitations placed on surgeons in time of war dictated that saving the extra femoral length required too many resources and too much risk up through the time of the Vietnam War³.

Currently, the United States Emergency War Surgery handbook states that the current general indications for amputation include "partial or complete traumatic amputation; irreparable vascular injury or failed vascular repair with an ischemic limb; life-threatening sepsis due to severe local infection, including clostridial myonecrosis; and severe soft-tissue and bone injury to the extremity precluding functional recovery."² Furthermore, amputations should be performed at the most distal viable level of soft tissues to preserve as much limb length as possible. Finally, "Fractures, when present proximal to the mangled segment, should not determine amputation level, but must be treated appropriately (cast, external fixator) to preserve maximal length."²

We report on the cases of two military service members, each of whom required a transfemoral amputation as a result of a traumatic lower-extremity blast injury and each of whom sustained a concomitant ipsilateral femoral fracture. The level of amputation was distal to the femoral fracture in each patient. The fractures were initially stabilized with external fixation in an emergent fashion in the Iraqi theater of operations. The fractures were reduced and stabilized with flexible intramedullary rods on a delayed basis after appropriate irrigation and débridement. Our patients were informed that data concerning the cases would be submitted for publication, and they consented.

Case Reports

Introduction | Case Reports | Discussion | References

Case 1. A twenty-eight-year-old male soldier sustained a blast injury in January 2004, resulting in traumatic transfemoral amputation of the right lower extremity and an ipsilateral femoral fracture proximal to the site of amputation. Initial surgical interventions were performed in Iraq before the patient was evacuated for definitive care. On the patient's arrival at Landstuhl Medical Center in Landstuhl, Germany, the femoral fracture was noted to be 1.0 cm distal to the lesser trochanter. The salvaged distal segment was 10.9 cm in length, with a butterfly fracture at the distal end. The distal segment of bone had sufficient vascular supply to remain viable, and the limb had sufficient remaining soft tissue to allow for coverage of the distal segment of the femur. The wound was thoroughly irrigated and débrided twice before the subtrochanteric femoral fracture was definitively treated with use of flexible intramedullary rods. Antibiotic-impregnated methylmethacrylate beads were placed as a temporary measure to control infection (Fig. 1-A). The patient was then evacuated to Walter Reed National Military Medical Center in Washington, D.C. for continued treatment. The butterfly fracture fragment at the distal end of the femur was reduced and stabilized with a cerclage wire and the intramedullary rods were shortened to the bone end (Fig. 1-B), resulting in a femoral length of 11.9 cm distal to the lesser trochanter. Delayed closure of the soft tissues and skin was performed, but a deep infection developed. The infection was treated with intravenous and oral antibiotics until the fracture healed (Fig. 1-C). Subsequently, heterotopic ossification developed within the soft tissues adjacent to the injured femur; the ossification was surgically excised in November 2004. An additional 6 cm of length was lost following infection and heterotopic ossification excision. The patient ultimately had 4.9 cm of additional femoral length that he would not have had if the femur had been amputated proximally at the fracture site. The additional femoral length permitted the patient to be fitted with a transfemoral prosthesis.

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Fig. 1-A: Figs. 1-A, 1-B, and 1-C Case 1. Femoral fracture and traumatic transfemoral amputation of the right lower limb in a twenty-eight-year-old male soldier. Fig. 1-A Radiograph made within the first week of injury, showing the placement of two intramedullary rods and antibiotic beads. Arrow points to butterfly fragment. The butterfly fragment is not yet fixed.

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Fig. 1-B Fig. 1-C: Fig. 1-B Radiograph made five weeks after amputation. The two intramedullary rods have been trimmed, the antibiotic beads have been removed, and the butterfly fragment has been secured with a cerclage wire. Fig. 1-C Radiograph made fourteen months after amputation, showing a healed femoral fracture. Note the extensive heterotopic ossification.

Case 2. A twenty-three-year-old male Navy Corpsman sustained a blast injury in October 2005, resulting in a massive injury that included a transfemoral amputation of the right lower extremity and an ipsilateral femoral fracture proximal to the site of amputation. Initial surgical interventions were performed in Iraq. The traumatic above-the-knee amputation was completed surgically, and the distal femoral fragment was stabilized with an external fixator (Fig. 2-A). The patient was then evacuated to Walter Reed National Military Medical Center in Washington, D.C., where the femoral fracture site was noted to be 4.5 cm distal to the lesser trochanter. The patient had sufficient remaining soft tissue distal to the fracture site to permit salvage of the distal femoral segment. The femoral fracture was reduced and was then stabilized with two flexible intramedullary rods (Fig. 2-B). The soft tissues were closed on a delayed basis. The fracture healed in good alignment. Heterotopic ossification developed in the soft tissues adjacent to the injured femur (Fig. 2-C); the ossification was surgically excised in April 2006. The final level of amputation was 16 cm distal to the lesser trochanter. Because the distal segment of the femur had been salvaged, the residual limb length had been increased by 11.5 cm, thus permitting the patient to be fitted with a transfemoral prosthesis after resection of the heterotopic ossification. Had the femur been amputated proximally at the fracture site, the shorter amount of remaining distal femoral bone would have necessitated the use of a hip-disarticulation prosthesis rather than a transfemoral prosthesis.

