Changli Xu
Yu Yin1,†- 1Department of Orthopedics, Bethune International Peace Hospital (The 980th Hospital of the People's Liberation Army Joint Logistics Support Force), Shijiazhuang, China
- 2Department of Orthopedics, The Third Affiliated Hospital of Naval Medical University, Shanghai, China
Introduction: Femoral neck fracture in a homolateral amputated extremity is not common and challenging for the surgeon to manage. In this article we share our experience of this unusual entity.
Methods: We present a case of a displaced femoral neck fracture of the right femur in a 69-year-old female, who underwent at the age of 29 an above-knee amputation of the homolateral limb. The fracture was managed by a primary total hip arthroplasty (THA). The post-operative course was uneventful. There was no infection, deep vein thrombosis, dislocation, or any other complication.
Results: Over one-year follow-up demonstrated that the patient while wearing the prosthetic limb received satisfactory and functional use of normal activities. The patient achieved a good functional outcome with a Harris Hip Score at 86/100. To date, the patient has returned to normal activities without symptoms.
Conclusion: Treating femoral neck fractures in homolateral above-Knee amputees is challenging. Surgical technical tips and rehabilitation exercises are necessary and crucial. Total hip arthroplasty can provide satisfactory functional outcome and return to pre-fracture daily life activities.
Introduction
Femoral neck fractures are a common source of morbidity and mortality worldwide, which account for approximately 3.6% of all fractures (1). Nevertheless, the discovery and development of hip arthroplasty have improved its prognosis, with a high survival rate, and satisfactory functional results. Although total hip replacement has been well described in the literature especially for healthy individuals, femoral neck fracture in an amputated extremity is not common and little has been published about this condition (2). There is little information about the technical features and outcomes of the surgery for lower limb amputees. Femoral neck fracture on amputated limb is an uncommon lesion and challenging for the surgeon to manage because of technical difficulties such as the patient setup, the surgical approach, immobilization, surgical reduction, and stabilization, as well as post operative rehabilitation. The goal of treatment is the return of the amputee to their pre-fracture status that includes satisfactory and functional use of the prosthetic limb.
In this study we present a rare case of femoral neck fracture in a patient with homolateral femoral amputation, treated with a primary total hip arthroplasty. Written informed consent for publication was obtained from the patient, and the case was reviewed by the ethics committee.
Case report
A 69-year-old female, who underwent at the age of 29 an above-knee amputation of the right higher limb as a life-saving procedure after a traffic accident, was taken to the emergency room for homolateral hip trauma. She tripped and fell down during walking, striking the lateral aspect of her right hip on the ground. She was diagnosed with a grade IV femoral neck fracture, according to Garden's classification (Figure 1). Before this injury, she was previously mobilizing using a prosthesis and returned to her normal activities.
Figure 1. Preoperative antero-posterior radiograph of the pelvis showing a displaced femoral neck fracture.
On physical examination, there was tenderness in the greater trochanter and groin area. Right thigh stump showed tenderness on the log roll test, and there was axial percussion pain. The overlying skin was intact, with a well healed surgical scar over the stump and normal sensation and circulation. There were no any vascular or neurologic complications. And no other injuries were identified.
Considering the patient's age and the need for rapid recovery, total hip arthroplasty (THA) was more suitable for this patient. The radiograph (Figure 1) included the complete stump which could assess the remaining femoral length and the width of the medullary canal. Figure 1 showed the residual limb length was 176 mm from the greater trochanter to the distal end with significant bone mass loss. Given that the patient has no underlying diseases and a long life expectancy, the cementless implant was a good candidate for this patient. However, further care should be taken to the implanting of prothesis to avoid intraoperative fracture. Following informed consent, the procedure was performed, under general anesthesia, with the patient in a left lateral decubitus position. A posterior lateral surgical approach of the right hip joint, with an approximately 12 cm skin incision centered around the greater trochanter of the femur, was required (Figure 2A). A Steinmann pin was inserted in the distal femur to facilitate the control of the stump (Figure 2B). A 48 mm porous coated uncemented acetabular shell (IRNENE Co., China) was aligned with the transverse acetabular ligament. The acetabular shell was transfixed with two 6.5 mm cancellous screws (IRNENE Co., China). A cementless size 15 type femoral stem was inserted (IRNENE Co., China) and a 32 mm Ceramic liner was used (IRNENE Co., China). Intraoperative testing confirmed stable mobility of the hip joint (Figure 2C).
