Treatment Of Knee Flexion Contracture Research Articles

Pathologic external tibial torsion as one of the causes of knee joint dysfunction and formation of pronation deformity in children with cerebral palsy

Introduction. One of the complications of the clinical course of cerebral palsy in children is external torsion of the tibia. The issue of localization and the mechanism of its formation, as well as effective methods of its elimination, is debatable. Purpose - to study the mechanisms of the formation of pathological external torsion of the tibia in children with cerebral palsy, its effect on knee joint contracture and foot deformity, and effective methods of their correction. Materials and methods. The data obtained during the observation of 45 patients (90 cases) aged from 6 to 16 years with spastic diplegia, spastic tetraparesis and foot pronation were analyzed. To study the mechanisms of formation of external torsion of the lower leg and its correction, 2 groups of patients were selected. The Group I - 24 patients with internal rotation contractures of the hip joint (10 patients with internal rotation contractures of the hip joint; 10 patients - in combination with pathological antetorsion of the femoral neck; 4 patients - in combination with flexion contractures of the knee joints). The relationship between internal rotation contracture of the hip joint and external torsion of the tibia. The Group II consisted of 21 patients who were diagnosed with flexion contracture of the knee joints in combination with external torsion of the tibia. In order to study the effectiveness of operative treatment of knee flexion contracture and external torsion of the tibia in the Group II, 2 subgroups were distinguished: the subgroup IIA - 9 patients who underwent osteotomy of the tibial bone; the subgroup IIB - 12 patients who only underwent biceps femoris transposition. Results. Based on the study of clinical and radiological indicators, it was established that pathological torsion of the tibial bone is combined with flexion contracture of the knee joints. Proximal derotational osteotomy of the tibia has a positive effect on the results of correction of knee flexion contracture and foot position. Conclusions. The main reason for the formation of external torsion of the tibia is the imbalance of the flexor muscles of the knee joint and the supinator and pronator muscles of the foot. Proximal tibial derotation osteotomy eliminates not only pathological torsion, but also flexion contracture of the knee joints and excessive pronation of the foot. The study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the local ethics committees of all institutions participating in the study. Informed consent of the patients was obtained for the research. No conflict of interests was declared by the authors.

Arthroscopic Posterior Capsulotomy for Knee Flexion Contracture Using a Spinal Needle

Knee flexion contractures can arise from posterior capsule arthrofibrosis secondary to trauma, surgery, or chronic degenerative disease. This leads to limited knee extension and increased mechanical stress on the contralateral joint. Depending on the severity of the contracture, a treatment option may include surgical release of the posterior capsule. Arthroscopic posterior capsular release has been reported previously to have excellent resolution of extension deficits with minimal risk of postoperative complications. These techniques typically use an array of instruments, including shavers, biters, or scissors to perform arthrolysis of the posteromedial and posterolateral capsules. Our primary objective is to present a modified arthroscopic surgical technique for percutaneous treatment of knee flexion contracture using a spinal needle to perform a posterior capsule release.

Flexion contracture is a risk factor for knee osteoarthritis incidence, progression and earlier arthroplasty: Data from the Osteoarthritis Initiative.

Knee joint osteoarthritis (OA) is often accompanied by flexion contracture (FC), but the impact of FC on important outcomes across the spectrum of OA, such as the incidence, progression and need for total knee arthroplasty (TKA), is not well established. We evaluated whether the presence and/or severity of knee FC were risk factors for worse OA clinical outcomes, radiographic incidence and progression as well as time to TKA. We evaluated longitudinal 9-year data from the Osteoarthritis Initiative (OAI) database for 3 sub-cohorts: at-risk of knee OA (n=3284), radiographically established knee OA (n=1390), and low-risk controls (n=122). We classified knee FC as none, mild, moderate or severe based on knee extension at enrolment. Knee OA outcomes were extracted from the database. FC was present in 32.4% of knees. Participants with FC had increased knee OA incidence with joint space narrowing in the definition (corrected odds ratio 1.31 [95% confidence interval (CI) 1.04-1.64]). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for pain, stiffness and function were worse with than without FC at nearly all times (p<0.001). Effect estimates were significant for all 3 WOMAC sub-scales comparing FC to no FC (pain: 0.15 [95% CI 0.02-0.28], stiffness: 0.11 [0.05-0.18], function: 0.49 [0.05-0.93]). Individuals with knee FC had higher Kellgren and Lawrence grade (effect size 0.31 [95% CI 0.25-0.37]) and were more likely to undergo TKA (corrected odds ratio 1.37 [95% CI 1.10-1.71]) than those without FC. All outcomes were worse with increasing FC severity. The presence of knee FC at enrolment was a risk factor for radiographic OA incidence including joint space narrowing, worse clinical outcomes, radiographic progression and the need for early TKA. Treatment of knee FC may represent an option across the OA spectrum. Further research is needed to evaluate the pathophysiology, joint structure alterations and longitudinal impact of treating FC in individuals with knee OA.

