CONTRACTUR

E OF THE
KNEE
 Pembimbing Supervisor
Nurul Annisari Al Maidin Dr. Andry Oesman, Sp.OT (K)
Giordano Bandi Lolok
Maharani Ave Maria Purba Pembimbing Residen
Nadya Primastuti Dr. Reza Fahlevi
Qanitah Nabilah Dr. Astrawinata

DEPARTMENT OF ORTHOPAEDIC AND TRAUMATOLOGY

HASANUDDIN UNIVERSITY
2019
DEFINITIONS
- Joint contracture: Loss of passive range motion
of diarthrodal joint.
- Knee flexion contracture: a loss of knee ROM in
extension.
- Knee extension contracture: a loss of knee
natural flexion amplitude.

Review Article: Noninflammatory Joint Contractures Arising from Immobility :Animal Models to Future Treatments, Biomed Research, 2015
ETIOLOGY
- Multiple congenital contractures
- Contractures in association with
chronic diseases or after trauma
- Contractures resulting from
prolonged immobility.

Review Article: Noninflammatory Joint Contractures Arising from Immobility :Animal Models to Future Treatments, Biomed Research, 2015
 • Trauma: inflammatory
pathways
• Chronic conditions: arthritic
diseases (RA and OA), total
knee arhroplasty (TKA), spinal
cord injury, brain injury,
severe burn, muscular
dystrophies, diabetes.

Abnormalities of - Bedridden patients

genes involved in in ICU
development of - Institutionalized
connective tissue elderly people
Review Article: Noninflammatory Joint Contractures Arising from Immobility
:Animal Models to Future Treatments, Biomed Research, 2015
Jain JK et al. Total knee arthroplasty in patients with fixed flexion
deformity: Treatment protocol and outcome.Current Orthopaedic
Practice. November 2013
 Risk Factor

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

PATOPHYSIOLOGY

Atrophy Reversible with

Muscle spontaneous
Spastic
<2 weeks remobilization

>2 weeks
Capsule
Trauma
Opposing synovial Decreases length
Bedridden
Immobilizati folds become of posterior
Elderly
on adherent capsule
Skin
contracture

Resist knee Prevent

fl/extension unfolding

Review Article: Noninflammatory Joint Contractures Arising from Immobility :Animal Models to Future Treatments, Biomed Research, 2015
 Patophysiology

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

 Patophysiology

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

 Classification

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

 Anatomy of Knee
• Muscle balance: quadriceps vs hamstrings
• Straight leg raise >60°
• Popliteal angle (from horizontal) >60°
• Sagittal plane: full extension
• Straight line between femoral cortex and
tibial cortex
• Open physes
• Patella location: between the Blumensat line
and physis
• Ground reaction force passes anterior to
knee’s center of rotation, knee locks
passively in extension
• Posterior capsule, gastrocnemius, and
hamstrings resist recurvatum

Pediatric Fixed Knee Flexion Deformities, taken from [https://emedicine.medscape.com/article/1358099-overview?src=medscapeapp-android&ref=email]

 Anatomy of Knee Contracture

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

 Anatomic Classification

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

History

Clinical  examination of the knee remains an essential step in evaluating  the knee patient.

Evaluation of every patient should begin with 

 a complete history of the symptoms and
 a full description of  the mechanism of injury.
 the history will direct the  examiner to the area of knee involvement.

This will sharpen the  physical examination, result in a more accurate diagnosis, and  allow the clinician to be
more proficient.

Insall & Scott SURGERY of the KNEE, Vol 1, 2018

 PHYSICAL
EXAMINATION
Crouch gait
- Patella alta, with reduced power of
voluntary knee extension
- Femoral condyles may be prominent
- Prominence and tenderness at either
pole of patella, over tibial tuberositas, Insall & Scott SURGERY of the KNEE, Vol 1, 2018

or both
- Knee crepitance
Youtube Channel “Spunky Shannon on Wheels”
OBSERVATION AND INSPECTION

 The examination should begin with observation of the patient’s  gait. The examiner should  note
the patient’s ability to ambulate, the use of gait aids, the  speed of ambulation, and the amount of
discomfort present  with attempted ambulation. Evaluation of the gait pattern and  the stance
position of the lower limb is performed while the  patient ambulates.

 Patellar alignment must also be observed. It is influenced by  femoral neck anteversion, tibial
torsion, the anatomy of the individual patellar facets, and the depth and angle of the
femoral Sulcus.

Insall & Scott SURGERY of the KNEE, Vol 1, 2018

OBSERVATION AND INSPECTION

 The Q angle is drawn from the middle of the tibial tubercle to the middle of the patella and then to
the anterior superior iliac spine of the pelvis. The normal angle is 10 to 20 degrees.
 Clinical effusion may be apparent visually. Active range of motion should be recorded, along with any
limitations to full extension or flexion. Active range of motion will be further evaluated with palpation and
should be compared with passive range of motion of the knee
 An inability to fully extend may represent lag, a locked knee, or a flexion contracture. An inability to fully
flex may be because of an effusion, pain, or extension contracture

Insall & Scott SURGERY of the KNEE, Vol 1, 2018

OBSERVATION AND INSPECTION

Jain JK et al. Total knee arthroplasty in patients with fixed flexion deformity: Treatment protocol and outcome.Current Orthopaedic Practice. November 2013
PALPATION

All bony landmarks should be palpated and identified.

