140THE JOURNAL OF BONE AND JOINT SURGERY
J.-P. Damsin, MD, Orthopaedic Surgeon
Hˆ opital d’Enfants Armand Trousseau, 26 Avenue du Docteur Arnold
Netter, 75012 Paris, France.
I. Ghanem, MD, Orthopaedic Surgeon
Hˆ otel-Dieu de France University Hospital, Achrafieh, Beirut, Lebanon.
Correspondence should be sent to Dr J.-P. Damsin.
©1996 British Editorial Society of Bone and Joint Surgery
TREATMENT OF SEVERE FLEXION
DEFORMITY OF THE KNEE IN CHILDREN AND
ADOLESCENTS USING THE ILIZAROV
JEAN-PAUL DAMSIN,ISMAT GHANEM
From the Hˆ opital d’Enfants Armand Trousseau, Paris, France
knees) between 1986 and 1994 and have followed them
up for an average of 4.1 years. The age of the patients
at operation ranged from 1.7 to 18.8 years.
The femoral and tibial components were connected
by two anterior hinges, medial and lateral, and two
posterior distraction rods. The deformity was
corrected to a femorotibial lateral shaft angle of less
than 20°. A permanent orthosis was applied after
removal of the fixator. Fractures occurred in four
patients and paralysis of the common peroneal nerve
in another. There was a recurrence of the deformity in
At the last review all patients were able to walk on
their operated leg with or without an orthosis.
We have found the Ilizarov method to be helpful in
correcting severe fixed flexion deformity of the knee,
with relatively few complications, but the basic
principles of the method must be carefully followed.
e have used the Ilizarov technique for severe
flexion deformity of the knee in 11 patients (13
J Bone Joint Surg [Br] 1995;77-B:140-4.
Received 26 April 1995; Accepted 8 June 1995
Two types of flexion contracture of the knee can be dis-
tinguished: that associated with joint destruction and ankyl-
osis and that in which joint anatomy and mobility are
preserved. In the first type the aim of treatment is to obtain
an ankylosed knee in a functional position, and in the
second correction of the deformity and preservation of
movement. Many types of treatment are available including
exercise, an orthosis, casting, soft-tissue release, and osteo-
tomies, alone or in combination. Treatment of the more
severe deformities is associated with serious complications
such as insufficient correction, skin necrosis, neurovascular
problems, leg-length discrepancy, posterior subluxation of
the tibia, fractures of the femur or tibia and recurrence of
deformity (Heydarian et al 1984).
We made a retrospective study of the uses and benefits
of progressive correction of flexion contracture using the
PATIENTS AND METHODS
Between 1986 and 1994, we treated 11 patients (13 knees)
with severe fixed flexion contracture, using the Ilizarov
external fixator (Table I). There were six boys and five girls
with a mean age at operation of 12 years (1.7 to 18.8). All
were able to walk or had the potential to do so. Posterior
subluxation of the tibia was present in six knees. Four
patients had undergone previous posterior soft-tissue
release operations, one had congenital absence of the fibula
and one had had poliomyelitis. The flexion contracture
exceeded 90° (90 to 150) in all.
Operative technique. The average duration of the opera-
tion was 140 minutes (70 to 240). The type of frame
commonly used for the femur included three proximal
Hoffman or Schanz screws, two pins on a metaphyseal half
ring and one distal epiphyseal pin connected to it. The tibial
fixation had a distal ring with two to three Kirschner wires
and similar epiphyseal and metaphyseal fixation as the
femur. The femoral and tibial components were connected
Table I. The aetiology of the flexion contracture in 11 patients (13
Number of patients
Congenital absence of the fibula1
Myelomeningocele + quadriceps aplasia1
Multiple pterygium syndrome1 (bil)
Complex knee malformation1 (bil)
Juvenile rheumatoid arthritis1
Electrical amputation of the leg1
by two anterior hinges, one medial and one lateral, which
determined the axis of correction, and two posterior distrac-
tion rods, one medial and one lateral.
Correction was obtained at the knee in 12 patients and at
the level of a femoral supracondylar osteotomy in one.
Tenotomy of the medial and lateral hamstrings was
required in three patients with popliteal webbing. Distrac-
tion was started as soon as the postoperative pain subsided
at an average of 3 to 4 mm per day, with the rate modified
according to the patient’s discomfort.
