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1. Dr Anil Jain MS, FRCS Professor of OrthopaedicsUniversity College of Medical Sciences, Delhi & Editor Indian Journal of Orthopaedics 2. Definition extention contracture of the knee due to extrarticular, intraarticular or combined pathology. Clinically it is often difficult to differntiate between predominantly intraarticular or extraarticular component Extrarticular pathology -due to quadriceps scarring, the affected knee has some degree of flexion possible when the hip is flexed and roentgenograms reveal an apparently normal joint space 3. Anatomy of knee stiffness Between full flexion to full extension- patella travels -9 cms (3.5 inches) This is the excursion of RF 4 ways to block flexion All prevent distal excursion of patella during flexion 4. Causes of blocking Fibrosis of VI – ties deep surface of RF to the front of femur in suprapatellar pouch and above. Adhesions of deep surface of patella to the femoral condyle Fibrosis and shortening of lateral expansion of vasti and their adherence to lateral aspect of femoral condyle. Actual shortening of RF 5. Clinically difficult to differntiate---- predominantly intraarticular or extraarticular component. Only extrarticular due to quadriceps scarring, knee has some degree of flexion possible when the hip is flexed roentgenograms even may reveal an apparently normal joint space. 6. Causes most commonly after fracture of thigh intraarticular fracture of the distal femur. Other causes of knee contracture – Post total knee arthroplasty Immobilization of knee for a period of 8 weeks or more, Arthogryposis; Cerebral palsy, Poliomyelitis, Spina bifida, Haemophilia 7. Post traumatic knee stiffness Femoral shaft fracture – NU,DU, normal union Fracture femoral condyle Fracture dislocation of knee Fracture of tibial plateau Contracture of knee may occur with the knee in complete extension, in flexion alone, or in flexion, external rotation, and valgus position, 8. Knee contrcture in extension commonly occurs ----- fracture of femur or extensive soft tissue damage of anterior aspect of thigh, scarring or fibrosis of all or part of the quadriceps mechanism, chronic osteomyelitis of femur/sequale of septic arthritis of knee. following total knee replacement, 9. Some issues -Indications Which knee to be operated- Any pt with total range of 70 degree will be happy This 70 degree in functional arc ( 20-90) would be better than 50-120 Career specific range 10. Some issues–when to intervene Sufficient time has elapsed from initial event and no further improvement is occuring with physiotherapy And Will not improve without operation. 11. Some issues- expectations If a pt gains 0-90 degree – it is a good outcome of surgery Predictors of outcome- Preoperative ROM Intraoperative gains in ROM Good postoperative mobilization programme. 12. Treatment Prevention – mobilize knee early Stiff knee – no improvement by physical therapy surgery indicated. Various techniques ---- gentle manipulation under anaesthesia, quadricepsplasty, quadricepsplasty by limited approach, quadricepsplasty with mini-incision and arthroscopic. 13. Manipulation contraindicated if any pathologic process- an inflammed joint following early injury or operation Caution- severe osteoporosis sudden, vigorous manipulation may lead to fractures around knee. successful manipulation - if the patella is relatively mobile, no fibrosis in suprapatellar region the resistance is elastic. does not work in an old contracture. 14. Manipulation Manipulation useful following total knee replacement. under GA with full muscle relaxation. No Undue force can feel adhesion separating and ROM improving. Post manipulation ------- the knee in fully flexed position. Ice –bags Immediate supervised active exercises . 15. Quadriceplasty: a surgical procedure to the quadriceps muscle Thompson Judet. success depends on; If rectus femoris muscle has escaped injury. How well the rectus femoris muscle can be isolated from the scarred parts of the quadriceps mechanism. How well the muscle can be developed by active use. Success on post surgery PT 16. Thompson quadriceplasty: Thompson (1944). RF freed completely from rest of the quadriceps vastus intermedius - if scarred - excise aponeurotic expansion of other vasti are divided on either side of patella. 17. Surgical procedure Incision- anterior incision from proximal one third thigh to patella . Exact location depends on position of scars. The medial and lateral para patellar two incisions approach by Hahn et al. The deep fascia is divided in line with skin incision. 