Flexion contracture sometimes occurs after primary total knee arthroplasty (TKA). In most cases, flexion contracture after TKA gradually improves over time. However, some severe cases require manipulation or revision surgery. We searched our clinical database for patients who underwent primary TKA at our institution between 2008 and 2015. By reviewing patient records, we identified three patients (one man and two women) with a severe flexion contracture 30° after primary TKA. Although all three patients gained more than 120° in flexion intraoperatively, they developed flexion contracture after discharge from our institution. We performed manipulation under anaesthesia (MUA) for all three cases several months later. The two female patients had improved range of motion (ROM) right after the manipulation. However, one of them regained flexion contracture 1 year after the MUA. We report the details of the male patient, who had the worst flexion contracture (−60°). An 80-year-old man had right knee osteoarthritis. His history indicated only hypertension. The right knee ROM before the TKA was −20° extension and 135° flexion. His radiographs showed advanced-stage osteoarthritis. We performed cemented TKA (posterior stabiliser design). Three weeks after the operation, his right knee pain improved. The right knee ROM was −10° extension and 100° flexion just before discharge. However, he returned to our institution because of right knee pain and flexion contracture 31 months after the surgery. The flexion contracture gradually worsened without any trauma. When he returned, the right knee ROM was −60° extension and 135° flexion. Manipulation under general anaesthesia was not effective. Therefore, we performed revision TKA immediately. We excised the scar tissue of the posterior knee joint. Then, we shortened the distal femoral end by 1 cm and reduced the size of the femoral component. After the operation, the right knee ROM was improved to −10° flexion and 130° extension. The reported prevalence of stiffness after TKA was from 1.3% to 13%. Although the deleterious effects of persistent flexion contractures > 15° is well understood, whether they resolve with time or need surgical intervention is controversial. MUA is generally the initial option for patients with flexion contractures, with the possibility of some improvement. If severe flexion contracture remains after manipulation, revision TKA, which may be considered as a useful treatment option, should be considered

Introduction. Surgeons commonly resect additional distal femur during primary total knee arthroplasty (TKA) to correct a flexion contracture to restore range of motion and knee function. However, the effect of joint line elevation on the resulting TKA kinematics including frontal plane laxity is unclear. Thus, our goal was to quantify the effect of additional distal femoral resection on passive extension and mid-flexion laxity. Methods. Six computational knee models with capsular and collateral ligament properties specific to TKA were developed and implanted with a contemporary posterior-stabilized TKA. A 10° flexion contracture was modeled by imposing capsular contracture as determined by simulating a common clinical exam of knee extension and accounting for the length and weight of each limb segment from which the models were derived (Figure 1). Distal femoral resections of 2 mm and 4 mm were simulated for each model. The knees were then extended by applying the measured knee moments to quantify the amount of knee extension. The output data were compared with a previous cadaveric study using a two-sample two-tailed t-test (p<0.05) [1]. Subsequently, varus and valgus torques of ±10 Nm were applied as the knee was flexed from 0° to 90° at the baseline, and after distal resections of 2 mm, and 4 mm. Coronal laxity, defined as the sum of varus and valgus angulation in response to the applied varus and valgus torques, was measured at 30° and 45°of flexion, and the flexion angle was identified where the increase in laxity was the greatest with respect to baseline. Results. With 2 mm and 4 mm of distal femoral resection, the knee extended an additional 4°±0.5° and 8°±0.75°, respectively (Figure 2). No significant difference was found between the extension angle predicted by the six models and the results of the cadaveric study after 2 mm (p= 0.71) and 4 mm (p= 0.47). At 2 mm resection, mean coronal laxity increased by 3.1° and 2.7° at 30° and 45°of flexion, respectively. At 4 mm resection, mean coronal laxity increased by 6.5° and 5.5° at 30° and 45° of flexion, respectively (Figures 3a and 3b). The flexion angle corresponding to the greatest increase in coronal laxity for 2 mm of distal resection occurred at 22±7° of flexion with a mean increase in laxity of 4.0° from baseline. For 4 mm distal resection, the greatest increase in coronal laxity occurred at 16±6° of flexion with a mean increase in laxity of 7.8° from baseline. Conclusion. A TKA computational model representing a knee with preoperative flexion contracture was developed and corroborated measures from a previous cadaveric study [1]. While additional distal femoral resection in primary TKA increases passive knee extension, the consequent joint line elevation induced up to 8° of additional coronal laxity in mid-flexion. This additional midflexion laxity could contribute to midflexion instability; a condition that may require TKA revision surgery. Further studies are warranted to understand the relationship between joint line elevation, midflexion laxity, and instability. For any figures or tables, please contact the authors directly

