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A contracture is a limitation of the normal range of motion in one of a person's joints or muscle segments. Most often, such manifestations are associated with cicatricial changes. skin, tendon fibers, muscles, damage to the constituent components of the joint, the presence of a pain reflex, a violation of the mechanism of muscle contraction due to damage to the motor centers of the brain. In literal translation from Latin, the word "contracture" means "contraction, narrowing, contraction."

It is important to understand that contracture is not individual disease, but only a consequence of numerous ailments, injuries and injuries. If no measures are taken to eliminate limited mobility in a particular part of the body, then over time all active and passive movements are lost, ankylosis develops ( complete absence any movements), which leads to the development of severe disability, the inability to take care of themselves and the need for constant outside help.

The reasons

Depending on the causes of occurrence, there are 2 large groups:

congenital,
acquired.

Congenital are the result of genetic, chromosomal diseases, fetal malformations. The most striking examples of such disorders are congenital clubfoot, muscular torticollis. As a rule, it is possible to diagnose a congenital form of pathology during the first days of a child's life. In this case, it is possible to achieve complete elimination of contracture with a favorable prognosis under the supervision of an orthopedic doctor. Late identification of cause and symptoms birth defect leads to delayed therapy and unsatisfactory results.

Acquired contractures(those that occur during a person's life) can develop as a result of such diseases and disorders:

after fractures of bones in the area of the joints (post-traumatic);
after traumatic injuries of the soft tissues of the joints (menisci, ligaments, tendons, capsule, muscles);
after inflammatory lesions fatty tissue;
due to the development of ischemia due to a violation of the blood supply to a certain part of the body (for example, contracture of the joints of the lower limb with diabetes with polyneuropathy);
due to degenerative-dystrophic diseases of the articular apparatus (deforming osteoarthritis);
autoimmune and other inflammatory joint disorders ( rheumatoid arthritis, reactive, gouty, psoriatic arthritis, etc.);
prolonged imposition of tight plaster bandages, tourniquets;
acute disorders of the blood supply to the brain (stroke);
traumatic, inflammatory damage to the structures of the central and peripheral nervous system;
due to the adaptation of the body to deformations, curvature of the spine, to the shortening of one leg, etc.;
due to gunshot wounds;
infectious lesions of bones, ligaments, muscles, joint components, skin;
due to burns;
medical interventions, for example, capsular contracture after mammoplasty;
prolonged immobilization of certain parts of the body;
due to flaccid and spastic paralysis;
for unknown reasons, such as Dupuytren's contracture of the fingers.

Classification

There are several classification options. Consider the most common.

Depending on the position of the distal (extreme) segment of the upper or lower limb, it happens:

flexion contracture - the process of extension in the joint is limited;
extensor - full flexion at the joint is impossible;
abductor - the process of adduction of the limb is disturbed;
adductor - the abduction of the arm or leg suffers;
rotational - rotational movements in the joint are limited.

Depending on what type of movement is disturbed, there are:

active,
passive,
active-passive.

A very important characteristic in the description is its functional advantage, which is determined by how much the preserved amplitude and direction of motor activity ensures the working capacity of the limb. Depending on this parameter, there are:

Functionally advantageous, that is, those that allow the patient to make purposeful movements and independently serve themselves.
Functionally disadvantageous those that create barriers to the right kind movements and do not allow a person to perform the necessary work, which creates serious inconvenience.

Depending on which tissue prevails in the development of contracture, there are:

dermatogenic: develop as a result of cicatricial changes in the skin, for example, after burns, extensive surgical interventions, injuries, inflammatory lesions;
desmogenic: develop as a result of damage to the ligaments, fascial membranes;
tendogenic: arise due to damage and shortening of the tendons;
myogenic: observed due to damage to certain muscles, their pathological tension, inflammation, injury;
arthrogenic: develop against the background of joint diseases and injuries;
neurogenic: arise due to damage to the structures of the nervous system.

special clinical significance have neurogenic variants, since their treatment causes the most difficulties. There are the following varieties:

psychogenic, which appear suddenly, for example, during a hysterical seizure;
peripheral, which occur when the peripheral part of the nervous system is damaged (individual nerve fibers, plexuses, roots);
central, which occur against the background of lesions of the brain or spinal cord (strokes, tumors, inflammatory diseases, neurodegenerative lesions, injuries).

All types of neurogenic contractures are called active, while the rest, which arose due to mechanical obstacles to the normal functioning of the joint, are passive. In clinical practice, there are also combined variants that combine the features of active and passive varieties.

Stages of development

Depending on the severity of signs of limited mobility in the joint area, there are 3 stages of progression of the pathology:

Actually contracture. In such cases, there is a limitation in the range of motion, but the remaining mobility in the joint can be seen with the naked eye and measured using conventional clinical methods such as goniometry.
Rigidity. The joint retains only a small amount of mobility that cannot be detected with a routine examination, and only specialized techniques will help measure the remaining range of motion.
Ankylosis. At the same time, both active and passive movements are completely absent in the joint.

Contracture should be distinguished from a sudden movement disorder in the joint, which is called blockade. With blockade of the joint, the inability to move the limb is associated with the presence of a movable third-party body in the articular cavity (bone fragment, meniscus, osteophyte, detached ligament). After removal of the articular body, mobility is fully restored and this condition is not accompanied by the development of stiffness.

Certain types of contractures

Symptoms of contracture depend on its location, type and cause. Consider the options that are most common.

The most common cause of the development of contracture of the knee joint is deforming gonarthrosis (degenerative-dystrophic lesion of the joint) and knee injury. In addition, such a violation may occur due to prolonged immobilization, infectious arthritis, recurrent synovitis and hemarthrosis (for example, with hemophilia), extensive burns, congenital deformities and diseases of the musculoskeletal system.

Contracture of the knee joint can be flexion or extensor. Among the symptoms of such a violation, it is worth highlighting the deformation of the right or left knee, limitation of flexion or extension in the joint, swelling, impaired support function of the leg, pain in the knee, shortening of the limb and its forced position.

The diagnosis is made on the basis of examination, x-ray of the knee joint, sometimes it may be necessary to measure the amplitude of movements (goniometry), MRI or CT.

Elbow contracture

The elbow joint is one of the most complex joints of the body, which performs 4 different types of movements: flexion, extension, adduction and abduction. Each of them may be limited due to the development of contracture elbow joint.

