Tendon Lengthening Surgery for Elbow Flexion Contractures in Brachial Plexus Birth Palsy.

PURPOSE: Flexion contracture of the elbow is a common deformity associated with brachial plexus birth palsy and is often managed with preventive night orthoses. For severe cases, however, surgical interventions may become necessary. This study evaluated the effectiveness of surgically releasing elbow flexion contractures exceeding 30° through partial tenotomy of the brachialis and biceps brachii muscles, along with a division of the lacertus fibrosus. METHODS: We performed 36 anterior elbow releases on patients with injury to the upper trunk (C5-C6) of the brachial plexus and elbow flexion contractures between 30° and 80°. All releases involved lacertus fibrosus section and partial lengthening of the distal portion of the brachialis tendon. In severe cases, biceps brachii tenotomy was also performed. All participants had a minimum follow-up of 12 months and preoperative elbow flexion strength of at least grade 4 on the British Medical Research Council scale, with no deformities in the shape of the ulnohumeral joint or radial head subluxation. RESULTS: Following a mean follow-up of 41 months, the average extension gain was 31° (range, 10°-50°). All patients maintained their flexion strength. Except for two participants with weaker triceps, the mean elbow extension gain was sustained throughout the follow-up period. There were no major or minor complications or reinterventions in the study. CONCLUSIONS: Partial tenotomy of the brachialis and biceps brachii muscles, coupled with lacertus fibrosus section, is an effective treatment for elbow contractures exceeding 30° flexion. This method is successful in individuals with a functioning triceps brachii and elbow extension strength of at least grade 3 on the British Medical Research Council scale. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparative analysis of surgical treatment modalities for a popliteal pterygium: a meta-analysis.

INTRODUCTION: Popliteal pterygium syndrome is a rare congenital disorder characterized by orofacial, cutaneous, musculoskeletal, and genital anomalies. The popliteal pterygium (PP) affects ambulation due to severe knee flexion contracture and equinovarus deformities. Surgical treatment aims to correct these deformities while preserving limb sensibility. However, due to its rarity, surgical guidelines are lacking. MATERIALS AND METHODS: A meta-analysis according to PRISMA guidelines was conducted to summarize and compare surgical methods for PP. 183 paper were identified in PubMed and data from 32 articles were analyzed, including patient demographics, treatment modalities (Ilizarov fixator, femoral osteotomy, skin/soft tissue procedures, hamstring release, nerve surgery, and amputation), pre- and post-operative abilities to walk, knee joint parameters, complications, and recurrent contractions. RESULTS: Among 58 patients (87 limbs), Ilizarov fixator demonstrated improved knee and ankle mobility postoperatively, but showed a relatively high surgical session count and complication rates. Femoral osteotomy achieved successful knee posture correction with fewer sessions and no complications. Isolated skin/soft tissue procedures improved flexion contracture and mobility, though they required several procedures. Hamstring release achieved notable contracture reduction but also necessitated multiple interventions. Nerve surgery and amputation had limited data, warranting further investigation. CONCLUSION: The management of PP demands a comprehensive approach, considering individual patient characteristics and treatment outcomes. While different surgical modalities offer distinct benefits, a classification or guideline to treat this deformity is still lacking. Further research is essential to validate findings, refine treatment approaches, and enhance the quality of life for individuals with PP.

Prevalence and predictors of elbow flexion contractures during early childhood following brachial plexus birth injury.

