OPTIMIZING FUNCTIONAL RECOVERY POST ABOVE-KNEE AMPUTATION: A

CASE REPORT
Anushka Biyani1, Tejaswini Fating2
1
UG Scholar, Department of Community Health, Ravi Nair Physiotherapy College, Datta
Meghe Institute of higher education and research Sawangi, Wardha, India (442001)
anushkabiyani5@gmail.com
2
Assistant professor, Department of Community Health Physiotherapy, Ravi Nair
Physiotherapy College, Datta Meghe Institute of Higher Education and Research Sawangi,
Wardha, India (442001)
tejaswinifating1997@gmail.com

Abstract: This case study deals with the holistic physiotherapy care of a 61-year-old male
patient suffering from a displaced distal tibia and fibula fracture of the right side, a car
accident caused by a fractured talus, and an above-knee amputation because of serious
infection. The primary objectives of rehabilitation for this patient were improving muscle
strength, relief of phantom limb pain, prevention of complications, maintenance of range of
motion, improvement in endurance, and encouragement of functional independence during
the postoperative period. An intensive physiotherapy program of four weeks was part of the
rehabilitation protocol. The regimen involved a range of interventions, including pain
management, oedema control, wound healing techniques, range of motion exercises, muscle
strengthening activities, mobility and transfer exercises, cardiovascular endurance training,
psychosocial support, education on prosthetic use, and independence in daily living activities.
The patient's improvement was assessed by range of motion measures, manual muscle
testing, and Functional Independence Measure (FIM) scores. Conclusion Statistics from the
two coupled states showed that the patient's physical health and functional independence
improved significantly. The patient's range of motion, muscle strength, and the overall
functional independence all improved after receiving treatment. The study highlights the
positive impacts of physical therapy interventions on a patient's quality of life, mobility, and
self-sufficiency as observed following the amputation and subsequent recovery period. These
findings support the patient's transition to a more self-sufficient and active lifestyle by
providing valuable insights into the efficient use of physiotherapy in the comprehensive post-
amputation treatment plan.
Keywords: Knee amputation, displaced distal tibia, fibula, talus fracture, rehabilitation

