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 Table of Contents 
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 5  |  Page : 2492-2495  

Functional ambulation with bent knee prostheses for an adult with bilateral 90 degrees knee flexion contractures—A case report


1 PhD Scholar, College of Physiotherapy, Sumandeep Vidyapeeth, Piparia, Waghodia, India
2 Principal, College of Physiotherapy, Sumandeep Vidyapeeth, Piparia, Waghodia, India
3 Medical officer, Rehabs Clinic, Opp. Baroda High School, Vadodara, Gujarat, India

Date of Submission21-Nov-2019
Date of Decision05-Dec-2019
Date of Acceptance20-Dec-2019
Date of Web Publication31-May-2020

Correspondence Address:
Dr. Lata D Parmar
Principal, College of Physiotherapy, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara . 391 760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1043_19

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  Abstract 


An adult male who never stood, ambulating on all four due to bilateral severe knee flexion contractures, since his childhood, was 21 years of age, and not deterred by his condition, was pursuing his higher education. He was coaxed by his friends to seek medical opinion and it was decided to give a trial and let the client have a feel of bipedal stance and ambulation. Although there is a paucity of recent evidence on the use of bent knee prosthesis, the trial successfully restored the dignity.

Keywords: Ambulation, bent knee prosthesis, knee flexion contractures, management, physiotherapy


How to cite this article:
Shandilya VK, Parmar LD, Shandilya AV. Functional ambulation with bent knee prostheses for an adult with bilateral 90 degrees knee flexion contractures—A case report. J Family Med Prim Care 2020;9:2492-5

How to cite this URL:
Shandilya VK, Parmar LD, Shandilya AV. Functional ambulation with bent knee prostheses for an adult with bilateral 90 degrees knee flexion contractures—A case report. J Family Med Prim Care [serial online] 2020 [cited 2020 Sep 23];9:2492-5. Available from: http://www.jfmpc.com/text.asp?2020/9/5/2492/285055




  Introduction Top


The knee flexion contractures of more than 80°–90° are not frequently seen and, when seen, pose a major challenge due to reported unsatisfactory results of insufficient correction, skin necrosis, neurovascular problems, leg-length discrepancy, posterior subluxation, and recurrence of the deformity[1],[2],[3],[4],[5]

The restriction of range of motion (ROM) due to contractures impacts negatively the ability to perform activities independently leading to disability and participation restriction.[2],[4],[6] The etiology of these flexion contractures is very complex and multifactorial.[2],[3],[4],[5],[6],[7]

More than 400 different conditions have been classified as arthrogryposis multiplex congenita with multiple joint contractures with etiology of fetal akinesia, earlier the onset severe the contractures.[6]

For ambulation, one requires the feet to be plantigrade, stability is when the hips are contained and the knees are free. More than 10–15° knee flexion contracture is said to hinder walking.[8] Cases with multiple joint contractures require early intervention by physiotherapy, manipulations, and orthotics within hours after birth. Later serial casts and multiple surgeries may be necessary.[8]

Primary care physicians are in a position to advocate for early diagnosis, also effectively counsel, educate such patients and their families and guide appropriately.

Prosthetic fittings are known to successfully return cases of lower limb amputations to functional ambulation. However, in cases of below-knee amputations with complications of flexion contractures and fixed deformities, alternatives such as revision of stump is more preferred but in certain cases with coexisting comorbidities, ambulation may be maintained by the use of “bent knee prosthesis (BKP).”

The BKP treats the patient as a case of knee disarticulation/above knee amputation, the person essentially rests his weight on the bent knee and the weight is distributed to the anterior proximal tibia, the patella tendon, patella, and the thigh corset. The residual limb is forced posterior. This makes the lower thigh look bulkier forcing alterations in the costume worn.[2],[3],[4] The external knee joints are essential to provide sitting.[9],[10],[11]

Ideally, the adult with fixed bilateral knee flexion contracture would benefit from surgical above-knee amputation to attain effective ambulation provided the hip is functionally good. This case report describes prosthetic management of bilateral knee flexion contractures to restore the dignity, providing bipedal stance, and ambulation to the client who was resistant to any surgical intervention.


  Case Report Top


A male of 21 years of age, who never stood, belonging to low socioeconomic status, was intelligent man, with good communication skills. He was not deterred by his impairment and had pursued his education and at this point of time when he was coaxed by his friends for consultation, was pursuing a diploma in Information and Technology Engineering. He was counseled that surgical intervention (bilateral knee disarticulation) might be able to give him effective bipedal status.

The possibility that above-knee amputation/knee disarticulation will allow this patient to ambulate with prosthesis effectively, but his apprehension due to unfavorable experiences in childhood and as he was almost convinced that he would never walk, he hesitated to undergo any kind of surgery. Therefore, he was examined in details and the conservative trial was given.