BACKGROUND: Elbow flexion contracture development in school-age children with a brachial plexus birth injury (BPBI) is common. Reports indicate onset between 2 and 4 years; however, little is known about early childhood prevalence, development, and trajectory of these contractures. PURPOSE: To determine the prevalence and predictors of BPBI elbow flexion contractures during early childhood. STUDY DESIGN: A retrospective cross-sectional study. METHODS: Demographic, diagnostic, treatment, and elbow contracture data were collected for children with a BPBI <4 years between 2015 and 2019 from a prospectively collected database. Spinal root motor contributions and injury were determined using Active Movement Scale (AMS) scores at 6 weeks of age and used to predict contracture development. RESULTS: Of the 171 children that met inclusion criteria, 87% (n = 149) had upper plexus injuries. The mean age at the time of evaluation for an elbow contracture was 21.4 ± 12.7 months. The prevalence of elbow flexion contractures was 22% (n = 38), with mean onset at 13.4 ± 11.0 months. Mean contracture degree was -10.8 ± -6.9 degrees with 76% (n = 29) <-10 degrees. AMS shoulder abduction, flexion, and external rotation; elbow flexion; forearm supination; and wrist extension scores at a mean 2.3 ± 1.4 months were significantly lower in children who developed elbow flexion contractures (p < 0.001). Logistic regression found that low AMS elbow flexion with high elbow extension scores were a significant (p < 0.003) predictor of elbow contracture development. CONCLUSIONS: The prevalence of elbow flexion contractures in early childhood is greater than previously understood. These findings indicate that C5-C6 injury affecting elbow flexion with relative preservation of elbow extension is a predictor of contracture development. Further research is needed to investigate the nature and sequelae of C5-C6 injury and its effects on elbow flexion contracture development.

Can a Total Knee System Providing 1 mm Increment of Polyethylene Insert Thickness Offer a Clinical Benefit?

Background and Objectives: The purpose of this study was to compare clinical outcomes and polyethylene (PE) insert thickness between total knee arthroplasty (TKA) systems providing 1 mm and 2 mm increments. Materials and Methods: In this randomized controlled trial, 50 patients (100 knees) undergoing same-day or staggered bilateral TKA were randomized to receive a TKA system providing 1 mm increments in one knee (1 mm group) and a TKA system providing 2 mm increments in the other knee (2 mm group). At 2 years postoperatively, Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Forgotten Joint Score (FJS), range of motion (ROM), and insert thicknesses were compared between the groups. Results: A total of 47 patients (94 knees) participated in follow-up analysis. In each group, patient-reported outcomes improved significantly after TKA (all, p < 0.05). There were no significant differences in patient-reported outcomes. The mean ROM was not significantly different between groups at preoperative and 2-year points. The rate of postoperative flexion contracture ≥ 5° was 2.1% and 4.3%, and the rate of postoperative recurvatum ≥ 5° was 4.3% and 2.1% in the 1 mm group and 2 mm, respectively (all, p = 1.000). Mean insert thickness was significantly thinner in the 1 mm group than the 2 mm group (p = 0.001). The usage rate of a thick insert (≥14 mm) was 12.7% and 38.3% in the 1 mm group and 2 mm group (p = 0.005). Conclusions: The use of a TKA system providing 1 mm PE insert thickness increments offered no clinical benefit in terms of patient reported outcomes over systems with 2 mm increments at 2 years of follow-up. However, the TKA system with 1 mm increments showed significantly thinner PE insert usage. As a theoretical advantage of 1 mm increments has yet to be proven, the mid- to long-term effects of thinner PE insert usage must be determined.

The effects of using heel protectors on the prevention of heel pressure injuries and plantar flexion contractures.

BACKGROUND: Immobilization in the intensive care unit can lead to pressure injuries and plantar flexion contractures. AIM: This study was conducted to evaluate the effectiveness of heel protectors applied for the prevention of heel pressure injuries and plantar flexion contractures in intensive care units. METHODOLOGY: This study was conducted as a randomized controlled trial in two adult intensive care units of a teaching and research hospital. The study sample consisted of 84 patients admitted to intensive care units between January 2022 and December 2022. Patients who had been in the intensive care unit for at least 5 days, scored 16 or less on the Braden Pressure Ulcer Risk Assessment Scale and scored 4 or more on the Ramsey Sedation Scale, were included in the study. Heel protector boots were applied to the heels of the patients in the intervention group, while standard positioning with a pillow and ROM exercises were continued in the control group. A sociodemographic data form, the Ramsey Sedation Scale and the Braden Pressure Ulcer Risk Assessment Scale were used to collect data. While pressure injuries were evaluated with the International NPUAP-EPUAP Pressure Ulcer Classification System, goniometric measurements were made to evaluate joint ROM. RESULTS: In the intervention group, heel pressure injuries did not develop during the study, whereas five patients in the control group developed heel pressure injuries. The risk of pressure injury development that was seen in the control group was 1.7 times higher compared with the risk for the intervention group (log 95% CI: 0.91-2.59). There were significant differences between the right foot (99%; F = 99.229; p = .000) and left foot (99%; F = 100.519; p = .000) in range of motion measurement values of the patients in the intervention group according to the measurement times. According to the results of the multiple comparison test (Bonferroni) performed to determine the range of motion measurement periods showing significant differences, it was observed that each measurement for both feet yielded lower results than the previous measurement (seven measurements from day 1 to day 13). CONCLUSION: The use of heel protector boots was found to be effective in preventing the development of heel pressure injuries and plantar flexion contractures in intensive care unit patients. RELEVANCE FOR CLINICAL PRACTICE: This study provides evidence that intensive care nurses can use heel protector boots to prevent the development of heel pressure injuries and plantar flexion contractures.

