Posterior Capsulotomy of the Knee: Treatment of Minimal Knee Extension Deficit

Does the timing of anterior cruciate ligament reconstruction surgery affect flexion contracture formation in rats?

BACKGROUND

Anterior cruciate ligament injuries are commonly treated with ligament reconstruction surgery, but post-operative joint contracture is a major complication. The optimal timing for anterior cruciate ligament reconstruction remains controversial, with some clinical studies suggesting that early surgery may increase the risk of joint contractures, while others have found no such association. To clarify this, we investigated the effects of the timing of reconstruction surgery on contracture formation using a rat model.

METHODS

Anterior cruciate ligament-transected rats were divided into groups based on the timing of reconstruction: immediate, early, and delayed (1, 14, and 28 days after transection, respectively). Some anterior cruciate ligament-transected rats did not receive reconstruction surgery. Untreated rats served as controls. At 56 days after ligament transection, we assessed knee extension range of motion before (including both myogenic and arthrogenic factors) and after myotomy (arthrogenic factor only), as well as fibrotic changes in the joint capsule.

FINDING

Anterior cruciate ligament transection alone significantly decreased range of motion before myotomy, but not after myotomy. In all reconstructed groups, both range of motions before and after myotomy were significantly reduced compared to the control, indicating the induction of arthrogenic contracture by reconstruction surgery. Fibrotic changes in the joint capsule were observed in all reconstructed groups, contributing to arthrogenic contracture formation. However, the timing of reconstruction had no effect on range of motions and fibrotic changes in the joint capsule.

INTERPRETATION

Our findings may help guide clinical decision-making regarding the timing of anterior cruciate ligament reconstruction surgery.

Stretching, Bracing, and Devices for the Treatment of Osteoarthritis-Associated Joint Contractures in Nonoperated Joints: A Systematic Review and Meta-Analysis

CONTEXT

Many patients with osteoarthritis (OA) develop range of motion (ROM) restrictions in their affected joints (contractures), associated with worse outcomes and rising healthcare costs. Effective treatment guidance for lost ROM in OA-affected joints is lacking.

OBJECTIVE

A systematic review and meta-analysis evaluating the effectiveness of stretching and/or bracing protocols on native (nonoperated) joint ROM in the setting of radiographically diagnosed OA.

DATA SOURCES

Seven databases, English-language.

STUDY SELECTION

Studies including participants with radiographically diagnosed OA in any native joint evaluating the effect of stretching or bracing on ROM.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Two reviewers independently screened articles for inclusion and assessed risk of bias in included trials. Primary outcomes were ROM, pain, and adverse events (AEs).

RESULTS

We identified 6284 articles. A total of 9 randomized controlled trials, all evaluating the knee, met eligibility criteria. For stretching, 3 pooled studies reported total ROM, which improved by mean difference (MD) of 9.3° (95% CI 5.0°,13.5°) versus controls. Two pooled studies showed improved knee flexion ROM (MD 10.8° [7.3°,14.2°]) versus controls. Five studies were pooled for knee extension with mean improvement 9.1° [3.4°,14.8°] versus controls. Seven pooled studies showed reduced pain (standardized MD 1.9 [1.2,2.6]). One study reported improved knee extension of 3.7° [2.9°,4.5°] with use of a device. No studies used orthoses. One study reported on AEs, with none noted. Performance bias was present in all included studies, and only 3 studies clearly reported blinding of outcome assessors. Strength of evidence for primary outcomes was considered moderate.

CONCLUSION

There was moderate-quality evidence that stretching is an effective strategy for improving knee total, flexion and extension ROM, and pain. Our findings suggest that stretching to regain joint ROM in OA is not futile and that stretching appears to be an appropriate conservative intervention to improve patient outcomes as part of a comprehensive knee OA treatment plan before arthroplasty.

Arthroscopic Posterior Capsular Release Effectively Reduces Pain and Restores Terminal Knee Extension in Cases of Recalcitrant Flexion Contracture

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.

Comparison of clinical outcomes between isolated ACL reconstruction and combined ACL with anterolateral ligament reconstruction: a systematic review and meta-analysis

BACKGROUND

To compare the clinical outcomes between isolated cruciate ligament reconstruction (ACLR) and combined ACL with anterolateral ligament reconstruction in chronic ACL injury especially with rotary instability problem.

METHODS

Systematic searches were conducted of literature published up to July 2021 on PubMed, Google Search, and Cochrane databases for studies comparing isolated ACLR and ACL with anterolateral reconstruction. Two reviewers independently determined eligibility, extracted outcome data, and assessed the risk of bias of eligible studies. Pooled clinical outcomes used random effects with mean differences and risk ratio for continuous and dichotomous variables, respectively.

RESULTS

After excluding 49 articles based on full-text screening, six studies were identified which met the inclusion criteria in the meta-analysis. Clinical outcomes such as residual laxity, rotatory instability, and graft failure were compared between isolated ACLR and combined ACL and anterolateral stability reconstruction. Overall, both clinical outcomes of isolated ACL and combined ACL with anterolateral reconstruction show improvement results in pivot shift test, the absence of residual laxity and incidence of graft failure. Compared to isolated ACLR, the prominent postoperative result was by combined ACL with anterolateral reconstruction which had significant differences in laxity outcome based on (I² = 89%, p < 0.00001) and (MD = 0.71, 95%CI: 0.33-1.08, p = 0.00002).

CONCLUSIONS

The combined ACL with anterolateral reconstruction tended to have superior clinical outcomes, especially in the absence of residual laxity, compared to the isolated ACLR, but the other results were not significantly different statistically. Combined ACL and anterolateral reconstruction were not performed routinely for patients undergoing ACL reconstruction, but more suitable for chronic rotatory instability problem.