Serial Cast Method in the Treatment of Knee Flexion Contractures in the Elderly

Knee flexion contracture is observed sometimes in the elderly walking. The serial cast method has been successful in treating knee contracture secondary to neurological diseases after injection of botulinum toxin. We focus on 3 cases: all patients were unable to walk because of knee flexion contracture. They have benefited from our protocol of serial casts and at the end of the treatment, knee flessum was less. All patients have recovered the ability to walk. Our method is simple and fast. For these 3 patients, we could discuss percutaneous needle tenotomies but it requires a trained team.

Treatment of knee flexion contracture with Ilizarov technology after burns

To summarize the effectiveness of Ilizarov technique in the correction of flexion contracture deformity of the knee after burn. Between April 2012 and July 2017, Ilizarov technique was used to treat 14 cases (17 knees) of knee flexion contracture patients. There were 11 males (13 knees) and 3 females (4 knees), with an age of 20-48 years (mean, 37 years). The duration of scar formation was 8 months to 24 years (mean, 5 years). The scar ranged from the upper part of the thigh, down to the middle part of the leg, from both sides to the inside and outside of the popliteal fossa, without ulceration. The area after scar contracture was 12 cm×10 cm to 30 cm×22 cm. Preoperative total activity of motion (TAM) was 30-115° (mean, 69°). There were 4 cases in wheelchair, 5 cases walking with double crutches, 3 cases with limp, and 2 cases with half squat walking. According to the knee function evaluation criteria by QIN Sihe, the preoperative knee function was fair in 3 knees, poor in 5 knees, and very poor in 9 knees. All patients were followed up 6 months to 5 years (mean, 2 years). No local skin necrosis, needle tract infection, limb numbness, and other complications occurred. Knee flexion deformities were all corrected. The postoperative TAM was 70-145° (mean, 125°). All patients were able to walk with plantar weight-bearing, and their gait improved when compared with that before operation. Five cases could walk without a crutch and only slightly claudication after operation. At last follow-up, according to the knee function evaluation criteria, the results were excellent in 9 knees, good in 5 knees, and fair in 3 knees, all were significantly improved when compared with that before operation ( Z=-3.677, P=0.000). Ilizarov technique has the advantages of minimally invasive, safe, and easy to operate for the treatment of flexion contracture deformity of the knee after burn.

Intra-articular collagenase injection increases range of motion in a rat knee flexion contracture model

ObjectivesA knee joint contracture, a loss in passive range of motion (ROM), can be caused by prolonged immobility. In a rat knee immobilization flexion contracture model, the posterior capsule was shown to contribute to an irreversible limitation in ROM, and collagen pathways were identified as differentially expressed over the development of a contracture. Collagenases purified from Clostridium histolyticum are currently prescribed to treat Dupuytren’s and Peyronie’s contractures due to their ability to degrade collagen. The potential application of collagenases to target collagen in the posterior capsule was tested in this model.Materials and methodsRats had one hind leg immobilized, developing a knee flexion contracture. After 4 weeks, the immobilization device was removed, and the rats received one 50 µL intra-articular injection of 0.6 mg/mL purified collagenase. Control rats were injected with only the buffer. After 2 weeks of spontaneous remobilization following the injections, ROM was measured with a rat knee arthrometer, and histological sections were immunostained with antibodies against rat collagen types I and III.Results/conclusionCompared with buffer-injected control knees, collagenase-treated knees showed increased ROM in extension by 8.0°±3.8° (p-value <0.05). Immunohistochemical analysis revealed an increase in collagen type III staining (p<0.01) in the posterior capsule of collagenase-treated knees indicating an effect on the extracellular matrix due to the collagenase. Collagen I staining was unchanged (p>0.05). The current study provides experimental evidence for the pharmacological treatment of knee flexion contractures with intra-articular collagenase injection, improving the knee ROM.

