Dr Anil Jain MS, FRCSProfessor of

Orthopaedics University College of

Medical Sciences,Delhi

&Editor

Indian Journal of Orthopaedics

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

Anatomy of knee stiffnessBetween full flexion to full extension- patella

travels -9 cms (3.5 inches)This is the excursion of RF4 ways to block flexionAll prevent distal excursion of patella during

flexion

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

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.

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

Post traumatic knee stiffnessFemoral shaft fracture – NU,DU, normal

unionFracture femoral condyleFracture dislocation of kneeFracture 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,

Knee contrcture in extensioncommonly 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,

Some issues -IndicationsWhich knee to be operated-Any pt with total range of 70 degree will be

happyThis 70 degree in functional arc ( 20-90)

would be better than 50-120Career specific range

Some issues–when to interveneSufficient time has elapsed from initial event

and no further improvement is occuring with physiotherapy

And Will not improve without operation.

Some issues- expectationsIf a pt gains 0-90 degree – it is a good

outcome of surgeryPredictors of outcome- Preoperative ROM Intraoperative gains in ROMGood postoperative mobilization programme.

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.

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.

ManipulationManipulation 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 .

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

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.

Surgical procedureIncision-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.

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

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.

Key issues Not to use tourniquet If used achieve satisfactory hemostasis Hematoma delays the progressAftercare ----Put knee on pearson knee attachment – that will

allow gravity assisted flexion and passive extentionOr CPMMore vigrous physiotherapy will give better

outcome.May require manipulation

Problems and obstaclesScar 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

periodRegains in one year – if RF is intactIf RF damaged – than may have extention lag.

Thompson quadricepsplastyResult – 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.

Chang Gung Med J. 2007 May-Jun;30(3):263-9. Modified Thompson quadricepsplasty to treat extension contracture of the

knee 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.

J Bone Joint Surg Br. 2000 Sep;82(7):992-5. A modified Thompson quadricepsplasty for the stiff knee. Hahn SB 1987 -1997modified 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.

Modified quadricepsplastySkin 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 ROMAnterolateral or lateral incision to release

adhesion around quadriceps muscles.

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.

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

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.

Advantages- controlled and sequential release of components limiting knee flexion

Theoretically reduces the potential for iatrogenic extention lag.

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 Judet's quadricepsplasty for loss of knee flexion. Alici T et.al.

Clin Orthop Relat Res. 2003 Oct;(415):214-20. Judet's 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 laginvolves less soft tissue dissection less blood loss.

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.

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.

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

Step 1- remove intraarticular obstaclesBy lateral or medial incisions

Step 2 – release extraarticular ObstaclesVM,VI and VL released

Distract the jointThan achieve flexionObviates the disadvantagesExtensor lagWound problem Rebound phenomennon of ilizarov

J Bone Joint Surg Am. 2007 Mar;89 Suppl 2 Pt.1:93-102. A new treatment 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.

•First stage – release of lateral patellar retinaculae•Percutaneous parapatellar lateral arthrotomy•Release lateral retinaculae fromlateral condyle of femur•VL and ilio tibial band freed• from distal femur

Stage two - mobilize suprapatellar pouch , PF compartment, anterior intervali.e. posterior to infrapatellar fat pad and anterior superior part of tibial plateau

Stage three- medial parapatellar release – med patellar retinaculae, PF and anterior interval

Fourth stage – transect VI at musculo-tendinous junctionfifth stage – lengthening of quadriceps tendon

Usually 90 degrees are gained But gives enough space for arthroscopic intraarticular release

Keep on manipulating in between the procedureClosed suction drainPost op management-IV mannitolCompressive dressingPhysical therapy

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.

N=19 post trauma stiffness combined intra- and extra- articular aetiology release- infrapatellar, suprapatellar and gutter adhesions, extra-articular proximal adhesions

Mean active flexion ( 1 Yr FU) 27.3 degrees to 119.3 degrees Mean extension lag from 6 degrees to 1 degrees No CPM daily PT Overall patient satisfaction was excellent; Arthroscopic aided quadriceps adhesion release is a good option

Arthroscopy. 1993;9(6):685-90. Stiffness of the knee--mixed arthroscopic and subcutaneous technique: 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.

Conclusions CausesManipulationQuadricepsplastyPost surgery protocolsArthroscopy assisted or minimally invasive

procedures

Thanks very much indeed for patient hearing

Thank you very much for patient hearing

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.

Plast Reconstr Surg. 2007 Jan;119(1):203-10. The advantages of free 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.

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.

J Pediatr Orthop B. 2004 Jul;13(4):254-8. Treatment of

severe 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.

J Bone Joint Surg Br. 2003 Mar;85(2):261-4. Quadricepsplasty for knee stiffness after femoral lengthening in congenital short femur. 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.

