International Medical Journal Vol. 24, No. 4, pp.

1 - 2 , August 2017 1
CASE REPORT

Improvement of Knee Flexion Deformity in Transtibial

Prosthesis User: A Case Report

Muhammad Hafiz1), Nur Karyatee Kassim2), Chung Tze Yang3)

ABSTRACT
Objective: This is a case illustration of improvement of knee flexion deformity in a left transtibial prosthesis user. We
describe in detail the events of this case management and outcome.
Method: We report a case of a gentleman, a hospital attendant, who had underwent left transtibial amputation secondary to
diabetic foot ulceration in January 2013, which prior to his prosthesis fitting in May 2013 was complicated with left knee flexion
deformity with popliteal angle of 30°. Nevertheless, he was able to wear his prosthesis without any accommodation to his defor-
mity and able to return to work. During his clinic follow up 6 months later, we noted improvement of his knee flexion deformity.
Conclusion: This article illustrates another probable benefit of prosthesis usage in transtibial amputees with knee flexion
deformity.

KEY WORDS
knee flexion deformity, transtibial prosthesis user, transtibial amputees

INTRODUCTION CASE PRESENTATION

The joint nearest to an amputation site is at risk of developing con-
tractures if full range of motion is not initiated early in the postoperative
phase1). Contractures most often occur as a result of range of motion
restriction as the patient want the remaining limb in a comfortable
flexed position. If this contracture occurs in the lower limb amputees, it
will interfere with proper prosthetic gait and increase the energy
requirements of ambulation.
Transtibial amputees, especially those with a short tibial segment,
are prone to develop knee flexion contractures in the first or second
week postoperatively2). A study by Van Valzen et al3). concluded that
early fitting by using rigid dressing as early as after the operation in the
operation theatre, is the treatment of choice to prevent knee fixed flex-
ion deformity. Hence, a circumferential rigid dressing of Plaster of Paris
or fiberglass with the knee in full extension is advised until the wound
heals sufficiently to allow the removal of sutures. The patella should be
well padded to prevent pressure necrosis of the pre patellar skin.
Severe knee fixed flexion contractures are difficult to reduce by
exercise alone once they become fixed2). Furthermore, if the deformity
angle is more than 15°, gait kinematics will be disturbed and will later
lead to quadriceps fatigue and anterior knee pain4) This will then causes
reduction in patient's endurance. Occasionally, moderate knee contrac-
ture (less than 15° contracture) in a proximal-third amputation may be
improved by fitting a prosthesis with the foot in slight equinus to pro-
vide a knee extension moment on foot contact2).
A 54 year old gentleman came had a premorbid history of type 2
diabetes mellitus, hypertension and dyslipidemia. He works as a hospi-
tal attendant, and his job require him to walk a lot around the hospital.
He sustained an ulcer 2 years ago to his left foot secondary to hitting a
hard object and his wound recovery was complicated with poor wound
healing and infection. His wound was later progressed to gangrene and
thus need to undergo below knee amputation to prevent worsening.
Although reluctant at first, he later complied to the doctor's advice.
He underwent left transtibial amputation successfully but post oper-
atively was noted to have depression and refused to do rehabilitation
therapy. On further questioning, his behavior was due to his fear of
inability to return to work with his current condition. He was counseled
and given time to get over his grief. He was discharged after few days
and was given outpatient physiotherapy session and clinic appointment.
He had tolerable phantom sensation and the wound healed well.
Six weeks post amputation, he came to his outpatient amputee clinic
and was noted to have better motivation to participate in his therapy and
willing to learn to walk with a prosthesis. Unfortunately at that time,
examination of his knee showed left knee flexion deformity with popli-
teal angle of 30°. He refused any surgical intervention. After discussion
with the prosthesis team, we agreed to prescribe him left transtibial
prosthesis with some modification of the socket to accommodate his
flexion deformity. While waiting for his prosthesis, he was advised to
continue his physiotherapist to improve his muscles strength, range of
motion, and endurance.
The prosthesis ready after 3 months, but another problem arises.
There was no modification done to accommodate his flexion deformity.
As he already tired of waiting for the prosthesis, he insisted to try that
prosthesis and continue his gait retraining with it. Education and thera-

Received on May 30, 2016 and accepted on November 8, 2016

1) Department of Neurosciences), School of Medical Sciences, Universiti Sains Malaysia
Kubang Kerian, 16150 Kelantan, Malaysia.
2) School of Medical Sciences, Universiti Sains Malaysia
Kubang Kerian, 16150 Kelantan, Malaysia
3) Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya
50603 Kuala Lumpur, Malaysia
Correspondence to: Muhammad Hafiz Hanafi
(e-mail: drmdhafiz@usm.my)

C 2017 Japan Health Sciences University

& Japan International Cultural Exchange Foundation
2 Hanafi M. H. et al.
pies were given to him and after few months, he was able to walk inde-
pendently with left elbow crutch due to fear of fall, and return to his
previous work. He claimed to be using the prosthesis about 12 hours per
day everyday and only removed it during sleep and taking shower.
Six months later, during his clinic appointment, measurement of his
knee deformity was done, and surprisingly, his popliteal angle had
improved to only 5°.
DISCUSSION
Amputation is an unavoidable consequence of a traumatic event or
illness and should not be treated as a tragedy. Advances in the prosthet-
ics technology and rehabilitation techniques have made it possible that
amputation has are regarded as a treatment and not failure of treatment5).
The main goal of postoperative amputation management includes pre-
vention of common complications which include swelling, edema, post-
operative pain and joint contracture.
The contractures may develop preoperative or postoperatively6). In
some preoperative contracture patients, joint disease or prolonged
immobilization before operation leads to their knee fixed flexion defor-
mity. These patients usually old and had vascular illness that lead to
long debilitating illness prior to surgery.
A study by Omer et al5). found that flexion deformities of the knee
in below knee amputees accounts for 10% of all refashioning of ampu-
tation stump in their center. Muscle imbalance and postoperative posi-
tioning to improve patient's comfort facilitates the development of knee
fixed flexion deformity in the residual amputated leg7). These contrac-
tures can be prevented through postoperative rehabilitation program that
emphasize on flexibility exercises and early mobilization.
Hawamdeh et al8). noted the prevalence of anxiety and depressive
symptoms were 37% and 20%, respectively. Factors associated with
high prevalence of psychological symptoms included female gender,
lack of social support, unemployment, traumatic amputation, shorter
time since amputation, and amputation below the knee. In this case, the
patient's depressive mood had lead to a period of immobility and thus
was assumed as one of the factors that lead to his contracture.
In transtibial patient with good expectation for ambulation, the knee
flexion deformity is suggested to be accommodated in the prosthetic
alignment during the prosthetic fitting process9). Once the patient starts
to walk with the prosthesis, his contracture is expected to improve due
to prolonged stretching during walking. In severe cases that do not
respond to this treatment, surgical intervention can be considered.
In this case, although during the prosthesis prescription the modifi-
cation to accommodate the deformity was planned, the end product was
without the adjustment. Interestingly, this lead to our finding; knee flex-
ion deformity of a transtibial amputee can be improved by using the
non-adjusted socket alignment prosthesis. One study noted the recent
trend of amputation has been on improving functional outcomes and
patient satisfaction after amputation surgery, rather than the amount of
tissue preserved or the residual limb length10).
CONCLUSION
In summary, knee flexion deformity in amputee need to addressed
better to enhance patient's ability to ambulate with prosthesis. The effect
of prolonged ambulation in improving contracture to the effected joint
should be further investigated.
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