Comparative analysis of length gain provided by five-flap f-flasty and fouble f-plasty fechniques for correction of digital flexion contractures.

INTRODUCTION: Persistent postburn flexion contractions of the digits present challenging deformities. The surgical goal is to lengthen the linear scar band on the flexion surface of a finger through local tissue rearrangement using different z-plasty techniques. This study aimed to analyse the length gain and compare outcomes between 5-flap z-plasty and double serial z-plasty techniques for correcting digital flexion contracture. PATIENTS & METHOD: This retrospective study was conducted from November 2022 to January 2024 on patients who presented with digital flexion contractures caused by volar linear scar contracture and who needed surgical intervention. All patients who underwent correction via the 5-flap z-plasty or double z-plasty technique were categorized into two groups. RESULTS: A total of 12 patients were included in this study. All patients successfully achieved complete release of their digital contracture in both groups. While there was a significant increase in the length of the contracture band and extensor lag angle postoperatively in both groups, the mean increase in band length for patients treated with five-flap Z-plasty was significantly greater than that for patients treated with double z-plasty (63.667±13.125% vs. 41.333±12.1764%, respectively). CONCLUSION: The 5-flap Z-plasty technique could be a more favourable alternative to the frequently used double z-plasty method due to its ability to achieve a superior rate of elongation in the contracture band and restore finger function when treating linear digital flexion contractures.

What effect does preoperative flexion contracture have on the component angles in unicompartmental knee arthroplasty?

PURPOSE: The indication for unicompartmental knee arthroplasty (UKA) has been extended to cases with some degree of preoperative knee flexion contracture recently. The purpose of this study was to clarify the effect of flexion contracture on component angles. MATERIALS AND METHODS: Thirty-five fixed-bearing UKAs using the spacer block technique with preoperative flexion contracture (Group FC) and 35 UKAs using the same technique without preoperative flexion contracture (Group NC) were included. Using radiographs, the coronal femoral component angle, coronal tibial component angle, sagittal femoral component angle, and sagittal tibial component angle were determined. Also, extension and flexion angles of the knee as well as coronal Hip-Knee-Ankle (HKA) angles in long-leg standing radiographs were measured. The data about the thickness of the selected insert were also collected. The above results were compared between the two groups. RESULTS: The femoral component tended to be placed in a more varus and flexed position in Group FC, while no significant difference was found about the tibial component angles. While there was no significant difference in pre- and postoperative knee flexion angles between the two groups, flexion contracture remained postoperatively in Group FC. Preoperative HKA angle was greater in Group FC while the difference was no longer significant postoperatively. Regarding the thickness of the selected insert, thicker inserts tended to be used in Group FC. CONCLUSIONS: In fixed-bearing UKA with the spacer block technique, the femoral component tended to be placed in a flexed and varus position in the knees with preoperative flexion contracture.

The Ilizarov technique in the management of haemophilic knee flexion contracture.

