Severe Knee Flexion Contractures Research Articles

Comparative analysis of surgical treatment modalities for a popliteal pterygium: a meta-analysis.

Popliteal pterygium syndrome is a rare congenital disorder characterized by orofacial, cutaneous, musculoskeletal, and genital anomalies. The popliteal pterygium (PP) affects ambulation due to severe knee flexion contracture and equinovarus deformities. Surgical treatment aims to correct these deformities while preserving limb sensibility. However, due to its rarity, surgical guidelines are lacking. A meta-analysis according to PRISMA guidelines was conducted to summarize and compare surgical methods for PP. 183 paper were identified in PubMed and data from 32 articles were analyzed, including patient demographics, treatment modalities (Ilizarov fixator, femoral osteotomy, skin/soft tissue procedures, hamstring release, nerve surgery, and amputation), pre- and post-operative abilities to walk, knee joint parameters, complications, and recurrent contractions. Among 58 patients (87 limbs), Ilizarov fixator demonstrated improved knee and ankle mobility postoperatively, but showed a relatively high surgical session count and complication rates. Femoral osteotomy achieved successful knee posture correction with fewer sessions and no complications. Isolated skin/soft tissue procedures improved flexion contracture and mobility, though they required several procedures. Hamstring release achieved notable contracture reduction but also necessitated multiple interventions. Nerve surgery and amputation had limited data, warranting further investigation. The management of PP demands a comprehensive approach, considering individual patient characteristics and treatment outcomes. While different surgical modalities offer distinct benefits, a classification or guideline to treat this deformity is still lacking. Further research is essential to validate findings, refine treatment approaches, and enhance the quality of life for individuals with PP.

The Ilizarov technique in the management of haemophilic knee flexion contracture.

The Ilizarov technique has the potential to be an attractive option for severe knee flexion contracture (KFC) patients with a high risk of bleeding. However, studies on this technique in the management of haemophilic KFC are scarce. The purpose of this study was to review and analyse the results of the Ilizarov technique in correcting haemophilic KFC and to evaluate the safety and efficacy of this technique. Twelve male haemophilia patients with severe KFC who underwent distraction treatment using the Ilizarov technique from June 2013 to April 2019 were included in this study. The hospital day, flexion contracture, range of motion (ROM) of the knees, complications and functional outcomes were recorded and analysed. Functional outcomes were evaluated according to the Hospital for Special Surgery (HSS) knee scores of the preoperation, end of distraction and last follow-up. The average preoperative flexion contracture and range of motion (ROM) of the knees were 55±15° and 66±18°, respectively. The average preoperative HSS knee score was 47±5. The average duration of follow-up was 75.5±30.1 months. All flexion contractures achieved full correction (≤5°) at the end of distraction, and the flexion contracture significantly decreased to 6±5° at the last follow-up (p<.0001). The ROM of the knees was significantly increased at the last follow-up compared with that before distraction treatment (p<.0001). The HSS knee scores at the end of distraction and at the last follow-up were both significantly higher than the preoperative HSS knee score (p<.0001). No major complications were encountered. This study provided evidence for the safety and effectiveness of Ilizarov technique plus physical therapy in the management of haemophilic KFC and accumulated clinical experience for the proper application of this technology.

Outcomes of double-incision posterior knee release for severe knee flexion contracture.

