Soft tissue contractures and Deformities around Knee Joint


Defrormities produced by Iliotibial band contracture.

LS Spine – Ipsilateral lumbar scoliosis , lumbar lordosis
Pelvis – Pelvic obliquity , with abduction contracture
Hip – FABER

Knee – Genu Valgum , knee flexion contracture ,
Leg – external tibial torsion with or without  knee subluxation .
Ankle / Foot – secondary deformity – talaipes equinovarus , heel varus.
Whole leg shortening (true ), initially there may be apparent lengthening due to abduction contracture at hip and pelvis obliquity.

Triple deformity
Classically described for TB Knee
Also seen with RA and ITB contracture

Deformity components
1.       Flexion – maximum joint space at 30 degrees
2.       Posterolateral subluxation of tibia -  exaggeration of physiological alignment in destructive disease
3.       ER of tibia over femur – various reasons
Quadriceps pull , Popliteal action, ITB etc.

                Quadrpupled deformity – added valgus





Quadriceps Contracture

Birth
                Stiff knee , extended
                Congenital recurvatum
                Toddleres

Toddlers
                Progressive painless loss of flexion at knee

Childhood
                Habitual dislocation of patella

Adults
                Painful knee due to habitual dislocation of patella

Common findings
                Genu Recurvatum
                Increased lumbar lordosis
                Posterior knee (femoral condylar ) prominence ,knee subluxation
                Lateral patellar subluxation
                Reduced knee creases
                Scars of previous surgery
                Wasting
                Gait
                                Stiff knee
                                Walks with IR of leg
                                Valgus thrust gait

                Sitting
                                Dimple over thigh (tethering of quadriceps )
Lateral position of tibial tuberosity and bayonette
 sign
Supine
                Knee flexion decreased
                Habitual dislocation of patella
                Ober’s test positive
                Positive Ely’s test
               
Commonest causes of quadriceps contracture
                Children and adolescent
                                Multiple injections (Antibiotics , Tetanus , Antiserum )
                                Infusion into thigh
                                Idiopathic (congenital ,surgical –femur plating )
                                Malunion / tethering of muscles , infection
                                Osteomyelitis (muscles adhered to bone )
                                Myonecrosis

Adults
                Post surgical intervention
                Poressive disease in children with ongoing fibrosis esp. idiopathic forms
                Muscle most commonly affected – Vastus Lateralis
Post injection , idiopathic / congenital cases – Vastus Intermedialis – has a precarious blood supply

How to identify contracture of Vastus Lateralis , intermedius and Rectus Femoris ?
                All have decreased of knee
                Rectus Femoris- Positive Ely’s Test , flexion at hip
                Combined contracture – difficult to assess
                1.Vastus Intermedialis only – decreased knee flexion ,genu recurvatum and hyperextension
                2.Vastus lateralis – 1 + genu valgum + lateral patellar subluxation
                3. Rectus Femoris only – 1+ positive Ely’s test hip
                4. combined – 1 +2 +3

                5.Gracilis Contracture – Positive Phelps test
               
Your Differentials ?
                Chronic Dislocation of patella
                                Congenital dislocation never  precedes dislocation
                Flexion contracture
                Genetic and Syndromic
Larsen , Down’s , Arthrogryposis Multiplex congenitalia , Nail Patella Diastrophic Dysplasia , Patellar Hypoplasia
                Congenital dislocation of Knee
                                Present at birth , hereditary , more in females (3 times ), 1/3 rd bilateral
Round condyles , absent suprapatellar pouch , , absent or hypopplastic cruciates , contracture of quadriceps



Where else same phenomenon ?
Post injection Deltoid Contracture
Gluteal Medius Extension Contracture

What next ?
AP and Lateral view of Knee
AP Pelvis and Femur
To look
infection and fracture
Secondary development in joint (patellar displacement , flattening of femoral condyles , anterior tibial .. , subluxation of tibia, Genu Recurvatum , fragmentation of superior and inferior pole of patella



How to plan for surgery
Factors to consider
(Thompson)
1.       Whether rectus femoris involved
2.       How well this muscle can be involved
3.       How well this muscle develops after surgery

Aim of surgery – to attain ROM 0-90 degrees , critical arc at knee joint

Options
Only Rectus involved – Sasaki type release
Early stage with no joint changes – proximal release (Sengupta )
More extensive involvement ; Thompson/ Pyar type – Quadricepsplasty
Genu Recurvatum ; Femoral Osteotomy
Arthritis and extensive involvement ;Arthrodesis
Simultaneous Patellectomy is indicated if deeper surface of patella grossly involved .

What precautions you take perioperatively ?
    Explain post operative extension lag following quadricepsplasty that however it may resolve                 gradually
    Obtain much haemostasis to avoid recurvatum and haemarthrosis

    Immobilization –     90 degrees flexion , Sengupta
                                    50 degrees less than that obtained on table
                                   (Thomposon ) for 2-3 days followed by continuous passive motion.


Please give me suggestions , comments /feedback sothat  I can make more notes with interest.

for those who think of FCPS
https://fcpsscope.blogspot.com

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