Results of surgical treatment of arthrofibrosis after ACL reconstruction

Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook

* Arthrofibrosis is a pathologic condition that is characterized by excessive periarticular scar-tissue formation. Arthrofibrosis may occur secondary to injury, surgical trauma, hemarthrosis, or infection, or it may occur idiopathically.* The pathogenesis of arthrofibrosis is incompletely understood but involves the dysregulation of normal reparative pathways, with transforming growth factor-beta (TGF-[beta]) as a principal mediator.* Current treatment options for arthrofibrosis primarily involve physiotherapy, operative manipulation, and surgical debridement, all with imperfect results.* Currently, there are no pharmacologic treatment options for arthrofibrosis. This has prompted increased investigational interest in the development of antifibrotic intra-articular therapies.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication

BACKGROUND

This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).

METHODS

The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.

CONCLUSIONS

This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.

Dynamic Splinting in Children and Adolescents With Stiffness After Knee Surgery

PURPOSE

The purpose of this study was to investigate the indications and outcomes of dynamic splinting (DS) of the arthrofibrotic knee in the pediatric population.

METHODS

Seventy-four patients (41 males, 33 females) with postoperative arthrofibrosis treated with DS after an index knee surgery were reviewed. Median age was 13 years (range, 4 to 18 y), and median follow-up was 17 months (interquartile range, 10 to 28 mo). Demographics, index surgery procedure, preoperative and postoperative knee range of motion (ROM) measurements, treatment length and subsequent need for manipulation under anesthesia (MUA), and surgical lysis of adhesions (LOA) were evaluated. A ROM deficit was defined as lack of extension ≥10 degrees or lack of flexion <130 degrees. Successful improvement of ROM was defined as an increase of ≥10 degrees in flexion, extension, or both. There were 23 patients with flexion deficit only, 17 with extension deficit only, and 34 with combined flexion and extension deficits. Wilcoxon signed-rank test was used to assess median improvement in ROM. Patients were classified into 4 surgical groups: anterior cruciate ligament (ACL) reconstruction without meniscal repair (n=19), ACL reconstruction with meniscal repair (n=12), tibial spine fracture repair (n=21), and other (n=22). Multivariable logistic regression was used to identify independent predictors of failure of DS requiring MUA and LOA.

RESULTS

A total of 57 patients with flexion deficits showed median improvement of 30 degrees in flexion (95% confidence interval, 0-90 degrees; P<0.001), and 51 patients with extension deficits showed median improvement of 7 degrees in extension (95% confidence interval, 0-60 degrees; P<0.001). DS was associated with ROM improvement in 84% and avoided the need for surgery in 58% of all 74 patients included in the study. Multivariate analysis of the ACL with meniscus repair subgroup revealed that each 1-month delay in DS treatment was associated with a 5-fold increased risk of undergoing a LOA (P=0.007). Thirty-six (63%) patients with flexion deficit avoided need for surgery, whereas 26 (51%) patients with extension deficits avoided surgery.

CONCLUSIONS

Our data suggest that DS is an effective method to increase knee ROM and reduce the need for subsequent MUA/LOA in the pediatric and adolescent patient with arthrofibrosis after an index knee surgery.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Novel Use of Botulinum Toxin to Ameliorate Arthrofibrosis: An Experimental Study in Rabbits

This study aimed to investigate the effects of intra-articular botulinum toxin in preventing arthrofibrosis. Arthrofibrosis was induced in both stifle joints of 20 rabbits by transecting the anterior cruciate ligament under intramuscular anesthesia with ketamine and xylazine. Intra-articular toxin at a dose of 0.6 ml (50 unit) and physiologic saline solution (0.6 ml) were injected into the right and left stifle joints, respectively, 3 times with a 1-week interval between each injection. The rabbits were euthanized in the 12th week via high dose anesthesia to remove the stifle joint. The severity of adhesions was assessed, applying a universal scoring system. Also the stifle joints were histologically evaluated for fibrosis. With regards to severity of adhesion a significant reduction in the adhesion score was observed in the toxin-treated group in comparison to untreated controls with mean ± SE values of 0.2 ± 0.1 and 2.4 ± 0.2, respectively ( p < 0.01). The histological evaluation showed no significant fibroblast in the toxin-treated group versus dense fibers with mature fibroblasts in the control group. Our results suggest that botulinum toxin demonstrated efficacy in preventing adhesion after knee surgery and all the parameters monitored showed consistent statistically significant improvement.