Many surgical solutions for knee flexiondeformity in the pediatric population alter the anatomical bony alignment in the distal femur. Posterior knee capsule release has been presented as an alternative surgical procedurethat maintains the anatomical shape of relevant bones while solving the issue of knee flexion contracture. The aim of this study is to assess the results of a double-incision posteriorknee capsulotomy release performed on pediatric patients with neuromuscular or congenital severe knee flexion deformity. Thirty cases (24 patients, mean age 7.4 years) of severe knee flexion contractures were retrospectively analyzed in a cohort of varying underlying conditions (including spina bifida, muscular dystrophy, cerebral palsy, sclerodermia, and congenital patellar dislocations). Posterior knee release was performed through medial and lateral short incisions with subsequent serial casting. Range and pace of correction as well as the complication rate were recorded. Follow-up information (>1 year) included functionality (FMS scale) and pain (Kujala/Knee Injury Osteoarthritis Score [KOOS]) scales. Significant correction in the knee position was achieved in all analyzed knees (from mean 40.2° to 0.7°; P < 0.01). Twenty-nine out of 30 cases achieved correction by 7 days postoperatively (average number of casts: 1.93 ± 1.05). Overall complication rate in the analyzed cohort reached 6.7% (2/30 cases; double metaphyseal fracture and arthrofibrosis). At follow-up (22.3 months on average), functional ambulation and pain parameters improved drastically, with no further complications observed. Double-incision posterior knee release is an effective method of knee contracture release, which does not affect the axial alignment of the distal femoral bone. Thus, posterior knee release should be considered as potential alternatives to osteotomies and eight-plate corrections, which are currently the basic methods of knee contracture treatment.

Treatment of Severe Knee Flexion Contracture After Below Knee Amputation Using Hinged Ilizarov Ring External Fixator

Flexion contracture of the knee is a common complication found after Below Knee Amputation (BKA). This condition is caused by muscle imbalance and prolonged stump malpositioning after BKA. Acute surgical correction of this deformity associated with high rates of complications.A 39-years-old man with chief complaint flexion contracture after BKA 3 months before. Physical examination showed flexion contracture deformity with knee range of motion at 90° to 120° with no possibility of further knee extension. This condition prevented him to use prosthesis and start walking exercises. Gradual correction of flexion deformity was performed using hinged Ilizarov ring external fixator with the rate of distraction was 1mm/day to prevent soft tissue and neurovascular complications. After 90 days of distraction, full extension of the knee joint was achieved with no complications.Gradual correction of knee flexion contracture using hinged Ilizarov device greatly reduced the complications risk of acute deformity correction with open surgery. This technique provides more advantage of minor operative trauma with a gradually controlled correction, permitting the soft tissue to regenerate, thus lowering the risk of neurovascular complications.

Novel Approach to Improving Knee Range of Motion in Arthrogryposis with a New Working Classification.

Arthrogryposis multiplex congenita (AMC) is a rare condition defined as contrac-tures in multiple joints. Surgical interventions for severe knee flexion contractures have included posterior release, distraction and extension with external fixation and distal femoral extension osteotomies. These operations have been able to achieve knee extension, but not increase the range of motion. The purpose of this study was to review our experience with peroneal nerve decompression, posterior knee release and proximal femoral shortening. We retrospectively reviewed the medical charts and radiographs of all patients with a diagnosis of arthrogryposis who underwent aforementioned procedure. There were 39 patients with 73 knees included in the analysis with a mean follow-up of 21 months. The mean preoperative arc of motion was 45° and last followup arc of motion was 79° (p < 0.0001). The mean last followup flexion contracture was 8° (p < 0.0001). Additional subanalyses were performed on those with followup greater than 24 months and those with flexion contractures >60°; there were no differences found in these groups. This study demonstrates that it is possible to achieve a functional range of motion of the knees in patients with AMC while improving ambulatory function.

Knee flexion contracture impacts functional mobility in children with cerebral palsy with various degree of involvement: a cross-sectional register study of 2,838 individuals

Background and purpose — The impact of knee flexion contracture (KFC) on function in cerebral palsy (CP) is not clear. We studied KFC, functional mobility, and their association in children with CP. Subjects and methods — From the Swedish national CP register, 2,838 children were defined into 3 groups: no (≤ 4°), mild (5–14°), and severe (≥ 15°) KFC on physical examination. The Functional Mobility Scale (FMS) levels were categorized: using wheelchair (level 1), using assistive devices (level 2–4), walking independently (level 5–6). Standing and transfer ability and Gross Motor Function Classification (GMFCS) were assessed. Results — Of the 2,838 children, 73% had no, 14% mild, and 13% severe KFC. KFC increased from 7% at GMFCS level I to 71% at level V. FMS assessment (n = 2,838) revealed around 2/3 were walking independently and 1/3 used a wheelchair. With mild KFC (no KFC as reference), the odds ratio for FMS level 1 versus FMS level 5–6 at distances of 5, 50, and 500 meters, was 9, 9, and 8 respectively. Correspondingly, with severe KFC, the odds ratio was 170, 260, and 217. In no, mild, and severe KFC 14%, 47%, and 77% could stand with support and 11%, 25%, and 33% could transfer with support. Interpretation — Knee flexion contracture is common in children with CP and the severity of KFC impacts function. The proportion of children with KFC rose with increased GMFCS level, reduced functional mobility, and decreased standing and transfer ability. Therefore, early identification and adequate treatment of progressive KFC is important.

