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Association between amputation, arthritis and osteopenia in British male war veterans with major lower limb amputations

Department of Rehabilitation, University Hospital of South Manchester, Manchester, UK

Judith Adams

Department of Diagnostic Radiology, University of Manchester, UK

Elaine Thomas

Alan Silman

ARC Epidemiology Research Unit, University of Manchester, UK

Objectives: To investigate the association between amputation, osteoarthritis and osteopenia in male war veterans with major lower limb amputations. Specific questions were to determine whether lower limb amputees following trauma are at subsequent risk of developing osteoarthritis (OA) and osteoporosis of the hip on both the amputated and nonamputated sides.

Design: Retrospective cohort study in British Male Second World War veterans with major unilateral lower limb amputations.

Subjects: Seventy-five male Second World War veterans with major lower limb amputations known to be alive were invited to participate from a subregional rehabilitation centre. After exclusions, 44 agreed to attend for examination and radiological screening.

Methods: The presence of hip OA was determined from a single anterior posterior pelvic X-ray using two approaches: minimum joint space and the Kellgren and Lawrence (K&L) scoring system. Bone mineral density (BMD) was measured by a dual energy X-ray absorptiometry (DXA) scan and prosthetic rehabilitation outcome measures were recorded.

Results: Twenty-seven (61%) hips on the amputated side and 10 (23%) on the nonamputated side were positive for OA (based on Kellgren and Lawrence grade of >2). Using a minimum joint space threshold of below 2.5 mm, 24 (55%) hips on the amputation side and 8 (18%) on the nonamputated side were also positive for OA. There was a threefold increased risk of OA for those with above-knee compared to a below-knee amputation. By contrast from published general population surveys, only 4 (11%) cases of hip OA would have been expected on both the amputated and nonamputated hips.

There was a significant decrease in femoral neck BMD in the amputated side (p< 0.0001) and significantly lower BMD in above-knee amputees than in below-knee amputees (p = 0.0027) as compared to normal age- and sexmatched population.

Conclusion: Male war veterans with unilateral major lower limb amputations develop significantly more osteoarthritis of the hip than expected on both ipsi- and contralateral sides. Amputation was also associated with loss of bone density. Above-knee amputees develop significantly more hip osteoarthritis and osteopenia of greater severity in the amputated side than below-knee amputees

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