Knee stiffness dr anil k jain
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Knee stiffness dr anil k jain

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  • Knee contracture is defined as ankylosis of the knee due to extrarticular, intraticular or combined pathology. The patient may have fixed flexion deformity or limited range of flexion or fixed extension deformity. Clinically it is often difficult to differntiate between predominantly intraarticular or extraarticular component. However When pathology is extrarticular due to quadriceps scarring, the affected knee has some degree of flexion possible when the hip is flexed and roentgenograms even may reveal an apparently normal joint space.
  • The best approach to the knee contracture is to prevent it from developing during initial stage of fracture management. This is achieved by early mobilization of knee or immobilization of knee in flexion. Once the knee is stiff and is not improving by physical therepy, the surgerical treatment is indicated. The Various techniques have been described for the treatment of extension contracture of the knee. They include gentle manipulation under anaesthesia, quadricepsplasty, quadricepsplasty by limited approach, quadricepsplasty with mini-incision and arthroscopic. Release of intraarticular adhesions In open fractures of distal femur9 involving the joint, contracture of surrounding ligaments and soft tissues may lead to stiff knee with scarred skin. The free flaps to cover soft tissue defects along with quadriceps release procedures are needed additionally
  • The manipulation is contraindicated in the presence of any pathologic process such as in an inflammed joint following early injury or operation In presence of severe osteoporosis sudden, vigorous manipulation may lead to fractures around knee. The manipulation may be successful if the patella is relatively mobile, there is no fibrosis in suprapatellar region and the resistance is elastic. Manipulation may be very useful following total knee replacement. This should be performed under general anaesthesia with full muscle relaxation. Undue force should not be used. As manipulation proceeds surgeon can feel adhesion separating and the range of motion is improving. Post manipulation, the knee should be kept in fully flexed position. Ice –bags should be used and the supervised active exercises stared immediately. Usually manipulation does not work in an old contracture.
  • Thompson quadriceplasty: Quadricepsplasty was first described by Thompson in 1944. Thompson’s operation (1944)8 depends upon the integrity of the rectus femoris, which is freed completely from rest of the quadriceps and retained with the patella. The vastus intermedius, if scarred is excised and the aponeurotic expansion of other vasti are divided on either side of patella. Thompsons quadricepsplasty may be complicated by skin necrosis and loss of full extension11 (extensor lag). The post operative management after quadricepsplasty is very important if flexion is to be maintained without loss of active extension. Vigrous exercises of quadriceps must be performed intensively for four weeks after operation and continued less intensively for six months11.
  • Surgical procedure :- The anterior longitudinal incision from proximal one third thigh to patella is made. Exact location of incision depends on position of scars. The medial and lateral para patellar two incisions approach was also described for arthrolysis by Hahn et al23. The deep fascia is divided in line with skin incision. The plane is developed dividing intervening tissue along each side of rectus femoris muscle from proximal end of the incision to the patella and this muscle is separated from vastus medialis and lateralis. Then anterior capsule of knee joint including the lateral expansions of vasti on both side of patella are divided far enough to overcome their contracture. The vastus intermedius is completely excised, which usually is a scarred band binding the posterior surfaces of rectus femoris and patella to the femur, but a fibrous or periosteal covering on anterior surface of femur is left. If the tendon of rectus femoris has been destroyed by the injury, a new is one created by making longitudinal incisions through the scar tissue in distal third of thigh. At this point , the knee is slowly flexed to 110 degree to release the remaining intrarticular adhesions. If the flexion of knee still does not improve, this suggests that the rectus femoris is itself shortened. In this instance, the tendon is to be lengthened but it should be avoided as best as possible because it always results in some loss of active extension (extensor lag). If the vastus medialis and lateralis are badly scarred, Subcutaneous tissue and fat is interposed between them and rectus. If these muscles are relatively normal, these are sutured to rectus as far distally as the distal third of thigh.
  • Traditional management by the Thompson quadricepsplasty may result in a variable amount of return of knee flexion and the possibility of significant extensor lag. Extensor lag has been reported to be as high as 67%12. This if permanent may be significant enough to affect the stability of the knee and some patients may require continuous bracing12. The extensor lag is more if the flexion attained on the operation table exceeds 90-1000.
  • Chang Gung Med J. 2007 May-Jun;30(3):263-9. Modified Thompson quadricepsplasty to treat extension contracture of the knee after surgical treatment of patellar fractures. Huang YC, Wu CC. Department of Orthopedics, Chang Gung Memorial Hospital, Taipei, ROC. BACKGROUND: This retrospective study reported on the treatment of extension contracture of the knee after surgical treatment of patellar fractures. METHODS: Twenty-eight patients who sustained extension contractures of the knee after surgical treatment of patellar fractures 8-14 months previously (mean, 12 months) were treated. A midline longitudinal approach was made. After implants were removed, adhesions between the vastus intermedius and the femur, and in the patellofemoral joint were released completely. The knee was flexed up to 110 degrees. Postoperatively, a continuous passive motion (CPM) machine was used to assist knee flexion. Physical therapy was continued at local clinics. No aids were necessary for ambulation. RESULTS: Twenty-four patients were followed-up for at least 2 years (range, 2.1-7.6 years; mean, 4.6 years). The mean arc of motion of the knee improved from 72 degrees preoperatively to 123 degrees (p < 0.001). Knee function improved from an unsatisfactory grade in all 24 patients preoperatively to a satisfactory grade in 21 patients (p < 0.001). There were no significant surgical complications. CONCLUSION: This surgical technique has a high success rate with few complications. Above all, the surgical procedure is relatively simple. Therefore, it can be considered for indicated cases.
  • J Bone Joint Surg Br. 2000 Sep;82(7):992-5. A modified Thompson quadricepsplasty for the stiff knee. Hahn SB, Lee WS, Han DY. Department of Orthopaedic Surgery, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea. Between March 1987 and March 1997, we performed a modified Thompson quadricepsplasty on 20 stiff knees and followed the patients for a mean of 35 months (24 to 52). After the operation, the knee was immobilised in flexion and periodically extended. At the final follow-up, the mean active flexion was 113.5 degrees (75 to 150). The final mean gain in movement was 67.6 degrees (5 to 105). One patient had a deep infection which resolved after wound care and intravenous antibiotics. The modified Thompson quadricepsplasty with appropriate postoperative care can give good results.
  • Surgical Procedure:- The procedure12 is done through two incisions: One is a short medial parapatellar incision extending to medial side of tibial tuberosirty ( 8-12cm in length)14 The medial retinaculum suprapatellar pouch and intra articular adhesions are released through this incision. The suprapatellar pouch is mobilized. The second is a long lateral incision made from lateral aspect of lower pole of patella to 5cm distal to greater trochanter. Through distal part of this incision, the patella and lateral retinacular tissues are freed ensuring that patella may be easily lifted off the femoral candyles. The vastus lateralis is completely released from the linea aspera and from the greater trochanter. The vastus intermedius is then lifted extra periosteally from lateral and anterior surfaces of femur. The vastus medialis is not disturbed as its origin is solely from linea aspera and has an oblique course to patella therefore playing only an accessary role in contractures. If necessary the rectus femoris is released from its iliac origin. Meticulous haemostasis is achieved, suction drains are inserted and only skin is closed.