Figure 2. (A) the posterior lateral surgical incision of the right hip joint. (B)The Steinmann pin inserted in the distal femur. (C) Intraoperative image showing the THA for the patient. (D) Postoperative radiographs revealed satisfactory.
Post-operatively, antibio prophylaxis for 72 h as well as sub cutaneous anticoagulation was prescribed to prevent thrombo-embolic and infectious. The post-operative course was uneventful. There was no infection, deep vein thrombosis, dislocation, or any other complication. We treated osteoporosis with zoledronic acid, calcium and vitamin D3 perioperatively. During her hospitalization, she was allowed to walk with a walking aid and underwent physiotherapy. She was discharged home five days after surgery. Two weeks postoperatively the wound had healed. Utilizing the assistance of a walker, she embarked on wearing prosthetics for her rehabilitation program, encompassing gait training and endurance training. Another two weeks later, she began to walk normally wearing her prosthesis without any walking aid or crutch. At the most recent follow-up, one year following THA, the amputation limb exhibited satisfactory condition (Figure 2D). Upon examination, the patient demonstrated good range of motion in the hip joint without any pain: her hip flexion was 90°, external and internal rotation was 30°, abduction was 40° and adduction was 20°. While wearing the prosthetic limb, no discrepancy in leg length was noted. The functional outcome was good with a Harris Hips Score at 86/100. The x-ray images revealed that the femur and acetabular components were well-incorporated, with no signs of osteolysis. To date, the patient has returned to normal activities without symptoms (Figure 3). Figure 4 shows the timeline of the complete illness course of this patient.
Figure 3. Postoperative radiographs and clinical pictures with prosthesis at 1 year-follow-up.
Figure 4. The timeline for this patient.
Discussion
This 69 years old female, active, trans-femoral amputee underwent cementless THA without complications and achieved her preoperative activity status, wearing her artificial limb prosthesis. However, residual lower limb fracture is not common, with little information available in the previous literature. Long-term wearing of prosthetics may induce osteo-articular as well as muscular modifications in residual lower limb. Total hip arthroplasty in amputees can be very challenging, with serious technical issues such as surgical preparation, hip dislocation and reduction, component positioning and rehabilitation. Therefore, a detailed plan is necessary for this surgery.
We conducted a systematic literature search on PubMed and Google Scholar for case reports published between 2009 and 2025 (Table 1). The keywords used included above-Knee amputation, total hip arthroplasty and femoral neck fracture.
Table 1. Summary of reported cases of femoral neck fractures in patients with ipsilateral above-knee amputations.
According to literature reports, for THA after lower extremity amputation, the posterior surgical approach was used for 51.2%, anterolateral approach for 48.2% and direct anterior approach for 0.6% (3). The selection of surgical approach does not significantly influence surgical outcomes and is predominantly determined by the surgeon's personal preference. The majority of surgeons prefer the posterior approach, as it facilitates the exposure of the hip joint and the process of joint replacement.