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. OBJECTIVE: Extension stiffness of knee joint is always treated by the quadricepsplasty, but the main deficiency of this method is that patient feels weakness of lower limb and easily kneels down. The aim of this article is to explore the method to resolve the complications after quadricepsplasty. METHODS: Since 1978 to 1997, on the basis of traditional procedures of quadricepsplasty, sartorius muscle was used to reinforce the extension of knee joint. The lower 2/3 of sartorius muscle was fully dissociated only with its insertion intact. A tendon-periosteal-bone flap, about 2 cm in width, was managed on the anterior surface of patella, with its pedicle on the medial edge of patella. The tendon-periosteal-bone flap was used to fix the dissociated sartorious into patella to reinforce the extension of knee joint. The very lower part of sartorius was mainly aponeurosis, with the help of an aponeurosis bundle of iliotibial tract, it was fixed into the insertion of patellar ligament, through a bony tunnel chiseled adjacent to the insertion of patellar ligament. By now the movement of knee joint extension was strengthened by the transferred sartorius muscle. Postoperatively, every patient was required to extend and flex knee joint actively and/or passively. Altogether 12 patients were treated, 9 of them were followed up with an average of 14 months. RESULTS: The average movement was increased from 15 degrees to 102 degrees, and the average myodynamia was improved from grade II to grade IV. CONCLUSION: Traditional quadricepsplasty co-operated with transfer of sartorius muscle can strengthen the myodynamia of knee joint extension. It is simple method and can really achieve good function.

Arthroscopy. 2001 May;17(5):504-9. Endoscopic quadricepsplasty: A new surgical technique. Blanco CE, Leon HO, Guthrie TB. Orthopaedic Division, Hospital Hermanos Ameijeiras, Havana, Cuba. We present a new surgical subperiosteal endoscopic technique for the release of fibrosis of the quadriceps to the femur caused by gunshot injuries, postsurgical scarring, and fractures, that was developed at the Arthroscopy Group at Hospital Hermanos Ameijeiras in Havana, Cuba. The technique used is a proximal endoscopic subperiosteal extension of the usual arthroscopic intra-articular release of adhesions, using periosteal elevators and arthroscopic scissors placed through medial and lateral superior knee portals to release adhesions and bands of scar tissue beneath the quadriceps mechanism. The technique was used in a prospective case series of 26 male patients aged 19 to 22 years between February 1997 and March 1998 who presented with clinically and ultrasonically documented extra-articular fibrosis resulting in ankylosis of the knee in extension. Only patients who had reached a plateau in their aggressive physiotherapy program with no further progression in knee flexion for 3 months were selected. Those with joint instability, motion-limiting articular surface pathology, and muscle or neurologic injury were excluded. All patients had obtained satisfactory results at 2-year follow-up. The extra-articular release gained at final follow-up was between 30 degrees and 90 degrees of flexion in addition to that obtained at the completion of the standard intra-articular release. Complications included 1 case of deep vein thrombosis, 2 cases of scrotal edema, 5 cases of hemarthrosis, and 2 cases of reflex sympathetic dystrophy. We have found this technique useful in obtaining additional flexion and improved function in a difficult class of patients with ankylosis caused by extra-articular fibrosis of the quadriceps to the femur, allowing immediate aggressive rehabilitation and presenting a useful outpatient alternative with fewer and less severe complications than described with the classic open Thompson's quadricepsplasty.

Mil Med. 2000 Apr;165(4):263-7. Quadricepsplasty after war fractures. fractures by explosive devices, intra-articular

fractures of the knee,N=10 . were treated by the external fixation methodmanifested markedly decreased knee flexion (15-

70 degrees, with an average of 32 degrees). After quadricepsplasty and physical therapy, the achieved knee flexion was enough for normal

walking (80-130 degrees, average 97.5 degrees). Mean knee mobility was increased 65.5 degrees..

Arthroscopy. 1998 Mar;14(2):212-4. Arthroscopically assisted percutaneous quadricepsplasty: a case report and description

of a new technique. . To our knowledge an arthroscopically

assisted method of performing a quadricepsplasty has not been previously described. We present such a case and the details of the arthroscopically assisted method that may provide an alternative, minimally invasive means of restoring knee flexion in the setting of a post-traumatic extension contracture.

Acta Orthop Belg. 1996 Jun;62(2):79-82. The Judet

quadricepsplasty: a retrospective analysis of 16 cases. severe extension contractures of the knee -

16 Preoperatively = average of 23 degrees flexion. 30 degrees flexion preoperatively = 2.

average improvement in knee flexion - 69 deg

11 (68.7%) patients achieving a final flexion of 90 degrees or more.

15 degrees loss of terminal active extension - 4. rapid recurrence of the contracture – 1

a deep infection 1 acute compartment syndrome - 1.

Injury. 1993 Feb;24(2):104-8. Quadricepsplasty following femoral shaft fractures. 12 quadricepsplasties performed on 10

patients with stiff knees following united femoral shaft fractures .

multiple operations and delayed union. The increased range of flexion achieved in this series is higher than in those reported previously.