Intra-articular celecoxib improves knee extension regardless of surgical release in a rabbit model of arthrofibrosis

Aims

Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release.

Methods

A total of 24 rabbits underwent contracture-forming surgery with knee immobilization followed by remobilization surgery at eight weeks. At remobilization, one cohort underwent capsular release (n = 12), while the other cohort did not (n = 12). Both groups were divided into two subcohorts (n = 6 each) – one receiving IA injections of celecoxib, and the other receiving injections of vehicle solution (injections every day for two weeks after remobilization). Passive extension angle (PEA) was assessed in live rabbits at 10, 16, and 24 weeks, and disarticulated limbs were analyzed for capsular stiffness at 24 weeks.

Results

IA celecoxib resulted in greater mean PEA at ten weeks (69.6° (SD 4.6) vs 45.2° (SD 9.6), p = 0.004), 16 weeks (109.8° (SD 24.2) vs 60.9° (SD10.9), p = 0.004), and 24 weeks (101.0° (SD 8.0) vs 66.3° (SD 5.8), p = 0.004). Capsular stiffness was significantly reduced with IA celecoxib (2.72 Newton per cm (N·cm)/° (SD 1.04), p = 0.008), capsular release (2.41 N·cm/° (SD 0.80), p = 0.008), and capsular release combined with IA celecoxib (3.56 N·cm/° (SD 0.99), p = 0.018) relative to IA vehicle (6.09 N·cm/° (SD 1.64)).

Conclusion

IA injections of a celecoxib led to significant improvements in passive extension angles, with reduced capsular stiffness, when administered to rabbit knees with established experimental contracture. Celecoxib was superior to surgical release, and the combination of celecoxib and a surgical release did not provide any additional value.

Cite this article: Bone Joint Res 2022;11(1):32–39.

Arthroscopic Posterior Capsulotomy for Knee Flexion Contracture Using a Spinal Needle

Knee flexion contractures can arise from posterior capsule arthrofibrosis secondary to trauma, surgery, or chronic degenerative disease. This leads to limited knee extension and increased mechanical stress on the contralateral joint. Depending on the severity of the contracture, a treatment option may include surgical release of the posterior capsule. Arthroscopic posterior capsular release has been reported previously to have excellent resolution of extension deficits with minimal risk of postoperative complications. These techniques typically use an array of instruments, including shavers, biters, or scissors to perform arthrolysis of the posteromedial and posterolateral capsules. Our primary objective is to present a modified arthroscopic surgical technique for percutaneous treatment of knee flexion contracture using a spinal needle to perform a posterior capsule release.

A rat model of arthrofibrosis developed after anterior cruciate ligament reconstruction without rigid joint immobilization

Purpose: Complications including arthrofibrosis have been reported after anterior cruciate ligament reconstruction (ACLR) even under accelerated rehabilitation. To overcome this, we developed an animal model of ACLR-induced arthrofibrosis without immobilization.Materials and Methods: Thirteen male Wistar rats were divided into ACL transection (ACLT) and ACLR groups. Surgery was performed in the right knees and untreated left knees were used as controls. After surgery, rats could move freely without joint immobilization.Results: One week after surgery, flexion contracture represented by passive ROM reduction was 49 ± 5° and 21 ± 6° in ACLR and ACLT groups, respectively. Thereafter, flexion contractures were gradually reduced to 21 ± 8° and 12 ± 6° after 12 weeks, respectively. Fibrosis, which is characterized by significant upregulation of fibrosis-related genes, thickening, and adhesion in the posterior joint capsule, was observed in the ACLR group after 12 weeks of surgery. Nociceptive behavior and joint swelling were more apparent in the ACLR group than in the ACLT group, especially after 1 week of surgery.Discussions: We developed a rat model of ACLR-induced joint contracture due to arthrofibrosis without rigid immobilization. Joint contracture was also observed in the ACLT group, but to a considerably milder degree than in the ACLR group. Thus, signs of inflammation as a result of reconstruction surgery, rather than ACL transection, play an important role in the formation of joint contracture after ACLR. Our animal model is suited to examine the mechanisms and efficacy of therapeutic strategies for arthrofibrosis following ACLR treated without rigid joint immobilization.

Posterior Knee Capsulotomy for the Relief of Patellofemoral Joint Pain: Long-Term Follow-up

Lack of full extension of the knee is a disabling condition that sometimes needs to be treated by a posterior capsulotomy of the knee. However, it is not clear if the full extension acquired can be kept throughout long-time follow-up. We conducted a retrospective cohort study of 20 patients diagnosed with minimal flexion contracture of the knee who underwent open posterior capsulotomy between 1990 and 2010. All patients (100%) presented with a preoperative Lysholm's score classified as poor or fair (mean = 58.6 ± 13.8, 95% confidence interval [CI]: 52.3-64.9), but 14 patients (70%) experienced an improvement to good or excellent scores (mean = 87.6 ± 8.8, 95% CI: 83.6-91.6) after the follow-up. The mean preoperative angle of fixed flexion was 25.0 ± 9.1 degrees (95% CI: 20.8-29.2), and it decreased to 4.2 ± 4.1 degrees (95% CI: 2.3-6.1) after the follow-up. We conclude that posterior capsulotomy of the knee proved to be an effective procedure to treat properly patients with painful knees secondary to lack of full extension after 10.3 years of follow-up.

Arthroscopic Complete Posterior Capsulotomy for Knee Flexion Contracture

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.