Case Connector | Development of Scoliosis Following Complex Combat-Related Lower-Extremity Amputations: Two Case Reports

Case Reports | May 09, 2012

Development of Scoliosis Following Complex Combat-Related Lower-Extremity Amputations: Two Case Reports

Daniel G. Kang, MD¹; Ronald A. Lehman, MD¹; David M. Laufer, CO¹; Adam J. Bevevino, MD¹

¹ Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address for D.G. Kang: daniel.g.kang@gmail.com

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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1Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address for D.G. Kang: daniel.g.kang@gmail.com

Investigation performed at Walter Reed National Military Medical Center, Bethesda, Maryland

Disclaimer: The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or United States Government.

JBJS Case Connector, 2012 May 09;2(2):e19 1-4. doi: 10.2106/JBJS.CC.K.00146

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Combat casualties that have been subjected to high-energy blast trauma have experienced devastating lower-extremity injuries and soft-tissue damage, resulting in complex lower-extremity amputations. There have been limited reports of scoliosis following upper and lower-extremity amputations^1-4. We report the development of scoliosis in two combat casualties following hemipelvectomy and hip disarticulation, respectively, for injuries sustained during the current conflicts in Iraq and Afghanistan. Both patients were informed that data concerning their cases would be submitted for publication, and they both provided consent.

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Introduction

Introduction | Case Reports | Discussion | References

Case Reports

Introduction | Case Reports | Discussion | References

Case 1. A twenty-one-year-old active duty Army soldier had had a right hemipelvectomy and left hip disarticulation following the explosion of a rocket-propelled grenade (RPG). Approximately two years after injury, the patient had sitting imbalance. A sitting spinal radiograph demonstrated a right lumbar scoliosis from L1 to L5 of 37°, with a 1+ Nash-Moe rotation (Fig. 1). He had limited prosthetic use and no back pain; he had some mobility with use of a manual wheelchair. He was able to perform independent transfers to and from the wheelchair as well as most activities of daily living (ADL).

Fig. 1

Anteroposterior radiograph of the spine (left) and anteroposterior radiograph of the pelvis (right) of the patient in Case 1 following a right hemipelvectomy and left hip disarticulation, demonstrating a right lumbar scoliosis from L1 to L5 of 37°, with a 1+ Nash-Moe rotation.

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Case 2. Following injury from an improvised explosive device (IED), a twenty-year-old active duty Marine had had bilateral transfemoral amputations, with the right lower-limb amputation considered a functional hip disarticulation. Approximately one year after injury, the patient reported moderate back pain. Radiographs demonstrated a right lumbar scoliosis from T12 to L5 measuring 17°, with a 2+ Nash-Moe rotation (Fig. 2). The back pain symptoms resolved and, at the last follow-up, the patient had no back pain. He was using bilateral lower-extremity prostheses as well as bilateral cane assist during physical therapy for gait training, but mostly was using a manual wheelchair for mobility. He was able to perform independent transfers to and from the wheelchair as well as all ADLs.

Fig. 2

Anteroposterior radiograph of the spine (left) and anteroposterior radiograph of the right hip (right) of the patient in Case 2 following bilateral transfemoral amputations (with the right proximal transfemoral amputation considered a functional hip disarticulation), demonstrating a right lumbar scoliosis from T12 to L5 of 17°, with a 2+ Nash-Moe rotation.

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Discussion

Introduction | Case Reports | Discussion | References

To our knowledge, these are the first case reports of patients who developed scoliosis following combat-related hip disarticulation and hemipelvectomy. Both patients were without substantial pain or symptoms, and review of immediate postinjury images (chest and abdomen radiographs as well as chest, abdomen, and pelvic computed tomography) demonstrated no spinal trauma or previous deformity. Both patients developed similar deformities with a sharp lumbar curve and convexity on the same side as the more proximal amputation. They were both treated with observation in well-fitted prostheses (the hemipelvectomy prosthetic device incorporated a brace extending into the axillae) and continued semiannual follow-up to monitor curve progression.

