All operations are performed with use of spinal anesthesia. The patient is
placed on the operating table in the supine position.
The operative procedure begins with a mini-invasive quadricepsplasty
followed by arthroscopic lysis of the arthrofibrotic knee. The
quadricepsplasty is performed in a standard sequence, consisting of five
stages. The range of flexion is measured after each stage of release, and the
quadricepsplasty procedure is terminated when the desired degree of flexion
(ideally, 120°) is achieved. Through a 2 to 4-cm longitudinal incision,
extending proximally from a point 3 cm proximal to the superolateral corner of
the patella, the quadricepsplasty is accomplished
(Fig. 1). A blunt curved
dissection scissor is the primary instrument used for the procedure.
The first stage consists of a release of the lateral patellar retinaculum.
With an inside-out technique, a percutaneous parapatellar lateral arthrotomy
is made by incising the lateral retinaculum from the patella along its lateral
border, from the superolateral corner of the patella down to the lateral
aspect of its lower pole (Fig.
2). In addition, to restore the lateral recess, the lateral
retinaculum is freed from the lateral condyle of the femur. Likewise, the
vastus lateralis tendon and the iliotibial band are freed from the distal
one-third of the femur.
The second stage consists of mobilizing the suprapatellar pouch, the
patellofemoral compartment, and the anterior interval by dividing the
adhesions within these spaces (Figs. 3-A
and 3-B). The anterior interval is the region of the knee
posterior to the infrapatellar fat pad and anterior to the anterosuperior
aspect of the tibial
plateau8. The
tendinous tissue of the vastus intermedius is separated from that of the
rectus femoris and the anterior surface of the femur
(Fig. 3-C). 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 typically intact and
can generally be more easily separated from the rectus and the femur.
CRITICAL CONCEPTSINDICATIONS:When a plateau of <90° of knee flexion movement during physiotherapy
has been reached at least three months after injury, an operative
quadricepsplasty is indicated. However, careful patient selection is paramount
because this is a major surgical procedure requiring vigorous postoperative
physiotherapy, which usually has to be continued for at least six months. This
part of the treatment requires the utmost cooperation and unremitting effort
from the patient, and unwavering compliance and motivation are essential for a
satisfactory outcome. This should be made clear to the patient and repeatedly
emphasized from the start.The mini-invasive operation is particularly indicated in cases in which
skin conditions are precarious on the anterior aspect of the knee as a result
of previous open trauma or operative procedures.CONTRAINDICATIONS:Quadricepsplasty is contraindicated in the presence of the following:Complex regional pain syndromeMarked disuse osteopenia around the kneeMechanical causes of limited motion, including loss of articular
congruency, interruption of the extensor mechanism, a meniscal tear or a loose
body, a cyclops lesion, or ligament graft malpositionQuadriceps muscle dysfunction secondary to neurological deficitFusion of the patella to the anterior aspect of the femurThe aforementioned issues must be addressed before or during the
quadricepsplasty procedure to ensure success.PITFALLS:Since flexion manipulation is an essential maneuver during the
quadricepsplasty procedure, in cases in which retained hardware around the
knee is to be removed at the same time, we suggest that the hardware not be
removed until after the quadricepsplasty procedure is accomplished, to avoid
creating a fracture during manipulation through stress risers created by empty
screw-holes.During the quadricepsplasty procedure, we prefer to regularly probe the
remnant fibrous bands between the extensor mechanism and the femur with a
gloved finger to identify and release any residual tight bands that could lead
to a loss of flexion.Vigorous postoperative physiotherapy has to be continued for at least six
months in order to obtain a good range of motion, and almost every effective
exercise is very painful for every patient. Normally, we do not use nerve
blocks or continuous epidural anesthesia for analgesia. If necessary,
nonsteroidal anti-inflammatory drugs or tramadol hydrochloride are
administered to control pain induced by the vigorous postoperative
physiotherapy.
