|Year : 2016 | Volume
| Issue : 2 | Page : 102-107
Gradual correction of knee flexion contracture using external fixation
Ettore Vulcano1, Jonathan S Markowitz2, Austin T Fragomen3, S Robert Rozbruch3
1 Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, USA
2 Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
3 Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
|Date of Submission||05-Aug-2016|
|Date of Acceptance||13-Sep-2016|
|Date of Web Publication||16-Sep-2016|
Icahn School of Medicine at Mount Sinai, 5 E 98th St., New York, NY 10029
Source of Support: None, Conflict of Interest: None
Introduction: Knee flexion contracture (KFC) is a debilitating condition that may affect patients with neurogenic conditions, congenital deformities, posttraumatic deformities, and after total knee replacement. The recurrence rate of the deformity following either operative or nonoperative treatment remains high. The aim of the present study is to assess clinical outcomes of patients with KFCs and associated ankle equinus using gradual correction with a circular external fixator (CEF).
Methods: Twenty-one patients with knee flexion contraction were treated using a CEF. Seven patients were also simultaneously treated for ankle equinus. All but two patients underwent a combination of open or arthroscopic knee arthrolysis, distal hamstrings lengthening, and gastrocsoleus release. The CEF was applied to match the residual deformity, following the minimal incision soft-tissue release.
Results: Mean follow-up was 13 months. The mean range of motion (ROM) at final follow-up was −10° extension, 64° flexion, 9° ankle dorsiflexion, and 29° ankle plantar flexion. The difference between preoperative and postoperative ROMs was statistically significant (P < 0.05).
Discussion: The present study suggests that gradual distraction using a CEF is a safe and effective technique in the management of KFC and concurrent ankle equinus. It is crucial to maintain the postoperative correction with braces for at least 1-3 months, depending on the severity of the condition.
Keywords: Equinus, external fixator, knee contracture, knee flexion contracture, Taylor Spatial Frame
|How to cite this article:|
Vulcano E, Markowitz JS, Fragomen AT, Rozbruch S R. Gradual correction of knee flexion contracture using external fixation. J Limb Lengthen Reconstr 2016;2:102-7
| Introduction|| |
Knee flexion contracture (KFC) is a debilitating condition that may affect patients with cerebral palsy (CP), congenital deformities, posttraumatic deformities, and after total knee replacement. In KFCs, the mechanical axis of the limb falls posteriorly to the knee, thus placing increasing demand on the quadriceps muscle to resist the progressive crouch.  KFCs cause crouch gait and excessive energy consumption during walking, making daily activities difficult such as standing, reaching for objects, and even walking.
Several non-operative treatments including serial casting, ,,, reverse dynamic sling , and extension de-subluxation hinges  have been indicated to correct mild to moderate contractures. Several operative approaches including hamstring tendon lengthening with posterior knee capsulotomy, , distal femoral extension osteotomy  and guided growth with anterior distal femoral hemiepiphysiodesis in skeletally immature patients,  have all been indicated to correct the KFCs.  However, the recurrence rate of these non-operative and operative procedures can be very high.
Acute correction of KFC with soft tissue release, osteotomy, or both may lead to serious complications.  In contrast, gradual correction of KFC, a circular frame and a constrained hinge, avoids acute stretch injury to soft tissues and prevents compression of the anterior joint. Furthermore, gradual correction with histogenesis leads to soft tissue lengthening which should make the contracture less likely to recur. Our study aims to assess clinical outcomes, including range of motion (ROM) and the use of walking aids, of patients with KFCs using gradual correction with a circular external fixator (CEF).
| Methods|| |
Between 2004 and 2015, 21 patients with knee flexion contraction were treated using a CEF. Seven patients were also simultaneously treated for ankle equinus. Two orthopedic surgeons from the same institution treated all patients. Fourteen patients (67%) were male, and 7 (33%) were female. The mean age was 45 years (range, 20-60 years). Etiologies for the contractures were neurogenic (11 patients), after total knee replacement (5 patients), posttraumatic (3 patients), and fibromatosis (2 patients). The degree of KFC was measured clinically using a goniometer. The patient was placed in the supine position while the examiner asked the patient to extend the knee maximally. The examiner placed the goniometer at mid-patellar level at the lateral femorotibial axis and aligned one arm of the goniometer with the greater trochanter and the other arm with the lateral malleolus, with full extension of the knee as 0°. Mean preoperative ROM was −44° extension (range, −10°-−120°), 96° flexion (range, 10°-130°). The degree of equinus contracture of the ankle was measured clinically along the middle plane of the lateral aspect of the leg and plantar surface of the foot, with neutral position of the foot as 0°. Mean preoperative ROM was −23° ankle dorsiflexion (range, −10°-−50°) and 41° ankle plantar flexion (range, 30°-50°).