Ilizarov technique for severe knee flexion contracture in juvenile rheumatoid arthritis

Severe flexion contracture deformity of the knee joint is often found in patients with rheumatoid arthritis (RA), which severly limiting the walking ability. Total knee arthroplasty (TKA) is a good option, but it is difficult and complicated to perform TKA, especially for juvenile patients with severe flexion deformity. There are limited reports about management of severe knee flexion contracture (KFC) of RA with Ilizarov technique. The aim of this study was to retrospectively analyzed the results of Ilizarov technique for the juvenile rheumatoid arthritis (JRA) patients with severe knee flexion contracture (KFC). From March 2000 to October 2018, nine patients (15 knees) with severe knee flexion contracture (KFC) of JRA who underwent Ilizarov knee joint distraction technique were reviewed retrospectively. There were 4 male (6 knees), 5 female (9 knees) with an average age of 15 years old (12–19years old). However, 6 cases also had equinus deformity, whose foot and ankle joint distraction device were installed simultaneously. The mean preoperative KFC and ROM angle of the knee were 48.8 ​± ​16.7° (mean ​± ​standard deviation) and 41.6 ​± ​15.3°, respectively. Preoperative VAS score (Visual analogue score) and HSS score (hospital for special surgery knee score) were 7.7 ​± ​2.5 and 37.4 ​± ​11.2, respectively. The average time of follow-up was 47.6 ​± ​21.3 months. All the patients achieved full correction of flexion contracture at the end of distraction. At the last follow-up, the mean flexion degree and ROM were 12.1 ​± ​11.7° and 23.5 ​± ​19.3° respectively, which were significantly different compared with preoperative condition. The total duration of ring fixation application was 10–21 weeks, with an average time of 14.3 weeks. The mean VAS and HSS score at the last follow-up were 1.4 ​± ​1.2 and 71.5 ​± ​7.3, which were significantly improvement to the preoperative condition. There were no severe complications during treatment in this study. Pin tract infection occurred in 7 cases during the knee joint distraction and the infection were controlled after slowing down the distraction speed and wrapping with alcohol gauze at the interface between the fixing pin and the skin. Ilizarov method is an effective and safe procedure to treat severe KFC in JRA which can correct deformities, relieve pain and improve the function of weight bearing. Pin tract infection and knee joint stiffness and even fusion are common problems, but correction of deformity of the knee using Ilizarov technique has possible positive outcome for possible further surgery if necessary. Our study shows that Ilizarov knee joint distraction for treatment of severe KFC in JRA is effective and safe. It is concluded that this method offers a new option for juvenile rheumatoid arthritis.

Distal Femoral Shortening Osteotomy for Severe Knee Flexion Contracture and Crouch Gait in Cerebral Palsy.

