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Franulic N, Laso J, Del Pino C, Brito C, Olivieri R, Gaggero N. Arthroscopic fibroarthrolysis and mobilization under anesthesia is a simple, reproducible, and satisfactory method for the treatment of patients with severe post-traumatic arthrofibrosis of the knee. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00123-1. [PMID: 38997005 DOI: 10.1016/j.recot.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 06/17/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVE To evaluate the range of motion (ROM) of the knee in patients with severe post-traumatic knee arthrofibrosis after being treated with arthroscopic fibroarthrolysis (AFA) and manipulation under anesthesia (MUA). METHODS Case series of patients with severe post-traumatic knee arthrofibrosis who underwent AFL+MUA in a national referral center. The primary outcome to be assessed was ROM before and after surgery and then at 3-month intervals until a minimum follow-up of one year was completed. RESULTS 51 patients were included. The main injuries preceding the stiffness were tibial plateau fracture (37.3%), distal femur fracture (27.5%), and femoral shaft fracture (15.7%). Forty-five patients had severe flexion deficits with a median preoperative flexion of 70°. Intraoperative flexion significantly improved to 110°. Significant loss of flexion was observed at 3 and 6 months, however, patients regained ROM in the 9 and 12-month follow-ups. At discharge, 80% of the patients achieved flexion of 90° or more. There were 4 intraoperative complications and 3 reinterventions were performed. CONCLUSION AFA+MUA can help patients with severe post-traumatic knee arthrofibrosis to recover ROM in most cases. However, this procedure is not without risks and complications, therefore, careful consideration should be given to its indication and execution.
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Affiliation(s)
- N Franulic
- Knee Surgeon Hospital del Trabajador ACHS, Santiago, Chile; Knee Surgeon Hospital Militar, Santiago, Chile; Assistant Professor at Universidad de los Andes, Santiago, Chile.
| | - J Laso
- Knee Surgeon Hospital del Trabajador ACHS, Santiago, Chile; Knee Surgeon, Hospital Barros Luco Trudeau, Santiago, Chile
| | - C Del Pino
- Orthopedics and Traumatology Resident, Universidad Andres Bello, Chile
| | - C Brito
- Knee Surgeon Hospital Naval Almirante Nef, Viña del Mar, Chile
| | - R Olivieri
- Knee Surgeon Hospital del Trabajador ACHS, Santiago, Chile
| | - N Gaggero
- Knee Surgeon Hospital del Trabajador ACHS, Santiago, Chile
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2
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Brinkman JC, Iturregui JM, Moore ML, Haglin J, Thompson A, Makovicka J, Economopoulos KJ. Arthroscopic Posterior Capsular Release Improves Range of Motion and Outcomes for Flexion Contracture After Anterior Cruciate Ligament Reconstruction in Athletes. Arthrosc Sports Med Rehabil 2024; 6:100914. [PMID: 39006795 PMCID: PMC11240015 DOI: 10.1016/j.asmr.2024.100914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 02/12/2024] [Indexed: 07/16/2024] Open
Abstract
Purpose To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction. Methods A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow-up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications. Results Eighteen athletes with minimum 2 years of follow-up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years' follow-up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant (P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively (P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension. Conclusions For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient-reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Joseph C Brinkman
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Jose M Iturregui
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - M Lane Moore
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, U.S.A
| | - Jack Haglin
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Adam Thompson
- University of Vermont School of Medicine, Burlington, Vermont, U.S.A
| | - Justin Makovicka
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
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Reddy R, Bernard C, Tarakemeh A, Morey T, Mulcahey MK, Vopat BG, Vopat ML. Manipulation Under Anesthesia and Lysis of Adhesions Are the Most Commonly Reported Treatments for Arthrofibrosis of the Knee After Arthroscopy or Anterior Cruciate Ligament Reconstruction in Both Pediatric and Adult Patients. Arthrosc Sports Med Rehabil 2024; 6:100896. [PMID: 38469123 PMCID: PMC10925934 DOI: 10.1016/j.asmr.2024.100896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 01/13/2024] [Indexed: 03/13/2024] Open
Abstract
Purpose To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations. Methods A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: ("arthrofibrosis" OR "stiffness" OR "stiff" OR "complications") AND ("arthroscopy" OR "arthroscop" OR "ACL" OR "anterior cruciate") AND ("treat" OR "care" OR "management" AND "knee"). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients. Results A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications. Conclusions Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications. Level of Evidence Level IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Ravali Reddy
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
| | | | - Armin Tarakemeh
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
| | - Tucker Morey
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
| | - Mary K. Mulcahey
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Bryan G. Vopat
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
| | - Matthew L. Vopat
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
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4
