JORT Journal

Introduction

Flexion deformity presented in many patients underwent Total Knee Arthroplasty (TKR). The degree of fixed flexion deformity varies from mild, moderate to severe types, most of flexion deformities can be corrected at surgery, part of deformity after induction of anaethesia, and the residual degrees by surgery. Correction of flexion deformity can be obtained by soft tissue release and proper bone cuts during TKR. Full extension must be obtained during and after surgery as residual flexion deformity cannot be tolerated by patients presented as a functional disability [1]. Contractures and shortening of hamstring muscles and ligaments causing knee flexion deformity and added to increasing the energy expenditure during walking, standing alone, and inability for long period standing [2,3].Osteophytes in intercondylar region of the knee acting as bony block limiting extension. Posterior osteophytes impinging on the posterior capsule increasing knee flexion deformity and consequently soft tissue contracture. Posterior tibial bone erosion decrease quadriceps strength and extension lag result in in flexion deformity [4]. Flexion deformity were classified by Lombardi, et al [5]. According to its severity into mild Grade I with limited contracture less than 15 degrees ,moderate Grade II with contractures between 15-30 degrees and severe grade more than 30 degrees flexion. Total knee replacement in patients with flexion deformity had to be evaluated clinically and radio logically for grade of flexion, associated coronal plane deformity, range of motion, and lag of extension. Radiologic evaluation including slandered views of the knee for posterior condylar bone erosion and deficiency as it can disturb the rotation of femoral component in posterior referencing guided systems and instrumentations, coronal deformity, posterior and intercondylar osteophytes, augments, allografts can be used in large bone defect; modular prostheses also can be used in such cases [6](Table 1).

The purpose of this study to evaluate the early results after TKR on knees with moderate to severe flexion contractures performed with TKR.

Materials and Methods

This prospective study had conducted on twenty five with 11 male and 12 female (25 knees) with primary OA knee with flexion deformity that underwent primary TKA and soft tissue balancing from June 2010 to July 2018. The mean age was 59.39±5.97 (range 48-71), mean flexion contracture deformity was 34±11.63 (range 20-60), and mean preoperative ROM was 65±9.34 (range 45-80). The mean postoperative ROM 99.2±934 (range 65-110) and the mean disease course was 3.53±0.811 (range 2.4-5.3) years (Table 2). The data included preoperative, intraoperative, and postoperative evaluation at standard intervals and annual followup reports. All patients were diagnosed as primary OA arthritis of the knee with varus knee deformity in ten knees (varus range 15-25°). The inclusion criteria were knees had flexion contracture with varus deformity. Exclusion criteria included pathologic conditions of the Rheumatoid Arthritis knee, infection, trauma and tumor. The patients were divided into two groups, Group I Moderate Flexion deformity group (MF) in 12 patients (14 knees) (56%) (With flexion contracture < 30°), 6 male and 6 female and group II Severe Flexion deformity group (SF) 11 patients with 11 knees (44%) three male and nine female (With flexion contracture >30°). In group I preoperative mean Knee Society Score (KSS) was 34 (0 to 71) and the KSS Functional Score was 43 (0 to 70). In Group II preoperative mean Knee Society Score (KSS) was 28(0 to 56) and the KSS Functional Score was 43 (0 to 70). All patients were encouraged to do physiotherapy in the postoperative period (Table 3).

Preoperative preparation

A knee flexion contracture patient requiring knee reconstruction will be tested for coronal plane deformities, degree of flexion deformity, extensor lag, and preoperative motion range. Standard X-rays should be evaluated to determine bone anatomy disorders, particularly posterior condylar deficiencies, coronal deformities and prominent osteophytes. The posterior condylar deficiency affects the rotation of the femoral component when a posterior reference system or a measured resection technique is used.

