Rehab Challenge

Corresponding Author:

A 36-year-old right-handed male patient, non-diabetic, normotensive, euthyroid of lower socioeconomic status presented in Physical Medicine and Rehabilitation (PMandR) Outpatient Department (OPD) of our institute with right transfemoral amputation and inability to walk. He had multiple fractures of both lower limbs following road traffic accident (RTA) 4 months ago. He was treated in orthopedics by knee sparring external fixation in the right lower limb (Fig. 1) and above-knee amputation in the left lower limb (Fig. 2). Postoperatively, he had complete healing of the wound on the amputated side except for some residual limb pain and tenderness over the right knee and shinbone with restricted range of motion (ROM) of the right knee.

On examination, he is fully oriented, conscious, and cooperative. He had left middle transfemoral amputation with a conical stump and poor soft tissue cover distally. The ROM and power are normal. He also had diffuse scar tenderness on the same side. Tinnel sign positive over medial one-third of the scar and distally. On the right side, restriction in flexion right knee (0°–40°). Power around the hip in right side 4/5, right knee—3/5 in available ROM. Right ankle dorsiflexors—2/5, plantarflexors—5/5, extensors hallucis longus—1/5 on manual muscle testing (MMT) (Fig. 3).

The patient is presently managed conservatively with strengthening exercise for the stump, desensitization technique, crutch muscle training, quadriceps, and core muscle strengthening on the right side. Electrical stimulation to quadriceps and ankle dorsiflexion of the right side.

We have planned left side exoskeletal transfemoral prosthesis with an ischial containment socket with a single-axis knee joint and solid ankle cushioned heel (SACH) foot for him. But the problem is that he had knee stiffness and foot drop and toe drag on the non-amputated side with weakness around the knee. The patient wants to be fully independent in his activities of daily living (ADL). Please opine about a proper orthosis for the right side so that he can have a near-normal gait with proper ground clearance.

Fig. 1: X-ray showing knee sparing external fixation in the right lower limb

Fig. 2: Above-knee amputation of lower limb

Fig. 3: Right knee stiffness, with foot drop and toe drop

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