Garamycin

Immobilization with external fixation bridging the knee joint in extension is frequently used after sustaining a war injury to the region of the knee joint with femoral and tibial bone fractures. Immobilization of the knee with plaster splints is performed in the same position. This usually prolonged treatment results in extension contractures of the knee joint. From June 1991 until March 1994, 54 patients with extension contractures of the knee caused by war wounds were treated at the Department of Orthopedics, Zagreb University Hospital Center, in Zagreb, Croatia. Results of surgical treatment of 44 patients are presented. The operative procedure consisted of extensive intra- and extra-articular adhesiolysis of the knee. The control group included 30 patients with knee contractures caused by injuries sustained in car crashes or secondary to previous operative procedures. The mean duration of immobilization was 5 months and 6 days. The mean preoperative knee motion amplitude ranged from 5 degrees in extension to 38 degrees in flexion. The mean postoperative knee motion was 98 degrees (range, 2 to 110 degrees). Treatment results did not depend on either duration of preoperative immobilization of the knee or previous infection in the region of injury. Previous knee joint bridging with an external fixator had no impact on the results of extension contracture treatment. Adequate intra- and extra-articular adhesiolysis with appropriate long-term postoperative rehabilitation is essential for the success of the operative treatment for knee joint contracture.

Introduction

Injuries to the extremities are the most common war injuries. According to various statistical data, injuries to the extremities account for 60% to 75% of all war injuries. In most cases, knee joint contracture is caused by immobilization and lesions to the knee joint itself or to the surrounding tissues.1 Extension contractures, otherwise much less frequent than flexion contractures, occur in severe, comminuted, and open fractures of the diaphysis and the distal part of the femur, the proximal part of the tibia, and the patella.2,3

Morphologic changes in knee joint contracture include intraarticular adhesions in recesses and between articular surfaces, retraction of the capsular-ligamentous system, and extra-articular obstructions such as cicatricial alterations and contractures of the muscles, tendons, and other soft tissues.1

During the war in Croatia (1991-1995), the use of external fixators on the front line spared many patients from extremity amputation.4 The fixators were frequently placed by bridging the knee in extension because of wound severity and localization. Because war injuries require considerably longer periods of immobilization than other types of bone fractures, the placement of such a fixator generally results in a more or less severe knee joint contracture.

The treatment of knee joint contracture, i.e., adhesiolysis of the knee, is performed by the open method or by arthroscopic surgery, with the advantages of the latter being emphasized in recent reports.5-8 The operative treatment should be followed by intensive, prolonged physical therapy to maintain the results obtained by the operation.9 The method of continuous passive motion on an electromotive splint is recommended.2,4,10

At the Department of Orthopedic Surgery, Zagreb University School of Medicine, primary total knee replacement was used for a number of patients with severe war injuries to the lower extremities and produced good results.11

Our own experience in the management of patients with knee contracture stimulated us to try to answer a number of related questions: What is the effect of the duration of immobilization on the success of treatment for knee joint contracture? Does prolonged knee joint bridging with a fixator or long-term immobilization, including the knee, influence the result of operative treatment for knee contracture? Does a war wound infection influence the outcome of treatment? The purpose of this report is to show that the use of major operative procedures and appropriate rehabilitation can produce good results in the management of severe knee contractures caused by war injuries to the knee.

Patients and Methods

From June 1991 until March 1994, 54 patients with knee contracture as a complication of war injuries to the knee were operatively treated at the Department of Orthopedics, Zagreb University Hospital Center. There were 50 men, Croatian Army soldiers, and 4 women, civilian war casualties. A control group consisted of 30 subjects with knee contracture caused by various injuries or previous surgical procedures.

Forty-four men and 4 women available at the time of the study were included in the study group. The control group had 22 men and 8 women. In the study group, the mean age at the time of wounding was 30.69 (range 18-56) years; in the control group, the mean age was 29.61 (range, 16-53) years. The mean follow-up period was 5.77 months, i.e., 4 years and 2.7 months.

A majority of study group patients had sustained severe explosive or gunshot wounds in the knee region. The thigh was the most common site of wounding. Isolated injury of the thigh was found in 38 study group patients and injury of the lower leg was found in 5 study group patients, whereas injuries to both the lower leg and the thigh were present in 5 patients. In the control group, the respective figures were 19, 3, and 8 patients.

Immobilization was the major cause of extension knee contracture. In the study group, immobilization was performed in 97.87% of patients. Various models of external fixator were used for 26 patients, and plaster immobilization was used for 21 patients. Immobilization was not performed for one study group patient.

Knee bridging was performed in 34 study group patients, and immobilization without knee bridging was performed in 14 study group patients. In the control group, knee immobilization with and without knee bridging was done in 17 and 13 patients, respectively.

In the study group, the mean duration of immobilization was 5.21 months vs. 2.57 months in the control group. The mean time elapsed between the injury and the operative procedure of adhesiolysis was 15.39 and 29 months in the study group and the control group, respectively.

Infection developed in 16 study group patients vs. 10 control group patients. Staphylococcus aureus was the most common cause of infection. All patients were preoperatively treated with high doses of penicillin (1.6 million IU) and Garamycin (3 x 120 mg).

Preoperatively, severe knee contracture was present in a majority of patients. In the study group, the mean amplitude of knee motion before adhesiolysis ranged from 4.79 degrees in extension to 38.22 degrees in flex[on. In the control group, the amplitude of knee motion before adhesiolysis ranged between 4.03 degrees in extension and 45.0 degrees in flexion.