Quengel Casting for the Management of Pediatric Knee Flexion Contractures: A 26-Year Single Institution Experience.

Quengel casting was introduced in 1922 for nonsurgical treatment of knee flexion contractures (KFC) associated with hemophilic arthropathy. It consists of an extension-desubluxation hinge fixed to a cast allowing for gradual correction of a flexion deformity while preventing posterior tibial subluxation. The purpose of this study is to report 1 center's experience with this technique for the treatment of pediatric KFC. A retrospective review was conducted over a 26-year period. All patients with KFC treated with Quengel casting were included. Demographic data, associated medical conditions, adjunctive soft tissue releases, complications, and the need for late surgical intervention were recorded. Tibiofemoral angle measurements in maximal extension were recorded at initiation and termination of casting, 1-year follow-up, and final follow-up. Success was defined as no symptomatic recurrence of KFC or need for subsequent surgery. Eighteen patients (26 knees) were treated for KFC with Quengel casting. Average age at initiation of casting was 8.1 years with average follow-up of 59.9 months. Fifteen knees (58%) underwent soft tissue releases before casting. An average of 1.5 casts per knee were applied over an average of 23.9 days. Average KFC before casting was 50.6 degrees (range, 15 to 100 degrees) which improved to 5.96 degrees (0 to 40 degrees) at cast removal (P<0.00001). Sixteen patients (22 knees) had 1-year follow-up or failed casting before 1 year. Of these, 11 knees (50%) had a successful outcome. Residual KFC of those treated successfully was 6.8 degrees (range, 0 to 30 degrees) at 1 year and 8.2 degrees (range, 0 to 30 degrees) at final follow-up, averaging 71.4 months (P=0.81). Of the 11 knees deemed failures, all had recurrence of deformity within an average of 1 year from cast removal. Surgical release before Quengel casting did not improve the chances for success (P=0.09). Quengel casting can improve pediatric KFC an average of 44.2 degrees with minimal complications. Although 50% of treated patients will demonstrate significant recurrence or need later surgery, the majority of those treated successfully have durable results at intermediate term follow-up. Level IV-therapeutic study.

Side effects and potential risk factors of botulinum toxin type A intramuscular injections in knee flexion contractures of hemophiliacs

ABSTRACTIntroduction: Knee flexion contracture (KFC) is a common complication of recurrent hemarthrosis in children and young adults with hemophilia. If the KFC is not prevented (by means of primary prophylaxis) and treated properly and early (be means of physical medicine and rehabilitation), it will become fixed.Areas covered: The aim of this article is to review the potential role of botulinum toxin type A (BTX-A) intramuscular injections for the treatment of KFC in people with hemophilia (PWH).Expert commentary: Although two recent reports have mentioned the benefits of intramuscular injections of BTX-A in PWH with KFC, the data are still scant and too preliminary. The use of intramuscular injections of BTX-A in PWH today should not be recommended until more case studies/small series (ideally well-designed clinical trials) fully demonstrate that this is safe and effective. The risks of intramuscular injections to a hemophilia patient cannot be underestimated (iatrogenic muscle hematomas and pseudotumors). This paper calls the attention of hemophilia treaters on the potential risks of this apparently interesting technique. The current use of BTX-A intramuscular injections in KFC of PWH could make no sense. Raising false expectations in these patients should be avoided.

