Degree Of Flexion Contracture Research Articles

Neurovascular Heterodigital Island Flap for Digital Pulp Defect Reconstruction: 58 Case Series

Aim: Our study aims to report the neurovascular heterodigital island flap reconstruction for finger pulp defects. Patients and Methods: This study included 58 patients presenting to our clinic with pulp defects between 2014 and 2022. The average age of the patients was 26 years (20 - 56 years). Injuries were Allen type 2 for 18 patients, type 3 for 33 patients, and type 4 for 7 patients. Pulp defects were caused by crush injury (n:42) and sharps injury (n:16). Results: None of the flaps administered to the participating patients developed any total loss. Three patients developed partial loss in the distal flap. Six patients were found to have superficial tissue infection. Two patients were found to have hyperpigmentation and hyperesthesia. While one patient with Allen type 3 pulp defect was detected to have 10 degrees of flexion contracture in the distal interphalangeal (DIP) joint and 5 degrees of flexion contracture in the proximal interphalangeal joint, three patients were found to have 5 degrees of flexion contracture only in the DIP joint. The mean static two-point discrimination of the pulp-administered flap was 5.2 mm (3-8 mm) and on the contralateral side was 3 mm. The mean Semmes-Weinstein monofilament test was 3.18 g (2.96 – 4.7 g) in the pulp administered flap and 2.92 g in the contralateral side. Conclusions: Reconstruction of pulp defects with neurovascular heterodigital island flap is a reliable treatment option with satisfactory functional and sensory outcomes.

Prospective analysis of grip strength and load distribution after surgical treatment of common diseases of the hand with novel's manugraphy® system.

Carpal tunnel syndrome, A1 annular pulley stenosis and Dupuytren's contracture are among the most common conditions of the hand. In this study, we investigated the impact of surgical procedure on hand grip strength and high-resolution spatial load distribution in individuals suffering from those diseases over a follow-up period of one year. In this prospective study, data of 9 patients with carpal tunnel syndrome, 12 patients with A1 annular pulley stenosis and 7 patients with Dupuytren's contracture were evaluated. Only patients with unilateral disease were included providing the contralateral hand as an intra-individual control. Grip strength was measured with cylindrical instruments in two different sizes with respect to the hand size of the patients. Maximum and average values of grip strength as well as spatial load distribution in each finger, thenar, hypothenar and palm were analyzed. Data of the affected patients were collected preoperatively and 6weeks, 6months and 1year postoperatively. Grip strength and spatial load distribution were compared preoperatively to postoperatively. In addition, DASH score, Levine score, 2-point discrimination and degree of flexion contracture were assessed. The patients with A1 annular pulley stenosis showed a significant increase in grip strength 6months and one year postoperatively. Patients with carpal tunnel syndrome and Dupuytren's contracture showed no significant difference in grip strength over the course of time. An increase in the percentual grip strength of the thenar in patients with carpal tunnel disease and within the affected finger in A1 annular pulley stenosis was observed over the course of time. The DASH score was significantly lower in all patient cohorts one year postoperatively. Surgical procedure in carpal tunnel syndrome, A1 annular ligament stenosis and Dupuytren's contracture improves the functionality of the hand in everyday life. Some areas of the hand seem to compensate other weaker areas in grip strength.

How much preoperative flexion contracture is a predictor for residual flexion contracture after total knee arthroplasty in hemophilic arthropathy and rheumatoid arthritis?

