Outcome of surgical treatment of arthrofibrosis following ligament reconstruction

A Preliminary Study of Post-Market Bridge-Enhanced ACL Restoration (BEAR) Suggests Non-Inferior Short-Term Outcomes and Low Complications

Background

To improve outcomes following anterior cruciate ligament (ACL) reconstruction, bridge-enhanced ACL restoration (BEAR) was introduced. Bridge-enhanced ACL restoration uses a collagen-based implant saturated with infused autologous blood to bridge the torn proximal and distal ACL fibers.

Purpose

We sought to analyze the short-term complications, clinical outcomes, and patient-reported outcome measures (PROMs) in patients undergoing BEAR outside of the initial clinical trials.

Methods

We conducted a retrospective cohort study of all skeletally mature patients who had a midsubstance or proximal ACL tear treated with BEAR by 2 surgeons at a single institution and had a minimum follow-up of 6 weeks. A total of 58 patients were included (average age was 38 years, average time from injury to surgery was 45 days). Data on demographic factors, functional outcomes, and complications were collected from electronic medical records. Patient-reported outcome measures and a descriptive return-to-activity survey were analyzed utilizing paired t-tests and Wilcoxon signed-rank tests.

Results

All 58 patients demonstrated a grade of 1A on the Lachman test at 6 weeks postoperatively. At 6 months postoperatively, the mean active flexion was 135° ± 5°, and all patients achieved 0° extension. Although not all patients completed PROM questionnaires, among those who did we observed a significant increase in PROMs between preoperative and postoperative measurements; more than half achieved the minimal clinically important difference in all PROMs, and 26 patients (87%) had a 1-level decrease in function. There were no cases of retear or instability. Three patients (5%) had postoperative arthrofibrosis.

Conclusion

Early results of this preliminary post-market approval study suggest that BEAR may provide a safe and non-inferior approach to ACL reconstruction in selected patients. Studies are needed to investigate the long-term outcomes of this novel technique.

Incidence and risk factors for cyclops syndrome after anterior cruciate ligament reconstruction: A systematic literature review

BACKGROUND

Cyclops syndrome after anterior cruciate ligament (ACL) reconstruction is due to a fibrous nodule that develops in the anterior part of the intercondylar notch and prevents full knee extension. The primary objective of this systematic literature review was to evaluate the incidence of symptomatic cyclops lesion after ACL reconstruction. The secondary objective was to identify risk factors for cyclops syndrome.

HYPOTHESIS

Cyclops syndrome is common after ACL reconstruction and has several risk factors reported in the literature.

METHODS

A systematic literature review was performed by searching the PubMed, Medline, CINAHL, Cochrane, and Embase databases with the key terms 'cyclops' and 'ACL reconstruction'. The data thus retrieved were evaluated independently by two investigators. All articles in English or French that reported the incidence and risk factors of cyclops syndrome after ACL reconstruction were included.

RESULTS

The search retrieved the titles and abstracts of 79 articles, of which 20 were selected to be read in full; among these, 10 were included in the study. The incidence of symptomatic cyclops lesion ranged from 1.9% to 10.9%. Identified risk factors were as follows: pre-operatively, knee inflammation and/or motion restriction at the time of ACL reconstruction; intra-operatively, narrow intercondylar notch and excessively anterior position of the tibial tunnel; and post-operatively, persistent hamstring muscle spasm.

DISCUSSION

Development of a cyclops lesion is common after ACL reconstruction, occurs early, and may require further surgery. The knowledge of the risk factors provided by this study may improve the ability to devise effective preventive measures.

LEVEL OF EVIDENCE

II, systematic literature review.

All-arthroscopic release for treating severe knee extension contractures could improve the knee range of motion and the mid-term functional outcomes

PURPOSE

To evaluate the safety, feasibility, and effectiveness of an all-arthroscopic technique for the intra- and extraarticular release of severe knee extension contractures.

METHODS

From 2012 to 2016, 25 patients with severe knee extension contractures (less than 45° range of flexion) were treated with an all-arthroscopic release technique. The patients underwent intra- and extraarticular arthroscopic release and arthroscopic-assisted mini-incision quadriceps plasty. The post-operative rehabilitation was initiated the first day after the procedures. Comprehensive clinical follow-up evaluations including the range-of-motion (ROM) assessment, the Lysholm score, and the International Knee Documentation Committee (IKDC) score were performed on all patients.

RESULTS

The median follow-up time was 28 months (range 12-65 months). The ROM improved from 23.9° ± 7.5° pre-operatively to 105.9° ± 6.5° at the final follow-up (P < 0.001). In addition, the Lysholm score increased from 59.9 ± 5.2 pre-operatively to 89.7 ± 3.3 (P < 0.001). The IKDC score increased from 47.6 ± 3.4 pre-operatively to 91.7 ± 2.4 (P < 0.001). All patients were satisfied with their final ROM and functional outcomes.

CONCLUSION

The all-arthroscopic release technique was a safe, feasible and effective method for treating severe knee extension contractures. The severe knee extension contractures may be successfully addressed by the all-arthroscopic release technique during our clinical practice.

LEVEL OF EVIDENCE

IV.

Immunohistochemical examination in arthrofibrosis of the knee joint

INTRODUCTION

Arthrofibrosis (AF) is the result of increased cell proliferation and synthesis of matrix proteins (collagen I, III, and VI). Especially after invasive knee surgery, e.g., ligament reconstruction or knee replacement, abnormal fibroblast proliferation with pathological periarticular fibrosis can be observed leading to severely limited joint motion. The pathogenesis of AF is currently not fully understood. The present work aims to determine pathogenic factors.

