The Journal of Medical Research 2017; 3(4): 195-197

Research Article
Minimally invasive posterior knee release
JMR 2017; 3(4): 195-197
1* 1 2
July- August Kevin Parfait Bienvenu Bouhelo-Pam , Espoir Amour Mokoko Louckou , Saeed Abdulrazak Badarou
1 1 1 1 1
ISSN: 2395-7565 Chaibou , Mohamed Shimi , Mohamed El Idrissi , Abdelhalim El Ibrahimi , Abdelmajid El Mrini
© 2017, All rights reserved 1 Department of osteoarticular surgery B4, Hassan II university hospital, Fez, Morocco
www.medicinearticle.com 2 Department of Trauma and orthopedic Surgery B3, Hassan II University Hospital, Fez, Morocco
Received: 21-06-2017
Accepted: 27-08-2017
Abstract

Background: Management of knee stiffness remains a subject of debate among orthopedic surgeons. There is no gain
saying that restoration of knee function greatly improves quality of life. Posterior approach offers an excellent view of
underlying causes of knee stiffness. Overall improvement in surgical approach as well as a better understanding of knee
anatomy has paved way to minimally invasive surgery. Some authors suggest a posterior release as a complement to
knee arthroscopy. The following study reports a significant improvement in knee function after posterior minimally
invasive knee arthrolysis. The authors intend by means of the present study and relevant literature to highlight the
indications, advantages and limitations of this approach. Methods: Our prospective study involving eight patients
presenting knee stiffness in flexion. They are treated by modified minimally invasive Trickey approach. Data was
analyzed using IBM software SPSS version 2015. Results: The latest range of motion at follow-up mean was 0.2 to 105
degrees and postoperative Lysholm-Tegner score mean was 88. Conclusion: Our study suggests a safe and effective
procedure for posterior knee release and the management of knee stiffness.

Keywords: Knee joint stifness, Knee release surgery, Range of motion, Articular, Walking.

INTRODUCTION

Knee stiffness, pain related or not, constitutes a permanent limitation on range of motion.If the hamstring
[1]
contracture progresses and is left untreated, the knee no longer comes to full extension . Because the
knee is never fully extended, the posterior knee capsule shortens and a fixed knee flexion contracture
develops. The knee must flex to 65° to walk along a level surface, 85° to negotiate a six-inch step and 95°
[2]
to rise from a chair easily . The treatment of fixed knee contracture depends on age of the patients and
the severity of the contracture. Structured physiotherapy and manipulation under anaesthetic may be
helpful in the early treatment of resistant cases. However, once the scar tissue has matured, the best
approach remains controversial. Posterior knee release or arthrolysis is a surgical procedure, which aims
at releasing any posterior attachments of the knee, by excising inextensible fibrotic tissue thus restoring
knee extension. It is indicated in the event of knee stiffness on flexion or on both extension and flexion,
[1, 3]
the latter often difficult to treat . The posterior knee capsulotomy is especially used in severe
contracture without the deformity of the femoral condyle. Our study aims to emphasize the medium and
long-term functional outcomes of minimally invasive posterior release for knee stiffness.

MATERIALS AND METHODS

A prospective study involving eight (08) patients presenting knee stiffness in flexion without any history of
infection, resistant to conservative treatment and physical therapy, spanning a period of four years,
between 2012 and 2016. All cases with radiological evidence of ankyloses were excluded. Functional
[4]
outcome was evaluated using Lysholm-Tegner scoring scale . Patients were installed in a prone position
[5]
with a thigh tourniquet. A modified Trickey approach following a posterior infero-medial route of the
knee on a 4-cm incision was used. Installation and approach have been shown in the picture 1. This
approach allows a sufficient exposure of the posterior capsule and various elements responsible for
*Corresponding author: retraction. Debridement is performed, as well as excision of adherences, a posterior release, with or
Kevin Parfait Bienvenu
Bouhelo-Pam without semitendinosus tendon repair referring to the picture 2, which may or not be associated with
Department of osteoarticular posterior capsulotomy. Excision and the release of anatomical elements is performed gradually and
surgery B4, Hassan II university depends on resulting functional outcome verified intraoperatively.Complementary knee immobilization in
hospital, Fez, Morocco.
extension was maintained 48 hours after surgery. Small walking steps were authorized without
Email: bopakev[at]yahoo.fr

