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Flexion Contracture of TKR

- 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




Posterior Medial Capsular Release and External Rotation of the Tibia to Enhance Exposure During TKA

Correcting Flexion Contractures: Getting It Straight