Technical Note

Minimally Invasive Quadricepsplasty

Flávio dos Santos Cerqueira, M.D., Guilherme Augusto T. Araújo Motta, M.D.,
José Leonardo Rocha de Faria, M.D., Diego Perez da Motta, M.D.,
Fernando dos Santos Cerqueira, M.D., and Fernando Adolphson, M.D.

Abstract: A modification of range of motion of the knee can significantly change a patient’s quality of life. In general,
range of motion of 0 to 125 is adequate for most activities of daily life. The rate of knee arthrofibrosis after ligament
reconstruction is reported to be between 0% and 4%; after tibial fracture due to high-energy trauma, the rate is about 7%,
with an undetermined incidence after limb lengthening. The purpose of this study was to describe a modification of the
operative technique of Judet. We describe minimally invasive quadricepsplasty in 4 steps, aiming to obtain an end result
with an arc of movement of at least 120 to 130 . We believe that our technique is a good option for the treatment of the
stiff knee, having low morbidity and being an easy method to perform.

A modification of range of motion (ROM) of the

knee can significantly change a patient’s quality of
life. In general, ROM of 0 to 125 is adequate for most
by Hosalkar et al.9 (2003) and Wang et al.10 (2006). The
Thompson quadricepsplasty and Judet quadricepsplasty
may be complicated by skin necrosis, loss of full exten-
activities of daily life. Gait analysis has shown that sion, wound dehiscence, and infection associated with
patients require 67 of flexion during the swing phase large exposures.7,11,12 The purpose of this study was to
of gait. A loss of extension of 5 can increase the energy describe a modification of the operative technique of
expenditure of the quadriceps muscle and produce a Judet.
gait alteration.1 The rate of knee arthrofibrosis after
ligament reconstruction is reported to be between 0% Operative Technique
and 4%2; after tibial fracture due to high-energy A 6-cm-long median incision is made extending prox-
trauma, the rate is about 7%,3 with an undetermined imally from the superior pole of the patella (Fig 1A), and
incidence after limb lengthening. the rectus femoris is seen generally involved by fibrotic
Many methods have been used to treat a knee with tissue. In the first step, by use of blunt curved dissection
arthrofibrosis. Bennet first described his method in scissors, a parapatellar lateral and medial arthrotomy is
1922, followed by Thompson4 (1944) and Judet5 (1959) made by incising the lateral and medial retinaculum,
and their modifications, described by Van Nes6 (1962), from the top of the patella down the lower pole (Fig 1B).
Nicoll7 (1963), and Hesketh8 (1963) and, more recently, The second step consists of breaking the adhesions
within the suprapatellar pouch and patellofemoral
compartment, by use of blunt capsule scissors and
sometimes a small osteotome. The third step consists of
From the Dysmetria and Deformities Center (F.d.S.C., G.A.T.A.M.,
D.P.d.M., F.d.S.C., F.A.) and Knee Surgery Center (J.L.R.d.F.), National isolating the rectus femoris from the vastus medialis,
Institute of Traumatology and Orthopedics of Brazil, Rio de Janeiro, Brazil. vastus lateralis, and vastus intermedius (Fig 2). Once
The authors report that they have no conflicts of interest in the authorship the rectus is isolated, the tendon of the vastus inter-
and publication of this article. Full ICMJE author disclosure forms are medius is transected adjacent to its patellar insertion
available for this article online, as supplementary material.
with a scalpel (Fig 3). The fourth step is to release
Received August 10, 2018; accepted November 7, 2018.
Address correspondence to José Leonardo Rocha de Faria, M.D., Dysmetria subcutaneous adhesions around the anterior and lateral
and Deformities Center, National Institute of Traumatology and Orthopedics aspect of the thigh with blunt scissors (Fig 4). Adhesion
of Brazil, Av Bartolomeu Mitre 254, Leblon, Rio de Janeiro, RJ, Brazil. sites are shown in Figure 5.
E-mail: [email protected] After the aforementioned steps, with the hip in 90 of
Ó 2019 by the Arthroscopy Association of North America. Published by
flexion, gentle manipulation of the knee in flexion is
Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/). made until maximum flexion is achieved (Fig 6). Our
2212-6287/18994 goal is at least 120 to 130 . We recommend that the
https://doi.org/10.1016/j.eats.2018.11.005 surgeon place his or her index finger on the patellar

Arthroscopy Techniques, Vol 8, No 3 (March), 2019: pp e343-e347 e343

e344 F. DOS SANTOS CERQUEIRA ET AL.