CRITICAL CONCEPTS
INDICATIONS:
When a plateau of <90° of knee flexion movement during physiotherapy
has been reached at least three months after injury, an operative
quadricepsplasty is indicated. However, careful patient selection is paramount
because this is a major surgical procedure requiring vigorous postoperative
physiotherapy, which usually has to be continued for at least six months. This
part of the treatment requires the utmost cooperation and unremitting effort
from the patient, and unwavering compliance and motivation are essential for a
satisfactory outcome. This should be made clear to the patient and repeatedly
emphasized from the start.The mini-invasive operation is particularly indicated in cases in which
skin conditions are precarious on the anterior aspect of the knee as a result
of previous open trauma or operative procedures.
When a plateau of <90° of knee flexion movement during physiotherapy
has been reached at least three months after injury, an operative
quadricepsplasty is indicated. However, careful patient selection is paramount
because this is a major surgical procedure requiring vigorous postoperative
physiotherapy, which usually has to be continued for at least six months. This
part of the treatment requires the utmost cooperation and unremitting effort
from the patient, and unwavering compliance and motivation are essential for a
satisfactory outcome. This should be made clear to the patient and repeatedly
emphasized from the start.
The mini-invasive operation is particularly indicated in cases in which
skin conditions are precarious on the anterior aspect of the knee as a result
of previous open trauma or operative procedures.
CONTRAINDICATIONS:
Quadricepsplasty is contraindicated in the presence of the following:
Complex regional pain syndromeMarked disuse osteopenia around the kneeMechanical causes of limited motion, including loss of articular
congruency, interruption of the extensor mechanism, a meniscal tear or a loose
body, a cyclops lesion, or ligament graft malpositionQuadriceps muscle dysfunction secondary to neurological deficitFusion of the patella to the anterior aspect of the femur
Complex regional pain syndrome
Marked disuse osteopenia around the knee
Mechanical causes of limited motion, including loss of articular
congruency, interruption of the extensor mechanism, a meniscal tear or a loose
body, a cyclops lesion, or ligament graft malposition
Quadriceps muscle dysfunction secondary to neurological deficit
Fusion of the patella to the anterior aspect of the femur
The aforementioned issues must be addressed before or during the
quadricepsplasty procedure to ensure success.
PITFALLS:
Since flexion manipulation is an essential maneuver during the
quadricepsplasty procedure, in cases in which retained hardware around the
knee is to be removed at the same time, we suggest that the hardware not be
removed until after the quadricepsplasty procedure is accomplished, to avoid
creating a fracture during manipulation through stress risers created by empty
screw-holes.
During the quadricepsplasty procedure, we prefer to regularly probe the
remnant fibrous bands between the extensor mechanism and the femur with a
gloved finger to identify and release any residual tight bands that could lead
to a loss of flexion.
Vigorous postoperative physiotherapy has to be continued for at least six
months in order to obtain a good range of motion, and almost every effective
exercise is very painful for every patient. Normally, we do not use nerve
blocks or continuous epidural anesthesia for analgesia. If necessary,
nonsteroidal anti-inflammatory drugs or tramadol hydrochloride are
administered to control pain induced by the vigorous postoperative
physiotherapy.
The third stage consists of releasing the medial patellar retinaculum
through the suprapatellar pouch, patellofemoral compartment, and anterior
interval that were reestablished in the second stage. This is again performed
percutaneously with use of the inside-out technique. Particular care is taken
to delineate the medial arthrotomy margin, which starts from the medial
epicondyle of the femur and slants laterally to the tibial tubercle, to avoid
detaching the vastus medialis from its insertion at the superomedial corner of
the patella (Figs. 1 and
4). The medial retinaculum is
freed from the medial condyle of the femur, and the vastus medialis is freed
from the distal one-third of the femur to restore the medial recess.
AUTHOR UPDATE:There have been no changes in the surgical technique since the publication
of the original article.
AUTHOR UPDATE:
There have been no changes in the surgical technique since the publication
of the original article.