Although there have been advancements of surgical techniques to correct gait abnormalities seen in patients with cerebral palsy, the crouch gait remains one of the most difficult problems to treat. The purpose of this retrospective study was to examine our results of distal femoral shortening osteotomy (DFSO) and patellar tendon advancement (PTA), performed in patients with crouch gait associated with severe knee flexion contracture. A total of 33 patients with a mean fixed knee contracture of 38° were included in the study. The mean age at the time of surgery was 12.2 years and the mean follow-up was 26.9 months. The measurements of clinical, radiological, and gait parameters were performed before and after surgery. The mean degrees of knee flexion contracture, Koshino index of patella height, and Gait Deviation Index were found to be significantly improved at the time of final follow-up. The maximum knee extension during the stance phase improved by an average of 25°, and the range of knee motion during gait increased postoperatively. On the other hand, the mean anterior pelvic tilt increased by 9.9°. Also, the maximum knee flexion during the swing phase decreased and the timing of peak knee flexion was observed to be delayed. We conclude that combined procedure of DFSO and PTA is an effective and safe surgical method for treating severe knee flexion contracture and crouch gait. However, the surgeons should be aware of the development of increased anterior pelvic tilt and stiff knee gait after the index operation.

Gradual distraction for treatment of severe knee flexion contractures using the Ilizarov’s apparatus

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Knee flexion contractures result in a significant amount of functional disability due to reduced mobility and limb length discrepancy. Treatment options include non-surgical methods like serial casting, dynamic splinting and traction or surgical methods like osteotomies and soft tissue procedures. External fixation has emerged as a highly successful means of achieving controlled gradual correction of joint contractures with low rates of complications including recurrence. The aim of this study is to evaluate the functional outcome in terms of residual deformity and change in ambulatory status following correction using the Ilizarov’s apparatus.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 12 patients with knee flexion contractures ranging from 20°-70° underwent correction using the Ilizarov’s external fixator (IEF). The use of simple mathematic formulae enabled us to calculate and estimate the rate and duration of distraction. End results were assessed at one year by the residual contracture as: Excellent: 0-5°, Good: 6-15°, Fair: 16-30° and Poor: &amp;gt;30°.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The functional assessment was graded as excellent in 7, good in 4 and fair in 1 out of 12 patients. All patients were independent ambulators and only 1 out of 12 patients required an additional orthosis for maintenance of the correction.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The IEF is a safe and precise modality even for the most complex contractures of the knee. Accurate placement of the hinges along the center of rotation of the knee avoids undue subluxation of the tibia during correction. In order to ensure a low rate of complications, it is imperative to have a detailed pre-operative plan and all principles of fixation should be meticulously adhered to. &lt;/p&gt;

Association of clinical findings with pre–radiographic and radiographic knee osteoarthritis in a population‐based study

To determine the prevalence of pre-radiographic osteoarthritis (ROA) and ROA of the knee in a symptomatic population-based cohort, and to evaluate the clinical correlates of pre-ROA and ROA. Subjects ages 40-79 years with knee pain were recruited as a random population sample and classified using magnetic resonance cartilage (MRC) scores (range 0-4) and Kellgren/Lawrence (K/L) scale grades (range 0-4) as no OA (MRC score<2, K/L grade<2), pre-ROA (MRC score ≥2, K/L grade<2), and ROA (MRC score≥2, K/L grade≥2). Logistic regression was used to evaluate the association of clinical variables with cartilage defects, comparing subjects with any cartilage defects (pre-ROA/ROA) with those without, and to determine associations with individual OA subgroups. Of 255 symptomatic subjects, no OA, pre-ROA, and ROA were seen in 13%, 49%, and 38%, respectively. The prevalence of pre-ROA/ROA compared with no OA was associated with age (odds ratio [OR] 2.89, 95% confidence interval [95% CI] 1.59-5.26), sports activity (OR 1.35, 95% CI 1.07-1.70), abnormal gait (OR 10.86, 95% CI 1.46-1,388.4), effusion (OR 16.58, 95% CI 2.22-2,120.5), and flexion contracture (OR 2.37, 95% CI 1.50-3.73). The prevalence of ROA versus no OA was significantly associated with age, body mass index, pain frequency, pain duration, severe knee injury, sports activity, gait, effusion, bony swelling, crepitus, flexion contracture, and flexion. The prevalence of pre-ROA versus no OA was increased with age, sports activity, effusion, and flexion contracture, and reduced with valgus malalignment. Cartilage defects were highly prevalent in this symptomatic population-based cohort, with 49% of subjects having pre-ROA and 38% having ROA. Prevalent cartilage defects were significantly associated with age, sports activity, abnormal gait, effusion, and flexion contracture.