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Malinowski K, Mostowy M, Koźlak M, Pękala PA, Kennedy NI, LaPrade RF. Complete Arthroscopic Posterior Knee Capsulotomy in Patients With Knee Extension Deficit: Preliminary Results of a Clinical Trial. Orthop J Sports Med 2023; 11:23259671231203606. [PMID: 38045767 PMCID: PMC10693213 DOI: 10.1177/23259671231203606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 12/05/2023] Open
Abstract
Background Guided physiotherapy and surgical arthrolysis are effective in most patients with knee extension deficit. However, in refractory cases, posterior knee capsulotomy may be needed. Purpose To assess extension restoration, pain reduction, and functional improvement after arthroscopic complete posterior knee capsulotomy in patients with extension deficit refractory to guided physiotherapy and surgical arthrolysis. Study Design Case series; Level of evidence, 4. Methods Included were patients with symptomatic asymmetric extension deficit >3° refractory to at least 6 months of guided physiotherapy and initial arthrolysis (15 patients with 12-month follow-up and 8 patients with 24-month follow-up). The mean duration of extension deficit was 24.6 months. An arthroscopic complete posterior knee capsulotomy was performed with transection of the posteromedial, posterolateral and central capsule, and the posterior septum. The primary outcome measure was knee extension, with hyperextension denoted as negative knee extension values. Secondary outcome measures included visual analog scale (VAS) for pain during maximum effort and exercise, International Knee Documentation Committee (IKDC) score, and Knee injury and Osteoarthritis Outcome Score (KOOS). Results The mean patient age was 40.0 years (range, 26-70 years); 6 out of 15 patients had developed knee contracture after isolated anterior cruciate ligament reconstruction. The mean knee extension deficit decreased from 16.9° (range, 7° to 45°) preoperatively to -0.2° (range, -5° to 5°) at 12-month follow-up (P = .003) and to -0.3° (range, -5° to 5°) at 24-month follow-up (P = .035). The mean VAS pain score decreased from 3.5 (range, 1-6) preoperatively to 1.1 (range, 0-2) at 12-month follow-up (P = .004) and to 1.5 (range, 0-4) at 24-month follow-up (P = .005). The mean IKDC increased from 37.9 (range, 21-62) preoperatively to 63.9 (range, 46-87) at 12-month follow-up (P < .001) and to 60.9 (range, 39-80) at 24-month follow-up (P = .003). The mean KOOS increased from 45.0 (range, 30-62) preoperatively to 75.3 (range, 49-94) at 12-month follow-up (P < .001) and to 72.3 (range, 49-92) at 24-month follow-up (P = .003). There were no significant differences between 12- and 24-month follow-up in extension deficit or functional outcomes. One patient had a midcalf subcutaneous hematoma 5 weeks postoperatively, requiring evacuation. Conclusion Arthroscopic complete posterior knee capsulotomy was able to restore knee extension, reduce pain, and improve function, with 12-month follow-up results sustained at 24-month follow-up. Registration NCT05385393 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Konrad Malinowski
- Department of Anatomy, Jagiellonian University Medical College, International Evidence-Based Anatomy Working Group, Kraków, Poland
- Artromedical Orthopaedic Clinic, Belchatow, Poland
| | - Marcin Mostowy
- Artromedical Orthopaedic Clinic, Belchatow, Poland
- Orthopedic and Trauma Department, Veteran’s Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
| | | | - Przemyslaw A. Pękala
- Department of Anatomy, Jagiellonian University Medical College, International Evidence-Based Anatomy Working Group, Kraków, Poland
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
- Lesser Poland Orthopedic and Rehabilitation Hospital, Kraków, Poland
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Fackler N, Chin G, Karasavvidis T, Bohlen H, Smith E, Amirhekmat A, Wang D. Outcomes of Arthroscopic Lysis of Adhesions for the Treatment of Postoperative Knee Arthrofibrosis: A Systematic Review. Orthop J Sports Med 2022; 10:23259671221124911. [PMID: 36186712 PMCID: PMC9523860 DOI: 10.1177/23259671221124911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/24/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Postoperative knee arthrofibrosis is a common and potentially detrimental complication affecting knee function and gait. Several cohort studies have reported good outcomes after arthroscopic lysis of adhesions (LOA) with manipulation under anesthesia (MUA). Purpose: To review the literature assessing the efficacy and complications of arthroscopic LOA and MUA for postoperative arthrofibrosis of the knee and evaluate whether any relevant subgroups are associated with different clinical presentation and outcomes. Study Design: Systematic review; Level of evidence, 4. Methods: This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies published from January 1, 1990, to April 1, 2021, were identified through a search of the US National Library of Medicine (PubMed/MEDLINE), EMBASE, and Cochrane databases. All studies included in this analysis included pre- and postoperative range of motion measurements for their treated patients. Studies reporting outcomes for patients with isolated cyclops lesions after anterior cruciate ligament reconstruction were excluded. Results: Eight studies comprising 240 patients were included. The mean time from index surgery to arthroscopic LOA and MUA was 8.4 months, and the mean postoperative follow-up was at 31.2 months. All studies demonstrated a significant improvement (41.6°) in arc of motion after arthroscopic LOA. Clinically significant improvements in outcome measures, including the International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score, were reported after arthroscopic LOA across all applicable studies. Of 240 patients, a single complication (synovial fistula) occurred after LOA and MUA, which resolved without intervention. Conclusion: The results of this review indicated that arthroscopic LOA and MUA is a safe and efficacious treatment for postoperative arthrofibrosis of the knee.