BackgroundAlthough total knee arthroplasty (TKA) in hemophilic arthropathy (HA) or rheumatoid arthritis (RA) can improve functional ability, the postoperative range of motion (ROM) and prosthesis durability are reduced compared with those in osteoarthritic patients.AimWe aimed to compare (1) the pre- and postoperative flexion contracture after TKA in HA and RA, (2) the threshold of preoperative flexion contracture as a predictor of residual contracture > 15° after TKA, and (3) the survival rate.MethodsData from a consecutive cohort comprising 48 TKAs in HA and 92 TKAs in RA were retrospectively reviewed. The degree of flexion contracture was analyzed. Through receiver operating characteristics analysis, we aimed to determine the cutoff value of preoperative flexion contracture that increases the risk of residual contracture > 15° after TKA and compare the cutoff value in HA and RA. The survival rate was evaluated based on life table analysis and the Kaplan–Meier method.ResultsThe degree of preoperative flexion contracture was not significantly different. The degree of postoperative residual flexion contracture was 5.6° in the HA group and 1.4° in the RA group, respectively (p < 0.001). The cutoff value of preoperative flexion contracture for residual contracture of > 15° at last-follow up was 25.0° in the HA group and 32.5° in the RA group. The 5- and 12-year survival rates were 96% and 87% in the HA and 99% and 95% in the RA group, respectively (n.s.).ConclusionsThe postoperative residual flexion contracture was greater and the cutoff value of preoperative flexion contracture for residual contracture was smaller in the HA group than the RA group. Appropriate intra- and postoperative care to avoid postoperative residual contracture is required in HA patients.Level of evidenceIII.

Is Repair of a Small Coronoid Fracture Required in the Surgical Treatment of Terrible Triad Injury of the Elbow?

Background: Multiple treatment protocols have been described in literature for the treatment of terrible triad injury (TTI) of the elbow. We believe that repair of the medial collateral ligament (MCL) should be performed in preference to repair of a small coronoid fracture if the elbow is unstable after fixation/replacement of the radial head and repair of the lateral collateral ligament (LCL). The aim of this study is to report the outcomes of surgical treatment of patients with TTI associated with a small coronoid fracture in whom the coronoid fracture was not addressed. Methods: This study is a retrospective case series of 12 consecutive patients who underwent surgery for acute TTI with a small coronoid fracture (9 Regan-Morrey type I and 3 Regan-Morrey type II). Ten patients had complete MCL injuries. All patients underwent repair of the torn LCL and MCL and treatment of the radial head. The coronoid fracture was not surgically treated. At the final follow-up, the range of motion, degree of flexion contracture, Mayo elbow performance score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) were measured. Results: The mean follow-up period was 13.5 months. At the final follow-up, the mean arc of elbow flexion was 132° and the mean flexion contracture was 10°. The mean arc of forearm rotation was 148°. None of the patients demonstrated elbow instability. The mean MEPS was 92.5 points with seven having excellent results and five having good results. The average DASH score was 11.2 points. Conclusions: Our results showed that good elbow stability, arc of motion and clinical outcomes could be achieved without repair of small coronoid fractures in the treatment of TTI. The repair of MCL injuries should be given priority over the fixation of small coronoid fractures to regain elbow stability. Level of Evidence: Level IV (Therapeutic).

Complex Fracture-Dislocations of the Elbow in the Pediatric Population.

Complex fracture-dislocations of the elbow, including terrible triad of the elbow, are serious injuries with guarded outcomes in adults. Although described extensively in adults, little is known about similar complex fracture-dislocations of the elbow in the pediatric population. The purpose of this study was to describe patterns of elbow dislocations with associated fractures in children and report the outcomes of these injuries. This was a retrospective review of patients who presented to a level I trauma center from 2007 to 2019 with an elbow dislocation and at least 2 associated fractures. Demographic data, fracture locations, and treatment modality were recorded. Operative reports and radiographs were reviewed to determine clinical outcomes and complications. A total of 26 patients (mean age, 9.8 y) were identified. The majority of patients sustained an elbow dislocation and a medial epicondyle fracture (n=16). The most common third fractures involved the lateral condyle (n=8) or radial neck (n=7). At mean 6.03±3.11 months follow-up, 3 patients lacked ≥10 degrees of extension, and 2 patients lacked ≥15 degrees of flexion. Most patients had a Flynn score of "excellent" (n=20, 76.9%) or "good" (n=2, 7.7%). One patient with significant residual stiffness (>30 degrees flexion contracture) eventually underwent open contracture release. The most common complex elbow fracture-dislocation pattern in this series was an elbow dislocation with fracture of the medial epicondyle and lateral condyle or radial neck. In contrast to adult terrible triad injuries, most patients had a favorable clinical outcome, with nearly 80% excellent results and a low rate of complications. Therapeutic Level IV-case series.

