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A Case Report of Nerve Damage and Knee Extensor Weakness as a Result of a TKA

A Case Report of Nerve Damage and Knee Extensor Weakness as a Result of a TKA. Robert Whittaker, SPT University of North Dakota. Patient Presentation. 49 y.o . female with (L) TKA in 2009 who suffered a fibular nerve palsy as well as having the quads “shut down”

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A Case Report of Nerve Damage and Knee Extensor Weakness as a Result of a TKA

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  1. A Case Report of Nerve Damage and Knee Extensor Weakness as a Result of a TKA Robert Whittaker, SPT University of North Dakota

  2. Patient Presentation • 49 y.o. female with (L) TKA in 2009 who suffered a fibular nerve palsy as well as having the quads “shut down” • Patient evaluated on 10/20/13 for posterior knee pain & discharged on 12/9/13 for a total of 5 visits. • Patient private pay & had 20 independent visits to clinic gym • Pt. instructed on home NMES use & to use clinic’s gym to recumbent bike, leg press/extension/curls with emphasis on eccentric contraction for duration of rehab. • Pt. progressed from lacking 50° of AROM (L) knee extension to lacking ~35° with some improvement in pain. • Referred to physician for genetic testing for nerve disease & nerve conduction test of femoral nerve (HNPP?). Pt. stated she was looking into getting a knee brace.

  3. Clinical Decision Making

  4. Patient Care • Accept • Familiar with TKAs and protocols, treatment appropriate for pt. to regain strength • Skills to improve quadriceps weakness, seen multiple TKAs in clinicals • Direct • Goals, extent of condition, patients availability, handling techniques • Indirect • Private pay, travel in winter, can do HEP, pain, past therapy, PMH, life • Refer • Refer back to MD eventually from little progress

  5. History • Patient is full time homemaker (military wife?) • C/O constant (L) posterior knee pain 5/10 • Patient has to lift her leg into car and leg gives out often • Pain and weakness in left leg cause her to ambulate with SPC • (R) knee pain secondary to DJD and hasn’t walked well for years • Pt. wore an AFO to ambulate after TKA but no longer wears • Also has neck & low back pain due to bulging discs • Indicated she has diabetes, thyroid trouble, arthritis, sleeping problems, frequent headaches, & degenerative joint disease for many years • Many imaging studies (none available)

  6. Pain Drawing

  7. History Cont’d • Medications: Aspirin (81mg), Inderal (120mg), Janumet XR-50/100xz), Lipitor (20mg), Lisinopril (40mg), Omeprazole (20mg), Synthroid (50mcg), Topamax (100mg), Zyrtec (10mg) • Allergy Meds: Penicillin, Ampicillin, Bactrim, Celocin, Feldene, Zomig • Family history: Her father had a myocardial infarction (MI) as well as COPD. Her mother has prediabetes. Both her parents have high blood pressure.

  8. Past Medical History • Cholecystectomy (1991) • (L) Carpal Tunnel release (1998), (R) release (1999) • 2008 • Cortisone Shots (March & July) • Arthroscopy & meniscectomy (June) • Arthroscopy, chondroplasty, partial meniscectomy (Dec) • 2009 • Orthovisc and cortisone shots (Jan-Sep) • TKA (Oct) with fibular nerve palsey knee manipulation (Dec) • PT – ionto, e-stim, strength (Nov – May 2010) • 2010 • EMG Nerve Study on Fibular/Femoral Nerve (June) • LLE Inching study fibular nerve (Oct) • 2011 • Fibular nerve release, knee manipulation (may) • More PT (14 sessions for IT band and fibular nerve pain) (Oct) • 2012 • More PT (12 sessions for fibular nerve and posterior knee pain) (Feb) • EMG nerve study (Nov) • 2013 • Epidural steroid injection (Jan)