INTRODUCTION: The Ilizarov technique has the potential to be an attractive option for severe knee flexion contracture (KFC) patients with a high risk of bleeding. However, studies on this technique in the management of haemophilic KFC are scarce. AIM: The purpose of this study was to review and analyse the results of the Ilizarov technique in correcting haemophilic KFC and to evaluate the safety and efficacy of this technique. METHODS: Twelve male haemophilia patients with severe KFC who underwent distraction treatment using the Ilizarov technique from June 2013 to April 2019 were included in this study. The hospital day, flexion contracture, range of motion (ROM) of the knees, complications and functional outcomes were recorded and analysed. Functional outcomes were evaluated according to the Hospital for Special Surgery (HSS) knee scores of the preoperation, end of distraction and last follow-up. RESULTS: The average preoperative flexion contracture and range of motion (ROM) of the knees were 55 ± 15° and 66 ± 18°, respectively. The average preoperative HSS knee score was 47 ± 5. The average duration of follow-up was 75.5 ± 30.1 months. All flexion contractures achieved full correction (≤5°) at the end of distraction, and the flexion contracture significantly decreased to 6 ± 5° at the last follow-up (p < .0001). The ROM of the knees was significantly increased at the last follow-up compared with that before distraction treatment (p < .0001). The HSS knee scores at the end of distraction and at the last follow-up were both significantly higher than the preoperative HSS knee score (p < .0001). No major complications were encountered. CONCLUSIONS: This study provided evidence for the safety and effectiveness of Ilizarov technique plus physical therapy in the management of haemophilic KFC and accumulated clinical experience for the proper application of this technology.

Patients With Dupuytren Disease Use Excessive Grip Force When Lifting and Holding Small Objects, Independent of the Degree of Contracture.

OBJECTIVE: To identify the extent and quality of fine motor skill alteration in patients with Dupuytren disease (DD) using an instrumented device measuring grip forces, beyond the commonly used measurement of contracture. DESIGN: Case-control study. SETTING: University outpatient clinic. PARTICIPANTS: Patients with DD (N=27) and a contracture >45° (Tubiana stage II, III, and IV) were included and compared with age-matched healthy control patients (N=27). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES(S): All individuals were subjected to a set of specific tests using a new instrumented device ("manipulandum"). These included lifting, grasping, and then holding the "manipulandum" with 4 different object characteristics (light and heavy weight, rough and smooth surface) along with a measurement of the precision grip strength. Standard measurements including the Nine-Hole Peg Test, a two-point discrimination, and the Disability of Arm, Shoulder and Hand score were evaluated in comparison. RESULTS: Although the measurements of precision grip, two-point discrimination, Nine-Hole Peg Test, and Disability of Arm, Shoulder and Hand score showed no statistically significant differences between both groups, patients with DD applied significantly greater forces when tested with the different subtests using the "manipulandum." Analysis of the 2-phase movement (lifting and holding the "manipulandum") revealed highly significant differences between the groups. CONCLUSIONS: Patients with DD use excessive grip forces when lifting and holding the "manipulandum" when compared with healthy control patients, independent of the degree of contracture. As no differences in precision grip strength were seen, the presented approach is useful to obtain additional important information about fine motor function in diseased hands.

Mathematical analysis in the design of digital artery-based V-Y advancement flap in treating proximal interphalangeal joint flexion contracture.

BACKGROUND: The digital artery-based V-Y advancement flap is a widely used flap for soft tissue coverage in the treatment of flexion contracture of the proximal interphalangeal (PIP) joint. A standard method for the flap design and a mathematical method to predict the advance distance have not been well established. In this study, we proposed a simplified method for the design of V-Y advancement flaps based on digital arteries and used a geometric model to predict the advance distance for the flexion contracture correction surgery. METHODS: According to the general concept of hand flap design and law of cosine, we proposed three principles in the design of the digital artery-based V-Y advancement flap that should be followed. Since 2021 to 2022, finger geometric data of 120 fingers (index, middle, ring, and small fingers) from 30 healthy participants were collected and analysed to evaluate the necessary advance distance and flap tip angle for PIP flexion contracture correction of different fingers by our flap design method. RESULTS: The middle finger needed a significantly longer advance distance compared to other fingers in the same degree flexion contracture correction. The ring finger had the largest length-to width ratio and smallest flap tip angle among the four fingers in the V-Y flap design. No vertical scar crossed the flexion creases and flap tip angle < 20° was found in the tentative V-Y flap design for the 120 fingers. CONCLUSIONS: Our flap design method provides a proper advance distance and flap length-to-width ratio without common skin complications in the flap design for PIP flexion contracture of index, middle, ring and small fingers. This geometric model provides a mathematical basis for prediction of advance distance and flap tip angle in the design of a digital artery-based V-Y advancement flap.

