Knee Contracture- Post Operative

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HISTORY: 68 yo male referred to Sports Medicine Clinic for persistent left knee contracture after total knee arthroplasty. He noted a 15 degree extension lag approximately 3 months postoperatively and was prescribed physical therapy and a dynamic extension splint by Orthopedic Surgery. His contracture did not improve despite several months of physical therapy and use of the splint for several hours daily. He tried Baclofen but the contracture did not improve and it was discontinued due to adverse effects. He reported persistent knee pain and gait dysfunction due to the contracture. PHYSICAL EXAMINATION: Active and passive range of motion of the left knee was 15- 120 degrees, 0-120 degrees in the right knee. There was no tenderness to palpation at the medial or lateral joint line or the medial or lateral hamstring tendons. Decreased flexibility was noted in the medial and lateral hamstring bellies on the left with forced extension. Light touch sensation was intact in the L2-S2 dermatomes. Quadriceps and hamstring strength were within functional limits. Gait was noted to be abnormal due to the knee flexion contracture with a shortened swing phase. DIFFERENTIAL DIAGNOSIS: 1. Loosening of Hardware 2. Capsular scarring/adhesions 3. Hamstring Muscle Contracture TEST AND RESULTS: AP and Lateral knee X rays demonstrated a well aligned total knee arthroplasty with no signs of osteolysis or loosening of hardware. MSK Ultrasound evaluation of the left knee was performed in the clinic and did not show any synovial thickening or capsular scarring. FINAL WORKING DIAGNOSIS: Post operative knee contracture secondary to hamstring muscle contracture TREATMENT AND OUTCOMES: 1. Ultrasound Guided Botox injection was performed 9 months s/p TKA, 50 Units each into the semimembranosus/semitendinosus and biceps femoris muscle bellies 2. Referred to physical therapy for aggressive ROM and soft tissue mobilization techniques including dry needling, graston, manual therapy and stretching. 3. Returned to the clinic after 1 month and his extension lag was 8 degrees. He underwent another Ultrasound Guided Botulinum A Toxin injection with 50 Units each into the semimembranosus/semitendinosus and biceps femoris muscle bellies. 4. Patient did not follow up due to COVID-19 but reported significantly improved ROM and gait via telephone follow up.