Long-term Results of Arthroscopic Arthrolysis for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction

PURPOSE

The current study was conducted to evaluate the long-term clinical and radiological outcomes after arthroscopic arthrolysis for arthrofibrosis after anterior cruciate ligament reconstruction (ACLR).

METHODS

All patients treated with arthrolysis between 1990 and 1998 were included. Indication was arthrofibrosis in at least one knee compartment or a cyclops syndrome limiting range of motion (ROM) by > 5° of extension deficit and 15° of flexion deficit. International Knee Documentation Committee (IKDC) 2000 subjective and objective, Lysholm score, and x-ray evaluation were documented. Statistical analysis and power calculation were performed (P < .05).

RESULTS

One hundred forty-one patients (follow-up, 71%) were examined at a mean of 18.7 ± 2.6 years after arthroscopic arthrolysis. Mean IKDC 2000 score was 79.49 ± 14.32. IKDC objective was normal in 0%, nearly normal in 6%, abnormal in 56%, and severely abnormal in 38%. One hundred percent of patients showed more than grade II osteoarthritis. ROM improvement after arthrolysis did not change significantly compared with midterm results (t = 4.5 years). Patients with persisting motion deficits (P = .02) and after medial meniscus resection (P < .001) at time of ACLR showed significantly greater progression of osteoarthritis in comparison with patients without these additional disorders. In case of arthrolysis later than 1 year after ACLR, a more severe osteoarthritis grade (4% vs 20% grade III; P = .038) and a lower jump distance (IKDC: 61% A, 25% B vs 39% A, 41% B; P = .028) were obvious compared with patients who underwent arthrolysis within the first year after ACLR.

CONCLUSIONS

Long-term motion improvement can be achieved by arthrolysis. Persistent loss of motion resulted in a higher degree of osteoarthritis in the study population. Early intervention seems advisable as patients with arthrolysis later than 1 year after index surgery reached worse IKDC objective grading.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Extension deficit after ACL reconstruction: Is open posterior release a safe and efficient procedure?

BACKGROUND

Extension loss is a potentially devastating consequence of anterior cruciate ligament reconstruction (ACLR). It can often be treated by anterior arthroscopic release. In rare cases, a chronic flexion contracture requires an additional posterior open release. To our knowledge, no study analysing the results of both posteromedial and posterolateral approaches has been performed so far. The purposes of this study were (1) to analyse the midterm outcome and complications of a combined procedure, anterior arthroscopic debridement and posterior open capsulotomy - for the treatment of chronic extension deficits after ACLR and (2) to describe the surgical technique of posterior open release with both posteromedial and posterolateral approaches.

MATERIAL AND METHODS

This is a retrospective clinical cohort study. Twelve patients presenting a chronic flexion contracture of 10° or more after ACLR treated by open posterior arthrolysis with an average follow-up time of 38months (range six to 90) were included. At last follow-up, they underwent both a clinical examination with range of motion analysis, International Knee Documentation Committee (IKDC) and KOOS scores.

RESULTS

At follow-up, all patients except one (93%) achieved complete extension. Only one patient (7%) had a residual post-operative flexion deformity of five degrees. The range of motion (ROM) improved significantly after arthrolysis from 96°±14.3° (SD) to 14.3°±7°(SD)(p<0.001). No post-operative complications were recorded. No patients required further open debridement. The post-operative objective IKDC score was grade A for five patients, B for seven versus C for five patients and D for seven preoperatively. The mean post-operative subjective IKDC score was 86.4±9.7. The post-operative Knee injury and Osteoarthritis Outcome Score (KOOS) distribution was as follows: pain 93.8±5 (SD); symptoms 88±8.6 (SD); ADL 96.8±3.7 (SD); sports activities 83.6±12.3 (SD); and quality of life 82.9±8.8 (SD). Mean patients' satisfaction was 9.25±0.6 (SD) out of 10 after arthrolysis.

CONCLUSIONS

Open posterior release with both posteromedial and posterolateral approaches is a safe and efficient additional procedure in case of persistent flexion contracture after ACLR with good ROM gain, functional scores and patients' satisfaction.

LEVEL OF EVIDENCE

Therapeutic study - Level IV.

The optimal concentration of topical hydroxycamptothecin in preventing intraarticular scar adhesion

10-Hydroxycamptothecin could reduce intraarticular adhesion by inhibiting fibroblasts proliferation after knee surgery. However, the ideal concentration of hydroxycamptothecin have not been defined. This study was tried to verify the optimal concentration of 10-hydroxycamptothecin in preventing knee intraarticular adhesion. Sixty rabbits were randomly divided into five groups. Approximately 10 mm × 10 mm of the cortical bone was removed from both sides of the femoral condyle and the underneath cancellous bone was exposed. Various concentrations of hydroxycamptothecin (0.1 mg/ml, 0.5 mg/ml, 1.0 mg/ml, 2.0 mg/ml) or saline were applied to the decorticated areas for 10 minutes. After four weeks, the degree of inraarticular adhesion was assessed by macroscopic evaluation, biochemical analysis of hydroxyproline content and histological evaluation. The results demonstrated that the extent of knee inraarticular adhesion in 1.0 mg/ml group and 2.0 mg/ml hydroxycamptothecin group were significantly lower than those of 0.5 mg/ml group, 0.1 mg/ml hydroxycamptothecin group and control group. Moreover, there was no significant difference between 1.0 mg/ml group and 2.0 mg/ml hydroxycamptothecin group. In conclusion, topical application of 1.0 mg/ml hydroxycamptothecin may be the optimal concentration in reducing intraarticular adhesion after knee surgery in rabbits.

Perioperative rehabilitation using a knee extension device and arthroscopic debridement in the treatment of arthrofibrosis

BACKGROUND

Arthrofibrosis is a postoperative complication of intra-articular knee surgery that can be difficult to treat. Evidence suggests that maximizing knee range of motion may improve outcomes in patients with arthrofibrosis who undergo arthroscopic debridement.

HYPOTHESIS

Patients who achieve greater knee range of motion will have better subjective scores.

STUDY DESIGN

Retrospective case series analysis.

METHODS

A review of records was performed for 33 patients with arthrofibrosis who underwent knee arthroscopy and scar resection coupled with perioperative rehabilitation to maximize knee range of motion. Patient demographics and preoperative and postoperative range of motion measurements were extracted from the records. The International Knee Documentation Committee (IKDC) Subjective Knee Form was administered to assess pain, activity, and knee function. Patients performed a preoperative and postoperative rehabilitation program utilizing a knee extension device to maximize knee extension.

RESULTS

According to the IKDC range of motion criteria, 27 of 33 patients achieved normal knee extension, and 14 of 33 achieved normal knee flexion at a mean of 8.6 months after surgery. Patients with normal knee motion had a mean IKDC Subjective Knee Form score of 72.6 ± 13.6, which was significantly higher than patients who did not achieve normal motion (P = .04). Overall, mean IKDC Subjective Knee Form scores improved from 45.3 ± 16.7 preoperatively to 67.1 ± 18.0 postoperatively (P < .01) at a mean of 14.7 months after surgery.

CONCLUSIONS

Perioperative rehabilitation that emphasizes restoration of normal knee range of motion appears to improve outcomes in patients with arthrofibrosis who undergo arthroscopic scar resection. In support of our hypothesis, patients who achieved greater knee range of motion had better subjective knee scores.

A comparative study of the preventive effects of mitomycin C and chitosan on intraarticular adhesion after knee surgery in rabbits

We sought to compare the preventive effects of mitomycin-C(MMC) and chitosan on intraarticular adhesion after knee surgery in rabbits. For this purpose, 48 New-Zealand rabbits were randomly and equally divided into MMC, chitosan, and control groups. Approximately 10 × 10 mm(2) of the cortical bone was removed from both sides of left femoral condyle and the cancellous bone underneath was exposed. The decorticated areas were topically treated with MMC and chitosan while control group was treated with physiological saline. The lower left limb was fixed in flexed position with Kirschner-wire for 4 weeks postoperatively. After 4 weeks, gross and histopathological examination, biochemical analysis, and fibroblast counts were performed on knee intraarticular adhesion in each group. The data show mild membrane-like fibrous intraarticular adhesion, presented in loose, in MMC group. There was moderate intraarticular adhesion in chitosan group while in controls; there was large-size compact fibrous tissue adhesion. Hydroxyproline contents and fibroblast quantity of MMC and chitosan groups were lower (P < 0.05) than that of control group. We, therefore, concluded that MMC and chitosan could prevent intraarticular adhesion of the knee in rabbits by inhibiting fibroblast proliferation and reducing collagenous fiber formation while MMC had a better preventive effect than that of chitosan.