The significance of the pelvic incidence measurement as a possible predictor of TKA outcome.

PURPOSE: To evaluate the association between the sagittal alignment of the pelvis and residual knee flexion contracture after total knee arthroplasty (TKA). This is important as a flexion contraction can be associated with the risk of poor outcomes and patient satisfaction after TKA. METHODS: This was a retrospective, case-control, study of 200 osteoarthritic knees, contributed by 200 patients, over a mean follow-up of 2.4 years. The following factors were compared between patients 'with' (46 knees) and 'without' (154 knees) a residual flexion contracture ≥ 10° after TKA: age, sex, pelvic incidence (PI), anterior femoral bowing, femoral component flexion angle (FFA), and patient-reported outcomes. Logistic regression and receiver operating characteristic curve analyses were used to identify predictive factors. RESULTS: The following factors were predictive of a residual flexion contracture ≥ 10°: a pelvic incidence ≥ 55° (odds ratio, 1.29; 95% confidence interval, 1.05-1.59; P = 0.031) and the FFA (odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P = 0.044). A pelvic incidence cutoff of 55° yielded a significant between-group difference, with a sensitivity of 78.4% and specificity of 89.9% to differentiate a residual knee flexion contracture ≥ 10° (P = 0.001), patient satisfaction (P = 0.029), EuroQol 5-Dimension score (P = 0.028), anterior femoral curvature (P = 0.031), and Knee Injury and Osteoarthritis Outcome Score-Joint Replacement score (P = 0.046). CONCLUSION: A pelvic incidence > 55° is associated with a residual knee flexion contracture ≥ 10° after TKA. The significance of the pelvic incidence measurement as a possible predictor of TKA outcome was highlighted, including its impact on patient satisfaction. LEVEL OF EVIDENCE: III.

The Green Transfer-Long-Term Results.

PURPOSE: The purpose of this study was to determine the long-term results of the Green transfer (flexor carpi ulnaris to extensor carpi radialis brevis) for patient-reported outcomes, wrist position, and range of motion. METHODS: We re-examined 13 patients from a previous prospective study involving surgery for hemiplegia that included a Green transfer. The average follow-up was 8 years with the range from 5 to 11 years. The wrist range of motion and the postoperative position of the wrists were measured. The surgical outcomes were measured via the Pediatric Orthopedic Data Collection Instrument, the Shriner's Hospital Upper Extremity Evaluation, Pediatric Quality of Life, and visual analog score for appearance from the patient and the parent. RESULTS: At this follow-up, only 7 of the 13 patients had a wrist position near neutral with the ability to flex and extend the wrist. Wrist range of motion was improved in four, decreased in four, and stayed the same in five patients. In contrast to these positional wrist results, statistically significant improvements were noted in several aspects of the Pediatric Orthopedic Data Collection Instrument, visual analog scores, and Shriner's Hospital Upper Extremity Evaluation scores. CONCLUSIONS: Long-term follow-up of the flexor carpi ulnaris to extensor carpi radialis brevis tendon transfer in hemiplegic patients reveals the results to be variable but favorable from a patient-reported outcome standpoint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Total knee arthroplasty in patients with lumbar spinal fusion leads to significant changes in pelvic tilt and sacral slope.

