Postoperative or posttraumatic arthrofibrosis of the knee occurs in patients who have had the knee immobilized in extension for a prolonged period1. Many methods have been used to treat the arthrofibrotic knee, including two classical procedures, the Thompson quadricepsplasty and the Judet quadricepsplasty and their modifications2-8. To reduce the high rate of associated complications, such as skin necrosis4, wound dehiscence5, and extension lag2-6, the senior author (J.-Z.Z.) developed a mini-incision operation for the treatment of this problem. The purpose of the present study was to describe the operative technique and to report its results in the treatment of twenty-two consecutive severely arthrofibrotic knees.
Materials and Methods
The present study was reviewed and approved by our institutional review board, and informed consent was obtained from all patients. Twenty-four consecutive patients were managed with this operative technique from September 1998 to October 2001. Two patients were lost to follow-up before the end of this study, leaving twenty-two patients (twenty-two knees) available for analysis.
The study group included sixteen male patients and six female patients who had a mean age of thirty-seven years (range, fourteen to sixty-six years) at the time of the index procedure. The underlying diagnosis associated with the arthrofibrosis was a femoral fracture in ten knees, a tibial plateau fracture in four, a patellar fracture in three, a femoral shaft fracture associated with an ipsilateral patellar fracture in one, a proximal tibial fracture in one, an anterior cruciate ligament avulsion fracture from the tibia in one, and anterior cruciate ligament reconstruction surgery in two (Table I). All patients had had failure of physical therapy and manipulation under anesthesia.
All patients had had a previous operation (Table I). The mean interval between the original operation and the index operation was thirty-five months (range, four to 138 months). The Hospital for Special Surgery knee-rating system9 was used to assess each patient preoperatively and at the time of the final follow-up examination. In addition, the final results of clinical function were assessed according to the criteria of Judet3.
The operative procedure begins with a mini-invasive quadricepsplasty followed by arthroscopic lysis of the arthrofibrotic knee. The quadricepsplasty is sequential, consisting of five stages. The range of flexion is measured after each stage of release, and the quadricepsplasty procedure is terminated when the desired degree of flexion is achieved.
The quadricepsplasty is accomplished through a 2 to 4-cm-long longitudinal incision, extending proximally from a point 3 cm proximal to the superolateral corner of the patella. A blunt curved dissection scissor is the primary instrument used for the procedure.
The first stage consists of a release of the lateral patellar retinaculum. With an inside-out technique, a percutaneous parapatellar lateral arthrotomy is made by incising the lateral retinaculum from the patella along its lateral border, from the superolateral corner of the patella down to the lateral aspect of its lower pole (Fig. 1). In addition, to restore the lateral recess, the lateral retinaculum is freed from the lateral condyle of the femur, and the vastus lateralis tendon and the iliotibial band are freed from the distal one-third of the femur.
The second stage consists of dividing the adhesions within the suprapatellar pouch, the patellofemoral compartment, and the anterior interval. The anterior interval is the region of the knee posterior to the patellar fat pad and anterior to the anterosuperior aspect of the tibial plateau10. The tendinous tissue of the vastus intermedius is separated from that of the rectus femoris and the anterior surface of the femur.
The third stage consists of releasing the medial patellar retinaculum through the suprapatellar pouch, the patellofemoral compartment, and the anterior interval. Care is taken to avoid detaching the vastus medialis from its patellar insertion (Fig. 1). The medial retinaculum is freed from the medial condyle of the femur, and the vastus medialis is freed from the distal one-third of the femur to restore the medial recess.
The fourth stage consists of transecting the vastus intermedius at a level near its musculotendinous junction.
The fifth stage consists of lengthening the quadriceps tendon. The rectus femoris is transected at a lower level than the vastus intermedius, adjacent to its patellar insertion (Fig. 2-A). Gentle manipulation of the knee in flexion is then performed until maximum flexion is achieved. The proximal tendinous end of the vastus intermedius and the distal portion of the rectus femoris tendon are then overlapped and sutured together with the knee in 90° of flexion (Fig. 2-B).
Manipulation in flexion is performed periodically throughout the operation to release intra-articular adhesions, to assess the arc of knee flexion, and to determine if there are remaining extra-articular adhesions. Once flexion of >120° has been achieved, the extra-articular portion of the operative procedure is terminated, closed suction drains are placed, and only the skin is closed.
Following the quadricepsplasty, arthroscopy is performed. The knee joint is thoroughly inspected and as much scar tissue as possible is released. For patients who have impingement of an anterior cruciate ligament graft, a notchplasty is performed. If the anterior cruciate ligament graft has been placed too anteriorly, it is partially or completely excised.
Mannitol (250 mL of a 20% solution every twelve hours) is administered intravenously for seventy-two hours after surgery to decrease edema, and a compressive wrap with elastic bandage is applied from the toe to the thigh.
Physical therapy is started on the first postoperative day. When the quadriceps tendon is lengthened, the rehabilitation program is modified in order to protect the repair of the quadriceps tendon during the first three weeks. A continuous passive motion machine is used as tolerated. The range and speed of motion are increased gradually without exceeding 90° of flexion during the first three weeks after surgery. In the current study, continuous passive motion was used for a mean of seven hours per day (range, four to twelve hours per day). Active-assisted flexion (with the same restriction of 90° of knee flexion) and patellar mobility exercises are done, beginning on the first postoperative day. Additional flexion and quadriceps-strengthening exercises, including active straightleg-raising, isometric quadriceps exercises, resistance exercises, and stationary bicycling, are encouraged from the fourth week to the sixth month after surgery.
