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Safety and efficacy of the modified Judet quadricepsplasty in patients with

post‑traumatic knee stiffness

Article in European Journal of Orthopaedic Surgery & Traumatology · April 2021

DOI: 10.1007/s00590-020-02802-3

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Fernando Bidolegui Sebastian P. Pereira

Hospital Sirio Libanes Hospital Sirio Libanes, Argentina, Buenos Aires
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European Journal of Orthopaedic Surgery & Traumatology
https://doi.org/10.1007/s00590-020-02802-3

ORIGINAL ARTICLE

Safety and efficacy of the modified Judet quadricepsplasty in patients

with post‑traumatic knee stiffness
Fernando Bidolegui1 · Sebastian P. Pereira1 · Robinson E. Pires2

Received: 16 June 2020 / Accepted: 3 October 2020

© Springer-Verlag France SAS, part of Springer Nature 2020

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

Abbreviations for early rehabilitation and therefore prevent knee stiffness.

CPM Continuous passive motion However, even with using all standard surgical principles of
ROM Range of motion articular fracture fixation, knee stiffness can still occur, thus
KSS Knee Society Score treatment represents a dilemma.
The life quality impact of a stiff knee is extremely high.
Normal gait requires full extension and about 70° of knee
Background flexion. Climbing stairs requires about 80° of knee flexion.
Around 100° of knee flexion are required to go downstairs,
With the increase in high-energy trauma, complex fractures depending on the stair height. Rising from a chair may need
around the knee are becoming relatively frequent. Articu- around 90° of knee flexion, also depending on the chair
lar congruency, anatomic articular surface restoration, knee height [1, 2].
alignment, and especially stable fixation are crucial to allow Knee stiffness can be classified as intra-articular, extra-
articular, or a mix of both. Intra-articular stiffness occurs
due to disorderly fibrous scar tissue proliferation, soft tis-
* Robinson E. Pires
[email protected] sue retraction, and bone impingement secondary to intra-
articular malunion. Extra-articular stiffness occurs due to
1
Department of Orthopaedic Surgery, Sirio Libanes Hospital, quadriceps adhesions to a femoral callus, muscle retraction
Buenos Aires, Argentina and ligament adhesions, as well as skin adhesions to the
2
Department of the Locomotor Apparatus, Federal University deeper soft tissue layers [3].
of Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa
Efegênia, Belo Horizonte, Minas Gerais, Brazil

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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.

Methods Surgical technique and postoperative

protocol
Collection of outcome data
The surgical procedure was performed in three stages,
All patients from a tertiary hospital presenting post-trau- according to Judet [10, 15–17]:
matic knee stiffness who underwent Judet quadriceplasty
from 2014 to 2017 met the inclusion criteria. Patients 1. A lateral parapatellar incision started on the tibial ante-
excluded were those who did not adhere to the rehabilita- rior tuberosity level and extended proximally, just below
tion protocol, those treated with an arthroscopically assisted the greater trochanter (Fig. 1a). Release of the lateral
release or medial parapatellar arthrotomy and those who lost retinaculum and release of the adhesions in the supra-
follow-up. Preoperative manipulation under anesthesia and patellar gutter and between the patella and the femoral
arthroscopic release were not performed. condyles was performed (Fig. 1b). Unlike the original
All patients were operated on by the same team of fellow- Judet technique, we did not perform an additional medial
ship-trained and board-certified orthopedic trauma surgeons. approach in any case. When necessary, medial release
Complications were evaluated after a minimum follow-up was performed through the lateral approach. Therefore,
of 1 year. Judet criteria for evaluation of range of motion we consider this procedure as a modification of the orig-
were applied after 1-year follow-up. Measurement of range inal Judet quadricepsplasty (Fig. 1c).

Fig. 1  a Illustration of the anter-

olateral parapatellar approach. b
Release of the lateral retinacu-
lum and release of the adhesions
in the suprapatellar gutter and
between the patella and the fem-
oral condyles. c Medial release
performed through the lateral
approach. Vastus intermedius is
also released and lifted off the
anterior and lateral surfaces of
the femur extraperiosteally. d
Vastus lateralis is detached from
the linea aspera until the level
of the greater trochanter with a
periosteal elevator

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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

