title: Total knee replacement in post-traumatic arthritic knees with limitation of flexion.
abstract: The objective of this study is to investigate the results of total knee arthroplasty (TKA) in traumatic osteoarthritis cases with flexion restriction and to describe the technical details of their management. A multicentre series comprising 40 patients with limitation of flexion less than or equal to 90° was selected from 152 cases of post-traumatic knee arthritis with malunion. We hypothesized that the arthroplasty complication rate would be higher than in other etiologies of limitation of flexion and would require specific management strategies.
  
  
  METHODS
  In 23 cases, intra-articular malunion was present, in 15 cases extra-articular, and in two cases combined. The mean flexion was 72±23°, extension was 6±6°, and total range of motion (ROM) 66±23°. Eight cases of flexion restriction were severe (flexion<50°), six intermediate (flexion, 50-70°) and 26 moderate. In 14 cases, the anterior tibial tuberosity was osteotomized (43% intra-articular malunion and 6% extra-articular malunion). Five simultaneous realignment osteotomies were necessary. In severe cases of limitation of flexion, five extensive quadriceps releases were associated.
  
  
  RESULTS
  Four mobilizations under general anesthesia were performed. In the cases of severe limitation of flexion, we noted three avulsions of the patellar tendon, two cases of cutaneous necrosis, one of which was associated with deep infection, and another case of deep infection. In the cases of moderate limitation of flexion, we noted one case of nonunion of the tibial tuberosity and two cases were revised for loosening, one aseptic and the other septic. With a mean follow-up of 5±4 years, the mean flexion was 99.4°±23 for a gain of 26.7±20°. The final flexion and the gain in flexion were correlated with preoperative flexion (r=0.62 and r=-0.47, respectively). The final amplitude was 99±27° for a gain of 33±21°. The flexion gains were comparable for both types of malunion, whether they were intra- or extra-articular.
  
  
  CONCLUSIONS
  Arthroplasty provided a substantial gain in flexion. Osteotomy of the tibial tuberosity and the realignment osteotomies should be performed if necessary, with no risk of compromising the result. Superior gains can be sought in severe cases of limitation of flexion by releasing the extensor apparatus, in absence of cutaneous scar tissue retractions and recent infection.
  
  
  METHODS
  Level 4. Noncomparative retrospective study.
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Bichat-Claude-Bernard Teaching Hospital center, Paris-Diderot University, 46, rue Henri-Huchard, 75877 Paris cedex 18, France. philippe.massin@bch.aphp.fr
authors.forename: P
authors.initials: P
authors.lastname: Massin
authors.forename: M
authors.initials: M
authors.lastname: Bonnin
authors.forename: S
authors.initials: S
authors.lastname: Paratte
authors.forename: R
authors.initials: R
authors.lastname: Vargas
authors.forename: P
authors.initials: P
authors.lastname: Piriou
authors.forename: G
authors.initials: G
authors.lastname: Deschamps
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019645:Arthroplasty, Replacement, Knee / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007718:Knee Injuries / Q000150:complications* / Q000503:physiopathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D016059:Range of Motion, Articular / Q000502:physiology*; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult