Contracture-Related Surgeries (Sx)

General Principles

• Simple fasciotomies correct only minor contractures; recurrence is common and they cannot correct severe contractures.
• Progressive correction using traction/splinting may be used before surgery to reduce the extent of operation and after surgery to increase correction.
• Once a contracture is corrected, the correction must be actively maintained, or it recurs.
• Surgery is indicated when the contracture interferes with function, hygiene, bracing, or ambulation.

1. Shoulder - Internal Rotation Contracture

• Release of Internal Rotation Contracture (eTechnique 35.6):
  • Anterior deltopectoral approach
  • Identify and excise the subscapularis tendon (preserve the anterior capsule)
  • Release the pectoralis major tendinous insertion with scissors passed distally along the humerus
  • Postop: sling for comfort; ROM exercises within first few days; pulley exercises by day 5
• Fractional Lengthening (eTechnique 35.7): Pectoralis major, latissimus dorsi, teres major
  • Deltopectoral approach in beach-chair position
  • Tendon divided at the musculotendinous junction
  • Long head of triceps can also be lengthened if elbow extension correction is needed

2. Elbow - Flexion Contracture

1. S-shaped incision over the antecubital flexor crease
2. Expose and resect the lacertus fibrosus
3. Identify and protect the lateral antebrachial cutaneous nerve
4. Z-plasty lengthening of the biceps tendon
5. Circumferential incision of the aponeurotic brachialis fibers distally
6. Anterior elbow capsulotomy if needed
7. Repair the biceps tendon; close subcutaneous tissue and skin
8. Cast in maximum (not forceful) extension with forearm supinated; bivalve cast

3. Forearm - Pronation Contracture

• If full passive pronation not yet possible: longitudinal incision on dorsum of forearm over radial shaft, divide the interosseous membrane
• Then detach and reroute the biceps tendon to convert it from a supinator to a neutral or pronating force

• Rerouting of biceps tendon (Zancolli)
• Manual osteoclasia of middle thirds of radius and ulna (Blount) - for children <12 years with insufficient muscle power for tendon transfer

4. Hip Contractures

Flexion, Abduction, and External Rotation Contracture

1. Lateral position; transverse incision medial and distal to the anterior superior iliac spine
2. Divide and excise 1 cm of the iliopsoas tendon distally
3. Detach sartorius from ASIS; detach rectus femoris from AIIS
4. Divide the tensor fasciae latae from its anterior border completely posteriorly

• For severe deformities: Campbell technique - complete release of all muscles from the iliac wing with transfer of the crest of the ilium

Abduction Contracture

• Incise skin along anterior 2/3 of iliac crest to ASIS
• Divide all thigh fascial/tendinous structures anterolaterally: fascia lata, gluteus medius/minimus fascia, tensor fasciae latae
• Fasciotomy of fascia lata distally (Yount) may also be required
• Hip spica cast in neutral abduction; removed at 2 weeks to begin ROM

Adduction Contracture

• Indicated when causing pelvic obliquity or interfering with sitting/walking
• Adductor Release (Technique 35.2)

5. Knee Contractures (Myelomeningocele)

Flexion Contracture

• 20-degree contractures at birth: mostly spontaneously correct
• >20 degrees + interferes with bracing/ambulation: surgical correction indicated
• Hamstring lengthening ± posterior capsular release: for 20-30 degree contractures in children walking with below-knee orthoses
• Supracondylar extension osteotomy of the femur: for >30-45 degree contractures in older community-walking children (after failed hamstring release)
• Anterior distal femoral hemiepiphysiodesis: newer effective method for growing children

Extension Contracture

• Less common than flexion
• May require quadriceps lengthening or V-Y plasty

6. Equinus Contracture (Ankle/Foot)

• Percutaneous Achilles tendon lengthening: for mild/moderate contractures
• Open Achilles tendon lengthening: for severe contractures; may also require lengthening/release of posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons
• Post-correction: ankle-foot orthosis (AFO) required to maintain correction and allow ambulation
• In Duchenne muscular dystrophy: release may allow 2-3 more years of ambulation, but by age 12-13 most can no longer walk regardless

7. Volkmann Ischemic Contracture (Forearm)

• Detaches the origin of the flexor mass from the medial epicondyle and slides it distally
• Allows passive extension of fingers without tendon rupture
• Appropriate for mild-moderate cases

8. Dupuytren's Contracture (Hand)

• Appropriate procedure depends on: degree of contracture, palmar skin nutritional status, bony deformities, patient's age/occupation/general health
• More severe involvement requires more extensive surgery, done in stages if necessary
• Subcutaneous fasciotomy + joint extension therapy may precede definitive surgery for severe cases

9. Metacarpophalangeal Joint Capsulotomy (Hand)

• Longitudinal incision 2.5 cm long over affected joint
• For multiple joints: second and fourth web space dorsal longitudinal incisions can release all four MCP joints
• Incise extensor hood dorsolaterally and dorsomedially (0.5 cm from tendon)
• Retract extensor hood and intrinsic tendons palmarward
• Longitudinal incision through dorsal capsule to expose metacarpal head
• Transect and remove dorsal joint capsule; excise portions of collateral ligaments sequentially to gain passive flexion (taking care not to destabilize joint)

Images: Contracture-Related Surgeries

1. Volkmann Ischemic Contracture - Forearm Anatomy

2. Elbow Contracture Release - Surgical Approach (Morrey)

• (A) Extended Kocher approach - 15 cm incision along the supracondylar ridge down to the lateral epicondyle, ending over the subcutaneous border of the ulna.
• (B) Deep dissection: brachialis elevated off the anterior joint capsule; retractors placed deep to brachioradialis and brachialis. The anconeal branch of the radial nerve is identified and protected. Green dashed line = incision line for anterior capsulectomy (from lateral to medial, preserving the lateral collateral ligament).

3. Percutaneous Needle Aponeurotomy (PNA) - Dupuytren's Contracture

• Needle inserted percutaneously through the skin
• Side-to-side sweeping maneuver (red arrows) releases the cord from superficial to deep
• Key layers visible: skin (pink), subcutaneous fat (yellow), Dupuytren's cord (grey/white ovoid), neurovascular bundles (orange), flexor tendon (central white), and underlying bone

4. Dupuytren's Contracture - Decision Algorithm for Surgery

• Poor health / not concerned with appearance → Subcutaneous fasciotomy (percutaneous or enzymatic aponeurotomy) → Partial (selective) fasciectomy
• Compromised hand function (Yes) → multiple branches based on pattern:
  • Less severe PIP contracture → Zigzag (Bruner) incision
  • Significant PIP contracture → Z-plasty
  • Well-defined disease + minor PIP contracture → Multiple transverse incisions to excise diseased tissue
  • Inability to spread fingers / natatory ligament → Excision of natatory ligaments
  • Adduction + MP flexion contracture → Transverse palmar incision
  • Severe PIP contracture → Staged resection with external fixation + open palm fasciectomy + dermafasciectomy with full-thickness skin graft
  • Severely contracted PIP that cannot be corrected → Joint resection and arthrodesis
  • Last resort → Amputation

5. Dupuytren's Subcutaneous Cordotomy - Step-by-Step Intraoperative Photos

6. Luck Subcutaneous Fasciotomy - Cross-Section Diagram

• (A) Palmar fascia (grey band - the target)
• (B) Neurovascular bundle (red dots)
• (C) Neurovascular bundle (labelled in diagram)
• (D) Flexor tendons (white ovals) and metacarpals (yellow)