Ultraflex® dynamic orthosis: High tolerance, key factor of its efficiency in the treatment of knee flexion contracture in child with cerebral palsy

Ultraflex® dynamic orthosis: High tolerance, key factor of its efficiency in the treatment of knee flexion contracture in child with cerebral palsy

Radical Posterior Capsulectomy Improves Sagittal Knee Motion in Crouch Gait

Knee flexion contracture leading to crouch gait is commonly seen in children with myelomeningocele. Progressive increase in knee flexion contracture increases energy cost, which interferes with efficient, functional ambulation. To prevent this, surgical release has been recommended when a knee flexion contracture exceeds 15° to 20°. We therefore asked whether knee flexion contracture release improved dynamic sagittal motion and walking velocity using computerized gait analysis. We retrospectively studied 11 patients (20 knees) with high-sacral-level or low-lumbar-level myelomeningocele and knee flexion contracture of greater than 15°. All patients underwent dynamic gait analysis pre- and postoperatively. Surgery consisted of selective hamstring lengthening (medial and lateral), gastrocnemius release from the femoral condyles, and posterior knee capsulectomy. We observed improvements postoperatively in clinical measurements and sagittal kinematics. The clinical knee flexion contracture improved from a mean of 24.9° preoperatively to 5.9° postoperatively. The knee flexion at initial contact improved from 37.6° to 9.0°, and minimum knee flexion in single-leg stance improved from 48.2° to 16.4. Walking velocity improved from 72.2% to 80.0% of age-matched normal. Surgical treatment of knee flexion contracture in patients with myelomeningocele using radical posterior knee capsulectomy leads to improvement in clinical knee flexion contracture, dynamic sagittal kinematics, and walking velocity.

Treatment of Knee Flexion Contracture Due to Central Nervous System Disorders in Adults

Studies concerning adult patients with spastic flexion contracture of the knee are rare. Such patients frequently have cutaneous and vascular complications as well as recurrence of the contracture after treatment. We present a strategy consisting of simultaneous correction of all deformities of both lower limbs, distal hamstring releases, and application of femorotibial external fixation when extension of the knee is limited by excessive posterior soft-tissue tension. A consecutive series of fifty-nine patients (ninety-seven knees) between the ages of twenty-one and seventy-seven years received surgical treatment for a flexion contracture of the knee secondary to neurological impairment. The flexion contracture was bilateral in thirty-eight patients. Preoperatively, the mean flexion contracture angle was 69 degrees and the mean passive range of motion was 61 degrees. The contracture was corrected, through medial and lateral approaches, with distal hamstring lengthening. A posterior capsulotomy was performed in thirty-five knees. Full extension of thirty-four knees was achieved intraoperatively. In seventy-seven knees, partial correction was maintained with a unilateral external fixator, and passive and active mobilization was performed four times daily after temporary removal of the spanning external fixator rod. At the time of final follow-up, ranging from one to five years postoperatively, the mean residual flexion contracture was 6.2 degrees. Forty-five knees had complete extension, and thirty-nine knees had a residual flexion contracture of <10 degrees. No recurrence of the flexion contracture or instability was noted in any knee at the time of follow-up. There were four cutaneous complications but no vascular or neurological complications. We believe that our surgical strategy for correction of fixed knee flexion contracture in adult patients is safe and effective. The correction improves nursing care and sitting posture, facilitating the upright position of patients who are unable to walk, and improves walking ability for patients who are able to walk.

Treatment of knee flexion contracture in patients with chronic juvenile arthritis: A case report

Knee flexion contractures are common after-effects of juvenile arthritis. Treatment is usually conservative and may include physical therapy and kinesitherapy. Surgical treatment, particularly of the soft parts, indicated for contractures resistant to conservative treatment, helps to correct the deformity, maintain movements, and relieves pain. Intensive postoperative physiotherapy is of special importance. A 23-year-old female patient with chronic juvenile arthritis since the age of one was admitted for treatment of flexion contractures in both knees, muscle hypotrophy, loss of strength and gait disability. The patient underwent arthroscopic synovectomy. The operation was first performed on the right and after 3 mouths on the left knee. The preoperative range of motion in the right knee was 30 degrees - 70 degrees and in the left 40 degrees - 80 degrees. The patient underwent intensive physical therapy to reduce postoperative swelling of knees and firstly passive and then active kinesitherapy. Nine months after the first surgery and six months after the second, the range of motion in the right knee was 0 degrees - 100 degrees and in the left 0 degrees - 105 degrees. The strength of tested muscles was increased and gait was improved. Management and rehabilitation of patients with chronic juvenile arthritis include maintenance or improvement in position and function of joints that is achieved with synovectomy. The results depend on combined interdisciplinary rehabilitation, well-experienced staff and pre- and post-operative physiotherapy as well as kinesitherapy. Arthroscopic synovectomy has many advantages and we believe that it was a better solution than open capsulosynovectomy in this patient with chronic juvenile arthritis of the knee.

