RESPONSES: Transfemoral and THA

RESPONSES: Transfemoral and THA

Schafer, Kristin

9/29/2016

Thanks once again to the list for the many responses I’ve received. I apologize as well, since I realised after the fact that many of your responses went into my junk email and I missed them at first. I thank you again if you responded twice! Such dedicated professionals. Here are the responses detailing your previous histories with clients who have had a hip replacement on the transfemoral side. I will be sending these comments on to his surgeon as well. Very good suggestions, comments and points to ponder. -Kristin


Use inflatable AK socket from OttoB as temporary measure. As edema goes down, switch him back to his old socket or, make a new one.
Also, you can do FloTech socket with added frame and distal attachment.
Whichever way it turns, he needs to be in shrinker very moment drain is out.


Speak to the surgeon if possible and get compression on it as soon as possible if not a shrinker than ace wrap and rewrap every four to six hours, usually weight bearing is permitted right away however with the incision the dr might not let him for 2 to 4 weeks. And just make check sockets and wrap with fiberglass to reduce cost during the transition back to his old socket. Hope it helps


Pay careful attention to getting the proper length of the prosthesis as this helps reduce stress on the hips. Just make him replacement sockets as needed until the residual limb has stabilized. The adduction angle may change more increased angle usually gives more muscle control better stability medial lateral. Have regular follow up appointments to maintain proper volume as the residual limb reduces in volume recheck the length and alignment as well.
Follow all surgeon protocols.


Your post made me recall a transtibial patient I had years ago who had a joints/leather corset prosthesis. Once he had recuperated post-THA, enough to get back into his prosthesis, some interesting characteristics had snuck into his gait in the form of a whip and rotatory movements throughout swing. I attributed these to the tracking of his newly installed prosthetic hip joint. The prosthesis required some major realignment. I can't recall any transfemoral amputees post-THA that presented similarly.
Has he been told by a physician that it is definitely his hip and not referred pain from a piriformis impingement on his sciatic nerve? The latter could be treated by a good massage therapist, PT and/or chiropractor


He may need to use a temporary adjustable type, post op prosthesis until his limb stabilizes. He probably won't be able to get back in his old socket so will need a new one after stabilization.

One thing I have found that can affect the hip over time is a short TF prosthesis. People feel better with it short if they don't use stance flexion, but it can catch up in the hip, SI joint, or low back. If he is in a lot of pain, check the height. Sometimes raising it will help the pain a lot!

My humble opinions, of course. Hope it helps. Let me know what happens :)​


I’ve had two patients very similar to yours, go through this about 2 years ago. As you may know, patients are mobilized very quickly after THA and amputees are no exception. One of the two was very anxious going into this but both of them came out great very quickly. Initially there were some challenges in getting the socket to fit “perfectly” again, but this resolved within a few day. Main priorities are wearing a shrinker sock post op (within a day or two, prior to prosthesis donning). The other main challenge is keeping the hip from flexing past 90 deg, so for someone with a long limb and short arms using a pull-sock, that may be an issue. They may need some help from you or the PT to don the socket for a few days during the hip precautions.
Good luck,


I am answering this because I saw you hadn't had any responses and though my experience is not exactly what you are looking for, I thought it might help just a little? I have an AK with a same side THA. However, both occurred at the same time from the traumatic injury that caused the limb loss. I don't have any info on immediate fit after a THA, but I can tell you now, many years after his initial injury and recovery, there are no residual effects that change my prosthetic plan with him compared to any other patients and he is quite active.


OK cut your frame and Lace it you can make several cut out to where you can expand the frame our top the frame and the inner socket may need to be heated to expand this would be for a Beadiant pot postop afterwords you can document for replacement socket if needed


I have had a couple amputees ( trans femoral and trans tibial) require hip replacement over the years.
In general; the surgeon has been requesting no weight bearing for the first 8-12-16 weeks. The surgeons do prefer to have the patient in a physical therapy program for stretching and strengthening. In general; once the swelling has decreased and the site is healed AND with the approval of the physician - the amputee can start wearing their prosthesis again. We do encourage our amputees to come in and have the alignment and the fit reassessed on the prosthesis.
BTW: The same is true for the handful of trans tibial patients who have received a TKA. Almost all of these amputees have returned to their previous activities.


I would fit an endo adjustable socket AK temp with a lock knee and a SACH foot for his rehab therapy. Change or adjust the adjustable socket for volume changes and you can switch the manual lock knee to free swing for his more aggressive walking. Add an off-set plate above the knee for mechanical stability.
Patient uses that leg until limb/stump stabilizes in volume. I don't see any other way for prosthetic use.


Make something adjustable for him to get him up ASAP and expect his current socket will never fit again.

Because the femur is not bering weight the same way the bone can be osteopenic it complicates surgery and recover sometimes, but is rarely an actual problem.

