Stiffness of the knee--mixed arthroscopic and subcutaneous technique: results of 67 cases

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.

Nonligamentous Soft Tissue Pathology About the Knee: A Review

Knee pain is one of the most frequent complaints evaluated by orthopedic surgeons. It encompasses a broad range of pathology and can present in a variety of ways. Most of this pain can be attributed to essential structures of the knee, including the menisci, cruciate or collateral ligaments, and articular cartilage. However, there are underrecognized structures in and around the knee that can frequently be a cause of knee pathology and pain. Knee pain stemming from these structures may be missed or incorrectly diagnosed, and these patients often present for second and third opinions because of failure to diagnose and treat the underlying pathology. The synovial plica, suprapatellar pouch, lateral retinaculum, infrapatellar fat pad, and infrapatellar branch of the saphenous nerve are less common but still significant causes of knee pain. Although initial treatment involves various nonoperative modalities, operative treatment is often warranted. Operative and nonoperative management of these soft tissue structures may occur in isolation or with concomitant procedures, including knee ligament reconstruction, total knee arthroplasty, tibial tuberosity osteotomy, or lysis of adhesions. With proper recognition of the role of these structures in knee pain, the orthopedic surgeon can offer a valuable primary or adjunctive treatment option for patients with knee pain, especially those without localizing signs of meniscal, ligamentous, or cartilage damage.

Post-traumatic knee stiffness: surgical techniques

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.

Prognostic factors of arthroscopic adhesiolysis for arthrofibrosis of the knee

Purpose

To assess the results of arthroscopic adhesiolysis for arthrofibrosis of the knee and to investigate possible prognostic factors.

Materials and Methods

Among the patients who developed arthrofibrosis after knee joint surgery, 68 patients who underwent arthroscopic adhesiolysis and were available for at least one-year follow-up were evaluated with regard to the Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee score, patient satisfaction, and range of motion (ROM) of the knee. The influence of possible prognostic factors including the cause of arthrofibrosis, duration of disease, and age of the patient on the postoperative ROM was analyzed.

Results

Sixty-one patients (89.7%) obtained an average increase of 48.6° in ROM; however, the remaining seven patients (10.3%) did not show any increase at the final follow-up. The Lysholm knee score and IKDC subjective knee score increased significantly at the final follow-up. Patient satisfaction was high or very high in 89.7% of the patients at the final follow-up. There was no association between the cause of arthrofibrosis and the increase in postoperative ROM. The duration of disease was significantly related to the postoperative recovery of ROM. Age had no significant influence on the postoperative recovery of ROM.

Conclusions

We believe that arthroscopic adhesiolysis is effective for the treatment of intraarticular arthrofibrosis. In particular, the duration of the disease had significant influence on the postoperative outcome.

Arthroscopic release of the posterior compartments in the treatment of extension deficit of knee

Fibroarthrosis following knee injury or synovial disease is characterized by the presence of dense adhesions filling the entire joint cavity and the fibrotic involvement of periarticular structures. In this particular subset of knee stiffness, both the open and the arthroscopic treatment may fail not addressing all pathology. The aim of the present study was to evaluate the efficacy of an all-arthroscopic treatment for the flexion contractures addressing both the intra-articular posterior adhesions and the fibrotic periarticular structures. From 2003 through 2007, 18 patients of the knee underwent on arthroscopic posterior arthrolysis with release of both gastrocnemius tendons using the trans-septal technique. The median interval between the index procedure and the arthrolysis was 15 (4-22) months. Eight patients had a previous arthroscopic arthrolysis, performed in other hospitals, and two patients had two arthroscopic procedures after the index procedure which failed to regain the extension deficit. The passive extension deficit averaged 34 degrees preoperatively (16 degrees-44 degrees). Six patients underwent a two-staged procedure: the first surgery addressed the presence of adhesions in the suprapatellar pouch and the medial and/or lateral gutters, to regain the flexion of the knee. At final follow-up, the passive extension deficit averaged 3 degrees (0 degree-5 degrees). In all patients, total knee arc of motion increased from 60 degrees (30 degrees-85 degrees) to 95 degrees (5 degrees-110 degrees). The trans-septal portal allows a safe approach of the posterior compartments and allows addressing pathology of both compartments and the release of gastrocnemius tendons.

Arthroscopic posteromedial capsular release for knee flexion contractures

Extension deficits of the knee can cause functional limitations in patients after knee surgery or injury. Most frequently, they are treated with manipulations, arthroscopic anterior compartment debridements, or open posterior capsular releases once nonoperative treatment fails. However, an arthroscopic posteromedial capsular release to manage flexion deficits has yet to be studied comprehensively. Arthroscopic posteromedial capsular releases of the knee can result in improved knee motion postoperatively. An arthroscopic posteromedial capsular release involves sectioning the posteromedial capsule at its meniscofemoral portion, midway between its femoral attachment and its posterior horn medial meniscus junction. A review of 15 patients who underwent this operation was performed. Passive knee extension and flexion was measured in patients in the supine position using a goniometer at preoperative evaluations, under anesthesia prior to and immediately after the posteromedial capsular release, and at postoperative follow-up evaluations. The average time from the arthroscopic posteromedial capsular release to the final postoperative follow-up was 24.1 months. Preoperative knee extension averaged 14.7 degrees in 15 patients. The average immediate postoperative knee extension averaged -0.9 degrees. At the final postoperative follow-up, knee extension averaged 0.7 degrees. Overall knee motion improved from an average are of motion of 101.6 degrees-129.4 degrees. Arthroscopic posteromedial capsular releases and the concurrent postoperative rehabilitation program were effective in the treatment of knee extension deficits. The encouraging results of this study compare well to data presented in open posterior capsular release studies. We believe that arthroscopic posteromedial capsular releases are an effective means to address symptomatic knee extension deficits.

