Old but gold: Is the Judet procedure still a viable option for posttraumatic knee stiffness in 2024? A comprehensive systematic review and meta-analysis

Abstract

Background: Posttraumatic extension contracture of the knee (PECK) is common after knee injury. Initial management is conservative to improve the range of motion; if it fails, surgery may be necessary. This systematic review analyses existing literature on Judet quadricepsplasty for PECK. We will assess clinical outcomes, complications, patient satisfaction and factors that may influence its success.

Methods: A search was conducted on 25 November 2023, adhering to preferred reporting items for systematic reviews and meta-analyses guidelines. PubMed, Embase and Google Scholar were used. Search strings were ([Judet] OR [quadricepsplasty]) AND (knee) AND (stiffness) and ([Judet] OR [quadricepsplasty]) AND (knee). Inclusion criteria: English articles focused on PECK, published between 2003 and 2023, and a minimum follow-up of 24 months. Exclusion criteria: case reports, alternative techniques, knee stiffness cases not only due to trauma, a sample size of <10 patients and articles not reporting functional outcomes.

Results: Among selected studies, 239 patients were considered. The average time between injury and Judet was 27 months. The population was predominantly male; the mean follow-up was 33 months. An average intraoperative knee range of motion improvement of 79.1 degrees (confidence interval 76.9; 81.3) compared to the average preoperative starting value of 30.7 degrees was observed. This improvement decreased by 13.5 degrees at the first postoperative check and by an additional 2.4 degrees at the follow-up, while maintaining an average value of bending above 90 degrees.

Conclusion: Judet quadricepsplasty appears an effective technique for the management of PECK. The heterogeneity of included studies and the absence of standardized outcome measures limit the ability to draw definitive conclusions.

Level of evidence: Level III.

Keywords: Judet quadricepsplasty; knee injury; posttraumatic knee extension contracture; range of motion.

Figure 1

Judet quadricepsplasty. (a) Dual surgical access both medial for arthrolysis and lateral for arthromyolysis. (b) Medial intra‐articular knee approach in according to Gernez for arthrolysis. (c) Release of adhesions between anatomical layers; release of the vastus lateralis and extra periosteal disconnection of the vastus intermedius from the anterolateral cortical of the femoral diaphysis. (d) The tendinous origin of the vastus lateralis is cut completely at the level of the subtrochanteric crest and the anterior aspect of the coxofemoral capsule. (e) Knee and hip flexion causes the vastus lateralis to descend. EMC, encyclopedie medico chirurgicale.

Figure 2

Modified Judet quadricepsplasty. (a) Illustration of the anterolateral parapatellar single open access (+possible medial mini‐open) and its proximal extension to the greater trochanter. (b) Release of the lateral retinaculum and release of the adhesions in the suprapatellar gutter and between the patella and the femoral condyles. (c) Medial release performed through the lateral approach. Vastus intermedius is also released and lifted off the anterior and lateral surfaces of the femur extraperiosteally. (d) Vastus lateralis is detached from the linea aspera until the level of the greater trochanter with a periosteal elevator without detaching its origin from the great trochanter.

Figure 3

Minimally invasive quadricepsplasty. (a) Median incision proximal at the superior patellar pole and following parapatellar lateral and medial arthrotomy. (b) Rectus femoris tendon isolation. (c) Vastus intermedius tendon resected near patellar insertion. (d) Release of subcutaneous adhesions at anterolateral thigh. (e) Possible variation: a zeta plastic execution. The proximal portion of the vastus intermedius tendon could be sutured with the distal portion of the rectus femoris tendon allowing the lengthening of the extensor apparatus.

Figure 4

Studies selection preferred reporting items for systematic reviews and meta‐analyses flowchart.