Difference in the degree of improvement in patient-reported outcomes after total knee arthroplasty between octogenarians and sexagenarians: a propensity score matching analysis.

As the population ages, the use of primary total knee arthroplasty (TKA) is on the rise in the octogenarian population. The objective of this study was to compare patient-reported outcomes after TKA in octogenarians versus sexagenarians. This retrospective case-controlled comparative study with a propensity score matching analysis was conducted by 251 patients who underwent TKA for degenerative osteoarthritis of the knee. After the propensity score matching analysis, 38 octogenarians and 41 sexagenarians were identified. Range of motion (ROM), degree of flexion contracture, Charlson Comorbidity Index score, Knee Society score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, the 36-Item Short-Form Health Survey (SF-36), postoperative complications, length of stay, and 90-day mortality after TKA were compared. The degree of improvement of each functional parameter was also assessed. There was no significant difference in the degree of improvement in postoperative ROM, flexion contracture, or KSS. There were only significant differences in length of hospital stay and volume of blood transfusion (p < 0.001 and p = 0.004, respectively). The octogenarian patient group showed significantly inferior outcomes for WOMAC and SF-36 score compared to the sexagenarian patient group (p = 0.009 and p = 0.022, respectively). Although the functional improvements after TKA were excellent regardless of age, TKA seemed to contribute little to quality of life in octogenarian patients. Therefore, a careful approach to improving satisfaction with subjective outcomes is needed for octogenarian patients who undergo TKA.

Modified anterolateral approach for internal fixation of Holstein–Lewis humeral shaft fractures

The authors modified the anterolateral approach for Holstein-Lewis humeral shaft fractures using a plating technique to achieve sufficient distal fixation by minimal splitting of the brachioradialis muscle to fix the most distal screws. The purpose of this retrospective study was to evaluate the efficacy of our modified anterolateral approach for Holstein-Lewis humeral fractures and document clinical and functional results. Between 2008 and 2014, 18 patients (mean age 35.4 years) with a Holstein-Lewis humeral shaft fracture who underwent open reduction and internal fixation with a plate and screws using the modified anterolateral approach and followed for a minimum of 12 months were included. Radiologic fracture configurations, number of distal cortical fixations, union rate, and time to union were analyzed. Clinical outcomes were evaluated using the Mayo elbow performance index system, range of elbow motion, and postoperative complications. Mean fracture length was 60.2±10.2mm (range 49.2-77.2) and mean distal cortical length was 41.4±7.04mm (range 22.8-59.6). Distal fragments were fixed at a minimum of six cortical points (range 6-8) in all cases using the modified anterolateral approach. Average time to union was 10.5 weeks (range 8-12 weeks). All cases of radial nerve palsy completely recovered within 3 months. Mean elbow range of motion at final follow-up was 3.2 degrees of flexion contracture (range 0-10) and 135.4 degrees of further flexion (range 120-140), and the average Mayo elbow performance score was 96.3 points (range 90-100). There were no non-union or metal failures. The results obtained indicate that the modified anterolateral approach is a safe and easy accessible method that provides sufficient distal osseous fixation for Holstein-Lewis humeral shaft fractures without serious complications. The modified anterolateral approach for plate osteosynthesis appears to be one of the most available options for the treatment of Holstein-Lewis humeral fractures. Level IV, retrospective case series.

