A new treatment strategy for severe arthrofibrosis of the knee. A review of twenty-two cases

Sequential surgery for the treatment of type I knee ankylosis: a series of 62 cases

BACKGROUNDS

The lack of systematic classification and standard treatment principles for knee ankylosis prevents optimal treatments. This study explored treatments for type I (mild) knee joint ankylosis.

METHOD

This retrospective study analysed patients with knee joint ankylosis admitted from March 2013 to January 2018 who underwent sequential arthroscopic release.

RESULT

The 62 patients had 12-36 (average, 18) months of follow-up. Thirty-eight patients were released; of these, 18 were assisted by limited incision with partial quadriceps femoris expansion myotomy and released according to arthroscopy. Six patients underwent lengthening and release of the quadriceps femoris. All surgeries combined with full-course rehabilitation resulted in improved joint mobility. The range of motion (ROM) of the knee joint recovered to a range of 0° to 85°-140° (mean: 118.32 ± 9.42°) from the preoperative range of 30°-70° (mean: 45° ± 15.50°). The clinical effect was evaluated according to the Judet criteria at the final follow-up. The outcomes at the last follow-up (at least for 1 year) were excellent in 55 cases, good in six cases, and fair in one case.

CONCLUSION

Sequential arthroscopic release, minimal selective invasion of limited incision of partial quadriceps femoris expansion myotomy, assisted by pie-crusting technique to release, or quadriceps femoris lengthening, and release surgery for type I knee joint ankylosis, accompanied by early rehabilitation training provided satisfactory results without significant complications.

Knee Arthrofibrosis following Tibial Plateau Fracture Treated with Arthroscopic Lysis of Adhesions with Manipulation

Posttraumatic arthrofibrosis is a common problem encountered in the orthopaedic setting for which there is no agreement on the optimal management strategy. The literature does not optimally describe the efficacy of arthroscopic lysis of adhesions for arthrofibrosis following tibial plateau fracture. The purpose of this study is to quantify the efficacy of arthroscopic lysis of adhesions with manipulation for the treatment of arthrofibrosis of the knee in patients who previously underwent surgical management of tibial plateau fracture. All patients who underwent arthroscopic lysis of adhesions from a single surgeon since 1999 were retrospectively reviewed. Clinical outcomes were evaluated by flexion, extension, and range of motion (ROM) preoperatively, intraoperatively, and postoperatively at intervals of 1, 4, 8, and 12 weeks, and any additional long-term follow-up. A total of 28 patients who had developed arthrofibrosis following surgical management of a tibial plateau fracture and failed nonsurgical management of knee stiffness were included in this study. There were significant improvements in total ROM following intervention at all time points compared with preoperative values (p < 0.001), with mean improvements of 59.3 degrees intraoperatively, 32.9 degrees (1 week), 37.1 degrees (4 weeks), 41.5 degrees (8 weeks), and 47.6 degrees (12 weeks). There were significant improvements in degrees of knee flexion following intervention at all time points compared with preoperative values (p < 0.001), with mean improvements of 50.8 degrees intraoperatively, 27.3 degrees (1 week), 36.0 degrees (4 weeks), 38.3 degrees (8 weeks), and 43.9 degrees (12 weeks). There were significant increases in degrees of knee extension intraoperatively (8.5 degrees) and at 1 week postoperatively (5.9 degrees) compared with preoperative values (p <0.01). At 12 weeks postoperatively, those who had previously undergone external fixation had significantly greater increases in ROM (p = 0.048). Arthroscopic lysis of adhesions for knee arthrofibrosis following surgical management of tibial plateau fracture significantly improves knee ROM.

Mini-invasive Quadriceps-plasty for Severe Flexion-Impeding Knee Stiffness

Severe flexion-impeding knee stiffness is a common clinical condition that challenges orthopaedic surgeons. A mini-invasive and effective release technique to address this special condition is still being pursued. We describe a mini-invasive quadriceps-plasty that is performed through a small incision on the supralateral side of the knee and includes release of the retinaculum and patellofemoral joint, re-creation of the suprapatellar pouch and medial and lateral gutters, overlapping Z-plasty of the rectus femoris and vastus intermedius, and transfer of the vastus lateralis. Our clinical results indicate that this technique is safe and effective. We present a detailed description with video illustration of this technique that is beneficial for its application.