The incidence and sequela of scoliosis following hip disarticulation and hemipelvectomy are not well described in the literature, and most reports concerning hemipelvectomy focus on complications such as wound complications, infection, hernia, and phantom pain^5-9. To the best of our knowledge, the development of scoliosis following upper and lower-limb amputations was first reported in the German literature in the 1970s^2,3. However, in 1978, Burke et al.¹ reported radiographic findings of the spine following lower-limb amputation in forty-two patients. They observed scoliosis in eighteen (43%) amputees and degenerative lumbar spine changes in thirty-two (76%) amputees. Other reports in the literature, particularly in rehabilitation/physiotherapy studies, have mentioned the existence of scoliosis following lower-limb amputation but have provided little relevant clinical information regarding the characteristics or treatment of the spinal deformity^10-12.

Recently, Papanastassiou et al.⁴ reported the development of scoliosis following extended hemipelvectomy in oncology patients. Eight of twelve patients died within seven months after surgery, most often because of disease progression. Six patients (three of four patients with >1-year survival) developed a scoliotic curve greater than 20°; only one patient had a symptomatic curve that required a fusion procedure. Although there was a high frequency of scoliosis development following extended hemipelvectomy, few of the long-term survivors developed a symptomatic curve that required operative treatment. Therefore, the authors recommended against routine spinal instrumentation and fusion after extended hemipelvectomy. They suggested initial treatment with observation and a well-fitted prosthesis or brace, with operative management dictated by the development of symptoms in patients with longer-term survival.

Our report of scoliosis following hemipelvectomy and hip disarticulation includes two healthy, young military service members following combat-related trauma, which makes their overall health substantially different from the oncology patients with a nearly 70% short-term mortality rate described by Papanastassiou et al.⁴. While the dichotomy in patient populations is apparent, the management of scoliosis as a sequela of hemipelvectomy has several similarities, whether the result of combat trauma or tumor resection. In particular, all hemipelvectomy patients have a high risk for wound complications and infection^4-8. While the development of symptomatic scoliosis or rapid curve progression following combat-related hemipelvectomy and hip disarticulation can warrant operative treatment, this appears to be relatively uncommon. Neither of our patients had developed symptomatic curves at their latest follow-up. Therefore, we recommend initial treatment with observation and bracing, and cannot overstate the importance of a well-fitting prosthesis¹³. It should be emphasized that the bracing is not to prevent additional scoliosis progression but to prevent sitting imbalance. We recommend meticulous socket sizing because an ill-fitting prosthesis that causes limb-length discrepancy, even with a 1-cm difference, has been shown to cause lateral tilting of the pelvis in the coronal plane, pelvic torsion in the sagittal plane, and a compensatory lumbar scoliosis with the concavity of the curve toward the side with the longer leg^10,14,15. We also design our sitting prosthetic socket with an upper trim line extended above the waist up to the axillae to act as a brace to control or prevent scoliosis^4,13. Even for patients who do not walk, we recommend a “sitting” prosthesis or brace to prevent the development of spinal deformity caused by sitting imbalance^4,13.

Treatment of the combat amputee, particularly following hip disarticulation and hemipelvectomy, requires comprehensive, multidisciplinary care to optimize patient outcomes. While our awareness of scoliosis following combat-related hip disarticulation and hemipelvectomy has increased, the prevalence and etiology of this sequela remain unknown. As previously described, functional scoliosis can develop as a result of limb-length discrepancy or sitting imbalance. However, disruption of anatomic structures can also play a substantial role, particularly with hemipelvectomy. Several authors have postulated that a greater degree of disruption or resection of anatomic structures around the lumbosacral area, such as the iliolumbar ligamentous complex or paraspinal musculature, can result in loss of spinal stability, which contributes to pelvic obliquity and scoliosis development^4,16-19. However, awareness of potential complications and sequelae will allow earlier identification and treatment, and an orthopaedic spinal surgeon should be consulted for the combat amputee if substantial back pain or spinal deformity is discovered.