The main reason for the development of contractures in the area of the elbow joint is the erroneous comparison of bone fragments in traumatic fractures. Among the factors that can also cause such a violation, one can single out hemarthroses (hemorrhages in the articular cavity), purulent arthritis, burns, extensive lacerations, brain diseases, and congenital anomalies in the development of the elbow joint. Changes in arthrosis, as a rule, are not very pronounced, so the function of the elbow is little affected.

Among the symptoms of the disorder are limitation of the range of motion in one or more directions, forced position of the arm, pain in the elbow, swelling, deformity and shortening of the limb.

Treatment for elbow contracture depends on the cause. It can be conservative, and in severe cases - operational. Such patients should be observed by a traumatologist or neurosurgeon.

Shoulder contracture

Contracture shoulder joint most often occurs due to traumatic injuries, as well as pathologies that affect the rotator cuff of the shoulder (scapulohumeral periarthritis, bursitis). In some cases, this condition is observed with complications of cervical osteochondrosis.

Symptoms of contracture depend on its cause, type and severity. In severe cases, the range of motion in the shoulder does not exceed 10-15º, which makes the articulation completely incapacitated.

Contracture of the hip joint

Restriction of mobility in the hip joint most often occurs against the background of congenital anomalies its structure, for example, with hip dysplasia, Perthes disease, as well as due to deforming coxarthrosis and traumatic injuries.

Symptoms of pathology depend on the cause, type of contracture and its severity. Patients complain about the limitation of the normal range of motion in the area hip joint, pain, forced position of the limb, shortening of the leg, atrophy of the muscles of the buttocks and thighs.

If the pathology cannot be eliminated by conservative methods, they resort to hip arthroplasty. Sometimes it only chance restore the ability to move independently.

Ankle contracture

The main cause of contractures of such localization are traumatic injuries leg bones, ankles and foot structures, arthrosis of the articulation, prolonged immobilization, incorrect application of a plaster cast, rheumatoid arthritis, damage to the Achilles tendon, diseases of the brain and spinal cord with the development of neurogenic contractures.

Among the symptoms, one can note a violation of flexion or extension in the joint, its deformation, forced position, pain and swelling. In advanced cases, not only the motor, but also the supporting function of the leg suffers.

Hand contracture

Most often, when referring to hand contracture, they mean Dupuytren's contracture. This is a fairly common disease, the cause of which is still unknown. In most cases, the ring finger or little finger is involved in the pathological process. Pathology can affect one or both hands at once. The disease affects most often middle-aged men, has a genetic predisposition.

By its nature, this pathology belongs to the group of desmogenic contractures. The disease develops due to wrinkling and reduction in the area of the palmar fascia. As a result of such changes, a flexion contracture of one or more fingers of the hand is formed. Nodules and strands form on the palmar surface, which are easy to feel, and on late stages maybe even see. Treatment can be either conservative or surgical.

Volkmann's contracture

Volkmann's contracture is the development of stiffness in the joint due to impaired blood supply (ischemic contracture). Its development is based on acute hypoxia of the muscles and nerve fibers of the extremities. As a rule, the disease begins acutely and progresses rapidly. The causes of this pathology are any pathological processes, which compress the nerves and prevent their normal blood supply, for example, injuries, tunnel syndromes.

Capsular contracture

it specific complication plastic surgery for breast augmentation or reconstruction, which is associated with the installation of breast implants. Such a violation occurs in 0.2-2% of cases of all operations for mammoplasty.

At the same time, a capsule of coarse fibrous tissue develops, which covers breast implant- a body foreign to the body. Such a “case” develops for several months after the operation and, as a rule, reaches no more than 0.1 mm, which makes it invisible. In some cases, the thickness of the scar tissue reaches 2-3 cm, which causes a noticeable deformation of the breast and pain.

Principles of treatment

Depending on the cause of stiffness in the joint, a traumatologist, orthopedist, neurologist, neurosurgeon, therapist, plastic surgeon. Treatment can be conservative and surgical.

Fresh and supple contractures are subject to conservative therapy. The patient is prescribed drug therapy (analgesics, muscle relaxants, drugs to normalize microcirculation, vitamins, antioxidants). Be sure to complement the treatment program with physiotherapy procedures, therapeutic gymnastics for joint development. In severe cases, treatment with position, mechanotherapy, and the use of articulated distraction devices are prescribed.

In the case of fixed contractures that are not amenable to conservative correction, apply different types reconstructive surgery.

Effects

The prognosis for contracture in most cases depends on the underlying disease that caused the restriction of mobility. It is very important that the prevention of contractures is carried out in a timely manner and in full.

Fresh contractures with full and timely treatment, regular classes of therapeutic exercises lend themselves well to conservative correction. In the case of chronic contractures of any etiology, the prognosis is less favorable, because over time pathological changes in the joint progress, fibrous degeneration develops not only in patients, but also in previously healthy tissues, which is almost impossible to correct without surgery.

Contracture of the knee joint: what is it, treatment of the knee

Contracture of the knee joint is usually a congenital defect or a consequence of an injury.

To restore the function of mobility and relieve pain, there are different kinds therapy. Timely adequate treatment leads to positive results.

Symptoms characteristic of contracture

The development of a pathological process in which there is no flexion function of the knee is called "knee joint contracture". This disease is caused by cicatricial contraction of tendons, skin or muscles. Translated from the Latin "contractura" means contraction.

Contracture in the knee joint is accompanied by several symptoms:

acute pain syndrome;
limitation of joint mobility (no flexion function);
pathological changes in the tissues adjacent to the joint (tightening of tendons and muscles);
leg deformity;
limb shortening;
complete loss of joint mobility (without appropriate treatment).

The nature of the course of the disease and its symptoms depend on the age category of the patient and the stage in which the disease is located (acute or chronic form).

To make an accurate diagnosis, the doctor must prescribe full examination sick. To date, the diagnostic technique is diverse:

CT scan;
x-ray examination;
magnetic resonance imaging (MRI).

Factors provoking the development of contracture

There are many causes for contracture. These can be various injuries, inflammatory processes, loss of elasticity of the ligaments, deformity of the limbs due to arthrosis or arthritis, shortening muscle tissue on which the motor mechanism of the joint depends.

A type of contracture called "arthrogenic" occurs due to a bone fracture, sprain, bruise, or intra-articular dislocation. Most often, this type of ailment affects people with chronic and acute illnesses joints. AT rare cases arthrogenic contracture can also develop in healthy joints.

Contracture of the knee joint is not inherently a disease - it is, as a rule, a consequence congenital pathology, illness or injury. This complication accompanies almost all serious injuries.

