- See: TKR Menu
- Discussion:
- soft tissue component is most frequently a result of of contracture of posterior capsule, but gastrocnemius, hamstrings, and PCL
are also frequently involved;
- references:
- Flexion Contracture Following Primary Total Knee Arthroplasty: Risk Factors and Outcomes
- Preoperative Considerations:
- note degree of quadriceps atrophy, since active quadriceps function will be required to regain full extension;
- some surgeons recommend that flexion contractures should be corrected as musch as possible before surgery with serial
wedging casts;
- in the study by Smith AJ, et al, there was no benefit to patellar resurfacing;
- in 22/73 knees (30.1%) with and 18/86 knees (20.9%) without patellar resurfacing there was some degree of anterior knee
pain (p = 0.183);
- a significant association between knee flexion contracture and anterior knee pain was observed in those knees with
patellar resurfacing (p = 0.006).
- ref: Total knee replacement with and without patellar resurfacing: a prospective, randomised trial using the profix total knee system.
- Intra-Operative Considerations:
- Resection of Distal Femur
- see extension gap
- flexion contracture may be corrected at time of surgery can be managed by judicious resection of femur and
tibia & stripping of posterior joint capsule & gastrocnemius origins from the distal femur;
- way not to release a fixed flexion deformity is to resect large amount of bone from proximal tibia, which would
create a very large flexion space is formed, and the knee may become unstable in flexion;
- Posterior Stabilized Implant
- in moderately severe contractures, consider removing the PCL using a posteriorly stabilized implant;
- w/ difficulty seeing plateau surface or if PCL is contracted (as occurs flexion-varus or flexion valgus deformities), then
PCL resection is needed;
- ref: - Influence of a Secondary Downsizing of the Femoral Component on the Extension Gap: A Cadaveric Study
- Posterior Capsule: Femoral Side
- after resection of the posterior femoral condyles, flex the knee and have the assistant lift up on the distal femur;
- carefully reflect the posterior capsule off the posterior femur with a perioteal elevator;
- this may include the origins of the medial and lateral heads of gastrocnemius muscles;
- inability to obtain full extension intraoperatively should not necessarily be corrected with increased
bone resection, although attention should be paid to
posterior capsular release & posterior
femoral osteophyte excision;
- always be mindful of the popliteal artery;
- references:
- Stripped knee capsule does not increase range of motion in total knee arthroplasty
- Release of the posterior knee joint capsule and range of knee motion- A prospective study.
- Posterior Capsule: Tibial Side
- oblique popliteal ligament
- The Role of the Oblique Popliteal Ligament and Other Structures in Preventing Knee Hyperextension
- posterior oblique ligament
- The role of the posterior oblique ligament in controlling posterior tibial translation in the posterior cruciate ligament-deficient knee
- references:
- V-Y quadricepsplasty in total knee arthroplasty.
- The management of fixed flexion contractures during total knee arthroplasty.
- Bone resection and ligament treatment for flexion contracture in knee arthroplasty.
- Total knee arthroplasty in patients with greater than 20 degrees flexion contracture
- Postoperative Considerations:
- radiographic workup:
- findings associated with flexion contracture:
- flexed femoral component - see saggital cutting errors
- internally rotated tibial component - see rotation of tibial component
- Internal rotation of the tibial component is frequent in stiff total knee arthroplasty.
- PT after TKR
- closed chain - press against the wall exercise;
- patient places his/her back and buttocks agaist the wall - standing and slight crouched;
- operative leg is extended as much as possible with the foot on the floor;
- patient then extends the knee, trying to fire the quadriceps as much as possible;
- crutch assist device:
- The use of an axillary crutch as a knee flexion contracture correction device.
- references:
- Does flexion contracture continue to improve up to five years after total knee arthroplasty?
- Does an outpatient physiotherapy regime improve the range of knee motion after total knee arthroplasty: a
- Flexion Contracture Persists If the Contracture is More Than 15° at 3 Months After Total Knee Arthroplasty
- natural history:
- Fixed flexion deformity following total knee arthroplasty. A prospective study of the natural history.
- Does flexion contracture continue to improve up to five years after total knee arthroplasty?
- night splints
- contralateral heel wedge
- boxtox injections into hamstring;
- Botulinum toxin type A injections for the management of flexion contractures following total knee arthroplasty.
- post arthroplasty surgery
- arthroscopic debridement
- peroneal nerve palsy as a cause of persistent knee flexion contracture (consider subclinical cases);
- ref: Peroneal Nerve Dysfunction After Total Knee Arthroplasty: Characterization and Treatment.
- references:
- Etiology and Surgical Interventions for Stiff Total Knee Replacements
TECHNIQUES IN PRIMARY TOTAL KNEE ARTHROPLASTY: Balancing ! Douglas E. Padgett, M.D.
Posterior Medial Capsular Release and External Rotation of the Tibia to Enhance Exposure During TKA