Military Medicine International Journal of amsus raising the bar: extremity trauma care guest editors
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into pathomechanics of knee OA in individuals with limb amputation. In general, findings from collected literature sup- port net overloading of the intact side relative to the prosthetic side, as well as relative to speed-matched nonamputees. For example, persons with unilateral transtibial amputation have a greater intact-limb peak vertical GRF during loading response relative to nonamputees, by as much as 4 to 10% during walking
46,47 and 35 to 45% during running. 48 Knee
flexion angle and external knee extension moments, which are associ- ated with GRF overloading and elevated axial knee joint com- pression, 49 have also been found greater in the intact limb of individuals with unilateral lower limb amputations compared to nonamputees. 14,47 Such net GRF differences may or may not lead to differences at each of the proximal joints, depending on concurrent kinematics and muscle activity. One study accounting for the latter factors found 23% greater peaks in axial knee joint total compression force on the intact limb relative to the prosthetic side, and 9% greater relative to nonamputee limbs. 11 Prosthetic device mechanical properties have also proven to have a signi ficant effect on mechanics of the proximal intact limb. Brie fly, findings indicate that prosthetic foot stiff- ness and energy return properties can effect intact limb early stance GRFs, with as much as a 7% of body weight increase in peak vertical GRF when using a solid ankle cushion heel foot versus an energy storage and return foot. 50,51 Energy
storage and return feet can also reduce intact limb peak KAM by as much as 13% versus a solid ankle cushion heel foot, 41 while an active prosthetic foot that provides timed, active pro- pulsion near prosthetic limb push-off can decrease the mag- nitude of intact limb peak KAM by as much as 26%. 43 Currently, there is a clear need to ascertain whether such prosthetic advancements are associated with a reduced inci- dence of knee joint pain and early OA in the intact limb of patients with unilateral amputation. MUSCLE WEAKNESS Lower limb muscle weakness is a hallmark impairment for primary knee OA in older adults. In general, muscular strength is critical for maintaining proper dynamic joint function as muscles aid in shock absorption and proper force transfer across the joint. 52 To this end, quadriceps muscle weakness has been suggested as a strong risk factor for primary knee OA.
6 Several mechanical theories have been previously suggested for the potential relationship between quadriceps muscle weakness and structural knee OA development and progression. For instance, it has been suggested that quadri- ceps muscle plays a joint protective role as a shock absorber to dampen the rate of knee loading such as decreasing the heel strike transient during the loading response phase of gait. 53
ies have shown a signi ficant decrease in quadriceps strength for the prosthetic limb when compared to the intact limb. 45,54
Quadriceps atrophy has also been noted on the prosthetic side in comparison to the intact limb. 55 Comparisons of individ- uals with unilateral transtibial amputations to a control group have also demonstrated that those with amputations have weaker quadriceps bilaterally compared to nonamputees, which were highly correlated with increased rates of vertical impact loading of the lower limb during gait. 45,54
While the quadriceps remain the major focus of research efforts examining the role of muscle weakness in pathogenesis of primary knee OA, a new body of evidence is emerging to suggest that hip muscle weakness may also be a risk factor for knee OA. 56,57
As the hip shares a common segment (i.e., the femur) with the knee, adequate hip muscle performance is necessary to provide dynamic proximal stability for maintaining appropriate knee joint mechanics during weight bearing. 58 For example, Chang et al 56 reported that a greater hip abductor strength is associated with a reduced likelihood of medial compartment knee OA progression. Other studies, however, have shown that strengthening of the hip muscula- ture can lead to signi ficant improvements in pain and function despite virtually no change in KAM in older adults with pri- mary knee OA. 59,60
Strength testing in individuals with unilat- eral transfemoral amputations, traumatic and nontraumatic, has shown that isometric hip abduction strength of the ampu- tated limb is 47 to 54% lower compared to the intact limb and 35 to 65% lower compared to nonamputees. 61,62
Con- versely, Nadollek et al 63 found no difference in elderly indi- viduals with unilateral transtibial amputations between the prosthetic and intact limbs; however, comparisons to hip strength in a control group were not made. Additional research is needed to provide a clearer picture of the preva- lence and extent of lower limb muscle weakness and its potential relationship with development and progression of knee OA after traumatic lower limb amputation. MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 41 Development of Knee Osteoarthritis After Unilateral Lower Limb Amputation PREVIOUS KNEE INJURY OR TRAUMA High-impact loading knee injuries such as tears of the meniscus, ligaments, or capsule; joint dislocations; and intra- articular fractures in young individuals has been previously linked with a 5.2-fold increased relative risk of developing subsequent knee OA. 22 The energy initially absorbed by the joint surfaces at the time of injury has been suggested as an important predictor of development of knee post-traumatic OA (PTOA). 64 This PTOA has fundamentally different etiol- ogy than the primary degenerative OA discussed previously in this review. The emerging hypothesis related to PTOA is that the severity of the initial trauma and the subsequent cas- cade of pathophysiological events such as in flammation and chondrocyte senescence, along with any residual joint insta- bility, incongruity, or alteration in biomechanics, contribute substantially to the onset and progression of knee OA. 65 The risk of knee PTOA is most likely even higher in young military Service Members due to the high-energy nature of most battle field injuries. In fact, in a recent report in combat-injured warriors who could not return to duty, injuries to the knee resulted in post-traumatic knee OA in every case at an average of 19 ± 10 months after injury. 66 This trajectory of knee PTOA development after combat injuries appears to be much steeper than the 10 to 15 year rate previously reported after anterior cruciate ligament rup- tures or meniscal damage in the general population. 67 –69 Given that most combat-related injuries resulting from high- energy explosions involve multiple limbs and joints, 66 it is
