Disclosures: Kyle D. Josephson, MD: Nothing to disclose

Case Description: The patient was admitted with right knee flexion contracture after undergoing her second right knee manipulation under anesthesia following a right total knee arthroplasty (TKA) 3 months prior to admission. The recurrent flexion contracture developed due to involuntary contraction of right hamstrings that limited her ability to participate in physical therapy and tolerate her knee extension brace. Despite adequate pain control and trial of multiple spasticity medications, she continued to develop contracture. She was noted to have a strong family history of HD, but despite this, had elected to not pursue genetic testing prior to presentation. Physical examination revealed athetosis in bilateral upper extremities, and non-stereotyped movements of her trunk. Involuntary right medial hamstring contraction was noted with removal of extension brace consistent with dystonia.

Setting: Inpatient Rehabilitation Hospital

Patient: A 57-year-old female with strong family history of Huntington’s Disease (HD).

Assessment/Results: After much deliberation, she agreed to pursue genetic testing given the suspected etiology for the recurrent flexion contracture. Right semitendinosus and semimembranosus were injected with OnabotulinumtoxinA resulting in symptomatic improvement and greater participation in physical therapy without recurrence of flexion contracture. She was discharged with plans to follow up with a Movement Disorder Clinic for further evaluation for HD.

Discussion: After what should have been an uncomplicated TKA, this patient underwent two manipulations under anesthesia due to undiagnosed and untreated dystonia. The dystonic movements characterized by excessive knee flexion illustrates the atypical dystonias that have been identified in HD. The orthopedic complication resulting from recurrent contracture typifies the severity of this dystonia.

Conclusion: This case represents a unique presentation in which a patient with family history of HD developed recurrent knee flexion contracture as a result of undiagnosed dystonia. Through the collaboration of the multidisciplinary rehabilitation team, the patient’s underlying dystonia was identified and treated, and diagnostic work-up for HD was initiated.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/recurrent-knee-flexion-contracture-after-total-knee-arthroplasty-unveils-movement-disorder-a-case-report/