Fig 1. (A) The patient is placed in the supine decubitus position, and a 6-cm-long median incision is made extending proximally
from the superior pole of the patella. (B) In the first step, by use of a blunt curved dissection scissor, a parapatellar lateral and
medial arthrotomy is made by incising the lateral and medial retinaculum (yellow dotted arrows), from the top of the patella
down the lower pole (right knee).

tendon during this step so that it is possible to feel any used for 2 days, 24 hours a day, while the patient is
initial ruptures on this tendon. The last step is closure of supervised by the medical and physiotherapy team.
the skin with heavy nonabsorbable sutures such as The patient must be seen weekly for the first month
Ethibond (Ethicon) (Fig 7), as shown in Video 1. and taught how to maintain ROM (Fig 6) when phys-
A femoral catheter is left in the operated leg for iotherapy is impossible. Pearls and pitfalls associated
continuous femoral nerve analgesia (Fig 8). A contin- with our technique are shown in Table 1, and advan-
uous passive motion machine (model 325; Stryker) is tages and disadvantages are shown in Table 2.

Fig 2. Isolation of rectus femoris in a left knee. Once the rectus is isolated, the vastus intermedius tendon is transected adjacent to
its patellar insertion.
 MINIMALLY INVASIVE QUADRICEPSPLASTY e345

Fig 3. Once the rectus is isolated, the vastus intermedius

tendon is transected (blue line) adjacent to its patellar inser-
tion with a scalpel; right knee.

Discussion
Judet5 (1959) and Nicoll7 (1963) (Nicoll, 1963) Fig 4. In the fourth step, subcutaneous adhesions around the
described several components that can limit flexion of anterior and lateral aspect of the thigh are released with a
the knee, including adhesions from the deep surface of blunt scissor (yellow dotted arrows); left knee.
the patella to the femoral condyles, fibrosis and short-
ening of the lateral expansions of the vastus muscles
and their adherence to the femoral condyles, fibrosis of being an easy method to learn. In associated with these
the vastus intermedius, and shortening of the rectus characteristics, the technique offers a minimally inva-
femoris muscle. We have also noticed that deep skin sive approach to a broad spectrum of indications and is
adhesions on the distal portion of the thigh play a not limited to 1 type of knee stiffness. However, it is
relevant role in the pathology. important to be alert to the risk of fracture of the patella
Khakharia et al.13 reviewed 16 patients treated with and rupture of the patellar and quadriceps tendons. We
limited quadricepsplasty. The mean age was 23 years and highly recommend that patients follow a physiotherapy
mean final flexion was 125 , but they used their tech- regimen after surgery.
nique only in cases resulting from femoral lengthening
complications. They had 1 case of extensor lag and did
not recommend the procedure for chronic cases.
Wang et al.10 developed a mini-incision operation for
the treatment of severe arthrofibrosis. Their study
included 22 patients whose mean age was 37 years. The
mean flexion gain by the end of the study was 88 . A
length of the quadriceps tendon was made in 16
patients, resulting in an extension lag in all 16 cases;
this resolved between 3 and 6 months postoperatively
in 15 cases but persisted in 1 case.
Hahn et al.14 described modified Thompson quad-
ricepsplasty. The operation was performed in 20 patients
with a mean age of 37 years, and the final mean gain in
ROM was 67.6 . A Z-plasty of the rectus femoris was
performed in 4 cases, resulting in an extension lag in 2. Fig 5. Adhesions on knee: patella (1), suprapatellar pouch
We believe that our technique is a good option for the and patellofemoral compartment (2), rectus femoris (3), and
treatment of the stiff knee, having low morbidity and subcutaneous adhesions (4).
e346 F. DOS SANTOS CERQUEIRA ET AL.

Fig 6. With the hip in 90 of flexion, gentle manipulation of the knee in flexion (arrows) is made until maximum flexion is
achieved. The surgeon should remember to leave the hip in flexion to avoid complications due to excessive tension on the
quadriceps; left knee.

Fig 7. In the last step, closure of the skin is performed with

heavy nonabsorbable sutures such as Ethibond; right knee.
Fig 8. A femoral catheter is left in the operated leg, on the
same side as the procedure, for continuous femoral nerve
analgesia for at least 24 hours; left leg.

Table 1. Pearls and Pitfalls

Pearls Pitfalls
The surgeon should place the hip at 90 before trying to flex the knee. Insufficient release of subcutaneous adhesions can occur.
Silence is recommended in the OR during knee flexion so that is possible to Femoropatellar osteophytes might be present.
hear the rupture of the adherences.
The surgeon should leave his or her finger on the patellar tendon so that it Bleeding can disrupt visualization.
is possible to feel any possible ruptures during flexion of the knee.
OR, operating room.

Table 2. Advantages and Disadvantages

Advantages Disadvantages
Less bleeding than classic techniques Difficulty releasing proximal adhesions
Low chance of fibrosis postoperatively
Low amount of damage to tissues
 MINIMALLY INVASIVE QUADRICEPSPLASTY e347

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