Thompson's quadricepsplasty for stiff knee

Thompson Versus Judet Techniques for Quadricepsplasty: A Systematic Review and Meta-analysis of Outcomes and Complications

Background

Quadricepsplasty has been used for over half a century to improve range of motion (ROM) in knees with severe arthrofibrosis. Various surgical techniques for quadricepsplasty exist, including Judet and Thompson, as well as novel minimally invasive approaches. The goal of this review was to compare outcomes between quadricepsplasty techniques for knee contractures.

Methods

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Available databases were queried for all articles on quadricepsplasty. Outcomes included postoperative ROM, outcome scores, and complication rates. Secondarily, we summarized rehabilitation protocols and descriptions of all modified and novel techniques.

Results

Thirty-three articles comprising 797 patients were included in final analysis. Thirty-five percent of patients underwent Thompson quadricepsplasty, 36% underwent Judet, and 29% underwent other techniques. After Judet and Thompson quadricepsplasty, patients achieved a mean postoperative active flexion of 92.7° and 106.4°, respectively (p < 0.01). Complication rates after Judet and Thompson were 17% and 24%, respectively. Wound infection was the most frequently recorded complication after Judet, whereas extension lag predominated for Thompson.

Conclusion

Both the Thompson and Judet quadricepsplasty techniques offer successful treatment options to restore functional knee ROM. Although the Thompson technique resulted in greater postoperative knee flexion compared with the Judet, the difference may be attributable to differences in preoperative flexion and time from injury to quadricepsplasty. Overall, the difference in flexion gained between the 2 techniques is comparable and clinically negligible.

Level of Evidence

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes of Arthroscopic Adhesiolysis: A Case Series of 40 Patients With Postoperative Knee Stiffness

Introduction Restricted range of motion over the knee joint is a known complication following the surgical procedure. Aggressive rehabilitation protocols can initially manage knee stiffness due to arthrofibrosis. If conservative management fails, surgical (open or arthroscopic) release is the preferred modality of management. We present a series of 40 patients with postoperative knee stiffness who were treated with arthroscopic adhesiolysis. Material and methods This is a retrospective study conducted at Phoenix Orthopedic Superspeciality Hospital, Nagpur, India, from 2017 to 2021. Our study included 40 patients with postoperative knee joint stiffness, of whom 27 were males and 13 were females. The study considered the duration of stiffness, which ranged from six months to five years. All patients underwent arthroscopic knee release. A rigorously supervised physical therapy program followed this procedure. Patients were examined at three months, six months, and one year to assess improvement in knee range of movement. Results Out of 40 patients, six were classified as Shelbourne type 4, and the remaining were Shelbourne type 3. Twenty-three of 40 patients developed arthrofibrosis following intra-articular or peri-articular fracture fixation surgery; 11 patients were operated on arthroscopically for anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction. Three patients developed stiffness following total knee replacement, one following patellectomy, and three following infection after fracture fixation. The mean pre-op knee range of motion (ROM) was 48.875 degrees. Following arthroscopic release, the mean improvement in ROM was 60 degrees intra-operatively. The average postoperative range was 108.25 degrees. Conclusion Arthroscopic adhesiolysis and quadriceps release are reliable methods for dealing with postoperative knee stiffness. It prevents wound complications and increases the chances of surgical site infection due to smaller incisions. Postoperatively, we achieved an average increase of 60 degrees in ROM over the knee joint.

4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children

BACKGROUND

Habitual and fixed patellar dislocations represent extreme forms of patellar instability and can lead to significant functional loss. The underlying complex pathoanatomy of a laterally positioned and shortened extensor mechanism poses challenges in its management. The purpose of our study was to evaluate the anatomic risk factors and outcomes of a 4-in-1 quadricepsplasty (wide lateral releases, Insall proximal tube realignment, Roux-Goldthwait patellar tendon hemi-transfer, and step-wise quadriceps lengthening) for stabilization of habitual and fixed patellar dislocation.

METHODS

In a retrospective study, all patients with habitual and fixed patellar dislocation who underwent 4-in-1 quadricepsplasty and had a minimum 2-year follow-up were identified. Preoperative magnetic resonance imagings were evaluated for the presence of anatomic risk factors. As a prospective part of the study, patient-reported outcomes were collected using validated instruments including Pedi-IKDC, HSS-Pedi FABS activity score, BPII 2.0 score, Kujala score, and KOOS score.