All but two patients underwent a combination of open or arthroscopic knee arthrolysis, distal hamstrings lengthening, and gastrocsoleus release. All total knee arthroplasties (TKAs) underwent open debridement for arthrofibrosis. Arthrolysis was done when there were adhesions in the joint and the patella was stiff. Arthrolysis included excision of scar tissue from the prepatellar space, medial and lateral gutters, and mobilization of the patella with medial and lateral retinacular releases, and release of adhesions in the suprapatellar space. In the TKA patients, the hamstrings were not tight and did not require to be released.
The CEF was applied to match the residual deformity, following the minimal incision soft tissue release. The knee and ankle were never forcefully manipulated to correct the contractures to prevent injury to the neurovascular structures. The CEF was prepared with one or two rings above and one or two rings below the knee joint.  The rings were connected using the hexapod Taylor Spatial Frame Struts (Smith and Nephew, Memphis, TN, USA) or hinges from the Ilizarov frame. Epiphysis needs to be avoided in children. In severe deformities, epiphyseal wires may be considered to protect displacement of the physis during correction. None of the cases in our series required that.
The hinge point of the knee was at intersection of the posterior cortex and Blumensaat's line. When using a hexapod frame, the origin and corresponding point were set at the hinge point and distraction was added to prevent crushing the articular cartilage of the knee. The formula: Minimum lengthening needed = W sin (deformity angle), where W is the distance from the hinge point to the anterior edge of the knee joint. When using an Ilizarov frame, the hinge placement can be anterior on the bisector line to add some distraction and prevent compression of cartilage. Our preference is to place the hinge directly on the hinge point of the knee and to add distraction by distracting the tibial ring and not effecting the location of the hinges at the center of rotation of the knee.
The hexapod frame provides very precise deformity correction. If a translation deformity develops, it can be corrected with a residual deformity correction. The disadvantage of the hexapod frame is that it cannot be unlocked for free ROM exercises.
The Ilizarov frame is less precise and correction of unintentional translation is more difficult, but it allows unlocking of the frame for free ROM exercises. Our current practice is to use the hexapod frame since we have not found the free ROM exercises to be useful or to have an effect on outcome ROM.
Correction of deformity started the first postoperative day, with the posterior capsule and the Achilles tendon representing the structure at risk at the knee and ankle, respectively. The rate of distraction was set at 1 mm/day. The aim was to hypercorrect the knee to 5-10° of hyperextension, and the ankle to 10-15° of dorsiflexion, to prevent recurrence of the contracture. Patients were monitored by standard anteroposterior and lateral X-rays every 1-2 weeks to rule out joint subluxation and monitor progress. At the end of the correction, the external fixator was maintained in full extension of the knee and ankle joints for at least as long as the correction time. , After removal of the external fixator under general anesthesia, we applied an off-the-shelf spring-loaded dynamic splint for 1-3 months.
Paired t-test is used to evaluate the parametric data before and after the surgery. A P < 0.05 is considered statistically significant.
| Results|| |
The mean duration of follow-up was 13 months (range, 10-18 months). The mean duration of external fixation was 3 months (range, 3-4 months). Mean ROM at final follow-up was − 10° extension (range, 0°-−50°), 64° flexion (range, 20°-100°), 9° ankle dorsiflexion (range, 0°-25°), and 29° ankle plantar flexion (range, 20°-40°). The difference between preoperative and postoperative ROMs was statistically significant (P < 0.05) [Table 1] and [Table 2]. At the knee, the preoperative arc of motion of 52° was similar to the postoperative arc of motion of 54°. Conversely, the arc of motion at the ankle increased from 18° to 38° (P < 0.001). Two patients with neurogenic etiologies required knee manipulation for excessive knee stiffness in extension. Fifteen patients (71%) developed a superficial pin infection that was successfully treated with oral antibiotics. One patient (4.8%) developed a femoral neck fracture secondary to pin loosening. Two patients (9.5%) had recurrence of the KFC (40° and 45°, respectively) without any benefit compared to preoperative deformity. Both patients had neurogenic etiologies. The remaining patients were all able to stand and walk with fewer or no aids compared to the preoperative state [Figure 1] [Figure 2] [Figure 3].