  • Advantages- controlled and sequential release of components limiting knee flexion If any stage the adequate flexion is obtained , the dissection is stopped. Theoretically reduces the potential for iatrogenic extention lag.
  • Postoperative treatment:- This protocol is same for both type of Quadricepsplasty. The immobilization after surgery is done in about 50 degree less than the maximal flexion obtained at surgery. This is maintained for 2 to 3 days. The extremity is then placed in a continous passive motion machine, and used until 900 of passive flexion achieved. Passive and active exercises for quadriceps and hamstrings are continued Until 900 passive flexion is achieved which is an arc of critical importance to the success of this procedure. The knee is kept in full extension during the night and is exercised during the day with active and active assisted exercises. The Thomas knee splint with Pearsons attachment is useful for these exercises. Hussein Ret al15 described a technique of conservative approach to quadricepsplasty with limited exposure, avoiding transverse incision in the rectus femoris. Through a midline incision, the extensor expansion is exposed. The rectus femoris is separated from the vastus medialis, lateralis, and intermedius to from a strap like structure. Vastus intermedius is separated from patella. If firm, careful manipulation of the knee is unsuccessful, incision are extended distally along both sides of patella and patellar tendon releasing the extensor mechanism from any underlying heterotrophic bone and further manipulation of knee is performed. There were no wound complications and no residual extensor lag in authors’ hand. Wang JH et al16 described an initial extrarticular mini-invasive quadricepsplasty and subsequent intraarticular arthroscopic lysis of adhesions during same anaesthesia session.
  • Arch Orthop Trauma Surg. 1986;104(6):346-51. Continuous passive motion after knee-joint arthrolysis under catheter peridural anesthesia. Ulrich C, Burri C, Wörsdörfer O. The results of arthrolysis of a stiff knee are often poor because postoperative pain prevents the early active mobilization that is so essential. Adequate analgesia may be ensured by the use of continuous anesthesia via a peridural catheter; in combination with continuous passive motion, such analgesia is able to maintain, and often improve, the range of movement obtained at surgery. Twenty-two patients treated in this way showed improvement in the range of movement between 39 degrees and 120 degrees. Patients with post-traumatic knee stiffness achieved an average improvement in the range of movement of 93%, while those with stiffness following infection improved by only 55% on the average. The preoperative loss of movement does not appear to determine the end result; the etiology of the stiffness is more important.
  • J Bone Joint Surg Am. 2007 Mar;89 Suppl 2 Pt.1:93-102. A new treatment strategy for severe arthrofibrosis of the knee. Surgical technique. Wang JH, Zhao JZ, He YH. Department of Orthopaedic Surgery, Shanghai Jiao Tong University Sixth People's Hospital, 600 YiShan Road, Shanghai 200233, People's Republic of China. shwangjianhua@hotmail.com BACKGROUND: To reduce the morbidity of traditional quadricepsplasty for the treatment of severe arthrofibrosis of the knee, we instituted a treatment regimen consisting of an initial extra-articular mini-invasive quadricepsplasty and subsequent intra-articular arthroscopic lysis of adhesions during the same anesthesia session. The purpose of the present study was to determine the results of this technique. METHODS: From 1998 to 2001, twenty-two patients with severely arthrofibrotic knees were managed with this operative technique. The mean age of the patients at the time of the operation was thirty-seven years. After a mean duration of follow-up of forty-four months (minimum, twenty-four months), all patients were evaluated according to the criteria of Judet and The Hospital for Special Surgery knee-rating system. RESULTS: The average maximum degree of flexion increased from 27 degrees preoperatively to 115 degrees at the time of the most recent follow-up (p < 0.001). According to the criteria of Judet, the result was excellent for sixteen knees, good for five, and fair for one. The average Hospital for Special Surgery knee score improved from 74 points preoperatively to 94 points at the time of the most recent follow-up (p < 0.001). A superficial wound infection occurred in one patient. Only one patient had a persistent 15 degrees extension lag. CONCLUSIONS: This mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome.
  • Arthroscopy assisted Quadricepsplasty: Arthroscopically assisted percutaneous quadricepsplasty is described, to reduce the morbidity of traditional Quadricepsplasty . Here an initial extaarticular mininvastive Quadricepsplasty followed by intraarticular arthrocopic lysis of adhesions during the same anesthesia session is performed. Arthroscopic technique for lysis and excision of postoperative adhesion, is combined with a gentle manipulation after the release. Sprague reported a mean gain of flexion of 28 degrees and improvement of extension of 6 degrees after arthroscopic procedures. Arthroscopic methods are more successful in increasing flexion than in increasing extension. The ideal time to perform the operation is with in the first 9 months after injury. The best results were obtained in 7 months. The results detoriated notably after one year. The age of patient does not seem to affect the end result.
  • Acta Orthop Belg. 2005 Apr;71(2):197-203. Extra articular arthroscopic release in post-traumatic stiff knees: a prospective study of endoscopic quadriceps and patellar release. Dhillon MS, Panday AK, Aggarwal S, Nagi ON. Apollo Hospital, Colombo, Sri Lanka. mandyrima@hotmail.com Knee stiffness due to mismanaged trauma is still common in underdeveloped countries. Many patients with distal femoral fractures, patellar injuries or other local trauma present with intra-articular and extra-articular adhesions between the quadriceps and anterior femur. Nineteen knees with post trauma stiffness due to combined intra- and extra- articular aetiology were taken up for arthroscopic aided release after failing an aggressive physiotherapy protocol. Ultrasound was used to identify the extra-articular adhesions. The intra-articular part of the release was done by a standard protocol involving the release of all infrapatellar, suprapatellar and gutter adhesions, and then the extra-articular proximal adhesions were released by using special long periosteal elevators and arthroscopic scissors. We were able to release the adhesions as high as 9 inches above the patella, and in one case bony ankylosis between the patella and the femur was arthroscopically osteotomised (after 11 years of stiffness). Delay before surgery averaged 2.7 years (6 months-11.3 years). Mean active flexion at one year follow-up improved from 27.3 degrees to 119.3 degrees (average increase: 92 degrees). Mean preoperative extension lag reduced from 6 degrees to 1 degrees postoperatively. No CPM machine was available, and patients had to undergo daily manual and assisted therapy, with appropriate analgesia. Overall patient satisfaction was excellent; one patient developed a supracondylar fracture (infected old fracture with bone loss and severe contracture) and was retrospectively a wrong case selection. Arthroscopic aided quadriceps adhesion release is a good option in cases of neglected trauma; results are excellent even without sophisticated CPM machines, and the periosteal elevators needed are cheap and indigenous.
  • Arthroscopy. 1993;9(6):685-90. Stiffness of the knee--mixed arthroscopic and subcutaneous technique: results of 67 cases. Achalandabaso J, Albillos J. Servicio de Artroscopia, Policlinica Guipuzcoa, San Sebastian, Spain. This study is an analysis of the treatment for mixed-cause stiffness of the knee: intraarticular and extraarticular. We examined 67 patients. The cause of stiffness was mostly ligamentous surgery, found in 51 cases (76%). Preoperative range of motion was 11 degrees extension and 89 degrees flexion. In 14 cases extension was complete. In the remaining 53 cases, extension was limited. Results achieved with arthroscopic arthrolysis were generally excellent. The ideal time to perform the operation is within the first 9 months after injury. The best results were obtained in the 7th month. Results deteriorate notably after 1 year. The age of the patient does not seem to affect the end result.
