Case Presentation: Ms S.H. and E-knee

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Case PresentationMs S.H. and E-knee
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Outline

• Background on Ms S.H.
• E-knee
• Video of lock knee vs E-knee
• Goals
• Rehabilitation
• Current status
• Current goals

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Background

• 2nd year student at Sydney Uni
• Presented to A E at RPAH on 5/10/04 with
• Rash
• Increased thirst
• Feeling extremely unwell
• Diagnosed with meningococcal septicaemia
• Intubated and ventilated within 0.5 hours

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• Spent 15 days in ICU at RPAH
• Transferred to Concord Hospital ICU/burns unit
• Multiple surgeries (skin grafts/debridements),
  currently
• R TTA, without a patella or patella tendon
• L TRA
• R TMCAs incision between 1st and 2nd MC to
  write
• Osteomyelitis of L ankle
• Spent 9 months in hospital
• d/c in July 05

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Prosthetics

• On discharge from Concord Hospital
• R thigh-lacer with locking knee
• sensor below elbow
• Rigid AFO for L ankle
• As above at 12/5/06
• July 06 3/12 trial of E-knee
• If measurable improvement with E-knee, then ALS
  would fund E-knee for subsequent prostheses

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Trial of E-Knee

• Frank Li (Burns physio at Concord) found the
  E-knee, manufactured by Becker Orthopaedics on
  the internet
• 3 letters from Dr Hawthorne (rehab specialist) to
  the discretionary committee
• Lobbying from S.Hs family

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• Dr Hawthorne and Judy Davidson approached Becker
  Orthopaedic representative at ISPO
• ALS and Becker Orthopaedic rep agreed on 3/12
  trial
• Cost of E-knee 12,000

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E-knee

• Pressure sensor in heel of foot (like foil)
• When pressure through heel, knee will lock
• Unlocks when no pressure through heel
• 3 LEDs for locking, no lights when un-locked
• Locked position is the off position
• Safety, if battery fails knee will not give way
• Can check battery charge by flicking a switch (3
  lights full, 1 light low)

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Problems

• Pain
• Ankle 2 to osteomyelitis (bone fragments still
  come out of ankle)
• LBP
• Meds gabapentin, tramal, endone
• Gait
• Trunk SF in R stance
• Increased R step length
• Increased pelvic rotation
• L knee hyperextension

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• Weakness
• Glut max
• Glut med
• Poor control of L quads
• Lumbar ext and transverse abdominus

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• Goals
• Increased walking speed
• Independent in stair ascent (step over) and
  descent
• Independent up and down curbs
• ? so that ALS would fund E-knee prosthesis
• Improve fitness
• Decrease in LBP during gait

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Rehabilitation strategies

• LBP
• Hip ext in prone (2 pillows under abdomen)
• Arm ext in prone
• Hip bridging on fit ball (feet on ball and trunk
  on ball), then lifting a foot up
• ? increase back ext endurance

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• Lateral pelvic shift (glut med)
• SLS
• SLS with swing leg on small ball (progressed to
  basketball)
• ? small movements of leg on ball, causes
  contralateral activation of glut med

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• Walking with small fit ball (progressed to medium
  then large ball)
• ? moving the ball to ipsilateral stance leg
  causes trunk rotation, therefore more difficult
  to SF trunk
• Carrying a bag with 2-4kgs and large fit ball
• ? carrying textbooks caused incr trunk SF
• Fitness
• Stationary cycle (8.5 min 2km)
• Walking carrying a large swiss ball

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• Steps/gutter practice
• Stepping onto with R and over with L, with 8cm
  and progressed to 12.5cm
• Stair ascent without ULs
• Stair descent (recently) step over step
• Thus far has managed 10 steps with SBA
• Abdominal muscles (pt request)
• situps
• Kicking a small soccer ball (novelty and pt used
  to play soccer)

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12/5/06 Lock knee 27/7/06 E-knee 24/10/06 E-knee
TUAG 20.7 8.8 6.8
10m 15.9 6.5 6.1
stair ascent stair descent 25 30 15 20 8.5 15
6 min walk 193 331 430
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SatPro and activities score
Lock-knee (12/5/06) E-knee (24/10/06)
SatPro (best score 15) 35/60 22/60
Basic Advanced Total 22/28 12/28 34/56 28/28 25/28 53/56
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Current Goals

• Swimming going to QLD in Dec
• Increase fitness further
• Step over gait in descending stairs
• Walking on uneven surfaces
• Getting off the floor

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Treatment plans

• Theraband Xs for ULs on fit ball
• Supine bridging
• Prone trunk ext with arm ext
• Stair descent practice
• Incr stationary cycle time to 15 min, and incr
  resistance from 4Nm to 8Nm
• Pec deck
• Scapula retraction/rowing with theraband