From wheelchair to walking: first Genium® knee fitting in a bilateral transfemoral amputee in Algeria (a case report)

¹Youcef EL Khatib University of Health Sciences, Algiers, Algeria

^&Corresponding author
Abdelghani Miliani, Youcef EL Khatib University of Health Sciences, Algiers, Algeria

Introduction    

Amputation of the thigh results in a major handicap. The evidence of impairment and bodily loss is immediate. It has the disadvantage of losing the anatomical knee, which even the most elaborate prosthetic knee could not replace. The management of these patients is further complicated if the amputation is bilateral, which makes walking practically impossible, because it is too energy-consuming [1]. The hope of a possible functional recovery rests entirely on the technological virtues of the device [2]. From the brand "Ottobock Healthcare Duderstadt, Germany», Genium was introduced in 2011 and is a microprocessor-controlled prosthetic knee (MPK) with hydraulic support but with advanced features, i.e., new sensors and algorithms to give the patient back intuitive walking. This smart electronic knee features force sensors pressure exerted on the knee and ankle; an accelerometer that detects the speed and cadence of walking, and a gyroscope that detects the direction and angular position of the knee in the three planes of space. Based on this data collected and processed through its microprocessors, this knee will react intelligently by making the appropriate movement, which allows optimized walking with perfect control during the two phases of walking: the support phase and the swing phase [3]. This article reports the case of the first Algerian transfemoral amputee who was fitted with a Genium® type smart knee.

Patient and observation     

Patient information: the patient a 36-year-old male soldier from Algeria. He was referred to our Physical Medicine and Rehabilitation department seeking advanced prosthetic solutions for a bilateral transfemoral amputation. His primary concern was the loss of functional independence and a strong desire to transition from a wheelchair to walking. He had sustained a bilateral transfemoral amputation following a blast injury (explosive trauma) in 2008 at the age of 31. His medical and family history were unremarkable, with no relevant genetic information. Psychologically, the patient had been severely affected by his handicap, leading to a long period of deconditioning during the five years spent in a wheelchair.

Clinical findings: physical examination revealed healthy, well-shaped, and painless bilateral thigh stumps with good muscle mass and no skin complications. However, significant global physical deconditioning was noted due to the prolonged sedentary state. Neurological and vascular exams of the stumps were normal.

Timeline of current episode: in 2008, the patient sustained a bilateral transfemoral amputation following explosive trauma at the age of 31. Between 2008 and 2013, five years of severe physical and psychological deconditioning followed. During this time, the patient was initially treated in a PRM department at the HMUSCORFA (Specialized Military Hospital) in Algeria, where several attempts to fit him with conventional prostheses failed to enable walking; consequently, he remained entirely wheelchair-bound (Figure 1). In early 2013, following the patient's insistence, a transfer request was made to the Robert Merle D'Aubigné Institute in France for a specialized evaluation. A multidisciplinary rehabilitation program was initiated, focusing on stump conditioning and psychological preparation. In mid-2013, after trials with C-Leg knees proved insufficient for his specific functional needs, the patient was fitted with bilateral Genium® microprocessor-controlled knees at the age of 36. Six weeks post-fitting, following the patient´s return to Algeria, the rehabilitation program was continued, based essentially on the development of a new neuromuscular proprioceptivity through balance training, development of different gait patterns, and exercise retraining. The patient achieved independent ambulation using two canes (Figure 2, Figure 3, Figure 4). Long-term follow-up: the patient achieved complete social reintegration, including the successful return to driving a vehicle (Figure 5, Figure 6, Figure 7), and continues to receive periodic maintenance at the prosthetics center in Algiers.

Diagnostic assessment: the diagnostic assessment included a rigorous evaluation of the stumps, joint range of motion, and muscle strength. We also performed a psychological screening to assess his readiness for high-tech prosthetic integration. The main diagnostic challenge was the technical platform and the financial cost associated with Genium® technology in a resource-limited setting. The final diagnosis was a stable bilateral transfemoral amputation with a high potential for functional recovery if provided with intelligent MPKs. The prognosis for mobility was deemed excellent given the patient´s motivation and the capabilities of the Genium® system.

Therapeutic interventions: the intervention was divided into three phases. 1) Pre-prosthetic phase: intensive physical therapy focusing on stump shaping, strengthening of the hip extensors and abductors, and psychological support. 2) Prosthetic fitting: fitting with bilateral Genium® microprocessor knees with modular sockets and AXON-Link technology for synchronized coordination. 3) Gait training: a 6-week intensive program focusing on standing balance, ramp walking, obstacle clearance, and sit-to-stand transitions. No changes in the intervention were required due to the patient's rapid adaptation.

Follow-up and outcome of interventions: outcomes were highly positive, with the patient achieving independent walking using two canes. Clinician-assessed outcomes showed improved gait symmetry and reduced metabolic cost compared to standard mechanical knees. The patient demonstrated high tolerability and adherence to the protocol. No adverse events or technical failures were reported during the follow-up period. He successfully resumed activities of daily living, including driving his own vehicle. Today, years after resuming walking, the patient is regularly monitored at the prosthetics center in Algiers with periodic checks for renewal, adjustment, and maintenance of his prosthesis.