  • Am J Sports Med. 1987 Jul-Aug;15(4):331-41. Infrapatellar contracture syndrome. An unrecognized cause of knee stiffness with patella entrapment and patella infera. Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbott P. Salt Lake City Knee and Sports Medicine Foundation, Utah 84103. Infrapatellar Contracture Syndrome (IPCS) is an infrequently recognized cause of posttraumatic knee morbidity. Unique to this group of patients is the combination of restricted knee extension and flexion associated with patella entrapment. IPCS can occur primarily as an exaggerated pathologic fibrous hyperplasia of the anterior soft tissues of the knee beyond that associated with normal healing. It can also occur secondarily to prolonged immobility and lack of extension associated with knee surgery, particularly intraarticular ACL reconstruction. IPCS follows a predictable natural history which is divided into three stages. Symptoms, diagnostic findings, and recommended treatment are determined by the stage at presentation. Once beyond its early presentation, IPCS is best treated by an anterior intraarticular and extraarticular capsular debridement and release, followed by extensive rehabilitation. The authors review 28 consecutive cases of IPCS. At followup 3 months to 4 years postoperation, the patients had averaged 2.3 additional surgical procedures following their index procedure or injury. The average increase in extension at followup was 12 degrees with the average increase flexion 35 degrees. Eighty percent of patients demonstrated signs and symptoms consistent with patellofemoral arthrosis; 16% of the patients demonstrated patella infera. The authors conclude that prevention or early detection and aggressive treatment are the only ways of avoiding complication in these problem cases.
  • Plast Reconstr Surg. 2007 Jan;119(1):203-10. The advantages of free tissue transfer in the treatment of posttraumatic stiff knee. Ulusal AE, Ulusal BG, Lin YT, Lin CH. Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan. BACKGROUND: Open fractures of the distal femur involving the joint, surrounding ligament, and soft tissues are among the worst types of injuries that may eventually lead to stiff knee. Release procedures have been described as the common treatment option for posttraumatic stiff knee. However, the importance of simultaneously applied free flaps to replace the pliable soft tissue around the knee joint has not been discussed previously. METHODS: Between 1996 and 2002, nine patients with posttraumatic severe stiff knees were operated on. All patients underwent release procedures, such as scar removal, quadricepsplasty, tendon lengthening, and/or capsulotomy. In addition, free tissue transfers were performed at the same stage as the release procedures to cover the resultant soft-tissue defects or carried out at a secondary stage because of wound-healing problems. The mean follow-up period was 38 months. RESULTS: Complete flap survival was 100 percent. There were no infection or wound-healing problems following free tissue transfer. After satisfactory rehabilitation, acceptable range of motion was regained. CONCLUSION: Surgical reconstruction of the posttraumatic stiff knee becomes more straightforward with the use of free flaps to cover soft-tissue defects, providing remarkable advantages for postoperative rehabilitation.
  • J Pediatr Orthop B. 2005 May;14(3):219-24. Quadricepsplasty in arthrogryposis (amyoplasia): long-term follow-up. Fucs PM, Svartman C, de Assumpção RM, Lima Verde SR. Orthopaedic Department, Santa Casa Medical School and Hospitals, Pavilhão 'Fernandinho Simonsen', São Paulo, Brazil. Eight patients with arthrogryposis multiplex congenita (amyoplasia type) (11 knees) with knee hyperextension deformity underwent quadricepsplasty and were analyzed during an average follow-up period of 11 years and 2 months. The results were clinically analyzed based on gait pattern, range of movement, and orthotic requirements. Joint congruency was evaluated by radiography according to the Leveuf Pais classification. A satisfactory result was the correction of the deformity, articular congruency, sufficient range of movement, adequate gait pattern and no need for orthosis. A satisfactory outcome occurred in five of the eight patients (eight knees). We considered an unsatisfactory result when any of these conditions occurred. Our experience demonstrated that the quadricepsplasty corrected the hyperextension deformity of the knee joint, improved function, gait pattern, and maintained the muscle power of the quadriceps.
  • Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 1999 Nov;13(6):355-8. [Application of sartorius muscle in the quadricepsplasty] [Article in Chinese] Chen QS, Zhu LX, Chen X. Department of Orthopedic Surgery, Zhujiang Hospital, First Military Medical University, Guangzhou, Guangdong, P. R. China, 510282. OBJECTIVE: Extension stiffness of knee joint is always treated by the quadricepsplasty, but the main deficiency of this method is that patient feels weakness of lower limb and easily kneels down. The aim of this article is to explore the method to resolve the complications after quadricepsplasty. METHODS: Since 1978 to 1997, on the basis of traditional procedures of quadricepsplasty, sartorius muscle was used to reinforce the extension of knee joint. The lower 2/3 of sartorius muscle was fully dissociated only with its insertion intact. A tendon-periosteal-bone flap, about 2 cm in width, was managed on the anterior surface of patella, with its pedicle on the medial edge of patella. The tendon-periosteal-bone flap was used to fix the dissociated sartorious into patella to reinforce the extension of knee joint. The very lower part of sartorius was mainly aponeurosis, with the help of an aponeurosis bundle of iliotibial tract, it was fixed into the insertion of patellar ligament, through a bony tunnel chiseled adjacent to the insertion of patellar ligament. By now the movement of knee joint extension was strengthened by the transferred sartorius muscle. Postoperatively, every patient was required to extend and flex knee joint actively and/or passively. Altogether 12 patients were treated, 9 of them were followed up with an average of 14 months. RESULTS: The average movement was increased from 15 degrees to 102 degrees, and the average myodynamia was improved from grade II to grade IV. CONCLUSION: Traditional quadricepsplasty co-operated with transfer of sartorius muscle can strengthen the myodynamia of knee joint extension. It is simple method and can really achieve good function.
  • Arthroscopy. 2001 May;17(5):504-9. Endoscopic quadricepsplasty: A new surgical technique. Blanco CE, Leon HO, Guthrie TB. Orthopaedic Division, Hospital Hermanos Ameijeiras, Havana, Cuba. We present a new surgical subperiosteal endoscopic technique for the release of fibrosis of the quadriceps to the femur caused by gunshot injuries, postsurgical scarring, and fractures, that was developed at the Arthroscopy Group at Hospital Hermanos Ameijeiras in Havana, Cuba. The technique used is a proximal endoscopic subperiosteal extension of the usual arthroscopic intra-articular release of adhesions, using periosteal elevators and arthroscopic scissors placed through medial and lateral superior knee portals to release adhesions and bands of scar tissue beneath the quadriceps mechanism. The technique was used in a prospective case series of 26 male patients aged 19 to 22 years between February 1997 and March 1998 who presented with clinically and ultrasonically documented extra-articular fibrosis resulting in ankylosis of the knee in extension. Only patients who had reached a plateau in their aggressive physiotherapy program with no further progression in knee flexion for 3 months were selected. Those with joint instability, motion-limiting articular surface pathology, and muscle or neurologic injury were excluded. All patients had obtained satisfactory results at 2-year follow-up. The extra-articular release gained at final follow-up was between 30 degrees and 90 degrees of flexion in addition to that obtained at the completion of the standard intra-articular release. Complications included 1 case of deep vein thrombosis, 2 cases of scrotal edema, 5 cases of hemarthrosis, and 2 cases of reflex sympathetic dystrophy. We have found this technique useful in obtaining additional flexion and improved function in a difficult class of patients with ankylosis caused by extra-articular fibrosis of the quadriceps to the femur, allowing immediate aggressive rehabilitation and presenting a useful outpatient alternative with fewer and less severe complications than described with the classic open Thompson's quadricepsplasty.