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exaggerated knee flexion during basic daily life activities. Knee flexion reconstruction with good range of motion and functional scores. But
exercises was prohibited during the first week of recovery. A they used both posteromedial and posterolateral approaches.
rehabilitation protocol was practiced immediately after surgery for up
to 6 weeks involving mainly physiotherapy and proprioception and CONCLUSION
gradual weight bearing at least with walking aid in the beginning
depending on pain tolerance and lymphatic drainage. Postoperative Minimally invasive open posterior knee release is a safe and effective
pain control was achieved using OMS analgesic ladder. Data was procedure in the management of knee stiffness. It ensured a significant
analyzed using IBM software SPSS version 2015. Quantitative data functional outcome in all our patients. It remains indicated in cases of
comparison was done using Student’s t-test. Variationwas considered chronic knee extension deficits. There are no notable complications
statistically significant if p-value is less than 0.05. associated when the procedure is carefully performed according to
anatomical marks and direct intraoperative functional gain.
RESULTS
Conflicts of interests
A mean age of 31.6 years (ranging from 23 to 42) and a female
predominance with a sex ratio of 1/7 was observed. A single patient The authors declare no potential conflict of interest in the conduct and
had mixed stiffness while other seven patients had knee stiffness in submission of this study.
flexion only. Lesions discovered intraoperatively were posterior
capsular retractions in seven cases, adherences in six cases, capsular Contribution of the authors
shrinkages in four cases, and shrinkages of retinaculum in one case.
Average delay before consultation was 74.1 months (between 6 and All authors contributed in the study and approve final version of
168 months). An average deficit in extension of 17 degrees (from 10 to manuscript.
30) while a fixed flexion deformity of 11.4 degrees (ranging between 0
Tables and Figures
and 25). Table I summarizes range of motion in our series.
Postoperative gain in extension ranged from 13 to 18 degrees, with an Table 1: Range of motion in our series.
average of 15 degrees. An example of functional recovery in a 19-year-
old patient has been represented in the picture 3. No patient Patient Time before Preoperative Range of Latest
presented with more than 5 degrees of residual deficit in extension at consultation range of motion 6 Range of
follow-up. The following represents the overall function outcome: (months) motion months post- motion
preoperative Lysholm-Tegner score: 62 (from 46 to 68); Postoperative arthrolysis atfollow-up
Lysholm-Tegner score: 88 (from 78 to 94) (p = 0.0001). After a mean 1 6 5 - 75 0 - 115 0 - 125
follow up of 18 months (range 6 to 38) postoperative recovery were 2 105 25 - 65 2 - 100 0 - 100
marked by two cases of persistent pain. 3 53 0 - 75 0 - 125 0 - 120

DISCUSSION 4 49 20 - 40 5 - 95 2 - 100
5 73 10 - 90 2 - 115 0 - 105
Several authors recommend posterior knee arthrolysis as a
[6, 7, 8] 6 168 15 - 95 2 - 130 0 - 110
complement to most arthroscopic procedures . The above study
demonstrates the advantages of open yet minimally invasive posterior 7 68 0 - 70 0 - 85 0 - 80
approach. It offers a better view on the posterior elements of the knee. 8 71 5 - 80 0 - 90 0 - 100
Functional outcome on deficit in knee extension was significantly Mean 74.1 10 - 73.7 1.3 - 106.8 0.2 - 105
[7]
improved in our series. Freiling D et al., found similar results: gain in
extension: 17 degrees; Lysholm-Tegner score: 84 although their
approach associated arthroscopic exploration with medial anterior
parapatellar access, a postero-medial access, a section of the medial
retinaculum of the knee and postero-medial arthrotomy.Posterior
capsulotomy although unsystematic and excision of the various
elements depended on intraoperative extension gain. Lobenhoffer et
[9]
al., demonstrated an average improvement in extension of 2 degree
after posterior capsulotomy.Hamstring tendon lengthening performed
[10]
in all our patients was also practiced by Dhawlikar et al., . The
authors reported a marked improvement in the popliteal angle after
one year. No vascular nor nervous complications were recorded in our
study. Residual postoperative pain reported by two of our patients was
controlled with analgesics and physical therapy. Sciatic nerve palsy was
[11]
reported in a similar series by Woratanarat et al., and so were cases
of operating wound dehiscence and posterior cruciate ligament
instability. Sciatic nerve palsy could be attributed to lengthening of
gemelli muscles, which was not practiced in any of our cases. Open
surgery offered considerably better results compared to arthroscopy in
a knee posterior release. Mean postoperative knee extension gains
after arthroscopic release was 0.7 degrees according to LaPrade et
[12]
al., . These results are clearly inferior compared to ours as
arthroscopy generally allows only posterior capsulotomy and no
complete excision of retracted elements as well as fibrosis. Tardy et
[13]
al., have described the surgical technique of posterior open knee
release in extension deficit after anterior cruciate ligament Picture 1: Patient installation and surgical approach.

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Picture 3: Functional outcome in a 19-year-old patient, two months after

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