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

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.