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Affiliation(s)
- Nathan Fackler
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA.,Department of Orthopaedic Surgery, University of California, San Diego, San Diego, USA
| | - Garwin Chin
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Theofilos Karasavvidis
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Hunter Bohlen
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Eric Smith
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Arya Amirhekmat
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Dean Wang
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA.,Department of Biomedical Engineering, University of California, Irvine, Irvine, California, USA
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6
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Gálvez-Sirvent E, Ibarzábal-Gil A, Rodríguez-Merchán EC. Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management. EFORT Open Rev 2022; 7:554-568. [PMID: 35924649 PMCID: PMC9458943 DOI: 10.1530/eor-22-0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.
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Affiliation(s)
- Elena Gálvez-Sirvent
- Department of Orthopaedic Surgery, "Infanta Elena" University Hospital, Valdemoro, Madrid, Spain.,Faculty of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Aitor Ibarzábal-Gil
- Department of Orthopaedic Surgery, "La Paz" University Hospital, Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Department of Orthopaedic Surgery, "La Paz" University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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7
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Arthroscopic Posterior Capsular Release Effectively Reduces Pain and Restores Terminal Knee Extension in Cases of Recalcitrant Flexion Contracture. Arthrosc Sports Med Rehabil 2022; 4:e1409-e1415. [PMID: 36033179 PMCID: PMC9402456 DOI: 10.1016/j.asmr.2022.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose To 1) evaluate the clinical efficacy of arthroscopic posterior capsular release for improving range of motion (ROM) in cases of recalcitrant flexion contracture and 2) determine patient-reported outcomes (PROs) postoperatively. Methods Retrospective chart review was performed to identify patients who underwent arthroscopic posterior capsular release due to persistent extension deficit of the knee despite comprehensive nonoperative physical therapy between 2008 and 2021. Knee ROM and PROs (International Knee Documentation Committee [IKDC], Tegner, and visual analog scale [VAS]) were collected at final follow-up. Results Overall, 22 patients were included with a median age of 37 years (interquartile range [IQR]: 20.5-44.3). Of these, 8 (36%) were male and 14 (64%) were female, and average follow-up was 3.7 ± 3.3 years. The most common etiology was knee flexion contracture after anterior cruciate ligament (ACL) reconstruction (59%). All patients failed a minimum of 3 months of nonoperative management. Prior to operative intervention, 100% of patients received physical therapy, 64% received extension knee bracing or casting, and 36% received corticosteroid injection. Median preoperative extension was 15° (IQR: 10-25) compared to 2° (IQR: 0-5) postoperatively (P < .001). At final follow-up, median extension was 0° (IQR: 0-3.5). Postoperative VAS pain scores at rest (2 vs 0; P = .001) and with use (5 vs 1.8; P = .017) improved at final contact, and most (94%) patients reported maintaining their extension ROM. Patients with ACL-related extension deficit reported better IKDC (81 vs 51.3; P = .008), Tegner (5.8 vs 3.6; P = .007), and VAS pain scores (rest: 0.2 vs 1.8; P = .008; use: 1.3 vs 5; P = .004) compared to other etiologies. Conclusion Arthroscopic posterior capsular release for recalcitrant flexion contracture provides an effective means for reducing pain and restoring terminal extension. The improvement in extension postoperatively was maintained for most (94%) patients at final follow-up with a 14% reoperation rate.