likely that the concurrent injury to the knee of the intact limb along with altered joint biomechanics after amputation could lead to a greater risk of developing PTOA in individ- uals with traumatic unilateral lower limb amputation. Addi- tional research to better understand the involvement of multiple joint tissues and the critical cellular and molecular events after trauma and injury is needed to develop strate- gies (e.g., surgical, pharmaceutical, rehabilitative, etc.) to slow or halt the onset or progression of knee PTOA after lower limb amputation. PHYSICAL ACTIVITY LEVEL Previous
findings concerning the association between exer- cise, sports participation, and risk of knee OA have been somewhat perplexing. For instance, regular exercise has been suggested as a favorable option for maintaining articu- lar cartilage health. 35 Experimental studies in animals have also shown that loading of healthy joints through moderate bouts of running is associated with increased articular carti- lage thickness, proteoglycan content, and mechanical stiff- ness of the tissue. 23,24 In addition, recreational- or even elite-athlete level long-distance running have shown to be unrelated to accelerated incidence or severity of radiographic knee OA in the absence of underlying joint disease. 70,71
In contrast, other studies have associated participation in spe- ci fic sports that involve running, jumping, and heavy lifting with higher incidents of knee OA and an increased rate of disease progression. 72,73 In general, individuals with unilateral transtibial amputa- tion, regardless of traumatic or nontraumatic origin of the initial injury, demonstrate decreased activity levels when compared to nonamputees. 74 In previous literature, it has been reported that individuals with lower limb amputation on average take 1,540 to 3,163 steps per day, 75,76 as com-
pared to healthy adults who ambulate anywhere between 4,000 and 18,000 steps per day. 77 Given that mechanical loading of the knee joint is inherently linked to mainte- nance of the articular cartilage, adequate levels of mechani- cal stimulation are essential for maintaining articular cartilage tissue homeostasis through balancing solid matrix synthesis and degeneration. 78 Therefore, lower frequency of knee joint loading due to diminished activity levels can lead to the reduction in cartilage tissue resiliency 35 needed
to meet the requirements of higher demanding activities, such as sports participation or returning to active duty that may be desired by young Service Members with lower limb amputations. It has been suggested that individuals with amputations who participate in sports and/or regular physical activity report signi ficant benefits both physically and psychologically, such as improved strength, endurance, balance, and improved self- esteem and QOL. 79 Previous studies have shown that 32 to 60% of individuals with lower limb amputation participate in some form of sports, whether recreationally or competi- tively. 80
with lower limb amputation could be a risk factor for onset and progression of knee OA remains unknown. In a small study, Melzer et al 1 found no differences in the intact limb knee OA incidence between individuals with amputations who did and did not play volleyball. Additional longitudinal data are needed to better understand how early return to high- demanding sports activities may contribute to the onset and progression of knee OA. Additionally, Service Members are anticipated to perform physical activities beyond level walk- ing and running, which warrants further investigation of such activities. CONCLUSIONS Available scienti fic evidence to date supports that young military Service Members with traumatic, unilateral lower limb amputations may be at increased risk for developing knee OA compared to nonamputees. Given the high life expectancy of young injured military Service Members, devel- opment of effective rehabilitative programs to prevent or delay knee OA through early risk factor identi fication and modifica- tion is a crucial step in optimizing long-term function and QOL after traumatic, unilateral limb amputations. Future development of such programs should span a comprehensive range. Components should include screening of the intact limb for prior high-energy trauma and joint pain, managing body weight, further study of intact side knee joint mechanics, and MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 42 Development of Knee Osteoarthritis After Unilateral Lower Limb Amputation addressing lower limb muscle weakness. In retraining undesir- able biomechanics, technological advancements to guide real-time feedback and adjustments in movement strategies may be useful. 81,82 Continued future research and clinical programs that address nonsystemic knee OA risk factors are anticipated to increase long-term preservation of intact limb function and overall QOL in young Service Members after unilateral lower limb amputation. REFERENCES 1. Melzer I, Yekutiel M, Sukenik S: Comparative study of osteoarthritis of the contralateral knee joint of male amputees who do and do not play volleyball. J Rheumatol 2001; 28(1): 169 –72. 2. Hungerford D, Cockin J: Fate of the retained lower limb joints in Second World War amputees. J Bone Joint Surg 1975; 57(1): 111. 3. Norvell DC, Czerniecki JM, Reiber GE, Maynard C, Pecoraro JA, Weiss NS: The prevalence of knee pain and symptomatic knee osteo- arthritis among Veteran Traumatic amputees and nonamputees. Arch Phys Med Rehabil 2005; 86(3): 487 –93.
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41. Underwood HA, Tokuno CD, Eng JJ: A comparison of two prosthetic feet on the multi-joint and multi-plane kinetic Gait compensations in MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 43 Development of Knee Osteoarthritis After Unilateral Lower Limb Amputation individuals with a unilateral trans-tibial Amputation. Clin Biomech (Bristol, Avon) 2004; 19(6): 609 –16. 42. Royer TD, Wasilewski CA: Hip and knee frontal plane moments in persons with unilateral, trans-tibial Amputation. Gait Posture 2006; 23(3): 303 –6.
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