Results Blood transfusion was required in 5 patients (45.4%). No

patients presented infection or wound dehiscence.
Functional outcomes, according to the Judet criteria, were
excellent in 4 patients (36.4%), good in 6 (54.5%), and
poor in 1 (9.1%). Discussion
Average of preoperative flexion was 36° (23–50°).
Average of intraoperative flexion was 125.4° (118–135°). Management of complex fractures around the knee remains
Average of final flexion after rehabilitation was 98.9° defiant. High energy trauma can lead to knee stiffness due
(75–120°). Average of flexion loss from the intraoperative to severe soft tissue damage, prolonged immobilization or
to final evaluation was 27.7°. Average of flexion achieved use of external fixator, and in consequence of postoperative
using the modified Judet technique in this case series was complications.
62.2°. Preoperative Knee Society Score average was 63.1 Early physiotherapy is usually the first step to prevent
and postoperative, 85.9. knee stiffness. However, anatomic articular fracture reduc-
Table 1 details patient data, such as gender, age, injury tion, knee alignment, and stable fixation are crucial to allow
pattern, pre-, intra-, and postoperative flexion, final flexion for early gain of mobility.
after rehabilitation, and degree of flexion loss (Table 1). Another treatment possibility is manipulation under anes-
Table 2 depicts the time from injury, pre- and postop- thesia. However, history of extensor mechanism rupture
erative KSS score (Table 2). and premanipulation range of motion (ROM) < 30° or flex-
No patients presented preoperative or postoperative ion < 40° are potential risk factors for treatment failure [18].
extension deficit. Blanco et al. reported favorable outcomes by using endo-
scopic release of quadriceps adhesions in combination with

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European Journal of Orthopaedic Surgery & Traumatology

Table 1  Epidemiologic data and degree of achieved flexion

Patient Age Gender Injury Preop- Intraop- Postop- Final flexion Flexion loss
erative erative erative
flexion flexion flexion

1 28 M Intra-articular distal femur fracture 40o 125o 99o 98o 27o

2 32 M Extra-articular distal femur fracture + patella fracture 23o 121o 95o 90o 31o
3 48 F Tibial plateau fracture 40o 120o 114o 96o 24o
4 40 M Extra-articular distal femur fracture + tibial plateau 32o 130o 110o 75o 55o
fracture
5 31 M Extra-articular distal femur fracture + tibial plateau 35o 135o 85o 90o 45o
fracture
6 28 M Extra-articular distal femur fracture + tibial plateau 50o 125o 90o 120o 5o
fracture
7 35 M Extra-articular distal femur fracture + patellar tendon 30o 130o 100o 120o 10o
rupture
8 25 M Tibial plateau fracture 30o 118o 100o 90o 28o
9 34 M Intra-articular distal femur fracture 42o 125o 110o 110o 15o
10 40 M Intra-articular distal femur fracture 38o 120o 90o 85o 35o
11 28 F Extra-articular distal femur fracture + tibial plateau 36o 130o 95o 100o 30o
fracture
Average 33 36o 125.4o 99o 98.9o 27.7o

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

Massé 21 23.1o 106o 95.6o 72.4o 10.4o

Tugrul 11 30o 111.3o 100o 70o 51.7o
Pérsico 31 17o 102o 82o 65o 20o
Alí 10 33o 105o 88o 55o 17o
Ebbrahimzadeh 40 30.7o 124o 95.7o 65o 28.3o
Our outcomes 11 36o 125.4o 98.9o 62.2o 27.7o
Average 28.3o 112.3o 93.4o 64.9o 25.8o

It is noteworthy that, even without using a medial

approach for medial release, our functional outcomes were
quite similar to the literature. Our final flexion was 98.9° Author contributions FB, SPP, and REP made substantial contribu-
tions to study design and conception. FB and SPP were responsible for
on average, with 27.7° of flexion loss, compared to the data acquisition and analysis. FB, SPP, and REP were responsible for
measurement achieved intraoperatively. Table 3 depicts our data interpretation and manuscript preparation. FB and SPP performed
functional outcomes compared to the literature [17, 20–23] all surgical procedures. All authors have read and approved the final
(Table 3). manuscript version.
We did not found any association between the final range
Funding The authors received no financial support for this research,
of motion and the time lapse from the previous injury to authorship, and/or publication for this article.
quadriceplasty. It is also noteworthy that the final range of
motion was not related with the preoperative flexion. This Compliance with ethical standards
would allow expecting satisfactory results regardless the
time since the previous injury and the preoperative range Conflict of interest REP received honorarium for educational activi-
of motion. ties from Zimmer Biomet AND AO Foundation. FB AND SPP declare
Our study presents some limitations. Our case series is that they have no conflict of interest.
limited to 11 patients, thereby compromising a more faithful Consent for publication The manuscript contains no individual per-
statistical analysis, especially in terms of complications eval- sonal data. No consent for publication was necessary.
uation. Moreover, our final functional evaluation was per-
formed with at least 1-year follow-up. Some patients were Ethical approval This study has been approved by the institutional
research ethics committee and has been performed in accordance with
evaluated more than one year after the procedure, which is the ethical standards as laid down in the 1964 Declaration of Helsinki.
a potential bias. However, we believe this information does
not compromise the results, since the probability of an ROM
change after 1 year is quite remote.
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