Arthroscopic Lysis of Adhesions and Anterior Interval Release With Manipulation Under Anesthesia for Severe Post-traumatic Knee Stiffness: A Simple and Reproducible Step-by-Step Guide

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.

Sequential surgery for the treatment of type I knee ankylosis: a series of 62 cases

BACKGROUNDS

The lack of systematic classification and standard treatment principles for knee ankylosis prevents optimal treatments. This study explored treatments for type I (mild) knee joint ankylosis.

METHOD

This retrospective study analysed patients with knee joint ankylosis admitted from March 2013 to January 2018 who underwent sequential arthroscopic release.

RESULT

The 62 patients had 12-36 (average, 18) months of follow-up. Thirty-eight patients were released; of these, 18 were assisted by limited incision with partial quadriceps femoris expansion myotomy and released according to arthroscopy. Six patients underwent lengthening and release of the quadriceps femoris. All surgeries combined with full-course rehabilitation resulted in improved joint mobility. The range of motion (ROM) of the knee joint recovered to a range of 0° to 85°-140° (mean: 118.32 ± 9.42°) from the preoperative range of 30°-70° (mean: 45° ± 15.50°). The clinical effect was evaluated according to the Judet criteria at the final follow-up. The outcomes at the last follow-up (at least for 1 year) were excellent in 55 cases, good in six cases, and fair in one case.

CONCLUSION

Sequential arthroscopic release, minimal selective invasion of limited incision of partial quadriceps femoris expansion myotomy, assisted by pie-crusting technique to release, or quadriceps femoris lengthening, and release surgery for type I knee joint ankylosis, accompanied by early rehabilitation training provided satisfactory results without significant complications.

Topical administration of tranexamic acid reduces postoperative blood loss and inflammatory response in knee arthroscopic arthrolysis: a retrospective comparative study

BACKGROUND

Knee arthroscopic arthrolysis serves as an effective treatment for knee arthrofibrosis. However, hemarthrosis is the most common complication in arthroscopic surgery, which has potential adverse effects on postoperative rehabilitation. The purpose of this study was to evaluate the effects of topical tranexamic acid (TXA) in knee arthroscopic arthrolysis.

METHODS

A total of 87 patients with knee arthrofibrosis who underwent arthroscopic arthrolysis from September 2019 to June 2021 were eligible for this retrospective review. Patients in the TXA group (n = 47) received topical administration of TXA (50 mL, 10 mg/mL) at the end of the surgery, and patients in the control group (n = 40) received no TXA. The postoperative drainage volumes, hematologic levels, inflammatory marker levels, knee range of motion (ROM), visual analog scale (VAS) pain scores, Lysholm knee scores and complications were compared between the two groups. The curative effect of each group was calculated according to Judet's criteria.

RESULTS

The mean drainage volumes on postoperative day (POD) 1 and POD 2, and total drainage volume were significantly lower in the TXA group than in the control group (P < 0.001 for all). The TXA group had significantly lower postoperative CRP and IL-6 levels on POD 1 and POD 2, and at postoperative week (POW) 1 and POW 2 than the control group. The VAS pain scores in the TXA group were significantly lower on POD 1 and POD 2, and at POW 1 and POW 2 than those in the control group (P < 0.001 for all). Patients in the TXA group showed better postoperative ROM and Lysholm knee scores at POW 1 and POW 2. No patient had any complications such as deep venous thrombosis (DVT) or infection. The excellent and good rates of knee arthroscopic arthrolysis were comparable between the two groups at the sixth postoperative month (P = 0.536).

CONCLUSIONS

Topical administration of TXA in knee arthroscopic arthrolysis can reduce postoperative blood loss and inflammatory response, alleviate early postoperative pain, increase early postoperative knee ROM, and improve early postoperative knee function without increased risks.

