Stretching exercises, gaining extension key after treatment of fixed flexion contractures
Patients with a fixed flexion contracture should be carefully evaluated and educated on stretching exercises and how to gain extension, according to a presenter at the Current Concepts of Joint Replacement Winter Meeting.
Adolph V. Lombardi Jr., MD, noted preoperative evaluation of a patient with a flexion contracture should include assessment of the patient’s ambulation, passive and active range of motion and a radiographic evaluation.
“I think you need to discuss with the patient that they have a flexion contracture [and] that you are going to do everything you can do to correct that,” Lombardi said in his presentation.
Surgeons need to think about bony, soft tissue and prosthetic considerations to accomplish a total knee arthroplasty that achieves full extension among patients with a fixed flexion deformity greater than 25°, according to Lombardi.
“You have to think about an increase in the degree of constraint in the real severe [flexion contractures], and postop passive stretching is important,” Lombardi said.
Postoperatively, Lombardi noted patients are usually placed in a knee immobilizer or plastic splint at full extension for about 24 hours.
“We’re going to discuss the fact that we spend a lot of time sitting during the day and watching television or reading a book, etc., and that, when they are doing that, they need to put their leg up on an ottoman or another chair and focus on extension,” Lombardi said.
He advises patients to place a bolster under their ankle when laying in bed and to avoid using a recliner, which places the knee in 20° to 30° of flexion. To gain full extension of the knee, patients can place a shoe lift under the contralateral limb, place the seat of a stationary bicycle in the high position and use extension bracing, according to Lombardi.
“It’s a slow stretch that seems to work better than trying to take this patient back to the OR and manipulate them,” Lombardi noted.
Perspective
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As highlighted by Adolph V. Lombardi Jr., MD, at the CCJR Winter Meeting, patients with preoperative flexion contractures can present a unique surgical challenge. Proper management of these patients begins preoperatively with a thorough physical exam of the ipsilateral hip and affected knee to truly understand the extent of the contracture and to rule out co-existing hip pathology (ie, hip flexion contracture) that may need to be addressed prior to TKA to optimize outcomes. Additionally, patients should be counseled on the typical outcomes of TKA with severe flexion contractures, and the importance of exercises and stretching postoperatively to maintain knee extension should be stressed.
Intraoperatively, recovery of full knee extension is achieved by adequate distal femoral resection, complete osteophyte removal and posterior capsular release. Additional distal femoral resection may necessary, but surgeons should ensure sufficient capsular release and osteophyte removal prior to continuing to resect additional distal femur. As pointed out by Lombardi, when patients have severe contractures, surgeons should have implants available to provide additional constraint if necessary.
Postoperatively, the primary focus of the patient should be to maintain gains in extension that were obtained at the time of TKA. Frequent stretches and positioning to maintain extension, in addition to physical therapy, can be helpful to prevent recurrence of the contracture.
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Lombardi AV Jr. Preoperative flexion contracture: Technical tips. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 8-11, 2021; Orlando (hybrid meeting).
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