  • Mil Med. 2000 Apr;165(4):263-7. Quadricepsplasty after war fractures. Jovanović S, Orlić D, Wertheimer B, Zelić Z, Has B. Department of Orthopedic Surgery, Osijek University Hospital, Croatia. sjovanov@vukovar.mefos.hr Knee movements after fractures caused by explosive devices, as well as after intra-articular fractures of the knee, are often inadequate. This paper presents the results of quadriceps-plasty performed in 10 patients with the purpose of improving knee function. All of the patients were treated by the external fixation method, either after femoral fractures caused by explosive devices or for intra-articular knee fractures. All of them manifested markedly decreased knee flexion (15-70 degrees, with an average of 32 degrees). After quadricepsplasty and physical therapy, the achieved knee flexion was enough for normal walking (80-130 degrees, average 97.5 degrees). Mean knee mobility was increased 65.5 degrees. Our paper presents indications, methods, results, and complications for quadricepsplasty performed after war injuries.
  • Arthroscopy. 1998 Mar;14(2):212-4. Arthroscopically assisted percutaneous quadricepsplasty: a case report and description of a new technique. Steinfeld R, Torchia ME. Department of Orthopedic Surgery, The Mayo Clinic, Rochester, Minnesota 55905, USA. Restricted motion of the knee occurs frequently after an intra-articular fracture of the distal femur. Treatment of this complication typically requires open release of the quadriceps muscle. To our knowledge an arthroscopically assisted method of performing a quadricepsplasty has not been previously described. We present such a case and the details of the arthroscopically assisted method that may provide an alternative, minimally invasive means of restoring knee flexion in the setting of a post-traumatic extension contracture.
  • Acta Orthop Belg. 1996 Jun;62(2):79-82. The Judet quadricepsplasty: a retrospective analysis of 16 cases. Bellemans J, Steenwerckx A, Brabants K, Victor J, Lammens J, Fabry G. Department of Orthopedic Surgery, University Hospital Pellenberg, K.U. Leuven, Belgium. Sixteen quadricepsplasties performed for severe extension contractures of the knee were reviewed. Preoperatively all cases showed a severe extension contracture with an average of 23 degrees flexion. Only two patients had more than 30 degrees flexion preoperatively. The average improvement in knee flexion at follow-up was 69 degrees with 11 (68.7%) patients achieving a final flexion of 90 degrees or more. In four cases there was a 15 degrees loss of terminal active extension. In one case a rapid recurrence of the contracture was seen during the initial postoperative weeks. One patient developed a deep infection, and another an acute compartment syndrome.
  • Z Orthop Ihre Grenzgeb. 1982 May-Jun;120(3):250-8. [Results of knee joint arthrolysis surgery (author's transl)] [Article in German] Blauth W, Hassenpflug J. This work reports the results of operative treatment of knee-stiffness from 1973-1981 in the Department of Orthopaedic Surgery, University Kiel. 42 out of 46 occurrences of age, were post-operatively controlled. In most cases the stiffness was of traumatic origin. In more than one half of the cases the pre-operative controlled. In most cases the stiffness was of traumatic origin. In more than half of the cases the pre-operative degree of motion was less than 60 degrees. Intraarticular revision alone or extraarticular revision alone or a combination of both and other bone surgery was performed in approximately 1/4 of the patients respectively. The absolute range of motion, an average of 58 degrees pre-operatively, improved to 114 degrees post-operatively. The mean relative improvement of motion, in regard to a norm of 140-0-0 degrees, was 68% at discharge. Among our patients complication were seldom. In our opinion operative arthrolysis in indicated cases is a tried and proven method for treatment of stiff knees.
  • West Indian Med J. 2005 Sep;54(4):238-41. Judet quadricepsplasty for extension contracture of the knee. Rose RE. Division of Orthopaedics, Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies, Kingston, Jamaica. recrose@hotmail.com Extension contracture of the knee is a well known complication of severe femoral fractures, especially in the supracondylar region. Traditional management by the Thompson quadricepsplasty may result in a variable return of knee flexion and the possibility of significant extension lag. The Judet technique of quadricepsplasty offers the advantages of a controlled, sequential release of the intrinsic and then the extrinsic components limiting knee flexion and a reduced potential for iatrogenic quadriceps rupture or extension lag. The modified Judet quadricepsplasty has definite advantages over the Judet technique since it usually involves less soft tissue dissection and consequently less blood loss.
  • Clin Orthop Relat Res. 2003 Oct;(415):214-20. Judet's quadricepsplasty, surgical technique, and results in limb reconstruction. Ali AM, Villafuerte J, Hashmi M, Saleh M. Academic Unit of Orthopedic and Traumatic Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom. amili@rcsed.ac.uk Quadricepsplasty has been described by Thompson and Judet to improve flexion in severely ankylosed knees. Judet's technique has potential advantages because it is less damaging to the quadriceps mechanism and addresses the problem of external fixator pin site tethering on the lateral side of the thigh. The outcome of Judet's quadricepsplasty was assessed in 10 consecutive patients who were treated with external fixation either as a primary treatment (three patients) or as a secondary treatment for nonunion or malunion (seven patients) in a limb reconstruction unit. The patients were reviewed and examined at a minimal followup of 20 months. Their average prequadricepsplasty flexion of 33 degrees was improved to 105 degrees in the operating room and to 88 degrees on final review after an average followup of 24 months. According to Judet's criteria, there were one fair, seven good, and two excellent results. Two patients had postoperative complications, one hematoma and one infection. A minimal extension lag (10 degrees ) developed in one patient. Judet quadricepsplasty successfully increases flexion range with minimum impairment of quadriceps function. Familiarity with this technique might lower the surgeon's threshold for considering quadricepsplasty in patients with severe knee ankylosis after severe femoral fractures and in particular after a prolonged period of external fixation.
  • Surgical Procedure:- An arthroscopic sheath and blunt trocar are inserted through standard anteromedial and anterolateral portals. The blunt trocar is carefully passed beneath the patella and suprapatellar pouch. The trocar is used to bluntly disrupt any adhesion in suprapatellar pouch and in both medial and lateral gutters. If adhesions are dense, patellofemoral joint usually is spared. The debridement is started in peripatellar region and extended outwards. Once the suprapatellar pouch has been restored, an inflow canula is inserted through a superior portal. The dissection is continued down into the medial and lateral gutters and compartments and finally into the intercondylar area. Occasionally proliferation of fibrous tissue is present within the intercondylar notch and anterior regions; this should be removed because it may limit the extension. Some investigators recommended a lateral retinacular release as part of the procedure if patellar mobility is restricted after the arthroscopic release. After the systemic lysis of adhesions, a gentle manipulation is performed. A bulky compressive dressing is applied. It is helpful to perform this procedure with the patient under a continuous epidural anesthesia, which is maintained for 2 to 3 days after surgery. The patient is placed on a continuous passive motion immediately after surgery. The suction drain is removed after 2 days
  • Fibrosis of vastus intermedius muscle, scarring down to the rectus femoris to the femur in suprapatellar pouch and proximally. Adhesions between the patella and the femoral condyles. Fibrosis and shortening of lateral expansions of vasti and their adherence to the femoral condyles. Actual shortening of rectus femoris muscle.