INTRODUCTION
Amputation is the surgical removal of all or part of a body part, for example, an arm or limb.
It is often differentiated from disarticulation, where a part is removed through a joint [1] [2].
The code numbers of the WHO classification system, ICD, were used to extract four groups
of aetiology: vascular insufficiency, diabetes mellitus, malignant neoplasia, and trauma. The
objective was to study the association between etiology, the cause of amputation, and level of
amputation: foot, below-knee, through-knee, above-knee, and hip. During the course of the
study, fewer individuals with and without diabetes mellitus were subjected to amputations
resulting from vascular insufficiency. The number of amputations resulting from road traffic
accidents and tumors seemed to be consistent [3]. The most common causes of hospital
admissions are fractures to the proximal tibia and fibula. A study states that around 78% of all
fractures are due to road traffic accidents (RTAs), and 42% of these are motorcyclists [4]. The
number of amputations for vascular insufficiency, both with and without diabetes mellitus, at
proximal levels above the knee and in the trauma, group was much lower. There was no
discernible shift in the amputation of tumours [5]. The distribution of the etiological
components level showed a distinctive pattern for each cause and for each amputation level
[6]. Amputations per year were between 14 and 32, with a mean of 21.6. The most
amputations occurred in 2003. The age range of the patients was between 3 and 73 years with
a mean of 39.26 ± 12.6 years. Male patients were 172 (79.62%), and female patients were 44
(20.37%) [7]. Among the lower limb amputations, about 27 percent are an above-knee
amputation. Although amputations can occur in any age group, they are more common in
those 65 and older [8]. Above-the-knee amputations involve cutting through the femoral bone
and thigh tissue to remove the limb from the body. Many conditions may require this surgery,
including trauma, infection, tumors, and vascular impairment [8]. Amputations of the lower
limb account for 94.8% of all amputations, whereas amputations of the upper limb account
for just 5.2%. The former is far more prevalent than the latter. The most common type of
lower limb amputation is below the knee, and above the knee comes second. 4% of people
worldwide live in developing nations, whereas 7% live in developed nations. In India, in
2001, the figure of having some form of disability was at 2.1–3.0% in the general population.
Reports for amputation cause vary with every country. Factors that influence major
amputation causes of different countries involve the industrialized level of those countries,
medical care service systems, and even transportation structures. For above and below-knee
amputation: PPI in 77% [9]. Diabetes mellitus, peripheral vascular disease, neuropathy, and
trauma are the commonest causes of amputation. The soft tissue vitality that has been used
for the acquisition of bone covering is what determines the amount of amputation [10] [11].
Physiotherapy treatment to an amputee is what gives them an upper hand to improvement in
quality life[12]. Phantom limb pain affects 50% to 85% of amputees. It has been found that
mirror therapy is an effective treatment for phantom limb pain [13] [14]. Once a patient with
an amputated lower limb is admitted to the hospital for acute care, physical therapy begins.
Physiotherapists instruct newly amputated patients on performing different transfers and
using a wheelchair and other assistive mobility devices such as crutches and walkers [15].
Every amputee desires to live a mobile and independent life. Most major lower-limb
amputations are carried out for peripheral vascular disease, particularly in the elderly, and
additional underlying medical diseases and social status with substantial accompanying artery
disease will further deteriorate the state of treatment problems. Besides all these adjustments
when using a prosthetic, such an amputee also requires a great sense of adjusting themselves
to the concept of a fundamentally changed perception concerning their body in general,
especially in cases approaching the emotions about the death of a love one. Hence, the patient
already has enough problems without having to deal with additional technical complications
from the amputation [16] [17].
Case presentation
Patient information
A 61-year-old man reported pain in the right-sided leg (amputated) for the last 1 month and
decreased Upper Limb Mobility for the past 4 days. He was all right a month ago when he
had road traffic accident (RTA) on 17/11/24 where he was hit by a vehicle from the rear.
Injuries included his right leg and shoulder with severe blood loss. A relative brought him to
the casualty, where certain investigations revealed comminuted fracture of the tibia and
fibula. The same was operated. He later complained of pus drainage over the operated part,
which indicated severe infection, and managed with above-knee amputation. The patient was
then referred for further physiotherapy management on 22/11/24.

Clinical findings: The patient's built was ectomorphic. The patient was conscious,
cooperative, and obeyed commands. The patient was examined lying down on the
examination couch to keep the patient's both Anterior Superior Iliac Spine aligned. The left
hip was aligned to extension. The patient's knee was flexed, and the patient's ankle was
aligned in a plantigrade fashion. On inspection, there were some bandages applied over the
right thigh. The skin covering the region was tensed in the patient's right leg. There was a
diffuse swelling over the proximal half of the left leg and knee. On palpation, tenderness was
present in grade 2 patient complains of pain and winces The length of the bandage is 15 cm.
On examination, superficial, deep, and cortical sensations above the level of amputation are
intact. The hip range of motion is evaluated with a goniometer, and the results are shown in
Table 1. Manual muscle testing was performed using a modified research council scale, and
the results appear in Table 2.

HIP Right left

flexion 20 60
extension 10 20
adduction 10 20
abduction 20 30
Table 1.
HIP Right left
flexors 2/5 3/5
extensors 2/5 3/5
Adductors 2/5 3/5
abductors 2/5 3/5
Table 2.
Clinical investigations
X-ray was done, which revealed a right-sided displaced distal tibia and fibula fracture in the
leg and a talus fracture at the foot. X-ray findings are shown in Figures 1 and 2.
Figure1. preoperative Xray showing distal tibia fibula fracture