Z Orthop Ihre Grenzgeb. 1982 May-Jun;120(3):250-8. [Results of knee joint arthrolysis surgery (author's transl)] [Article in German] Blauth W, Hassenpflug J. This work reports the results of operative treatment of knee-stiffness from 1973-1981 in the Department of Orthopaedic Surgery, University Kiel. 42 out of 46 occurrences of age, were post-operatively controlled. In most cases the stiffness was of traumatic origin. In more than one half of the cases the pre-operative controlled. In most cases the stiffness was of traumatic origin. In more than half of the cases the pre-operative degree of motion was less than 60 degrees. Intraarticular revision alone or extraarticular revision alone or a combination of both and other bone surgery was performed in approximately 1/4 of the patients respectively. The absolute range of motion, an average of 58 degrees pre-operatively, improved to 114 degrees post-operatively. The mean relative improvement of motion, in regard to a norm of 140-0-0 degrees, was 68% at discharge. Among our patients complication were seldom. In our opinion operative arthrolysis in indicated cases is a tried and proven method for treatment of stiff knees.

Knee contrcture in extensionAdhesions - single common factor .in synovial cavity, especially is supra

patellar pouch, in capsular and periarticular tissue, between quadriceps and the femur and fascia latae and the femur. Vastus intermedius most commonly

affected by fibrosis. Adhesions of rectus femoris/ vastus medialis are rare whole quadriceps mass may be involved.

Knee. 2006 Aug;13(4):280-3. Epub 2006 May 2. Modified Judet's quadricepsplasty for loss of knee flexion. Alici T et.al.

N=11 average follow-up of 49 months mean pre-operative knee flexion - 30

degrees final follow-up to 100 degrees extension lag –no . excellent (3) , good ( 7) useful procedure to correct the disabling

flexion loss in the knee.

West Indian Med J. 2005 Sep;54(4):238-41. Judet quadricepsplasty

for extension contracture of the knee. Rose RE. Thompson quadricepsplasty - variable return

of knee flexion and possibility of significant extension lag.

Judet quadricepsplasty – controlled, sequential release of the intrinsic

and extrinsic components limiting knee flexion

reduced potential for iatrogenic quadriceps rupture or extension lag. The modified Judet quadricepsplasty has definite advantages over the Judet technique since it usually involves less soft tissue dissection and consequently less blood loss.

Clin Orthop Relat Res. 2003 Oct;(415):214-20. Judet's quadricepsplasty, surgical technique, and results in limb reconstruction. Ali AM et.al. Judet's technique - potential advantages less damaging to the quadriceps mechanism addresses external fixator pin site tethering on lateral

side n- 10 consecutive patients treated with EF minimal followup of 20 months.flexion of 33 degrees to 105 degrees in OT and to 88

degrees on final . one fair, seven good, and two excellent results. postoperative complications, one hematoma and one

infection. extension lag (10 degrees ) developed in one patient.

Judet quadricepsplasty successfully increases flexion range with minimum impairment of quadriceps function.

Surgical Procedure:- An arthroscopic sheath and blunt trocar are inserted through standard

anteromedial and anterolateral portals. The blunt trocar is carefully passed beneath the patella and suprapatellar pouch. The trocar is used to bluntly disrupt any adhesion in suprapatellar pouch and in both medial and lateral gutters. If adhesions are dense, patellofemoral joint usually is spared. The debridement is started in peripatellar region and extended outwards. Once the suprapatellar pouch has been restored, an inflow canula is inserted through a superior portal. The dissection is continued down into the medial and lateral gutters and compartments and finally into the intercondylar area. Occasionally proliferation of fibrous tissue is present within the intercondylar notch and anterior regions; this should be removed because it may limit the extension. Some investigators recommended a lateral retinacular release as part of the procedure if patellar mobility is restricted after the arthroscopic release. After the systemic lysis of adhesions, a gentle manipulation is performed. A bulky compressive dressing is applied.

It is helpful to perform this procedure with the patient under a continuous epidural anesthesia, which is maintained for 2 to 3 days after surgery. The patient is placed on a continuous passive motion immediately after surgery. The suction drain is removed after 2 days

Knee contrcture in extension Fibrosis of vastus intermedius muscle,

scarring down to the rectus femoris to the femur in suprapatellar pouch and proximally.

Adhesions between the patella and the femoral condyles.

Fibrosis and shortening of lateral expansions of vasti and their adherence to the femoral condyles.

Actual shortening of rectus femoris muscle.

J Knee Surg. 2008 Jan;21(1):39-42. A conservative approach to quadricepsplasty: description of a modified surgical technique and a report of three cases. Hussein R et.al.

Various techniques ,large exposures, a permanent extensor lag.

technique with limited exposure, principles remain the same