  • J Knee Surg. 2008 Jan;21(1):39-42. A conservative approach to quadricepsplasty: description of a modified surgical technique and a report of three cases. Hussein R, Miles J, Garlick N, Dowd GS. Royal Free Hospital, London, United Kingdom. ramihussein2@aol.com Various techniques have been described for the treatment of soft tissue extension contracture of the knee. Some involve large exposures, and others can result in a permanent extensor lag. We describe a technique with limited exposure, avoiding transverse incisions in the rectus femoris. Through a midline incision, the extensor expansion is exposed. The rectus femoris is separated from the vastus medialis, lateralis, and intermedius to form a strap-like structure. Vastus intermedius is separated from the patella. If firm, careful manipulation of the knee is unsuccessful, the incisions are extended distally along both sides of the patella and patellar tendon, releasing the extensor mechanism from any underlying heterotopic bone, and further manipulation of the knee is performed. Postoperatively, a rehabilitation program is begun. A good outcome following this technique is described in 3 knees presenting with severe restriction of knee flexion. There were no wound complications and no residual extensor lag.

Knee stiffness dr anil k jain Knee stiffness dr anil k jain Presentation Transcript

  • Dr Anil Jain MS, FRCS Professor of OrthopaedicsUniversity College of Medical Sciences, Delhi & Editor Indian Journal of Orthopaedics
  • Definition extention contracture of the knee due to extrarticular, intraarticular or combined pathology. Clinically it is often difficult to differntiate between predominantly intraarticular or extraarticular component Extrarticular pathology -due to quadriceps scarring, the affected knee has some degree of flexion possible when the hip is flexed and roentgenograms reveal an apparently normal joint space
  • Anatomy of knee stiffness Between full flexion to full extension- patella travels -9 cms (3.5 inches) This is the excursion of RF 4 ways to block flexion All prevent distal excursion of patella during flexion
  • Causes of blocking Fibrosis of VI – ties deep surface of RF to the front of femur in suprapatellar pouch and above. Adhesions of deep surface of patella to the femoral condyle Fibrosis and shortening of lateral expansion of vasti and their adherence to lateral aspect of femoral condyle. Actual shortening of RF
  •  Clinically difficult to differntiate---- predominantly intraarticular or extraarticular component. Only extrarticular due to quadriceps scarring, knee has some degree of flexion possible when the hip is flexed roentgenograms even may reveal an apparently normal joint space.
  • Causes  most commonly after fracture of thigh  intraarticular fracture of the distal femur.  Other causes of knee contracture –  Post total knee arthroplasty  Immobilization of knee for a period of 8 weeks or more,  Arthogryposis;  Cerebral palsy,  Poliomyelitis,  Spina bifida,  Haemophilia
  • Post traumatic knee stiffness Femoral shaft fracture – NU,DU, normal union Fracture femoral condyle Fracture dislocation of knee Fracture of tibial plateau Contracture of knee may occur with the knee in complete extension, in flexion alone, or in flexion, external rotation, and valgus position,
  • Knee contrcture in extension commonly occurs ----- fracture of femur or extensive soft tissue damage of anterior aspect of thigh, scarring or fibrosis of all or part of the quadriceps mechanism, chronic osteomyelitis of femur/sequale of septic arthritis of knee. following total knee replacement,
  • Some issues -Indications Which knee to be operated- Any pt with total range of 70 degree will be happy This 70 degree in functional arc ( 20-90) would be better than 50-120 Career specific range
  • Some issues–when to intervene Sufficient time has elapsed from initial event and no further improvement is occuring with physiotherapy And Will not improve without operation.
  • Some issues- expectations If a pt gains 0-90 degree – it is a good outcome of surgery Predictors of outcome- Preoperative ROM Intraoperative gains in ROM Good postoperative mobilization programme.
  • Treatment  Prevention – mobilize knee early  Stiff knee – no improvement by physical therapy  surgery indicated.  Various techniques ----  gentle manipulation under anaesthesia,  quadricepsplasty,  quadricepsplasty by limited approach,  quadricepsplasty with mini-incision and arthroscopic.
  • Manipulation contraindicated if any pathologic process- an inflammed joint following early injury or operation Caution- severe osteoporosis sudden, vigorous manipulation may lead to fractures around knee. successful manipulation - if the patella is relatively mobile, no fibrosis in suprapatellar region the resistance is elastic. does not work in an old contracture.
  • Manipulation Manipulation useful following total knee replacement. under GA with full muscle relaxation. No Undue force can feel adhesion separating and ROM improving. Post manipulation ------- the knee in fully flexed position. Ice –bags Immediate supervised active exercises .
  • Quadriceplasty:  a surgical procedure to the quadriceps muscle  Thompson  Judet.  success depends on;  If rectus femoris muscle has escaped injury.  How well the rectus femoris muscle can be isolated from the scarred parts of the quadriceps mechanism.  How well the muscle can be developed by active use. Success on post surgery PT
  • Thompson quadriceplasty: Thompson (1944). RF freed completely from rest of the quadriceps vastus intermedius - if scarred - excise aponeurotic expansion of other vasti are divided on either side of patella.
  • Surgical procedure Incision- anterior incision from proximal one third thigh to patella . Exact location depends on position of scars. The medial and lateral para patellar two incisions approach by Hahn et al. The deep fascia is divided in line with skin incision.
  • Surgical procedure:- rectus femoris muscle separated to full extent separated from VM and VL. anterior capsule of knee joint including the lateral expansions of vasti on both side of patella are divided far enough to overcome their contracture. vastus intermedius is completely excised, rectus femoris if destroyed - creat a new from ant. scar
  • Surgical procedure:- knee is slowly flexed to 110 degree remaining intrarticular adhesions are released. If the flexion still does not improve RF tendon is to be lengthened should be avoided as best as possible Subcutaneous tissue and fat is interposed between VM ,VL and rectus. If these muscles are relatively normal, these are sutured to rectus as far distally as the distal third of thigh.
  • Key issues Not to use tourniquet If used achieve satisfactory hemostasis Hematoma delays the progress Aftercare ---- Put knee on pearson knee attachment – that will allow gravity assisted flexion and passive extention Or CPM More vigrous physiotherapy will give better outcome. May require manipulation
  • Problems and obstacles Scar problem – delays recovery –incision Infection ???? Extention lag – most common complication, 10 deg in 67% cases – Moore et.al. ( J trauma 1987) 18 deg in 33% cases – Pick RY . ( Clin Ortho 1976) Usually 20 degree or more in immediate post op period Regains in one year – if RF is intact If RF damaged – than may have extention lag.
  • Thompson quadricepsplasty Result – variable amount of return of knee flexion Extensor lag has been reported to be as high as 67%. affect the stability of the knee some patients may require continuous bracing. extensor lag more if flexion attained on the operation table 90-100 degrees.