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8
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Ebisz M, Mostowy M, Góralczyk A, Hirschmann MT, Skowronek P, LaPrade RF, Malinowski K. Both arthroscopic and open posterior knee capsulotomy are effective in terms of extension recovery and functional improvement-systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:1443-1452. [PMID: 34117895 DOI: 10.1007/s00167-021-06634-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To assess the recovery of extension and improvement in functional scores after an arthroscopic or open posterior knee capsulotomy in the setting of an extension deficit. METHODS A systematic search of articles published between 1980 and 2020 was performed in the MEDLINE/PubMed database, EMBASE/Ovid database and Web of Science database. The inclusion criteria consisted of patients with primary extension deficits > 5° who underwent an arthroscopic or open posterior knee capsulotomy. The assessed outcomes were preoperative and postoperative range of motion and functional outcome scores. Randomized controlled trials, cohort studies and case series with a follow-up longer than 6 months were included. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for case series. The certainty of evidence was assessed using the GRADE approach. RESULTS Of 226 records identified through database searching, 7 studies were included in the final analysis. The outcomes of 107 patients with a mean age of 34.1 (range 15-63) years were available. In all the included studies, a posterior capsulotomy resulted in the restoration of knee extension to normal or nearly normal values (mean postoperative extension deficit: 0.4-4.2 degrees) with a significant increase in functional outcome scores. No neurovascular complications were reported within the studies. Due to the diverse methodology of studies, the direct comparison of arthroscopic versus open approaches was not possible. Concerning the risk of bias assessment, the greatest concerns raised the selection of participants among the included studies and the methods of outcome measurement. The certainty of evidence was very low according to the GRADE. CONCLUSIONS Both arthroscopic and open posterior capsulotomy of the knee results in restoration of normal or nearly normal knee extension and significant improvement in functional outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michał Ebisz
- Artromedical Orthopaedic Clinic, Antracytowa 1, 97-400, Belchatow, Poland
| | - Marcin Mostowy
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Zeromskiego 113, 90-549, Lodz, Poland
| | | | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland.,University of Basel, CH-4051, Basel, Switzerland
| | - Paweł Skowronek
- Department of Orthopaedic, Trauma Surgery S. Zeromski Hospital, Os. Na Skarpie 66, 31-913, Krakow, Poland
| | - Robert F LaPrade
- Twin Cities Orthopedics, 4010 W 65th St Edina, Minnesota, 55435, USA
| | - Konrad Malinowski
- Artromedical Orthopaedic Clinic, Antracytowa 1, 97-400, Belchatow, Poland.
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9
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Lee DR, Therrien E, Song BM, Camp CL, Krych AJ, Stuart MJ, Abdel MP, Levy BA. Arthrofibrosis Nightmares: Prevention and Management Strategies. Sports Med Arthrosc Rev 2022; 30:29-41. [PMID: 35113841 PMCID: PMC8830598 DOI: 10.1097/jsa.0000000000000324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathologic periarticular fibrosis and symptomatic joint stiffness. The knee, elbow, and shoulder are particularly susceptible to AF, often in the setting of trauma, surgery, or adhesive capsulitis. Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss. Reliable nonoperative modalities exist and outcomes are improved when etiology, joint involved, and level of dysfunction are considered in the clinical decision making process. Surgical procedures should be reserved for cases recalcitrant to nonoperative measures. The purpose of this review is to provide an overview of the current understanding of AF pathophysiology, identify common risk factors, describe prevention strategies, and outline both nonoperative and surgical treatment options. This manuscript will focus specifically on sterile AF of the knee, elbow, and shoulder.
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Affiliation(s)
- Dustin R. Lee
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Erik Therrien
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bryant M. Song
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L. Camp
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J. Krych
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J. Stuart
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Mathew P. Abdel
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bruce A. Levy
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
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10
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Malinowski K, Góralczyk A, Hermanowicz K, LaPrade RF, Więcek R, Domżalski ME. Arthroscopic Complete Posterior Capsulotomy for Knee Flexion Contracture. Arthrosc Tech 2018; 7:e1135-e1139. [PMID: 30533360 PMCID: PMC6262078 DOI: 10.1016/j.eats.2018.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/25/2018] [Indexed: 02/03/2023] Open
Abstract
Knee flexion contracture is a clinically important complication that can be observed after trauma, after knee surgery, or as a result of osteoarthritis. When it is left untreated, knee shearing forces increase not only in the affected joint but also in the contralateral knee, leading to mechanical overload in both limbs. Conservative management is a first-line treatment option for extension deficits, but when it fails, surgical treatment is necessary. Open as well as arthroscopic techniques focus mainly on an anterior arthrolysis and a posterior capsular release. Until now, posterior capsulotomy involved either a medial posterior capsular release or medial and lateral posterior capsular releases. Our aim is to present the technique of arthroscopic complete posterior capsulotomy for knee flexion contractures.
