Introduction: Due to abnormal gait patterns in patients with lower extremity amputation (LEA), it has been hypothesized that this population experiences early onset of osteoarthritis (OA) of sound side limb causing pain and impaired function which may lead to surgical intervention.
Purpose: The purpose of this case report is to present a transfemoral LEA who received sound limb total knee arthroplasty (TKA). Just prior to and immediately following surgery, there is a time period where a person with LEA can experience a decrease in physical functional performance and become dependent on assistance for daily activities. Case
Description: The patient was a 56-year-old male who contracted necrotizing fasciitis in the right knee that resulted in a transfemoral LEA three years later. The onset of OA of the sound side knee was due to abnormal gait patterns and increased stresses. A TKA was performed to improve function and decrease pain. The Continuous Scale-Physical Functional Performance-10 (CS-PFP-10) test consists of 10 standardized daily living tasks that evaluate overall physical functional performance and performance in five individual functional domains: upper body strength (UBS), upper body flexibility (UBF), lower body strength (LBS), balance and coordination (BAL), and endurance (END). Physical Functional Performance (PFP) Total and individual domain scores of 0-47 indicates: Increased likelihood of functional dependence. Scores of 48-56 indicates: Likely at risk of losing independence, while scores of 57-100 indicate: Independent function likely.
Outcomes: CS-PFP-10 test was administered one week preoperative as well as one, three, six and twelve-month post-operative TKA. The patient received skilled physical therapy and progressed to a supervised wellness program focusing on strength, balance, coordination and endurance. The skilled physical therapy lasted six months and supervised wellness up to one-year post surgery. One week preoperatively, three of five domains were at Increased likelihood of functional dependence, while two domains and PFP total were scored at the low end of at risk of losing independence. Following the one year of skilled physical therapy and supervised wellness program, all five domain scores as well as the total score were at the 70-95 range.
Discussion: Due to the abnormal stresses placed on the sound limb during gait activities, a patient with a transfemoral amputation may develop early onset sound side OA. There is a dearth of evidence on unilateral LEA confounded by sound side TKA. There is a need for research in this population due to an increase in unilateral LEA and the need to develop a standard of care for optimal outcomes. A motivated patient with a LEA and sound side TKA can benefit from skilled physical therapy in terms of potentially attaining maximal functional independence with ADLs. Physical therapy should focus on rehabilitation for the TKA, but also must incorporate core strengthening, balance, coordination and endurance in order to improve physical functional performance to maintain independence. Introduction In the United States (U.S.), there are approximately 185,000 lower extremity amputations (LEA) per year, and in 2009 associated healthcare costs were over $8.3 billion.1,2 Amputations occur in patients with diabetes, vascular disease, trauma, cancer, congenital disorders, and infections.3 Angoules et al.4 reviewed 10 studies encompassing 451 patients, they examined the incidence of amputation following necrotizing fasciitis. The authors found that 22.3% of patients underwent limb amputation after failed attempts to control infection and avoid limb loss.4 Patients with LEA experience secondary impairments of osteoarthritis (OA) of the sound side limb.5,6 In unilateral LEA,7 it is important to recognize early onset OA and how function could improve with surgical intervention. OA is a chronic and degenerative synovial joint condition, primarily affecting articular cartilage. Late stage OA presents with persistent pain, which can be immobilizing.8 Abnormal gait patterns and joint mechanics, and lack of prosthetic confidence increases risk for knee OA in LEA patients.5,6 Dynamic analysis of transfemoral amputation (TFA) gait demonstrated decreased gait speed, cadence, and stride length, and increased stance phase on sound limb.9 New prosthetic technology has been developed to address unequal weight bearing through extremities in LEA to help prevent contralateral knee OA.10 However, not all patients have access to this technology. Similarly, rehabilitation access may also be disparate leading to highly individualized courses of prosthetic care, rehabilitation and outcomes. This case presents increased scores in Continuous Scale Physical Functional Performance Test (CS-PFP 10 Test) in a TFA patient with contralateral TKA following standard physical therapy (PT) interventions supplemented by high intensity, whole body strength training