Arthrofibrosis Nightmares: Prevention and Management Strategies

Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathologic periarticular fibrosis and symptomatic joint stiffness. The knee, elbow, and shoulder are particularly susceptible to AF, often in the setting of trauma, surgery, or adhesive capsulitis. Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss. Reliable nonoperative modalities exist and outcomes are improved when etiology, joint involved, and level of dysfunction are considered in the clinical decision making process. Surgical procedures should be reserved for cases recalcitrant to nonoperative measures. The purpose of this review is to provide an overview of the current understanding of AF pathophysiology, identify common risk factors, describe prevention strategies, and outline both nonoperative and surgical treatment options. This manuscript will focus specifically on sterile AF of the knee, elbow, and shoulder.

Intra-articular celecoxib improves knee extension regardless of surgical release in a rabbit model of arthrofibrosis

Aims

Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release.

Methods

A total of 24 rabbits underwent contracture-forming surgery with knee immobilization followed by remobilization surgery at eight weeks. At remobilization, one cohort underwent capsular release (n = 12), while the other cohort did not (n = 12). Both groups were divided into two subcohorts (n = 6 each) – one receiving IA injections of celecoxib, and the other receiving injections of vehicle solution (injections every day for two weeks after remobilization). Passive extension angle (PEA) was assessed in live rabbits at 10, 16, and 24 weeks, and disarticulated limbs were analyzed for capsular stiffness at 24 weeks.

Results

IA celecoxib resulted in greater mean PEA at ten weeks (69.6° (SD 4.6) vs 45.2° (SD 9.6), p = 0.004), 16 weeks (109.8° (SD 24.2) vs 60.9° (SD10.9), p = 0.004), and 24 weeks (101.0° (SD 8.0) vs 66.3° (SD 5.8), p = 0.004). Capsular stiffness was significantly reduced with IA celecoxib (2.72 Newton per cm (N·cm)/° (SD 1.04), p = 0.008), capsular release (2.41 N·cm/° (SD 0.80), p = 0.008), and capsular release combined with IA celecoxib (3.56 N·cm/° (SD 0.99), p = 0.018) relative to IA vehicle (6.09 N·cm/° (SD 1.64)).

Conclusion

IA injections of a celecoxib led to significant improvements in passive extension angles, with reduced capsular stiffness, when administered to rabbit knees with established experimental contracture. Celecoxib was superior to surgical release, and the combination of celecoxib and a surgical release did not provide any additional value.

Cite this article: Bone Joint Res 2022;11(1):32–39.

Quadriceps strength and knee joint function in patients with severe knee extension contracture following arthroscopic-assisted mini-incision quadricepsplasty

PURPOSE

To evaluate reserve quadriceps function and improve knee activity in patients with severe knee extension contracture following arthroscopic-assisted mini-incision quadricepsplasty as well as post-operative complications.

METHODS

From 2012 to 2019, 32 patients with severe knee extension contractures (less than 45° range of flexion) were treated with an all-arthroscopic release technique. The clinical results, including range of motion (ROM), quadriceps function (quadriceps index, QI), and knee function, were evaluated, and MRI of the healed tendon after partial quadricepsplasty was performed. The patellar track and length during knee flexion were measured on three normal knees under fluoroscopy. Three formalin-fixed lower limbs were used to mimic severely contracted quadriceps to evaluate the extension of the patellar track.

RESULTS

The median follow-up time was 2.1 years (1-5 years). The average QI was 92.0 ± 6.2, and the quadriceps muscle strength was increased from 3.28 to 4.72. At the final follow-up, 90% of the patients had no difficulty going upstairs, going downstairs, or rising from a chair. The ROM improved by 25.69 ± 3.6 preoperatively to 105.88 ± 6.6 at the final follow-up (P < 0.001). The open surgery showed that a 2-cm extension could be achieved by partly cutting the quadriceps tendon, and two cuts achieved a total extension of 5.2 ± 0.52 cm. The patellar tracking distance was 7.7 ± 0.43 cm, and the gap between the patella and femur was also reduced.

CONCLUSION

Partial quadricepsplasty of the rectus femoris extended the contracted quadriceps and maintained quadriceps strength, allowing for full knee flexion and satisfactory clinical outcomes of knee function with few complications.

