Innovative Patient Positioning for Proximal Femoral Nailing in a Bilateral Above-knee Amputee: A Case Report and Technical Note

Abstract

Introduction

Proximal femur fractures in amputees present unique surgical challenges, primarily due to the inability to use standard traction table attachments. Bilateral above-knee amputations further add to this difficulty. The literature mainly describes unilateral amputees and delayed fractures in previously amputated limbs, while reports involving bilateral above-knee amputations are rare. The challenge becomes greater when the fracture and bilateral traumatic amputations occur in the same index trauma, because stump length, soft-tissue condition, fluoroscopic access and infection risk all constrain conventional positioning and reduction methods.

Case presentation

A 47-year-old male who sustained bilateral lower-limb traumatic amputations and a left intertrochanteric fracture following a railway accident. He underwent staged revision amputations and stump management, resulting in bilateral healthy above-knee stumps before definitive fixation of the left proximal femur fracture. Traction-table positioning was achieved by inserting a Steinmann pin through the left above-knee stump and coupling it to the traction apparatus, while the contralateral stump was secured to the side post to permit reduction, rotational control and unobstructed fluoroscopic imaging. Closed reduction and fixation with a short Proximal Femur Nail Anti-rotation II (PFNA2) were done.

Conclusion

It is a safe, reproducible and effective technique for traction, rotational control and C-arm access in a polytrauma patient with bilateral transfemoral stumps.

Introduction

The standard surgical approach for the closed reduction and internal fixation of intertrochanteric fractures relies on the use of an orthopaedic traction table.^1,2 Conventionally, the injured limb is secured by placing the intact foot into a traction boot, allowing the surgeon to apply mechanical longitudinal traction and rotational manipulation to reduce the fracture.¹ Furthermore, the contralateral limb is typically positioned in a lithotomy position to allow unimpeded access for the C-arm fluoroscope to obtain necessary anteroposterior and lateral views.

However, in patients with lower limb amputations, positioning and reduction on a traction table becomes a significant challenge.^2,3 In above-knee amputees, there is no distal segment to engage a traction boot, and the stump may be too short or conical to tolerate skin traction, jeopardising reduction and intraoperative imaging. Bilateral above-knee amputations present a formidable obstacle, as patients lack both a distal lever arm for traction and a contralateral limb that can be easily placed in a standard hemi-lithotomy position.

The available literature on hip fracture fixation in amputees consists largely of isolated case reports and small case series. These describe several workarounds, including inverted boot fixation for below-knee amputees, skin traction with bandages, manual control of the stump, Schanz or Steinmann pin-based skeletal traction, AO distractors on a radiolucent table, and custom adaptations of the contralateral stump position. However, reports of acute intertrochanteric fracture fixation in a patient who sustained bilateral traumatic above-knee amputations during the same injury event remain exceptionally uncommon.

We present a novel positioning technique based on a Steinmann pin through the fractured-side stump and side-post stabilisation of the opposite stump. The case is notable for the acute trauma setting, bilateral transfemoral stump status at the time of fixation, use of cephalomedullary nailing and the adaptation of fracture-table mechanics to achieve reduction in a resource-conscious trauma practice.

Case Presentation

A 47-year-old male with no known comorbidities presented to the Emergency Department following a train accident. The patient sustained bilateral lower limb auto-amputation and a left-sided comminuted intertrochanteric fracture (Fig. 1). There were no other systemic injuries. Local examination revealed total amputation of the right lower limb at the knee level and near-total amputation of the left lower limb below the knee. Both stumps were heavily contaminated with exposed muscle and bone. Plastic surgery consultation determined the amputated parts were non-salvageable.

Figs 1A and B.

(A) Preoperative and (B) postoperative radiographs

The patient underwent a series of revision amputations and debridement, skin grafting, leading to bilateral optimal Above Knee Amputation (AKA) stumps. Definitive orthopaedic fixation of the left intertrochanteric fracture was then performed.

Surgical Technique

Under spinal anaesthesia, the patient was transferred to a radiolucent orthopaedic fracture table. Under sterile conditions, a 4 mm Steinmann pin was inserted through the distal femur of the left amputation stump in an anteromedial to posterolateral direction to avoid damaging neurovascular structures. A Böhler traction stirrup was securely attached to the pin. Cables were then used to connect the stirrup to the table's traction apparatus (Fig. 2). This setup provided mechanically controlled longitudinal traction and internal/external rotational adjustments to reduce the fracture.

