Treatment with posterior capsular release, botulinum toxin injection, hamstring tenotomy, and peroneal nerve decompression improves flexion contracture after total knee arthroplasty: minimum 2-year follow-up

Abstract

Purpose No definite treatment option with reasonable outcome has been presented for old and refractory flexion contracture after total knee arthroplasty (TKA). We describe a surgical technique for 21 refractory cases of knee flexion contracture, including 12 patients with history of failed manipulation under anesthesia (MUA). Methods Retrospective review was conducted for procedures performed by a single surgeon between 2005 and 2016. Twenty‐one knees (19 patients) with knee flexion contracture after primary TKA were treated with all the following procedures: posterior capsular release, hamstring tenotomy, prophylactic peroneal nerve decompression, and botulinum toxin type A injections. Twelve of the 21 knees had at least 1 prior unsuccessful MUA before this soft‐tissue release procedure. Mean age at intervention was 60 years (range 46–78 years). Mean preoperative knee range of motion (ROM) was – 27° extension (range – 20° to – 40°) to 100° flexion (range 90°–115°). All radiographs were evaluated for proper component sizing and signs of loosening. Results Full extension was achieved immediately after surgery in all patients. Only one knee required repeat botulinum toxin type A injection. All patients had full extension at mean follow‐up of 31 months (range 24–49 months). No significant change was observed in knee flexion after the procedure (n.s.). Significant improvement was noted in the postoperative Knee Society Score (KSS) (mean 80, range 70–90) when compared with preoperative KSS (mean 45, range 25–65) (p = 0.008). Conclusion The proposed surgical technique is efficacious in treating patients with refractory knee flexion contracture following TKA to gain and maintain full extension at minimum 2‐year follow‐up. Level of evidence IV, retrospective case series.

Extra‐articular biceps tendon supplement release in total knee arthroplasty for valgus deformity combined with severe flexion contracture

“…26 Although 12 of our patients (12 knees) retained mild valgus after surgery (Figure 6), none of our patients had postoperative knee instability. Hamed et al 27 reported the treatment of flexion contracture after TKA by means of hamstring release, intraoperative release of the lateral structures of the knee joint (ITB, biceps femoris), and achieved good results through a 2-year follow-up.…”

Mid-term outcomes of posterior capsular release for fixed flexed deformity after total knee arthroplasty

“…Fixed flexion deformity decreased from a mean of 24° preoperatively to a mean of 2.9° after procedure. Recently, in their retrospective review, Vahedi et al (17) described a more invasive procedure. In fact, they combined posterior soft-tissue release (posterior capsule and hamstring tendons) with prophylactic peroneal nerve decompression and botulinum toxin type A injection.…”

“…88 -2 -2022 may be without clinical relevance. Nevertheless, beyond 15 degrees, it may cause severe disability and functional limitation, hence surgical treatment is required (16,17). Several procedures have been described in the literature to deal with flexion contracture after TKA persisting to the conservative treatment (15,22,23).…”

“…The majority of the cases presenting minor fixed flexion deformity may be tolerated by the patient and resolved with time or may be without clinical relevance (15). However, for severe contractures, above 15°, surgical treatment is necessary (16,17).…”

“…Different treatment modalities have been described to cope with this significant issue, including manipulation under anaesthesia (MUA), arthroscopic or open debridement, and lastly, implant revision (1,15,(17)(18)(19).…”