  • Chang Gung Med J. 2007 May-Jun;30(3):263-9. ModifiedThompson quadricepsplasty to treat extension contracture of theknee after surgical treatment of patellar fractures. Huang YC,  N- 28  extension contractures , surgical treatment of patellar fractures  FU = 2 years  arc of motion improved from 72 degrees to 123 degrees (p < 0.001).  no significant surgical complications.  CONCLUSION: This surgical technique has a high success rate with few complications.
  • J Bone Joint Surg Br. 2000 Sep;82(7):992-5. A modifiedThompson quadricepsplasty for the stiff knee. Hahn SB  1987 -1997  modified Thompson quadricepsplasty  N = 20 stiff knees  mean FU of 35 months (24 to 52).  mean active flexion was 113.5 degrees (75 to 150).  mean final gain in movement was 67.6 degrees (5 to 105).  deep infection - 1  The modified Thompson quadricepsplasty with appropriate postoperative care can give good results.
  • Modified quadricepsplasty Skin incision – medial and lateral parapatellar incision and anterolateral incision Step wise release – first medial and lateral retinaculae and adhesion in suprapatellar, femoral condyle and intraarticular If no adequate gain in ROM Anterolateral or lateral incision to release adhesion around quadriceps muscles.
  • The Judet Quadricepsplasty: Judet (1959) technique using principal of muscle disinsertion and sliding minimises damage to quadriceps mechanism Advantages - a controlled, sequential release of the intrinsic and then the extrinsic components which are limiting the knee flexion It reduces potential for iatrogenic quadriceps rupture or extension lag.
  • Surgical Procedure:- two incisions: short medial parapatellar incision The medial retinaculum suprapatellar pouch and intra articular adhesions are released through this incision. The suprapatellar pouch is mobilized. long lateral incision
  • Surgical Procedure:- Patella and lateral retinacular tissues are freed ensuring that patella may be easily lifted off the femoral candyles. The vastus lateralis is completely released from the linea aspera and from the greater trochanter. The vastus intermedius lifted extra periosteally from lateral and anterior surfaces of femur. The vastus medialis is not disturbed If necessary the rectus femoris is released from its iliac origin. Meticulous haemostasis is achieved, suction drains are inserted and only skin is closed.
  •  Advantages- controlled and sequential release of components limiting knee flexion Theoretically reduces the potential for iatrogenic extention lag.
  •  West Indian Med J. 2005 Sep;54(4):238-41. Judet quadricepsplasty for extension contracture of the knee. Rose RE. Knee. 2006 Aug;13(4):280-3. Epub 2006 May 2. Modified Judets quadricepsplasty for loss of knee flexion. Alici T et.al. Clin Orthop Relat Res. 2003 Oct;(415):214-20. Judets quadricepsplasty, surgical technique, and results in limb reconstruction. Ali AM et.al. mean pre-operative knee flexion - 30 degrees final follow-up to 100 degrees Advantage – no iatrogenic quadriceps rupture or extension lag involves less soft tissue dissection less blood loss.
  • Postoperative treatment same for both Quadricepsplasty. immobilization after surgery -50 degree less than the maximal flexion obtained at surgery. maintained for 2 to 3 days CPM until 90deg of passive flexion achieved. The Thomas knee splint with Pearsons attachment is useful Passive and active exercises for quadriceps and hamstrings is exercised during the day with active and active assisted exercises.
  •  Arch Orthop Trauma Surg. 1986;104(6):346-51. Continuous passive motion after knee-joint arthrolysis under catheter peridural anesthesia. Ulrich C, Burri C, Wörsdörfer O. Adequate analgesia by continuous anesthesia via a peridural catheter; in combination with continuous passive motion, N=22 improvement ROM - 39 degrees to 120 degrees. Gain depends – not on severity of contracture but on -- etiology of the stiffness is more important.
  • JOT -201010 pts of metaphyseal fractures over 7 yrs periodStep one – removal of intraarticular obstaclesStep two - removal of extraarticular obstacleStep three- gradual distraction by ilizarov fixator
  • Step 2 – release extraarticular Obstacles VM,VI and VL releasedStep 1- removeintraarticular obstaclesBy lateral or medialincisions
  • Distract the jointThan achieve flexionObviates the disadvantagesExtensor lagWound problemRebound phenomennon of ilizarov
  • J Bone Joint Surg Am. 2007 Mar;89 Suppl 2 Pt.1:93-102. A newtreatment strategy for severe arthrofibrosis of the knee.Surgical technique. Wang JH, Zhao JZ, He YH. extra-articular mini-invasive quadricepsplasty and subsequent intra- articular arthroscopic lysis of adhesions 1998 to 2001, N=22 severely arthrofibrotic knees. The mean age - 37 years. mean duration of follow-up 44 mos RESULTS: flexion increased from 27 degrees to 115 degrees excellent (16) , good (5), and fair (1). superficial wound infection - one. persistent 15 degrees extension lag in one. CONCLUSIONS: This mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome.
  • •First stage – release of lateralpatellar retinaculae•Percutaneous parapatellarlateral arthrotomy•Release lateral retinaculaefromlateral condyle of femur•VL and ilio tibial band freed• from distal femur
  • Stage two - mobilize suprapatellar pouch ,PF compartment, anterior intervali.e. posterior to infrapatellar fat pad andanterior superior part of tibial plateau
  • Stage three- medial parapatellarrelease – med patellar retinaculae, PFand anterior interval
  •  Fourth stage – transect VI at musculo-tendinous junction fifth stage – lengthening of quadriceps tendon Usually 90 degrees are gained But gives enough space for arthroscopic intraarticular release
  • Keep on manipulating in between the procedureClosed suction drainPost op management-IV mannitolCompressive dressingPhysical therapy
  • Arthroscopy assisted Quadricepsplasty: to reduce the morbidity of traditional Quadricepsplasty . initial extaarticular mini invasive Quadricepsplasty followed by intraarticular arthrocopic lysis of adhesions a gentle manipulation after the release. Sprague - mean gain of flexion of 28 degrees and improvement of extension of 6 degrees after arthroscopic procedures. Arthroscopic methods are more successful in increasing flexion than in increasing extension. ideal time to perform the operation is with in the first 9 months after injury. The best results were obtained in 7 months. The results detoriated notably after one year. The age of the patient does not affect the end result.
  • N=19post trauma stiffness combined intra- and extra- articular aetiology release- infrapatellar, suprapatellar and gutter adhesions, extra-articular proximal adhesionsMean active flexion ( 1 Yr FU) 27.3 degrees to 119.3 degreesMean extension lag from 6 degrees to 1 degreesNo CPM daily PTOverall patient satisfaction was excellent;Arthroscopic aided quadriceps adhesion release is a good option
  • Arthroscopy. 1993;9(6):685-90. Stiffness of theknee--mixed arthroscopic and subcutaneoustechnique: results of 67 cases. . mixed-cause stiffness of the knee: intraarticular and extraarticular. N= 67 cause of stiffness - mostly ligamentous surgery, (76%). Preoperative ROM - 11 deg ex and 89 deg flex. arthroscopic arthrolysis Outcome generally excellent.