The Treatments for Severe Knee Flexion Contracture in Patients with Rheumatoid Arthritis

The Treatments for Severe Knee Flexion Contracture in Patients with Rheumatoid Arthritis

Popliteal pterygium knee contracture: Treatment with the Ilizarov technique

Various treatment options are in use to address severe knee flexion contractures in children. Their success depends on an adequate selection of the proper one applying to each individual anatomical situation. Applied to limb deformity, the Ilizarov technique combines progressive correction, to joint structures flexibility restitution in case of severe knee flexion contracture. We review a continuous series of popliteal pterygium syndrome patients managed with this technique. Medical records of eight children (11 knees), consecutively treated between 1986 and 2007, were reviewed. Knee flexion ranged from 40 to 120 degrees. Contracture (> 90 degrees) was extremely severe in 10 cases. Progressive correction was gained by Ilizarov external fixation. Complications during and following articular chain distraction-lengthening were noted. Follow-up ranged from 1 to 21 years. Surgical realignment was rendered particularly complex by the popliteal cutaneous band itself, partly responsible of the joint stiffness and sciatic nerve shortening. Deformities were corrected by the Ilizarov technique. Complete extension was obtained in all cases. In six cases, flexion contracture reccurrence required to repeat the correction, using the same technique, at a mean interval of 3-4 years. During follow-up, four evolutive partial posterior tibial dislocations and one complete dislocation were diagnosed, all associated with recurrence of the flexion contracture. Level IV. Therapeutic Study.

Exposure in difficult total knee arthroplasty using coronal tibial tubercle osteotomy.

Exposure in a total knee arthroplasty can be challenging regardless of whether it is a difficult primary or a revision. Various techniques both proximal and distal to the patella have been described and implemented to gain exposure and improve knee flexion. When patella eversion is not possible due to previous surgery or severe preoperative knee flexion contracture, a coronal tibial tubercle osteotomy may be utilized. We present successful results utilizing the coronal tibial tubercle osteotomy procedure. The technique involved in this series is based on that described by Whiteside. It involves the development of a long lateral musculoperiosteal flap incorporating the tibial tubercle and anterior tibia, and leaving the proximal tibial cortex intact. This is extended along the tibia distally for 10 cm. It finishes by gradually osteotomising the anterior surface of the tibial crest. The tubercle is reattached with wires at the end of the procedure. This technique minimizes complications that have been associated with the tibial tubercle osteotomy. The 10 knees in 9 patients, who had total knee arthroplasty with a coronal tibial tubercle osteotomy, were reviewed pre and postoperatively. All knees were assessed using the Hospital for Special Surgery knee score (HSS). The scores averaged 43.6 preoperatively (range, 29 57) and 79.2 postoperatively (range, 67 90), and the mean range of motion was 59.5 degrees preoperatively and 78.0 degrees postoperatively. There were no cases of extension lag. Fixed flexion deformity was present in 3 cases postoperatively. Average time to union at the proximal and distal ends of the osteotomy was 8 and 24 weeks respectively. There was no evidence of nonunion and no other significant complications occurred.

Therapeutic options in the management of articular contractures in haemophiliacs.

Haemophilic contracture is seen most commonly as an equinus deformity of the ankle, or at the knee or elbow in the form of a flexion deformity. Treatment options are varied, and decision-making is based on the degree of the contracture, its chronicity, the presence of articular subluxation, the patient's ability to participate in treatment, and the available medical facilities. The treatments available fall into four categories: physiotherapy, orthotics, corrective devices, and surgical procedures. Treatment should be primarily by physiotherapy, splintage, and corrective devices. The late or severe case may require surgical correction in the form of soft-tissue procedures. Soft-tissue correction of muscle shorthening may be performed such as lengthening of the Achilles tendon for equinus deformity of the ankle, or hamstring release of the flexor muscles of the knee. Lower femoral osteotomy has been used for correction of flexion deformity at the knee joint. Mechanical distraction using external fixators for treatment of severe knee flexion contractures has been recently reported with satisfactory results. The main principle underlying the treatment of haemophilic contracture is the restoration of the patient's lifestyle and mobility, rather than anatomic or radiographic normality.