RESULTS

Seventeen knees (12 patients) formed the study cohort. Twelve knees had habitual dislocation (9 in extension and 4 in flexion) and 5 had fixed dislocation. Mean age was 9 years. 6/17 (35.3%) knees were associated with syndromes. On magnetic resonance imaging, trochlear dysplasia was the most common anatomic risk factor present in 15/17 (88.2%) knees. 13/17 (76%) knees had presence of 2 or more risk factors. At the mean follow-up of 43.3 months, the mean Pedi-IKDC score was 88.1, the HSS-Pedi FABS activity score was 15.6, the BPII 2.0 score was 78.2, the Kujala score was 90, KOOS score was 93.9, and overall patient satisfaction score was 83.3. For complications, 3/17 knees (17.6%) had recurrent patellar instability, 1 knee had postoperative stiffness that required manipulation under anesthesia and 1 knee had a superficial wound infection.

CONCLUSIONS

Most patients with habitual and fixed patellar dislocation present during the first decade of life. There are several underlying anatomic risk factors, the most common being trochlear dysplasia and patellar tilt. The 4-in-1 quadricepsplasty technique provides reliable patellar stabilization, satisfactory clinical results, and acceptable patient-reported outcomes at a minimum 2-year follow-up, with a 17.6% redislocation rate.

LEVEL OF EVIDENCE

Level IV.

Treatment of Simultaneous Femoral Supracondylar Nonunion and Tibial Plateau Malunion along with Stiff Knee in a Young Patient: A Case Report

A 41-year-old man underwent Total Knee Arthroplasty with NexGen Legacy Constrained Condylar Knee (LCCK) system to treat his nonunion of distal femur, stiff knee, and malunion of tibia plateau. The treatment involved femoral and tibial stems and PS polyethylene. As a result, his knee range of motion improved, and he no longer experienced pain. After two years, he resumed work without any signs of loosening or stiffness.

Post-traumatic Arthritic Stiff Knee in a Malunited Distal Femur Fracture Treated with Total Knee Arthroplasty - A Case Report

Introduction

Post-traumatic knee arthritis is defined as any structural osteochondral damage to the knee after an injury. About 12% cases of symptomatic osteoarthritis of the knee mainly due to post-traumatic arthritis. Primary total knee arthroplasty in a post-traumatic arthritic stiff knee with a malunited distal femur fracture is a technically difficult procedure due to secondary deformity, poor bone quality, bone loss, ligament incompetence, tissue adhesion, and stiffness.

Case Report

A 65-year-old male presented with chief complaints of pain and stiffness in the left knee for 15 years. On inspection no scar, sinuses, and dilated veins on palpation, tenderness was present over both the medial and lateral joint lines. Radiographs of the left knee in anteroposterior and lateral views were taken, which showed united distal femur fracture with Grade 4 Kellegren Lawrence knee arthritis. Due to severe knee stiffness and with the patient demanding early mobilization and functional knee ROM, total knee arthroplasty with intra-articular and extra-articular adhesion release was planned for the patient.

Conclusion

In cases of post-traumatic arthritis with severe stiffness, total knee arthroplasty is a viable option in providing good pain relief with excellent functional improvement; however, the procedure is technically more demanding.

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.

Association Between Femoral "Spike" Size After Intramedullary Nailing and Subsequent Knee Motion Surgery

OBJECTIVES

To determine the association between displaced femoral shaft bone fragments ("spikes") seen on radiographs after intramedullary nail insertion and the need for future motion surgery.

DESIGN

Retrospective case-control study.

SETTING

Academic trauma center.

PATIENTS

We included patients with femoral shaft fractures treated with intramedullary nail insertion. Case patients (n = 22) had developed knee stiffness treated with motion surgery. The control group was a randomly selected sample (1:3 ratio).

MAIN OUTCOME MEASURES

Motion surgery to address knee stiffness. We defined a "spike distance ratio" and "spike area ratio" from initial postoperative anteroposterior and lateral radiographs. Multivariable logistic regression determined the effect of spike distance and area ratios on the likelihood of need for motion surgery, controlling for polytraumatic injuries and bilateral fractures.