  9. Examination – Systems Review • Initial Eval (10/20) • Weight 190lbs, 61.5” (BMI 36) • Mature scaring on anterior knee from TKA, posterolateral knee from fibular nerve release, small scars on wrists from carpal tunnel releases • AROM: (L) knee ext -50° sitting. (L) ankle AROM appears to be WFL • PROM: 110° (L) knee flexion, 0° (L) knee. • Strength: 4/5 (L) knee flexion, 2/5 (L) knee extension • 11/15 • AROM: -35° left knee ext • Discharge (12/14) • AROM: -38° left knee ext. PROM (L) ankle DF 7° • Strength: Hip flexion 4/5 (B), (R) ER 3/5 (pain felt in her knee when resisted), (L) ER 4/5, (R) IR 5/5, (L) IR 3/5 (pain felt on lateral knee), and 4/5 for (L) hip abd/add/ext. (L) ankle eversion 3/5 (pain in lateral knee), 4/5 DF/PF/INV. • Palpation: (L) vastuslateralis, lateral gastrocnemius head, and distal biceps femoris were tender to palpation • RHR 60 BPM, BP 124/76, SaO2 98%. • Dermatomes L1-L3 feel same (B), L4-S2 diminished sensation to touch on (L) compared to (R) • Reflexes: (R) L3 & S1 normal, (L) L3 & S1 diminished • Special Test: (+) varus stress test

  10. Trigger Points13

  11. Rigor – Assessment8 • Varus Stress Test18 • 20-30° Flexion: LCL, posterolateral capsule, arcuate-poplitus complex, ITB, biceps femoris tendon • Extension: fibular or lateral collateral ligament, arcuate-popliteus complex, biceps femoris tendon, PCL, ACL, lateral gastrocnemius muscle, ITB • Article: investigated reliability of multiple knee clinical tests in CE, EUA, and by comparing to arthroscopic techniques • 6 (+) in CE, 10 (+) EUA (p=0.0277, Wilcoxon) • Limited to collateral ligament tear: 4 subjects, 1 instability found in CE and 3 EUA • Sensitivity = 25%, Specificity not reported

  12. ICF Model

  13. ICF Model Cont’d • Health Condition • (L) Dysfunctional Quadriceps, (L) fibular nerve dysfunction, (R) knee DJD • Body Structures/Function (impairments) • ROM: (L) knee ext -50° sitting. PROM: 110° (L) knee flexion, 0° (L) knee. (L) ankle AROM appears to be WFL. *(L) ankle DF PROM 7° • Strength: 4/5 (L) knee flexion, 2/5 (L) knee extension. *Hip flexion 4/5 (B), (R) ER 3/5 (pain felt in her knee when resisted), (L) ER 4/5, (R) IR 5/5, (L) IR 3/5 (pain felt on lateral knee), and 4/5 for (L) hip abd/add/ext. (L) ankle eversion 3/5 (pain in lateral knee), 4/5 DF/PF/INV. • *Dermatomes L1-L3 feel same (B), but L4-S2 diminished sensation to touch on (L) compared to right • *Reflexes: (R) L3 & S1 normal, (L) L3 & S1diminished • Posterior (R) knee pain (5/10) • *Vastuslateralis, lateral gastrocnemius head, and distal biceps femoris were tender to palpation – guarding/trigger points? • *Laxity in lateral knee • Excessive BMI • Scars

  14. ICF Model Cont’d • Activities • Ambulates independently with SPC • Can transfer into/out of car with difficulty • Participation • No mention of being able to not participate in what she desires • If health condition not addressed may possibly lead to further deterioration in QOL  need for assistive equipment, TKA revision/other knee, amputation from diabetes? • Contextual • Personal Factors (internal) • motivated to get better, pessimistic, pain in other knee/neck/back • Environmental Factor (external) • Husband/family?, home, weather

  15. Evaluation • Initial Evaluation • The patient presents with (L) knee weakness with decreased PROM/AROM with increased pain with motion. The patient’s functional mobility is decreased and will be instructed on a gym program and how to operate a home NMES unit to improve quadriceps activation and knee functionality. • Reevaluation • The patient has not gained quadriceps strength like expected. Patient has laxity with varus stress test and is being referred back to MD.