During correction modifications were made to the appa-
ratus, the position of the hinges and the distraction rods
being adapted to each case individually. Deformity of the
foot was present in three patients and was corrected simul-
taneously using the Ilizarov apparatus. Diaphyseal length-
ening was undertaken after the knee correction in three
patients with leg-length inequality. The average duration of
the correction was 54 days (5 to 10 weeks), and the average
fixation time 105 days (8 weeks to 1 year). After removal of
the fixator a long plaster case was applied in maximum
extension, followed later by the use of a long-leg brace.
Other procedures. At the end of correction of the flexion
deformity, five knees were arthrodesed, using femorotibial
compression. Three arthrodeses were for popliteal webbing,
and two were in one patient with bilateral severe malforma-
tion. Total replacement of the knee is planned in one patient
with juvenile rheumatoid arthritis after correction of a
flexion deformity from 150° to 0° (Fig. 1).
141 SEVERE FLEXION DEFORMITY OF THE KNEE IN CHILDREN TREATED BY THE ILIZAROV TECHNIQUE
VOL. 78-B, NO. 1, JANUARY 1996
Fig. 1a Fig. 1b
Fig. 1c Fig. 1d
Juvenile rheumatoid arthritis in an 18-year-old boy. Figure 1a – Flexion contracture of 150°. Figure 1b – The radiograph shows the posterior subluxation
of the tibia. Figure 1c – The Ilizarov apparatus with two lateral hinges at the level of the femoral condyles. Distraction of the femoral rods allows
progressive correction of the posterior subluxation and of the tibial rods produces distraction of the knee to avoid damage to the articular cartilage during
correction. Figure 1d – Radiological appearance at the last follow-up. The posterior subluxation of the tibia is not corrected. A total knee arthroplasty
is planned for this patient.
The deformity was corrected to an average contracture of
6.5° (0 to 20). Mild varus occurred in one knee. After
removal of the fixator, the knee was stable in 12 patients
but unstable in one with congenital absence of the fibula.
Of the six cases of posterior subluxation of the tibia, only
three were adequately corrected.
Minor complications. During correction acute pain was
encountered in three knees due to physometaphyseal frac-
ture, but this did not lead to interruption of the correction.
Pin-track infection occurred in five cases; all responded to
Major complications. Paralysis of the common peroneal
nerve was seen in a patient with juvenile rheumatoid
arthritis and a flexion contracture of 150° two weeks after
the beginning of the correction. No recovery had taken
place after three months.
A Salter-Harris type-I or type-II fracture occurred in
three knees in two patients; bilateral distal femoral fractures
and a proximal tibial fracture were seen in the first case and
a proximal tibial lesion in the second. These three knees
had congenital webbing; one patient had the multiple pter-
ygium syndrome (Escobar et al 1978) with bilateral flexion
contractures and the other had a myelomeningocele with
unilateral congenital absence of the quadriceps muscle (Fig.
2). In the first patient correction of the contracture occurred
both at the fracture site and the knee with a final lateral
femorotibial shaft angle of 10° and a bayonet appearance of
the knee in the sagittal plane. In the second patient fixation
of the epiphysis with a Kirschner wire was undertaken and
there was no displacement of the fracture. Ilizarov distrac-
tion was not stopped.
Recurrence of the deformity was seen in four patients at
142J.-P. DAMSIN,I. GHANEM
THE JOURNAL OF BONE AND JOINT SURGERY
Fig. 2aFig. 2b
A 5-year-old girl with myelomeningocele and quadriceps aplasia. Figure 2a – Flexion
contracture of 100°. Figure 2b – Appearance using the Ilizarov apparatus during correction
with femoral and tibial epiphyseal wires. Figure 2c – Clinical appearance after correction.
Figure 2d – Radiological appearance. There is good correction with no fracture or joint
an average of 1.7 years (9 months to 2.9 years) after
removal of the fixator. In one patient with a moderate
recurrent deformity secondary to a popliteal angioma, treat-
ment was by repeated casting followed by the use of a
long-leg brace. The three other recurrences, all with con-
genital webbing, were due to failure of arthrodesis of the
knee for severe and progressive deformity. Repeated Ilizar-
ov distraction was followed by successful compression
arthrodesis also using the Ilizarov apparatus.
