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 GoalsRehabilitation Current status Current goals

3. Background 2 nd year student at Sydney Uni 2 nd year student at Sydney Uni Presented to A & E at RPAH on 5/10/04 with: Presented to A & E at RPAH on 5/10/04 with: Rash Rash Increased thirst Increased thirst Feeling extremely unwell Feeling extremely unwell Diagnosed with meningococcal septicaemia Diagnosed with meningococcal septicaemia Intubated and ventilated within 0.5 hours Intubated and ventilated within 0.5 hours

4. Spent 15 days in ICU at RPAH Spent 15 days in ICU at RPAH Transferred to Concord Hospital ICU/burns unit Transferred to Concord Hospital ICU/burns unit Multiple surgeries (skin grafts/debridements), currently: Multiple surgeries (skin grafts/debridements), currently: R TTA, without a patella or patella tendon R TTA, without a patella or patella tendon L TRA L TRA R TMCAs – incision between 1 st and 2 nd MC to write R TMCAs – incision between 1 st and 2 nd MC to write Osteomyelitis of L ankle Osteomyelitis of L ankle Spent 9 months in hospital Spent 9 months in hospital d/c in July ‘05 d/c in July ‘05

5. Prosthetics On discharge from Concord Hospital: On discharge from Concord Hospital: R thigh-lacer with locking knee R thigh-lacer with locking knee sensor below elbow sensor below elbow Rigid AFO for L ankle Rigid AFO for L ankle As above at 12/5/06 As above at 12/5/06 July ’06: 3/12 trial of E-knee July ’06: 3/12 trial of E-knee If measurable improvement with E-knee, then ALS would fund E-knee for subsequent prostheses 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 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 3 letters from Dr Hawthorne (rehab specialist) to the discretionary committee Lobbying from S.H’s family Lobbying from S.H’s family

7. Dr Hawthorne and Judy Davidson approached Becker Orthopaedic representative at ISPO Dr Hawthorne and Judy Davidson approached Becker Orthopaedic representative at ISPO ALS and Becker Orthopaedic rep agreed on 3/12 trial ALS and Becker Orthopaedic rep agreed on 3/12 trial Cost of E-knee $12,000 Cost of E-knee $12,000

8. E-knee Pressure sensor in heel of foot (like foil) Pressure sensor in heel of foot (like foil) When pressure through heel, knee will lock When pressure through heel, knee will lock Unlocks when no pressure through heel Unlocks when no pressure through heel 3 LEDs for locking, no lights when un-locked 3 LEDs for locking, no lights when un-locked Locked position is the “off” position Locked position is the “off” position Safety, if battery fails knee will not give way Safety, if battery fails knee will not give way Can check battery charge by flicking a switch (3 lights full, 1 light low) Can check battery charge by flicking a switch (3 lights full, 1 light low)

9. Problems Pain Pain Ankle 2° to osteomyelitis (bone fragments still come out of ankle) Ankle 2° to osteomyelitis (bone fragments still come out of ankle) LBP LBP Meds: gabapentin, tramal, endone Meds: gabapentin, tramal, endone Gait Gait Trunk SF in R stance Trunk SF in R stance Increased R step length Increased R step length Increased pelvic rotation Increased pelvic rotation L knee hyperextension L knee hyperextension

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

11. Goals: Goals: Increased walking speed Increased walking speed Independent in stair ascent (step over) and descent Independent in stair ascent (step over) and descent Independent up and down curbs Independent up and down curbs → so that ALS would fund E-knee prosthesis Improve fitness Improve fitness Decrease in LBP during gait Decrease in LBP during gait

12. Rehabilitation strategies LBP LBP Hip ext in prone (2 pillows under abdomen) Hip ext in prone (2 pillows under abdomen) Arm ext in prone Arm ext in prone Hip bridging on fit ball (feet on ball and trunk on ball), then lifting a foot up 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) Lateral pelvic shift (glut med) SLS SLS SLS with swing leg on small ball (progressed to basketball) 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) 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 a bag with 2-4kgs and large fit ball → carrying textbooks caused incr trunk SF Fitness Fitness Stationary cycle (8.5 min = 2km) Stationary cycle (8.5 min = 2km) Walking carrying a large swiss ball Walking carrying a large swiss ball

15. Steps/gutter practice Steps/gutter practice Stepping onto with R and over with L, with 8cm and progressed to 12.5cm Stepping onto with R and over with L, with 8cm and progressed to 12.5cm Stair ascent without ULs Stair ascent without ULs Stair descent (recently) step over step Stair descent (recently) step over step Thus far has managed 10 steps with SBA Thus far has managed 10 steps with SBA Abdominal muscles (pt request) Abdominal muscles (pt request) situps situps Kicking a small soccer ball (novelty and pt used to play soccer) Kicking a small soccer ball (novelty and pt used to play soccer)

16. 12/5/06 Lock knee 27/7/06E-knee24/10/06E-knee TUAG20.78.86.8 10m15.96.56.1 stair ascent stair descent 253015208.515 6 min walk 193331430

21. SatPro and activities score Lock-knee(12/5/06)E-knee(24/10/06) SatPro (best score 15) 35/6022/60 BasicAdvancedTotal22/2812/2834/5628/2825/2853/56

24. Current Goals Swimming – going to QLD in Dec Swimming – going to QLD in Dec Increase fitness further Increase fitness further Step over gait in descending stairs Step over gait in descending stairs Walking on uneven surfaces Walking on uneven surfaces Getting off the floor Getting off the floor

25. Treatment plans Theraband Xs for ULs on fit ball Theraband Xs for ULs on fit ball Supine bridging Supine bridging Prone trunk ext with arm ext Prone trunk ext with arm ext Stair descent practice Stair descent practice Incr stationary cycle time to 15 min, and incr resistance from 4Nm to 8Nm Incr stationary cycle time to 15 min, and incr resistance from 4Nm to 8Nm Pec deck Pec deck Scapula retraction/rowing with theraband Scapula retraction/rowing with theraband