The scar formed on the damaged tissue is not elastic, so it interferes with normal functional activity joint. Contracture various degrees severity is present in any injury musculoskeletal system. arthrosis, affecting people in old age and arthritis developing in the younger generation, significantly deform the joints and entail a complication in the form of contracture.

This disease can manifest itself against the background of diseases of the nervous system. But most common cause yet is mechanical damage. rehabilitation period after an injury, it requires rest, but the longer the limb rests, the greater the risk of developing contractures and the process of getting rid of it becomes more complicated.

If adequate treatment is not started in a timely manner, contracture of the knee joint leads to its complete immobility. advanced disease treated exclusively by surgery. To avoid surgery, you need to consult a doctor at the first manifestation of symptoms. Acquired or congenital contracture leads to sad consequences.

Note! Contracture in the advanced stage limits the patient's ability to move, excluding a full-fledged lifestyle and reducing physical abilities the person as a whole.

Treatment with conservative methods

At present, two types of contracture treatment are carried out in domestic and foreign clinics: surgical and conservative.

Conservative therapy includes physical education, therapeutic exercises, various restorative exercises, massages. The complex of physiotherapy includes:

drug treatment;
shock wave therapy (therapeutic technique using acoustic waves);
thermal procedures;
manual therapy (technique of influencing muscles and joints);
electrophoresis.

A number of medications are represented by painkillers for pain in the joints (lidocaine, novocaine) and hormonal injections. When they are introduced into the affected joint, the pain sensations are significantly reduced, the muscles relax and acquire a normal tone.

Such procedures significantly slow down the development of knee contracture.

When conducting a massage session, doctors recommend strenuously acting on weakened muscles, and superficially on antagonist muscles. Therapeutic gymnastics and physical education involves simple exercises that should be done with great care. To begin with, they perform passive movements, gradually moving to active actions.

Consider some effective exercises for the treatment of contractures:

alternately pull the legs to the stomach, bending the knees;
lying on your back, bend your legs and straighten them up;
standing, bend the leg at the knee and lift it up, then straighten it, lowering it to the floor;
alternately with one and then the other leg to perform movements that imitate cycling
perform cycling exercises with both legs at the same time;
lift up the leg in a straightened state;
make circular movements with the lower leg with the knee bent on weight;
rest the straightened leg on the gymnastic ball and perform pressing actions;
squat with the ball sandwiched between the knees;
roll the ball towards and away from you, putting your feet on it;
lift the ball up, holding it between the lower leg and buttock;
put the ball under your knees and press hard on it with your heels;
lying on your side, perform cycling movements;
lie on your stomach and alternately bend your knees;
in the same position, raise the straightened leg up;
lie on your side and swing up with a bent leg, gradually straightening your knee;
lie on your stomach and take the straightened leg to the side;
lying on your stomach, bend your leg at the knee and perform circular movements with your lower leg (ten times in each direction).

All of the above exercises should be performed 10 times. Therapeutic exercise should be regular, minimal amount classes - 3 times a week. A prerequisite is medical supervision.

Another effective means are thermal procedures in the form of baths (initially with a temperature of 36. Then they move on to mud and paraffin treatment.

Conservative treatment, exercise and other manipulations are necessary for recovery motor function limbs. With complex treatment:

pain disappears;
muscle tissue is strengthened;
the joint acquires normal mobility;
nutritional intra-articular processes are normalized;
healthy blood circulation is restored;
the formed adhesions dissolve.

In the process of rehabilitation, the so-called mechanotherapy is used. It includes restorative therapeutic exercises with the use of special equipment and simulators.

Surgery

In situations where physical exercises and medications do not lead to the desired results, it is necessary to use a surgical method of treatment. With the help of surgery, doctors lengthen the muscles; restore tendons (release them from healed tissues); perform osteotomy, transplantation and elimination of skin scars.

When the tendon is seriously damaged, the patient is implanted with tissues made of special plastic or canned, which easily take root in the body. They also perform various corrective operations on bone tissues. For example, when the length of the limbs does not match, the shortened bone can be lengthened or, conversely, shortened.

Surgical intervention in the treatment of contracture of the knee joint is often combined with physiotherapy and balneotherapy.

Forecast

The main goals of treating contractures are to relieve pain, reduce inflammation, and return joint mobility. To date, medicine has been quite successful in treating this disease in varying degrees its complexity.

The most important factor in successfully getting rid of the disease is the time that has elapsed since the onset of the disease. Doctors attach great importance to the degree and type of damage, the age of the patient. It must be remembered that the sooner treatment is started, the higher the likelihood of positive dynamics and complete recovery.

Bilateral gonarthrosis of the 3rd degree - how and with what is it treated?

Most large joint of our body - the knee. It allows the leg to move and helps in maintaining body weight, and therefore it is he who is most susceptible to various injuries and diseases. The most common cause of knee joint disease is the natural aging of the body. That is why gonarthrosis most often occurs in older people.

Why are we sick of it?
How does the disease manifest itself in different stages?
How is the disease diagnosed and treated?

Why are we sick of it?

However, there are other factors that negatively affect the health of the knee joints:

Firstly, these are any injuries that result in post-traumatic arthrosis: ligament rupture, meniscus injury, hip fracture, etc. Especially often such injuries occur in athletes.
Secondly, diseases that cause cartilage destruction, such as chondromatosis or arthritis, are the cause.
Thirdly, a person may simply be genetically predisposed to this disease.
Also, gonarthrosis is often found in overweight people, severe varicose veins, and in those who take drugs of a certain group for a long period.

What kind of disease is this?

Bilateral gonarthrosis affects both knees at once. Here's what happens:

Impaired blood circulation in small bone vessels,
This triggers a degenerative-dystrophic process in cartilage, which begins at the molecular level,
Gradually, the cartilage becomes less dense and elastic, while gradually becoming cloudy, exfoliating and becoming covered with cracks and depressions,
The result of this process is the partial or complete disappearance of the cartilage and the exposure of the underlying bone. Any physical activity at the same time causes difficulties, as it is associated with pain.

Further development of the disease leads to tissue damage around the joint. The synovium becomes inflamed and the fluid it produces loses its functionality. The joint capsule thickens. Osteophytes appear on the exposed surfaces of the bones - bone spikes that cling to each other when moving, further complicating it.