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Affiliation(s)
- Konrad Malinowski
- Artromedical Orthopaedic Clinic, Belchatów, Poland,Address correspondence to Konrad Malinowski, M.D., Ph.D., Artromedical Orthopaedic Clinic, Chrobrego 24, 97-400 Belchatów, Poland.
| | | | | | - Robert F. LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A
| | - Rafał Więcek
- Artromedical Orthopaedic Clinic, Belchatów, Poland
| | - Marcin E. Domżalski
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Lodz, Poland
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11
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Wierer G, Runer A, Gföller P, Fink C, Hoser C. Extension deficit after anterior cruciate ligament reconstruction: Is arthroscopic posterior release a safe and effective procedure? Knee 2017; 24:49-54. [PMID: 27742158 DOI: 10.1016/j.knee.2016.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/15/2016] [Accepted: 09/20/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Postoperative extension deficits following anterior cruciate ligament (ACL) reconstruction can cause major limitation during daily life. The purpose of this study was to evaluate the efficiency of an all-arthroscopic approach and posterior capsule release for the treatment of persistent knee extension deficits following ACL reconstruction. METHODS Between 2009 and 2013 a total of 10 patients with knee flexion contractures after ACL reconstruction were assessed following an all-arthroscopic approach and posterior capsulotomy. The clinical outcomes were reviewed using the range of motion (ROM), Tegner Activity Level, Lysholm score and visual analogue pain scale (VAS). RESULTS Four women and six men with a median age of 34years (range: 17 to 49years) were included in the study. The median follow-up period was 25months (range: 14 to 69months). The median preoperative extension deficit was 15° (range: 10 to 20°) compared to the normal contralateral knee. Postoperatively at final follow-up the median extension deficit was one degree (range: 0 to five degrees) (P<0.01). The median preoperative Lysholm score improved from 52 (range: 32 to 67) to 92 (range: 84 to 100) postoperatively (P<0.01), while the median Tegner Activity Level improved from three (range: two to six) to six (range: three to seven) respectively (P<0.02). The median VAS status for pain decreased from five (range: one to 10) to one (range: 0 to three) (P<0.01). No complications were observed. CONCLUSIONS Arthroscopic posterior capsulotomy is a safe and effective additional procedure in the treatment of persistent knee extension deficits following ACL reconstruction with excellent results regarding ROM and subjective outcomes. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Guido Wierer
- Department of Traumatology and Sports Injuries, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria; Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
| | - Armin Runer
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria; Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Peter Gföller
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
| | - Christian Fink
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria; Research Unit for OSMI, UMIT/ISAG, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria.
| | - Christian Hoser
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
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Shang P, Liu HX, Zhang Y, Xue EX, Pan XY. A mini-invasive technique for severe arthrofibrosis of the knee: A technical note. Injury 2016; 47:1867-70. [PMID: 27346423 DOI: 10.1016/j.injury.2016.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/09/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE In this article, a mini-invasive technique is described, which consists of arthroscopic adhesiolysis and quadriceps pie-crusting lengthening basing on pre-operative sonographic examination. Sonographic diagnostic value of quadriceps tendon fibrosis is also evaluated. METHODS Pre-operative sonographic examination was performed to make an accurate location diagnosis of quadriceps fibrosis. After arthroscopic adhesiolysis, percutaneous pie-crusting release was performed basing on preoperative sonographic examination. An 18-gauge needle was used to puncture the stiff fibrous band of the distal and lateral quadriceps tendon under maximum knee flexion. The contractural quadriceps tendon is gradually released after 60-100 needle punctures. RESULTS This technique was performed in five post-traumatic stiff knees and three stiff knees after previous infection. The contractural rectus femoris tendon is average 22% thinner than contralateral parts according to sonographic measurement. Mean maximum flexion increased from 35° preoperatively to 80° after arthroscopic adhesiolysis and 120° after pie-crusting. CONCLUSIONS This technique is a simple, effective and mini-invasive method, allowing an immediate, aggressive rehabilitation postoperatively. Pre-operative sonographic location of quadriceps tendon fibrosis could potentially improve the efficacy and accuracy of percutaneous pie-crusting procedures.