BACKGROUND: The knee-hip-spine syndrome has been well elucidated in the literature in recent years. The aim of this study was to evaluate the effect of total knee arthroplasty (TKA) on spinopelvic sagittal alignment in patients with and without pre-TKA lumber spinal fusion. METHODS: This is a retrospective cohort study of 113 patients who underwent TKA for primary osteoarthritis. Patients were stratified into the following three groups: (1) patients who had pre-TKA spinal fusion (SF, n = 19), (2) patients who had no spinal fusion but experienced pre-TKA flexion contracture (FC, n = 20), and (3) patients without flexion contracture or spinal fusion before TKA (no SF/FC, n = 74). Spinopelvic sagittal alignment parameters, including pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), and plumb line-sacrum distance (SVA) were measured preoperatively and 3 months postoperatively on lateral standing full-body low-dose images. RESULTS: TKA resulted in significant pre- to postoperative changes in pelvic tilt (average ∆ PT = - 8.6°, p = 0.018) and sacral slope (average ∆ SS = 8.6°, p = 0.037) in the spinal fusion (SF) group. Non-significant changes in spinopelvic sagittal alignment parameters (PT, SS, LL, TK, SVA) were noted postoperatively in all patients in the FC and the no SF/FC groups. CONCLUSIONS: TKA can lead to meaningful changes in spinopelvic alignment in patients with prior lumbar fusion compared to those without spinal fusion. Patients with spinal fusion who are candidates for both hip and knee replacements should consider undergoing TKA first since changes in spinopelvic sagittal alignment can increase the risk of future complications. LEVEL III EVIDENCE: Retrospective Cohort Study.

Case report illustrating use of serial elastic tension digital neoprene orthoses (ETDNO) protocol in the treatment of proximal interphalangeal joint flexion contracture.

INTRODUCTION: This case report details the application of a treatment regimen using a serial elastic tension digital neoprene orthosis (ETDNO) protocol for a patient with an eight-month-old finger crush injury who experienced recurrence of a 45º proximal interphalangeal joint (PIPJ) flexion contracture two months after arthrolysis. PURPOSE OF THE STUDY: To illustrate how the application strategy of ETDNO can increase the daily total end range time (TERT) and modify finger stiffness. RESULTS: The patient reached full extension following 15 weeks of ETDNO treatment. The six-month follow-up evaluation revealed that the PIPJ was stable with full flexion and extension. The joint did not require continued orthosis use. DISCUSSION: The literature describes orthosis application as the treatment of choice for PIPJ flexion contracture, but no study has described an ideal program for use nor the full and stable resolution of the flexion contracture. The current literature describes a maximum daily total end range time (TERT) of 12 hours a per day. The serial ETDNO protocol that this study described increased the daily TERT to nearly 24 hour per day and demonstrated an excellent result in the treatment of PIPJ flexion contracture CONCLUSION: This outcome suggests that clinicians will want to consider this new orthosis design and management protocol as a novel option for the treatment of PIPJ flexion contracture. We need future research to better define the optimum number of hours of daily TERT for the effective treatment of PIPJ flexion contracture. In addition, we will also benefit from the exploration of the optimum orthosis design to enable the highest amount of TERT.

Effect of hip flexion contracture on the pelvic sagittal tilt in the supine position: A retrospective case-series study.

OBJECTIVES: The functional pelvic plane, which adopts the natural pelvic sagittal tilt in the supine position, is a good reference for determining the cup angle in total hip arthroplasty. However, hip flexion contracture may change pelvic tilt postoperatively by the release of contracture. This study investigated the influence of hip flexion contracture on pelvic sagittal tilt in the supine position. METHODS: This study included 300 patients who underwent primary unilateral total hip arthroplasty. We divided the participants into two groups: with a preoperative hip extension angle of <0° (hip flexion contracture group) and without (non-contracture group). The pelvic sagittal tilt and femoral flexion angle were investigated using computed tomography or pelvic radiographs performed preoperatively and postoperatively. RESULTS: The femoral flexion angle had significantly reduced postoperatively in the hip flexion contracture group but remained unchanged in the non-contracture group. The preoperative and postoperative pelvic sagittal tilt showed no significant differences between the two groups up to 1 year postoperatively. CONCLUSIONS: The influence of hip flexion contracture on the pelvic sagittal tilt in the supine position was minimal. The functional pelvic plane in the supine position could be a good reference to ascertain the cup orientation, even in hip flexion contracture cases.

Outcomes of Arthroscopic Elbow Contracture Release: Improvement for Severe Prosupination and Flexion Contracture.

