A less invasive procedure for posttraumatic knee stiffness

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

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.

Thompson Versus Judet Techniques for Quadricepsplasty: A Systematic Review and Meta-analysis of Outcomes and Complications

Background

Quadricepsplasty has been used for over half a century to improve range of motion (ROM) in knees with severe arthrofibrosis. Various surgical techniques for quadricepsplasty exist, including Judet and Thompson, as well as novel minimally invasive approaches. The goal of this review was to compare outcomes between quadricepsplasty techniques for knee contractures.

Methods

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Available databases were queried for all articles on quadricepsplasty. Outcomes included postoperative ROM, outcome scores, and complication rates. Secondarily, we summarized rehabilitation protocols and descriptions of all modified and novel techniques.

Results

Thirty-three articles comprising 797 patients were included in final analysis. Thirty-five percent of patients underwent Thompson quadricepsplasty, 36% underwent Judet, and 29% underwent other techniques. After Judet and Thompson quadricepsplasty, patients achieved a mean postoperative active flexion of 92.7° and 106.4°, respectively (p < 0.01). Complication rates after Judet and Thompson were 17% and 24%, respectively. Wound infection was the most frequently recorded complication after Judet, whereas extension lag predominated for Thompson.

Conclusion

Both the Thompson and Judet quadricepsplasty techniques offer successful treatment options to restore functional knee ROM. Although the Thompson technique resulted in greater postoperative knee flexion compared with the Judet, the difference may be attributable to differences in preoperative flexion and time from injury to quadricepsplasty. Overall, the difference in flexion gained between the 2 techniques is comparable and clinically negligible.

Level of Evidence

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes of Arthroscopic Adhesiolysis: A Case Series of 40 Patients With Postoperative Knee Stiffness

Introduction Restricted range of motion over the knee joint is a known complication following the surgical procedure. Aggressive rehabilitation protocols can initially manage knee stiffness due to arthrofibrosis. If conservative management fails, surgical (open or arthroscopic) release is the preferred modality of management. We present a series of 40 patients with postoperative knee stiffness who were treated with arthroscopic adhesiolysis. Material and methods This is a retrospective study conducted at Phoenix Orthopedic Superspeciality Hospital, Nagpur, India, from 2017 to 2021. Our study included 40 patients with postoperative knee joint stiffness, of whom 27 were males and 13 were females. The study considered the duration of stiffness, which ranged from six months to five years. All patients underwent arthroscopic knee release. A rigorously supervised physical therapy program followed this procedure. Patients were examined at three months, six months, and one year to assess improvement in knee range of movement. Results Out of 40 patients, six were classified as Shelbourne type 4, and the remaining were Shelbourne type 3. Twenty-three of 40 patients developed arthrofibrosis following intra-articular or peri-articular fracture fixation surgery; 11 patients were operated on arthroscopically for anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction. Three patients developed stiffness following total knee replacement, one following patellectomy, and three following infection after fracture fixation. The mean pre-op knee range of motion (ROM) was 48.875 degrees. Following arthroscopic release, the mean improvement in ROM was 60 degrees intra-operatively. The average postoperative range was 108.25 degrees. Conclusion Arthroscopic adhesiolysis and quadriceps release are reliable methods for dealing with postoperative knee stiffness. It prevents wound complications and increases the chances of surgical site infection due to smaller incisions. Postoperatively, we achieved an average increase of 60 degrees in ROM over the knee joint.

Arthroscopic Lysis of Adhesions for Treatment of Post-Traumatic Knee Arthrofibrosis: A Prospective Study

BACKGROUND

Post-traumatic knee arthrofibrosis can have a significant effect on patients' function and the management can be challenging with a variety of options ranging from manipulation under anaesthesia (MUA) to more invasive procedures such as quadricepsplasty. The aim of the study is to evaluate the improvement of both knee range of motion (ROM) and functional outcomes after arthroscopic lysis of adhesions (ALA) for post-traumatic knee arthrofibrosis.

