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Robinson E. Pires
Federal University of Minas Gerais
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ORIGINAL ARTICLE
Abstract
Background Knee stiffness is a challenging complication following complex fractures around the knee. Several treatment
strategies have been described in the last decades, but clinical results and complication rates still remain as potential draw-
backs. The aim of this study was to access the clinical outcomes and complications of the modified Judet quadricepsplasty
following knee stiffness secondary to complex fractures around the knee.
Methods A total of 11 patients presenting post-traumatic knee stiffness underwent modified Judet quadricepsplasty from
2014 to 2017. All procedures were performed by the same surgical team, and all patients followed the same postoperative
pain control and rehabilitation protocols. No patients underwent medial approach for medial release. When necessary, medial
release was performed through the lateral approach. Patients were evaluated using the Judet criteria for final range of motion
after 1-year minimum follow-up.
Results According to the Judet criteria, 4 patients (36.4%) presented excellent, 6 (54.5%) good, and 1 (9.1%) poor clinical
outcomes. Blood transfusion was required in 5 patients (45.4%). No patients presented infection or wound dehiscence.
Conclusions Although quadricepsplasty is considered a high morbidity surgical procedure, our favorable functional outcomes
with very low complication rates using this modified Judet quadricepsplasty confirmed safety and efficacy of this helpful
surgical procedure for the challenge of post-traumatic knee stiffness.
Level of evidence Level 4 retrospective case series.
Keywords Knee stiffness · Distal femur fractures · Tibial plateau fractures · Judet quadricepsplasty · Floating knee
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European Journal of Orthopaedic Surgery & Traumatology
Several treatment strategies have been used for knee stiff- of motion was performed by the same surgical team with a
ness, including physiotherapy, manipulation under anesthe- manual goniometer. Knee function was assessed with the
sia, arthroscopic release, quadriceps release under endo- Knee Society Score (KSS).
scopic view, and quadricepsplasty using the standard Judet This study included 11 patients (9 male and 2 female)
and Thompson techniques or their variants [4–14]. with knee stiffness. Age ranged from 25 to 48 years old (33
The aim of this study was to evaluate the efficacy and average). All patients were followed up for a minimum of
safety of the modified Judet quadricepsplasty in patients 12 months (average 22.9 months).
presenting post-traumatic knee stiffness.
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European Journal of Orthopaedic Surgery & Traumatology
2. Removal of bone protuberances that could disturb the Postoperatively, an epidural catheter was applied with
freedom of movement and all the adhesions between continuous infusion of 0.125% bupivacaine at 4 ml/hour,
any hardware and soft tissues was performed. Vastus for 48 h.
intermedius was released and then lifted off the anterior Partial weight bearing using crutches was permitted,
and lateral surfaces of the femur extraperiosteally. Vas- with load progression according to patient tolerance. Con-
tus lateralis was detached from the linea aspera until the tinuous passive motion (CPM) was initiated in the immedi-
level of the greater trochanter (Fig. 1d). After stages 1 ate postoperative period (day 0). Maximal flexion accord-
and 2, cautious knee manipulation was performed. ing to patient tolerance was intended. In the first 15 days,
3. If knee flexion was still limited, skin incision was pro- CPM was used continuously (24/7 h/day). Subsequently,
longed proximally and the rectus femoris detached from CPM was interspersed with active and passive assisted
its insertion at the anterior inferior iliac spine. Another exercises until the end of the first month (6 h of CPM/
knee manipulation was subsequently performed. Hard- day). Then kinesiotherapy was used alone until complete
ware removal before Judet procedure was not performed rehabilitation (average of 30 sessions encouraging active
due to fracture risk. If necessary, hardware removal can exercises).
be indicated after finishing all the stages of knee release. Patient discharge was usually allowed after 7–9 days.
Functional Judet criteria were applied after 1 year.
Figures 2 and 3 depict 2 cases of knee stiffness treated Results were considered excellent when final flexion was
using modified Judet quadricepsplasty (Figs. 2 and 3). greater than 100°, good when the final flexion was between
Tourniquet was not used. After soft tissue closure (only 80 and 100°, poor when the final flexion was between 50
skin and subcutaneous were sutured), a single suction drain and 80°, and bad when the final flexion was less than 50°.
was used to prevent hemarthrosis. A bulk compressive dress-
ing was applied using an elastic bandage wrapping from
foot to thigh.
Fig. 2 a and b Preoperative images showing knee stiffness with 23° of flexion. c Intraoperative image after the modified Judet quadricepsplasty
showing 121° of knee flexion. e and f Images of the knee during CPM
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European Journal of Orthopaedic Surgery & Traumatology
Fig. 3 a A female patient sustained a tibial plateau fracture and evalu- during the first 48 h after the surgical procedure. d CPM regulated in
ated with knee stiffness. Observe preoperative flexion of 40°. b Intra- 120° of knee. e Lateral view of the knee still with stitches after two
operative knee view after modified Judet quadricepsplasty showing weeks post-surgery. f Lateral view of the knee in flexion during CPM
120° of flexion. c Epidural catheter with bupivacaine for pain control
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European Journal of Orthopaedic Surgery & Traumatology
Table 2 The time from injury, pre- and postoperative KSS from the extra-articular procedure to obtain at least 90° of
Patient Time from injury Preoperative Postop-
flexion. Eight patients gained 90° or more of flexion [14].
(months) KSS erative Complication rates were relatively low, and the authors
KSS recommend this technique as a helpful procedure in obtain-
ing additional flexion in patients with ankylosis caused by
1 23 71 93
extra-articular fibrosis of the quadriceps [14].
2 13 69 87
However, quadricepsplasty with or without arthroscopic
3 17 65 91
release remains the standard treatment for complex knee
4 42 61 85
stiffness. Several variants of the standard quadricepsplas-
5 27 55 78
ties described by Judet and Thompson have been reported
6 15 72 90
in the literature.
7 28 63 91
Thompson described his procedure based on isolating the
8 21 60 78
rectus femoralis completely from the vastus. If the rectus
9 19 62 90
femoralis is tight, Thompson recommended V–Y plasty [9,
10 21 59 86
19].
11 26 58 76
Judet quadricepsplasty, as originally described or with
Average 22.9 63.1 85.9
some variations, is probably the most used technique for
treating complex knee stiffness, especially in combined
(intra-articular and extra-articular) patterns.
arthroscopic intra-articular release. The authors used a Although Judet quadricepsplasty is unquestionably a
proximal endoscopic subperiosteal extension of the usual major procedure, favorable functional outcomes supplant
arthroscopic intra-articular release of adhesions, using the complication rates. The complication rate reported in
arthroscopic scissors and periosteal elevators placed through the literature rise up to 23%, including deep infection, wound
lateral and medial superior knee portals. In a total of 26 dehiscence, skin necrosis, patellar tendon rupture, extension
patients, two patients presented extensive fibrosis of the lag, and femoral fracture [17, 20–23]. In our series of 11
quadriceps muscle and precarious skin condition subsequent patients, even with 45.4% requiring blood transfusion due
to burns and gained between 20° and 49°. Seven patients to a high morbidity procedure, no infection or wound dehis-
gained 50° to 69° from the extra-articular procedure for a cence, neither other major complication were observed, and
total flexion of 75° or more. Nine patients gained 70° to 89° just one patient presented poor functional outcome.
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European Journal of Orthopaedic Surgery & Traumatology
Table 3 Comparison of our Author Number of Preopera- Intraopera- Final flexion Flexion gain Flexion loss
outcomes with the literature patients tive flexion tive flexion
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European Journal of Orthopaedic Surgery & Traumatology
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