Introduction. Stiffness postTotal Knee Replacement (TKR) is a common, complex and multifactorial problem. Many reports claim that component mal-rotation plays an important role in this problem. Internal mal-rotation of the tibial component is underestimated among surgeons when compared to femoral internal mal-rotation. We believe the internal mal- rotation of thetibial component can negatively affect the full extension of Knee. We performed an in-vivo study of the impact of tibial internal mal-rotation on knee extension in 31 cases. Method. During TKR, once all bony cuts were completed and flexion/extension gaps balanced, we assessed the degree of knee extension using the trial component in the setting of normaltibial rotation and with varying degrees of internal rotation (13–33°, mean 21.2±4.6°). Intra-operative lateral knee X-ray was done to measure the degree of flexion contracture in both groups. We also compared the degree of flexion contracture between CR and PS spacers. Results. The average degree of knee flexion contracture with normal rotation of the tibial component was 0.7±4.1° (range:-9 to 10), whereas after tibial internal rotation was 7.3±4.6° (range:-1 to 23)(P – value:0.001). The increase in the flexion contracture deformity was higher with PS spacer (7.18±2.61) than with CR spacers (5.22±2.05). Conclusion. The internal mal-rotation of the tibial component limits the ability of the tibia to externally rotate on the femur, thereby limiting full knee extension and leading to flexion contracture

Introduction. The effect of the implant posterior condylar offset has recently generated much enthusiasm among researchers. Some reports were concerned about the relationship between the posterior condylar offset and an extension gap. However, the posterior condylar offset was measured in a flexed knee position or in reference to femoral anatomy alone. Posterior femoral condylar offset relative to the posterior wall of the tibia (posterior offset ratio; POR) is possibly the risk of knee flexion contracture associated with posterior femoral condylar offset after TKA. However, there are no reports concerning the relationship between POR and flexion contracture in vivo. The aim of this study is to evaluate the relationship between the measurement of POR and flexion contracture of the knee in vivo. Methods. Twenty-seven patients who underwent a primary total knee arthroplasty (PFC Sigma RP-F) were participated in the study. The lateral femoro-tibial angle (lateral FTA) was measured using lateral radiographs obtained by two procedures. Two procedures are applied to obtain true lateral radiographs of the lower extremities. (1) Full-length true lateral radiographs on standing, (2) True lateral radiographs in the prone position (Fig. 1A). ‘Posterior offset ratio’ was defined as Fig. 1B. Significant differences among groups were assessed using two-tailed Student's t-tests. Spearman's correlation analysis was performed to evaluate the relationship between lateral FTA and posterior offset ratio of patients. Results. The mean value of the POR on standing was 14.94 ± 7.53%. The mean value of flexion contracture of the knee on standing was 11.67 ± 9.21 degree and that in the prone position was 4.22 ± 6.17 degree (P = 0.001). The POR was negatively correlated with flexion contracture of the knee in all procedures with statistical significance (standing: r = 0.62, P = 0.0039; prone: r = 0.66, P = 0.0001) (Fig. 2). Discussion. We have evaluated flexion contracture by two procedures. The mean value of flexion contracture of the knee on standing was 11.67 ± 9.21 degree, whereas that in the prone position was 4.22 ± 6.17 degree. We surmised that this discrepancy occurred due to the flexor muscle tension on standing. In terms of the evaluation of posterior soft tissue tightness of the knee, muscle relaxation can be achieved in prone position is rather than standing position. Our study investigated the relationship between the posterior protrusions of the posterior condyle of the femur relative to the tibia (POR) and flexion contracture after TKA evaluated by two measurement procedures. POR is strongly correlated with flexion contracture evaluated by both measurement procedures. The value of POR of this implant in vitro was about 25% in previous study, whereas the mean value of POR in vivo was 14.94%, suggesting that POR in the flexion contracture knee relatively reduced because posterior soft tissue pushed femoral component anteriorly. Our result clearly showed that if posterior clearance is insufficient, flexion contracture occur due to posterior soft tissue tightness. In conclusion, POR after TKA in vivo negatively correlate with flexion contracture presumably because posterior soft tissue pushed femoral component anteriorly