References

Introduction | Case Reports | Discussion | References

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Freude AD; Scholz A. [Studies on the occurrence of scolioses following arm amputation]. Zentralbl Chir. 1972;97:300-3. German.[PubMed]

Krämer J; Heisel JM; Ullrich CH. [Late results of patients with amputation of the thigh (author's transl)]. Z Orthop Ihre Grenzgeb. 1979;117:801-7. German.[PubMed]

Papanastassiou I; Boland PJ; Boachie-Adjei O; Morris CD; Healey JH. Scoliosis after extended hemipelvectomy. Spine (Phila Pa 1976). 2010;35:E1328-33.[PubMed][CrossRef]

Baliski CR; Schachar NS; McKinnon JG; Stuart GC; Temple WJ. Hemipelvectomy: a changing perspective for a rare procedure. Can J Surg. 2004;47:99-103.[PubMed]

Rieger H; Dietl KH. Traumatic hemipelvectomy: an update. J Trauma. 1998;45:422-6.[PubMed][CrossRef]

Apffelstaedt JP; Driscoll DL; Spellman JE; Velez AF; Gibbs JF; Karakousis CP. Complications and outcome of external hemipelvectomy in the management of pelvic tumors. Ann Surg Oncol. 1996;3:304-9.[PubMed][CrossRef]

Senchenkov A; Moran SL; Petty PM; Knoetgen J 3rd; Clay RP; Bite U; Barnes SA; Sim FH. Predictors of complications and outcomes of external hemipelvectomy wounds: account of 160 consecutive cases. Ann Surg Oncol. 2008;15:355-63.[PubMed][CrossRef]

Shin KH; Rougraff BT; Simon MA. Oncologic outcomes of primary bone sarcomas of the pelvis. Clin Orthop Relat Res. 1994;304:207-17.[PubMed]

Gailey R; Allen K; Castles J; Kucharik J; Roeder M. Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. J Rehabil Res Dev. 2008;45:15-29.[PubMed][CrossRef]

Fuchs B; Yaszemski MJ; Sim FH. Combined posterior pelvis and lumbar spine resection for sarcoma. Clin Orthop Relat Res. 2002;397:12-8.[PubMed][CrossRef]

Douglass HO Jr; Razack M; Holyoke ED. Hemipelvectomy. Arch Surg. 1975;110:82-5.[PubMed][CrossRef]

Carroll K. Lower extremity socket design and suspension. Phys Med Rehabil Clin N Am. 2006;17:31-48.[PubMed][CrossRef]

Friberg O. Biomechanical significance of the correct length of lower limb prostheses: a clinical and radiological study. Prosthet Orthot Int. 1984;8:124-9.[PubMed]

Ingelmark BE; Lindstrom J. Asymmetries of the lower extremities and pelvis and their relations to lumbar scoliosis. A radiographic study. Acta Morphol Neerl Scand. 1963;5:221-34.[PubMed]

Leong JC; Luk KD; Chow DH; Woo CW. The biomechanical functions of the iliolumbar ligament in maintaining stability of the lumbosacral junction. Spine (Phila Pa 1976). 1987;12:669-74.[PubMed][CrossRef]

Yamamoto I; Panjabi MM; Oxland TR; Crisco JJ. The role of the iliolumbar ligament in the lumbosacral junction. Spine (Phila Pa 1976). 1990;15:1138-41.[PubMed][CrossRef]

Panjabi M; Abumi K; Duranceau J; Oxland T. Spinal stability and intersegmental muscle forces. A biomechanical model. Spine (Phila Pa 1976). 1989;14:194-200.[PubMed][CrossRef]

Goel VK; Kong W; Han JS; Weinstein JN; Gilbertson LG. A combined finite element and optimization investigation of lumbar spine mechanics with and without muscles. Spine (Phila Pa 1976). 1993;18:1531-41.[PubMed]

Topics

post-amputation rehabilitation ; back pain ; blast injuries ; hemipelvectomy ; lumbar vertebra ; scoliosis ; acquired scoliosis ; lower extremity amputation ; disarticulation of hip ; leg amputation

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Daniel G. Kang, MD, Ronald A. Lehman, MD, David M. Laufer, CO, Adam J. Bevevino, MD; Development of Scoliosis Following Complex Combat-Related Lower-Extremity AmputationsTwo Case Reports. JBJS Case Connector. 2012 May;2(2):e19 1-4.

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