  16. Diagnosis5 • Pattern 5F: impaired peripheral nerve integrity and muscle performance associate with peripheral nerve injury • She was diagnosed with left weakness and dysfunctions S/P a left TKA with DJD in her right knee. • ICD-9-CM Codes • 728.87 - muscle weakness-general • 719.4 - joint pain-lower leg

  17. Prognosis & POC • STG • To be independent with HEP • To have EMG/NCV results by next visit • LTG • Independent with gym exercise program in 4 weeks • To improve knee extension to be -20° in 4-6 weeks • Patient Goals • Walk without use of assistive device • Be completely pain free • POC • Patient will be seen once/week for 6 weeks and be independent in a gym exercise program ASAP due to being Private Pay • Prognosis5 • Patient will demonstrate optimal peripheral nerve integrity and muscle performance over the course of 4-8 months • Expected range of visits 12-56

  18. Rigor – Intervention14 • Article: Review of 4 recent RCTs since 2009 • Initiation: 2 days post-op, sooner the better! • Volume: 30 minutes to 4 hours per day • Intensity: The higher the better, methods to make pt. comfortable! • Adjust to supervised PT: combined modalities may possibly increase improvements • Home unit available to decrease costs of PT • Home exercises and free gym access while a patient.

  19. Patient Education • Content: Demonstrated, 1 on 1, pamphlet (NMES), flow sheet, written instructions • Pt. instructed on NMES by demonstrating to pt. how to set it up, having the pt. repeat it, and providing written instructions & the pamphlet. Pt’s. concerned addressed at additional visits. • Pt. instructed on setting up recumbent bike & using clinic’s equipment with appropriate settings with demonstration & return demo (pt. able to ask available PT if confusion arises) • Pt. needed additional help 1 time with knee flexion machine. • General anatomy/physiology of condition • POC and to maintain the lowest cost • Barriers • Pt. wears glasses • Somewhat quiet (pessimistic?)

  20. Patient Education • Learning type: did not address patients type (maybe reflective observation?) • SPT learning style: Accommodator • Cognitive Domain (facts) – recall exercise prescription from flow sheet, where to place electrodes (parameters on HEP), setting up equipment, comparing past PT, establish why exercises were prescribed, plan • Affective (attitude) – listening to instruction, participating/informed consent, going through HEP independently, resolve confusing equipment • Psychomotor (skills) – observing our demonstration, return demonstrating, practice HEP independently after learning and perfecting it • Documentation: use of NMES on location setting and duration and time/day, exercises with times on pt. flow sheet • No weight/duration in computer documentation for resistance

  21. Strengths & Limitations to Pt. Education • Strengths: available to help if confused with equipment, provided instructions to HEP with demo/return demo • Weaknesses: Small hand writing (make more legible!), was all of pt’s. concerns addressed?, no written instructions for D/C?

  22. Evaluating Clinical Change • Goals • STG: Pt. to be independent with HEP at next visit (C, EF) • Following PT intervention, the pt. will be independent with a HEP and familiar with clinic gym equipment as pt. is private pay and would like to minimize cost. • LTG: To improve (R) knee extension AROM to -20° in 4-6 weeks (A, C, EF) • Following PT intervention, the pt. will improve (R) knee extension AROM in sitting to -20° to be able to transfer into a car more efficiently. • Functional Assessment • Not performed but would have wanted to use The Knee Outcome Survey Activities of Daily Living • Estimated evaluation score – 27/70 = 38.6% • Estimated discharge score – 28/70 = 40%

  23. Knee Outcome Survey ADLs1 • 2 Parts to Questionnaire – 14 total questions (also 11 question sport questionnaire) • Symptoms (6 Questions) – Pain, stiffness, swelling, giving way/buckling/shifting of knee, weakness, limping • No symptoms (5), symptoms but: does not effect activity (4), slightly affects (3), moderately affects (2), severely effects (1), unable (0) • Function – walk, ascending stairs, descending stairs, stand, kneel on front of your knee, squat, sit with knee bent, rise from chair • Activity not difficult (5), minimally difficult (4), somewhat difficult (3), fairly difficult (2), very difficult (1), unable to do (0)

  24. Knee Outcome Survey ADLs10 • Low SEM (but not the lowest) • 73% of subjects score above MDC • Large ESand ESSEM (4-5x SEM – indicative of sensitivity) • Smaller ceiling effect compared to other functional assessments • Missing data? – bad translation

  25. Values Little treatment time as possible

  26. Johari Window

  27. Force Field Analysis – Improved ROM • Driving Forces • Motivated to be normal • Doesn’t want to use SPC • Free gym use • Not a busy schedule/free time? • Improve function for family? • Therapy instructions/help • Restraining Forces • Weakness • Pain • $$$ • Weather (winter) • Slow progress  Doubt • Comorbidities (diabetes, back/neck pain bulge) • Anatomical/Physiological knowledge • LTG: To improve (R) knee extension AROM to -20° in 4-6 weeks – not met