The surgical treatment of knee stiffness following anterior cruciate ligament reconstruction

Knee stiffness following anterior cruciate ligament (ACL) reconstruction remains a common complication, which can substantially impair knee function. The aim of this study was to assess the effectiveness of arthroscopic arthrolysis, in conjunction with manipulation under anaesthetic (MUA), in treating stiffness post-ACL reconstruction. We reviewed the records of 18 patients who underwent arthroscopic arthrolysis to treat established stiffness following primary isolated ACL reconstruction. Eight of these patients underwent concomitant MUA at time of arthrolysis. The median time between reconstruction and arthrolysis was nine months. Seven patients had arthrolysis performed within eight months of reconstruction, while 11 patients underwent arthrolysis greater than eight months postreconstruction. Following arthrolysis, the mean extension loss improved from 7° to 1°. In patients with mild extension stiffness (prearthrolysis extension deficits <10°), the mean improvement to extension was 3°. In patients with severe extension stiffness (prearthrolysis extension deficit ≥10°), the mean improvement to extension was 10°. Arthroscopic arthrolysis was significantly more effective in restoring extension loss if carried out within eight months of the primary reconstruction (P < 0.03). In the patients who underwent MUA at time of arthrolysis, the mean flexion loss improved from 16° to 4°. In conclusion, arthroscopic arthrolysis, in conjunction with MUA, is an effective treatment for knee stiffness post-ACL reconstruction but ideally should be carried out within eight months.

Outcome of surgical treatment of arthrofibrosis following ligament reconstruction

PURPOSE

Clinical outcome following surgical treatment and intensive physiotherapy was evaluated in patients with arthrofibrosis as a complication to varying knee-ligament reconstructions.

METHODS

From 2003 to 2007, 31 patients underwent surgery for arthrofibrosis as a postoperative complication following knee-ligament reconstruction. Treatment for reduced range of motion consisted of forced manipulation or arthroscopic arthrolysis followed by intensive physiotherapy. Twenty-seven patients (12 men and 15 women; median age 35(12-70) years) were followed up. Objective examination, Pain, KOOS and Tegner scores were used to evaluate the clinical outcome at follow-up.

RESULTS

Fourteen patients were treated with forced manipulation alone, and the remaining thirteen were treated with forced manipulation and arthroscopic arthrolysis. The patients' median follow-up was 51 months (19-73 months). Median interval between primary surgery and surgical release was 4 (1-32) months. Median range of motion (ROM) improved from -0°(0 to 20) to 0°(+2-9) in extension deficit and from 90°(40-145) to 130°(90-155) in flexion. Mean KOOS score were symptoms 63, pain 72, ADL 77, sport 42, QOL 45. Median Tegner score was 4 (2-9).

CONCLUSION

Surgical arthrolysis combined with intensive physiotherapy improved range of motion to nearly normal values. Subjective outcome scores revealed relatively poor outcome levels compared to uncomplicated knee-ligament reconstruction. Predictors of poor outcome were global arthrofibrosis and greater than 6-month time interval from primary reconstruction and surgical release.

LEVEL OF EVIDENCE

Retrospective clinical case series, Level IV.

[Rupture of the anterior cruciate ligament. Diagnostics and therapy]

Rupture of the anterior cruciate ligament (ACL) is the most common ligamentous knee injury. The knee is stabilized by the cruciate ligaments and the collateral ligaments. The ACL originates from the inner surface of the lateral condyle of the femur, runs in an anterior medial direction and inserts at the tibial plateau in the intercondyle area. The most common injury is an indirect knee trauma, typically a joint torsion in sports. Patients often describe a snapping noise followed by hemarthrosis. Concomitant injuries are lesions of the medial collateral ligament, the medial meniscus (unhappy triad) and chondral fractures. The age peak is between 15 and 30 years with a higher incidence in females. The cardinal symptom of the ACL rupture is the giving way phenomenon. The clinical diagnosis is provided by a positive Lachman test, a positive pivot shift test and the anterior drawer test. Fractures can be excluded by X-ray examination. Magnetic resonance imaging (MRI) allows the evaluation of the internal knee structures. ACL repair is carried out by arthroscopically assisted bone-tendon-bone or semitendinosus grafting techniques. Early rehabilitation is important for a good functional outcome.