MATERIALS AND METHODS

A prospective study of 30 patients with post-traumatic knee arthrofibrosis was managed by arthroscopic arthrolysis. Aggressive rehabilitation protocol was initiated on the first day postoperatively. Comprehensive clinical follow-up evaluations including the ROM assessment and the Lysholm score were done for all patients.

RESULTS

The mean age was 36.17 years (±9.51). The mean follow-up time was 6.7 months (six to nine months). The ROM improved from 75° (±10.91°) preoperatively to 119.83° (± 10.38°) at the final follow-up (P < 0.001). Additionally, the Lysholm score increased from 56.90(±2.64) preoperatively to 85.27(±3.46) (P < 0.001). The ultimate final ROM and functional outcomes for all patients were satisfactory.

CONCLUSION

ALA for knee arthrofibrosis significantly improves the knee ROM and functional outcomes and can be a successful alternative to open quadricepsplasty.

Online Rehabilitation Protocols for Medial Patellofemoral Ligament Reconstruction With and Without Tibial Tubercle Osteotomy Are Variable Among Institutions

Purpose

To compare and contrast the various rehabilitation protocols for medial patellofemoral ligament (MPFL) reconstruction and MPFL reconstruction plus tibial tubercle osteotomy (TTO) published online by academic orthopaedic surgery residency programs and private practice institutions throughout the United States.

Methods

We performed a systematic electronic search of MPFL reconstruction rehabilitation protocols in academic orthopaedic surgery residency programs in the United States using Google’s search engine (www.google.com) based on the Fellowship and Residency Electronic Interactive Database Access System (FREIDA). Private practice organizations publishing MPFL reconstruction or MPFL reconstruction–TTO rehabilitation protocols that were found on the first page of search results were also included, but no comprehensive search for private practice protocols was performed. Protocols specifying an MPFL reconstruction with TTO were included for separate review because of altered weight-bearing status postoperatively. A list of comparative criteria was created to assess the protocols for the presence and timing of the various rehabilitation components.

Results

From the list of 189 U.S. academic residency programs, as well as additional private practice protocols found in the Google search, 38 protocols were included for review (31 protocols for isolated MPFL reconstruction and 7 protocols for MPFL reconstruction plus TTO). A return to full range of motion by week 6 was recommended by 15 (48.4%) of the isolated MPFL reconstruction protocols and 6 (85.7%) of the MPFL reconstruction–TTO protocols. Six weeks of knee brace wear was recommended by 13 isolated MPFL reconstruction protocols (43.3%) and 4 MPFL reconstruction–TTO protocols (57.1%). Moreover, 6 isolated MPFL reconstruction protocols (19.4%) and 3 MPFL reconstruction–TTO protocols (42.9%) recommended use of a patellar stabilizing brace postoperatively.

Conclusions

There is substantial variability among rehabilitation protocols after MPFL reconstruction, as well as MPFL reconstruction plus TTO, including postoperative range of motion, weight-bearing status, and time until return to sport. Furthermore, many online protocols from academic orthopaedic surgery residency programs and private practices in the United States fail to mention several of these parameters, most notably functional testing to allow patients to return to sport.

Clinical Relevance

Proper rehabilitation after MPFL reconstruction with or without TTO is an important factor to a patient’s postoperative outcome. This study outlines the variability in online rehabilitation protocols after MPFL reconstruction with or without TTO published online by academic residency programs and private practice institutions.

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.

Comparison of minimally invasive arthrolysis vs. conventional arthrolysis for post-traumatic knee stiffness

BACKGROUND

Minimally invasive surgery in knee arthroplasty can reduce postoperative pain and the rehabilitation period. The goal of this study was to explore the therapeutic effect of minimally invasive arthrolysis in post-traumatic knee stiffness.