The open method of intra- and extra-articular knee adhesiolysis was used for all patients. Various methods of adhesiolysis have been described2,12-15; however, localization of the main obstruction to joint motion is the most important consideration for the proper choice of method to be used. In our patients, adhesiolysis was carried out by a modification of the open method according to the Judet technique16 using intraand extra-articular adhesiolysis. Our modification consisted of the use of a single skin incision with a lateral approach for both intra- and extra-articular adhesiolysis of the knee. Upon debridement of intra-articular adhesions, with special attention paid to the release of lateral adhesions on the medial and lateral femoral condyles and freeing of other recesses, extraarticular adhesiolysis was performed, extending the skin incision along the lateral femoral condyle-trochanter major line. All adhesions on the quadriceps femoris muscles (intermedius, vastus lateralis, vastus medialis, and rectus femoris muscles) were carefully freed from the femur. Occasionally, the iliotibial band was incised as necessary. Adhesiolysis was carried out in a stepwise manner, regularly checking whether the previous step had increased the amplitude of knee motion. Postoperatively, a plaster splint was placed that would be removed in knee flexion of approximately 95 degrees; in some patients, plaster splints were placed alternately in flexion and extension. Splints were placed during the first 8 to 14 days postoperatively. As early as day 2 postoperatively, the patients were included in the program of intensive physical therapy with the use of an electromotive splint (Kinetec), followed by rehabilitation at special centers, usually 2 weeks after surgery, where they continued physical therapy for an additional 4 weeks to 3 months. In addition to the use of an electromotive splint, room and underwater knee exercises were continuously performed along with exercises for quadriceps strengthening, quadriceps electrostimulation, and later static bike exercise. Postoperative analgesia via epidural catheter was used in seven patients. The epidural catheter was applied for 3 to 10 days, and its exchange was required in two patients. The anesthetic was administered 15 minutes before workout exercise to allow the planned rehabilitation program to perform.

The data thus obtained were expressed in percentages and classified into five groups: very good, good, satisfactory, poor, and very poor. The Hospital for Special Surgery (HSS) scoring was used for final analysis.

Motion amplitude of the operated knee was measured immediately after the operative procedure of adhesiolysis, after 3 months, and on the last follow-up examination, generally performed 3 years after surgery.

Results

Preoperative knee motion amplitude was 90 degrees was not recorded in any of the study group patients. The motion amplitude measured immediately after the surgery was 99.47 degrees in the study group vs. 96.26 degrees in the control group. Three months postoperatively, the knee motion amplitude in the study group and the control group decreased to 91.35 and 88.22 degrees, respectively. On the last measurement, the knee motion amplitude increased to a mean of 101.56 degrees in the study group and 97.74 degrees in the control group (Fig. 1).

The relative increase in knee motion amplitude is shown in Table I. According to the evaluation scale mentioned above, the results obtained were ranked as very good in 4.18%, good in 41.8%, satisfactory in 45.68%, poor in 6.27%, and no improvement in only 2.07% of patients.

Results achieved in the amplitude of knee motion were analyzed in patients with and without knee bridging. On the last follow-up examination, the amplitude of knee motion was 2.45 to 101.56 degrees in patients with knee bridging and 1.74 to 97.32 degrees in those for whom this procedure had not been performed. The HSS scale was used for final analysis of the results obtained by operative treatment. On this scale, the maximal score is 100. According to HSS scoring, the mean scores were 68.83 and 70.06 for the study and control groups, respectively.

Infection was present in 16 study group and 10 control group patients. However, postoperative results were good in patients-- with infection, i.e., there was no statistically significant difference in the knee motion achieved compared with the results recorded in patients without infection.

Figure 2 shows a patient with knee bridging immediately after wounding and the degree of knee flexion after a complex operative procedure. Figure 3 shows a patient without knee bridging and the degree of knee flexion after a complex operative procedure.

Discussion

Analysis of the data obtained in the study group of 48 patients with extension knee contracture caused by war injuries and the control group of 30 patients with extension knee contracture of other causes, i.e., car crashes or postoperative complications, showed no statistically significant differences in the results of knee adhesiolysis between the two groups of patients.

In our study, the success of operative treatment depended neither on the patient's age nor on the duration of immobilization, previous wound infection, and the severity of preoperative joint contracture, in contrast to the studies of Riel et al.,17 Falkiewisz et al.,18 and Kuhne and Theermann,19 respectively (Table I). In fact, satisfactory results of knee motion were achieved in a patient with 20-month knee immobilization in extension. This study demonstrated that there was no significant difference between operative treatment results achieved in patients with prolonged immobilization with knee bridging and patients with immobilization without knee bridging. The use of extensive open intra- and extra-articular knee joint adhesiolysis was found to produce the best results in the management of knee contracture caused by war injuries. Knee adhesiolysis should be followed immediately by early intensive physical rehabilitation.18 The amplitude of knee flexion achieved by surgery decreases in the early postoperative course, to increase again 6 to 12 months after the procedure, with high-dose analgesia and possible insertion of an epidural catheter.

In conclusion, the results of our study show that operative treatment for extension knee contracture should always be tried, irrespective of the time elapsed from injury, the duration of knee immobilization, and the possible previous presence of infection, because quite good and functionally satisfactory results can be expected.

References

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Guarantor: Miroslav Smerdelj

Contributors: Miroslav Smerdelj*; Marko Pecina*; Miroslav Hapl*; Branko Tripkovic*; Vladimir Kovac^

* Department of Orthopedic Surgery, School of Medicine, University of Zagreb, Salata 6, 10 000 Zagreb, Croatia.

^Dubrava University Hospital, Av. Gojka Suka 6, 10 000 Zagreb, Croatia.

This manuscript was received for review in March 2000. The revised manuscript was accepted for publication in December 2000.

Reprint & Copyright by Association of Military Surgeons of U.S., 2001.

Copyright Association of Military Surgeons of the United States Jul 2001
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