Judet's Quadricepsplasty Technique Offers Excellent Functional Outcome Without an Extension Lag for Extension Contracture of the Knee: A Retrospective Cohort of 33 Patients

Purpose

The Judet's technique of quadricepsplasty for an extension contracture of the knee joint offers the benefit of a sequential and controlled release of the intrinsic and extrinsic soft tissue constituents restricting the knee flexion. The main principle of our study was to analyze the clinical as well as functional outcome and to assess an extension lag following Judet's quadricepsplasty for the knee extension contracture deformity.

Materials and Methods

This is a retrospective cohort study comprises of thirty three patients, operated for extension contracture with Judet's quadricepsplasty with the mean follow-up was 30 months. Knee range of motion of the operated knee was recorded preoperatively and at 6, 12 and 24 month follow-up after the surgery. Judet's criteria were used to evaluate the outcomes following the procedure.

Results

92.42° (range, 60°-110°) of knee flexion was achieved after an average follow-up of 24 months compared to preoperative knee flexion was 14.09° (range 5°-25°), reflecting a 74.69° average improvement in knee flexion. Twelve patients had excellent results, nineteen had good results as per Judet's criteria but there were no patients with extension lag. The two patients with fair results had superficial wound infection which healed without any further surgical intervention.

Conclusions

Judet's quadricepsplasty offers sequential release without extension lag of the knee joint. Patients with the knee extension contractures deformity can be successfully managed with the Judet's quadricepsplasty to gain useful knee motion and function.

Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

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.

Mini-invasive Quadriceps-plasty for Severe Flexion-Impeding Knee Stiffness

Severe flexion-impeding knee stiffness is a common clinical condition that challenges orthopaedic surgeons. A mini-invasive and effective release technique to address this special condition is still being pursued. We describe a mini-invasive quadriceps-plasty that is performed through a small incision on the supralateral side of the knee and includes release of the retinaculum and patellofemoral joint, re-creation of the suprapatellar pouch and medial and lateral gutters, overlapping Z-plasty of the rectus femoris and vastus intermedius, and transfer of the vastus lateralis. Our clinical results indicate that this technique is safe and effective. We present a detailed description with video illustration of this technique that is beneficial for its application.

Arthrofibrosis Nightmares: Prevention and Management Strategies

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.

Arthroscopic Release of Severe Flexion- and Extension-Impeding Knee Stiffness With Inaccessible Joint

Knee stiffness with severe flexion and extension impediment is a common clinical condition that challenges orthopaedic surgeons. Arthroscopic release techniques have been reported, mostly for slight extension or flexion deficits. However, for severe flexion- and extension-impeding knee stiffness, especially when there is no intra-articular space in which to place the arthroscope, effective arthroscopic release techniques are still being pursued. We introduce a systemic arthroscopic release technique to address this special condition, in which a trans-infrapatellar fat pad release technique is developed to obtain access to the joint and to perform intra-articular and periarticular release, as well as scar tissue removal. One critical point of this technique is to create the posteromedial and posterolateral portals to re-establish the posterior compartments, remove the fibrotic posterior septum, and release the posterior capsule. This technique combines almost all related arthroscopic techniques in the treatment of knee stiffness. We consider that the introduction of this technique will provide a useful guide when surgical release is selected for this special condition.

Stiffness after unicompartmental knee arthroplasty: Risk factors and arthroscopic treatment