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Affiliation(s)
- Ping Shang
- Department of Rehabilitation, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China
| | - Hai-Xiao Liu
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China.
| | - Yu Zhang
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China
| | - En-Xing Xue
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China
| | - Xiao-Yun Pan
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China.
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Tardy N, Thaunat M, Sonnery-Cottet B, Murphy C, Chambat P, Fayard JM. Extension deficit after ACL reconstruction: Is open posterior release a safe and efficient procedure? Knee 2016; 23:465-71. [PMID: 26875053 DOI: 10.1016/j.knee.2016.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/24/2015] [Accepted: 01/02/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Nicolas Tardy
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, 24 Avenue Paul Santy, 69008 Lyon, France.
| | - Mathieu Thaunat
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, 24 Avenue Paul Santy, 69008 Lyon, France.
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, 24 Avenue Paul Santy, 69008 Lyon, France.
| | - Colin Murphy
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, 24 Avenue Paul Santy, 69008 Lyon, France.
| | - Pierre Chambat
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, 24 Avenue Paul Santy, 69008 Lyon, France.
| | - Jean-Marie Fayard
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz, 24 Avenue Paul Santy, 69008 Lyon, France.
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Dean CS, Chahla J, Mikula JD, Mitchell JJ, LaPrade RF. Arthroscopic Posteromedial Capsular Release. Arthrosc Tech 2016; 5:e495-500. [PMID: 27656368 PMCID: PMC5021185 DOI: 10.1016/j.eats.2016.01.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/28/2016] [Indexed: 02/03/2023] Open
Abstract
Post-traumatic or postsurgical flexion contractures of the knee can significantly limit function and lead to gait abnormalities. In this setting, interventions to regain full extension may include bracing, physical therapy, and open or arthroscopic surgery. Open surgical approaches to restore full motion often demand extensive recovery and promote further adhesions and loss of motion, which has led to the advent of arthroscopic techniques to address these pathologies. We present a safe, effective, and reproducible arthroscopic technique for posteromedial capsular release to address knee flexion contractures.
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Affiliation(s)
- Chase S. Dean
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jacob D. Mikula
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Justin J. Mitchell
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A
| | - Robert F. LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Robert F. LaPrade, M.D., Ph.D., Steadman Philippon Research Institute, The Steadman Clinic, 181 W Meadow Dr, Ste 400, Vail, CO 81657, U.S.A.Steadman Philippon Research InstituteThe Steadman Clinic181 W Meadow DrSte 400VailCO81657U.S.A.
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15
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Ohishi T, Takahashi M, Suzuki D, Matsuyama Y. Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal. World J Orthop 2015; 6:505-512. [PMID: 26301179 PMCID: PMC4539473 DOI: 10.5312/wjo.v6.i7.505] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/27/2015] [Accepted: 06/19/2015] [Indexed: 02/06/2023] Open
Abstract
Arthroscopic surgery of the posterior compartment of the knee is difficult when only two anterior portals are used for access because of the inaccessibility of the back of the knee. Since its introduction, the posterior transseptal portal has been widely employed to access lesions in the posterior compartment. However, special care should be taken to avoid neurovascular injuries around the posteromedial, posterolateral, and transseptal portals. Most importantly, popliteal vessel injury should be avoided when creating and using the transseptal portal during surgery. Purpose of the present study is to describe how to avoid the neurovascular injuries during establishing the posterior three portals and to introduce our safer technique to create the transseptal portal. To date, we have performed arthroscopic surgeries via the transseptal portal in the posterior compartments of 161 knees and have not encountered nerve or vascular injury. In our procedure, the posterior septum is perforated with a 1.5-3.0-mm Kirschner wire that is protected by a sheath inserted from the posterolateral portal and monitored from the posteromedial portal to avoid popliteal vessel injury.
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16
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Pace JL. Arthroscopic Posterior Knee Capsulotomy for a Fixed Flexion Contracture in a Ten-Year-Old Boy Due to a Hypertrophied Ligamentum Mucosum: A Case Report. JBJS Case Connect 2015; 5:e73. [PMID: 29252859 DOI: 10.2106/jbjs.cc.n.00214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE Knee flexion contractures are difficult to treat effectively. We present the case of a ten-year-old boy with a flexion contracture due to a hypertrophied ligamentum mucosum treated with an arthroscopic posterior capsular release. The patient obtained full extension and maintained it at the time of final follow-up. CONCLUSION This case represents a unique cause of an impinging ligamentum mucosum and provides anecdotal support to the concept of an arthroscopic posterior capsular release as a safe and effective option for flexion contractures.