Moreover, with the development of the disease, the muscles around the joint also atrophy. Contracture occurs - the inability to fully bend or straighten the legs. This leads to almost complete immobility of the knee joint. AT difficult cases complete fusion of the bones may occur.

How does the disease manifest itself in different stages?

In total, there are three stages in the development of gonarthrosis:

Disease of the 1st degree is characterized by slight discomfort and mild pain in the knee joints during long walking and physical exertion. Sometimes areas of the joints can swell, recovering from rest.

Bilateral gonarthrosis of the 2nd degree is associated with stronger and more prolonged manifestations: “creaking”, “crunching”, “starting pain”, which occurs during prolonged rest and passes after some time; stiffness of movements and an increase in the size of the knee joints.
With a disease of the 3rd degree, contracture becomes pronounced, the joints are deformed, the legs are bent and the gait is disturbed. acute pain accompanies the patient both in motion and at rest, which often leads to sleep disturbance. In addition, diseased joints react sharply to weather changes.

How is the disease diagnosed and treated?

Identification of gonarthrosis and the establishment of its degree begins with a medical examination. Then an x-ray is taken, which helps to see the deformities of the joints and track the dynamics of the development of the disease. Also, with gonarthrosis of 1-2 degrees, detection is possible using magnetic resonance imaging. To clarify the diagnosis, differential diagnosis and additional research: blood test and detection of rheumatoid factor.

As a rule, gonarthrosis is treated with conservative methods. But only if it has not developed to 2-3 degrees, since at these stages this approach is simply ineffective.

Firstly, such therapy consists in taking painkillers and anti-inflammatory drugs, as well as medicines that nourish cartilage and strengthen bone tissue.

Secondly, electrophoresis, phonophoresis with hydrocortisone, laser and magnetic therapy, and ultraviolet irradiation help to normalize metabolic processes in the knee joints and improve cartilage nutrition. As a result, pain is relieved and motor activity is improved, which slows down the development of the disease and prevents contractures.
Thirdly, to strengthen muscles and restore blood circulation in the joints, it is prescribed physiotherapy and massage.

With a more serious development of gonarthrosis of the knee joint, treatment is not complete without surgical intervention. Usually one of the following operations is carried out.

Osteotomy - correction of deformities and improvement of the functionality of the joints with the help of artificial fractures and dissections of bones and subsequent fixation.
Arthrodesis - complete immobilization of the joint to restore support.
Arthroplasty is the modeling of new surfaces of the joints and the placement between them of a gasket that replaces cartilage and is made from the patient's tissues or artificial materials. Unlike arthrodesis, this operation allows you to maintain the mobility of the knee joints.

What causes contracture of the knee joint and how to get rid of it? In the treatment of leg fractures, temporary immobilization is performed using plaster casts, traction or. Immobilization is necessary for proper fusion of bone fragments. However, it contributes to the emergence of various. The most common among them is flexion contracture of the knee joint. It is the immobilization of the legs that is considered its main cause. Knee dysfunction can be observed after arthroplasty, as well as arthroscopy. The treatment plan for injuries of the lower extremities should include measures aimed at preventing the formation of contractures.

Causal factors

The reasons why this pathological condition occurs can be different. Functional and organic disorders in the joint appear with a long course of the inflammatory process, injuries, arthritis or arthrosis, a decrease in the elasticity of the ligaments, shortening of the muscles. Arthrogenic contracture is formed when a bone is dislocated or fractured, bruised and sprained. This problem is faced by people suffering from joint diseases. However, it can also occur in a perfectly healthy person.

contract does not count full disease, it is referred to post-traumatic and postoperative complications. Less common congenital forms pathology.

Almost any complex fracture contributes to the disruption of the functions of nearby joints. Affected tissues begin to scar and lose their elasticity. This interferes with the movements of one or another department of the musculoskeletal system. The post-traumatic type of contracture appears with injuries of any severity. The destruction of cartilaginous tissues can also contribute to its occurrence.

Other causes include damage to nerve endings. However, most often the contracture has a mechanical origin. Recovery from any injury requires reducing stress on the knee. The longer it stays immobilized, the higher the risk of complications.

Signs of contractures

The joint can be fixed in an extended or flexed state, with rotation and abduction. The main types of disorders are flexion and extensor contractures of the knee joint. Its combined appearance is characterized by complete immobility of the affected area. This is the most severe complication, practically not amenable to conservative therapy.

By origin, violations can be:

Desmogenic. Their appearance is facilitated by scarring of tissues against the background of injuries and inflammatory processes.
Tendogenic. Appear when the ligaments are damaged.
Myogenic. The cause of the development of such contractures is considered to be acute and chronic myositis, ischemia or tissue compression.
Arthrogenic. Develop against the background long course destructive processes in the joint.
Neurogenic. Paresis and paralysis of the limbs contribute to their occurrence. Rarely occur in pathologies of the spinal cord.
Dermatogenic. Their appearance is associated with thermal and chemical burns, as well as injuries of the skin and underlying tissues.
Conditionally reflex. This type of contractures is formed under the influence of adaptive reactions.

The main symptoms of these pathological conditions are a decrease in joint mobility and its deformation. Additionally there are:

Other manifestations depend on the cause of the disease. In people with arthrogenic forms of contractures, signs of destruction of cartilage tissues are almost always found. To determine the type of pathology, the volume of movements is measured.

Ways to treat pathology

In order to improve the condition of the joint after arthroscopy or injury, it is necessary to relieve inflammation and pain, restore mobility. Modern therapeutic techniques allow you to get rid of contractures without surgery. Recovery time largely depends on the type and severity of the violation, the amount of time that has passed since the injury. The sooner treatment begins, the higher the chances of a full recovery.

For the development of the joint are used:

physiotherapy;
massage;
physiotherapy procedures (electrophoresis, thermal exposure, SWT).

Treatment at home involves the use of non-steroidal anti-inflammatory drugs and analgesics. In a hospital setting, it is injected into the knee joint hormonal agents. They eliminate pain, increase muscle tone, slow down the process of tissue destruction.

Massage of the knee joint should be performed according to a specific pattern. Active influence turns out to be weakened muscles and cautious - to those that are in increased tone. First, soft movements are performed, then active ones. Only after a while, elements of resistance are introduced.

Exists exercise therapy complex aimed at improving the condition of the joint in the presence of contractures. The legs are pulled to the stomach and begin to alternately bend them at the knees. The bent limb is lowered to the floor, after which it is straightened. The bicycle exercise is performed first for one leg, then for the second. It is useful to hold the bent leg on weight for a long time. The straightened limb is placed on the gymnastic ball and pressed on it. After that, rotational movements of the lower leg are performed.