There are some difficulties during the surgical process for above-knee amputees. The short lever arm with difficulties to handle the proximal femur during the hip dislocation and implants insertion. Some surgeons inserted a Steinman pin into the great trochanter, while someone inserted Schanz pins into the distal femur, to provide rotational control and facilitate dislocation/relocation (4–6). Some surgeons resorted to use bone clamps or hooks in the intertrochanteric region, while someone used bone clamps or forceps on the proximal femoral shaft itself, up to 5 cm distal to the lesser trochanter (7–10). Meanwhile, positioning the femoral stem within the femoral canal, regarding anteversion, poses a significant challenge in such procedures in above knee amputees. It can be achieved by palpating the lesser trochanter and following the anatomic alignment of the femoral canal, during its preparation for insertion of the uncemented femoral prosthesis. In some cases, several technical tips may be necessary for patients with above-knee amputation. The contracture of the hip flexors and abductors may require soft tissue release. The femoral stem should be placed with adequate length and in the appropriate depth according to the level of amputation. Of note, a larger femoral head is preferred to be selected to ensure better stability. Considering that the muscle tone of patients with femoral amputation is weaker than that of normal individuals, we made the head socket slightly tighter during the surgery to reduce postoperative dislocation. Additional care should be brought to the skin of residual limb during closure of the operative wound to protect the scar subsequently from pressure related to the limb prosthesis. Compression wraps and bandages could be routinely utilized in amputees to prevent this occurring.
Another important factor to be taken into consideration is osteoporosis caused by the amputation which can lead to preoperative or post-operative peri prosthetic fractures, or an early loosening of the implant. Pre-operative planning is extremely important; radiographs or CT scans should include the full-length of the remaining femoral to assess the bone mineral density and distal bony geometry and facilitate preoperative planning for prosthesis selection (11). If patients with osteoporosis, there is an increased risk of intraoperative calcar fracture during femoral prosthesis implantation. To mitigate this risk, some authors suggest using cerclage wires preoperatively to reduce calcar fracture incidence. In those patients, the use of cemented implants should be considered. If patients don't have a diagnosis of severe osteoporosis and have a long-life expectancy, the cementless prosthesis is a good choice, given long-term risks of cement aging and late loosening (3, 9, 12). And muscular deficiency in the residual limb increases the risk of hip dislocation (13, 14). Hence, it is of utmost importance to initiate rehabilitation exercises at the earliest possible opportunity.
Conclusion
Treating femoral neck fractures in homolateral above-Knee amputees can be challenging. Total hip arthroplasty provides a better rehabilitation with an early full-weight bearing and return to ambulation in the management of femoral neck fractures. Surgical technical tips and rehabilitation exercises are necessary and crucial. Satisfactory functional outcome and return to pre-fracture daily life activities can be achieved after THA.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.
Ethics statement
The studies involving humans were approved by Bethune International Peace Hospital Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
CX: Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. YY: Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing. HS: Data curation, Formal analysis, Investigation, Supervision, Visualization, Writing – review & editing. ZL: Formal analysis, Software, Validation, Writing – review & editing. SQ: Conceptualization, Data curation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing. JB: Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing – review & editing, Writing – original draft.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This study received funding from the “Yanzhen” Talent Plan and the Technology Innovation Incubation Program Project of the Bethune International Peace Hospital (2024FYMSXM08).
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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The author(s) declared that generative AI was not used in the creation of this manuscript.
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Keywords: above-knee amputations, femoral neck, hip fracture, total hip arthroplasty, total hip replacement
Citation: Xu C, Yin Y, Shi H, Li Z, Qiao S and Bu J (2026) Primary total hip arthroplasty for a femoral neck fracture in a homolateral above-knee amputee: a case report. Front. Surg. 12:1732504. doi: 10.3389/fsurg.2025.1732504
Received: 26 October 2025; Revised: 30 November 2025;
Accepted: 8 December 2025;
Published: 8 January 2026.
Edited by:
Roberto Tedeschi, Independent Researcher, Bologna, ItalyReviewed by:
Xiangde Zhao, Sir Run Run Shaw Hospital, ChinaPouria Chaghamirzayi, Alborz University of Medical Sciences, Iran
Copyright: © 2026 Xu, Yin, Shi, Li, Qiao and Bu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jianli Bu, ZG9jdG9yYnVqaWFubGlAMTYzLmNvbQ==; Suchi Qiao, c3UtY2hpQDE2My5jb20=
†These authors have contributed equally to this work and share first authorship