Posterior cruciate-retaining versus posterior-stabilized total knee arthroplasty for osteoarthritis with severe varus deformity

ObjectiveThe aim of this study was to compare the radiological and functional results of posterior cruciate ligament (PCL) – retaining and posterior-stabilized total knee arthroplasties in patients with severe varus gonarthrosis. MethodsMedical records of 112 knees of 96 patients who underwent total knee arthroplasty for severe varus (≥15°) were reviewed. PCL-retaining and PCL-stabilizing groups consisted of 58 and 54 knees, respectively. Mean follow-up time was 56.6 months (range: 24–112 months). Knee Society (KS) clinical rating system was used in clinical evaluation. Range of motion, degree of flexion contracture, postoperative alignment, and complication rates were compared between the groups. ResultsMean preoperative mechanical tibiofemoral angle was 20.1° in varus alignment, and was restored to 4.6° in valgus postoperatively. No statistically significant differences were found between PCL-stabilizing and PCL-retaining groups when KS knee scores, function scores, and flexion arc were evaluated. Two patients in PCL-retaining group underwent revision surgery due to aseptic loosening of tibial component. One patient in PCL-stabilizing group needed arthrotomy due to patellar clunk syndrome. ConclusionThere were no notable differences between the 2 groups and PCL-retaining design had outcomes as good as PCL-stabilizing total knee implant in osteoarthritic knees with severe varus deformity. Level of evidenceLevel III, Therapeutic study.

Relationship between flexion contractures of the joints of the lower extremities and the sagittal profile of the spine in patients with cerebral palsy: a preliminary report

Background. The considerable incidence of kyphosis in patients with cerebral palsy (CP) causes back pain and aggravates movement disorders. However, few studies have investigated the pathogenesis of this condition.Aim. To identify the relationship between patient motor abilities, the severity of flexion contractures of the knee and hip joints and spinal sagittal profile changes, and the impact on the latter by surgical correction of flexion contracture of the knee joint.Material and methods. The study cohort included 17 pediatric CP patients (11 boys and 6 girls) with a mean age of 13.1 ± 1.3 (range, 10–16) years and level 2–4 spastic diplegia according to the Gross Motor Function Classification System. The relationship between radiological indicators of the spine sagittal profile and motor abilities of children, as well as the severity of flexion contractures at the hip and knee, and the degree of insufficiency of the active extension of the knee were investigated. Of these 17 patients, 12 underwent surgery to correct flexion contracture of the knee, which involved lengthening of leg flexors, to analyze the impact of contracture on the sagittal profile of the spine. The following radiological indicators were assessed: angle of thoracic kyphosis (CC), lordosis angle (UL) of the lumbar spine, and sacral inclination angle (SS). The study included patients with a CC of at least 30°.Results. Results of an X-ray study showed that the severity of kyphosis was 50.7° ± 2.1°, lordosis was 30.3° ± 4.3°, and SS was 30.5° ± 3.3°. There was a significant association between kyphosis and flexion contracture of the knee joint, as well as between lordosis and insufficient active extension of the knee joint. After elimination of the flexion contracture of the knee, the degree of severity of the CC (thoracic kyphosis) was unchanged, while UL (lordosis angle) and SS (sacral inclination angle) increased by approximately 10°.Conclusion. The severity of kyphosis in patients with CP is mainly dependent on the degree of flexion contracture of the knee joint. Although elimination of contractures does not lead to kyphosis correction, it increases the degree of lumbar lordosis and tilting of the sacrum.

Treatment of flexion contracture of the knee joint in children with arthrogryposis: A literature review

Knee joint lesions are observed in 58%-90% of patients with arthrogryposis. Majority of these cases involved flexion contracture of the knee. Ambulation is possible with a deficit of knee extension of 15-20°. Currently there is no standardized treatment in global practice, which makes the treatment of this disease extremely challenging. Clinicians must take into account the degree of flexion contracture, segmental level of the spinal cord lesion, and the age of the child when considering treatment options. In this study, national and international literature relating to the clinical profile, classification, and conservative and surgical treatment of this condition were reviewed. The following treatments have been considered for this condition: casts, extensor osteotomy, arthrolysis of the knee, the use of external fixation devices, and hemi-epiphysiodesis. The high probability of relapse for flexion contracture of the knee joint in children with arthrogryposis has been described.