Introduction. Stiffness post Total Knee Replacement (TKR) is a common, complex and multifactorial problem. Many reports claim that component mal-rotation plays an important role in this problem. Internal mal-rotation of the tibial component is underestimated among surgeons when compared to femoral internal mal-rotation. We believe the internal mal-rotation of the tibial component can negatively affect the full extension of Knee. We performed an in-vivo study of the impact of tibial internal mal-rotation on knee extension in 31 cases. Method. During TKR, once all bony cuts were completed and flexion/extension gaps balanced, we assessed the degree of knee extension using the trial component in the setting of normal tibial rotation and with varying degrees of internal rotation (13–33°, mean 21.2±4.6°). Intra-operative lateral knee X-ray was done to measure the degree of flexion contracture in both groups. We also compared the degree of flexion contracture between CR and PS spacers. Results. The average degree of knee flexion contracture with normal rotation of the tibial component was 0.7±4.1° (range: −9 to 10), whereas after tibial internal rotation was 7.3±4.6° (range: −1 to 23) (P – value:0.001). The increase in the flexion contracture deformity was higher with PS spacer (7.18±2.61) than with CR spacers (5.22±2.05). Conclusion. The internal mal-rotation of the tibial component limits the ability of the tibia to externally rotate on the femur, thereby limiting full knee extension and leading to flexion contracture

Introduction. The range of motion (ROM) obtained after total knee arthroplasty (TKA) is an important measurement to evaluate the postoperative outcomes impacting other measures such as postoperative function and satisfaction. Flexion contracture is a recognized complication of TKA, which reduces ROM or stability and is a source of morbidity for patients. Objectives. The purpose of this study was to evaluate the influence of intra-operative soft tissue release on correction of flexion contracture in navigated TKA. Methods. This is prospective cohort study, 43 cases of primary navigation assisted TKA were included. The mean age was 68.3 ± 6.8 years. All patients were diagnosed with grade 4 degenerative arthritis in K-L grading system. The average preoperative mechanical axis deviation was 10.3° ± 5.3 and preoperative flexion contracture was 12.8° ± 4.8. All arthroplasties were performed using a medial parapatellar approach with patellar subluxation. First, medial release was performed, and posterior cruciate ligament was sacrificed. After all bone cutting was performed and femoral and tibial trials were inserted, removal of posterior femoral spur and capsular release were performed. The degree of correction of flexion contracture was evaluated and recorded with navigation. Results. After the medial soft tissue release, as a first step, the flexion contracture was recorded as 7.2° ± 4.3 and 4.1° ± 4.0 as varus. The second step, posterior cruciate ligament was sacrificed, the flexion contracture was recorded as 7.2° ± 4.4 and 5.5° ± 3.0 as varus. After posterior clearing procedure and capsular release, the flexion contracture was showed as 3.9° ± 1.2 and 1.4° ± 1.2 as varus. The final angles after cemented real implant were recorded as 3.3° ± 1.4 in flexion contracture, 0.9° ± 1.8 in varus. There were significant differences all steps except between medial release step and posterior cruciate sacrifice step and between posterior clearing step and final angle. Conclusions. The appropriate soft tissue balancing could correct flexion contracture intra-operatively. The medial release could correct the flexion contracture around 5° compared with preoperative flexion contracture, and posterior clearing procedure could improve further extension. However, the sacrifice of posterior cruciate ligament provided little effect on correction of the flexion contracture intra-operatively

Dupuytren's contracture is a common condition affecting 25% of men over the age of 65. With less advanced disease or with patients not suitable for a general or regional anaesthetic needle fasciotomy is the surgical option of choice. The aim of this audit is to see whether the Department of Trauma and Orthopaedic surgery at Wirral University Teaching Hospital NHS Foundation Trust comply with the NICE guidelines. All patients who underwent needle fasciotomy for Dupuytren's contracture at Wirral University Teaching Hospital NHS Foundation Trust from December 2008 and November 2010 were identified. The case notes of these patients were reviewed. In a 23 month period 9 patients (13 fingers), underwent needle fasciotomy. There were 6 female and 3 male patients. The mean age at the time of surgery was 70 years (61-84 years). Of the 13 MCPJ contractures 12 had a full correction. At the PIPJ 5 of the 8 had a full correction. Of the one contracture affecting the DIPJ, this was fully corrected. None of the patients undergoing needle fasciotomy had any complications recorded. At a minimum follow up 4 months and a mean follow up of 14 months, none of our patients have returned to the unit with recurrence of disease. In our unit needle fasciotomy is a safe and effective in correcting deformity. To date we have no complications or recurrence. None of these patients have returned for further surgery. We are compliant with the NICE guidelines

