Judet’s Quadricepsplasty Technique Offers Excellent Functional Outcome Without an Extension Lag for Extension Contracture of the Knee: A Retrospective Cohort of 33 Patients

Abstract

Purpose

The Judet’s technique of quadricepsplasty for an extension contracture of the knee joint offers the benefit of a sequential and controlled release of the intrinsic and extrinsic soft tissue constituents restricting the knee flexion. The main principle of our study was to analyze the clinical as well as functional outcome and to assess an extension lag following Judet’s quadricepsplasty for the knee extension contracture deformity.

Materials and Methods

This is a retrospective cohort study comprises of thirty three patients, operated for extension contracture with Judet’s quadricepsplasty with the mean follow-up was 30 months. Knee range of motion of the operated knee was recorded preoperatively and at 6, 12 and 24 month follow-up after the surgery. Judet’s criteria were used to evaluate the outcomes following the procedure.

Results

92.42° (range, 60°–110°) of knee flexion was achieved after an average follow-up of 24 months compared to preoperative knee flexion was 14.09° (range 5°–25°), reflecting a 74.69° average improvement in knee flexion. Twelve patients had excellent results, nineteen had good results as per Judet’s criteria but there were no patients with extension lag. The two patients with fair results had superficial wound infection which healed without any further surgical intervention.

Conclusions

Judet’s quadricepsplasty offers sequential release without extension lag of the knee joint. Patients with the knee extension contractures deformity can be successfully managed with the Judet’s quadricepsplasty to gain useful knee motion and function.

Introduction

The knee extension contracture deformity is a serious consequence encountered after injuries around knee joint and distal femur. Seldom, it may develop following inadequate immobilization in the management of fracture shaft of femur [1]. The commonest cause for loss of the knee range of motion is inadequate rehabilitation after the surgery [2]. Knee stiffness occurs due to the peri-articular and intramuscular soft tissue adhesions. This can subsequently deteriorate into the knee extension contracture deformity. Though, the flexion contractures are more common than extension contractures of the knee, nevertheless the knee extension contracture deformity is more prone to cause disability in daily routine activities [3]. In severe cases of extension contracture of the knee the conservative treatment is usually inadequate to restore the optimum knee range of motion required for daily routine activities. Hence, the surgical intervention is required in most of these patients to achieve functional knee range of motion [1].

Management of extension contracture by the procedures such as Thompson quadricepsplasty or V–Y procedure of quadriceps lengthening is associated with variable outcome and the significant extension lag of the knee joint which may result in poor outcome. These surgeries can give adequate results in children in comparison to adult due to increase in the length of the bone with growth. This restores the tension in the quadriceps muscle [4] The Judet’s technique of quadricepsplasty, popularized by Letournel, offers the advantages of a controlled, chronological release of the intrinsic and extrinsic soft tissue constituents restricting the knee flexion and thereby reducing the tendency for quadriceps injury or the knee joint extension lag [3, 5, 6]. The main objective of our study was to analyze the clinical as well as functional outcome and to assess an extension lag following Judet’s quadricepsplasty for the knee extension contracture deformity.

Materials and Methods

This retrospective study was conducted in accordance with the Institute’s ethical committee’s standard on human experimentation between January 2007 and January 2017. Thirty three patients, operated for extension contracture with Judet’s quadricepsplasty, were included in the study. The inclusion criteria included for the cohort study were, knee flexion less than 50 degrees with skeletally mature patients, congruent joint without osteoarthritis and failure to gain flexion even after 6 months of physiotherapy. The exclusion criteria include patients with skeletally immaturity with minimal loss of flexion, infection around knee joint, osteoarthritis changes on radiographs, incongruent joint surfaces, patella Baja and previous history of patellectomy. Patient’s data which includes age, sex, mechanism of injury, type of injury, data related to fracture management and the time of initial injury to the procedure were recorded. Knee range of motion of the operated knee was recorded preoperatively and at 6, 12 and 24 month follow-up after the surgery.

The following Judet’s criteria were used to assess and classify the outcomes after the procedure [7, 8].