  28. Ethical Issues • Private pay – distress • Solutions – expensive vs. least expensive • Least expensive as pt. does not have the financial resources for extensive PT • Pain through exercise– issue • Solutions – modalities vs. informed consent vs. referral • Informed consent as pt. would have to pay additional for modalities, eventual referral • Code of ethics 1, 2, 3, 5, 6 • Respect, trustworthy, accountable for judgment, legal/professional obligation, enhance expertise • RIPS

  29. Evidence Based Practice20 • Functional exercises/outpatient rehabilitation better resultscompared to traditional/home therapy • Benefits did not persist to 12 months • Short term rehabilitation focusing on functional exercises!

  30. Cost/benefit analysis • Patient Private Pay Out of Pocket • PTC charges $25/unit (code 00050) • Gym free to use during business hours for current patients - $20/mo 1 month after D/C • Potential Costs? • Commuting • TKA revision/other knee? • Conduction/genetic testing • MD visits • Role in society – pt. homemaker and has been living with this condition, overall unchanged • Fair service – I believe I would have been satisfied as I’ve seen 2 units cost ~$100 instead

  31. Outcome • So far the patient has gained about 15° of knee extension since initial visit and feels she has improved since starting. • She has been discharged for now until she gets further testing done on her femoral nerve function to see if she has potential for more rehabilitation. • She mentioned she is talking with her physician about doing just a bicompartmental partial knee replacement in her right knee to help with pain, but is very hesitant in doing so after her current TKA dysfunction. • Patient working with MD to get genetic testing for HNPP • May return to therapy if potential for further gains • Looking into brace to provide knee stability preventing joint stress

  32. Reflection • Examination • Did a full evaluation right away • Provided functional assessment to evaluate how the patient perceives change • Mapped out dermatones – diabetic education? • Gathered postop reports • Biofeedback? • POC • Provided more functional exercises & adjust NMES volume • Use pain modalities – Pro bono?

  33. References • Knee outcome survey activities of daily living scale (ADLS). http://www.ptbyart.com/media/file/341881/Knee%20Outcome%20Survey2%20RETYPED.pdf. Accessed March 19, 2014. • Guide to physical therapy practice. 2nd ed. APTA; 2003. • BaxL, Staes F, Verhagen A. Does neuromuscular electrical stimulation strengthen the quadriceps femoris? A systematic review of randomised controlled trials. Sports Med. 2005;35(3):191-212. • Cameron MH. Physical agents in rehabilitation: From research to practice. Elsevier/Saunders; 2012. • Clarke JV, Wilson WT, Wearing SC, Picard F, Riches PE, Deakin AH. Standardising the clinical assessment of coronal knee laxity. ProcInstMechEng H. 2012;226(9):699-708. • Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function: International knee documentation committee (IKDC) subjective knee evaluation form, knee injury and osteoarthritis outcome score (KOOS), knee injury and osteoarthritis outcome score physical function short form (KOOS-PS), knee outcome survey activities of daily living scale (KOS-ADL), lysholm knee scoring scale, oxford knee score (OKS), western ontario and McMaster universities osteoarthritis index (WOMAC), activity rating scale (ARS), and tegner activity score (TAS). Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S208-28. doi: 10.1002/acr.20632; 10.1002/acr.20632. • DelportH, Labey L, De Corte R, Innocenti B, Vander Sloten J, Bellemans J. Collateral ligament strains during knee joint laxity evaluation before and after TKA. ClinBiomech (Bristol, Avon). 2013;28(7):777-782. doi: 10.1016/j.clinbiomech.2013.06.006; 10.1016/j.clinbiomech.2013.06.006. • HarilainenA, Myllynen P, Rauste J, Silvennoinen E. Diagnosis of acute knee ligament injuries: The value of stress radiography compared with clinical examination, stability under anaesthesia and arthroscopic or operative findings. Ann ChirGynaecol. 1986;75(1):37-43. • HarilainenA. Evaluation of knee instability in acute ligamentous injuries. Ann ChirGynaecol. 1987;76(5):269-273. • ImpellizzeriFM, Mannion AF, Leunig M, Bizzini M, Naal FD. Comparison of the reliability, responsiveness, and construct validity of 4 different questionnaires for evaluating outcomes after total knee arthroplasty. J Arthroplasty. 2011;26(6):861-869. doi: 10.1016/j.arth.2010.07.027; 10.1016/j.arth.2010.07.027. • Keeney JA, Eunice S, Pashos G, Wright RW, Clohisy JC. What is the evidence for total knee arthroplasty in young patients?: A systematic review of the literature. ClinOrthopRelat Res. 2011;469(2):574-583. doi: 10.1007/s11999-010-1536-9; 10.1007/s11999-010-1536-9. • Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: A systematic review. J Orthop Sports PhysTher. 2010;40(7):383-391. doi: 10.2519/jospt.2010.3184; 10.2519/jospt.2010.3184.