Arthroscopic treatment of patients with moderate arthrofibrosis after total knee replacement

The purpose of this study was to document the effect of arthroscopic management in patients with knee stiffness after total knee replacement. We present a case series study, in which 32 patients have been treated for moderate arthrofibrosis of the knee after total knee replacement, with the same regimen. We have excluded all cases of stiffness, because of infection, mechanical mal-alignment, loosening of the implants and other obvious reasons of stiffness of the knee, rather than pure arthrofibrosis. All patients first underwent a trial of conservative treatment before going for arthroscopic management. A pain catheter for femoral nerve block was inserted just before anesthesia for post-operative pain management. Arthroscopic arthrolysis of the intra-articular pathology was performed in a standardized technique with release of all fibrous bands in the suprapatellar pouch, reestablishing the medial and lateral gutter, release of the patella, resection of the remaining meniscal tissue or an anterior cyclops, if needed. Intensive physiotherapy and continuous passive motion were to start immediately post-operatively. All the patients were available for the follow up and they were evaluated using the knee society rating system. A total of 25 of the 32 procedures resulted in an improvement of the patients knee score. All the knees operated upon had intra-articular fibrous bands, hypertrophic synovitis and peri-patellar adhesions. A total of eight patients suffered from an anterior cyclops lesion and six patients showed pseudomenicus. In 19 cases a medial and lateral relapse of the patella was performed; only 5 patients got an isolated lateral release. The mean knee flexion was 119 degrees (100-130) at the end of arthroscopy and was 97 degrees (75-115) at the last follow up. The eight patients with extension lags decreased from 27 degrees (10 degrees-35 degrees) pre-operatively to 4 degrees (0-10) at time of follow up. The average knee society ratings increased from 70 points prior to the arthroscopy to 86 at time of follow up, which was found to be statistically significant (P < 0.01, student's t test). The average function score also showed improvement from 68 points pre-operatively to 85 at the time of final follow up. The average pain scores improved from 30 points pre-operatively to 41 at the time of final follow up. Our results showed that arthroscopic management of knee stiffness following total knee replacement is a safe and efficient method of treatment. Pain and functional knee scores can improve markedly.

Arthroscopic treatment of the arthrofibrotic knee

The management of motion loss of the knee is challenging. A clear understanding of the pathoanatomic causes of motion loss is necessary to establish a careful and rational approach to treatment. Early recognition and physical therapy are effective for the majority of patients, but when these conservative measures fail, operative intervention is indicated. The purpose of this article is to outline a comprehensive approach to the arthroscopic evaluation and treatment of the arthrofibrotic knee. This technique is designed to allow the surgeon to systematically address the numerous causes of motion loss of the knee.

Classification and management of arthrofibrosis of the knee after anterior cruciate ligament reconstruction

We report 72 patients with disabling knee arthrofibrosis who were treated at our clinic. All patients had painful restriction of extension or limitation of both extension and flexion that had persisted despite physical therapy. The level of arthrofibrosis was categorized into one of four types: Type 1 (25 patients), < 10 degree extension loss and normal flexion; Type 2 (16 patients), > 10 degree extension loss and normal flexion; Type 3 (15 patients), > 10 degree extension loss and > 25 degree flexion loss with a tight patella; and Type 4 (16 patients), > 10 degree extension loss, 30 degrees or more flexion loss, and patella infera with marked patellar tightness. All patients were treated with outpatient arthroscopic surgery. Anterior scar resection down to the proximal tibia was required for all patients with Types 2, 3, and 4 arthrofibrosis. Notchplasty was performed when necessary. Medial and lateral capsular releases and knee manipulation were required for patients with Type 3 or 4 arthrofibrosis. Postoperatively, all patients with Types 2, 3, and 4 arthrofibrosis were treated with outpatient serial extension casting. At the time of latest followup (28 to 115 months), the mean improvement of range of motion was as follows: Type 1, 7 degrees of extension; Type 2, 14 degrees of extension; Type 3, 13 degrees of extension and 28 degrees of flexion; and Type 4, 18 degrees of extension and 27 degrees of flexion. Improvement was also found for the mean stiffness, self-evaluation, functional activity, and Noyes knee scores in all groups.

Arthroscopic management of postoperative arthrofibrosis of the knee joint: indication, technique, and results

From October 1987 through March 1991, 58 patients with postoperative joint stiffness underwent arthroscopic fibroarthrolysis. Forty-six knees in 46 patients were followed. The indication for arthroscopic management was decreased range of motion after surgery. Eighty-seven percent had been treated by arthrotomy. Thirteen percent had been managed by arthroscopic surgery. The indication for primary surgery was a torn anterior cruciate ligament in 74%. The mean interval between arthroscopic fibroarthrolysis and follow-up was 22.1 months. The average age was 32.7 years. A modified Blauth and Jäger score was used for classification of fibroarthrosis: grade I (mild 17.4%), grade II (moderate 63%), grade III (severe 15.2%), and grade IV (bad 4.3%). The gain in range of motion was evaluated by the Cauchoix index: the results were excellent in 54.5%, good in 21.7%, and fair and poor in 23.8%. Pain was evaluated according to a modification of the Lysholm score: 80.4% of the patients experienced a reduction in pain. The sports activity level in the Tegner activity scale increased from 2.3 to 4.8. Patient satisfaction was excellent or good in 56.5% (n = 26), fair in 39.1% (n = 18), and poor in 4.3% (n = 2). On the basis of our retrospective study, we feel that arthroscopic fibroarthrolysis is of benefit to the patients with postoperative joint stiffness even after a prolonged period.