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Fixed Flexion Contracture

  • Fred D. CushnerEmail author
  • Andrew A. Freiberg
  • Tiffany N. Castillo
  • Jared S. Preston
  • Dexter K. Bateman
  • Bertrand W. Parcells
  • Alfred J. Tria
Chapter

Abstract

Total knee arthroplasty has become a very common procedure over the last decade. Patients are being treated earlier, and the severe deformities seen in previous decade are encountered less frequently. Despite this, there are occasions where the patient presents with a significant fixed deformity. A stepwise approach is required to safely deal with these severe deformities. Failure to do so may lead to skin compromise and further complicate the surgery. Once the arthrotomy is performed, in a stepwise fashion, tight structures need to be released to enable good surgical exposure. Quadriceps snip and an early lateral release are two techniques that can improve exposure. The bone cuts are also important, and often additional distal bone is resected to allow for full extension. A post-capsule release is also often required to enable achievement of full extension. Caution is needed, and patients need to be counseled when there is a severe flexion contracture as well as valgus deformity, since this deformity can be associated with a postoperative foot drop.

Keywords

Contracture Deformity Quadriceps snip Lateral release Stiff 

References

  1. 1.
    Bhan S, Malhotra R, Kiran EK. Comparison of total knee arthroplasty in stiff and ankylosed knees. Clin Orthop Relat Res. 2006;451:87–95.CrossRefPubMedGoogle Scholar
  2. 2.
    Hwang YS, Moon KP, Kim JW, Park WS. Total knee arthroplasty for severe flexion contracture in rheumatoid arthritis knee. Knee Surg Relat Res. 2016;28(4):325–9.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Meftah M, Blum YC, Raja D, Ranawat AS, Ranawat CS. Correcting fixed varus deformity with flexion contracture during total knee arthroplasty: the “inside-out” technique: AAOS Exhibit Selection. J Bone Joint Surg Am. 2012;94(10):e66.  https://doi.org/10.2106/JBJS.K.01444.CrossRefPubMedGoogle Scholar
  4. 4.
    Berend KR, Lombardi AV, Adams JB. Which total knee replacement implant should I pick? Correcting the pathology: the role of knee bearing designs. Bone Joint J. 2013;95-B(11 Suppl A):129–32.CrossRefPubMedGoogle Scholar
  5. 5.
    Su EP. Fixed flexion deformity and total knee arthroplasty. J Bone Joint Surg Br. 2012;94(11Suppl A):112–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Scuderi GR, Kochhar T. Management of flexion contracture in total knee arthroplasty. J Arthroplasty. 2007;22(4 Suppl 1):20–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Berend KR, Lombardi AV, Adams JB. Total knee arthroplasty in patients with greater than 20 degrees flexion contracture. Clin Orthop Relat Res. 2006;452:83–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Firestone TP, Krackow KA, Davis JD IV, Teeny SM, Hungerford DS. The management of fixed flexion contractures during total knee arthroplasty. Clin Orthop Relat Res. 1992;(284):221–7.Google Scholar
  9. 9.
    Liu DW, Reidy JF, Beller EM. The effect of distal femoral resection on fixed flexion deformity in total knee arthroplasty. J Arthroplasty. 2016;31(1):98–102.CrossRefPubMedGoogle Scholar
  10. 10.
    Vince K. Mid-flexion instability after total knee arthroplasty: woolly thinking or a real concern? Bone Joint J. 2016;98-B(1 Suppl A):84–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Okamoto S, Okazaki K, Mitsuyasu H, Matsuda S, Mizu-Uchi H, Hamai S, et al. Extension gap needs more than 1-mm laxity after implantation to avoid post-operative flexion contracture in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014;22(12):3174–80.CrossRefPubMedGoogle Scholar
  12. 12.
    Kim SH, Lim JW, Jung HJ, Lee HJ. Influence of soft tissue balancing and distal femoral resection on flexion contracture in navigated total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2016.  https://doi.org/10.1007/s00167-016-4269-9. Epub ahead of print.
  13. 13.
    Perry J, Antonelli D, Ford W. Analysis of knee-joint forces during flexed-knee stance. J Bone Joint Surg Am. 1975;57(7):961–7.CrossRefPubMedGoogle Scholar
  14. 14.
    Harato K, Nagura T, Matsumoto H, Otani T, Toyama Y, Suda Y. Knee flexion contracture will lead to mechanical overload in both limbs: a simulation study using gait analysis. Knee. 2008;15(6):467–72.CrossRefPubMedGoogle Scholar
  15. 15.
    Harato K, Nagura T, Matsumoto H, Otani T, Toyama Y, Suda Y. A gait analysis of simulated knee flexion contracture to elucidate knee-spine syndrome. Gait Posture. 2008;28(4):687–92.CrossRefPubMedGoogle Scholar
  16. 16.
    Harato K, Nagura T, Matsumoto H, Otani T, Toyama Y, Suda Y. Extension limitation in standing affects weight-bearing asymmetry after unilateral total knee arthroplasty. J Arthroplasty. 2010;25(2):225–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Quah C, Swamy G, Lewis J, Kendrew J, Badhe N. Fixed flexion deformity following total knee arthroplasty. A prospective study of the natural history. Knee. 2012;19(5):519–21.CrossRefPubMedGoogle Scholar
  18. 18.
    Mitsuyasu H, Matsuda S, Miura H, Okazaki K, Fukagawa S, Iwamoto Y. Flexion contracture persists if the contracture is more than 15 degrees at 3 months after total knee arthroplasty. J Arthroplasty. 2011;26(4):639–43.CrossRefPubMedGoogle Scholar
  19. 19.
    Bellemans J, Vandenneucker H, Victor J, Vanlauwe J. Flexion contracture in total knee arthroplasty. Clin Orthop Relat Res. 2006;452:78–82.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Fred D. Cushner
    • 1
    Email author
  • Andrew A. Freiberg
    • 2
  • Tiffany N. Castillo
    • 2
  • Jared S. Preston
    • 3
  • Dexter K. Bateman
    • 4
  • Bertrand W. Parcells
    • 5
  • Alfred J. Tria
    • 6
  1. 1.North Shore-Long Island Jewish Medical GroupNew YorkUSA
  2. 2.Department of Orthopaedic SurgeryMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  3. 3.Department of OrthopedicsRobert Wood Johnson University HospitalNew BrunswickUSA
  4. 4.Department of Orthopaedic SurgerySaint Peter’s University HospitalNew BrunswickUSA
  5. 5.Department of OrthopedicsRutgers – Robert Wood Johnson University HospitalNew BrunswickUSA
  6. 6.Orthopedic Center of New JerseySomersetUSA

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