Introduction: One of the principal complications after total knee arthroplasty (TKA) is stiffness. There are no publications concerning stiffness after unicompartmental knee arthroplasty (UKA). Study objectives were to describe the incidence of stiffness after UKA, to look for risk factors, and to describe safe and effective arthroscopic treatment. Methods: There were 240 UKA performed between March 2016 and January 2019 included. Robotic-assisted surgery was performed in 164 patients and mechanical instrumentation in 76 patients. Stiffness was defined as flexion < 90° or a flexion contracture > 10° during the first 45 post-operative days. Patients with stiffness were treated with arthroscopic arthrolysis. Several factors were studied to look for risk factors of stiffness: body mass index, gender, age, mechanical or robotic instrumentation, preoperative flexion, previous meniscectomy, and anticoagulant treatment. Arthrolysis effectiveness was evaluated by flexion improvement and UKA revision rate. Results: 22 patients (9%) developed stiffness. Mechanical instrumentation significantly increased the risk of stiffness with OR = 0.26 and p = 0.005. Robotic-assisted surgery decreased the risk of stiffness by five-fold. Before arthrolysis, mean knee flexion was 79°, versus 121° (53% improvement) after arthroscopic arthrolysis. Only 2 patients (9%) underwent UKA revision after arthrolysis. Discussion: Stiffness after UKA is an important complication with an incidence of 9% in this study. Arthroscopic arthrolysis is a safe and effective treatment with a range of motion improvement of > 50%. Robotic-assisted surgery significantly decreases the risk of postoperative stiffness.

Level of evidence: Level III, therapeutic study, retrospective cohort study

Arthrofibrosis after total knee arthroplasty: patients with keloids at risk

BACKGROUND

Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without.

METHODS

Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant.

RESULTS

Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9).

CONCLUSION

Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

Hydraulic distension as a treatment for patellofemoral pain syndrome (PFPS) non-responsive to standard rehabilitation

BACKGROUND

The occurrence of Patellofemoral Pain Syndrome (PFPS) is often found in daily medical care. Rehabilitation is usually applied with good results. However, patients often do not respond to standard rehabilitation, suggesting there may be some undetected factors that standard treatments cannot address. It is known that post-traumatic adhesive capsulitis in the knee often shows symptoms similar to those of PFPS, but idiopathic adhesive capsulitis (IAC) has seldom been mentioned as a possible cause of PFPS. Adhesive capsulitis in the shoulder joint causes frozen shoulder (FS), and hydraulic distension (HD) is often applied to FS effectively.

PURPOSE

The purpose of this study was to investigate and report on the clinical application of HD to treat PFPS non-responsive to rehabilitation treatment.

PATIENTS AND METHODS

HD was applied to 72 knees that had resisted regular conservative treatments for PFPS. Follow-up data (e.g. visual analogue scale) was collected immediately after HD, and at periods of 1, 3 and 6 months later.

RESULTS

Of the 72 patients, 64 patients obtained pain relief after HD. Pain was relieved for at least 6 months for 33 of the 64 patients. No benefit was received for 8 patients.

CONCLUSIONS

HD could be an additional conservative option for some PFPS that resisted rehabilitation. Assuming that the mechanisms of action for HD in the knee are the same as those in FS, there is evidence to suggest that IAC might play a role in the development of PFPS for some patients.

Etiopathology and Management of Stiff Knees: A Current Concept Review

BACKGROUND

Knee stiffness after trauma, fracture fixation, arthroscopic surgery, infection, and knee arthroplasty is a known complication, which is challenging to manage and causes significant disability to the patients.

METHODS

We did a comprehensive search on the stiff knees, in the last week of May 2020, from the search engines of PubMed, SCOPUS, Google Scholar, and Research Gates using the appropriate keywords.

RESULTS

We found two types of articles related to knees stiffness: (a) following trauma, internal and external fixation of fractures and arthroscopic surgery, and (b) following total knee arthroplasty. Arthroscopic surgery was found to be a favored mode of management of stiff knees in both of the above groups. The Manipulation under Anesthesia (MUA) was also found effective if done carefully and in the early course of the stiffness.

CONCLUSION

Knee stiffness due to any cause is a trouble proposition to both patients and treating surgeons. Various methods of management have been described to deal with knee stiffness. Amongst the operative treatment, MUA and arthroscopic surgery were found to be the most effective. Arthroscopic surgery offers a good option of release stiff knees in the majority of cases, and it is most valuable and effective if done earlier in the course of the stiffness (preferably between 3 and 6 months).