Fig 2. Preoperative Xray showing talus fracture at the foot

Treatment
Medical treatment
Under general anaesthesia, the patient was positioned supine on the operating table. The right
lower limb was cleaned, painted, and draped following meticulous aseptic protocols. Upon
examination, severe contamination was evident in the wound on the right leg, with degloved
skin and foreign objects such as grass and wooden sticks removed. A thorough wash with 6
litres of normal saline was administered. Exposed bone with severe contamination at the
distal tibia. Of note, there was a clear separation of the distal tibia's anterior cortex from the
surrounding soft tissue. Arteries, vessels, and nerves remained intact despite the presence of
considerable contamination. All necrotic tissue was debrided, and the wound edges were
refreshed. Meticulous washes with betadine, hydrogen peroxide, and normal saline were then
performed. Reduction was done with care, under traction and manipulation with Carm's
fixation subsequently confirmed under Carm. For the injury stability, stay sutures were
applied and Schanz pins were inserted- one from medial to lateral in the calcaneum and the
other in the anteromedial aspect of the shaft of the proximal tibia, at a distance of 5 cm from
each other. These pins were joined with rods by using pin-to-rod clamps. Connecting rods
were used to connect the proximal tibia pins to pins bilaterally positioned on either side of the
calcaneum, using pin-to-rod clamps. An external fixator applied included the delta fixator.
The stability of the construct was minutely checked and satisfactory. The wound was further
curetted, and necrotic edges refreshed before a thorough wash with a solution of betadine and
normal saline was administered. Post-operatively x-ray was done as shown in figure 3 & 4.

Figure 3 Post operative Xray of leg Figure 4. Postoperative Xray of foot

Given that an infection spread occurred in the right leg bones, the patient had to be
preoperatively scheduled for an amputation of above the knee level. The procedure was done
via an above knee amputation from the right side with the patient resting supine in the
operating bed, under spinal anaesthesia using strict aseptic precaution rules. The preparation,
cleaning and painting, of the right lower limb, preceded by the establishment of a complete
sterile field are done. A circumferential fish-mouth incision was created, approximately 12
centimetres above the knee. All soft tissue dimensions of the amputation site were dissected.
The quadriceps muscle group was transected and haemostasis ensured. From the anterior
approach of the distal thigh, a bone dissection was conducted. During the dissection, the
sciatic nerve and femoral vessels were identified on the posteromedial aspect of the distal
femur. The sciatic nerve was gently retracted, ligated (tied off), and cut to ensure proper
management. Subsequently, the femoral vessels were also ligated and cauterized to prevent
bleeding. Using a bone saw, the femur was divided anteriorly to posteriorly, thus severing the
distal part amputated distally. Smoothed cut ends of the distal femur were taken to form the
stump. More shaping of the stump was attained through myogenesis, including all the
muscles found in the groups of hamstring, adductor, and quadriceps. Thorough cleansing of
the surgical area was done, and stay sutures were placed for optimal wound closure. The
wound was dressed sterilely, and crepe bandaging was applied. X-ray was done post-

operatively, as shown in Figure.

Figure 5. Xray of above knee amputation
Physiotherapy management
In inpatient care, a four-week protocol was made with each session 60, twice daily, with
appropriate rest intervals. The outcome measures were recorded before and after the
completion of treatment. The treatment protocol is elicited in Table 3

Table 3. Treatment protocol

Goals Interventions Dosage

To educate patient about the  Patient Education Before treatment
condition and physiotherapy
management.
To reduce pain and control  RICE PROTOCOL 2-3 times a day,
edema  Elevation of the
residual limb
 Compression
bandaging
 Manual lymphatic
drainage (MLD)
Wound Healing  IRR As per wound condition, 2-3
 Wound inspection times a week
and scar.
 Scar massage and
desensitization
To prevent chest  Deep breathing 10 reps. 1 set
complications exercises
 Thoracic expansion
exercises

To prevent contracture  Stretching

 Promote prone lying
for 20 mins to
prevent flexion
contracture
To restore Range of Motion  Passive and active 2-3 times a day, 10reps.1set
(ROM) ROM exercises for
bilateral hip joint and
left knee joint
To increase strength of  Isometric exercises 3-4 times a week,
muscles for residual limb 10reps.1set
muscles
 Progressive
resistance training
 Theraband exercises
For strengthening of upper  Strengthening of 10 reps .1set
limb muscles upper limb muscles
using 1kg of weight
cuff.
To improve Balance and  Balance exercises on 3-4 times a week, 20-30
Coordination stable and unstable minutes/session
surfaces
 Proprioceptive
training
 Gait training with
assistive device
walker.
Mobility and Transfers  Bed mobility Daily, progressively
exercises increasing duration
 Transfer training
(bed to chair, chair to
 toilet)
 Ambulation with
assistive device:
walker
Psychosocial Support and  Counselling and Regular sessions based on
Education emotional support patient needs
 Peer support groups
 Education on
prosthetic use and
maintenance
Independence in Activities  Training in self-care Integrated into daily therapy
of Daily Living (ADLs) activities (dressing, sessions
bathing, grooming)
 Adaptive equipment
assessment and
training
 Home modification
recommendations

