Extra articular arthroscopic release in post-traumatic stiff knees: a prospective study of endoscopic quadriceps and patellar release

Knee stiffness due to mismanaged trauma is still common in underdeveloped countries. Many patients with distal femoral fractures, patellar injuries or other local trauma present with intra-articular and extra-articular adhesions between the quadriceps and anterior femur. Nineteen knees with post trauma stiffness due to combined intra- and extra- articular aetiology were taken up for arthroscopic aided release after failing an aggressive physiotherapy protocol. Ultrasound was used to identify the extra-articular adhesions. The intra-articular part of the release was done by a standard protocol involving the release of all infrapatellar, suprapatellar and gutter adhesions, and then the extra-articular proximal adhesions were released by using special long periosteal elevators and arthroscopic scissors. We were able to release the adhesions as high as 9 inches above the patella, and in one case bony ankylosis between the patella and the femur was arthroscopically osteotomised (after 11 years of stiffness). Delay before surgery averaged 2.7 years (6 months-11.3 years). Mean active flexion at one year follow-up improved from 27.3 degrees to 119.3 degrees (average increase: 92 degrees). Mean preoperative extension lag reduced from 6 degrees to 1 degrees postoperatively. No CPM machine was available, and patients had to undergo daily manual and assisted therapy, with appropriate analgesia. Overall patient satisfaction was excellent; one patient developed a supracondylar fracture (infected old fracture with bone loss and severe contracture) and was retrospectively a wrong case selection. Arthroscopic aided quadriceps adhesion release is a good option in cases of neglected trauma; results are excellent even without sophisticated CPM machines, and the periosteal elevators needed are cheap and indigenous.