Knee-attributable medical costs and risk of re-surgery among patients utilizing non-surgical treatment options for knee arthrofibrosis in a managed care population

OBJECTIVE

To determine if differences in costs and risks of re-hospitalization and/or re-operation exist between arthrofibrosis patients treated with low intensity stretch (LIS) or high intensity stretch (HIS) mechanical therapies, or physical therapy alone (No Device).

STUDY DESIGN

This observational cohort study utilized administrative claims data to identify arthrofibrosis patients, age <65 years, with continuous enrollment for the 6 months prior to and following the index knee event date.

METHODS

The index knee event was defined as the knee injury/surgery preceding device use for the LIS and HIS groups and the knee injury/surgery prior to the diagnosis of arthrofibrosis for the No Device group. Knee-attributable medical costs (KAMC), accrued over 6-month pre- and post-index periods, as well as risks of re-operation, re-injury, and re-hospitalization were compared between groups. Multivariate models were used to evaluate group differences in utilization and costs when controlling for age, sex, and comorbidities.

RESULTS

A total of 60 359 patients (143 HIS; 607 LIS; 59 609 No Device) met the inclusion criteria. Unadjusted post-index KAMC were significantly less (p < 0.0001) among HIS patients ($8213 +/- 10 576) relative to LIS ($16 861 +/- 17 857) and No Device ($9345 +/- 14 120) patients. A significantly greater percentage of LIS Device patients had total knee replacements than HIS Device or No Device patients, and the LIS group had a significantly higher percentage of patients with musculoskeletal disease. When controlling for these group differences, the multivariate predictive model results were similar to the unadjusted results, with greater post-index KAMC for the LIS patients (24%, p = 0.025) and No Device (9%, p = 0.323) relative to HIS patients. No Device patients were 71% (p < 0.0001) more likely to have a subsequent knee event than HIS patients, and HIS patients had significantly lower rates of re-hospitalization than LIS and No Device patients (p < 0.0001).

CONCLUSIONS

Patients treated with HIS mechanical therapy demonstrated significantly reduced rates of re-hospitalization which corresponded to reduced knee-attributable medical costs.

LIMITATIONS

Limitations of this study include those inherent in the use of retrospective claims data to identify the cohorts and for analytic purposes. The authors attempted to control for these as much as possible with the multivariate analyses, and inclusion of the model covariates specified above demonstrated a scaled deviance of 1.16 indicating a reasonable goodness-of-fit for the selected model covariates.

Knee stiffness following anterior cruciate ligament reconstruction: the incidence and associated factors of knee stiffness following anterior cruciate ligament reconstruction

We reviewed 100 patients retrospectively following primary ACL reconstruction with quadruple hamstring autografts to evaluate the incidence and factors associated with postoperative stiffness. Stiffness was defined as any loss of motion using the contra-lateral leg as a control. The median delay between injury and operation was 15 months. The incidence of stiffness was 12% at 6 months post-reconstruction. Both incomplete attendance at physiotherapy (p<0.005) and previous knee surgery (p<0.005) were the strongest predictors of the stiffness. Anterior knee pain was also associated with the stiffness (p<0.029). Factors that failed to show a significant association with the stiffness included associated MCL sprain at injury (p=0.32), post-injury stiffness (p=1.00) and concomitant menisectomy at reconstruction (p=0.54). Timing of surgery also did not appear to influence the onset of stiffness (median delays: 29 months for stiff patients; 14 months for non-stiff patients). The rate of stiffness fell to 5% at 12 months postreconstruction, without operative intervention.