  • Conclusions  Causes  Manipulation  Quadricepsplasty  Post surgery protocols  Arthroscopy assisted or minimally invasive procedures
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  • Am J Sports Med. 1987 Jul-Aug;15(4):331-41.Infrapatellar contracture syndrome. infrequently recognized cause of posttraumatic knee morbidity. combination of restricted knee extension and flexion associated with patella entrapment. occur primarily as an exaggerated pathologic fibrous hyperplasia of the anterior soft tissues of the knee beyond that associated with normal healing. secondarily to prolonged immobility and lack of extension associated with knee surgery, particularly intraarticular ACL reconstruction. IPCS follows a predictable natural history which is divided into three stages. Symptoms, diagnostic findings, and recommended treatment are determined by the stage at presentation. best treated by an anterior intraarticular and extraarticular capsular debridement and release, followed by extensive rehabilitation. 28 consecutive cases . At followup 3 months to 4 years postoperation, the patients had averaged 2.3 additional surgical procedures following their index procedure or injury. The average increase in extension at followup was 12 degrees with the average increase flexion 35 degrees. Eighty percent of patients demonstrated signs and symptoms consistent with patellofemoral arthrosis; 16% of the patients demonstrated patella infera. prevention or early detection and aggressive treatment are the only ways of avoiding complication in these problem cases.
  • Plast Reconstr Surg. 2007 Jan;119(1):203-10. The advantages offree tissue transfer in the treatment of posttraumatic stiff knee.Ulusal AE, et.al Open fractures of the distal femur involving the joint, surrounding ligament, and soft tissues are among the worst types of injuries that may eventually lead to stiff knee. Release procedures + simultaneously applied free flaps N- 9 with posttraumatic severe stiff knees All patients underwent release procedures, In addition, free tissue transfers were performed at the same stage as the release procedures to cover the resultant soft-tissue defects or carried out at a secondary stage because of wound-healing problems. The mean follow-up period was 38 months. RESULTS: Complete flap survival was 100 percent. no infection or wound-healing problems CONCLUSION: Surgical reconstruction with the use of free flaps to cover soft-tissue defects, providing remarkable advantages for postoperative rehabilitation.
  •  J Pediatr Orthop B. 2005 May;14(3):219-24. Quadricepsplasty in arthrogryposis (amyoplasia): long-term follow-up. Fucs PM, Svartman C, de Assumpção RM, Lima Verde SR. Orthopaedic Department, Santa Casa Medical School and Hospitals, Pavilhão Fernandinho Simonsen, São Paulo, Brazil. Eight patients with arthrogryposis multiplex congenita (amyoplasia type) (11 knees) with knee hyperextension deformity underwent quadricepsplasty and were analyzed during an average follow-up period of 11 years and 2 months. The results were clinically analyzed based on gait pattern, range of movement, and orthotic requirements. Joint congruency was evaluated by radiography according to the Leveuf Pais classification. A satisfactory result was the correction of the deformity, articular congruency, sufficient range of movement, adequate gait pattern and no need for orthosis. A satisfactory outcome occurred in five of the eight patients (eight knees). We considered an unsatisfactory result when any of these conditions occurred. Our experience demonstrated that the quadricepsplasty corrected the hyperextension deformity of the knee joint, improved function, gait pattern, and maintained the muscle power of the quadriceps.
  • J Pediatr Orthop B. 2004 Jul;13(4):254-8. Treatment ofsevere iatrogenic quadriceps retraction in children. severe iatrogenic infantile quadriceps retraction two different surgical techniques of quadricepsplasty: Judet technique other based on Thompson techniques. N= 76 FU 3 years - maximal knee flexion average of -3 to 81 degree in the first group 37 to 115 degree in the second group. The most frequent complications - skin necrosis after the Judet quadricepsplasty and active extension lag after the Thompson procedure.
  • J Bone Joint Surg Br. 2003 Mar;85(2):261-4. Quadricepsplastyfor knee stiffness after femoral lengthening in congenital shortfemur. N- 5 children stiffness of the knee after femoral lengthening for congenital short femur using an Ilizarov external fixator Unifocal lengthening distal metaphysiodiaphyseal region -mean gain of 6.5 cm. mean percentage lengthening was 24%. At the end of one year after removal of the Ilizarov frame and despite intensive physiotherapy all patients had stiffness. Physiotherapy was continued after the quadricepsplasty and, at the latest follow-up (mean 27 months), the mean active flexion was 102 degrees (80 to 130). The gain in movement ranged from 50 degrees to 100 degrees.. Quadricepsplasty is a useful procedure for stiffness of the knee after femoral lengthening which has not responded to physiotherapy.
  •  Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 1999 Nov;13(6):355-8. [Application of sartorius muscle in the quadricepsplasty] [Article in Chinese] Chen QS, Zhu LX, Chen X. Department of Orthopedic Surgery, Zhujiang Hospital, First Military Medical University, Guangzhou, Guangdong, P. R. China, 510282. OBJECTIVE: Extension stiffness of knee joint is always treated by the quadricepsplasty, but the main deficiency of this method is that patient feels weakness of lower limb and easily kneels down. The aim of this article is to explore the method to resolve the complications after quadricepsplasty. METHODS: Since 1978 to 1997, on the basis of traditional procedures of quadricepsplasty, sartorius muscle was used to reinforce the extension of knee joint. The lower 2/3 of sartorius muscle was fully dissociated only with its insertion intact. A tendon-periosteal-bone flap, about 2 cm in width, was managed on the anterior surface of patella, with its pedicle on the medial edge of patella. The tendon-periosteal-bone flap was used to fix the dissociated sartorious into patella to reinforce the extension of knee joint. The very lower part of sartorius was mainly aponeurosis, with the help of an aponeurosis bundle of iliotibial tract, it was fixed into the insertion of patellar ligament, through a bony tunnel chiseled adjacent to the insertion of patellar ligament. By now the movement of knee joint extension was strengthened by the transferred sartorius muscle. Postoperatively, every patient was required to extend and flex knee joint actively and/or passively. Altogether 12 patients were treated, 9 of them were followed up with an average of 14 months. RESULTS: The average movement was increased from 15 degrees to 102 degrees, and the average myodynamia was improved from grade II to grade IV. CONCLUSION: Traditional quadricepsplasty co-operated with transfer of sartorius muscle can strengthen the myodynamia of knee joint extension. It is simple method and can really achieve good function.
  •  Arthroscopy. 2001 May;17(5):504-9. Endoscopic quadricepsplasty: A new surgical technique. Blanco CE, Leon HO, Guthrie TB. Orthopaedic Division, Hospital Hermanos Ameijeiras, Havana, Cuba. We present a new surgical subperiosteal endoscopic technique for the release of fibrosis of the quadriceps to the femur caused by gunshot injuries, postsurgical scarring, and fractures, that was developed at the Arthroscopy Group at Hospital Hermanos Ameijeiras in Havana, Cuba. The technique used is a proximal endoscopic subperiosteal extension of the usual arthroscopic intra- articular release of adhesions, using periosteal elevators and arthroscopic scissors placed through medial and lateral superior knee portals to release adhesions and bands of scar tissue beneath the quadriceps mechanism. The technique was used in a prospective case series of 26 male patients aged 19 to 22 years between February 1997 and March 1998 who presented with clinically and ultrasonically documented extra-articular fibrosis resulting in ankylosis of the knee in extension. Only patients who had reached a plateau in their aggressive physiotherapy program with no further progression in knee flexion for 3 months were selected. Those with joint instability, motion-limiting articular surface pathology, and muscle or neurologic injury were excluded. All patients had obtained satisfactory results at 2-year follow-up. The extra-articular release gained at final follow-up was between 30 degrees and 90 degrees of flexion in addition to that obtained at the completion of the standard intra-articular release. Complications included 1 case of deep vein thrombosis, 2 cases of scrotal edema, 5 cases of hemarthrosis, and 2 cases of reflex sympathetic dystrophy. We have found this technique useful in obtaining additional flexion and improved function in a difficult class of patients with ankylosis caused by extra-articular fibrosis of the quadriceps to the femur, allowing immediate aggressive rehabilitation and presenting a useful outpatient alternative with fewer and less severe complications than described with the classic open Thompsons quadricepsplasty.