|Figure 1: Preoperative photo demonstrating severe bilateral knee flexion contracture and ankle equinus in a non-ambulatory patient|
Click here to view
|Figure 2: Immediate postoperative photo following application of the external fixator|
Click here to view
|Figure 3: The photo demonstrates the patient at 1 year follow-up after bilateral correction of the deformities. The patient was able to ambulate with a walker|
Click here to view
|Table 1: Compares pre- and post-operative range of motion at the knee and ankle joints |
Click here to view
| Discussion|| |
KFCs cause marked physical disability. Progressive knee flexion places more force on the quadriceps, leading to overstretching of the muscle fibers and the infrapatellar tendon, causing patella alta, patellar fragmentation, chondromalacia, joint instability, muscle weakness in terminal extension and pain secondary to patellofemoral degenerative joint disease. ,, This increases the loading on several joints, especially on the patellofemoral joint, and becomes an important problem causing anterior knee pain and stress fractures of the patella and tibial tubercle. , Hoffer et al. found that a KFC >30° was incompatible with functional ambulation. 
Serial casting is one nonoperative treatment option for KFCs. Fernandez-Palazzi and Battistella utilized a serial casting/wedging technique in the management of 58 patients with flexion contractures resulting from hemophilia. The pretreatment flexion deformity improved by 9.1°. They determined that it was possible to achieve −5° of extension in 4 weeks, with little improvement thereafter.  Westberry et al. performed a retrospective review of all CP patients with resistant or recurrent KFCs treated with serial stretch-casting. They noted correction to within 10° of full extension in 76% of patients. They reported that 17 of the 26 cases maintained a flexion angle of <5° at the 1-year follow-up.  Narcis reported that the amount of corrective force that may be applied with casts, splints, and braces is limited by the inability of the skin to tolerate direct pressure.  Factors that predicted successful maintenance of correction from serial casting were if the age of the patient was <12 years and if the initial knee flexion angle was <15°.
Various surgical procedures have been proposed to treat severe fixed KFCs. Wallny et al. performed a retrospective study of hemophiliac patients treated with hamstring release and posterior capsulotomy. Patients had KFCs that ranged from 10° to 45° At mean 12.5 years follow-up, only 11 patients maintained the correction.  Heydarian et al. studied 42 knees with severe KFCs (average 69°) that were treated by posterior capsulotomy followed by traction and/or casting. At 2.5 years follow-up, 39 knees maintained correction to <15° of flexion. They recommend this treatment for severe flexion contracture of the knee, in patients with poliomyelitis, but not in patients with insensitive skin.  Wallny et al. reported that after the operation, there was still muscular imbalance, which needed intensive treatment to avoid instability or impaired range of movement. 
Distal femoral extension osteotomies are an alternative surgical treatment to correct KFCs. DelBello and Watts performed a retrospective study of patients with arthrogryposis multiplex congenita and severe KFCs. They performed 32 osteotomies in 13 patients. All patients had a minimum of 24-month follow-up. During follow-up, there was a loss of correction of 22° at a rate of 0.9°/month. They observed a recurrence of the flexion contracture in all patients, which could be related to the remodeling of the distal femur.  Osteotomies seem to be effective but change the anatomy of the joint. , Balci et al. reported that distal femoral extension osteotomies change the arc of motion.  Leong et al. reported substantial loss of ROM after treatment of patients with contractures >40°.  They reported that of 17 knees having a contracture of 40° or more before operation, only four had a postoperative range of 120°-155°. The same range, however, was found in 53 out of 72 knees that had a contracture of <40°. Two patients developed posterior tibial subluxation, and both had a significant amount of pain. 
The use of CEFs to correct KFCs offers a number of advantages. It allows progressive correction of complex knee deformities with simultaneous correction of associated foot deformities and limb length discrepancies. External fixator application along with soft tissue releases has been used by other authors. , Balci et al. studied six hemophiliac patients with KFCs that underwent correction using external fixators. The mean arc of motion was 58.3° preoperatively and 51.6° postoperatively. At 8 years follow-up, patients' arc of motion lost an average of 6.7°. They found that the total arc of motion changed, which they attributed to the late start of physical therapy because of the risk of bleeding for these patients during the correction period. He also reported a recurrence of 10° of flexion deformity on average in their series at 7.9 years follow-up. 
Concurrent treatment of ankle equinus was necessary for one-third of our cohort. Carmichael et al. reviewed 23 cases of postburn ankle equinus treated by the Ilizarov technique of gradual distraction histogenesis. They reported that the rate of recurrence after correction of equinus deformity in children using the Ilizarov technique was 74% and that the average time to recurrence was 17.3 months.  Emara utilized the Ilizarov technique for the treatment of acquired equinus deformity in children. A cohort of 26 children was managed by a percutaneous tendo-Achilles lengthening, followed by application of an Ilizarov external fixator. The rate of recurrence, degree of equinus at recurrence, and number of episodes of external fixation surgery showed statistically significant differences between the groups. 
