Quadricepsplasty is the term applied to describe a surgical procedure to the quadriceps muscle designed to improve knee flexion in severely ankylosed knees. 21 It is done most commonly after traumatic injuries and in particular, fractures of the distal femur. 3,17,21 Quadricepsplasty also may be used to describe tightening of the quadriceps in an extensor lag.
Various treatment modalities have been developed for distal femoral fractures, and more limbs are being salvaged as a result of modern surgical practices. 20 Salvage and limb reconstruction procedures often involve external fixation and techniques of bridging the knee; such methods inevitably transfix the soft tissues to the adjacent bone. 1
In young patients a significant degree of loss of flexion frequently is accepted because many surgeons are reluctant to recommend quadricepsplasty, fearing the high rate of complications that may follow this major procedure. 16,17,21 Extensor lag has been reported to be as high as 67%. This, if permanent, may be significant enough to affect the stability of the knee and some patients may require continuous bracing. 16 Mira et al 15 showed that 83% of patients with femoral fractures had permanent impairment of the function of the quadriceps with decreased strength and reduced passive flexion in the fractured knee compared with the normal side; despite this, quadricepsplasty rarely is done to improve quadriceps function. 5
Judet 12 described his technique using the principle of muscle disinsertion and sliding, minimizing damage to the quadriceps mechanism. Judet’s procedure has not gained much popularity as judged by the few reports in the English literature 4,5,22 (Table 1).
This technique is particularly useful after limb reconstruction with external fixators because it may be used to address pin site tethering in the lateral femur. There is no report in the literature for the use of this procedure in limb reconstruction surgery. The technique and assessment of outcomes of Judet’s quadricepsplasty are described for a consecutive series of patients treated using external fixation for femoral fractures. The factors that contribute to a successful outcome were analyzed.
MATERIALS AND METHODS
Ten consecutive patients had Judet’s quadricepsplasty for severe extension contractures of the knee at the authors’ institute. Indication for quadricepsplasty was restriction less than 60° in knee flexion, which was incompatible with a normal gait. All patients had at least one manipulation under general anesthesia before the quadricepsplasty, which failed to improve the knee movement. The inclusion criteria were distal femoral fractures treated with external fixation for stabilization or deformity correction. All these fractures were as a result of motor vehicle accidents. Six were Gustilo and Anderson Grade III open fractures. 6 Five patients had leg lengthening with an average gain of 6 cm. Four involved fixation across the knee (Table 2). The average prequadricepsplasty flexion was 33° (range, 10°–60°). The average interval between the injury and quadricepsplasty was 65 months. All patients were assessed clinically with a minimum followup of 20 months.
Judet’s quadricepsplasty is a sequential procedure with the range of flexion determined after each stage of dissection, affording the opportunity to stop as soon as adequate flexion is obtained. 4
The procedure is done through two incisions; one is a short medial parapatellar incision extending to the medial side of the tibial tuberosity. This permits access to the patellar tendon releasing the medial retinaculum, suprapatellar pouch, and intraarticular adhesions. The second is a long lateral incision made from the lateral aspect of the lower pole of the patella to 5 cm distal to the greater trochanter (Fig 1). Through the distal part of this incision, the patella and lateral retinacular tissues are freed ensuring that the patella may be easily lifted off the femoral condyles. This incision permits release of pin site adhesions, and frees the vastus lateralis from the linea aspera (Fig 2). The vastus intermedius then is lifted extraperiosteally from the lateral and anterior surfaces of the femur. 14 In most instances, this muscle is fibrotic and requires resection. Cautious debulking of redundant bone within the fracture callus may be done at this stage. The third stage is proximal release of the vastus lateralis at its origin from the greater trochanter, and if necessary the rectus femoris from its iliac origin, with care being taken to protect the femoral nerve (Fig 2). 12 The tissues are extensively fibrotic and surgical release with a scalpel may lead to large raw bleeding surfaces in which hemostasis is difficult; for this reason the use of cutting diathermy is recommended. Meticulous hemostasis is essential, suction drains are inserted, and only the skin is closed. Autologous blood transfusion was used in the current patients. The range of flexion after release and skin closure was recorded. The latter was 20° lower because there was a relative lack of skin and reluctance to apply tension to the repaired wound. The postoperative regime involves immediate slow continuous passive motion from 0° to 60° flexion, under epidural pain control with ice packs to reduce swelling. The range and speed gradually were increased until the maximum possible flexion was achieved. Gentle manipulation under general anesthesia was done when necessary during the first 6 weeks if the patient did not maintain at least 90° flexion. After discharge, supervised physiotherapy as an outpatient was done three times weekly.
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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