Patient perspective: the patient expressed profound relief and satisfaction, stating: "Being able to stand at the same height as others and walk again has changed my life. I no longer feel trapped in my wheelchair. This technology gave me back my dignity as a soldier and a man." He particularly emphasized the newfound confidence when walking on uneven terrain and the ability to drive, which restored his social autonomy.

Informed consent: the patient provided written informed consent for the publication of this case report, including the use of clinical data and de-identified photographic materials documenting his rehabilitation process.

Discussion     

This work documents the first Algerian case of a bilateral transfemoral amputee successfully fitted with bionic knee prostheses. Bilateral thigh amputation remains a major handicap where the loss of the anatomical knee creates a functional deficit that mechanical prostheses often fail to compensate [4]. As highlighted in our observations, walking with conventional prostheses for a bilateral amputee is often practically impossible due to prohibitive energy consumption and the lack of synchronization between limbs [5]. The evolution of microprocessor-controlled knees (MPKs) has been a turning point in prosthetic history. While the world's first bilateral fitting with Genium® is not individually documented in public records, early case studies indicate that such fittings primarily emerged in the United States around 2011. Specifically, the Walter Reed National Military Medical Center (USA) played a pioneering role, fitting veterans wounded in Iraq or Afghanistan shortly after the Genium® was released [6].

In Europe, the history of bilateral Genium® fitting is marked by both clinical practice and formal literature. Frédéric Mess is publicly recognized as the first bilateral transfemoral amputee in Europe to receive two Genium® knees, fitted by BOP Technologies in Nantes, France, in 2012, though this case was not formally published in a medical journal. However, the scientific literature provides a documented clinical case from 2015 describing a patient who received Genium® knees following the failure of conventional prostheses. This specific case involved a complex surgical procedure in Germany in 2012 for bone-integrated titanium rods (osseointegration), followed by fitting and rehabilitation at a military center in the Netherlands in 2013 [7].

The transition from a C-Leg to the Genium® system in our patient represents the local integration of this "Mechatronic" era [8]. The remarkable functional outcome is largely attributed to the sophisticated architecture of the system, specifically the AXON-Link technology. Unlike independent MPKs, the AXON-Link provides a high-speed communication protocol allowing both prosthetic units to exchange sensor data in real-time. This inter-prosthetic synchronization is critical for bilateral amputees; it ensures that the swing phase of one limb is perfectly coordinated with the stance stability of the other [9]. For our patient, this allowed for the transition from "step-to-step" gait to the more advanced "step-over-step" pattern on stairs, significantly reducing the risk of falls and decreasing the high metabolic cost of ambulation.

Our findings align with the systematic review by Mileusnic et al, confirming that the Genium® offers superior advantages over conventional MPKs regarding safety and performance in activities of daily living [10]. The ability of our patient to achieve independent ambulation and return to driving after five years in a wheelchair mirrors the success stories seen in leading military rehabilitation centers in the US and Europe. However, implementing such technology in Algeria presents unique challenges. The success of this "first" underscores the importance of a specialized technical platform and the local transfer of expertise. The efforts of the hospital (HMUSCORFA, Algiers) in ensuring maintenance and long-term follow-up are vital for sustainability. This case proves that when high-tech solutions are paired with dedicated multidisciplinary coordination, it is possible to restore autonomy to complex cases in North Africa, achieving international standards of care.

Conclusion     

In low- and middle-income countries, the prosthetic fitting of bilateral transfémoral amputees remains a challenge. Advanced technologies have revolutionized prosthetic management, but high costs and accessibility issues limit their widespread use.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Abdelghani Miliani: conceptualization, methodology, data collection, analysis, writing original draft. Mahmoud Dib: iconography (clinical photography and visual documentation). Ayatoulah Amamri: writing, review and editing, iconography (photographic documentation and image selection). All authors have read, revised, and approved the final version of this manuscript.

Figures     

Figure 1: baseline condition (2008-2013) showing failure of traditional prosthetic rehabilitation and persistent loss of mobility

Figure 2: post-fitting rehabilitation phase in Algeria; gait training within parallel bars focusing on the development of new neuromuscular proprioception and static balance

Figure 3: advanced gait retraining in Algeria: obstacle-clearing exercise aimed at developing dynamic balance and enhancing neuromuscular coordination with the bionic knees

Figure 4: stair ascent and descent training in Algeria; achieving reciprocal gait (step-over-step) enabled by the microchip-controlled hydraulic resistances of the Genium® system

Figure 5: full social reintegration: the patient demonstrating independent community ambulation in an urban environment, including the safe navigation of curbs and uneven terrain

Figure 6: functional reintegration into activities of daily living (ADL); the patient demonstrating prolonged walking endurance and stability during a shopping activity

Figure 7: return to driving: a key milestone in the patient's journey from wheelchair dependence to full community participation

References