18. Surgical procedure:- rectus femoris muscle separated to full extent separated from VM and VL. anterior capsule of knee joint including the lateral expansions of vasti on both side of patella are divided far enough to overcome their contracture. vastus intermedius is completely excised, rectus femoris if destroyed - creat a new from ant. scar 19. Surgical procedure:- knee is slowly flexed to 110 degree remaining intrarticular adhesions are released. If the flexion still does not improve RF tendon is to be lengthened should be avoided as best as possible Subcutaneous tissue and fat is interposed between VM ,VL and rectus. If these muscles are relatively normal, these are sutured to rectus as far distally as the distal third of thigh. 20. Key issues Not to use tourniquet If used achieve satisfactory hemostasis Hematoma delays the progress Aftercare ---- Put knee on pearson knee attachment – that will allow gravity assisted flexion and passive extention Or CPM More vigrous physiotherapy will give better outcome. May require manipulation 21. Problems and obstacles Scar problem – delays recovery –incision Infection ???? Extention lag – most common complication, 10 deg in 67% cases – Moore et.al. ( J trauma 1987) 18 deg in 33% cases – Pick RY . ( Clin Ortho 1976) Usually 20 degree or more in immediate post op period Regains in one year – if RF is intact If RF damaged – than may have extention lag. 22. Thompson quadricepsplasty Result – variable amount of return of knee flexion Extensor lag has been reported to be as high as 67%. affect the stability of the knee some patients may require continuous bracing. extensor lag more if flexion attained on the operation table 90-100 degrees. 23. Chang Gung Med J. 2007 May-Jun;30(3):263-9. ModifiedThompson quadricepsplasty to treat extension contracture of theknee after surgical treatment of patellar fractures. Huang YC, N- 28 extension contractures , surgical treatment of patellar fractures FU = 2 years arc of motion improved from 72 degrees to 123 degrees (p < 0.001). no significant surgical complications. CONCLUSION: This surgical technique has a high success rate with few complications. 24. J Bone Joint Surg Br. 2000 Sep;82(7):992-5. A modifiedThompson quadricepsplasty for the stiff knee. Hahn SB 1987 -1997 modified Thompson quadricepsplasty N = 20 stiff knees mean FU of 35 months (24 to 52). mean active flexion was 113.5 degrees (75 to 150). mean final gain in movement was 67.6 degrees (5 to 105). deep infection - 1 The modified Thompson quadricepsplasty with appropriate postoperative care can give good results. 25. Modified quadricepsplasty Skin incision – medial and lateral parapatellar incision and anterolateral incision Step wise release – first medial and lateral retinaculae and adhesion in suprapatellar, femoral condyle and intraarticular If no adequate gain in ROM Anterolateral or lateral incision to release adhesion around quadriceps muscles. 26. The Judet Quadricepsplasty: Judet (1959) technique using principal of muscle disinsertion and sliding minimises damage to quadriceps mechanism Advantages - a controlled, sequential release of the intrinsic and then the extrinsic components which are limiting the knee flexion It reduces potential for iatrogenic quadriceps rupture or extension lag. 27. Surgical Procedure:- two incisions: short medial parapatellar incision The medial retinaculum suprapatellar pouch and intra articular adhesions are released through this incision. The suprapatellar pouch is mobilized. long lateral incision 28. Surgical Procedure:- Patella and lateral retinacular tissues are freed ensuring that patella may be easily lifted off the femoral candyles. The vastus lateralis is completely released from the linea aspera and from the greater trochanter. The vastus intermedius lifted extra periosteally from lateral and anterior surfaces of femur. The vastus medialis is not disturbed If necessary the rectus femoris is released from its iliac origin. Meticulous haemostasis is achieved, suction drains are inserted and only skin is closed. 29. Advantages- controlled and sequential release of components limiting knee flexion Theoretically reduces the potential for iatrogenic extention lag. 30. West Indian Med J. 2005 Sep;54(4):238-41. Judet quadricepsplasty for extension contracture of the knee. Rose RE. Knee. 2006 Aug;13(4):280-3. Epub 2006 May 2. Modified Judets quadricepsplasty for loss of knee flexion. Alici T et.al. Clin Orthop Relat Res. 2003 Oct;(415):214-20. Judets quadricepsplasty, surgical technique, and results in limb reconstruction. Ali AM et.al. mean pre-operative knee flexion - 30 degrees final follow-up to 100 degrees Advantage – no iatrogenic quadriceps rupture or extension lag involves less soft tissue dissection less blood loss. 31. Postoperative treatment same for both Quadricepsplasty. immobilization after surgery -50 degree less than the maximal flexion obtained at surgery. maintained for 2 to 3 days CPM until 90deg of passive flexion achieved. The Thomas knee splint with Pearsons attachment is useful Passive and active exercises for quadriceps and hamstrings is exercised during the day with active and active assisted exercises. 