Purpose of study. Internal rotation (IR) contracture of the shoulder is a frequent complication of obstetric brachial plexus injury, even in the face of full neurological recovery. Surgical procedures to treat this complication include tendon transfers, capsular release and osteotomies. We compared the outcomes in patients who had arthroscopic release only and those who also underwent a tendon transfer. Methods. We retrospectively reviewed the clinical records of all patients with OBPI presenting to our unit in the years 2002–2012 who underwent surgical procedures for the treatment of an IR contracture of the shoulder. Increase in range of external rotation (ER) in adduction and abduction intra-operatively was recorded. At follow-up, active ER, the Mallet score, presence of an ER contracture and the “drop-arm” sign was recorded. Results. 25 procedures were performed in 22 patients. Mean intra-operative gain in ER was greatest in those patients who had simultaneous arthroscopic release and a tendon transfer (83.3° and 60.5° in adduction and abduction respectively). This group had the greatest average range of active ER at follow up (47.5°), the lowest incidence of a “drop-arm” sign (14%), but also the highest incidence of ER contracture (75%). Patients who underwent arthroscopic anterior shoulder release only, had the highest average Mallet score at final follow up (17.1 compared to 16.3 in the scope and tendon transfer group), 45% incidence of a “drop-arm” sign and also the lowest incidence of ER contracture (32%). General satisfaction was greatest in the scope plus tendon transfer group. Conclusion. Patients who had arthroscopic release and tendon transfer had better ER range and power but more severe ER contractures than patients who underwent arthroscopic release only. Patient satisfaction and Mallet scores were comparable between the two groups and therefore bring into question the need for early tendon transfer in these patients. NO DISCLOSURES

Objective. In a cruciate retaining total knee arthroplasty (CR-TKA) for patients with flexion contracture, to ensure that an extension gap is of sufficient size to install an implant, the amount of distal femur bone resection needed is frequently larger in a patient with knee flexion contracture than in one without contracture. In this study, we compared the distal femur bone resection amount, the component-secured extension gap margin value, and the range of motion at 6 months after surgery between patients with knee flexion contracture and those without knee flexion contracture. Method. We examined 51 joints including 27 joints in patients with preoperative extension limitation of less than 5 degrees (the F0 group) and 24 joints in patients with limitation of 15 degrees or larger (up to 33 degrees; the FC group) who underwent CR-TKA with LCS RP (DePuy Synthes) between May 2013 and April 2014. In case with an extension gap 3 mm or smaller than the flexion gap after initial bone resection, we released posterior capsule adequately, trying to minimize the distal femur additional bone resection amount as possible. With installation of a femoral trial, the component gaps were measured using spacer blocks. The measured parameters included the intraoperative bone resection length, gap difference (FG − EG, i.e., difference between the flexion gap [FG] and extension gap [EG]), and range of motion 6 months after surgery. Results. No inter-group difference was found in the length of the distal femur bone initially resected in the medial side of distal femur(F0: 6.7 ± 1.3 mm, FC: 6.1 ± 1.4 mm) and total length of bone resection (= first + additional resection) in the lateral proximal tibia (F0: 10.3 ± 1.9 mm, FC: 10.4 ± 2.1 mm). The length of the additional distal femur bone resected was 0.9 ± 1.3 mm in the F0 and 1.5 ± 1.2 mm in the FC (P = 0.06; Mann-Whitney U). The FG-EG (F0: 0.7 ± 0.9 mm, FC: 0.6 ± 0.8 mm) showed no remarkable inter-group difference. The mean range of motion was changed from −2.3° to −0.6° at extension and from 130.4° to 128.7° at flexion in the F0 and from −19.8° to −2.7° at extension and from 113.7° to 122.3° at flexion in the FC. Conclusions. The amount of distal femur bone resected should not be simply increased because this may elevate the joint line, narrow the flexion range, and cause the joint instability in mid-flexion. The results of this study show that, in CR-TKA for patients with flexion contracture up to 30°, the length of distal femoral bone resection of approximately 1 mm larger than that in patients without contracture may ensure an extension gap of necessary and sufficient length to install an implant