Soft tissue distraction using pentagonal frame for longstanding traumatic flexion deformity of interphalangeal joints

ObjectiveInterphalangeal joint contracture is a challenging complication of hand trauma, which reduces the functional capacity of the entire hand. In this study we evaluated the results of soft tissue distraction with no collateral ligament transection or volar plate removal in comparison with traditional operation of contracture release and partial ligament transection and volar plate removal. MethodsIn this prospective study, a total of 40 patients in two equal groups (A and B) were studied. Patients suffering from chronic flexion contracture of abrasive traumatic nature were included. Group A were treated by soft tissue distraction using pentagonal frame technique and in Group B the contracture release was followed by finger splinting. ResultsAnalyzed data revealed a significant difference between the two groups for range of motion in the proximal interphalangeal joints (P<0.05), while it was not meaningful in the distal interphalangeal joints (P>0.05). There was not a significant difference in the degrees of flexion contracture between groups (P>0.05). Regression analysis showed that using pentagonal frame technique significantly increased the mean improvement in range of motion of proximal interphalangeal joints (P<0.001), while the higher the preoperative flexion contracture was observed in proximal interphalangeal joints, the lower improvement was achieved in range of motion of proximal interphalangeal joints after intervention (P<0.001). ConclusionSoft tissue distraction using pentagonal frame technique with gradual and continuous collateral ligament and surrounding joint tissues distraction combined with skin Z-plasty significantly improves the range of motion in patients with chronic traumatic flexion deformity of proximal and/or distal interphalangeal joints.

Outcome after total knee arthroplasty in haemophilic patients with stiff knees.

Advanced haemophilic arthropathy of the knee is associated with progressive joint stiffness. Results after total knee arthroplasty (TKA) in stiff knees are considered to be inferior compared to those with less restricted preoperative range of motion (ROM). There is only very limited data on the results of primary TKA in haemophilic patients with stiff knees. The purpose of this retrospective study was to evaluate the clinical outcome after TKA performed in haemophilic patients with preoperative ROM of 50° or less. Twenty one patients (23 knees) undergoing TKA with stiff knees were retrospectively evaluated. Mean follow-up was 8.3years (range, 2-25). Clinical assessment included ROM, degree of flexion contracture and complication rate. Functional evaluation and pain status were assessed using the Knee Society's Scoring System (KSS). Range of motion improved from 26.7° preoperatively to 73.0° postoperatively. Flexion contracture decreased from 21.7° to 8.3°. KSS increased from 22.9 to 72.9 points. Evaluation of pain revealed a decrease from 8.4 points preoperatively to 2.1 points postoperatively. All these differences were statistically significant (P<0.005). The complication rate was 8.7% including one late periprosthetic infection, and one aseptic implant loosening. Nine patients who required VY-quadricepsplasty for knee exposure developed a mean postoperative extensor lag of 7°. Total knee arthroplasty in haemophilic patients presenting with stiff knees results in significant improvement of function and reduction in pain. Although the clinical outcome is inferior compared to nonstiff knees reported in the literature, joint replacement surgery can be successfully performed in this particular group of patients.

Does hyperflex total knee design improve postoperative active flexion?