32. Arch Orthop Trauma Surg. 1986;104(6):346-51. Continuous passive motion after knee-joint arthrolysis under catheter peridural anesthesia. Ulrich C, Burri C, Wörsdörfer O. Adequate analgesia by continuous anesthesia via a peridural catheter; in combination with continuous passive motion, N=22 improvement ROM - 39 degrees to 120 degrees. Gain depends – not on severity of contracture but on -- etiology of the stiffness is more important. 33. JOT -201010 pts of metaphyseal fractures over 7 yrs periodStep one – removal of intraarticular obstaclesStep two - removal of extraarticular obstacleStep three- gradual distraction by ilizarov fixator 34. Step 2 – release extraarticular Obstacles VM,VI and VL releasedStep 1- removeintraarticular obstaclesBy lateral or medialincisions 35. Distract the jointThan achieve flexionObviates the disadvantagesExtensor lagWound problemRebound phenomennon of ilizarov 36. J Bone Joint Surg Am. 2007 Mar;89 Suppl 2 Pt.1:93-102. A newtreatment strategy for severe arthrofibrosis of the knee.Surgical technique. Wang JH, Zhao JZ, He YH. extra-articular mini-invasive quadricepsplasty and subsequent intra- articular arthroscopic lysis of adhesions 1998 to 2001, N=22 severely arthrofibrotic knees. The mean age - 37 years. mean duration of follow-up 44 mos RESULTS: flexion increased from 27 degrees to 115 degrees excellent (16) , good (5), and fair (1). superficial wound infection - one. persistent 15 degrees extension lag in one. CONCLUSIONS: This mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome. 37. •First stage – release of lateralpatellar retinaculae•Percutaneous parapatellarlateral arthrotomy•Release lateral retinaculaefromlateral condyle of femur•VL and ilio tibial band freed• from distal femur 38. Stage two - mobilize suprapatellar pouch ,PF compartment, anterior intervali.e. posterior to infrapatellar fat pad andanterior superior part of tibial plateau 39. Stage three- medial parapatellarrelease – med patellar retinaculae, PFand anterior interval 40. Fourth stage – transect VI at musculo-tendinous junction fifth stage – lengthening of quadriceps tendon Usually 90 degrees are gained But gives enough space for arthroscopic intraarticular release 41. Keep on manipulating in between the procedureClosed suction drainPost op management-IV mannitolCompressive dressingPhysical therapy 42. Arthroscopy assisted Quadricepsplasty: to reduce the morbidity of traditional Quadricepsplasty . initial extaarticular mini invasive Quadricepsplasty followed by intraarticular arthrocopic lysis of adhesions a gentle manipulation after the release. Sprague - mean gain of flexion of 28 degrees and improvement of extension of 6 degrees after arthroscopic procedures. Arthroscopic methods are more successful in increasing flexion than in increasing extension. ideal time to perform the operation is with in the first 9 months after injury. The best results were obtained in 7 months. The results detoriated notably after one year. The age of the patient does not affect the end result. 43. N=19post trauma stiffness combined intra- and extra- articular aetiology release- infrapatellar, suprapatellar and gutter adhesions, extra-articular proximal adhesionsMean active flexion ( 1 Yr FU) 27.3 degrees to 119.3 degreesMean extension lag from 6 degrees to 1 degreesNo CPM daily PTOverall patient satisfaction was excellent;Arthroscopic aided quadriceps adhesion release is a good option 44. Arthroscopy. 1993;9(6):685-90. Stiffness of theknee--mixed arthroscopic and subcutaneoustechnique: results of 67 cases. . mixed-cause stiffness of the knee: intraarticular and extraarticular. N= 67 cause of stiffness - mostly ligamentous surgery, (76%). Preoperative ROM - 11 deg ex and 89 deg flex. arthroscopic arthrolysis Outcome generally excellent. 45. Conclusions Causes Manipulation Quadricepsplasty Post surgery protocols Arthroscopy assisted or minimally invasive procedures 46. Thanks very much indeed forpatient hearing 47. Thank you very much for patient hearing 48. Am J Sports Med. 1987 Jul-Aug;15(4):331-41.Infrapatellar contracture syndrome. infrequently recognized cause of posttraumatic knee morbidity. combination of restricted knee extension and flexion associated with patella entrapment. occur primarily as an exaggerated pathologic fibrous hyperplasia of the anterior soft tissues of the knee beyond that associated with normal healing. secondarily to prolonged immobility and lack of extension associated with knee surgery, particularly intraarticular ACL reconstruction. IPCS follows a predictable natural history which is divided into three stages. Symptoms, diagnostic findings, and recommended treatment are determined by the stage at presentation. best treated by an anterior intraarticular and extraarticular capsular debridement and release, followed by extensive rehabilitation. 