In December 2012 the orthopaedic Hand and wrist unit at Derriford hospital introduced the use of collagenase injections for the treatment of Dupuytrens' contracture, and currently remains the only centre to use it in the southwest peninsula. We present the short term results of our first year of use of the therapy. There was a statistically significant improvement in PEM scores by 1 and 3 months post-treatment (P: 0.0001 and 0.0016 with 95% confidence). Full correction was obtained in 81% of all MCPJ contractures included in the analysis. Success with PIPJ contractures was more limited, however there was still an average correction of 30 degrees achieved. Complications were limited to skin tears, all of which healed at subsequent follow-up, and 2 failures of therapy. We will continue to use this therapy and as experience and expertise build we hope we can improve our outcomes further

Late presentation and rapid progression of Dupuytren's contracture significantly increases operating time, complications and likelihood of incomplete correction; however, surgical timing is usually more a function of waiting list length than of clinical criteria. We sought to measure the rate of progress of Dupuytren's contracture. All patients with Dupuytren's contracture referred to the sole Consultant Hand Surgeon for Highland Region between June 1997 and February 2003 were prospectively included. Fixed flexion deformities at each finger joint and thumb-index angle to the point of firm resistance to extension were recorded by a single observer (QGNC) at presentation and immediately pre-operatively. Of 151 participants 37% had a family history. There was a male predominance of 5:1, with bilaterality in 77% at presentation. Five percent had diabetes, 3% had epilepsy, 52% acknowledged tobacco habits and 24% regular alcohol in excess of recommended limits. Angular deterioration was observed in 52% of digits, over one quarter of this occurred at the small finger joints, where 58% of PIPJs progressed. Mean delay from presentation to surgery was 11 months (2-55.5). Mean age at presentation of 62 (16-86) years did not correlate with angular deformity at presentation or with velocity of deterioration or with manual/non-manual employment. Mean severity of deformity at presentation for manual (34°) was double non-manual workers (17°) although angular deterioration was faster in the non-manual group (3.8 cf 0.7°/month respectively). Similar speeds of deterioration were seen at MCPJ and PIPJ, speed of deterioration was 2.2°/month for each of the three ulnar digits. Speed of deterioration correlated (r=0.7) with severity of deformity at presentation for ring and small fingers. This study offers the first quantification of rate of deterioration in Dupuytren's contracture. This could be used as a waiting list tool to predict the delay before a digit is likely to pose increased surgical risk

Objective. To assess patterns of recurrence in patients with Dupuytren's disease after surgery for proximal interphalangeal joint (PIPJ) deformity. Methods. 81 patients (94 fingers) with Duputyren's contracture of the proximal interphalangeal joint underwent surgery to have either a ‘firebreak’ skin graft (46 fingers) or a fasciectomy (48 fingers). They were reviewed after three weeks, six weeks, 6, 12, 24 and 36 months to note the range of movement and recurrence. Both groups were similar with regard to age, gender and factors considered to influence the outcome such as bilateral disease, family history, and the presence of diabetes, smoking and alcohol intake. Results. The rate of recurrent contracture of PIP joint was 12.2%. Four patterns were identified: Group 1 (Responsive group: Immediate improvement, maintained over three years), Group 2 (Improved group: Initial mild loss of position but improvement maintained), Group 3 (Stiffness group: Immediate significant worsening but maintained), and Group 4 (Recurred group: Immediate loss of position with further progressive contracture). Time since onset of Dupuytren's disease and pre-op PEM showed significant association with recurrent contracture on regression analysis (GEE, Wald chi square test, P< 0.01). Conclusion. Four distinct patterns of recurrent contracture of PIP joint were identified three years after corrective surgery for Dupuytren's disease. Pre-operative PEM and disease duration could predict recurrence