 The Q angle, Gerdy’s tubercle, the fibular head, the epicondyles of the  femur, the patellar
margins, and the tibiofemoral joint lines can be readily palpated in most patients.
 Effusions can be graded in size by compressing the suprapaellar pouch and then noting any fluid
(grade 1), slight lift-off of the patella (grade 2), a ballotable patella (grade 3), or a tense  effusion
with no ability to compress the patella against the  femoral sulcus (grade 4).

Insall & Scott SURGERY of the KNEE, Vol 1, 2018

PALPATION

 If muscle atrophy was noted on observation, thigh circumference should now be measured.
 The calf should be measured at its greatest circumference in the lower part of the leg.
 Crepitation in and of itself may or may not represent evidence of a disorder. The location should
be recorded for future  reference.

Insall & Scott SURGERY of the KNEE, Vol 1, 2018

The move

 ROM

 Ely Test

Insall & Scott SURGERY of the KNEE, Vol 1, 2018

Physical Examination
OBER TEST
Insall & Scott SURGERY of the KNEE, Vol 1, 2018
The move

Insall & Scott SURGERY of the KNEE, Vol 1, 2018

Radiography

Jain JK et al. Total knee arthroplasty in patients with fixed flexion deformity: Treatment protocol and outcome.Current Orthopaedic Practice. November 2013
 Treatment

Jain JK et al. Total knee arthroplasty in patients with fixed flexion deformity: Treatment protocol and outcome.Current Orthopaedic
Practice. November 2013
Treatment

Pujol, N et al. Review Article : Post-Traumatic Knee Stiffness : Surgical Techniques. Orthopaedics & Traumatology: Surgery & Research 101 (2015) 5179 - 5186
NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Treatment
NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Treatment
Operation Technique (Knee Contracture)

• Arthroscopic Soft Tissue Releases

• Open Z-Plasty, Medial-Lateral Retinacular Tissues
• Posterior Medial-Lateral Capsulotomy

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Arthroscopic Soft Tissue Releases

• A demonstration of an arthroscopic technique for

debridement of contracted tissues in a knee with
arthrofibrosis.

• In this patient, there was a restriction in medial-to-lateral

translation (glide) of the patellofemoral joint, with a
contracture of the medial and lateral retinaculum.

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Arthroscopic Soft Tissue Releases

• indicating that an arthroscopic technique could be used and

an open extensive technique was not necessary.

• There were limitations of motion at 0/5/90 degrees.

• The procedure was performed after tourniquet inflation.

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Arthroscopic Soft
Tissue Releases
 NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Arthroscopic Soft
Tissue Releases
Open Z-Plasty, Medial-Lateral Retinacular Tissues

• The demonstration of the operative technique for an open Z-plasty

release of the medial and lateral retinacular tissues.

• An arthroscopic release alone is contraindicated in this case because

the release is so extensive (extending above the proximal patella and
releasing all medial and lateral soft tissues) that there would be open
communication of the joint into the subcutaneous tissues.

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Open Z-Plasty, Medial-Lateral Retinacular Tissues

• The principal shown is to preserve the function of the medial and

lateral retinacular soft tissues and, as well, debride the tissues to a
normal thickness.

• The Z-plasty open release allows an arthrotomy to thoroughly debride

infrapatellar contracted tissues, protect the patellar tendon, and
lengthen contracted medial and lateral patellar tissues.

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Open Z-Plasty,
Medial-Lateral
Retinacular Tissues
• Posterior Medial-Lateral Capsulotomy

• The technique for a posterior medial-lateral capsulotomy involves the

same exposure as that used for a medial or lateral meniscus.

• On the medial side, the posterior capsule is sectioned at its femoral

attachment proximally.

• On the lateral side, the capsule is sectioned in its proximal aspect just
below the attachment of the lateral gastrocnemius to the posterior
capsule.

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

• Posterior Medial-Lateral Capsulotomy

• The dissection and posterior capsule excision are carried directly over the posterior
femoral condyles and not into the posterior intercondylar region because scar tissue
may extend to the neurovascular structures.It is often impressive how dense the
posterior capsular structures are, and with their release, further gains in knee
extension are possible on the operating table.

• The remaining posterior intercondylar tissues are easily stretched with the
overpressure program. The posterior capsule releases are also accompanied with an
arthroscopic procedure to remove any tissue that has grown into the notch producing
an anterior impingement that would also block extension.

NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

 NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Posterior Medial-
Lateral Capsulotomy
NOYES’ KNEE DISORDERS Surgery, Rehabilitation, Clinical Outcomes 2 nd Edition, 2017

Posterior Medial-
Lateral Capsulotomy
THANK
YOU
 Insall & Scott SURGERY of the KNEE, Vol 1, 2018

The move
Prone Position Supine Position
Straight leg raise
• if degree of knee flexion
• The inward-outward range
increases as the hip is flexed,
• Hip rotation
then a concomitant hamstring
• Thigh-foot axis contracture is likely.
• Ely test • If there is no change in the
popliteal angle, then fixed knee
flexion deformity is the
diagnosis.
Insall & Scott SURGERY of the KNEE, Vol 1, 2018
 Hip Rotation

PRONE
POSITION
EXAM

Inward Outward Range Thigh Foot Angle Ely Test