Quadriceps Snip

The patient is a 68-year-old female who was referred 18 months after a total knee arthroplasty (TKA) because of complaints of pain and instability of her knee while ambulating. A TKA had been performed for osteoarthritis, and her perioperative course was unremarkable for wound drainage or difficulty with wound healing. She reported that she was compliant with her postoperative range-of-motion (ROM) rehabilitation but was unable to achieve flexion beyond 70 degrees despite postoperative manipulation.

The patient’s past history did not reveal any unusual disease or remote history that may have contributed to her knee problems.

The examination revealed a pleasant woman with a height of 63 inches and a weight of 190 pounds. Her body mass index was 33.7. The patient was afebrile. The knee was diffusely tender with a palpable effusion. The patient was able to extend her knee fully and had limited flexion to approximately 70 degrees. Ligamentous examination found her knee to be stable to varus and valgus stresses. Quadriceps strength was 4/5, and the peripheral neurocirculatory examination of the extremity was normal.

The radiographs, including weight-bearing anteroposterior and lateral views, revealed that the limb was well aligned ( Fig. 7.1 ). The components appeared to be well fixed and cemented on radiographs. Laboratory evaluation included a normal erythrocyte sedimentation rate (ESR) and normal C-reactive protein level. An aspiration of the knee included fluid that was yellow and had a white blood cell count of 1100 cells/μL.

The diagnosis was arthrofibrosis after TKA.

The patient consented for revision surgery and was brought to the operating room for that procedure. The surgical approach for the revision TKA was facilitated by removal of hypertrophic synovium and scar, allowing for reestablishment of the medial and lateral gutters of the knee. An additional exposure included an extensile release of the soft tissues from the proximal medial and posteromedial tibia. Finally, a quadriceps snip was performed because of the difficulty of the exposure. The knee components were revised without complications. Flexion and extension gaps were also restored.

The patient’s postoperative course has been unremarkable to date. The patient has occasional mild discomfort associated with prolonged activity but has been able to resume a normal walking program for pleasure and exercise. The patient reports that her knee is stable and she has been able to regain knee motion with full extension and flexion to approximately 105 degrees. Radiographs of the knee show the reconstructed components ( Fig. 7.2 ).