Intraoperative Traction for Cephalomedullary Nailing in Amputation Patients

Femoral fracture fixation in lower-limb amputees is challenging due to limited limb purchase, altered biomechanics, and sparse guidance. We describe an intraoperative skeletal-traction technique to facilitate cephalomedullary nailing (CMN).

Two amputee patients with extracapsular proximal femur fractures underwent CMN. Under biplanar fluoroscopy, a 5-mm distal femoral traction pin was placed through the residual limb and secured to the traction boot to restore length, correct alignment, and permit controlled reduction.

Patient 1 (65-year-old female; prior left below-knee amputation, contralateral above-knee amputation) achieved an acceptable reduction and implant position; she died on post-operative day 3 from cardiopulmonary arrest. Patient 2 (77-year-old male; prior right above-knee amputation) achieved anatomic reduction with the nail tip proximal to the traction pin; the pin was removed at the case end. At 13 months, his outcome remained satisfactory; he later required contralateral amputation for ischemia.

Intraoperative skeletal traction through a distal femoral pin offers reliable control of length and rotation during CMN in amputees and may provide superior stump control to skin traction. Careful pin placement is essential to mitigate neurovascular risk. This approach appears feasible for both above- and below-knee amputees; larger series are needed to define indications and long-term outcomes.