1. The outcome was measures as an excellent if the knee flexion postoperatively was greater than 100°

2. It was considered good if the knee flexion was between 80° and 100°

3. The knee flexion between 50° and 80° was considered fair

4. Poor, if the post operative knee flexion was less than 50°

Surgical Technique

After induction of anesthesia, the patient was draped in supine position following the standard surgical precautions (Fig. 1). Tourniquet was not used. Tranexemic acid (500 mg) was given intravenously at the time of induction to reduce the intra-operative bleeding. The contracture release was executed in three phases. In the initial phase release, two incisions were made. The first incision was made anteromedially extending from a point just medial to superior pole of patella to a point just medial to tibial tuberosity (Fig. 2A). Medial parapatellar arthrotomy was done. This incision allowed access to the patellar tendon, the medial retinaculum, the suprapatellar recess. All intra articular adhesions were removed. The second incision was made starting from distal part of the greater trochanter and extended to the lateral region of the lower pole of patella (Fig. 2B). Tight lateral retinaculum was released through this incision. Fibrous adhesions were removed from patella-femoral joint, tibio-femoral joint, medial and lateral gutters and anterior fat pad. Vastus lateralis was released from the linea aspera. The vastus intermedius was also released up from the anterior surface of the femur. Transverse incisions in fascia lata were be made at multiple levels. In the second phase, any excessive bone callus was removed meticulously without damaging the native bony cortex. Improvement in range of movement was checked intra operatively. If it was less than 100 degrees, the third phase of release was executed by releasing the vastus lateralis proximally from its origin on greater trochanter region. The rectus femoris can also be released from iliac region in severe contracture. However, we did not perform this release in any of treated case in the study group.

Fig. 1.

Pre-operative knee flexion

Fig. 2.

A Intra-operative lateral incision and knee flexion achieved. B Intra-operative picture showing medial incision

Wound closure was done without suturing the deep fascia. Drain was applied (Fig. 2A) and intermittent suturing of superficial fascia was done prior to skin closure. Dressing was done and limb was secured in maximum flexion with an anterior plaster of Paris slab. This was to ensure the minimum loss of flexion. After the removal of drain on second postoperative day, continuous passive motion of the knee was started. Active exercises were initiated when the pain is reduced, and the patient was comfortable to perform them. The suture removal was done at 2 weeks after surgery and supervised physiotherapy was continued at least for 6 weeks after the surgery. We injected 40 mg of methyl prednisolone acetate in the knee joint at 4 weeks if the range of motion did not improve and attempted flexion was painful.

Results

There were 28 males and 5 females were analyzed in this study. The age ranged from 20 to 40 years and the mean age of 32.6 years. Cases of extension contracture managed with any other procedures and patient with follow-up less than 24 months were also excluded from this study. Twenty eight patients had intra articular fractures of distal femur out of 33 patients, while 5 patients developed knee stiffness following an extra articular distal shaft femur fracture. The mean follow-up of this retrospective study was 30 months. The average duration of surgery was 120 min and average hospital stay was 5 days. The average preoperative knee flexion was 14.09° (range 5°–25°) and it improved in the operating room to 110.15° (range 90°–130°). After an average follow-up of 24 months the mean loss in knee flexion observed was 17.73° compared with the recorded range in the operating room (Fig. 3). The final flexion achieved was 92.42° (range 60°–110°) reflecting a 74.69° average improvement in knee flexion. No patients in our study group had any extension lag at the end of final follow-up (Fig. 4). According to the Judet’s criteria [7, 8], 12 patients had excellent results, nineteen had good results and two patients had fair outcome. The two patients with fair results had superficial wound infection and were treated with daily dressing and antibiotics because of which there may be inadequate physiotherapy.

Fig. 3.

Post-operative knee flexion showing loss of flexion achieved during intra-operative period

Fig. 4.

Post-operative straight leg raising showing no extension lag

Discussion

The study cohort of 33 patients shows good to excellent outcome in about 94% of the patients because of anatomical continuity of an extensor mechanism of the knee in Judet’s quadricepsplasty helps in reducing an occurrence of post operative extensor lag which is evident in our study.

Stiff knee in extension is a serious complication following peri-articular knee injuries as well as distal femur fractures more commonly due to inadequate mobilization.

Quadricepsplasty is often considered as an ideal procedure for the management of severe extensor knee contracture in a patient who is not showing any improvement in flexion even after adequate physiotherapy for more than 6 months duration. Arthroscopic arthrolysis is suitable when pathology is exclusively intra articular. Most of the intra articular and distal femur shaft fractures are treated by plating, thus making the pathology both intra articular and extra articular; such a situation would require quadricepsplasty. Although 70° flexion is optimum for walking, this would not be sufficient for daily routine activities, such as squatting and stair climbing. In young active patient, the minimum 110° flexion is required for performing most of the daily routine activities. However, careful selection of patient is very important for good prognosis for quadricepsplasty procedure [9]. Thompson quadricepsplasty was described for the treatment of knee stiffness. This technique involves the detachment of the vastus lateralis, vastus medialis and vastus intermedius from the patella through an anterior midline approach. The rectus femoris alone is left intact to facilitate knee extension. An inherent risk of Thompson quadricepsplasty is the possibility of developing an extension lag and shown by many authors due to insufficient power of rectus femoris to oppose the hamstrings or to maintain extension at the knee as it takes the body weight when walking [10–15].