Chronic, Active Inflammation in Patients With Failed Total Knee Replacements Undergoing Revision Surgery

Chronic pain and restricted knee motion is a significant problem following the total knee arthroplasty (TKA). The molecular pathogenesis of pain post-TKA is not known and no targeted therapeutic intervention is available. The aim of this study was to investigate whether pro-inflammatory mediators are elevated in revision knee patients, indicating an active, ongoing inflammatory process that may contribute to pain. Twelve key markers (pro-inflammatory cytokines granulocyte-macrophage colony-stimulating factor [GM-CSF], interleukin 5 [IL-5], IL-8 and IL-10, chemokines CCL2, CCL3, CCL4, and CCL13, mediators of angiogenesis Flt-1, vascular endothelial growth factor, and cell migration vascular cell adhesion molecule 1 and intercellular adhesion molecule 1) were measured in knee tissue and synovial fluid (SF) from primary TKA (n = 29) and revision patients (n = 32). Indications for surgery were osteoarthritis (OA) for primary TKA, and component loosening (n = 11), stiffness (n = 11), laxity pattern (n = 8), or progression of OA in patella resurfacing (n = 3) for revision surgery. Pain levels (WOMAC score) were higher in revision than primary patients (p ≤ 0.05). Time from primary to revision ranged from 8 months to 30 years (median 10 years). All markers were elevated in revision TKA; there was no trend toward decreasing levels with greater time from primary surgery for any marker studied in SF. Similar results were seen in knee tissue. We found no differences comparing indications for revision surgery (p ≥ 0.05). The elevation of inflammatory mediators in painful post-TKA knees requiring revision suggests active, chronic inflammation. Characterization of upregulated markers provides rationale for targeted therapy, even many years from the primary surgery. © 2019 The Authors. Journal of Orthopaedic Research^® published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:2316-2324, 2019.

All-arthroscopic release for treating severe knee extension contractures could improve the knee range of motion and the mid-term functional outcomes

PURPOSE

To evaluate the safety, feasibility, and effectiveness of an all-arthroscopic technique for the intra- and extraarticular release of severe knee extension contractures.

METHODS

From 2012 to 2016, 25 patients with severe knee extension contractures (less than 45° range of flexion) were treated with an all-arthroscopic release technique. The patients underwent intra- and extraarticular arthroscopic release and arthroscopic-assisted mini-incision quadriceps plasty. The post-operative rehabilitation was initiated the first day after the procedures. Comprehensive clinical follow-up evaluations including the range-of-motion (ROM) assessment, the Lysholm score, and the International Knee Documentation Committee (IKDC) score were performed on all patients.

RESULTS

The median follow-up time was 28 months (range 12-65 months). The ROM improved from 23.9° ± 7.5° pre-operatively to 105.9° ± 6.5° at the final follow-up (P < 0.001). In addition, the Lysholm score increased from 59.9 ± 5.2 pre-operatively to 89.7 ± 3.3 (P < 0.001). The IKDC score increased from 47.6 ± 3.4 pre-operatively to 91.7 ± 2.4 (P < 0.001). All patients were satisfied with their final ROM and functional outcomes.

CONCLUSION

The all-arthroscopic release technique was a safe, feasible and effective method for treating severe knee extension contractures. The severe knee extension contractures may be successfully addressed by the all-arthroscopic release technique during our clinical practice.

LEVEL OF EVIDENCE

IV.

Araújo Motta GA, Rocha de Faria JL, Perez da Motta D, dos Santos Cerqueira F, Adolphson F. Minimally Invasive Quadricepsplasty

A modification of range of motion of the knee can significantly change a patient's quality of life. In general, range of motion of 0° to 125° is adequate for most activities of daily life. The rate of knee arthrofibrosis after ligament reconstruction is reported to be between 0% and 4%; after tibial fracture due to high-energy trauma, the rate is about 7%, with an undetermined incidence after limb lengthening. The purpose of this study was to describe a modification of the operative technique of Judet. We describe minimally invasive quadricepsplasty in 4 steps, aiming to obtain an end result with an arc of movement of at least 120° to 130°. We believe that our technique is a good option for the treatment of the stiff knee, having low morbidity and being an easy method to perform.