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Fig. 2-A Fig. 2-B: Figs. 2-A, 2-B, and 2-C Case 2. Femoral fracture and traumatic transfemoral amputation of the right lower limb in a twenty-three-year-old male Navy corpsman. Fig. 2-A Radiograph made preoperatively, one week after injury, demonstrating external fixation and stabilization of the proximal diaphyseal femoral fracture. Fig. 2-B Radiograph made immediately postoperatively, showing the flexible intramedullary rods that were used to stabilize the femur. The soft tissues were revised.

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Fig. 2-C: Radiograph made at five months after injury showing the development of heterotopic ossification about the well-healed fracture.

Discussion

Introduction | Case Reports | Discussion | References

Previously, a battlefield fracture proximal to an amputation site was difficult to treat because of limited resources, lack of battlefield surgical capability, and the large numbers of casualties to be treated. The cases of our two patients show that the residual femoral length of a limb that has sustained traumatic amputation can be improved through stabilization of the ipsilateral fracture with flexible intramedullary rods and that this can be done without overburdening our medical resources or creating undue risk for the patient. Our patients had final femoral lengths of 5.9 cm (Case 1) and 16 cm (Case 2) distal to the lesser trochanter. In both cases, the increased length improved the final outcome by preventing the need for a hip-disarticulation prosthesis and permitting the fitting of a transfemoral prosthesis, the use of which is associated with more efficient walking and a better quality of life.

Normal walking at a self-selected pace requires an average oxygen expenditure of 0.15 mL/kg for each meter walked. A transtibial amputee expends oxygen at a rate of 0.20 mL/kg for each meter walked; a transfemoral amputee, 0.25 mL/kg; and a hip-disarticulation amputee, even greater energy consumption⁸. These large, stepwise differences in walking efficiency highlight the importance of maintaining the most distal anatomic level of amputation possible. It is important to take into consideration any opportunity to increase the functional residual length of a lower limb because longer limb length is often associated with an improved outcome for the patient. Fisher and Gullickson state that "the more disabled a person, the more determinants of gait are lost; therefore the more [energy]/(unit distance) is used in walking and the less efficient is the gait."⁸ Additionally, patients reduce their walking speed to match this reduced level of efficiency^8,10,11. Amputees consistently report better qualitative function with greater residual limb length¹⁷. This includes a subjective improvement in walking, better prosthetic fit, more prosthetic options, and greater mobility and function when not wearing a prosthesis¹⁷. It should be noted that, even though the general consensus among experts is that shorter residual limb length causes less efficient gait^{2,8,10,11,13-24}, there are no quantitative data to confirm or refute a change in gait efficiency when comparing amputees who have residual limbs of varying lengths but the same anatomic level of amputation.

The risk of infection with the use of intramedullary rods is a concern in patients with traumatic amputations². Dead tissue and foreign objects can be blasted proximally into viable tissue, particularly along fascial planes at the time of the initial injury². Frequent débridements and early initiation of antibiotic therapy are instrumental in decreasing the risk of infection. However, experience has shown that all traumatic amputations should be left open initially. In military patients, closure should typically be delayed until the patient reaches the hospital in which he or she will be receiving definitive care^1-6,9,25,26. The insertion of an intramedullary rod carries the risk of driving superficial bacteria deep into the sterile proximal part of the femur. The use of intramedullary rods was contraindicated in the theater of operations as recently as the time of publication of the 2004 surgical guidelines of the United States Department of Defense². However, the use of intramedullary rods has been pushed steadily toward the front line during the conflict in Iraq, and they are now being used in a limited capacity²⁷. In each of our patients, the wound was irrigated and débrided multiple times before the intramedullary rods were placed. The rods were inserted more than three days after the blast injury, and the amputation wound was left open to allow for adequate drainage. Also, the administration of systemic antibiotics was started in each patient more than forty-eight hours prior to fixation.

Heterotopic ossification is another complication of extensive bone and soft-tissue trauma as well as blast injuries²⁸ and head injuries, and it is a well-recognized complication of traumatic amputation^29-31. Both of our patients required surgical removal of heterotopic ossification within fourteen months of injury. Each of these procedures was uncomplicated and, following removal, both patients were able to walk well with use of a prosthesis. Image Not Available

References

Introduction | Case Reports | Discussion | References

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Topics

amputation ; fracture ; femoral fractures ; amputation above-knee ; femur fractures, proximal end ; intramedullary rods

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Second Lieutenant C. Jesse Pickard-Gabriel, Major Cheryl L. Ledford, Lieutenant Colonel Donald A. Gajewski, Colonel Robert R. Granville, Lieutenant Colonel Romney C. Andersen; Traumatic Transfemoral Amputation with Concomitant Ipsilateral Proximal Femoral FractureA Report of Two Cases. The Journal of Bone & Joint Surgery. 2007 Dec;89(12):2764-2768.

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