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N. TARDY, M. THAUNAT, B. SONNERY-COTTET, C.G. MURPHY, P. CHAMBAT, J.M. FAYARD
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Benum
et al.
[4] reported their results for
7 patients that underwent open extensive
capsulotomy to treat knee loss of motion. They
used a single medial parapatellar anterior
approach to treat mainly flexion deficit. In all
7 patients, a posteromedial capsular release
was carried out while only 4 of the 7 patients
had an associated posterolateral release. The
mean preoperative extension deficit was only
4 degrees and 3 of the 7 patients (43%) retained
a post-operative extension deficit. Similarly,
Millett
et al.
[8] reported a series of 8 patients
who experienced flexion contracture, and were
treated by anterior and posterior release using a
single anterior extensile approach. This open
procedure permitted a 62° ROM gain with
good subjective outcomes but two patients
retained an extension deficit (25%) and
3 patients required subsequent procedures
(Table 3).
Treating a posterior flexion contracture using
an isolated anterior approach seems to us
technically difficult and needs an extensive and
invasive approach.
In a series of 21 patients with chronic flexion
contracture, Lobenhoffer
et al.
[6, 7] reported
their outcome at a mean of 18 months’ follow-
up (range 6-36 months). They also performed
an anterior arthroscopic release, followed by a
posterior open release. In their series the
capsulotomy was performed using a single
posteromedial approach. The mean extension
deficit of 17° improved to a mean of 2° but
6 patients (29%) retained an extension deficit,
albeit moderate. In a similar cohort, Freiling
et al.
[5] reported their series of 86 patients
who underwent a single posteromedial open
release. With a mean follow-up of 4.6 years,
the mean extension increased by 17° following
the posterior debridement but several patients
had a residual extension deficit (Table 3). Post-
operative ROM was not precisely reported.
Three patients required revision surgery (1 for
haematoma, 2 for synovial fistulas).
Unlike Lobenhoffer
et al.
[6] and Freiling
et al.
[5], who insisted on the importance of a single
posteromedial approach to avoid a peroneal
nerve injury, we prefer a dual posteromedial
and posterolateral approach as it allows good
visual and tactile access to both posterior
recesses to fully and safely release the
contracted posterior capsule, with no
complications experienced in our series.
Recently, several authors have described
arthroscopic posterior release [3, 38-40] for
treating extension deficit of the knee. The
results of the three posterior arthroscopic
release series are presented in Table 3.Although
it seems attractive to use modern arthroscopic
techniques to perform posterior release of the
knee, we still prefer the open procedure, which
permits a more extensive release and a more
thorough haemostasis than arthroscopic
treatment. Indeed, posterior arthroscopic
dissection of the scar tissue or adhesion is
technically demanding, especially when
posterior recesses are almost completely
obliterated. Even in the most experienced
hands, it’s a difficult and time-consuming
procedure. Moreover, the arthroscopic
treatment may fail because it is unable to
remove all fibrotic tissue in the posterior
compartments. Indeed, Laprade
et al.
[38] and
Tröger
et al.
[40] only performed a
posteromedial portal without a posterolateral
portal. It seems difficult to completely release
both posteromedial and posterolateral
compartments byusing a single posterior portal.
Finally, the clinical outcomes of these
arthroscopic series are not completely
satisfying as extension deficit persists at
follow-up. Four of the 15 patients (27%) in the
series of Laprade
et al.
[38] had an extension
deficit after the procedure including one of 15°.
Mean extension loss is still 3 degrees in the
series of Mariani
et al.
[39] and Tröger
et al.
[40] after the posterior arthroscopic procedure.
The main limitations of this study are its
retrospective design and the small sample size,
which did not allow us to statistically
underscore pejorative factors for functional
results. However, open posterior release is a
salvage procedure for treating rare cases of
chronic ROM deficit, so the overall study
patient number is considered acceptable.
Further follow-up is also warranted, especially
to study degenerative changes after this