Squats are done with the ball between the legs. The same object is placed under the knees and they begin to put pressure on it with the heels. Lying on its side, the leg is bent and lifted up. In the same position, the limb should be held on weight. Lying on your stomach, bend both legs. In the same position, the straightened limb is raised. All actions are performed at least 10 times. Classes should be held regularly, at least 1 time in 2 days. The constant supervision of an experienced instructor is required.

For the treatment of neurogenic and post-traumatic forms of contracture, warm baths are used, over time they are supplemented with paraffin baths and mud therapy. The development of contracture allows you to restore mobility and function of the joint. In this case, the disease does not lead to complications, discomfort disappear, the muscles are strengthened, the nutrition of cartilaginous tissues is restored.

During the recovery period, it is shown, which includes therapeutic and supportive exercises, exercises on simulators.

When is surgery required?

Operations are used when medical treatment of contracture of the knee joint is ineffective. Surgical intervention implies:

dissection of scars;
restoration of the volume of muscles and tendons;
decompression.

With significant tissue damage, artificial or natural implants are used. Surgery to correct bones may be prescribed.

Prolonged development of contracture of the knee joint can lead to its immobilization. Advanced forms of diseases are treated exclusively by surgery. Therefore, when the first signs of dysfunction of the joint are found, you should contact an orthopedist. Mixed contracture does not allow you to use the leg as a support, walk and run normally. In severe cases, a deformity of the joint is revealed, which makes a person unable to work and significantly worsens the quality of his life.

Alternative ways to eliminate pathology

Treatment with folk remedies is effective only on early stages development of degenerative phenomena. For this, rubbing and infusions based on medicinal plants. They enhance the effectiveness of drug therapy, allow you to reduce the dosage of drugs.

You can relieve muscle tension with warm compresses or baths. Add to water essential oils coniferous plants. Salt baths Dead Sea have a healing effect, restore blood supply to tissues. They can be used to treat post-traumatic or post-operative contractures.

All folk remedies must be used with the permission of the attending physician. This will help to get the best result and avoid the development of allergic reactions.

Contracture of the knee joint in most cases has a favorable prognosis. With the timely start of therapy, the mobility of the affected area is completely restored.

With a persistent violation of the movement of the knee joint, they speak of a contracture of this joint. Contracture - what is it, why does it appear and how to treat it correctly?

The reasons

So, contracture of the knee joint is a symptom in which the normal amplitude of movements produced by a person is disturbed. In other words, a person cannot fully or partially bend or straighten the left or right lower limb at the knee. This also includes the stiffness of the joint, in which the movement seems to be possible, but it takes too much effort, and the joint at this time is very worn out and hurts. The most common causes of this condition are the following conditions.

Inflammatory processes

Rheumatoid, tuberculous and other types of arthritis most often cause limited mobility of the knee. Because inflammation often affects soft tissues, synovial capsule, tendon attachment site, ligamentous apparatus, these pathological processes become a source of chronic diseases:

calcification of tendons and muscle fibers;
hypertrophy and deformation of the synovial capsule and adjacent tissues;
leg length asymmetries.

Traumatic injuries

This phenomenon has twice bad consequences: on the one hand, violations of the integrity of bone tissues, ligamentous apparatus or synovial bag almost always lead to the appearance of an inflammatory process with insufficiently good blood circulation and other provoking factors, on the other hand, rehabilitation after an injury involves a long stay of a person in a cast or with a minimum of movements for several weeks.

By the way, it is believed that even a 20-day immobilization can lead to such conditions. This leads to atrophic processes in the muscles, blood flow worsens, the functions of all structures and tissues are partially lost. They lose their elasticity and former efficiency. These processes can lead to:

weakening or excessive stretching of other, adjacent muscles and tendons;
in some muscles there is a spasm, their hardening is observed, due to this, the structures surrounding them are shortened and hardened (desmogenic contracture);
cicatricial adhesive processes in skin and muscle layers(dermatogenic and diogenic contractures).

Skin injuries of the knee

We are talking about burns, lacerations, in which healing is extremely slow and often leads to scarring (dermatogenic contracture).

Arthropathy of the knee

This may be the result of aseptic necrosis, gonarthrosis, chondromalacia of the patella, Schlatter's disease and other diseases in which persistent deformation or structural change occurs not due to injury. Extension and flexion contracture of the knee joint: in this case, it can be expressed by persistent stiffness or complete blockage of the joint. In the future, this can lead to improper fixation of the knee, which is difficult to treat with therapeutic methods.

A gunshot wound to the knee almost always leads to grave consequences and complications. They are much easier to prevent by preventive measures, which the traumatologist should warn the patient about.

Gunshot wound to the knee

In this case, a complex injury occurs, in which there is damage to all tissues of the knee, including soft structures, bones, cartilage and tendons. Often, an inflammatory process begins to develop at this place, which has the name gunshot contracture.

Also knee contractures distinguished by type:

Active, or neurogenic. They are mainly caused by prolonged tonic tension of the muscles and the associated impairment of the movement of the knee joint. If active contractures of the knee joint take on a persistent character, then irreversible deformations occur in the joint, including cicatricial-dystrophic changes, which makes this type pass into the category of passive ones.
Passive, or structural. They are associated with changes in the structure of tissues and anatomy of the knee joint. In the vast majority of cases, these situations are post-traumatic.

In some cases, there is a mixed contracture of the knee, that is, the cause of the condition is combined.

Congenital contracture of the knee joint

How earlier pathology will be identified, the greater the chance of its correction without consequences. The same rule applies to children. Even if the diagnosis is made to a child who is not even a month old, such small patients can also be helped using certain therapy: it consists in massage and delicate corrective movements aimed at correcting a dislocation or subluxation in the baby.

Subsequently, the child needs to apply a splint or fixing bandage. It is difficult to diagnose in such small patients. So, some types of examinations - MRI and CT - cannot be performed for children because of the danger of anesthesia.

Symptoms

chief clinical manifestation contracture is a violation of the flexion and extensor function of the knee joint. In addition, the following symptoms can be observed:

unnatural protrusion of the lower leg outward;
the appearance of pain during movement;
violation of the feeling of support, depreciation;
change in gait;
forced position of the leg, in which the pain disappears;
the appearance of deformations at the junction of the articular parts in the knee;
swelling of soft tissues in the area of the knee joint;
visual shortening of the diseased lower limb (in the last stages of the disease).