  34. References • KisnerC, Colby LA. Therapeutic exercise: Foundations and techniques. F a Davis Company; 2007. • KittelsonAJ, Stackhouse SK, Stevens-Lapsley JE. Neuromuscular electrical stimulation after total joint arthroplasty: A critical review of recent controlled studies. Eur J PhysRehabil Med. 2013. • Koehler PJ. Hereditary neuropathy with liability to pressure palsies: The first publication (1947). Neurology. 2003;60(7):1211-1213. • Levine M, McElroy K, Stakich V, Cicco J. Comparing conventional physical therapy rehabilitation with neuromuscular electrical stimulation after TKA. Orthopedics. 2013;36(3):e319-24. doi: 10.3928/01477447-20130222-20; 10.3928/01477447-20130222-20. • LosinaE, Walensky RP, Kessler CL, et al. Cost-effectiveness of total knee arthroplasty in the united states: Patient risk and hospital volume. Arch Intern Med. 2009;169(12):1113-21; discussion 1121-2. doi: 10.1001/archinternmed.2009.136; 10.1001/archinternmed.2009.136. • Magee DJ. Orthopedic physical assessment. Elsevier Health Sciences; 2007. • MalangaGA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: A review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehabil. 2003;84(4):592-603. doi: 10.1053/apmr.2003.50026. • MinnsLowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: Systematic review and meta-analysis of randomised controlled trials. BMJ. 2007;335(7624):812. doi: 10.1136/bmj.39311.460093.BE. • MiznerRL, Petterson SC, Stevens JE, Vandenborne K, Snyder-Mackler L. Early quadriceps strength loss after total knee arthroplasty. the contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg Am. 2005;87(5):1047-1053. doi: 10.2106/JBJS.D.01992. • OdumSM, Springer BD, Dennos AC, Fehring TK. National obesity trends in total knee arthroplasty. J Arthroplasty. 2013;28(8 Suppl):148-151. doi: 10.1016/j.arth.2013.02.036; 10.1016/j.arth.2013.02.036. • PettersonS, Snyder-Mackler L. The use of neuromuscular electrical stimulation to improve activation deficits in a patient with chronic quadriceps strength impairments following total knee arthroplasty. J Orthop Sports PhysTher. 2006;36(9):678-685. doi: 10.2519/jospt.2006.2305. • RasenbergEI, Lemmens JA, van Kampen A, et al. Grading medial collateral ligament injury: Comparison of MR imaging and instrumented valgus-varus laxity test-device. A prospective double-blind patient study. Eur J Radiol. 1995;21(1):18-24. • Sharma L, Song J, Dunlop D, et al. Varusand valgus alignment and incident and progressive knee osteoarthritis. Ann Rheum Dis. 2010;69(11):1940-1945. doi: 10.1136/ard.2010.129742; 10.1136/ard.2010.129742. • Singh JA, Lewallen DG. Diabetes: A risk factor for poor functional outcome after total knee arthroplasty. PLoS One. 2013;8(11):e78991. doi: 10.1371/journal.pone.0078991; 10.1371/journal.pone.0078991. • ZywielMG, Mont MA, McGrath MS, Ulrich SD, Bonutti PM, Bhave A. Peroneal nerve dysfunction after total knee arthroplasty: Characterization and treatment. J Arthroplasty. 2011;26(3):379-385. doi: 10.1016/j.arth.2010.03.020; 10.1016/j.arth.2010.03.020.

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