Freiling Denise, Lobenhoffer Philipp
Klinik für Unfall- und Wiederherstellungschirurgie, Diakoniekrankenhaus Henriettenstiftung Hannover, Hannover, Germany.
Oper Orthop Traumatol. 2009 Dec;21(6):545-56. doi: 10.1007/s00064-009-2004-0.
Restoration of full knee extension in patients with chronic extension deficits, especially in posttraumatic and postoperative cases.
Chronic knee extension deficits of more than 10 degrees .
Local intraarticular problems caused by cyclops syndrome, graft hypertrophy or graft impingement after anterior cruciate ligament reconstruction (notch impingement). These patients should be treated with arthroscopic procedures. Spastic flexion contracture. Noncompliant patients. Acute or chronic infections. Poor soft-tissue conditions on site of surgery.
If necessary, arthroscopy before arthrolysis to assure that the extension deficit is not caused by a local problem (cyclops, osteophytes, graft hypertrophy or graft impingement after anterior cruciate ligament reconstruction). Anterior skin incision at the medial border of the patellar ligament. Resection of Hoffa's fat pad, which is extremely fibrotic in almost all cases. Second skin incision at the posteromedial side of the knee joint. Incision of the medial retinaculum between the posterior border of the medial collateral ligament and the posterior oblique ligament. Posteromedial arthrotomy between the distal part of the tendon of the adductor magnus muscle and the posterior horn of the medial meniscus. Release of all adhesions in the posterior recess of the knee joint. Complete release of the posterior joint capsule from the femoral shaft.
Immobilization for 48 h after surgery in full extension (no knee motion allowed in the first 48 h). For 48 h after surgery only short walks to the bathroom are allowed. Special dynamic extension brace (Dynasplint((R)), CDS((R)) Forte, Albrecht company, Stephanskirchen, Germany) for 4-6 weeks after surgery 6-8 h per day. Painkillers following WHO (World Health Organization) protocol. Manual lymph drainage and electric muscle stimulation help to decrease pain and swelling. Physiotherapy twice daily starting at the 2nd postoperative day. No flexion exercises for the first 7 days after surgery. 15 kg partial weight bearing for 4-6 weeks. Daily physiotherapy is recommended after discharge.
121 patients underwent anterior and posterior arthrolysis between 1990 and 2000. 86 of these patients could be included in this study. The average follow-up was 4.6 years (1-10 years). The extension deficit before surgery averaged 20 degrees compared with the opposite side. At follow-up, the average extension had increased by 17 degrees , no patient had more than 5 degrees of flexion contracture. The Lysholm Score was 84 postoperatively. The Tegner Activity Scale increased from 1.9 to 4.0 after arthrolysis. In the AOSSM Subjective Outcome Score, 35 patients showed excellent and 60 good results. 14 patients were satisfied after surgery and nine were not. Three patients required revision surgery (two synovial fistulas, one hematoma).
恢复慢性伸直受限患者的全膝关节伸直功能，尤其是创伤后和术后病例。
慢性膝关节伸直受限超过10度。
独眼巨人综合征、移植物肥大或前交叉韧带重建术后移植物撞击（髁间窝撞击）引起的局部关节内问题。这些患者应接受关节镜手术治疗。痉挛性屈曲挛缩。不配合的患者。急性或慢性感染。手术部位软组织条件差。
如有必要，在关节松解术前进行关节镜检查，以确保伸直受限不是由局部问题（独眼巨人、骨赘、移植物肥大或前交叉韧带重建术后移植物撞击）引起的。在髌韧带内侧缘做前侧皮肤切口。切除霍法脂肪垫，几乎在所有病例中该脂肪垫都极度纤维化。在膝关节后内侧做第二个皮肤切口。在内侧副韧带后缘与后斜韧带之间切开内侧支持带。在内收肌大肌腱远端与内侧半月板后角之间做后内侧关节切开术。松解膝关节后隐窝内的所有粘连。从股骨干完全松解后关节囊。
术后伸直位固定48小时（术后前48小时膝关节不得活动）。术后48小时内仅允许短距离步行去卫生间。术后4 - 6周每天使用特殊的动态伸直支具（Dynasplint((R))、CDS((R)) Forte，德国施特凡斯基兴的阿尔布雷希特公司）6 - 8小时。按照世界卫生组织（WHO）方案使用止痛药。手法淋巴引流和电肌肉刺激有助于减轻疼痛和肿胀。术后第2天开始每天进行两次物理治疗。术后前7天不进行屈曲练习。4 - 6周部分负重15千克。出院后建议每天进行物理治疗。
1990年至2000年间，121例患者接受了前后关节松解术。其中86例患者可纳入本研究。平均随访4.6年（1 - 10年）。与对侧相比，术前伸直受限平均为20度。随访时，平均伸直增加了17度，没有患者屈曲挛缩超过5度。术后Lysholm评分为84分。关节松解术后Tegner活动量表从1.9提高到4.0。在AOSSM主观结果评分中，35例患者结果优秀，60例良好。14例患者术后满意，9例不满意。3例患者需要翻修手术（2例滑膜瘘，1例血肿）。
