oandp.com

I am hoping my prosthetic colleagues will offer input regarding an
unusual inquiry from an orthotic patient of mine. The patient is
considering elective bilateral knee disarticulation or above knee
amputations so that he might remain a pain-free community ambulator.

D.P. is a 60 year old post-polio patient, having contracted the disease
at the age of 11 months old. At age 12 he had a triple arthrodesis on his
left ankle, bilateral heel cord lengthening procedures, and a lateral
hamstring to quad tendon transfer at the right knee. On the right side,
hip flexors are absent though extension is good/normal; quad function is
2/5 (only because of lateral hamstring transfer. Right ankle plantar
flexion is 4/5, with dorsiflexion 3-4/5. On the left side, hip flexion and
extension are both good/normal; quad activity is trace only. Left
hamstrings are normal. No left ankle plantar or dorsiflexion. To
complicate matters somewhat, as a result of compound midshaft left femur
fracture and tibia/fibula fractures just distal to the knee (suffered in an
auto accident at the age of 17 years), there is an 8 degree knee flexion
deformity and 18 degree internal rotation deformity of the tibia. Also of
note, due to decades of using axillary crutches and in spite of several
rotator cuff injuries resulting from falls on slippery surfaces while using
the crutches, his overall shoulder strength is very good.

D.P. is community ambulatory with two wooden axillary crutches, he is
employed in health care, and his responsibilities (and leisure activities)
require him to stand approximately 50% of a typical day. Although being a
bit overweight, he is otherwise in excellent overall health, and, possibly
equally importantly, is very highly motivated to remain as active as
possible. For about 11 years, he had worn a left metal leather double
upright AFO with a dorsiflexion stop ankle hinge, which functioned well to
assist in knee extension, but did not protect the knee during falls which
resulted in some instability in the joint. Since the age of about 20, he
had worn no orthoses on the right leg and relied on recurvatum to maintain
knee stability.

When D.P. initially came to my office two years ago, his chief complaint
was progressive internal knee/popliteal fossa pain and progression of genu
recurvatum deformity of the right knee. We fabricated a metal & leather
custom knee orthosis with offset knee joints for the right side, but
deterioration of the knee joint has continued. In late 2010, the inability
to maintain full extension of the left knee while ambulating began
resulting in an overuse syndrome in the left shoulder, with pain and
limitation of range of motion. To relieve the left shoulder of some of
it's weight-bearing function, we fabricated a stance control KAFO for the
left leg, which has worked quite well (aside from his concern about the
clicking sound at terminal knee extension as the knee joint locks).

The normal aging process and, shoulder injuries, combined with years
of heavy dependence on crutches, has taken its toll on both shoulders. In
order to remain ambulatory over the coming years, he feels he must become
less dependent on his crutches. D.P. has severe degenerative right knee
arthritis and his pain is as a result of weight through the joint rather
than any particular movement, other than hyperextension. His orthopedic
surgeon has offered a total knee replacement but, with all things
considered, significantly less than a 50% likelihood of a good outcome (a
stable pain free leg).

D.P. wishes to continue working at least 8-9 more years, hopefully
followed by further years of more leisurely activity (he is a hobby
woodworker). He would particularly like to be able to ambulate in more
normal fashion, becoming less dependent upon crutches. He is hopeful that
knee disarticulation or above knee amputations and prostheses will improve
his gait and eliminate his pain. He envisions prostheses that include
servo-controlled knee and ankle joints powered by batteries housed in the
lower leg segments of the prostheses.



My questions to all of you are:

1. Do you feel his goals are reasonable?

2. Has anyone worked with patients that have made this choice, if so would
they be willing to share their story with my patient?

3. Which would be better, above knee amputation or knee disarticulation
amputation?
4. What type of components might be utilized?

Thank you in advance for your expert opinions.
Steve Williams C.O.
Flint, MI