The fourth stage consists of transecting the previously mobilized vastus
intermedius at a level near to its musculotendinous junction
(Fig. 5-A).
The fifth stage consists of lengthening the quadriceps tendon. The rectus
femoris is transected at a more distal level than the vastus intermedius,
adjacent to its patellar insertion (Fig.
5-A). The free tendinous ends of the vastus intermedius and rectus
femoris are then delivered through the wound
(Fig. 5-B). Gentle manipulation
of the knee in flexion is then repeatedly performed until maximum flexion is
achieved. The proximal tendinous end of the vastus intermedius and the distal
portion of the rectus femoris tendon are then overlapped and sutured with a
number-2 nonabsorbable Ethibond suture with the knee held in 90° of
flexion (Figs. 5-C and 5-D).
The passive range of motion at the completion of the repair of the quadriceps
tendon is tested to ensure that the lengthened tendon is under substantial
tension but remains competent at 90° of flexion. If the knee can be flexed
beyond 90° easily, the overlapping is increased by more proximal
advancement of the vastus intermedius tendon to reduce the risk of creating an
extension lag. If flexion is restricted, the overlapping is decreased by more
distal fixation of the vastus intermedius tendon.
Manipulation in flexion is performed periodically throughout the operation
to release intraarticular adhesions, to assess the arc of knee flexion, and to
determine if there are remaining extra-articular adhesions. Once flexion in
excess of 120° has been achieved, the extra-articular portion of the
operative procedure is terminated, closed suction drains are placed, and the
skin is closed.
In severely arthrofibrotic knees, both intra-articular and extra-articular
structures are extensively involved in pathological fibrosis and adhesions to
varying degrees. The medial and lateral parapatellar recesses, suprapatellar
pouch, infrapatellofemoral compartment, and anterior interval can be
completely obliterated by dense scar and fibrous tissue, which usually have to
be released as described, in a progressive, sequential fashion. The
extra-articular structures, including the quadriceps, the iliotibial band, and
the medial and lateral retinacula, are fibrotic, contracted, scarred, and
severely adherent to the distal one-third of the femur and should also be
freed gradually and subperiosteally on the medial, anterior, and lateral
aspects of the femur. During the quadricepsplasty procedure, we prefer to
frequently probe the remaining fibrous bands between the extensor mechanism
and the femur with a finger and to release any that could lead to loss of
flexion.
In cases of moderate arthrofibrosis, the first four stages often allow knee
flexion beyond 120°. In contrast, in cases of severe arthrofibrosis, the
fifth stage (quadriceps lengthening) is most often necessary to gain knee
flexion beyond 90°.
After the initial mini-invasive quadricepsplasty, the primary arc of knee
flexion should reach 90° (more than 90° of flexion would place the
repair at risk for the lengthened quadriceps tendon), and the suprapatellar
pouch, patellofemoral compartment, anterior interval, lateral recess, and
medial recess are reestablished. With these spaces restored, arthroscopic
surgery can be safely performed with easy insertion of instruments and
adequate visualization.
The arthroscopic treatment is accomplished through proximal anterolateral
and anteromedial portals. Additionally, a superolateral portal can be added as
necessary for the arthroscope or for instrumentation. First, intra-articular
abnormalities are systematically evaluated by means of routine arthroscopic
assessment and are appropriately treated. Then, as much scar tissue as
possible is released, especially in the medial and lateral parapatellar
recesses, the suprapatellar pouch, the intrapatellofemoral compartment, the
anterior interval, and the intercondylar notch. Usually, the density of the
scar tissue is too great to be débrided with motorized shavers, so we
prefer to use radiofrequency ablation; frequently, heavy scissors, robust
baskets, and motorized shavers are all needed to incise and excise the
offending scar tissue. In cases of graft impingement following anterior
cruciate ligament reconstruction, a notchplasty is performed. If the anterior
cruciate ligament graft has been placed too anteriorly, it is partially or
completely excised. When nodules that block knee extension are present in the
intercondylar notch, they are thoroughly removed.