International consensus on the definition and classification of fibrosis of the knee joint

AIMS

The aim of this consensus was to develop a definition of post-operative fibrosis of the knee.

PATIENTS AND METHODS

An international panel of experts took part in a formal consensus process composed of a discussion phase and three Delphi rounds.

RESULTS

Post-operative fibrosis of the knee was defined as a limited range of movement (ROM) in flexion and/or extension, that is not attributable to an osseous or prosthetic block to movement from malaligned, malpositioned or incorrectly sized components, metal hardware, ligament reconstruction, infection (septic arthritis), pain, chronic regional pain syndrome (CRPS) or other specific causes, but due to soft-tissue fibrosis that was not present pre-operatively. Limitation of movement was graded as mild, moderate or severe according to the range of flexion (90° to 100°, 70° to 89°, < 70°) or extension deficit (5° to 10°, 11° to 20°, > 20°). Recommended investigations to support the diagnosis and a strategy for its management were also agreed.

CONCLUSION

The development of standardised, accepted criteria for the diagnosis, classification and grading of the severity of post-operative fibrosis of the knee will facilitate the identification of patients for inclusion in clinical trials, the development of clinical guidelines, and eventually help to inform the management of this difficult condition. Cite this article: Bone Joint J 2016;98-B:1479-88.

A mini-invasive procedure for treating arthrofibrosis of the knee

Objective

The aim of this study was to introduce the results of a novel mini-invasive operative technique comprising mini-incision release, “pie-crusting” lengthening of the quadriceps extensor, and arthroscopic lysis in severe arthrofibrotic knees.

Methods

From 2010 to 2014, 17 patients (12 males and 5 females with a mean age of 44 years (range, 19–62 years)) with severely arthrofibrotic knees were treated with this operative technique. The mean follow-up duration was 23 months. The knee range of motion (ROM) was assessed with a goniometer. The functional outcomes were evaluated according to the Hospital for Special Surgery (HSS) score and Judet's criteria.

Results

The ROM significantly improved from 29.7° (range, 7°–56°) preoperatively to 127° (range, 120°–136°) at the final follow-up in all patients (p < 0.001). According to Judet's criteria, all patients achieved excellent results (ROM > 100°). The HSS score was improved from 70 points (range, 60–85 points) preoperatively to 91 points (range, 84–98 points) (p < 0.001) at the final follow-up. No extension lag, skin necrosis, quadriceps weakness, wound dehiscence or quadriceps tendon rupture occurred.

Conclusions

Mini-invasive quadricepsplasty-associated arthroscopic lysis and manipulation of the knee in flexion is simple and easy and should be considered as a legitimate treatment for arthrofibrosis of the knee.

Arthrofibrosis After Periarticular Fracture Fixation

Arthrofibrosis after periarticular fractures can create clinically significant impairments in both the upper and lower extremities. The shoulder, elbow, and knee are particularly susceptible to the condition. Many risk factors for the development of arthrofibrosis cannot be controlled by the patient or surgeon. Early postoperative motion should be promoted whenever possible. Manipulations under anesthesia are effective for a period of time in certain fracture patterns, and open or arthroscopic surgical debridements should be reserved for the patient for whom nonoperative modalities fail and who has a clinically significant deficit.

Neglected rotatory knee dislocation: A case report

We report here a unique case of a 3 year neglected rotatory tibiofemoral dislocation associated with a lateral patellar dislocation. The rotational deformity was gradually corrected using a Taylor spatial frame and the patella was realigned by tibial tubercle osteotomy and transfer. The patient also underwent multiple soft tissue releases and quadricepsplasty to improve knee flexion. At nine year follow-up, the patient has good knee range of motion, a congruent knee joint and a good functional result.

CLINICAL RELEVANCE

Taylor spatial frame combined with other orthopedic approaches can be a useful tool while dealing with neglected knee dislocations.