Late results. We reviewed our patients at a mean follow-
up of 4.1 years (3 months to 7.2 years) and at a mean age
of 14 years (6.5 to 22.2). All were able to walk on their
operated leg, with or without an orthosis or crutches.
Bilateral recurrence of the deformity had occurred in the
patient with multiple pterygium syndrome. This was more
severe on the left side where there was evidence of failure
of the knee arthrodesis, but with a stiff knee. Correction
was undertaken by supracondylar osteotomy.
No recurrence was seen in the other cases. The mean
residual angle of flexion contracture at the last follow-up
was 10° (0 to 30). The knee was mobile in eight cases (5°
to 50°), and stiff in five with a solid arthrodesis in two. A
long-leg brace was used in nine knees.
Previous methods for managing flexion contracture of the
knee have included casting (Hart 1934; Hughes and Risser
1934), bipolar traction (Queneau 1952), posterior soft-
tissue release (Wilson 1929; Eggers 1952; Abraham, Ver-
inder and Sharrard 1977; Heydarian et al 1984), osteoto-
mies (Leong, Alade and Fang 1982; Zimmermann, Smith
and Oppenheim 1982), and femoral shortening (Saleh,
Gibson and Sharrard 1989). These have been used alone or
in combination with various degrees of success depending
on the severity of the deformity and its aetiology.
The surgical correction of fixed and severe contracture
requires extensive soft-tissue release which may create an
unstable knee. Plastic and reconstructive procedures may
be needed which may require neural and microvascular
reconstruction (Gartsman, Bennett and Cain 1988). Non-
operative methods are very demanding and are ineffective
in the ankylosis type of contracture.
The Ilizarov technique is an improvement on conserva-
tive methods. It allows progressive correction of the most
complex deformities of the knee (Damsin and Carlioz
1994), with simultaneous correction of associated foot
deformities and limb lengthening. Nevertheless, rigorous
application of the basic principles is mandatory (Plawecki
1987; Merloz 1989; Paley 1989; Bell, Boyer and Arm-
strong 1992; Damsin and Carlioz 1994). A minimum of
three Ilizarov femoral and tibial pins, in two different
planes, is essential (Bianchi-Maiocchi et al 1983).
‘Olive’ wires are used to prevent slipping and tilting of
the rings and should be placed accurately on the convex
side near the knee and on the concave side far from it. The
rings must be perpendicular to the shaft and of equal
diameter to simplify the frame and to facilitate the surgical
procedure. The femoral and tibial components are con-
nected by two hinges and two posterior distraction rods.
When the contracture is associated with posterior subluxa-
tion of the tibia, the axis of rotation, which is determined
by the two hinges, is progressively displaced more ante-
riorly until correction is obtained.
The rate of correction depends on the severity of the
deformity, the degree of contracture of the capsule and the
ligaments, the tolerance of pain by the child and the
presence of vascular or neural complications. Distraction at
a daily rate of 1 mm at the knee should be the aim; this
corresponds to a rate of 3 to 4 mm per day at the distraction
rod which is located in the concavity far from the knee.
Flexion contracture of the knee secondary to congenital
webbing in a young child is the most difficult type to treat.
The five fractures in our series were in two children with
congenital webbing treated at the ages of 1.7 and 4.8 years
of age. The fractures occurred during the correction of
posterior subluxation of the tibia and were considered to be
due to shearing forces. Primary articular distraction may
help to avoid this complication (Damsin and Carlioz 1994)
and to facilitate the correction of posterior subluxation. The
femoral and tibial epiphyses should be stabilised with
wires, placed under radiographic control, to reduce the risk
Paralysis of the common peroneal nerve should be pre-
vented whenever possible (Aspden and Porter 1994), and
the rate of correction must be planned carefully with
respect to the severity of the contracture and the distance of
the distraction rods from the knee.
Severe, fixed contracture at the knee remains one of the
most challenging deformities in children, mainly because of
the high risk of recurrence. Arthrodesis of the knee or, at
least, the creation of a stiff knee in the most extended
position at the end of correction, may be the best solution in
some cases. In others the use of a long-leg brace, after
removal of the external fixator, allows stabilisation of the
The Ilizarov apparatus is a very effective tool for manag-
ing severe cases of knee contracture but careful attention to
every detail is required.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
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THE JOURNAL OF BONE AND JOINT SURGERY