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Effect of Quadriceps Excursion on Knee Flexion in Patients with Osteoarthritis

Samih Tarabichi MD 1, Mohamed Elfekky MD 2, Alisina Shahi MD 3*

1 Tarabichi Joint Replacement Institute, Dubai, UAE
2 Dubai Health Authority, Dubai, UAE
3 Postdoctrate Research Fellow, Rothman Institute, PA, USA

* Corresponding Author

Vol 2, Num 2, April 2015




The numerous benefits of attaining a substantial post-operative range of motion (ROM) in patients with osteoarthritis undergoing total knee arthroplasty (TKA) has been extensively discussed and well documented.[1-3]

Patients with advanced osteoarthritis retain a restricted ROM even when placed under general anesthesia, suggesting the causative factors to be permanent pathological changes in the knee. Sources of the restriction have been hypothesized to include osteophytes, irregularities in the bone surface, synovitis, adhesive capsulitis, restrictive soft tissues and adhesions of the quadriceps muscle, and/or tendon to surrounding structures.[4,5]

Stiffness after periods of limited activity is characteristic of the arthritic knee as well as the posttraumatic knee, highlighting a potentially shared etiology for both. Structural pathologies that may limit flexion in the stiff posttraumatic knee have been discussed in the literature and include adhesions from the deep surface of the patella to the femoral condyles, fibrosis, and shortening of the lateral expansions of the vasti and their adherence to the femoral condyles, fibrosis of the vastus intermedius, and shortening of the rectus femoris.[6] All of these restrict flexion by blocking the normal distal excursion of the quadriceps, which Wendt et al [7] reported to be an average of 6.62 cm for flexion up to 90° and [6] reported to be up to 9 cm for “full flexion” to occur.

In our study, we considered, tethering adhesions of the quadriceps muscle to be the major pathological structures responsible for limited ROM in the stiff arthritic knee, as is the case in the posttraumatic stiff knee.

There were a total of 42 quadriceps releases carried out on 24 fully consenting patients (10 men and 14 women) by the same practicing surgeon. Of the 24 patients, 18 had a bilateral TKA, whereas 6 had only a unilateral TKA. The mean patient age was 68 years (range, 58-83 years), and the mean weight was 77.7 kg (range, 65-94 kg).

Our intraoperative procedure was designed to assess the direct effect of the release of adhesions tethering the quadriceps muscle to the femur and its surrounding structures. The rationale behind this is demonstrated in Figure 1. As can be inferred from Figure 1B, removal of the supra-patellar pouch is necessary to gain access to the inferior aspect of the quadriceps muscle. Once access is gained, the adhesions may be systematically resected until the quadriceps muscle is freed enough to allow a greater degree of flexion to occur.

The singular effect of the quadriceps release was demonstrable by the immediate and successive improvement in ROM as the release was continued proximally in all patients. Range of motion improved in all patients at an average 34.2° (SD 7.8, P < 0.001) post release before any soft tissue balancing, bone resection or resurfacing, or any other surgical interventions were applied. In fact, any knee deformities, including the presence of large osteophytes in 6 of the 42 cases, seemed to hinder the improvement in ROM post release (Figure 2).

The success in obtaining an immediate and significant improvement in ROM by releasing only the quadriceps muscle from its tethering adhesions and keeping other pathological changes such as large osteophytes, severe knee deformities, and irregular articular surfaces intact clearly demonstrates that the inadequate excursion of the quadriceps muscle and tendon is the main limiting factor to better knee flexion.

    Figure 1: Simplified illustrations demonstrating the basic principle of our approach.
    Figure 2: Case number 10, a 74-year-old woman who underwent bilateral quadriceps release prior to commencing TKA. Despite the large posterior osteophytes that can be seen in the prerelease lateral x-ray (left), we were able to dramatically improve flexion from 105 to 140° as shown in the postrelease lateral x-ray (right).

    Samih Tarabichi MD
    Orthopaedic Surgeon, Tarabichi Joint Replacement Institute, Dubai, UAE


    Mohamed Elfekky MD
    Orthopaedic Surgeon, Dubai Health Authority, Dubai, UAE


    Alisina Shahi MD
    Postdoctrate Orthopaedic Research Fellow, Rothman Institute, PA, USA


    None declared.


    Financial disclosure:
    None declared.



    1. Ritter MA, Campbell ED. Effect of range of motion on the success of a total knee arthroplasty. J Arthroplasty 1987;2:95.

    2. Schurman DJ, Rojer DE. Total knee arthroplasty: range of motion across five systems. Clin Orthop Relat Res 2005;132.

    3. Chiu KY, Ng TP, Tang WM, Yau WP. Review article: knee flexion after total knee arthroplasty. J Orthop Surg 2002;10:194.

    4. McGinty JB, Tippet JW. Operative arthroplasty. 2nd ed. 1996. p. 411.

    5. Jung-Man K, Myung-Sang M. Squatting following total knee arthroplasty. Clin Orthop Relat Res 1995;313:177.

    6. Nicoll EA. Quadricepsplasty. J Bone Joint Surg 1963;45-B:183.

    7. Wendt PP, Johnson RP. A study of quadriceps excursion, torque, and the effect of patellectomy on cadaver knees. J Bone Joint Surg Am 1985;67:726.