Arthroscopic posteromedial capsular release for knee flexion contractures

Extension deficits of the knee can cause functional limitations in patients after knee surgery or injury. Most frequently, they are treated with manipulations, arthroscopic anterior compartment debridements, or open posterior capsular releases once nonoperative treatment fails. However, an arthroscopic posteromedial capsular release to manage flexion deficits has yet to be studied comprehensively. Arthroscopic posteromedial capsular releases of the knee can result in improved knee motion postoperatively. An arthroscopic posteromedial capsular release involves sectioning the posteromedial capsule at its meniscofemoral portion, midway between its femoral attachment and its posterior horn medial meniscus junction. A review of 15 patients who underwent this operation was performed. Passive knee extension and flexion was measured in patients in the supine position using a goniometer at preoperative evaluations, under anesthesia prior to and immediately after the posteromedial capsular release, and at postoperative follow-up evaluations. The average time from the arthroscopic posteromedial capsular release to the final postoperative follow-up was 24.1 months. Preoperative knee extension averaged 14.7 degrees in 15 patients. The average immediate postoperative knee extension averaged -0.9 degrees. At the final postoperative follow-up, knee extension averaged 0.7 degrees. Overall knee motion improved from an average are of motion of 101.6 degrees-129.4 degrees. Arthroscopic posteromedial capsular releases and the concurrent postoperative rehabilitation program were effective in the treatment of knee extension deficits. The encouraging results of this study compare well to data presented in open posterior capsular release studies. We believe that arthroscopic posteromedial capsular releases are an effective means to address symptomatic knee extension deficits.

Adhesion reduction after knee surgery in a rabbit model by Hyaloglide, a hyaluronan derivative gel

A randomized controlled experimental trial was performed in a rabbit model of surgical adhesions to investigate the anti-adhesive effects of Hyaloglide, a highly viscous hyaluronan derivative absorbable gel after knee surgery. Twenty New Zealand white rabbits were prepared and randomly divided into two groups of 10 animals each. An intra-articular fibro-adhesive scar was created in the right knee joint of the hind paw of each rabbit using a standardized surgical procedure, and Hyaloglide was administered into the joint cavity of the knee at the end of intervention in the animals belonging to the treatment group. No anti-adhesive treatment was applied in the control group. Additionally, immobilization using a Kirschner wire was applied in order to increase the risk of adhesions. Six weeks after surgery the animals were euthanized and after removal of the immobilization system, adhesions were evaluated both macroscopically and histologically. Results of gross observations using a specific adhesion scoring system showed a significant reduction (p<0.01) of both incidence and severity of adhesions in the hyaluronan-treated group compared to the control group. Histologically, adhesions in the treated group were thinner with less collagenic fibers. In conclusion, Hyaloglide may be considered as a promising absorbable barrier for prevention of post-operative fibrotic adhesions after knee surgery.

[ACL reconstruction with BTB graft--unusual evolution of knee arthrofibrosis case report]

Knee arthrofibrosis, which usually occurs after trauma or surgery, can inhibit joint biomechanics. An elaborated interaction of growth factors and other inflammatory mediators initiates and coordinates this deleterious tissue proliferation. Knowledge of risk factors can aid clinicians in helping patients avoid knee arthrofibrosis. Once the condition is present, a history and examination are imperative to institute the most appropriate treatment regimen. Nonoperative measures can be used as therapy, though surgery is often necessary for optimal results. We have analyzed problems in patient with uncommon evolution of knee arthrofibrosis following ACL recontruction with BTB autograft.

Prevention of shoulder stiffness after rotator cuff repair

Predisposing factors for shoulder stiffness after rotator cuff repair have yet to be determined. The potential for recovery of range of motion and amelioration of pain in patients with this complication also remains unclear. Accordingly, data collected prospectively for 209 patients with a primary rotator cuff repair were retrospectively reviewed. Two groups, Group A (early motion recovery) and Group B (shoulder stiffness), were selected according to passive shoulder range of motion outcomes 6 weeks postoperatively. Both groups were compared for 10 descriptive and clinical characteristics, and for passive range of motion, muscle force, and functional outcomes obtained 0, 6, 12, 24, and 76 weeks postoperatively. Of the potential prognostic factors examined, restriction of range of motion for the preoperative hand behind the back best predicted shoulder stiffness at 6 weeks postoperatively. For patients with postoperative shoulder stiffness, pain had subsided by 24 weeks postoperatively, whereas range of motion steadily improved between 6 weeks and 76 weeks postoperatively. Results of the current study support a predictive role for restriction of range of motion for the preoperative hand behind the back, and affirms the potential for nearly complete recovery of range of motion and amelioration of pain in patients who have shoulder stiffness after rotator cuff repair.

LEVEL OF EVIDENCE

Prognostic study, Level I-1 (prospective study).

Alpha-smooth muscle actin containing contractile fibroblastic cells in human knee arthrofibrosis tissue. Winner of the AGA-DonJoy Award 2003

INTRODUCTION

Primary arthrofibrosis is of major concern after joint trauma or knee ligament surgery. The underlying mechanism in detail remains unclear. Highly differentiated fibroblastic cells, so-called myofibroblasts, express the actin isoform alpha-smooth muscle actin (ASMA) and have been found to play a major role in tissue contraction during wound healing and organ fibrosis. We therefore studied the expression of myofibroblasts in human primary knee arthrofibrosis tissue.