Introduction. In TKA, it is important to make the equal extension and flexion gap (EG and FG) of the knee. Although, this principal concept applies to all knees, flexion contracture is known to have difficulties to achieve the equal EG and FG because of its smaller EG than usual. Whereas, it is also well known that PCL resection makes FG wider than EG, however, many surgeons recommend PCL resection in case of flection contracture because it is easy to manage during surgery, nevertheless the risk of further gap unbalance. Although, flexion contracture is not rare in TKA, the controversial problem of the PCL resection for the flexion contracture still remains even in today. Materials and methods. To investigate this contradiction, we measured intra-operative EG and FG of the knee with 20 degree or more pre-operative flexion contracture. The gaps were measured by 3 different ways; a tension device system with 30 and 40 pound tension (group 1 and 2) and a spacer block system which had 1 mm increment thickness variation (group 3). The cases were 41, 46 and 51 knees in group 1, 2 and 3 respectively. Group 1 and 2 have overlapping in 27 knees. Results. In our hospital, femoral posterior condylar 4 mm pre-cut is routinely used, so the data of the FG was corrected by the amount of pre-cut. After usual distal femoral cut and tibial cut and the femoral posterior condylar pre-cut, EG and FG before PCL resection were 16.2±2.7 and 20.3±3.3 mm / 17.7±4.0 and 22.2±3.8 mm / 15.3±4.0 and 18.7±2.8 mm in group 1, 2 and 3 respectively. Group 3 showed smaller gaps than group 1 and 2 and group 1 showed smaller than group 2. EG was significantly smaller than FG in all groups (p<0.001). The difference between both gaps was 4.1±3.2, 4.4±3.9 and 3.4±3.7 mm in group 1, 2 and 3 respectively. Nevertheless the different measurement methods, the results were similar among 3 groups. To avoid additional widening of the gap difference due to PCL resection, CR components were implanted with 84 knees and PS with 27 knees. Discussion. Although, the gap measurement methods are often discussed about their reliabilities, how much distraction force is necessary with the tension device systems and how accurate measurement is possible with the spacer block systems are obscure. Our results showed some different results among 3 groups, however, the EG was apparently smaller than the FG and the difference between EG and FG was similar among 3 groups. PS component is usually selected in TKA in patients with flexion contracture, especially with severe contracture because it is easy to manage during surgery without PCL. The purpose of TKA is to make adequate EG and FG, however, our results indicated the risk of severe unbalance between EG and FG when the PCL was resected in every knee with flexion contracture. Regardless of the measurement methods, intra-operative estimation of the difference between EG and FG is important, especially in the knees with flexion contracture

Background. There are some critical points of Cruciate retaining (CR) TKA. We recognized that it is one of the most important issue how to manage for release of PCL contracture. PCL contracture would lead to poor ROM, stiff or painful knee after CR TKA. PCL release at insertion of femoral / tibial side or cut in PCL itself, “pie craft” were reported. However, for retaining of PCL function after TKA, peeling off PCL itself would be not desirable. Therefore, we proposed to perform V shape-osteotomy at PCL insertion of tibia with osteotome (Fig.1,2) and cancellous bone graft at osteotomy site to get bony union (V-shape osteotomy with cancellous bone graft: VOCG). We would present how to perform VOCG at CR TKA and clinical results. Patients and Methods. 188 knees in 126 patients were received NRG CR TKA (Stryker) at Nagano Matsushiro General Hospital between February 2008 and August 2009. Mean age at operation was 75.1±5.9 years old. The indications for VOCG were positive of POLO test positive, inadequate soft tissue balance because of PCL contracture, or poor pre-operative ROM et al. All patients were reviewed with clinical and radiographic assessments. Clinical evaluation was carried out using the Knee Society Score (knee score and functional score). The range of motion (ROM) was pre- and post-operatively. In order to evaluate the effect of VOCG, clinical outcomes were compared between two groups (with VOCG vs without VOCG). Results. Of 126 patients (188 knees), 4 (6 knees) died in cardiac disease or malignant tumor within 1 year. 3 (5 knees) suffered from some comorbidities. Therefore, 177 knees in 119 patients available for review at a minimum 1 year (one to six). There were no revision cases. No patients had PCL dysfunction, infection or deep vein thrombosis in current study. 21 knees (11.8%) received VOCG. The reasons for VOCG: lift off positive:11 knees, inadequate soft tissue balance: 8 knees, flexion contracture: 1 knee There were no significant difference in FTA before TKA and KS between with VOCG and without VOCG cases. In pre-oprerative varus knee group (n=133), there was significant difference in pre-oprerative ROM between with VOCG group (94.4°±25.5°) and without VOCG group (106.0°±25.5°) (p<0.05). In addition, post operatively ROM of without VOCG group (125.6°±17.3°) was significantly better than with VOCG group(112.8°±13.5°)(p<0.05). However, there was no significant difference in improvement rate of ROM between two groups. In radiographic evaluation, no cases revealed non-union at osteotomy site. Conclusions. In current series, no cases revealed PCL dysfunction after CR TKA in two groups. Our clinical results suggested that VOCG would provide reasonable PCL release and remain PCL function in CR TKA