RESULTS

The case group had a median femoral spike distance ratio of 1.9 [interquartile range (IQR), 1.6-2.5] compared with 1.5 (IQR, 1.2-1.8) in the control group. An increased femoral spike distance ratio was associated with increased odds of motion surgery (P < 0.01). A femoral spike distance >2 times the femoral radius had 32 times the odds (95% confidence interval, 2-752) of motion surgery compared with patients with distance ratios <1.25. Median femoral spike area ratios were similar between the case (0.2; IQR, 0.1-0.5) and control (0.2; IQR, 0.0-0.5) groups and were not associated with increased odds of motion surgery (P = 0.34).

CONCLUSIONS

A larger spike distance ratio is associated with increased odds of subsequent motion surgery.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Thompson's quadricepsplasty results in patients with knee stiffness resulted from femoral fracture

Background:

Posttraumatic and/or postsurgical knee stiffness is one of the orthopedic complications which is difficult to be treated and can affect individual's life negatively. The aim of this study is to investigate the results of quadricepsplasty in patients with knee stiffness resulted from femoral fracture.

Materials and Methods:

This is a cross-sectional study on all patients with femoral fracture which has caused knee flexion limitation referred to Kashani and Al-Zahra Hospitals in Isfahan from January 2010 to March 2013. The type and site of fracture, joint extension, and fracture fixation technique were recorded. Moreover, the range of motion (ROM) before surgery, under general anesthesia, and 3- and 6-month postoperation were measured.

Results:

Among the patients, 13 had a simple fracture (48%) and 14 had a segmental fracture (51.9%). Considering the fracture site, 11, 10, and 6 patients had femoral (40.74%), supracondylar (37.3%), and femoral supracondylar (22.2%) fractures, respectively. The fracture fixation was performed by the plate, external, and Wagner fixation techniques for 24 (88.9%), 2 (7.4%), and 1 (3.7%) patients, respectively. The mean ROM before operation, under general anesthesia, and 3- and 6-month postoperation were determined to be 33.15° ± 24.73°, 122.60° ± 10.22°, 99.63° ± 16.52°, and 100.74° ± 15.67°, respectively. The mean ROM value at various stages was not similar (P < 0.001). The mean changes in the ROM were 79.2° ± 24.6° and 62.1° ± 19.7° in the cases with simple and segmental fractures, respectively. The mean changes in the knee ROM were significantly higher in simple fractures in comparison with the segmental femoral fracture (P = 0.03).

Conclusion:

We found Thompson's quadricepsplasty may successfully increase the range of knee flexion in knee fracture and also regardless of quadriceps time.

Treatment and Rehabilitation of Knee Joints Straight Stiffness After Burns

The knee release surgery and postoperative rehabilitation of patients after burns and knee straight stiffness were investigated. Eleven patients were treated for 16 side burns and knee stiffness who consisted of nine males and two females, aged 19 to 54 years (mean = 33.2). The duration of the patients' knee stiffness ranged from 8 to 26 months, with an average of 12.6 months. Their preoperative flexion ranged from 5° to 50°, with an average of 26.2°. Their preoperative Hospital for Special Surgery (HSS) knee scores ranged from 46 to 72 points, with an average of 55.8 points. All stiff knees were treated with release surgery, along with total release of intra-articular adhesion and excision of vastus intermedius. After the arthrolysis of the stiff knee joint, the tight skin was completely loose in the adhesions. The soft tissue contracture was not grafted, but the shade fascia was freed to increase skin ductility. All knee joints were released to more than 90° of flexion in the operation, and reversed fascia flaps were used to suture the loss of the deep fascia at the position of flexion of 90°. After the operation, the knee joint was fixed in flexion for 72 h while being actively cared for by early rehabilitation. Subsequently, the patient's skin coverage, joint motion, and joint function recovery were observed. Based on the follow-up of the patients for the following 16 to 36 months (mean = 25.7), the knee flexion of the patients ranged from 110° to 135°, with an average of 122.2° and 96° increase (P < 0.01). Furthermore, the patients had better skin ductility to meet the increase in joint flexion. HSS knee function scores at the end of follow-up ranged from 93 to 100 points, with an average of 97.5 points and an increase of 41.7 points (P < 0.01). The joint function improved significantly. The arthrolysis of straight stiff knee joints after burns can ease muscle contracture and free the shade fascia, thus avoiding the need to undergo skin grafting. Short-term fixation of the joints after surgery and active flexion rehabilitation may also be the key to improve skin ductility and joint function of the patients.