If, in addition to contracture, an active inflammatory process occurs in the joint, then in soft and cartilage tissues an abscess may occur and, as a result, osteomyelitis. In the future, this can lead to a complete failure of joint function and subsequent disability. Most often this happens in the chronic form of contracture, when the process has gone deep into the bone structures.

Diagnostics

For the most part, it is based on instrumental examination, among which: radiography, CT or MRI of the joint, as well as a diagnostic operation - arthroscopy. Also, the specialist will definitely ask the patient about the duration of the onset of the first symptoms, a history of injuries, the nature of work and other data that can help identify the cause. In addition, an examination of the affected knee is mandatory.

MRI of the knee joint is one of the best ways to correctly and fully assess the condition of the bone tissue, soft structures. Later you can do control study, as well as periodically monitor the state of the articulation for preventive purposes

Based on the results of the diagnosis, the attending physician can refer the patient to other specialists: a neurologist, a psychiatrist, a cardiologist.

Treatment

Traditional therapy involves taking medicines that contribute to the elimination of the main cause of the disease. So, with arthrosis, anti-inflammatory drugs, chondroprotectors, as well as injections will be useful. hyaluronic acid. Very often, treatment involves the use of physiotherapy.

The following will be especially helpful here:

Shock wave therapy. Waves of a special frequency accelerate blood supply to the diseased area and thereby help to accelerate regeneration processes.
Electrophoresis. It will help faster and more complete assimilation of therapeutic components used directly on the knee joint during this procedure. Preparations (ointments, gels, creams) can have an analgesic, anti-inflammatory, regenerating effect.
thermal procedures. This includes both therapeutic warm baths and paraffin therapy, in which the joint is heated for a long time.
Manual therapy. Massage with the sensitive hands of a specialist will remove the deformity and restore the correct anatomy of the knee joint. Keyword in this offer - a specialist. The person must have specialized education and practice in the use of such a method of treatment.

Physiotherapy

She is of great importance in this disease. The exercises are as simple as possible, but it is very important to correctly perform their technique:

Raising a straight leg from a sitting or lying position.
Alternately bending the knee and pulling it to the stomach both lying down and sitting.
Pressing with the foot on the gymnastic ball, which creates pressure and loads the muscles of the diseased lower limb.
"Bicycle" is very popular and effective exercise, which allows you to quickly cope with knee contracture.
Circular movements of the leg. They must be done alternately with each foot 10 times.
Raising a bent leg, and then straightening it from a lying position on its side.
Abduction of a straight leg from a prone position.

Mechanotherapy is considered very effective in this matter. In this case, the exercises are performed using special devices. As a rule, such gymnastics is carried out not at home, but in special medical centers. In general, the development of the joint may take long time: from several weeks to several months. The result depends on the stage at which the therapy was started, as well as on the patient's own capabilities.

Surgical treatment

It is carried out with low efficiency traditional methods treatment, as well as in case of severe deformity of the articulation. The operation can be performed both by a minimally invasive method - arthroscopy, and by an open method. After arthroscopy, the rehabilitation period is milder and more painless than with open intervention in the knee.

Endoprosthetics - an operation that is performed with severe contractures

What the surgeon can do during the operation: excise and remove scar areas, normalize the shape of the articular surfaces, that is, plastic surgery of the joint, lengthen the muscle fibers. If the damage to the joint is very pronounced, then the patient may be shown to replace it (arthroplasty). The rehabilitation period after arthroplasty should include physiotherapy, massage and exercise therapy (exercise therapy), which will help you recover quickly.

Knee contracture is a condition in which normal movement foot becomes impossible. Accordingly, in the worst case, a person can become disabled, and the dream of active life will be closed to him forever. The sooner a patient gets an appointment with a specialist, the greater the chance of effective treatment without consequences or complications.

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In the treatment of limb fractures, temporary therapeutic immobilization is carried out: skeletal traction, plaster cast, osteosynthesis.

Immobilization is carried out in order to create conditions for the consolidation of bone parts. However, due to immobility, complications arise.

Thus, it is extremely common to observe contractures of the knee joints after leg fractures.

It is the immobility of the leg during this period that mainly causes the appearance of contractures.

Therefore, when restoring patients with leg injuries, one of the main tasks is to combat this phenomenon.

Reasons why contracture may occur

Contracture can be caused by various reasons.

Inflammation, trauma, changes in the articular bones due to arthritis or arthrosis, loss of elasticity of the ligaments, and shortening of the muscles can initiate a violation. "Arthrogenic" contracture appears due to a dislocation in or near the joint, a broken bone, a sprain, or a bruise.

People with joint diseases suffer from this disorder, but sometimes it can also be observed in healthy joints.

Knee contracture is not a disease - it is the result of an illness, injury or congenital abnormality.

Almost any serious injury entails this problem. A scar forms on the affected tissue. It is not elastic, and therefore interferes normal operation joint.

A lesion of varying severity appears with any damage to the musculoskeletal system. Violations such as and can also cause pathology.

It can occur due to damage to the nervous system. But often the nature of the joint damage is mechanical.

To recover from any injury, the damaged area needs rest.

But the longer the affected area is at rest, the higher the risk of contracture and the harder it is to get rid of it.

Types of contractures

The joint can be reduced:

during extension;
when bending;
when bringing;
when withdrawing;
during rotation.

Extension and flexion types of pathology

The main types of disorders are flexion (flexion disorder) and extensor (extension disorder); restrictions and other movements - rotational, lateral.

Symptoms of occurrence

The main manifestation is the restriction of flexion or extension. Basically, there is a pronounced deformity of the joint.

The following symptoms may be observed:

edema;
violation of the support;
joint pain;
shortening and uncomfortable position of the leg.

The rest of the manifestations depend on the provoking disease. With prolonged existence of contracture, signs of arthrosis of the knee are standardly detected.

To assess the severity of contracture, measurements of the range of motion are carried out.

Treatment and development of the knee with contracture

Doctors pursue the goal of eliminating inflammation, pain and restoring joint mobility. Modern medicine has achieved some success in this.

The prognosis fully depends on the type and degree of damage, on the amount of time since the onset, on the age of the patient and his condition, on the time from which treatment began.

The sooner you start it, the higher the likelihood of positive dynamics, and as a result, an absolute cure.

To date, conservative and surgical treatment of the disorder is used.