  • Mil Med. 2000 Apr;165(4):263-7.Quadricepsplasty after war fractures. fractures by explosive devices, intra-articular fractures of the knee, N=10 . were treated by the external fixation method manifested markedly decreased knee flexion (15-70 degrees, with an average of 32 degrees). After quadricepsplasty and physical therapy, the achieved knee flexion was enough for normal walking (80-130 degrees, average 97.5 degrees). Mean knee mobility was increased 65.5 degrees..
  • Arthroscopy. 1998 Mar;14(2):212-4. Arthroscopically assistedpercutaneous quadricepsplasty: a case report and descriptionof a new technique.  . To our knowledge an arthroscopically assisted method of performing a quadricepsplasty has not been previously described. We present such a case and the details of the arthroscopically assisted method that may provide an alternative, minimally invasive means of restoring knee flexion in the setting of a post-traumatic extension contracture.
  • Acta Orthop Belg. 1996 Jun;62(2):79-82. The Judetquadricepsplasty: a retrospective analysis of 16 cases. severe extension contractures of the knee - 16 Preoperatively = average of 23 degrees flexion. 30 degrees flexion preoperatively = 2. average improvement in knee flexion - 69 deg 11 (68.7%) patients achieving a final flexion of 90 degrees or more. 15 degrees loss of terminal active extension - 4. rapid recurrence of the contracture – 1 a deep infection 1 acute compartment syndrome - 1.
  • Injury. 1993 Feb;24(2):104-8. Quadricepsplasty followingfemoral shaft fractures. 12 quadricepsplasties performed on 10 patients with stiff knees following united femoral shaft fractures . multiple operations and delayed union. The increased range of flexion achieved in this series is higher than in those reported previously.
  •  Z Orthop Ihre Grenzgeb. 1982 May-Jun;120(3):250-8. [Results of knee joint arthrolysis surgery (authors transl)] [Article in German] Blauth W, Hassenpflug J. This work reports the results of operative treatment of knee- stiffness from 1973-1981 in the Department of Orthopaedic Surgery, University Kiel. 42 out of 46 occurrences of age, were post-operatively controlled. In most cases the stiffness was of traumatic origin. In more than one half of the cases the pre-operative controlled. In most cases the stiffness was of traumatic origin. In more than half of the cases the pre-operative degree of motion was less than 60 degrees. Intraarticular revision alone or extraarticular revision alone or a combination of both and other bone surgery was performed in approximately 1/4 of the patients respectively. The absolute range of motion, an average of 58 degrees pre-operatively, improved to 114 degrees post- operatively. The mean relative improvement of motion, in regard to a norm of 140-0-0 degrees, was 68% at discharge. Among our patients complication were seldom. In our opinion operative arthrolysis in indicated cases is a tried and proven method for treatment of stiff knees.
  • Knee contrcture in extension  Adhesions - single common factor .  in synovial cavity, especially is supra patellar pouch,  in capsular and periarticular tissue,  between quadriceps and the femur  and fascia latae and the femur.  Vastus intermedius most commonly affected by fibrosis. Adhesions of rectus femoris/ vastus medialis are rare whole quadriceps mass may be involved.
  • Knee. 2006 Aug;13(4):280-3. Epub 2006 May 2. ModifiedJudets quadricepsplasty for loss of knee flexion. Alici T et.al. N=11 average follow-up of 49 months mean pre-operative knee flexion - 30 degrees final follow-up to 100 degrees extension lag –no . excellent (3) , good ( 7) useful procedure to correct the disabling flexion loss in the knee.
  • West Indian Med J. 2005 Sep;54(4):238-41. Judet quadricepsplastyfor extension contracture of the knee. Rose RE. Thompson quadricepsplasty - variable return of knee flexion and possibility of significant extension lag. Judet quadricepsplasty – controlled, sequential release of the intrinsic and extrinsic components limiting knee flexion reduced potential for iatrogenic quadriceps rupture or extension lag. The modified Judet quadricepsplasty has definite advantages over the Judet technique since it usually involves less soft tissue dissection and consequently less blood loss.
  • Clin Orthop Relat Res. 2003 Oct;(415):214-20. Judetsquadricepsplasty, surgical technique, and results in limbreconstruction. Ali AM et.al. Judets technique - potential advantages less damaging to the quadriceps mechanism addresses external fixator pin site tethering on lateral side n- 10 consecutive patients treated with EF minimal followup of 20 months. flexion of 33 degrees to 105 degrees in OT and to 88 degrees on final . one fair, seven good, and two excellent results. postoperative complications, one hematoma and one infection. extension lag (10 degrees ) developed in one patient. Judet quadricepsplasty successfully increases flexion range with minimum impairment of quadriceps function.
  • Surgical Procedure:- An arthroscopic sheath and blunt trocar are inserted through standard anteromedial and anterolateral portals. The blunt trocar is carefully passed beneath the patella and suprapatellar pouch. The trocar is used to bluntly disrupt any adhesion in suprapatellar pouch and in both medial and lateral gutters. If adhesions are dense, patellofemoral joint usually is spared. The debridement is started in peripatellar region and extended outwards. Once the suprapatellar pouch has been restored, an inflow canula is inserted through a superior portal. The dissection is continued down into the medial and lateral gutters and compartments and finally into the intercondylar area. Occasionally proliferation of fibrous tissue is present within the intercondylar notch and anterior regions; this should be removed because it may limit the extension. Some investigators recommended a lateral retinacular release as part of the procedure if patellar mobility is restricted after the arthroscopic release. After the systemic lysis of adhesions, a gentle manipulation is performed. A bulky compressive dressing is applied. It is helpful to perform this procedure with the patient under a continuous epidural anesthesia, which is maintained for 2 to 3 days after surgery. The patient is placed on a continuous passive motion immediately after surgery. The suction drain is removed after 2 days
  • Knee contrcture in extension Fibrosis of vastus intermedius muscle, scarring down to the rectus femoris to the femur in suprapatellar pouch and proximally. Adhesions between the patella and the femoral condyles. Fibrosis and shortening of lateral expansions of vasti and their adherence to the femoral condyles. Actual shortening of rectus femoris muscle.
  • J Knee Surg. 2008 Jan;21(1):39-42. A conservativeapproach to quadricepsplasty: description of amodified surgical technique and a report of threecases. Hussein R et.al.  Various techniques ,large exposures, a permanent extensor lag.  technique with limited exposure,  principles remain the same