Follow-up study after treatment of knee flexion contractures in spina bifida patients.

Knee flexion contractures in spina bifida patients are seen in all levels of paralysis. The majority is encountered in children with thoracolumbar lesions. Positional deformation, spinal reflex activity, fractures around the knee joint and a weak quadriceps are the main causes of the flexion deformity of the knee. One hundred and forty-five knee flexion contractures in 80 children have been treated between 1980 and 1995; 15 with unilateral contracture, 65 with bilateral involvement. The age at the time of correction in 38 patients with thoracolumbar lesions was between 24 months and 11 years (average, 7.7 years). In 42 patients with sacral or lumbosacral lesions, the age at the time of correction was between 10 and 19 years (average, 16.3 years). Associated surgery was mainly carried out on hip flexors, adductors and triceps surae. Complete posterior release was practiced in thoracolumbar lesions including posterior capsulotomy and release of the posterior cruciate ligament. In lumbosacral lesions, the lengthened tendons are sutured to prevent flexor weakness in the postoperative course. Vascular and neurologic structures are spared. Postoperative serial casts are helpful to achieve full extension without vascular or skin troubles. The long-term results were very good in 59 patients with 106 knees, good in 16 patients with 29 knees, and unsatisfactory in 5 patients with 10 knees. Slow deterioration years after surgery can be anticipated. The main causes are lack of personal initiative to stand and to walk, and obesity.

Low-Load, Prolonged Stretch in the Treatment of Knee Flexion Contractures in Nursing Home Residents

The purpose of this study was to do a pilot test of the effectiveness of prolonged stretch (use of splint) in reducing knee flexion contractures more than a traditional program of passive range of motion (PROM) in a group of nursing home residents. The subjects were 28 nursing home residents with 10 degrees or more of knee flexion contracture bilaterally. Eighteen subjects completed the study. Data were collected prior to the initiation of the intervention and at monthly intervals during the 6 months of treatment. Repeated measurements were made of hip, knee, and ankle range of motion (ROM); the torque required to maintain passive impairment. knee extension; knee pain; several indicators of function; and cognitive impairment. Both legs of each subject received PROM and manual stretching twice a week; in addition, one leg was given a prolonged stretch (use of a splint) five times a week. There were no differences in knee ROM between the side that received prolonged stretching and the side that received only PROM and manual stretching at the beginning of the study. No differences in ROM or torque measurements existed between the side that received prolonged stretching and the side that received only PROM and manual stretching at any interval, nor in ROM or torque over time for either side. Because of the low statistical power of the study, the results should be viewed with caution. Physical therapists need to question whether prolonged stretch for nursing home residents with knee flexion contractures greater than 10 degrees is of any greater benefit than PROM and manual stretching. Investigations of other treatment protocols and treatment doses are needed, including work in the area of prevention of knee flexion contractures. For the pilot group of nursing home residents studied, gains in knee extension did not occur with the use of prolonged stretch for 3 hours a day, 5 days per week. [Steffen TM, Mollinger LA. Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents.

The management of knee flexion contractures in haemophilia: brief report.

Description of the use of Flowtron, an intermittent compression system in treatment of knee flexion contractures in haemophiliac patients

Continuous Passive Motion in the Treatment of Knee Flexion Contractures

Joint contractures are a problem frequently encountered by therapists. Methods of treating joint contractures traditionally have consisted of range-of-motion and stretching exercises. The medical literature suggests that, to be effective, ROM and stretching exercises must be performed with well-controlled speed, force, and duration. The patient in our case study used continuous passive motion machines after conventional methods of exercise failed. He subsequently demonstrated a 55-degree, bilateral reduction in knee flexion contractures. The purpose of this case report is to illustrate the use of continuous passive motion machines in the treatment of severe knee flexion contractures.