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

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

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

3. 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

4. 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

5. 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

6. 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.H’s family

7. 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

8. 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)

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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)

21. SatPro and activities score

24. 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

25. 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