Figs 2A and B.

Attachment of the ipsilateral stump to the traction apparatus

To allow unimpeded access for the C-arm fluoroscope, the contralateral (right) above-knee stump was elevated, flexed and abducted. It was securely positioned over a side post (Fig. 3). This manoeuvre successfully cleared the radiographic pathway for orthogonal (anteroposterior and lateral) imaging while providing essential counter-traction against the perineal post.

Figs 3A to C.

Positioning of the contralateral stump

Closed reduction was achieved through the traction table mechanisms and verified under fluoroscopy. The proximal femur was prepared, and a short Proximal Femur Nail Anti-rotation II (PFNA2) was inserted and locked using standard minimally invasive techniques. Post-operative radiographs confirmed excellent alignment and implant positioning.

Discussion

Achieving and maintaining fracture reduction on a traction table requires creative modifications for amputee patients. The level of amputation strictly dictates the available positioning options.

For below-knee amputees, securing the flexed stump within an inverted traction boot is a widely utilised and highly successful non-invasive method. Multiple reports have demonstrated that this technique provides effective rotational control and linear traction without the risks associated with invasive pin insertion.^1,3 However, this “reverse boot” technique relies entirely on the presence of an intact knee joint to anchor the limb, rendering it inapplicable for above-knee amputees.²

For above-knee amputees, published solutions include skin traction or adhesive bandage methods attached to the boot, manual manipulation of the stump, skeletal traction using Schanz, Steinmann, K-wire or Denham pins, table-free strategies using AO distractors or osteosynthesis performed in non-standard positions, such as lateral decubitus. While skin traction techniques (using adhesive tape or elastic bandages) have been reported, they offer limited rotational stability and are unsuitable for short or conical stumps or those with poor skin condition. Skeletal traction utilising a Steinmann or Denham pin inserted through the distal femur, connected to a traction boot via a Böhler stirrup, is the most reliable method.^2,4 As described in a few reports, inserting a distal femur pin provides direct femoral traction and rotational control, facilitating fracture reduction while minimising soft tissue complications. The direction of pin insertion is essential due to the proximity of the distal femur to major neurovascular structures. Anteromedial to posterolateral insertion offers the safest passage, as described in the cross-sectional diagram of the distal femur (Fig. 4).

Fig. 4.

Cross-sectional diagram of the femur depicting the safe zone for pin placement

Bilateral amputees introduce an additional challenge for intraoperative imaging. Typically, the uninjured limb must be positioned out of the way (in lithotomy) to allow the C-arm to pivot for lateral imaging. In our case, the patient lacked a contralateral limb to place in standard stirrups. By flexing and abducting the contralateral right stump and securing it against the side post, our technique successfully removed the radiographic obstruction and provided countertraction.⁵ This eliminated the need for more invasive open reduction manoeuvres or external femoral distractors, allowing the surgical team to utilise standard cephalomedullary nailing protocols.

Conclusion

The combination of ipsilateral skeletal traction via a Steinmann pin and contralateral side-post fixation is a highly effective positioning strategy for bilateral above-knee amputees with proximal femur fractures. This reproducible technique restores the mechanical advantages of the orthopaedic traction table, ensures unobstructed fluoroscopic imaging and provides optimal soft-tissue handling.

Clinical Significance

This Steinmann pin-based traction technique safely restores standard fracture table mechanics and unobstructed imaging for complex bilateral above-knee amputees. It provides a practical solution that eliminates the need for highly invasive open reduction manoeuvres or specialised external distractors.

Data Availability Declaration

The datasets generated during and/or analysed during the current case report are available from the corresponding author on reasonable request.

Artificial Intelligence (AI) Disclosure

The authors state that no AI was used in the preparation of this manuscript.

Acknowledgement

Nil.

Author's Contribution

Saroj K Patra: Overall supervision of work.

Deepak R Patro: Data collection, manuscript writing.

Unais TT: Manuscript writing.

Gandharav Mehta: Data collection.

Orcid

Deepak R Patro https://orcid.org/0009-0008-1300-9836

Unais TT https://orcid.org/0009-0006-1341-8766

Gandharav Mehta https://orcid.org/0009-0007-7624-0624