MATERIALS AND METHODS

Tissue samples were taken from the infrapatellar fat pad and intercondylar region of nine patients who underwent revision surgery due to arthrofibrosis after anterior cruciate ligament (ACL) reconstruction (study group). Control tissue was taken from five patients who underwent primary ACL reconstruction (control group I) and from eight patients, who underwent second-look arthroscopy after primary ACL reconstruction (control group II). ASMA containing fibroblasts were immunostained with a monoclonal antibody. Histomorphometry was performed for total cell amount, ASMA containing fibroblasts, and vessel cross-sections.

RESULTS

The arthrofibrosis group showed a tenfold higher amount of ASMA containing myofibroblasts (23.4% vs. 2.3%) than in control group I. There was a significantly higher total cell count and lower vessel density than in control group I. Control group II showed an upregulation of myofibroblasts almost five times that in control group I; nevertheless there was no evidence of scar formation or tissue fibrosis.

CONCLUSIONS

Myofibroblasts are responsible for scar tissue contraction during wound healing. In arthrofibrosis tissue fibroblast contraction may be involved in tissue fibrosis and contraction with consecutive loss of motion. We found that myofibroblasts are upregulated in arthrofibrosis tissue. ACL reconstruction itself caused an up regulation of myofibroblast content. Nevertheless these patients did not show any clinical or histological signs of arthrofibrosis. Thus it is reasonable to assume that the ratio of myofibroblasts and total cell amount in connective tissue are responsible for the onset of arthrofibrosis. Address the expression of this highly differentiated cell type may therefore present a target for future therapeutic interventions.

Arthroscopic treatment of the arthrofibrotic knee

The management of motion loss of the knee is challenging. A clear understanding of the pathoanatomic causes of motion loss is necessary to establish a careful and rational approach to treatment. Early recognition and physical therapy are effective for the majority of patients, but when these conservative measures fail, operative intervention is indicated. The purpose of this article is to outline a comprehensive approach to the arthroscopic evaluation and treatment of the arthrofibrotic knee. This technique is designed to allow the surgeon to systematically address the numerous causes of motion loss of the knee.

Motion loss after ligament injuries to the knee. Part I: causes

Motion loss continues to be a difficult complication after ligament injury and surgery to the knee. A better understanding of the pathoanatomic causes of motion loss can lead to improved prevention and treatment strategies. When motion loss does occur, early recognition and appropriate treatment can be expected to restore motion and improve function in most patients. Treatment options, although varied, should improve outcome when implemented appropriately. This article is composed of two parts. The first part reviews the current concepts on definitions, incidence, and causes of motion loss. In the second part, to be published later, current strategies on prevention and treatment of motion loss after ligament injury to the knee are reviewed. Emphasis is placed on risk factors and prevention as well as on diagnosis and treatment. The article summarizes the latest information from the basic sciences as well as clinical studies on the problem of motion loss of the knee and attempts to provide a rational approach to these difficult clinical problems.

A symptomatic cyclops lesion 4 years after anterior cruciate ligament reconstruction

The cyclops lesion is a fibrous nodule with central granulation tissue located anterolateral to the tibial tunnel after intra-articular reconstruction of the anterior cruciate ligament (ACL) that has been shown to be a cause of failure to regain full extension in the early postoperative period. We present the case of a 23-year-old woman who had undergone arthroscopic ACL reconstruction with a patellar tendon autograft 4 years prior to presentation. Following her reconstruction, she regained full range of motion and returned to collegiate cheerleading. At presentation, she complained of a gradual loss of full extension and joint-line pain with terminal extension. On examination, her graft was stable and she lacked 3 degrees of extension. Magnetic resonance imaging documented a 1-cm mass of low signal intensity immediately anterior to the ACL graft within the intercondylar notch. At arthroscopy, a large amount of thick, immobile scar tissue was found immediately anterior to the ACL, consistent with a cyclops lesion. The lesion was debrided and the patient did well postoperatively. Patients who present with delayed-onset loss of extension after ACL reconstruction should undergo careful evaluation including radiographs and magnetic resonance imaging. If a cyclops lesion is diagnosed, arthroscopic resection should be undertaken.