Postoperative functional outcomes and patients’ satisfaction after total knee arthroplasty are associated with postoperative range of motion. Severe deformities require surgical correction such as soft tissue release and appropriate bone resection. The goal of surgery is to correct the contracture and bring the knee to good range of motion. Using gap-balancing technique is one of the major techniques to obtain good range of motion. Although the gaps are well balanced, the thickness of tibial insert would affect the range of motion. In this study, we analyzed the difference between intraoperative extension joint gap and the thickness of implanted insert (DJI). The objective of this study was to investigate whether DJI affected the postoperative extension of the knee. A total of 155 knees were analyzed retrospectively. Subject included 27 males and 128 females with an average of 72.7 ± 7.0 years. The mean preoperative knee flexion angle was 136.1 ± 20.0°and the mean preoperative knee extension deficit was 4.0 ± 6.1°. All the patients had a diagnosis of varus-type osteoarthritis, identical prostheses (Stryker NRG posterior-stabilized type) implanted with a modified gap-balancing technique and no postoperative complications which may have affected the range of motion. Range of motion was measured using a goniometer before surgery and 12 months after surgery. Joint gap between femoral component and proximal tibia in full extension was measured by a tensor/ balancer device which added joint gap an expansion force by 30 inch pounds intra-operatively. Although we empirically regarded the appropriate DJI was 5 mm for this prosthesis, we determined the thickness of the tibial inserts considering preoperative range of motion. Thinner inserts compared with the joint gap was implanted for knees with flexion contracture and thicker inserts was implanted for knees with hyperextension. In this study, to determine the relationship of DJI and flexion contracture, the correlation coefficient between DJI and extension deficit was calculated. The diagram of DJI and postoperative extension angle is shown in Figure 1. The correlation coefficient between DJI and postoperative extension deficit was 0.24, which showed that DJI slightly affected the postoperative extension of the knee. Flexion contracture cannot be corrected by simply adjusting DJI

This study aimed to determine if the adoption of collagenase treatment is economically viable. Xiapex collagenase was trialled at Gloucestershire Hospitals NHS Trust in 50 patients suitable for fasciectomy, with a palpable cord and up to two affected joints. Retrospective data for contracture angle pre-injection, immediately post-manipulation and at an average 6 weeks (range 2–17) clinic follow up was collected from medical notes. At follow up the post-procedure number of days required for return to activities of daily living (ADLs) and/or work were recorded, along with overall patient satisfaction rating. Complete data was obtained for 43 patients of average age 67 (range 45–82). At follow up 88% had ≤ 20° residual contracture. Average days return to full ADLs was 9 and work was 11. Overall satisfaction was 8.6 out of 10. Xiapex patients required an average 1 hand physiotherapy appointment post-manipulation compared to 6 for fasciectomy, saving £172.20. Total cost for one treatment course, excluding physiotherapy, was £1166 for Xiapex compared to £2801 for palmar fasciectomy and £5352 for digital fasciectomy. The level of contracture after one Xiapex treatment course permitted return of hand function in the majority of patients whose overall treatment course required less financial and hospital resources

Melorheostosis is a very rare mesenchymal dysplasia of bone, characterized by sclerosing hyper-pigmentation appearances on the bone, may involve the adjacent soft tissues and lead to joint pain, limitation of joint motion and stiffness as a result of abnormal ossifications and soft tissue contractures, due to periarticular fibrosis. It is well known to tend to affect only one limb, but multifocal involvement, such as multiple limbs, spine and rib, has been extremely rarely reported. A variety of treatment options have been tried so far, none being specific surgical treatments. Here we present a case of a 43-year-old man who sustained melorheostosis with multifocal involvement including the axial skeleton and a whole entire lower limb. He had painful swelling of his left lower limb and mainly complained of difficulty walking due to severe hip pain and knee stiffness, which persisted for 20 years and was aggravated during the last 5 years. Total hip arthropasty [Fig. 1] was done first, and then total knee arthroplasty [Fig. 2, 3] was performed. During operation, there were difficulties in bone cutting and implant insertion due to mixed pattern of hard sclerotic portion and osteoporotic portion despite complete synovectomy and sufficient soft tissue release. He was eventually free of pain during walking and able to walk without a crutch and joint motion of hip and knee was substantially improved after surgery. We found that hip pain and contracture due to osteoarthritis and knee contracture secondary to multifocal melorheostosis could be successfully treated by total hip and knee arthroplasty. To the best of our knowledge, this is the first reporting the total joint arthroplasty performed in the patients with multifocal melorheostosis