Wish you well.


You are obviously a caring and wise practitioner. It speaks well of you to consult with peers prior to
an unknown situation. I hope you get more replies for comparison to this one C.P
review {based on 33+ years of active hands on practice}.

With respect, here are some thoughts on your pt's possible hip replacement and use of T.F. Prosthesis.
- He seems to be a savvy person having come to you to consult prior to the event.
- Hope you have good communications with the Surgeon - M.D. His analysis; testing & plan are paramount.
A} The Pt. has NOT been weight bearing on that Hip/Femur. He has been weight bearing on the
Pelvic contact areas of your socket. Thus, the hip deterioration
should not have come from joint pressure-grinding due to weight bearing up through
the Femoral shaft into the Acetabulum.
There may be considerable bone resorbsion over the last 30+ years. Some
ossteo-fragility is likely to be present. Reference: Wolff's Law on bone density/strength
related to stress over time.
A bone density picture/evaluation - comparing sound Femur; Neck and Head with the amputated
remaining Femur, Neck & Head might be indicated.
B} Couple that with the Femoral lever arm. The stem of the hip internal prosthesis is
Going to dramatically change the stress riser focal point along whatever Femoral shaft
is remaining. Will the Internal Hip Prosthesis stem be the same length as the amputated shaft?
C} His hx. of leading a very active lifestyle with the prosthesis. May well lead him to put high stress
along that modified Femoral shaft - in the manner he is accustomed to.
D} What is the condition of the contralateral Femoral Joint?


I think everyone including myself realizes you have a difficult case.
However I do feel it is with his current prosthesis but with informing and educating the doctor and the patient that your patient will need a temporary AK socket while he cooperates. You inquiry has stated the obvious and with a skin/suction fit there is NOTHING you can do except to do but go to a temporary socket non-suction brim. Unfortunately this will set the a patient back quite a bit. No one know what is going to happen after his surgery. They cannot expect you to do anything beyond telling them the truth. Right now I would get the doctor and the patient on the same page with your advice. AND I would find a suitable temporary socket set up to go on top of the components he is currently wearing. Sorry to give you the news. Please post your replies.


I assume this patient is ok for a a hip replacement after many years as an amputee? Assuming there may be loss of bone density through lack of loading of the femur?


Hi Kristen, have you considered trying to utilize the ossur hip brace for OA, I believe they offer a free trial, and if it works, maybe he can avoid surgery.


As a prosthetist, I have had an unusually large amount of exposure recently to hip replacements. Considering your patient's condition, I would recommend that he go with a cemented stem.
Research shows that 10% of hip replacements need revisions at 10 years. It's a big pain (is there an ICD-10 code for big pain?) for the orthopedic surgeon to pull out a cemented stem. I'm guessing they often try for a press fit if they think they will be coming back to switch it out. Cutting out a pesky stem can thin out the host femur, increasing risk of fracture.
But with the smaller forces generated by the transfemoral residual limb (30% less according to the Mayo Clinic), I believe that he will be at a much lower risk for revision.
Orthopedic aquatic rehabilitation is also a viable option for your patient. A patient had a revision for heterotopic ossification and the surgeon cleared them for aquatic walking at 2 weeks instead of 4 (chest height is approximately 75% body weight offloading).
A meta-analysis of aquatic orthopedic rehabilitation for joint replacement shows that early aquatic protocols dressing the incision site would allow aquatic ambulation at 6 days.
The water pressure will aid in reducing volume, although you will probably want to grab a belt (although you probably figured that out already).
Using socket, pylon-only, and a waterproof Avalon with articulating ankle is my preferred configuration. One of my skeptical Genium wearers was amazed how well it worked without a knee.
Motorized underwater treadmill will allow activity with symmetrical resistance. Slow walking is okay at first, but check with the surgeon because it stresses the hip extensors more to push the trunk through the water.
Another option instead of aquatic is the treadmill with the air bladder to offload weight. Just remember to adjust joint resistance for any therapy affecting the ability to flex a mechanical joint. (that comes from 20 minutes of me arguing with a patient before the lightbulb went off in my mind).

Frankly, there hasn't been a lot of major innovation in hip implants. In a recent (2014-ish?) article at www.fiercemedicaldevices.com< <URL Redacted>> that shows that in just one year, the prices of hip prostheses dropped 16% and it was directly attributed to lack of recent innovation.

Hope this was helpful!





Kristin Schafer, B.Sc.(Kin), CP(c)
Certified Prosthetist
Health Sciences North
Rehabilitation Engineering
41 Ramsey Lake
Sudbury, ON
P3E 5J1
P: 705-523-7100 x3176
F: 705-523-7051

Health Sciences North's vision is to be globally recognized for patient-centred innovation.
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