The rotating platform flexion (RPF) Sigma total knee prosthesis (DePuy; Warsaw, Indiana) was designed for maintaining the contact of the condyles with their corresponding tibial plateau throughout the high-flexion range. However, this requires an additional 3-mm bone cut of the posterior condyles. Compared to the conventional design, this modification is intended to improve the flexion range. This hypothesis was tested by studying the increase in flexion (flexion gain, range of motion [ROM], active flexion) of 59 consecutive patients who had received the hyperflex design implant (RPF), whose preoperative mobility values were retrospectively compared to these same values in another 59 consecutive matched patients who had received an implant with the conventional design of the same implant (rotating platform [RP]) between June 2005 and June 2006. Postoperative mobility was measured visually with a goniometer. Only osteoarthritic knees were eligible to be included. Knees with more than 20 degrees flexion contracture or less than 90 degrees flexion, and patients with a body mass index (BMI) greater than 30 were excluded. Both groups were comparable with regard to age, preoperative mobility values, and BMI. The sex ratio differed significantly, but preoperative mobility did not differ significantly in male and female patients in the RP and in the RPF groups. The difference in sex ratio did not appear to be a bias influencing preoperative mobility. Overall, the flexion gain was correlated to preoperative flexion (r=-0.75, p<0.001). The flexion gain in the RPF group was significantly greater than in the RP group (13+-20 versus 6+-13; p=0.02) as was the ROM gain (10+/-17 degrees versus 4+/-12 degrees; p=0.02). However, the one-year active mean flexions were not significantly different (118+/-14 degrees versus 116+/-6 degrees; p=0.47). In patients whose preoperative flexion was less than 120 degrees (18 and 27 RPF prostheses), the flexion and ROM gains were significantly greater in the RPF group (23+/-16 degrees versus 14+/-16 degrees; p=0.03 and 26+/-18 degrees versus 17+/-9 degrees; p=0.05), and the mean one-year active flexion was also greater in the RPF group (124+/-13 degrees versus 116+/-8 degrees, p=0.02). In patients with more than 120 degrees of preoperative flexion, the flexion and ROM gains and the final mean flexions in both groups were comparable. In particular, there were nine patients in the RP group and ten patients in the RPF group whose flexion decreased. Thus, the Sigma RPF prosthesis provided a significant additional flexion gain in patients with 90-120 degrees preoperative flexion, and less than 20 degrees flexion contracture. Patients with a preoperative flexion greater than 120 degrees were exposed to a decrease in flexion range whichever implant was used, RP or RPF. Level 3, therapeutic study.

Treatment of a Neglected Displaced Transverse Patella Fracture

A case of a displaced transverse fracture of the patella untreated for 2 years in a 67-year-old woman is presented. The patient requested treatment for giving way of the knee. Surgery included mobilization of the proximal fracture fragment, fixation with two cannulated screws, and repair of the medial retinaculum. The lateral retinaculum was left open to provide for better motion. At 1 year postoperatively, she ambulated with a cane, with range of motion examination revealing 5 degrees flexion contracture and 80 degrees flexion.

Acute digital ischemia: A neglected microsurgical emergency. Report of 17 patients and literature review

This study was performed to review our 16-year experience in acute finger ischemia. A review of the literature was also performed. A retrospective chart review of 17 patients, 14 men and 3 women, was conducted. Etiologies were ulnar aneurysm in 11 cases, atrial fibrillation in five cases and thoracic outlet syndrome in one case. Upto the palmar superficial arch, embolus due to atrial fibrillation or thoracic outlet syndrome could be loosened by a Fogarty catheter. In cases of aneurysm of the ulnar artery, we performed each time an aneurysm resection followed by direct anastomose alone, while three patients had additional grafts: artery graft (epigastric artery) or reversed vein grafts (superficial forearm vein). Microsurgical dissection of the digital collateral arteries enabled us to perform a thrombectomy. The transversal arteriotomies were closed after the collateral arteries were washed. The immediate perfusion of digit after the reconstruction of the aneurysm was each time excellent. The disoccluded vessels, investigated by Allen testing and Doppler ultrasound, were all patents. Two patients suffered from a small ulcer of the small fingertip that disappeared after 2 weeks. One patient had a 30 degrees ischemic flexion contracture in the metacarpophalangeal joint and 25 degrees flexion contracture in the proximal interphalangeal joint of the third digit. With regards to long-term outcomes, no secondary amputations were necessary and there was no recurrence after a mean follow-up of 10.7 years. Diagnostic of acute digital ischemia is often neglected. An early recognition and an aggressive microsurgical treatment are necessary to ensure low morbidity.