Our study aimed to assess clinical outcomes, including ROM and the use of walking aids, in patients with KFCs and associated ankle equinus using a CEF. Hosny and Fadel retrospectively studied fifty patients with fixed flexion knee deformities that were treated with the Ilizarov external fixator. 
They reported that the mean angle of maximum extension to maximum flexion improved from a preoperative average of 68° to an average of 3.5° after fixator removal. At last follow-up, the average angle was 13.5°. After a minimum follow-up of 1 year, 18 of 20 of the preoperative nonambulatory patients who had bilateral surgery were able to walk.  Our study reported similar results. Only two patients had recurrence of the KFC without any benefit compared to preoperative deformity. Both patients were affected by neurogenic conditions and had been living with the deformity for over 20 years. The remaining patients were all able to stand without aids (n = 12), walk with fewer aids (n = 2) compared to preoperative state, and sit more comfortably (n = 5). Hosny and Fadel did not perform soft tissue releases in any patient. Rather, they applied arthrodiastasis by transferring the forces from the bone to the soft tissues including ligaments, tendons, muscles, and neurovascular structures in all, except two patients.  Our cohort included patients with KFCs and concurrent ankle equinus. Our use of an external fixator with concurrent soft tissue releases was justifiable to prevent a plantar flexion contracture while the external fixator stretches the gastrocnemius muscle into extension. The use of external fixators is effective in treating concomitant ankle equinus as our patients saw an overall increase in ankle ROM from 18° to 38°. The use of an external fixator prevented the risk of stretching the sciatic nerve and its branches and did not cause large skin defect posteriorly, both of which could have occurred by acute correction of the deformity.
We observed a clinically and statistically significant improvement between preoperative and postoperative ROMs. In our study, preoperative arc of motion, 52°, and postoperative arc of motion, 54°, was almost identical. This finding is consistent with previous work by Herzenberg et al., who studied a cohort of 14 patients with an average preoperative KFC of 60°. They too report that the functional position of patient's arc of motion improved significantly while the average total arc of motion remained essentially unchanged when comparing preoperative (59°) with the follow-up results (63°).  However, flexion was sacrificed in favor of extension to provide a more functional ROM. This was clinically evident as most patients were able to stand or walk without or use fewer aids and were all able to sit more comfortably. Moreover, application of the CEF not only fully corrected the equinus contracture but also significantly increased arc of motion by 20°.
Damsin and Ghanem used the Ilizarov technique to treat severe flexion deformity of the knee in 13 knees. They reported recurrence of the deformity in four cases at an average of 1.7 years after removal of the fixator.  Huang used Ilizarov frames in 26 patients for correction of severe contractures in 10 knees and 19 ankles. At minimum 3 years follow-up, 11 contractures had recurred.  Hosny and Fadel reported a 7% recurrence of the deformity at a minimum of 2-year follow-up.  Despite a shorter follow-up, all but two patients in the present study reported an overall improved function compared to the preoperative state.
Our study had some limitations. These include a limited follow-up, a small number of patients, the retrospective nature of the study, and the lack of validated questionnaires to assess clinical outcome.
| Conclusion|| |
The present study suggests that gradual distraction using a CEF is a safe and effective technique in the management of KFC and concurrent ankle equinus. It is crucial to maintain the postoperative correction with braces for at least 1-3 months, depending on the severity of the condition. While functional ROM and patient mobility were improved after surgery, the arc of motion in the knee did not change. Patients with a long-standing history of neurogenic conditions determining the flexion contracture should be informed of being at a greater risk of recurrence of the deformity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Iobst C. Pediatric joint contractures. In: Sabharwal S, editor. Lower Limb Deformities: Principles and Techniques of Management. 1 st
ed. Springer, New York: Spring; 2016. p. 170.
Temelli Y, Akalan NE. Treatment approaches to flexion contractures of the knee. Acta Orthop Traumatol Turc 2009;43:113-20.
Karam MD, Pugely A, Callaghan JJ, Shurr D. Hinged cast brace for persistent flexion contracture following total knee replacement. Lowa Orthop J 2011;31:69-72.
Fernandez-Palazzi F, Battistella LR. Non-operative treatment of flexion contracture of the knee in haemophilia. Haemophilia 1999;5:20-4.