Surgical technique

After induction of anesthesia, a pneumatic tourniquet is applied over the limb to be operated and activated immediately before incision. The operating leg is examined again under anesthesia to determine the degree of deformity. Limb is wrapped and packed according to hospital guidelines with betadine or chlorhexidine solution. (Table 4). An incision of the midline skin extending approximately 5 cm proximally to the suprapatellar pouch to a point only of medial to tibial tubercle. Medial parapatellar osteotomy is done with patella eversion, which reveals both lateral and medial femoral condyle. Standard total knee arthroplasty is initiated with “measured resection” in which the bone that is resected is the same dimension as the prosthesis. In group I: As in primary uncomplicated arthroplasty, tibial and femoral cuts are carried out in a usual way. The contracture of flexion is due to subsequent recess and osteophytes indenting upon the capsule. Using 3⁄4 inch osteotomies, the osteophytes can be easily visualized and removed after the bony cuts. The loose osteophytes may be extracted with the aid of curette. The subsequent obliterated recess may then be formed with osteotomies. The osteophytes can be extracted from the posterior part of tibia with the help of curette and osteotomies. Further release of posterior recess is accomplished in the event that the extension gap is less than the flexion gap. If the extension gap is greater than the flexion gap, the rear tibia slope may be raised to 8° to balance the knee. Tight flexion distance will cause the femoral portion to roll back improperly and rise off the tibial tray.

In group II: In addition to release of posterior recesses and removal of osteophytes as described in grade I flexion management, the posterior cruciate ligament is released first from the femoral end and then from the tibial end. In cases where there is a significant weakening of the posterior cruciate ligament, posterior stabilized components are indicated. If the extension gap is smaller than the flexion gap, the distal femur is respected by 2 mm with cruciate retaining knee components, and then distal femur should be respected by more than 4 mm as it can result in dysfunction of the posterior cruciate ligament due to the elevation of joint line (Figures 1&2) (Table 2).

Results

Twenty three patients with 25 knees with primary OA with severe flexion deformity and varus knee deformity 12 patients female (14 knees 56%) and 11 patients male (11 knees 44%). The mean age of patients at the time of sugary was 59±5.97 (range, 48-71) years (Figure 1). Bilateral TKA was done in 23 patients and unilateral TKA in 21 patients. The average follow-up was 46 months. The varus deformities were in 10 knees with the range 15-25° (Figures 3-5).

Group I: the mean age was 58.85±6.34 (range 48-70) years, the mean flexion deformity 25.36±3.65 (range 20-30°), the ROM improved from 67.5±9.14 (range 45°-70°)(Figure 2) to 102.5±4.70 (range 95°-110°)(Figure 3) and the mean disease course 3.17±0.51 (range 2.4-3.8) years. The mean Knee Society Score (KSS) improved from 34 (range 0 to 71) to 88 (range 38 to 100) (p < 0.001) and the KSS Functional Score from 43 (range 0 to 70) to 86 (range 0 to 100). No knees required manipulations under anaethesia (MUA) and none of the knees had flexion instability (Table 4).

Group II: the mean age was 60±5.69 (range 50-71) years, the mean flexion deformity 45±8.36 (range 35-60°), the ROM improved from 62.7±9.31 (range 50°-80°) to 95±12.04 (range 65°-105°) and the mean disease course 3.99±0.90 (range 2.4-5.3) years. The mean Knee Society Score (KSS) improved from 28(range 0 to 56) to 85 (range 40 to 100) and the KSS Functional Score from 43 (range 0 to 70) to 84 (range 0 to 100). Two knees (8%) required manipulations under anaethesia (MUA) and none of the knees had flexion instability (Table 4).

The postoperative flexion deformity residual was not significant in this study and all patients gain full extension. No improvement in range of motion and residual flexion deformity was recorded after one year. Complications were skin necrosis in two knees and multiple blister formation in three knees. For skin necrosis, thorough debridement was done and the wounds healed satisfactorily. No peroneal nerve palsy occurred in this study.

Discussion

Knees with extreme flexion contracture generally present with back subluxation of the tibia, proximal tibial bone insufficiency joined with valgus distortion, and external rotation of the tibia, which can be in partially attributed to the contracture and the traction of the biceps muscle and iliotibial tract [7].