Outcome measures
Range of Pre-treatment Post-treatment
motion
Hip joint Right Left Right Left
Flexion 30 60 50 80
Extension 15 20 20 30
Adduction 10 20 25 40
Abduction 25 30 45 50
Table 4. Improvement in ROM before and after the treatment
Manual muscle Pre-treatment Post-treatment
testing
Hip joint Right Left Right Left
Flexors 2/5 3/5 3/5 4/5
Extensors 2/5 3/5 3/5 4/5
Adductors 2/5 3/5 3/5 4/5
Abductors 2/5 3/5 3/5 4/5
Table 5. Improvement in MMT before and after the treatment

Functional independence Pre-treatment Post-treatment

measure
Score 33/126 80/126
Table 6. Functional independence measure scale
The data presented in Tables 4, 5, and 6 give insight into the progress after the individualised
rehabilitation programme, indicating maximum improvement in both the patient's physical
health status and functional mobility. Prior to treatment, hip joint ROMs were significantly
limited for both hips to 20 degrees in the right one and 60 degrees on the left one. Post-
treatment, there was significant improvement, with the right hip flexing to 50 degrees and the
left hip improving dramatically to 80 degrees. Extension, adduction, and abduction also
showed significant improvements, which highlighted the success of the intervention. MMT
scores indicated the strength of the hip joint muscles, with pre-treatment scores showing
limited muscle function at 2/5 for flexors, extensors, adductors, and abductors. After the
treatment, these scores improved significantly to 3/5 for the right hip and 4/5 for the left hip,
which underlined the significant strengthening.
In addition to this, he was assessed by a Functional Independence Measure (FIM) scale
whose score increased tremendously from 33 before treatment up to 80 after treatment,
indicating a much-improved functional independence. This overall improvement in self-
sufficiency and mobility reveals the holistic gains of the rehab program on her overall
mobility level. The data would indicate the successful intervention and also the remarkable
recovery of the patient, which stresses the success of the therapeutic method in improving the
quality of life and functional abilities of an individual.

Discussion: In this case, the patient had developed an infection in the bone of the right leg as
a complication of a right-sided displaced distal tibia and fibula fracture in the leg and a talus
fracture at the foot as a result of knee amputation was performed. We designed a
physiotherapy program in which we focused on increasing muscular strength, reducing
phantom limb pain, preventing complications, and maintaining range of motion, endurance,
and functional independence in the postoperative period. Following an amputation, balance
and posture training are vital in helping the amputee to regain their independence. A lot of
studies have been conducted to find new advancements in these conditions. In 2012, research
was conducted to find out the impact of video games on balance training during rehabilitation
in children and adolescents with lower limb amputations. The result was promising but the
long-term implications were partially evident [18]. In our case, we trained the gait and
balance of the patient using traditional physiotherapy methods, which enhanced their total
functional independence. A study in the year 2007 reported that short, strenuous physical
rehabilitation therapy enhances velocity of walking along with other physical functions [19].
As enhancement of the independence of the total patient was also our main purpose, the
balancing and gait training was taken after the implantation of prosthetic. Analysis of the
recent literature published in 2018 concluded that utilization of physiotherapy had favorable
effects on the functional status. In research, a proper prosthesis and early physiotherapy
rehabilitation considerably improve functional results. Results included lower energy
consumption, improved balance, and normalization of gait patterns [20]. In this case, there
was a remarkable improvement in the patient's functional activity. He became more confident
as well
Conclusion: From the statistics, functional independence and the patient's overall health
status have significantly improved. Post-treatment, there is evidence that functional
independence has been regained regarding muscular strength and range of movement. The
article points out how the patient's mobility, independance, and lifestyle quality following
amputation and treatment were improved as a re sult of the interventions taken by the
physiotherapist. These results help transition the patient into a more independent and active
lifestyle by providing insightful information about the effective integration of physiotherapy
in the treatment of post-amputation using the multidisciplinary approach.
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