Westberry DE, Davids JR, Jacobs JM, Pugh LI, Tanner SL. Effectiveness of serial stretch casting for resistant or recurrent knee flexion contractures following hamstring lengthening in children with cerebral palsy. J Pediatr Orthopaedics 2006;26:109-14.
Kale JS, Ghosh K, Mohanty D, Pathare AV, Jijina F. Use of the dual force system to correct chronic knee deformities due to severe haemophilia. Haemophilia 2000;6:177-80.
Stein H, Dickson RA. Reversed dynamic slings for knee-flexion contractures in the hemophiliac. J Bone Joint Surg Am 1975;57:282-3.
Mcdaniel WJ. A modified subluxation hinge for use in hemophilic knee flexion contractures. Clin Orthop Relat Res 1974;103:50.
Wallny T, Eickhoff HH, Raderschadt G, Brackmann HH. Hamstring release and posterior capsulotomy for fixed knee flexion contracture in haemophiliacs. Haemophilia 1999;5:25-7.
Heydarian K, Akbarnia BA, Jabalameli M, Tabador K. Posterior capsulotomy for the treatment of severe flexion contractures of the knee. J Pediat Orthop 1984;4:700-4.
DelBello DA, Watts HG. Distal femoral extension osteotomy for knee flexion contracture in patients with arthrogryposis. J Pediatr Orthopaedics 1996;16:122-6.
MacWilliams BA, Harjinder B, Stevens PM. Guided growth for correction of knee flexion deformity: A series of four cases. Strategies in Trauma and Limb Reconstruction 2011;6:83-90.
Balci HI, Kocaoglu M, Eralp L, Bilen FE. Knee flexion contracture in haemophilia: Treatment with circular external fixator. Haemophilia 2014;20:879-83.
Herzenberg JE, Waanders NA. Calculating rate and duration of distraction for deformity correction with the Ilizarov technique. Orthop Clin North Am 1991;22:601-11.
Drummond DS, Rogala E, Templeton J, Cruess R. Proximal hamstring release for knee flexion and crouched posture in cerebral palsy. J Bone Joint Surg Am 1974;56:1598-602.
Gage JR, DeLuca PA, Renshaw TS. Gait analysis: Principle and applications with emphasis on its use in cerebral palsy. Instructional Course Lectures 1996;45:491-507.
Sutherland DH, Davids JR. Common gait abnormalities of the knee in cerebral palsy. Clinical Orthopaedics and Related Research 1993;288:139-47.
Topoleski TA, Kurtz CA, Grogan DP. Radiographic abnormalities and clinical symptoms associated with patella alta in ambulatory children with cerebral palsy. J Pediatr Orthopaedics 2000;20:636-9.
Hoffer MM, Swank S, Eastman F, Clark D, Teitge R. Ambulation in severe arthrogryposis. J Pediatr Orthopaedics 1983;3:293-6.
Tepeneu NF, Tepeneu P, Serban M, Petrescu C, Pop L, Popescu B, et al
. Orthopaedic Non-Surgical Treatment in Chronic Haemophilic Joint Contractures of the Knee. Timisoara Medical Journal 2010:60:215-22.
Hosny GA, Fadel M. Managing flexion knee deformity using a circular frame. Clinical Orthopaedics and Related Research 2008;466:2995-3002.
Leong J, Alade C, Fang DA. Supracondylar femoral osteotomy for knee flexion contracture resulting from poliomyelitis. J Pediatr Orthopaedics 1982;2:335.
Carmichael KD, Maxwell SC, Calhoun JH. Recurrence rates of burn contracture ankle equinus and other foot deformities in children treated with Ilizarov fixation. J Pediatr Orthop 2005;25:523-28.
Emara KM, Allam MF, ElSayed MN, Ghafar KA. Recurrence after correction of acquired ankle equinus deformity in children using Ilizarov technique. Strategies in Trauma and Limb Reconstruction 2008;3:105-8.
Herzenberg JE, Davis JR, Paley D, Bhave A. Mechanical distraction for treatment of severe knee flexion contractures. Clinical Orthopaedics and Related Research 1994;301:80-8.
Damsin JP, Ghanem IS. Treatment of severe flexion deformity of the knee in children and adolescents using the Ilizarov technique. Bone and Joint Journal 1996;78:140-4.
Huang SC. Soft tissue contractures of the knee or ankle treated by the Ilizarov technique: High recurrence rate in 26 patients followed for 3-6 years. Acta Orthopaedica Scandinavica 1996;67:443-9.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]