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Affiliation(s)
- J Lee Pace
- Sports Medicine Program, Children's Orthopedic Center, Keck School of Medicine of the University of Southern California, Children's Hospital Los Angeles, 4650 Sunset Boulevard MS #69, Los Angeles, CA 90027.
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Post-traumatic knee stiffness: surgical techniques. Orthop Traumatol Surg Res 2015; 101:S179-86. [PMID: 25583236 DOI: 10.1016/j.otsr.2014.06.026] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 05/20/2014] [Accepted: 06/29/2014] [Indexed: 02/02/2023]
Abstract
Post-traumatic knee stiffness and loss of range of motion is a common complication of injuries to the knee area. The causes of post-traumatic knee stiffness can be divided into flexion contractures, extension contractures, and combined contractures. Post-traumatic stiffness can be due to the presence of dense intra-articular adhesions and/or fibrotic transformation of peri-articular structures. Various open and arthroscopic surgical treatments are possible. A precise diagnosis and understanding of the pathology is mandatory prior to any surgical treatment. Failure is imminent if all pathologies are not addressed correctly. From a general point of view, a flexion contracture is due to posterior adhesions and/or anterior impingement. On the other hand, extension contractures are due to anterior adhesions and/or posterior impingement. This overview will describe the different modern surgical techniques for treating post-traumatic knee stiffness. Any bony impingements must be treated before soft tissue release is performed. Intra-articular stiff knees with a loss of flexion can be treated by an anterior arthroscopic arthrolysis. Extra-articular pathology causing a flexion contracture can be treated by open or endoscopic quadriceps release. Extension contractures can be treated by arthroscopic or open posterior arthrolysis. Postoperative care (analgesia, rehabilitation) is essential to maintaining the range of motion obtained intra-operatively.
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Trudel G, Laneuville O, Coletta E, Goudreau L, Uhthoff HK. Quantitative and temporal differential recovery of articular and muscular limitations of knee joint contractures; results in a rat model. J Appl Physiol (1985) 2014; 117:730-7. [DOI: 10.1152/japplphysiol.00409.2014] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Joint contractures alter the mechanical properties of articular and muscular structures. Reversibility of a contracture depends on the restoration of the elasticity of both structures. We determined the differential contribution of articular and muscular structures to knee flexion contractures during spontaneous recovery. Rats (250, divided into 24 groups) had one knee joint surgically fixed in flexion for six different durations, from 1 to 32 wk, creating joint contractures of various severities. After the fixation was removed, the animals were left to spontaneously recover for 1 to 48 wk. After the recovery periods, animals were killed and the knee extension was measured before and after division of the transarticular posterior muscles using a motorized arthrometer. No articular limitation had developed in contracture of recent onset (≤2 wk of fixation, P > 0.05); muscular limitations were responsible for the majority of the contracture (34 ± 8° and 38 ± 6°, respectively; both P < 0.05). Recovery for 1 and 8 wk reversed the muscular limitation of contractures of recent onset (1 and 2 wk of fixation, respectively). Long-lasting contractures (≥4 wk of fixation) presented articular limitations, irreversible in all 12 durations of recovery compared with controls (all 12 P < 0.05). Knee flexion contractures of recent onset were primarily due to muscular structures, and they were reversible during spontaneous recovery. Long-lasting contractures were primarily due to articular structures and were irreversible. Comprehensive temporal and quantitative data on the differential reversibility of mechanically significant alterations in articular and muscular structures represent novel evidence on which to base clinical practice.