Purpose of the study. To assess use of Taylor Spatial Frame to correct posttraumatic equinus contracture of ankle by soft tissue distraction. Description of a successful technique. Methods and end results. We have treated five cases of severe and resistant equinus contracture (20–30 degrees) between 2005 and 2010. All cases resulted from severe soft tissue injury and compartment syndrome of affected limb. They had undergone prolonged treatment for open fracture of tibia prior to referral to our institute and failed to respond to at least six months of aggressive physiotherapy. In all cases fractures did not involve ankle articular surface and all tibial fractures had united. Three out five cases also had associated peroneal nerve palsy. Our procedure included Tendo Achilles Lengthening, ankle and subtalar capsulotomy and application of two-ring Taylor Spatial Frame. We used long bone module to correct the deformity gradually. All deformities were over corrected by 5–10% to prevent recurrence. We successfully corrected equinus deformity in all cases. Follow up ranged from three months to five years and we found no recurrence. Patients with peroneal palsy were provided with Ankle Foot Orthosis (AFO). Conclusion. Taylor Spatial Frame treatment provides a safe, finely controllable, accurate and reproducible method of correcting soft tissue equinus deformity

Objective. To assess the long term functional and objective outcomes for 2 stage Dupuytrens contracture correction. Methods. Patients with severe contracture were offered a 2 stage correction. This involved application of external fixator to distract the contracture over the course of 2 weeks and subsequent partial fasciectomy (in primary contractures) and dermofasciectomy with full thickness skin graft (in recurrent contractures). A series of 54 corrections in 47 patients were identified. Of these, 6 were lost to follow-up, 1 deceased. Pre-operative total range of active movement (TRAM), total flexion contracture and PIP flexion contracture, Tubiana grade and DASH/Michigan Hand Scores were recorded and compared to post-operative data. Results. Mean age was 61 (range 43–90), 44 male, 10 females. The average duration of follow-up was 32 months (range 6–96). The mean fixed flexion deformity (FFD) in the PIPJ improved from 84 degrees (range 50–110, SD-12) to 30 degrees (range −5–90, SD-27) (p< 0.0001). Mean total flexion contracture improved from 123 degrees(range 50–210, SD-34) to 46 degrees (range 0–195, SD-50) (p< 0.0001). The mean TRAM improved from 70 degrees (range 10–140, SD-33) to 148 degrees (range 25–135, SD-52) (p< 0.0001). DASH scores improved from 32.0 to 27.6. Michigan hand scores improved from 68 to 76. There was no statistical difference in pre- and post-op hand scores. Complications include CRPS (8%), infection (6%), stiffness (4%), graft failure (4%), neurovascular injury (2%), fracture (4%). Conclusions. Long term follow-up of this two stage technique shows that the correction, range of movement and function is maintained. We consider that the complications rate is acceptable for these very severe deformities where amputation, joint fusions and total collateral ligament and volar plate release are the only other comparable surgical alternatives

Study. This is a prospective double blind, placebo controlled trial. Collagenase Clostridium Histolyticum was effective and well tolerated used in well palpable cords of Dupuytren's Contracture. Concurrent fingers treatment with early complications have been reported. Patients reported outcome measures have been obtained. Materials & Method. 143 fingers were treated in 125 patients. Deformity of more than 30° at metacarpo phalangeal joints and more than 20° at proximal interphalangeal joints with well palpable cord were selected in this study. Finger straightening procedure was undertaken at 24–72 hours post injection. Prospectively evaluated for early complications, extent of correction, residual deformity and recurrence rate at 3 years and 6 months follow up. Concurrent fingers were treated without serious side effects. Results. Full correction was achieved in 130 fingers (91%). Residual flexion deformity noted in mainly in PIPJ with flexion 80° or more. At four years follow up, the recurrence rate was noted in Metacarpophalangeal Joints in 4(3%)fingers and Proximal Inter Phalangeal Joints in 12(9%) fingers. Patient reported outcome measures have been collected and expressed high degree of satisfaction. Conclusion. Most local complications resolved within two weeks of the injection. Isolated MPJ deformity is more likely to be corrected fully. Isolated Proximal Interphalangeal Joints and combined Proximal Interphalangeal Joints and Metacarpo Phalangeal Joints contractures are mostly end up in residual flexion. Concurrent finger treatment was uneventful