Case Presentation of Quadriceplasty.pptx

Case presentation on quadroceplasty

1. Quadricepsplasty

2. Contents Case Report Discussion

3. Case report - History A.M is a 35 year old male who was involved in MBA 5 year ago. He complained of LOC, in ability to ambulate and pain in his left elbow. No Ent bleed, neck pain or paresthesia

4. Past Medical History No chronic illnesses No hospitalizing Past Surgical History- Non Drug History- No allergies

5. Examination General – painful distress mm pink, Vitals – Stable RS, CVS, GI, CNS- unremarkable

6. Examination Cont’d MSK- 10cm laceration on the right dorsal forearm extending to the elbow joint , Olecranon exposed. Radial pulse intact and no neurological deficits. Left lower extremity was shortened and externally rotated. With abnormal motion the thigh. DP + PT intact. No Neurological deficits

7. Investigation Cervical Spine AP, Lateral, Open mouth- normal Chest- Normal Right elbow+ FA- Normal AP Pelvis- Normal Right Femur- transverse Middle 3 rd Shaft of femur # Images Not available

8. Assessment Mid TBI Right Closed Middle 3 rd SOF # Right FA Degloving injury

9. Management Fluid resus, analgesic, DVT prophylaxis Placed on Skeletal traction Definitive management was ORIF with Standard Locking Anterograde IM nail after 3 week on traction.

10. Post Operative course Immediate post op was uneventful Patient was discharged 3 days post op after Limb physio and crutches mobilization At 3 months patient presented at the outpatient department with right knee stiffness while on physiotherapy Patient Knee range of motion was limited from 5 to 20 degrees MUA Done but Unsuccessful

11. Post Operative course Bone union achieved at 6 months post op with extensive callous formation noted. Knee ROM remained at 20-30 degrees which reduced the patient’s quality of life Judets Quadricepsplasty subsequently performed

12. Xray of Right femur with IM nail In situ Heterotopic ossification noted

13. Modified Judets Quadriceplasty The procedure was done under GA ( Ideally epidural catheter could be placed for continuous epidural anesthesia post op) Iv Cefuroxime 1.2 given on induction and continued for 3 days post op In supine position patients right leg was cleaned and draped above the level of the ASIS to the foot.

14. Procedure cont’d Lateral 10cm skin incision made along the lateral thigh to the lateral aspect of the patellar tendon Medial Parapatellar S shaped incision was also made Knee joint was entered via a lateral parapatellar capsular incision and intra-articular adhesions between femoral condyles, tibia and patella released. Medial parapatellar approach was used to release adhesions medially At this point Knee flexion attempted, however no improvement noted

15. Procedure cont’d Lateral incision was extended to the level of the greater trochanter Muscle slide was the performed by elevating the quadriceps muscle off the femur along the intramuscular septum using an extraperiosteal approach Meticulous cauterization and ligation of perforating vessels performed to prevent blood loss

16. Procedure cont’d Heterotopic bone that was tethering quadriceps to the femur

17. Procedure cont’d Knee flexion from 0 to 120 was achieved The subcutaneous tissue and skin closed with knee the in flexion Capsule intentionally left open to prevent capsular adhesion formation

18. Post Op Care Patients knee was kept in 90 degree flexion with POP at nights with ROM exercise during the day. Adequate analgesic required Patient able to actively flex up from 0 to 110 degrees Discharged after 5 days to continue aggressive physiotherapy as outpatient

19. Post op Xrays

20. Knee contractures Persistent reduction in Range of motion of the Knee joint Due to Intrinsic or extrinsic causes

21. Etiology Congenital Acquired -infection, ischemia, trauma Traumatic injuries to the knee and thigh, as well as periarticular fractures can often result in extension contractures, especially after prolonged periods of immobilization.

22. Discussion the normal individual requires less than 90 degrees of knee flexion for normal gait and slopes, 90 to 120 degrees of flexion for staircases, seating in chairs and approximately 135 degrees of flexion for a bath

23. Discussion cont’d Knee extension contractures may be treated conservatively initially with aggressive physical therapy and range of motion exercises. For patients who fail conservative management, surgical techniques such as manipulation under anesthesia, arthroscopic adhesiolysis and quadricepsplasty may be considered There are different techniques of quadricepsplasty , such as Thompson and Judet methods.

24. Discussion cont’d The Thompson method involves a complete lengthening of the quadriceps tendon, which can result in a loss of knee extension strength The Judet method involves a staged release of the contracted structures and a muscle slide that preserves the quadriceps tendon, which can lead to better functional outcomes and less extensor lag.

25. Thompson’s quadricepsplasty Thompson quadricepsplasty was first described in 1944 for the treatment of knee extension contractures. This technique involves the detachment of the vastus medialis, vastus lateralis and vastus intermedius from the patella  via  an anterior midline approach. The rectus femoris is left intact as the sole knee extensor resulting in frequent complications of extensor lag.

26. The Judet quadricepsplasty The Judet technique of quadricepsplasty is divided into a sequential 5 phase release of the intrinsic and extrinsic structures of the knee.

27. The Judet quadricepsplasty The first phase involves a limited lateral incision and lateral adhesiolysis. The second phase involves a medial incision with adhesiolysis, release of the medial capsule and medial collateral ligaments.

28. The Judet quadricepsplasty The third phase involves release of the rectus femoris. The rectus femoris can be released through an inguinal incision inferior to the ASIS and AIIS as described by Judet. Or modified by doing the release by an extension of the lateral incision The fourth phase is the quadriceps slide

29. The Judet quadricepsplasty The fifth phase is the fractional lengthening of the fascia lata and fascia of the vastus lateralis. This allows the surgeon to limit the procedure at any phase once adequate flexion is obtained thus preventing further soft tissue dissection and potential risk of greater extensor lag from over release.

30. The Judet quadricepsplasty Young et al found that Knee flexion might fall slightly compared to intraoperative Due to: Knee joint is in a relaxed state under anesthesia Patient cannot exercise effectively and timely due to fear and pain Muscle tissue fibrosis and loss of contraction function especially in old injuries Slight adhesions will form at surgical site again

31. Complications Infections Quadriceps tendon rupture skin dehiscence and delayed wound healing Fractures – patella, lateral femoral ( gradually release adhesions, do not violently bend the knee during surgery) Extensor lag

32. Complications Wound and surgical site infections are the most common complication of this procedure One of the concerns of quadricepsplasty is the transmission of bacteria through the tissue planes as only the skin is closed, with no fascial, muscular or capsular plane closure. Closing the tissue plane my theoretically reduce the risk of infection but this will reduce the final range of motion It is more important to have meticulous hemostasis, early ROM and Intravenous antibiotics until minimal wound drainage

33. Questions

34. References Luo Y, Li H, Mei L, Mao X. Effects of Judet Quadricepsplasty in the Treatment of Post-traumatic Extension Contracture of the Knee. Orthop Surg. 2021 Jun;13(4):1284-1289. doi : 10.1111/os.12950. Epub 2021 May 6. PMID: 33955701; PMCID: PMC8274180. Ding BTK, Khan SA. The judet quadricepsplasty for elderly traumatic knee extension contracture: a case report and review of the literature. Biomedicine (Taipei). 2019 Sep;9(3):21. doi : 10.1051/ bmdcn /2019090321. Epub 2019 Aug 27. PMID: 31453802; PMCID: PMC6711318.