To develop a joint using conservative treatment:

physical Culture;
massotherapy;
physiotherapy;
shock wave therapy;
electrophoresis;
manual therapy;
thermal procedures;
medicinal treatment.

Of the drugs used hormones and painkillers (novocaine, lidocaine). They are injected into the diseased joint, the pain recedes, because of this, the muscles again acquire a healthy tone, and the process slows down significantly.

When performing massage with limited mobility of the knee, it is necessary to actively influence weak muscles and carefully - on the antagonist muscles. Exercise therapy when performed carefully. First, calm movements are performed, then active ones.

Only after a certain period are elements of resistance introduced. There are a number of fairly effective exercises:

alternately bend your knees, pulling up to your stomach;
raise the bent leg, then straighten it, lowering it to the floor;
perform movements with one leg similar to cycling, then change legs;
bend your legs and straighten up;
move your legs like on a bicycle;
raise a straight leg;
bend the leg at the knee, holding on weight;
then carry out circular rotations of the lower leg;
put a straight leg on the gymnastic ball and put pressure on it;
bend your legs with the ball sandwiched between them;
putting the limbs on the ball, roll it away from you and towards you, trying to pull your legs;
placing the ball under the knees, press on it with the heels;
hold the ball between the thigh and lower leg and lift it;
carry out cycling movements with the foot, lying on its side;
lying on your side, raise the bent leg and straighten it, performing a swing up;
in the same position, raise the leg, holding it in weight;
alternately bend your knees, lying on your stomach;
lying on your stomach, bend both legs;
in the same position, raise a straight leg;
and, again on the stomach, bend the knee;
then - rotation of the lower leg in a circle;
on the stomach - take the straight leg to the side.

All exercises are performed 10 times. You should do it regularly - three times a week, or better - daily. But certainly under the supervision of a doctor.

Thermal baths are also used, starting from 36 degrees, with time they connect paraffin and mud therapy.

Conservative methods in the complex are aimed at restoring normal mobility and limb function.

When using them, the disease is not aggravated by complications, pain is neutralized, the joint becomes mobile, muscles are strengthened, the joint receives nutrients.

The blood flow is restored, stagnant processes stop, adhesions disappear. At the stage of recovery, mechanotherapy is used, which combines therapeutic, restorative exercises with the use of special devices and simulators.

Surgery

If the contracture is not treated with conservative methods, surgical intervention is performed.

Through it, scars are excised, the length of muscles and tendons is restored, they are released from scars, transplantation, osteotomy, etc. are made.

If the tendon is significantly damaged, tissue canned or made from a special material is used.

Various corrective bone tissue surgeries can be performed.

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Consequences and complications

Without timely competent treatment, contracture of the joint leads to its immobility. The disease at this stage is treated only surgically, so at the first sign it is necessary to contact a specialist.

A neglected lesion does not allow the patient to move normally and causes deformation of the limb, preventing a person from living normally and reducing his physical activity to a minimum.

conclusions

Thus, subject to regular exercise, physiotherapy exercises for contracture of the knee joint will help the diseased joint to restore work and will subsequently favor its strengthening.

The prognosis significantly depends on the underlying disorder, the severity of changes in the joint and adjacent tissues. Fresh contractures, with proper treatment and constant therapeutic exercises, generally respond well to conservative treatment.

When the process is running, the prognosis is less positive, because over time, changes in the joint are aggravated, cicatricial degeneration of not only the affected, but also previously healthy tissues appears, secondary arthrosis appears.

Etiology and pathogenesis

Persistent dysfunction of the knee joint can be the result of three main clinical situations: 1) union of fractures of the femur; 2) defects of the femur and 3) treatment of patients with fractures complicated by purulent infection (Scheme 31.5.1). Patients of each of these groups have pathological features. The tactics of their treatment are also different.

Scheme 31.5.1. The main causes of the development of contractures of the knee joint in fractures of the femur.

The main reasons for the development of contractures of the knee joint in patients with fractures of the femur are:
- degenerative-dystrophic and cicatricial changes capsules of the knee joint with prolonged immobilization of the limb;
- cicatricial adhesive processes in the area of torsion of the knee joint (especially the upper one), developing with periarticular injuries;
- fibrous degeneration of the heads of the quadriceps femoris muscle with the appearance of an additional fixation point;
- loss of normal extensibility of the quadriceps femoris muscle with prolonged immobilization of the limb.

Due to the fact that almost always lower limb immobilized in the position of extension in the knee joint, combined contractures of the knee joint are predominantly extensor in nature.

Degenerative-dystrophic changes in the joint capsule during prolonged immobilization. Due to the long periods of fusion of femoral fragments (A-6 months or more, depending on the nature of the fracture) best results treatment of patients is achieved using internal stable osteosynthesis of bone fragments, the most important advantage of which is the possibility early start functioning of the knee joint.

Otherwise, prolonged immobilization of the knee joint is inevitably accompanied by the development of degenerative-dystrophic changes in the capsule of the knee joint with loss of its elasticity.

Cicatricial tissue changes in the area of the upper inversion of the knee joint. When the fracture is located in the lower third of the femur, scar tissue changes can spread to the area of the upper torsion of the knee joint. And even with fractures in middle third segment, an extensive hematoma may descend distally to this level. In addition, concomitant injuries of the knee joint with damage to the ligamentous apparatus and menisci, as well as fractures of the condyles of the femur and patella, are generally not uncommon in fractures of the femur. All this leads to direct scarring of the damaged elements of the knee joint, which, combined with prolonged immobilization, can lead to the development of arthrogenic contracture.

Cicatricial changes in the muscles in the fracture area and their fixation by scars to the femur. As is known, the quadriceps muscle of the thigh has a significant amplitude of movements, which, when the limb is bent at the knee joint to an angle of 90 °, are 7-10 cm. The inevitable development of extensive scars in the fracture zone quickly leads to a strong fixation of the muscle to the femur. This is especially true of the broad intermediate muscle, which starts from the anterior surface of the femur throughout its middle and upper thirds.

Cicatricial processes are aggravated by direct traumatization of the thigh muscles by the ends of bone fragments, as well as by the direct impact of a traumatic force on the fracture area. Finally, internal osteosynthesis of bone fragments is accompanied by additional tissue trauma, and even when using external fixation devices, the wires passed through the muscles block their movement.

All together, this is manifested by the loss of the ability of the muscle to move in relation to the femur.

The processes described above are significantly enhanced with the development of suppuration of the wound (with open and especially gunshot fractures) with the development of osteomyelitis. Therefore, in patients of this group, combined contracture of the knee joint occurs in almost 100% of cases.