Die operative Behandlung von Streckdefiziten am Kniegelenk

Restoration of full knee extension in patients with chronic extension deficits, especially in posttraumatic and postoperative cases. Chronic knee extension deficits of more than 10 degrees . Local intraarticular problems caused by cyclops syndrome, graft hypertrophy or graft impingement after anterior cruciate ligament reconstruction (notch impingement). These patients should be treated with arthroscopic procedures. Spastic flexion contracture. Noncompliant patients. Acute or chronic infections. Poor soft-tissue conditions on site of surgery. If necessary, arthroscopy before arthrolysis to assure that the extension deficit is not caused by a local problem (cyclops, osteophytes, graft hypertrophy or graft impingement after anterior cruciate ligament reconstruction). Anterior skin incision at the medial border of the patellar ligament. Resection of Hoffa's fat pad, which is extremely fibrotic in almost all cases. Second skin incision at the posteromedial side of the knee joint. Incision of the medial retinaculum between the posterior border of the medial collateral ligament and the posterior oblique ligament. Posteromedial arthrotomy between the distal part of the tendon of the adductor magnus muscle and the posterior horn of the medial meniscus. Release of all adhesions in the posterior recess of the knee joint. Complete release of the posterior joint capsule from the femoral shaft. Immobilization for 48 h after surgery in full extension (no knee motion allowed in the first 48 h). For 48 h after surgery only short walks to the bathroom are allowed. Special dynamic extension brace (Dynasplint((R)), CDS((R)) Forte, Albrecht company, Stephanskirchen, Germany) for 4-6 weeks after surgery 6-8 h per day. Painkillers following WHO (World Health Organization) protocol. Manual lymph drainage and electric muscle stimulation help to decrease pain and swelling. Physiotherapy twice daily starting at the 2nd postoperative day. No flexion exercises for the first 7 days after surgery. 15 kg partial weight bearing for 4-6 weeks. Daily physiotherapy is recommended after discharge. 121 patients underwent anterior and posterior arthrolysis between 1990 and 2000. 86 of these patients could be included in this study. The average follow-up was 4.6 years (1-10 years). The extension deficit before surgery averaged 20 degrees compared with the opposite side. At follow-up, the average extension had increased by 17 degrees , no patient had more than 5 degrees of flexion contracture. The Lysholm Score was 84 postoperatively. The Tegner Activity Scale increased from 1.9 to 4.0 after arthrolysis. In the AOSSM Subjective Outcome Score, 35 patients showed excellent and 60 good results. 14 patients were satisfied after surgery and nine were not. Three patients required revision surgery (two synovial fistulas, one hematoma).

Total knee arthroplasty in patients with greater than 20 degrees flexion contracture

Does total knee arthroplasty (TKA) correct the flexion contracture in knee stiffness associated with osteoarthritis, inflammatory disease, hemophilia or post-traumatic sequelae? The results of 107 TKAs from five specialized centers were retrospectively reviewed. Only knees with greater than or equal to 20 degrees flexion contracture on extension were included, 46 of which also had less than 90 degrees flexion. As a result of the arthroplasty, extension increased by 20+/-6 degrees in group 1 (flexion contracture only, n=61), and by 22+/-11 degrees in group 2 (combined stiffness, n=46), in which the total range of motion increased of 39+/-21 degrees. Overall, mean residual flexion contracture was 7+/-7 degrees. Improvements in mobility were greater in the cases with severe preoperative stiffness. One-year functional results correlated with final residual flexion contracture. Mobility at last follow-up did not depend on preoperative mobility, except in group 2, in which the final postoperative range of motion (ROM) correlated with preoperative ROM. Hemophilia was a factor of poor prognosis. Recovering full extension at end of surgery is mandatory, by first releasing the posterior capsule and the collateral ligaments from their osteophytes, and secondly by extending the distal femoral cut where necessary. Level 4 retrospective.