Judet’s procedure offers a staged correction and involves sequential release of the involved intrinsic and extrinsic components to correct the extension contracture deformity of the knee joint. It is based on the principle of muscle release and sliding which results in minimum damage to the quadriceps mechanism. Because of many reasons described by many authors the risk of iatrogenic extension lag is reduced in Judet’s technique [7, 8, 11, 16, 17].

Our Results are comparable to the results reported by Judet’s [18] and by many other authors [4, 6–8, 11, 17]. We have achieved good to excellent outcome 94% of the patients which is comparable to results of Bari MM et al. [4], Manimaran et al. [19] and Oliveira et al. [16] but in contrast to these authors we have not released rectus femoris proximally, whereas all these authors released rectus femoris proximally at stage 3 release of soft tissue. Other authors [6–8, 11, 13, 17] have reported good to excellent result in and around 80% of their respective cohort which is inferior to our result, this may be due to better selection of the patients for the procedure and absence of extensor lag in our result.

Various modifications to the index technique have been proposed in the recent years. Paley proposed proximal release of rectus femoris from the ilium before the release of vastus lateralis and vastus intermedius from the femur [1]. Hussein et al. described another modification of Judet’s quadricepsplasty for the management of extensor contracture of knee. In their technique, incisions are made on both the sides of the rectus femoris to separate it from the vastus lateralis and medialis. Subsequently vastus intermedius is also separated from both the rectus femoris and the patella by blunt dissection to create a band of rectus femoris muscle [20]. Lee et al. also described a technique that combined quadricepsplasty and the Ilizarov fixation for correcting extension contracture after fracture around the knee joints. They treated 10 patients with this technique and reported improvement in knee range of motion without rebound phenomenon. Rebound phenomenon is reported often after the treatment of stiff knee with the Ilizarov frame or quadricepsplasty alone [21].

Wang et al. suggested a mini incision quadricepsplasty for the treatment of severe stiff knee [22]. They treated 22 patients and achieved the mean flexion gain of 88°. Lengthening of the quadriceps tendon was performed in 16 patients. Extension lag was reported in all the 16 cases. However, it resolved between 3 and 6 months postoperatively in 15 cases but persisted in 1 case. In comparison, Judet’s quadricepsplasty depends on sliding of the rectus femoris in cases of severe knee stiffness and extensor lag is not observed frequently after the surgery as was also reflected in our study group.

The reported rate of complications has been up to 23% and it included deep sepsis, skin necrosis, wound dehiscence, quadriceps tendon rupture, loss of extension or severe post-operative pain, intra-operative patellar fracture or lateral femoral condyle fracture [23]. The most common complication of several studies [4, 6–8, 11, 16, 17, 19] are infection such as we encountered in 6% of patients in our series. Adequate rehabilitation in post-operative period is very important to maintain the intra-operative range of motion. Besides a good surgical release of extensor mechanism, proper patient counseling, adequate pain control and physical therapy are essential components for obtaining the desired outcome. The limitations of this study are that it is a retrospective study with absence of control group, small number of cases. The randomized study with comparison to other technique would have helped to understand the advantages and disadvantages of Judet’s quadricepsplasty.

Conclusions

Judet’s quadricepsplasty, though proposed in middle of the twentieth century, offers sequential release without extension lag of the knee joint and reproduces good to excellent outcomes in majority of the patients with extensor contracture of the knee. Judet’s quadricepsplasty also provides less probability of extensor lag in the post operative period due to non-disruption in the anatomy of the extensor mechanism of the knee.

Author Contributions

RM: Contribution Patient selection, Performed Surgery. VkD: Contribution Study design, surgery assistant, manuscript proof reading. SJ: Contribution Study design, performed measurements, manuscript preparation.

Funding

No funding from any source is received for the study.

Declarations

Conflict of interest

There are no conflicts of interests of any kind from the authors of the manuscript.

Ethical approval

Consent from all the patients was taken for the participation in the study and proper ethical committee approval is taken for the study and publication.

Informed consent

For this type of study informed consent is not required.