Eight of 10 patients achieved a satisfactory range of flexion intraoperatively after the first and second stages of the procedure. The remaining two patients required a third stage by releasing the origin of the vastus lateralis and rectus femoris to achieve satisfactory flexion.
The average preoperative knee flexion of 33° (range, 10°–60°) was improved in the operating room to 105° (range, 85°–135°).
Seven patients lost a considerable amount of knee flexion in the first 6 weeks postoperatively, which necessitated manipulation under anesthesia. After an average followup of 24 months the average loss in knee flexion was 18° compared with the recorded range in the operating room. The final flexion achieved was 88° (range, 50°–115°) reflecting a 55° average improvement (flexion gain) (Table 2). Only one patient (Patient 8) had a 10° extension lag develop. This patient had a postoperative hematoma necessitating surgical washout but had a satisfactory outcome with a final flexion of 95°.
The results were assessed according to Judet’s criteria 12 and were considered excellent if the final flexion was greater than 100°; good if flexion was between 80° and 100°; fair if flexion was between 50° and 80°; and poor, if flexion was less than 50°. Using these criteria there were no poor results. There were one fair, seven good, and two excellent results (Table 2).
The one fair result occurred in a patient (Patient 1) with a wound infection who was treated with surgical debridement and his knee flexion improved from 30° to only 50°. Analysis was done for possible influencing factors. The final flexion gain showed a weak correlation with the time in external fixation (r = 0.16), and with the interval between the onset of the stiff knee and quadricepsplasty (r = 0.24).
One patient (Patient 3) had a long interval between the onset of the stiff knee and quadricepsplasty (240 months) which did not influence the final outcome as he had a good result.
We were unable to show any negative effect of crossing the knee with external fixation on the final results, as four of the current patients had cross-knee fixation with one fair and three good results.
Deep infection occurred in one patient, which was treated successfully, however the patient’s knee flexion range only improved from 0° to 30° preoperatively to 0° to 50° at the final followup, but the patient was discharged with a fair result.
Posttraumatic joint stiffness may cause various degrees of disability depending on the joint involved. Some joints, such as the wrist or ankle, can tolerate significant loss of movement and still be compatible with good function; whereas in others, such as the knee, stiffness can impose a severe handicap and degree of disability that can severely threaten the occupational and leisure activities of the patient. 17
Quadricepsplasty is the recommended procedure for release of severe extensor knee ankylosis. The four conditions that cause a block to knee flexion are fibrosis and shortening of the medial and lateral parapatellar retinaculum, adhesions from the deep surface of the patella to the femoral condyles, fibrosis of the vastus intermedius with adherence to the rectus femoris muscle and to the front of the femur, and actual shortening of the rectus femoris. 2,12,17
In addition fracture callus and adherence of skin to underlying muscle should be included. Furthermore, where unilateral external fixation has been used, pin site tethering on the lateral side of the femur may occur. This problem is common particularly in limb lengthening when the fixator is applied for a long period and is conveniently treated by Judet’s technique because of the long lateral incision.
Thompson described a technique which is based principally on isolating the rectus femoris completely from the vasti, and releases it to such an extent that it takes over the action of knee extension. 21 This involves sectioning the vasti from their patellar insertion causing a major weakness to the quadriceps muscle. If the rectus femoris remains tight limiting flexion, lengthening of the rectus femoris is done, which in turn might cause considerable weakening of the extensor mechanism and an extensor lag. 7,17 Extensor lag has been widely reported using the Thompson technique. 8,9,11,16–18,21 Pick 18 reported two of three patients with an extensor lag, Moore et al 16 had six of nine, and Ratliff 19 had three of four. Nicoll 17 reported seven of 30 patients with an average 20° extensor lag, but this was evident only when the rectus femoris was lengthened. In comparison, Judet’s 12 technique depends on sliding of the rectus femoris for severe cases, and we think extensor lag is less of a problem. Judet 12 reported a 4% rate of extensor lag. Similar favorable results were reported by Ebraheim et al 5 in a series of 11 patients using Judet’s technique with one case of extensor lag and no infection or skin breakdown.
In the current study, only one patient had a 10° extensor lag, and these results compared favorably with those reported in the literature. 2,4,5,14,22
Judet’s procedure as an alternative technique offers a controlled staged correction of the stiffness. It permits sequential release of the intrinsic and extrinsic components limiting knee flexion and affords the opportunity to stop as soon as adequate flexion is obtained, therefore minimizing disturbance to the quadriceps muscle. 4
Patients may be considered candidates for quadricepsplasty when they reach a plateau in gaining flexion movement during their physiotherapy at least 1 year after injury and when flexion remains less than 90°. 2 Although a minimum of 70° flexion is acceptable for walking, this would not be sufficient for normal daily activities and a minimum of 110° would be preferable in young patients. 13 However, careful patient selection is paramount because this is a major procedure requiring vigorous postoperative physiotherapy. Compliance and motivation is essential for a satisfactory outcome.
Postoperative management is an integral part of the quadricepsplasty, because postoperative motion should be maintained with continuous active and passive exercises to minimize loss of the final range of movement. This requires adequate pain control to allow continuous exercise and an experienced physiotherapy team. Manipulation under general anesthesia has been used frequently postoperatively. Fifty-five percent of patients in Nicoll’s series 17 had manipulation under anesthesia compared with 14% in the series of Merchan and Myong. 14 In the current series, although 105° average knee flexion was obtained in the operating room, a significant amount of this flexion was lost during the first 6 weeks postoperatively, necessitating manipulation under anesthesia in seven of 10 patients. Therefore early manipulation under anesthesia as soon as any noticeable loss of flexion arises postoperatively is recommended.
Early postoperative rehabilitation is critical and exercises should start long before the wound has healed, which may increase the risk of wound complication. 10
Furthermore the combination of hematoma and bacterial colonization at the pin sites may increase the risk of postoperative infection, however in the current study only one case of infection occurred.
Because the population studied was small, we could not show any influence in the time from injury to quadricepsplasty, the duration of external fixation, or bridging the knee with the fixator on the final outcome of the knee flexion after the quadricepsplasty.
There are limitations of this study, particularly its retrospective nature. However, the data of this consecutive series were collected prospectively into a general database, and all the patients were clinically examined specifically for this report.
Another limitation is the small number of patients included in this study; this in fact reflects the infrequency of this procedure, as many studies in the literature have comparable numbers (Table 1). Furthermore, in contrast to the published reports which included patients with injuries of mixed etiologies, the current study is the only one that has an homogeneous group of patients, who had knee stiffness develop after a prolonged period of treatment for femoral fracture using external fixation. Although posttraumatic knee stiffness cannot always be prevented, this is not a common problem, and the limb reconstruction surgeon will face similar cases infrequently. Therefore, quadricepsplasty, although a major surgical procedure with demanding rehabilitation, should be considered a useful procedure to correct this disabling complication.
Judet’s technique of disinsertion and muscle sliding is a useful technique in fixed knee extension contracture, a problem commonly seen in limb reconstruction surgery after a prolonged application of external fixators.
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