PURPOSE: The purpose of this study was to investigate outcomes following arthroscopic elbow contracture release to describe the use of arthroscopy for improvement in extension/flexion and pronation/supination arcs of motion at a single institution for degenerative and posttraumatic etiologies. METHODS: Consecutive arthroscopic elbow arthrolysis performed between 2003 and 2015 were retrospectively reviewed. Basic patient demographics, indications for surgery, preoperative and postoperative elbow range of motion, postoperative patient outcome score, and all complications were recorded and analyzed. RESULTS: Fifty-two patients were included with an average follow-up of 5.1 years (range 1.4 to 9.4). Severe contractures made up 50% of cases, followed by 23% moderate, and 27% mild. Average extension/flexion for the post-traumatic group (n = 30) increased by 63° ± 31 and by 29° ± 24 for the degenerative group (n = 22). Average gain in pronosupination was 38° ± 62 in the post-traumatic group and 13°±23 in the degenerative group. Postoperative DASH scores were 17.5 ± 18.4 for post-traumatic cases and 12.8 ± 19.3 for degenerative cases. CONCLUSION: Arthroscopic elbow contracture release is an effective intervention for degenerative and post-traumatic elbow contracture for both flexion/extension and pronosupination contracture. Furthermore, a two-stage release should be considered when both flexion and pronosupinaton contractures are present. LEVEL OF EVIDENCE: IV, case series, treatment study.

Both arthroscopic and open posterior knee capsulotomy are effective in terms of extension recovery and functional improvement-systematic review.

PURPOSE: To assess the recovery of extension and improvement in functional scores after an arthroscopic or open posterior knee capsulotomy in the setting of an extension deficit. METHODS: A systematic search of articles published between 1980 and 2020 was performed in the MEDLINE/PubMed database, EMBASE/Ovid database and Web of Science database. The inclusion criteria consisted of patients with primary extension deficits > 5° who underwent an arthroscopic or open posterior knee capsulotomy. The assessed outcomes were preoperative and postoperative range of motion and functional outcome scores. Randomized controlled trials, cohort studies and case series with a follow-up longer than 6 months were included. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for case series. The certainty of evidence was assessed using the GRADE approach. RESULTS: Of 226 records identified through database searching, 7 studies were included in the final analysis. The outcomes of 107 patients with a mean age of 34.1 (range 15-63) years were available. In all the included studies, a posterior capsulotomy resulted in the restoration of knee extension to normal or nearly normal values (mean postoperative extension deficit: 0.4-4.2 degrees) with a significant increase in functional outcome scores. No neurovascular complications were reported within the studies. Due to the diverse methodology of studies, the direct comparison of arthroscopic versus open approaches was not possible. Concerning the risk of bias assessment, the greatest concerns raised the selection of participants among the included studies and the methods of outcome measurement. The certainty of evidence was very low according to the GRADE. CONCLUSIONS: Both arthroscopic and open posterior capsulotomy of the knee results in restoration of normal or nearly normal knee extension and significant improvement in functional outcomes. LEVEL OF EVIDENCE: IV.

Comparative Study of A1 Pulley Release and Ulnar Superficialis Slip Resection in Trigger Finger With Flexion Contracture of the Proximal Interphalangeal Joint.

PURPOSE: The purpose of this study was to compare the clinical outcomes of A1 pulley release with ulnar superficialis slip resection (group A) and simple A1 pulley release (group B) in trigger finger with flexion contracture of the proximal interphalangeal (PIP) joint. METHODS: From January 2016 to December 2019, the 2 surgical procedures were performed alternately every year for trigger fingers with preoperative PIP joint flexion contractures of ≥10°. Twenty-six fingers in group A and 29 fingers in group B that were followed up for >1 year were reviewed in this retrospective study. The visual analog scale (VAS) score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; degree of PIP joint flexion contracture; grip strength; and pinch strength were measured after surgery and compared. RESULTS: The differences in postoperative PIP joint flexion contracture between groups were <4° at 2 and 6 weeks, and there were no clinically relevant differences at 6 weeks and 12 months. At the final follow-up, PIP joint flexion contractures of 5° were observed in 2 fingers in each group. The difference in VAS scores between groups was less than half of a point until 3 months, and there were no clinically relevant differences at 6 weeks and 12 months. The DASH score did not show any difference between groups at the final follow-up. There were clinically relevant differences in the grip and pinch strengths between groups at 6 weeks. However, there were no clinically relevant differences at the final follow-up. CONCLUSIONS: Proximal interphalangeal joint flexion contracture measurements and clinical scores did not differ between groups at the final follow-up. Therefore, we recommend use of a simple A1 pulley release, which is simpler than an A1 pulley release with ulnar superficialis slip resection, in cases of trigger finger with PIP joint flexion contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Mid-Level Constrained Insert Reduces Coupled Axial Rotation but Not Coronal Mid-Flexion Laxity Induced by Joint Line Elevation in Posterior-Stabilized Total Knee Arthroplasty: A Computational Study.