MATERIALS AND METHODS

A descriptive, histological and immunohistochemical comparative study was performed on tissue samples of 14 consecutive patients undergoing arthrolysis for joint stiffness due to AF. Seven human autopsy specimens served as control. Samples were stained for expression of relevant markers such as CD68, α-smooth muscle actin (ASMA), beta-catenin, BMP-2 and examined for the histological grade of AF (cell-rich versus cell-poor) and compared to a control. Furthermore, a microscopic evaluation of the samples for cell differentiation and number was performed.

RESULTS

Tissue sections of cell-rich fibrosis showed a significantly higher expression of CD68 compared to the control with less than 10% of CD68 positive cells (p = 0.002). In cell-poor fibrosis no statistically significant difference was obvious (p = 0.228). Expression of ASMA in synovia, vessels, cell-rich and cell-poor fibrosis showed median values of 2.00 in the AF group and 1.75 in the control. Both groups differed significantly (p = 0.003). AF tissue showed a significantly difference in expression of β-catenin (p < 0.001) compared to the control. The overall difference between AF and control group in expression of BMP-2 was also statistically significant (p = 0.002).

CONCLUSIONS

Expression of CD68, ASMA, beta-catenin and BMP-2 is significantly increased in AF tissue samples. Based on presented findings, histological evaluation and immunohistochemical assessment of CD68, ASMA, β-catenin and BMP-2 expression may proof useful to diagnose AF and to analyze AF activity.

Presentation and management of arthrofibrosis of the knee: A case report

STUDY DESIGN

Case report.

BACKGROUND

Arthrofibrosis is a debilitating condition that results in pain, decreased range of motion, and decreased function. Although surgical management of arthrofibrosis has been well described in the literature, rehabilitation of the arthrofibrotic knee is less well described.

CASE DESCRIPTION

A 28-year-old female presented with swelling, pain, and decreased strength, range of motion, patellar mobility, and function following an exploratory arthroscopy of her left knee. After failed conservative management, the patient underwent two additional surgeries to remove scar tissue. Following each surgery, the emphasis was on decreasing inflammation and maintaining patellar mobility while increasing joint range of motion and strength. Therapy progression was determined by the presence or absence of inflammatory signs. The second scar tissue removal surgery resulted in a femoral neuropathy that further complicated the rehabilitation process.

OUTCOMES

At 3-year follow-up, the patient continued to present with decreased range of motion and strength compared to the uninvolved limb, but had returned to a modified running program and reported pain no longer limited her ability to participate in activities of daily living.

DISCUSSION

This case report highlights the importance of recognizing that arthrofibrosis may result following a minor knee surgery and with minimal range of motion loss. Additional complications also may result during arthrofibrosis treatment. Progressing rehabilitation based on the inflammatory response may decrease the likelihood of additional scar tissue formation and potentially improve the outcome for the patient.

Procedural intervention for arthrofibrosis after ACL reconstruction: trends over two decades

PURPOSE

Arthrofibrosis is a rare complication after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to (1) report a population-based incidence of arthrofibrosis (as defined by manipulation under anaesthesia or surgical lysis of adhesions) following ACL injury and reconstruction, (2) identify risk factors associated with development of arthrofibrosis, and (3) report outcomes of intervention for arthrofibrosis.

METHODS

This was a historical cohort study performed in Olmsted County, Minnesota. The Rochester Epidemiology Project (REP) was used to identify a population-based cohort of individuals with new-onset, isolated ACL tears between 1 January 1990 and 31 December 2010. The REP database provides access to all medical records for each resident of Olmsted County, regardless of the facility where the care was delivered. A total of 1841 individuals were identified with new-onset, isolated ACL tears and were confirmed with chart review. The intervention incidence for arthrofibrosis was then calculated, and various predictive factors including age, sex, calendar year, and meniscal injury were investigated.

RESULTS

During follow-up, 5 patients (1.0 %) in the non-operative cohort and 23 patients (1.7 %) in the ACL reconstruction cohort received intervention for arthrofibrosis, corresponding to an incidence of 0.7 per 1000 person-years in the non-operative cohort and 1.9 per 1000 person-years in the ACL reconstruction cohort. Female patients were 2.5 times more likely to have arthrofibrosis than males. The mean preoperative range of motion was -8° to 83° and improved to a mean of -2° to 127° post-operatively.

CONCLUSIONS

Arthrofibrosis remains a rare but potentially devastating complication after ACL reconstruction, and roughly 2 % of patients had post-operative stiffness that required intervention. Female patients are at higher risk of arthrofibrosis. However, when patients develop severe motion complications after ACL injury, interventions are generally effective in preventing permanent arthrofibrosis.

Arthroscopic-assisted removal of proximal tibia locking plates

We present a new technique to remove plates from the proximal tibia arthroscopic-assisted with all advantages of the minimally invasive surgery and the possibility to treat concomitant intraarticular pathologies. The initial results (n = 7) are promising with an increase of the Lysholm score in all cases studied [preop. median 78 (range 32–100), postop. median 89 (range 60–100)]. In conclusion, arthroscopic-assisted hardware removal at the proximal tibia is feasible and may provide patients with all the benefits of minimal-invasive hardware removal. The described technique can be recommended for all surgeons familiar with arthroscopic surgery.