Arthroscopic lysis of adhesions for stiff total knee arthroplasty

The goal of this study was to evaluate the efficacy of arthroscopic lysis of adhesions after total knee arthroplasty (TKA) in improving range of motion (ROM) and providing an improvement in knee function. The authors retrospectively examined 19 patients who underwent arthroscopic lysis of adhesions following TKA due to poor ROM. The criterion for lysis was the inability to flex to 90° at 3 months. All patients were followed for at least 2 years after lysis. Patient demographics, postoperative and follow-up ROM,number of prior surgeries, Knee Society Scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) functional scores were collected. Average ROM increased from 75.37° preoperatively to 98.95° postoperatively. The authors found an association between preoperative knee score and change in ROM between pre-arthroscopic lysis and ROM at final follow-up (P=.0188). When the authors examined the relationship between patient body mass index (BMI) and change in ROM,they found that patients with a BMI higher than 30 kg/m2 had a change of 26.44° compared with patients with a BMI lower than 30 kg/m2, who had a change of only 8.75°. A strong association was found between patient height and change in ROM and final ROM achieved (P=.0062 and .0032, respectively). The authors report a successful outcome among study patients. Furthermore, they found an association between patient height, BMI, and preoperative knee score and the improvement achieved after arthroscopic lysis of adhesions following TKA. The current study's results are comparable with those of published results. The authors recommend arthroscopic lysis of adhesions as a treatment option for stiff knees after TKA that fails after at least 3 months of nonoperative treatment.

Outcome of surgical treatment of arthrofibrosis following ligament reconstruction

PURPOSE

Clinical outcome following surgical treatment and intensive physiotherapy was evaluated in patients with arthrofibrosis as a complication to varying knee-ligament reconstructions.

METHODS

From 2003 to 2007, 31 patients underwent surgery for arthrofibrosis as a postoperative complication following knee-ligament reconstruction. Treatment for reduced range of motion consisted of forced manipulation or arthroscopic arthrolysis followed by intensive physiotherapy. Twenty-seven patients (12 men and 15 women; median age 35(12-70) years) were followed up. Objective examination, Pain, KOOS and Tegner scores were used to evaluate the clinical outcome at follow-up.

RESULTS

Fourteen patients were treated with forced manipulation alone, and the remaining thirteen were treated with forced manipulation and arthroscopic arthrolysis. The patients' median follow-up was 51 months (19-73 months). Median interval between primary surgery and surgical release was 4 (1-32) months. Median range of motion (ROM) improved from -0°(0 to 20) to 0°(+2-9) in extension deficit and from 90°(40-145) to 130°(90-155) in flexion. Mean KOOS score were symptoms 63, pain 72, ADL 77, sport 42, QOL 45. Median Tegner score was 4 (2-9).

CONCLUSION

Surgical arthrolysis combined with intensive physiotherapy improved range of motion to nearly normal values. Subjective outcome scores revealed relatively poor outcome levels compared to uncomplicated knee-ligament reconstruction. Predictors of poor outcome were global arthrofibrosis and greater than 6-month time interval from primary reconstruction and surgical release.

LEVEL OF EVIDENCE

Retrospective clinical case series, Level IV.

A less invasive procedure for posttraumatic knee stiffness

INTRODUCTION

Management of posttraumatic knee stiffness (PTKS) is among the most difficult challenges in postoperative rehabilitation.

AIM

The purpose of this retrospective study was to present the outcomes of a procedure for PTKS. In this study, a less invasive procedure was introduced, which included intra-articular arthroscopic release, extra-articular mini-incision release and "multiple Z" lengthening of the knee extensor, as well as an early, aggressive rehabilitation protocol.

PATIENTS

A series of patients aged from 29 to 60 years were treated with this procedure from April 2005 to May 2009, and the mean duration of follow-up was 13.5 months.

RESULTS

The range of motion increased significantly in all patients. Flexion improved from a mean of 51° preoperation to a mean of 100° at discharge, and the average extension loss improved from 10° to 3° (p < 0.000). The average knee score, according to the Hospital for Special Surgery system, improved from 62 points preoperatively to 77 points at discharge, and 91 points at final follow-up (p < 0.000). All the patients were satisfied with the final ROM gain.

Prognostic factors and long-term outcomes following a modified Thompson’s quadricepsplasty for severely stiff knees

Between 1987 and 2006 we performed a modified Thompson’s quadricepsplasty on 40 fracture-related stiff knees and followed the patients for a mean of 7.9 years (2 to 11.1). The factors affecting the final gain of movement were investigated. A total of 15 knees required lengthening of the rectus femoris. The mean flexion gain was 70.2° (42.3° to 112.5°). According to Judet’s criteria, the results were excellent in 30 knees, good in seven, and fair in three. The range of movement which was achieved intra-operatively was related to the gain of knee flexion on univariate analysis. Five patients had complications: deep infection in one, recurrent patellar dislocation in one, and rupture of the extensor mechanism in three. This modified technique gives satisfactory results. Achieving maximum knee flexion intra-operatively seems to be the most important factor in enhancing the outcome in patients with stiffness of the knee following fracture.