Flexion Contractures: Getting It Straight

The importance of correcting soft tissue imbalance at the time of total knee arthroplasty is well recognized. Fixed knee flexion contractures are common preoperatively and can make balancing more challenging for the surgeon. In addition, restoration of full passive knee extension is required at the time of total knee arthroplasty to achieve optimal function. The objective of this article is to give the reader a stepwise approach, based on the degree of flexion contracture, to effectively attain full extension in the operating room.

Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair

The medial collateral ligament provides valgus stability to the elbow. The purpose of the present study was to describe the pathoanatomy of acute traumatic medial collateral ligament ruptures and to report the rationale and results of direct repair. Between 1996 and 2006, eleven athletes presented with acute rupture of the medial collateral ligament of the elbow and no history of dislocation. Three patients had received steroid injections for the treatment of medial epicondylitis, but none had a history of medial elbow insufficiency. All patients demonstrated gross valgus instability on clinical examination and medial joint space widening on valgus stress radiographs. Complete avulsion of the medial collateral ligament from its humeral origin was documented with magnetic resonance imaging in all patients. Operative findings uniformly demonstrated avulsion of the flexor-pronator muscles with distal retraction. The underlying medial collateral ligament was avulsed in a sleeve-like fashion from the denuded medial epicondyle. The ligament was directly reattached to its footprint. The avulsed flexor-pronator tendon was repaired to the residual tendon with use of interrupted figure-of-eight nonabsorbable sutures. All patients were followed for a minimum of sixteen months with serial clinical examinations, radiographs, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Full active range of motion was achieved in ten patients; the remaining patient had a 20 degrees flexion contracture. Three patients had acute ulnar nerve palsies at the time of the injury, and all three recovered complete motor and sensory function by six months after the injury. Nine of the eleven patients returned to competitive college athletics between four and six months. The mean DASH score at the time of the most recent follow-up was 6. Direct repair of an acute traumatic medial collateral ligament avulsion of the elbow reliably restores valgus stability, even in throwing athletes.

Radial Head Arthroplasty with a Modular Metal Spacer to Treat Acute Traumatic Elbow Instability

The use of a metal radial head prosthesis to help stabilize an elbow with traumatic instability is appealing because internal fixation of multifragment, displaced fractures of the radial head is susceptible to either early or late failure. The newer modular prostheses are easier to size and implant, but their effectiveness has not been investigated, to our knowledge. Twenty-seven patients in whom a radial head replacement with a modular metal spacer prosthesis had been performed to treat traumatic elbow instability were evaluated with use of the Mayo Elbow Performance Index (MEPI), the American Shoulder and Elbow Surgeons Elbow Evaluation Instrument (ASES), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Radiographs were evaluated for arthrosis, periprosthetic radiolucency, and heterotopic ossification. Seven patients underwent one or more subsequent operations to treat residual instability, heterotopic ossification and elbow contracture, ulnar neuropathy, or a misplaced screw. In two of these patients, the prosthesis was removed as part of an elbow contracture release or to treat infection. At an average of forty months postoperatively, elbow motion in the entire group of twenty-seven patients averaged 131 degrees of flexion with a 20 degrees flexion contracture, 73 degrees of pronation, and 57 degrees of supination. Stability was restored to all twenty-seven elbows, and twenty-two patients had a good or excellent result according to the MEPI. Seventeen patients had radiographic evidence of lucency around the neck of the prosthesis that was not associated with increased pain, thirteen patients had clinically inconsequential heterotopic ossification anterior to the radial neck, and nine patients had radiographic changes in the capitellum. An intentionally loosely placed modular metal radial head prosthesis can help to restore stability in conjunction with repair of other fractures and reattachment of the lateral collateral ligament to the epicondyle in the setting of traumatic elbow instability with a comminuted fracture of the radial head. While a prosthesis that is too large can cause problems, lucencies around the stem of the intentionally loose prosthesis and most changes in the capitellum do not appear to cause problems, at least in the short term.