28 consecutive cases . At followup 3 months to 4 years postoperation, the patients had averaged 2.3 additional surgical procedures following their index procedure or injury. The average increase in extension at followup was 12 degrees with the average increase flexion 35 degrees. Eighty percent of patients demonstrated signs and symptoms consistent with patellofemoral arthrosis; 16% of the patients demonstrated patella infera. prevention or early detection and aggressive treatment are the only ways of avoiding complication in these problem cases. 49. Plast Reconstr Surg. 2007 Jan;119(1):203-10. The advantages offree tissue transfer in the treatment of posttraumatic stiff knee.Ulusal AE, et.al Open fractures of the distal femur involving the joint, surrounding ligament, and soft tissues are among the worst types of injuries that may eventually lead to stiff knee. Release procedures + simultaneously applied free flaps N- 9 with posttraumatic severe stiff knees All patients underwent release procedures, In addition, free tissue transfers were performed at the same stage as the release procedures to cover the resultant soft-tissue defects or carried out at a secondary stage because of wound-healing problems. The mean follow-up period was 38 months. RESULTS: Complete flap survival was 100 percent. no infection or wound-healing problems CONCLUSION: Surgical reconstruction with the use of free flaps to cover soft-tissue defects, providing remarkable advantages for postoperative rehabilitation. 50. J Pediatr Orthop B. 2005 May;14(3):219-24. Quadricepsplasty in arthrogryposis (amyoplasia): long-term follow-up. Fucs PM, Svartman C, de Assumpção RM, Lima Verde SR. Orthopaedic Department, Santa Casa Medical School and Hospitals, Pavilhão Fernandinho Simonsen, São Paulo, Brazil. Eight patients with arthrogryposis multiplex congenita (amyoplasia type) (11 knees) with knee hyperextension deformity underwent quadricepsplasty and were analyzed during an average follow-up period of 11 years and 2 months. The results were clinically analyzed based on gait pattern, range of movement, and orthotic requirements. Joint congruency was evaluated by radiography according to the Leveuf Pais classification. A satisfactory result was the correction of the deformity, articular congruency, sufficient range of movement, adequate gait pattern and no need for orthosis. A satisfactory outcome occurred in five of the eight patients (eight knees). We considered an unsatisfactory result when any of these conditions occurred. Our experience demonstrated that the quadricepsplasty corrected the hyperextension deformity of the knee joint, improved function, gait pattern, and maintained the muscle power of the quadriceps. 51. J Pediatr Orthop B. 2004 Jul;13(4):254-8. Treatment ofsevere iatrogenic quadriceps retraction in children. severe iatrogenic infantile quadriceps retraction two different surgical techniques of quadricepsplasty: Judet technique other based on Thompson techniques. N= 76 FU 3 years - maximal knee flexion average of -3 to 81 degree in the first group 37 to 115 degree in the second group. The most frequent complications - skin necrosis after the Judet quadricepsplasty and active extension lag after the Thompson procedure. 52. J Bone Joint Surg Br. 2003 Mar;85(2):261-4. Quadricepsplastyfor knee stiffness after femoral lengthening in congenital shortfemur. N- 5 children stiffness of the knee after femoral lengthening for congenital short femur using an Ilizarov external fixator Unifocal lengthening distal metaphysiodiaphyseal region -mean gain of 6.5 cm. mean percentage lengthening was 24%. At the end of one year after removal of the Ilizarov frame and despite intensive physiotherapy all patients had stiffness. Physiotherapy was continued after the quadricepsplasty and, at the latest follow-up (mean 27 months), the mean active flexion was 102 degrees (80 to 130). The gain in movement ranged from 50 degrees to 100 degrees.. Quadricepsplasty is a useful procedure for stiffness of the knee after femoral lengthening which has not responded to physiotherapy. 53. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 1999 Nov;13(6):355-8. [Application of sartorius muscle in the quadricepsplasty] [Article in Chinese] Chen QS, Zhu LX, Chen X. Department of Orthopedic Surgery, Zhujiang Hospital, First Military Medical University, Guangzhou, Guangdong, P. R. China, 510282.