Static progressive stretch improves range of motion in arthrofibrosis following total knee arthroplasty

Arthrofibrosis is a relatively common complication after total knee arthroplasty that negatively affects function and quality of life. Static progressive stretching is a technique that has shown promising results in the treatment of contractures of the elbow, ankle, wrist and knee. This study evaluated a static progressive stretching device as a treatment method for patients who had refractory knee stiffness after total knee arthroplasty. Twenty-five patients who had knee stiffness and no improvement with conventional physical therapy modalities were treated with the device. After a median of 7 weeks (range, 3-16 weeks), the median increase in range of motion was 25 degrees (range, 8-82 degrees). The median gain in knee active flexion was 19 degrees (range, 5-80 degrees). Ninety-two percent of patients were satisfied with the results. The authors believe static progressive stretching devices may be an effective method for increasing the ranges of motion and satisfaction levels of patients who develop arthrofibrosis after total knee arthroplasty.

Disorders of the suprapatellar pouch of the knee

Proper recognition and treatment of pathological conditions of the suprapatellar pouch of the knee is dependent on the knowledge of normal pouch anatomy and of the various conditions which affect this area of the knee and contribute to knee pain. This article includes a comprehensive review of the surgical anatomy of the pouch, current surgical techniques and review of the common conditions that have a predilection for this often overlooked area of the knee.

Arthrofibrosis of the knee

Better understanding of surgical timing, improved surgical technique, and advanced rehabilitation protocols has led to decreased incidence of motion loss after anterior cruciate ligament injury and reconstruction. However, motion loss from high-energy, multiligament injuries continues to compromise functional outcome. Prevention, consisting of control of inflammation and early motion, remains the key element in avoiding motion loss. However, certain techniques, such as manipulation under anesthesia in conjunction with arthroscopic lysis of adhesions, are reliable treatment options. Open surgical débridement is rarely necessary and should be considered only as a salvage procedure. A greater understanding of the pathogenesis of arthrofibrosis and related inflammatory mediators may result in novel therapies for treating the patient with motion loss.

Thompson's quadricepsplasty for stiff knee

BACKGROUND

Stiffness of the knee after trauma and/or surgery for femoral fractures is one of the most common complications and is difficult to treat. Stiffness in extension is more common and can be reduced by vigorous physiotherapy. If it does not improve then quadricepsplasty is indicated. The present study was undertaken to evaluate the results of Thompsons quadricepsplasty.

MATERIALS AND METHODS

Twenty-two male patients (age range 20-45 years) with posttraumatic knee stiffness following distal femoral fractures underwent Thompson's quadricepsplasty where knee flexion range was less than 45°. The index injury in these patients was treated with plaster cast (n=5), plates (n=3), intramedullary nailing (n=3) and external fixator for open fractures (n=9). Thompson's quadricepsplasty was performed in all the patients using anterior approach, with incision extending from the upper thigh to the tibial tubercle. Release of rectus femoris from underlying vastus intermedius and release of intraarticular adhesions were performed. After surgery the patients needed parenteral analgesia for three days and then oral analgesics for three weeks. Active assisted knee mobilization exercises was started on the first postoperative day. Continuous passive motion machine was used from the same day. Supervised physiotherapy was continued in hospital for six weeks followed by intensive knee flexion and extension exercise including cycling at home for atleast another six months.

RESULTS

Out of 22 patients, 20 had excellent to good results and two patients had poor results using criteria devised by Judet. One poor result was due to peroperative fracture of patella which was then internally fixed and hence the flexion of knee could not be started immediately. There was peroperative avulsion of tibial tuberosity in another patient who finally gained less than 50° knee flexion and hence a poor result.

CONCLUSION

Thompsons quadricepsplasty followed by a strict and rigourous postoperative physiotherapy protocol successfully increases the range of knee flexion.