1. Proximal Femoral Focal Deficiency Treatment:
Effects of Van Nes Rotationplasty vs. Transfemoral Amputation on Gait and Energy Efficiency
Megan Kaiser, Student PT Briana Ulanowski, Student PT
Introduction
Transfemoral Amputation
Conclusion
Performed if femur is < 50% of contralateral femur1
Effects on gait
Decreased hip extension on prosthesis side causing increased pelvic tilt during heel strike of intact limb due to stump-socket interference2
Greater stress on intact limb due to loss of proprioception and decreased balance on prosthetic limb; including transtibial amputations3
Increased vaulting on intact limb4
Muscle weakness (hip abductors, flexors, and extensors)4 creating an increase in gait asymmetry
Effects on energy efficiency
Amputation VO2 cost was 151% of normal5
Self-selected walking velocity was 80% of normal5
Transfemoral amputation
Increased anterior pelvic tilt to control balance by shifting COG2,6
Decreased hip ROM due to extrinsic factors2
After gait training there was decreased LBP, increased muscle strength, and more symmetrical gait2,4
Vaulting on intact limb was decreased after gait training, but increased at follow-up; suggests repeated training may reduce vaulting3
Van Nes rotationplasty
Decreased hip ROM due to intrinsic factors6
Both transfemoral amputation and Van Nes rotationplasty
Amputation should be done at the lowest possible level for energy conservation5
Asymmetrical weight bearing/shifting with anticipatory movement6
Decreased hip strength in both types and ankle strength decreased only in Van Nes rotationplasty4,6
Definition: proximal femur and acetabulum fail to form correctly during development 1
Shortening of the lower limb
Classified using Aitken’s System
Class A or B: femoral head still intact; limb lengthening procedure 1
Class C or D: femoral head is absent; Van Nes rotationplasty or transfemoral amputation1
Van Nes rotationplasty: lower limb is rotated and ankle joint is used to function as knee joint, prosthesis is fitted to new “knee joint” 1
Individualized treatment plan
Van Nes Rotationplasty
Reflection
Performed if ipsilateral foot is at level of contralateral knee1
Effects on gait
Decreased hip extension on prosthesis side resulting in increased anterior pelvic tilt due to limited ROM and strength6
Decreased hip flexion power6
Asymmetrical weight-bearing6
Effects on energy efficiency
Transtibial amputation walk as fast as their normal peers without increasing energy cost5
Further Research should include:
Association between postural instability and musculoskeletal impairments
Effects on low-back pain
Comparison of transfemoral and Van Nes rotationplasty amputations
Proposed treatment plan:
Gait training
Muscle strengthening
Balance and Proprioception
References
1. Westberry D, Davids J. Proximal focal femoral deficiency (PFFD): management options and controversies. Hip International. 2009;19(1):S18-S25. Accessed November 12, 2013.
2. Rabuffetti M, Recalcati M, Ferrarin M. Trans-femoral and amputee gait: socket-pelvis constraints and compensation strategies. Prosthet Orthot Int. 2005;29: Accessed November 11, 2013.
3. Nolan L, Wit A, Dudziñski K, Lees A, Lake M, Wychowañski M. Adjustments in gait symmetry with walking speed in trans-femoral and trans-tibial amputees. Gait & Posture. April 2003;17(2):142. Available from: SPORTDiscus, Ipswich, MA. Accessed November 12, 2013.
4. Sjödahl C, Jarnlo G-B, Söderberg B, Persson BM. Kinematic and kinetic gait analysis in the sagittal plane of trans-femoral amputees before and after special gait re-education. Prosthet Orthot Int. 2002;26: Accessed November 11, 2013.
5. Jeans K, Browne R, Karol L. Effect of amputation level on energy expenditure during overground walking by children with an amputation. The Journal Of Bone And Joint Surgery. American Volume [serial online]. January 5, 2011;93(1): Available from: MEDLINE, Ipswich, MA. Accessed November 13, 2013.
6. Ackman J, Altiok H, Flanagan A, Peer M, Graf A, Krzak J, Hassani S, Eastwood D, Harris GF. Long term follow-up of Van Nes rotationplasty in patients with congenital proximal femoral focal deficiency. Bone Joint J. 2013;95-B: Accessed November 10, 2013.