Loss of normal extensibility of the quadriceps femoris. With prolonged immobilization of the limb in the position of extension of the head of the quadriceps muscle, the ability to increase its length when flexed at the knee joint gradually decreases. This is especially true for the rectus femoris, which starts from pelvic bones and has the greatest length, and consequently, contractility.

Treatment of patients with persistent contractures of the knee joint

Treatment of patients with severe contractures of the knee joint can vary significantly in different groups of patients:
1) with the consequences of diaphyseal fractures of the femur;
2) with diaphyseal fractures and concomitant fractures of the condyles of the femur or patella;
3) with the consequences of a fracture of the femur, complicated by osteomyelitis.

Contractures of the knee joint after diaphyseal fractures of the femur. The main task in the treatment of patients in this group is to restore the ability for free movement of the quadriceps femoris muscle and the normal extensibility of its heads, which provides a full range of flexion and extension in the knee joint.

Operation technique. The operation is started from a linear longitudinal approach along the anterior surface of the thigh just above the patella.

After mobilization and shifting of the skin-fascial flaps to the sides, the anterior surface of the quadriceps muscle is exposed. Due to the fact that the superficially located rectus femoris muscle has the greatest length, the surgeon mobilizes it, separating from it (in a sharp way) tendon stretching of the medial and lateral broad muscles(Fig. 31.5.1, a).

Rice. 31.5.1. Stages of mobilization of the quadriceps femoris muscle.
a - isolation of the tendon of the rectus muscle; b - suture of the tendon of the rectus muscle with the tendons of the lateral and medial wide muscles.
If necessary, the muscle is isolated more proximally. Then, moving the tendon of this muscle aside, the surgeon separates the cicatricial adhesions that connect the medial and lateral broad muscles to the surface of the femur.

Due to the fact that the main cicatricial tissue changes occur in the intermediate wide muscle and that it is impossible to restore its normal contractility, the cicatricial tissues are excised or cross the muscle near the place of its transition to the tendon. In this case, the plane of dissection of the muscle passes in the oblique direction (Fig. 31.5.2).

Rice. 31.5.2. The level of intersection of the vastus intermedius muscle of the thigh (arrow) according to V.I. Karptsov (1988) (explanation in the text).
Rice. 31.5.3. Moving the tendon stretch of the lateral wide muscle of the thigh (M) to a more proximal level (according to V.I. Karptsov, 1988).

The second element of this operation is the separation of adhesions between the lateral and medial heads of the muscle on one side and femur- with another.

At normal condition sliding elements of the knee joint, this allows you to restore the mobility of the entire quadriceps muscle.

The effectiveness of the performed operation is assessed by the degree of restoration of the volume of passive movements in the knee joint.

In some cases, due to the secondary shortening of the lateral and medial wide muscles of the thigh, full flexion in the knee joint is restored only when their tendons are sutured to the tendon of the rectus muscle at a more proximal level (Fig. 31.5.3).

With pronounced cicatricial changes in the tissues in the area of the upper constipation of the knee joint, the tissues in this area are additionally excised.

We emphasize that the complete transection of the tendon of the quadriceps femoris and its suturing with lengthening give poor results due to the fact that full active extension in the knee joint is not restored.

According to the indications (pronounced cicatricial changes in tissues), the operation can be completed by applying an external fixation device with a hinge located at the level of the knee joint. This allows slow and therefore less painful flexion of the joint in the postoperative period.

postoperative treatment. Movements in the knee joint begin on the 6th-7th day after the operation, and isometric contractions of the quadriceps muscle - from the 3rd-4th day. The device is removed after reaching a significant volume active movements with the rods of the apparatus removed.

After the removal of the latter, the treatment is supplemented with a complex of physiotherapeutic procedures. Contractures of the knee joint with a combination of a diaphyseal fracture with intra-articular fractures of the condyles of the femur and patella. Due to the fact that near- and intra-articular scarring plays a significant role in patients of this group, the surgical techniques described above are combined with intra-articular intervention. Depending on the predominant location of scar tissue changes, internal or external parapatellar access is used. Scar adhesions between articular surfaces separate, mobilizing (or excising) torsion of the joint. The effectiveness of the operation is assessed by the degree of restoration of movements in the knee joint.

In these patients, in contrast to the patients of the previous group, the prognosis for the restoration of function is much less favorable, and the development of deforming gonarthrosis is almost inevitable.

Contractures of the knee joint in combination of hip fractures with osteomyelitis. The significant distribution and complex topography of cicatricial tissue changes in patients with femoral osteomyelitis determine the particular complexity of their treatment. In this situation, the operation to mobilize the elements of the quadriceps femoris muscle should be supplemented by an intervention aimed at eliminating the suppuration process. This includes not only the radical excision of the affected tissues, but also the filling of the resulting cavity with well-perfused tissues.

With widespread cicatricial tissue changes in the lower third of the thigh, and in particular in the area of tendon stretching of the quadriceps muscle, tendon mobilization often does not lead to restoration of muscle gliding due to rapid re-scarring. This was the basis for the use by surgeons of an insulating siloxane film temporarily implanted under a tendon sprain, the edges of which protrude into the wound.

The film is removed on the 7-10th day after the operation, and immediately begin to move in the knee joint. This approach has serious drawbacks, which primarily include the risk of suppuration associated with the introduction of foreign material into the wound that is in contact with the external environment. On the other hand, the effect of using the film can hardly be noticeable due to the fact that the fibroplastic period of scar formation (from the 2nd week after the operation until the end of the 3rd month) passes under unfavorable conditions after its removal.

An alternative to this may be transplantation of a well-perfused fat flap into the region of the superior torsion of the knee joint, which can become a permanent and reliable biological seal between the quadriceps tendon and the surface of the femur. As a tissue complex, fat flaps from the outer surface of the thigh, based on the 3rd or 4th perforating arteries located in the lateral intermuscular septum, can be used. The points of exit of these vessels can be determined using a Doppler flowmeter, and they are the points of rotation of the flaps, the long axes of which are directed proximally. Once the tissue complex has been isolated, it can be moved under tendon stretching of the quadriceps femoris.

In some cases, complex free tissue polycomplexes can also be used, with the help of which, on the one hand, osteomyelitic cavities of complex shape can be replaced, and on the other hand, a favorable environment for sliding segment structures.

IN AND. Arkhangelsky, V.F. Kirillov