Proximal femur fractures present a significant surgical challenge, especially in patients with fused hip and spine conditions. These cases demand a highly specialized approach, taking into consideration the complexities of the patient’s overall health and skeletal structure. In this blog, we explore the unique intricacies of a recent case and discuss the strategies employed to manage these complexities.
Case Overview
Our patient, a 52-year-old female, presented with a proximal femur fracture. She had a medical history of ankylosing spondylitis and was on HCQ (hydroxychloroquine) and SAAZ (sulfasalazine) for her condition. Additionally, she was diabetic, though her condition was well-controlled. With a severe kyphotic deformity due to her ankylosed spine and hip, her physical movement had been severely restricted prior to the injury. Following a fall, her mobility was further compromised.
Unique Challenges in This Case
- Ankylosed Spine and Severe Kyphosis: This patient’s spine had undergone significant kyphotic changes due to ankylosing spondylitis, which led to difficulties in anesthesia administration. The cervical, thoracic, and lumbar spine were fused, making intubation and ventilation extremely difficult during surgery.
- Compromised Cardiac Function: With an ejection fraction (EF) of 45%, her cardiac health further complicated the decision-making process.
- Chest and Respiratory Limitations: Due to restricted chest expansion, the patient was deemed unfit for general anesthesia, complicating the surgical plan further.
Surgical Approach
Given the patient’s fragile condition, the surgical team was faced with a critical decision—whether to opt for a staged procedure or a single-stage intervention. After careful deliberation, it was determined that a single-stage approach involving fixation and replacement would offer the best outcome.
- Anesthesia Management: Given the fused spine and ligamentous ossification, a combination of pelvic and sacral block, along with Total Intravenous Anesthesia (TIVA), was chosen to avoid the complications of general anesthesia. This decision was pivotal in reducing the risks associated with intubation and ventilation.
Postoperative Care and Outcomes
The surgery was a success, despite the difficulties posed by the patient’s anatomical and medical conditions. Postoperative care focused on maintaining mobility, managing her underlying diabetes, and ensuring effective respiratory support. The case highlights the importance of tailored surgical strategies and multidisciplinary teamwork in managing complex fractures in patients with comorbidities like ankylosing spondylitis.
Conclusion
Managing proximal femur fractures in patients with ankylosed hips and spines requires a detailed understanding of both the orthopedic and anesthetic challenges. In this case, the combined expertise of orthopedic surgery and anesthesia allowed for a successful outcome despite significant challenges. For patients with complex conditions, personalized surgical strategies are critical to ensuring both the short-term success of the surgery and the long-term mobility of the patient.