Distal Femoral Extension Osteotomy for Knee Flexion Contracture in Patients with Arthrogryposis

Severe knee flexion contractures in patients with arthrogryposis multiplex congenita were treated by distal femoral extension osteotomy. Thirty-two operations were followed for an average of 32 months. Contractures were corrected from 49 degrees to 6 degrees. During follow-up there was a loss of correction of 22 degrees at a rate of 0.9 degrees/ month. The angle of the distal femoral physis and the shaft of the femur was 2 degrees of flexion preoperatively, and postoperatively it measured 43 degrees of extension and at late follow-up it measured 19 degrees. Remodeling occurred at a rate of 1.0 degrees/month, which correlated with recurrence. All patients increased their ambulatory ability at least one level. There was one wound infection. Distal femoral extension osteotomy is effective and safe for the correction of knee flexion contracture. Recurrence occurs in all growing children.

Mechanical Distraction for Treatment of Severe Knee Flexion Contractures

Ten patients (14 knees) with severe knee flexion contractures were treated by gradual mechanical distraction using either the Ilizarov or Orthofix external fixator. Range of motion improved from an average flexion contracture of 60 degrees before surgery to 16 degrees at the follow-up evaluation. Range of motion results were graded good or excellent in five knees, fair in two knees, and poor in three knees. Average total arc of motion remained essentially unchanged when comparing the preoperative (59 degrees) with the follow-up results (63 degrees). However, the functional position of this arc improved significantly. Problems encountered included a "rebound" phenomena after frame removal, with loss of the temporarily increased total arc of motion. The role of hamstring tenotomy and radical posterior knee release remains unclear.

Efficacy of Soft Splints in Reducing Severe Knee-Flexion Contractures

Efficacy of Soft Splints in Reducing Severe Knee-Flexion Contractures

Slow, Gradual External Fixation Distraction for Treatment of Postburn Knee Flexion Contracture

Although surgical release and reconstruction have been used extensively to treat severe postburn knee flexion contractures, the degree of correction is sometimes unsatisfactory, and the procedure is not exempt from significant complications. Based on the principle of slow, gradual external fixation distraction, we have designed a triangular articulated frame to be mounted with the ASIF-BM fixator to deal with joint flexion contractures. One successfully treated patient is reported. This is a percutaneous surgery, with very mild aggression to the patient and very low iatrogenic risks. The technique is easy, the degree of correction may be almost complete, and the hospital stay is very short because it is an ambulatory surgery.

Modified posterior soft tissue release for management of severe knee flexion contracture.

A modified posterior soft tissue release has been used in treating severe flexion contracture of the knee in 30 patients (36 knees). The operative technique has been modified with respect to the skin incision, and lengthening of the medial hamstrings. It is performed without a tourniquet. Postoperative skeletal traction was applied with gradual increasing weight to rapidly correct residual deformity. The deformity was fully corrected in 30 knees. The only complication was superficial skin necrosis over a small area, which occured in two knees. In six knees, 10 degrees of flexion deformity persisted after treatment. In four additional knees, 10 degrees of flexion deformity recurred due to lack of continued therapy. The modified posterior soft tissue release operation gave good results without any serious complications.

Efficacy of soft splints in reducing severe knee-flexion contractures.

This study evaluated the effectiveness of soft splints made from polyurethane foam in reducing severe knee-flexion contractures of patients with cerebral palsy. The splints were applied nightly over a period of 10 months. Knee-flexion contractures were reduced by an average of 24 degrees in all patients. Younger patients generally presented with less severe initial contractures and had the greatest percentage of improvement. When used on a single limb when bilateral contractures were present, sympathetic reduction of the contracture occurred to varying degrees in the unsplinted limb. It is recommended that the splints be replaced regularly to maximize their effectiveness. The benefit-to-cost ratio is extremely high and their low cost makes soft splints feasible for use in developing countries and by low-income families.