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Affiliation(s)
- Guy Trudel
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bone and Joint Research Laboratory, University of Ottawa, Ottawa, Ontario, Canada
| | - Odette Laneuville
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
| | - Elizabeth Coletta
- Bone and Joint Research Laboratory, University of Ottawa, Ottawa, Ontario, Canada
| | - Louis Goudreau
- Biomedical Engineering, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada; and
| | - Hans K. Uhthoff
- Bone and Joint Research Laboratory, University of Ottawa, Ottawa, Ontario, Canada
- Division of Orthopedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
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Tjoumakaris FP, Tucker BC, Post Z, Pepe MD, Orozco F, Ong AC. Arthroscopic lysis of adhesions for the stiff total knee: results after failed manipulation. Orthopedics 2014; 37:e482-7. [PMID: 24810826 DOI: 10.3928/01477447-20140430-60] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 11/25/2013] [Indexed: 02/03/2023]
Abstract
Arthrofibrosis after total knee arthroplasty (TKA) is a potentially devastating complication, resulting in loss of motion and function and residual pain. For patients in whom aggressive physical therapy and manipulation under anesthesia fail, lysis of adhesions may be the only option to rescue the stiff TKA. The purpose of this study is to report the results of arthroscopic lysis of adhesions after failed manipulation for a stiff, cruciate-substituting TKA. This retrospective study evaluated patients who had undergone arthroscopic lysis of adhesions for arthrofibrosis after TKA between 2007 and 2011. Minimum follow-up was 12 months (average, 31 months). Average total range of motion of patients in this series was 62.3°. Average preoperative flexion contracture was 16° and average flexion was 78.6°. Statistical analysis was performed using Student's t test. Pre- to postoperative increase in range of motion was significant (P<.001) (average, 62° preoperatively to 98° postoperatively). Average preoperative extension deficit was 16°, which was reduced to 4° at final follow-up. This value was also found to be statistically significant (P<.0001). With regard to ultimate flexion attained, average preoperative flexion was 79°, which was improved to 103° at final follow-up. This improvement in flexion was statistically significant (P<.0001). Patients can reliably expect an improvement after arthroscopic lysis of adhesions for a stiff TKA using a standardized arthroscopic approach; however, patients achieved approximately half of the improvement that was obtained at the time of surgery.
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Abstract
Intra-articular inflammation or fibrosis may lead to decreased soft-tissue and capsular compliance, which may result in pain or loss of motion within the knee. Etiology of intra-articular fibrosis may include isolated anterior interval scarring and posterior capsular contracture, as well as fibrosis that involves the suprapatellar pouch or arthrofibrosis that involves the entire synovial space. Initial nonsurgical management, including compression, elevation, and physical therapy, can decrease knee pain and inflammation and maintain range of motion. Surgical management is indicated in the patient who fails conservative treatment. Surgical options include arthroscopic releases of the anterior interval, posterior capsule, and peripatellar and suprapatellar regions. Recent advances in arthroscopic technique have led to improved outcomes in patients with intra-articular fibrosis of the knee.
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Kim SJ, Song HT, Moon HK, Chun YM, Chang WH. The safe establishment of a transseptal portal in the posterior knee. Knee Surg Sports Traumatol Arthrosc 2011; 19:1320-5. [PMID: 21311859 DOI: 10.1007/s00167-011-1429-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Accepted: 01/27/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE The aims of this study were as follows: (1) to determine the dimensions of the posterior compartments and the location of the popliteal artery with regard to the posterior septum by magnetic resonance arthrography; (2) to assess the effect of demographic factors on the measurements taken; and (3) to find a safe means of establishing the transseptal portal. METHODS Thirty magnetic resonance arthrographies taken in 90° of flexion were evaluated to simulate knee position during arthroscopic surgery. Coronal and axial images were obtained in positions parallel and perpendicular to the long axis of the tibia, respectively. The anterior-to-posterior dimensions of the posteromedial and posterolateral compartments and popliteal artery locations were measured in the safe zone to establish transseptal portals. These dimensions were measured in axial images corresponding to the mid-PCL level. RESULTS The average anterior-to-posterior dimension was 11.7 ± 2.9 mm in the posteromedial compartment versus 7.9 ± 1.8 mm in the posterolateral compartment. The anterior-to-posterior dimension was consistently greater in the posteromedial compartment, and the average ratio of the two dimensions was 1.5 ± 0.3. The average posterior deviation of the popliteal artery from the PCL was 27.1 ± 4.8 mm. The popliteal artery was always located lateral to the septum, and the lateral deviation on averaged measured 10.2 ± 4.0 mm. CONCLUSIONS The safe margin of the posteromedial compartment is consistently wider than that of the posterolateral compartment, and the popliteal artery is consistently located lateral to the posterior septum. Therefore, injury to the popliteal artery can be avoided when penetrating the septum lateral to medial direction, even if the penetrating stick slips posteriorly. LEVEL OF EVIDENCE Diagnostic study, Level IV.
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Affiliation(s)
- Sung-Jae Kim
- Department of Orthopaedic Surgery and the Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, 120-752, Republic of Korea
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