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A New Treatment Strategy for Severe Arthrofibrosis of the KneeA Review of Twenty-Two Cases
Jian-Hua Wang, MD1; Jin-Zhong Zhao, MD1; Yao-Hua He, MD1
1 Department of Orthopaedic Surgery, Shanghai Jiao Tong University Sixth People's Hospital, 600 YiShan Road, Shanghai 200233, People's Republic of China. E-mail address for J.-H. Wang: shwangjianhua@hotmail.com
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Shanghai Jiao Tong University Sixth People's Hospital, Shanghai, People's Republic of China

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Jun 01;88(6):1245-1250. doi: 10.2106/JBJS.E.00646
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Abstract

Background: To reduce the morbidity of traditional quadricepsplasty for the treatment of severe arthrofibrosis of the knee, we instituted a treatment regimen consisting of an initial extra-articular mini-invasive quadricepsplasty and subsequent intra-articular arthroscopic lysis of adhesions during the same anesthesia session. The purpose of the present study was to determine the results of this technique.

Methods: From 1998 to 2001, twenty-two patients with severely arthrofibrotic knees were managed with this operative technique. The mean age of the patients at the time of the operation was thirty-seven years. After a mean duration of follow-up of forty-four months (minimum, twenty-four months), all patients were evaluated according to the criteria of Judet and The Hospital for Special Surgery knee-rating system.

Results: The average maximum degree of flexion increased from 27° preoperatively to 115° at the time of the most recent follow-up (p < 0.001). According to the criteria of Judet, the result was excellent for sixteen knees, good for five, and fair for one. The average Hospital for Special Surgery knee score improved from 74 points preoperatively to 94 points at the time of the most recent follow-up (p < 0.001). A superficial wound infection occurred in one patient. Only one patient had a persistent 15° extension lag.

Conclusions: This mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Jian-Hua Wang, M.D.
    Posted on October 25, 2006
    Dr. Wang et al. respond to Dr. Garg
    Shanghai Jiao Tong University Sixth People's Hospital, 600 YiShan Road, Shanghai 200233, PRCHINA

    To The Editor:

    We appreciate the interest of Dr. Garg and colleagues in our article(1) and the opportunity to clarify the following two reservations raised by them.

    As to severe arthrofibrosis of the knee with an extension contracture, although in most cases, the muscular tissue of the vastus intermedius is severely fibrotic and scarred, its tendinous part in the distal one-third is relatively intact, and can be separated comparatively easily.

    In the initial mini-invasive quadricepsplasty, both the medial and the lateral retinaculum are released. Adhesions in the anterior interval, the suprapatellar pouch, the patellofemoral compartment, and the anterior interval are divided. With the help of arthroscopy, as much scar tissue as possible can be incised and excised with direct visualization.

    Reference:

    1. Wang JH, Zhao JZ, He YH. A New Treatment Strategy for Severe Arthrofibrosis of the Knee. A Review of Twenty-Two Cases. J Bone Joint Surg Am 2006; 88: 1245-1250.

    Bhavuk Garg
    Posted on July 28, 2006
    Drs. Jiang and Liu respond to Dr. Rompe
    All India Institute of Medical Sciences, New Delhi, INDIA

    To The Editor:

    The authors have described excellent results and easy postoperative rehabilitation with their technique; however we have several reservations about their procedure.

    When there is severe arthrofibrosis of the knee with an extension contracture, there is extensive fibrosis of the vastus intermedius muscle, sometimes to such a severe extent that it becomes a fibrotic cord. In the Thompson quadricepsplasty (1), the cord is excised. How do the authors identify the musculotendinous junction in such a fibrotic muscle?

    What is the rationale for performing arthroscopy after quadricepsplasty when the authors already have gained 120 degrees of flexion? If one has cleared the scar tissue from the suprapatellar area, released both medial and lateral retinaculum, and cleared the anterior interval through a small incision at superolateral corner of patella, there is no need for arthroscopy. It can be justified in those cases with ACL involvement, but even in them arthroscopy should be done first.

    The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

    References:

    1. Thompson TC. Quadricepsplasty to improve knee function. J Bone Joint Surg.1944; 26:366 -79

    2. Judet R. Mobilization of the stiff knee [abstract]. In: Proceedings of the British Orthopaedic Association. J Bone Joint Surg Br. 1959; 41:856 -7

    3. Nicoll EA. Quadricepsplasty. J Bone Joint Surg Br. 1963;45:483 -90

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