The paired-sample t test was used for comparisons between preoperative and final values for knee flexion and knee scores. Statistical analyses were performed with use of the SPSS software package (SPSS for Windows, Release 11.0; SPSS, Chicago, Illinois). The level of significance was set at p < 0.05.
The mean duration of follow-up was forty-four months (range, twenty-four to sixty-three months).
The maximum degree of intraoperative flexion improved from a mean of 27° (range, 5° to 45°) before the incision to a mean of 141° (range, 120° to 150°) at the completion of the procedure, and the maximum intraoperative extension improved from a mean of 0.9° (range, 0° to 10°) before the incision to a mean of 0.45° (range, 0° to 5°) at the completion of the procedure (Table I). At the time of the final follow-up, the average maximum amount of flexion was 115° (range, 75° to 150°), indicating a mean flexion gain of 88° (range, 45° to 125°) (p < 0.001). The average extension was 1.1° (range, 0° to 15°), indicating an average extension loss of 0.2° compared with the value achieved at the time of surgery (Table I).
According to the criteria of Judet3, the result was excellent for sixteen knees (Figs. 3-A and 3-B), good for five, and fair for one. Furthermore, the average knee score according to the system of The Hospital for Special Surgery improved from 74 points (range, 48 to 87 points) preoperatively to 94 points (range, 79 to 100 points) at the time of the latest follow-up examination (mean improvement, 21 points; p < 0.001). Subjectively, all patients but one were fully satisfied with the operative result. The remaining patient (Case 16) was non-compliant with the postoperative treatment regimen; nevertheless, the range of motion improved from 5° of extension to 30° of flexion preoperatively to 5° of extension to 75° of flexion at the time of the final follow-up.
A superficial wound infection occurred in one patient. It was treated successfully with dressing changes and antibiotic therapy. There was no skin necrosis, skin-tearing, or wound dehiscence. All of the sixteen patients in whom the quadriceps tendon was lengthened had an extension lag postoperatively. In fifteen patients, the extension lag resolved between three and six months postoperatively. The remaining patient (Case 18) had a persistent extension lag of 15°; however, it did not interfere with the activities of daily living or work.
Judet3 and Nicoll4 described several elements that can block flexion of the knee, including fibrosis and shortening of the lateral expansions of the vastus medialis and vastus lateralis and their adherence to the femoral condyles, adhesions between the deep surface of the patella and the femoral condyles, fibrosis of the vastus intermedius tying down the deep surface of the rectus femoris muscle to the front of the femur in the suprapatellar pouch and proximally, and shortening of the rectus femoris muscle. In the mini-invasive quadricepsplasty portion of our procedure, all of these elements can be addressed.
Many operative techniques of quadricepsplasty have been described for the treatment of restricted knee flexion2-8. These operations often require a large incision in the anterior or lateral aspect of the thigh, involve an extensive approach, and produce a profound inflammatory response resulting in postoperative extremity edema and severe pain during the early postoperative period. In a normal knee, the skin envelope expands during flexion. In patients with arthrofibrosis of the knee, the skin envelope is deprived of flexion stimulation and becomes contracted. Ali et al.11 noted that when the skin is closed following a Judet quadricepsplasty, the maximum range of flexion that had been achieved is reduced by about 20°, hence compromising postoperative rehabilitation. Moreover, the intensive postoperative extremity edema along with a profound inflammatory response will aggravate this condition.
In the present series, the mini-invasive quadricepsplasty procedure was not compromised by those troublesome problems. We believe that our technique does not invoke an intensive postoperative inflammatory response. The short incision is made proximal to the main tension area of the knee in flexion and extends proximally, thereby facilitating early postoperative rehabilitation.
In the present series, there were no wound-healing problems or episodes of skin necrosis except for one superficial wound infection. The average gain in the maximum amount of knee flexion was 88°, which we believe compares favorably with the findings associated with traditional open methods of quadricepsplasty4-8 and solely arthroscopic methods12-15.
The Thompson quadricepsplasty2 and its modification8 involve stripping the rectus femoris entirely off the vastus muscles, releasing the vastus medialis and vastus lateralis from their patellar insertion, and lengthening the rectus femoris when necessary. These procedures may result in substantial weakness of the extension mechanism and an extension lag4,8. Extension lag following quadricepsplasty has been widely reported in the literature2-6,8. In comparison, favorable results were achieved in our series, with only one of twenty-two knees having a persistent extension lag of 15°. We believe that these favorable results may be related to several factors, including preservation of the patellar insertion of the vastus medialis, the lengthening of the rectus femoris in order to produce more effective extension, less disturbance of quadriceps muscle function by the mini-invasive approach, and an intensive postoperative rehabilitation program to restore quadriceps function.
In conclusion, we believe that our new technique for the treatment of the severely arthrofibrotic knee addresses the major intra-articular and extra-articular elements that limit knee flexion and has the advantages of low morbidity and ease of application. It provides an alternative mini-invasive approach to the difficult problem of severe arthrofibrosis. ▪
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Shanghai Jiao Tong University Sixth People's Hospital, Shanghai, People's Republic of China
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