BACKGROUND: Surgeons may resect additional distal femur during primary posterior-stabilized (PS) total knee arthroplasty (TKA) to correct a flexion contracture. However, the resultant joint line elevation (JLE) increases mid-flexion laxity. We determined whether a mid-level constraint (MLC) insert reduced mid-flexion laxity after JLE. METHODS: Six computational knee models were developed using computed tomography scans and average soft tissue properties yielding balanced extension gaps but with a 10° flexion contracture. Distal femoral resections of +2 and +4 mm were simulated with PS and MLC inserts. Varus-valgus ±10 Nm moments were applied at 30°, 45°, and 60° of flexion. Coronal laxity (the sum of varus-valgus angulation) and coupled axial rotation (the sum of internal/external rotation) were measured and compared between insert models. RESULTS: At 30° of flexion, coronal laxities with the PS insert at the +2 and +4 mm resections averaged 7.9° ± 0.6° and 11.3° ± 0.6°, respectively, and decreased by 0.8° (P = .06) and 1.0° (P = .07), respectively, with the MLC insert. PS rotational laxities at the +2 and +4 mm resections averaged 11.1° ± 3.9° and 12.5° ± 4.6°, respectively, and decreased by 5.6° (P = .01) and 7.1° (P = .02), respectively, with the MLC insert. Similar patterns were observed at 45° and 60° of flexion. CONCLUSION: With additional distal femoral resections to alleviate a flexion contracture, utilizing an MLC insert substantially reduced coupled axial rotation but had a minimal impact on coronal laxity compared to a PS insert. Efforts should be taken to avoid JLE in primary total knee arthroplasty as even MLC inserts may not mitigate coronal laxity.

Evaluation of the balance function before and after total knee arthroplasty using Berg balance scale.

INTRODUCTION: The purpose of this study was to evaluate balance function before and after total knee arthroplasty (TKA) using Berg balance scale (BBS). The study also aimed to identify factors associated with balance impairment. MATERIALS AND METHODS: Ninety-three knees in 90 patients were prospectively evaluated using their BBS scores, passive knee extension/flexion angles, Visual analogue scale for pain scores, hip-knee-ankle angles, and knee extensor/flexor muscle strengths before and after TKA. A total BBS score of less than 45 indicates an enhanced risk of multiple falls. Multivariate logistic regression models were performed to elucidate factors associated with post-operative BBS score. RESULTS: A significant difference in mean pre- and post-operative BBS scores were noted (49.3 ± 6.4 vs. 52.2 ± 4.7) (p < 0.05). The percentage of pre- and post-operative BBS scores less than 45 were 20% and 10% (p < 0.05). Rheumatoid Arthritis (RA), lower pre-operative BBS score, and larger post-operative knee flexion contracture were significantly associated with lower post-operative BBS score (p < 0.01). The post-operative knee flexion contracture greater than 10° was significantly associated with substantially high odds of post-operative BBS scores less than 45 (Odds ratio 7.6; 95% confidential interval 1.69-34.17). CONCLUSIONS: While TKA significantly improved BBS scores, 10% of the patients remained at a risk for multiple falls. RA, lower pre-operative BBS score, and post-operative knee flexion contracture greater than 10° retained balance impairment even after TKA.