METHODS

From March 2002 to March 2016, a prospective investigation was performed on seventy post-traumatic knee stiffness patients treated with minimally invasive knee arthrolysis or conventional knee arthrolysis. Curative effect was evaluated according to Judet's criteria. Operative time, incision length, blood loss, the angle of intraoperative release and the final postoperative joint mobility in two groups were compared using the student's t-test.

RESULTS

The mean follow up time was 15.37 ± 4.93 months (ranged from 6 months to 2 years).The excellent and good rate was significantly higher in minimally invasive group (95.0%) than conventional arthrolysis group (73.33%) (P < 0.05). Minimally invasive arthrolysis group had shorter operative time (29.38 ± 4.84 vs. 86.00 ± 9.77 min), smaller incision length (6.59 ± 0.86 vs. 20.47 ± 2.91 cm), less intraoperative blood loss (93.25 ± 15.26 vs. 473.33 ± 79.58 ml) and better postoperative final joint activity (104.75 ± 17.87° vs. 90.67 ± 19.64°) compared to conventional arthrolysis group (P < 0.001).

CONCLUSIONS

The findings suggest that minimally invasive knee arthrolysis is a much better option for the treatment of post-traumatic knee stiffness due to its advantages such as shorter operative time, little trauma, less blood loss and better postoperative final joint activity. Further studies with a long term of follow-up are wanted.

A mini-invasive technique for severe arthrofibrosis of the knee: A technical note

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.

A mini-invasive procedure for treating arthrofibrosis of the knee

Objective

The aim of this study was to introduce the results of a novel mini-invasive operative technique comprising mini-incision release, “pie-crusting” lengthening of the quadriceps extensor, and arthroscopic lysis in severe arthrofibrotic knees.

Methods

From 2010 to 2014, 17 patients (12 males and 5 females with a mean age of 44 years (range, 19–62 years)) with severely arthrofibrotic knees were treated with this operative technique. The mean follow-up duration was 23 months. The knee range of motion (ROM) was assessed with a goniometer. The functional outcomes were evaluated according to the Hospital for Special Surgery (HSS) score and Judet's criteria.

Results

The ROM significantly improved from 29.7° (range, 7°–56°) preoperatively to 127° (range, 120°–136°) at the final follow-up in all patients (p < 0.001). According to Judet's criteria, all patients achieved excellent results (ROM > 100°). The HSS score was improved from 70 points (range, 60–85 points) preoperatively to 91 points (range, 84–98 points) (p < 0.001) at the final follow-up. No extension lag, skin necrosis, quadriceps weakness, wound dehiscence or quadriceps tendon rupture occurred.

Conclusions

Mini-invasive quadricepsplasty-associated arthroscopic lysis and manipulation of the knee in flexion is simple and easy and should be considered as a legitimate treatment for arthrofibrosis of the knee.

Inflammatory cytokine expression in the quadriceps of rats with posttraumatic knee stiffness: A preliminary study

The primary purpose of this study was to investigate cytokine expression in the quadriceps of rats with posttraumatic knee stiffness (PTKS) and to determine the effect of exercise training on these cytokines at different follow-up time points. The PTKS rats were randomly assigned into two even groups. The treatment group received exercise training, while the control group received no treatment. Quadriceps specimens were harvested randomly from each group at 8, 12, 16, and 20 weeks. RT-qPCR and immunohistochemical analyses were used to assess the protein and mRNA expression levels of the cytokines IL-1, IL-2, TNF-α, COX-1, and COX-2. TNF-α immunostaining did not differ between the treated and control group tissues, whereas weak immunostaining was observed for all other cytokines in the specimens from the treatment group compared with those from the control group at approximately 12 and 20 weeks. The cytokine levels decreased at approximately 8 weeks in the treatment group, whereas these levels remained elevated or plateaued in the control group. These differences were statistically significant (p<0.05). This study demonstrated that the expression of cytokines IL-1, IL-2, COX-1, and COX-2 increased in the quadriceps of rats with PTKS and that exercise training affected the observed profile trends of these cytokines.