Judet's Quadricepsplasty Technique Offers Excellent Functional Outcome for Extension Contracture of the Knee

The Judet's technique of quadricepsplasty for an extension contracture of the knee joint offers the benefit of a sequential and controlled release of the intrinsic and extrinsic soft tissue constituents restricting the knee flexion.

Ravi Mittal et al conducted a study to analyze the clinical as well as functional outcome and to assess an extension lag following Judet's quadricepsplasty for the knee extension contracture deformity.

A retrospective cohort study was conducted with thirty three patients, operated for extension contracture with Judet's quadricepsplasty with the mean follow-up was 30 months. Knee range of motion of the operated knee was recorded preoperatively and at 6, 12 and 24 month follow-up after the surgery.

The following Judet's criteria were used to assess and classify the outcomes after the procedure.

1. The outcome was measures as an excellent if the knee flexion postoperatively was greater than 100°

2. It was considered good if the knee flexion was between 80° and 100°

3. The knee flexion between 50° and 80° was considered fair

4. Poor, if the post operative knee flexion was less than 50°

The contracture release was executed in three phases. In the initial phase release, two incisions were made - the first incision was made anteromedially extending from a point just medial to superior pole of patella to a point just medial to tibial tuberosity. Medial parapatellar arthrotomy was done. All intra articular adhesions were removed. The second incision was made starting from distal part of the greater trochanter and extended to the lateral region of the lower pole of patella. Tight lateral retinaculum was released through this incision. Fibrous adhesions were removed from patella-femoral joint, tibiofemoral joint, medial and lateral gutters and anterior fat pad. Vastus lateralis was released from the linea aspera. The vastus intermedius was also released up from the anterior surface of the femur. Transverse incisions in fascia lata were be made at multiple levels.

In the second phase, any excessive bone callus was removed meticulously without damaging the native bony cortex. Improvement in range of movement was checked intra operatively. If it was less than 100 degrees, the third phase of release was executed by releasing the vastus lateralis proximally from its origin on greater trochanter region. The rectus femoris can also be released from iliac region in severe contracture.

Anterior plaster of Paris slab was applied to ensure the minimum loss of flexion. After the removal of drain on second postoperative day, continuous passive motion of the knee was started. Active exercises were initiated when the pain is reduced, and the patient was comfortable to perform them. The suture removal was done at 2 weeks after surgery and supervised physiotherapy was continued at least for 6 weeks after the surgery. 40 mg of methyl prednisolone acetate was injected in the knee joint at 4 weeks if the range of motion did not improve and attempted flexion was painful.

Key findings of the study were: There were 28 males and 5 females were analyzed in this study.

• The age ranged from 20 to 40 years and the mean age of 32.6 years.

• 92.42° (range, 60°–110°) of knee flexion was achieved after an average follow-up of 24 months compared to preoperative knee flexion was 14.09° (range 5°–25°), reflecting a 74.69° average improvement in knee flexion.

• Twelve patients had excellent results, nineteen had good results as per Judet's criteria but there were no patients with extension lag. The two patients with fair results had superficial wound infection which healed without any further surgical intervention.

The authors concluded that – "Judet's quadricepsplasty, though proposed in middle of the twentieth century, offers sequential release without extension lag of the knee joint and reproduces good to excellent outcomes in majority of the patients with extensor contracture of the knee. Judet's quadricepsplasty also provides less probability of extensor lag in the post operative period due to non-disruption in the anatomy of the extensor mechanism of the knee."

Further reading:

Judet's Quadricepsplasty Technique Offers Excellent Functional Outcome Without an Extension Lag for Extension Contracture of the Knee: A Retrospective Cohort of 33 Patients Ravi Mittal, Vijaykumar Digge et al Indian Journal of Orthopaedics (2022) 56:1913–1917 https://doi.org/10.1007/s43465-022-00696