The contribution of the periarticular delicate tissues is a part of pathology in rheumatoid arthritis. Consequently, it is basic to accomplish amendment of deformity, adjust the medial and lateral soft tissue pressure, and embed the parts precisely. Proper soft tissue balancing as the capsule and the tendons release during arthroplasty is basic for the achievement of the technique [8,9]. Regarding the staying some flexion in activity, it was particularly critical to appropriately situate the individual segments and the subsequent generally arrangement of the lower furthest point in knee with one-phase TKA [10]. In the current investigation, successful TKA was acted in moderate flexion contracture patients as well as in severe flexion deformity of patients, and all cases had great clinical outcomes. When the right hard arrangement is accomplished, it is very important for the good result of TKA that the medial and lateral joint laxity does not exceed more than 2 mm in the stress test (varus and valgus stress testing) when prostheses are implanted. In spite of the fact that TKA can be performed in this difficult patients [11,12]. Complete intraoperative correction of severe flexion deformity introduced a difficult challenging for orthopedic surgeons [11,12]. Different procedures of tending to these deformities have been depicted including extra hard resection, ligamentous discharges, and the utilization of the constraint prosthesis [13]. In any case, a perfect delicate tissue balance is hard to acquire during medical procedure [14].

For achieving an obvious correction of the flexion contracture and also effectively improves the range of motion and the functional recovery of the knee joint after TKA by good soft tissues balancing as ligamentous and capsular release intraoperative [9,12].However, indications of orthopedic procedure on the flexion contracture were complex and required special attention of the good collateral stability and good experience in TKA surgery [15- 17]. In our study early we had instability during TKA procedure. So, the good soft tissue balancing in the form of the release of the ligament and capsule at the time of arthroplasty is mandatory for the good result of TKA procedures in severe flexion contractures of RA patients. Flexion contracture is a typical deformation experienced during all Total knee arthroplasty, and severe fixed deformity requires careful surgical correction with release of the contracted soft tissues and proper management of the femoral bone cuts [18]. Customary techniques for remedying a severe flexion deformity of the knee during total knee arthroplasty can regularly prompt the excessive release of the posterior capsule and medial or lateral collateral ligament. The same number of reports on flexion contracture the management in the knee is accessible in the literature; the peroneal nerve paralysis in TKA was concerned already [19]. Preoperative severe flexion contracture was accepted as the hazard factor for the advancement of the nerve paralysis after TKA [20,21]. In TKA, complete intraoperative remedy of severe flexion deformity is dangerous, which can cause complications, for example, the peroneal nerve paralysis [22]. At present study, the careful decompression of peroneal nerve was performed and we had no peroneal nerve injury. Therefore, the great outcome ought to be because of the proper soft tissue adjusting other than a massive release during arthroplasty.

The achievement of TKA in extreme flexion distortion of patients relies upon numerous elements, including the preoperative state of the joint, careful procedure, and postoperative recovery [23,24]. Braces are acceptable strong gadgets in flexion patients. The experience of Sarokhan, et al [25]. has indicated that the utilization of preoperative and postoperative sequential throws helps enormously in the remedy of serious flexion deformation of the knee. The utilization of dynamic expansion bracing around evening time is gainful to improve flexion contractures for this situation considers. Physiotherapy is another significant segment of flexion patients [26]. In this study, braces are strong gadgets in flexion patients until the some leftover flexion contractures were completely amended. Rand [27] announced that the most significant entanglement influencing the after effects of absolute knee substitution in patients is disease. Paces of disease have been accounted for to be around multiple times more noteworthy in patients with RA than in those with OA [28-30].

Conclusion

The complexity of the surgical procedure increases with an increased flexion deformity of the knee. Less complex deformities are corrected with the usual bone resections and removal of osteophytes. Special attention should be paid to the development of the posterior capsule. Bone resection, especially distal femur, should be reserved in cases where soft tissue release results in insufficient flexion-extension gaps.

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