  Examination Top


  • The patient had fixed flexion deformities of 90° of both the knees with further flexion full [Picture 1]; both legs grossly wasted with nonfunctional severely deformed feet, supinated, almost fully rotated. Left foot has three toes.[video 1]


  • Apparently rudimentary feet never borne weight [Picture 2].
  • Bilateral hips are free of contractures, X-ray of pelvis showed both hips contained [[Picture 3]×-ray]
  • He was capable of standing on knees with support. His hip musculature had atrophy but muscle strength—functional.
  • His upper limbs and trunk were functionally good ambulating on all fours, unable to stand with/without support.



At this point conservative/surgical methods of releasing contractures etc., would not only fail but lead to frustration, therefore, try to make him bipedal, make him stand and walk with customized prostheses with modified sockets, with Velcro strap suspension to brace his limbs, with his existing condition. This was necessary to assure him that he could stand, so as to restore his faith.


  Management Top


The patient was measured and cast with full flexion of knee and hip in extension (fully bend the knee). Inner ethylene vinyl acetate (EVA) foam liner socket with polymer-draped socket assembled on the newly designed, economically viable prosthetic knee joints (“Safe Gait” indigenously made), which has optional locking system for assured stability, extended universal 30 mm Pylon attached to the solid ankle, cushioned heel (SACH) feet. [[Picture 4], [Picture 5] of BKP]. Optional lock/unlock at will was the need to make him stable at the initial phase of weight-bearing with gait training.



He could stand without any discomfort on his own with prosthetic legs with support immediately on the first trial. He required 2 weeks’ physiotherapy sessions and gait training, progressing from parallel bars, eventually to elbow crutch and then independent walking [Picture 6] and [Picture 7] [Video 2].









  Result Top


The patient is now independent for more than a year, taking up a job and comfortable with BKP throughout the day. Training for free knee gait is on.


  Conclusion Top


The BKP successfully restored the dignity of the patient also it is hoped that the patient now will be able to take favorable steps independently.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
HeQ, Xiao L, Ma J, Zhao G. A case report of successful treatment of 90° knee flexion contracture in a patient with adult-onset Still's disease. BMC Surg 2016;16:1-4.  Back to cited text no. 1
    
2.
Badawi Ihab. Ilizarov treatment of severe type I fixed flexion deformities of the knee joint. Egypt Orthop J 2018, 53:21-5.  Back to cited text no. 2
    
3.
Gomes JLE, Leie MA, de Freitas Soares A, Ferrari MB, Sánchez G. Posterior capsulotomy of the knee: Treatment of minimal knee extension deficit. Arthrosc Techn 2017;6:e1535-9.  Back to cited text no. 3
    
4.
Malinowski K, Góralczyk A, Hermanowicz K, LaPrade RF, Więcek R, Domżalski ME. Arthroscopic complete posterior capsulotomy for knee flexion contracture. Arthrosc Tech 2018;7:e1135-9.  Back to cited text no. 4
    
5.
Salam A, Islam MA, Khan MZ, Sharif MS, Milon MH, Khan MA, et al. Total knee arthroplasty in patients with fixed flexion deformity. KYAMC J 2018;8:2-7.  Back to cited text no. 5
    
6.
Wong K, Trudel G, Laneuville O. Noninflammatory Joint contractures arising from immobility: Animal models to future treatments. Biomed Res Int 2015;2015:1-6. Article ID 848290. doi: 10.1155/2015/848290.  Back to cited text no. 6
    
7.
Ghazali MF, Abd Razak NA, Abu Osman NA, Gholizadeh H. Effect of stump flexion contracture with and without prosthetic alignment intervention towards postural stability among transtibial prosthesis users. IOP Conf Ser Mater Sci Eng 2017;210:012002.  Back to cited text no. 7
    
8.
Pontén E. Management of the knees in arthrogryposis. J Child Orthop 2015;9:465-72.  Back to cited text no. 8
    
9.
Pennell CR, Mayfield GW. Bent knee pylon for B K amputee. Phys Ther 1972;52:1051-5.  Back to cited text no. 9
    
10.
Hays RD, Leimkuehler JP, Miknevich MA, Troyer D. An alternative bent-knee prosthesis. Arch Phys Med Rehahil 1992;73:1118-21.  Back to cited text no. 10
    
11.
Bannister PJ. The prosthetic problems of below knee amputees with flexion contractures. Aust J Physiother 1978;24;21-5.  Back to cited text no. 11
    




 

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  In this article
   Abstract
  Introduction
  Case Report
  Examination
  Management
  Result
  Conclusion
   References

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