Incidence of Manipulation Under Anesthesia or Lysis of Adhesions After Arthroscopic Knee Surgery

Arthroscopic Posterior Capsular Release Improves Range of Motion and Outcomes for Flexion Contracture After Anterior Cruciate Ligament Reconstruction in Athletes

Purpose

To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction.

Methods

A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow-up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications.

Results

Eighteen athletes with minimum 2 years of follow-up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years' follow-up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant (P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively (P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension.

Conclusions

For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient-reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels.

Level of Evidence

Level IV, therapeutic case series.

Arthrofibrosis of the knee in pediatric orthopedic surgery

Arthrofibrosis is a challenging complication associated with knee injuries in both children and adults. While much is known about managing arthrofibrosis in adults, it is necessary to understand its unique aspects and management strategies in the pediatric population. This paper provides an overview of arthrofibrosis in pediatric orthopedic surgery, focusing on its causes, implications, classifications, and management. This paper is a comprehensive review of the literature and existing research on arthrofibrosis in pediatric patients. Arthrofibrosis is characterized by excessive collagen production and adhesions, leading to restricted joint motion and pain. It is associated with an immune response and fibrosis within and around the joint. Arthrofibrosis can result from various knee injuries in pediatric patients, including tibial spine fractures, ACL and PCL injuries, and extra-articular procedures. Technical factors at the time of surgery play a role in the development of motion loss and should be addressed to minimize complications. Preventing arthrofibrosis through early physical therapy is recommended. Non-operative management, including dynamic splinting and serial casting, has shown some benefits. New pharmacologic approaches to lysis of adhesions have shown promise. Surgical interventions, consisting of arthroscopic lysis of adhesions (LOA) and manipulation under anesthesia (MUA), can significantly improve motion and functional outcomes. Arthrofibrosis poses unique challenges in pediatric patients, demanding a nuanced approach that includes prevention, early intervention with non-operative means, and improvements in surgical techniques. Modern pharmacological interventions offer promise for the future. Customized interventions and research focused on pediatric patients are critical for optimal outcomes.

Manipulation Under Anesthesia and/or Lysis of Adhesions After Anterior Cruciate Ligament Reconstruction in Female Basketball Players: Does Race Play a Role?

BACKGROUND

Arthrofibrosis can limit function and return to sport after anterior cruciate ligament (ACL) reconstruction. Previously reported risk factors for developing arthrofibrosis after ACL reconstruction include female sex, age <18 years, time from injury to surgery <28 days, concomitant meniscal repair, prolonged immobilization, and genetic factors. There is a lack of evidence regarding whether race plays a significant role.

HYPOTHESIS

The risk of undergoing manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) after primary ACL reconstruction with bone-patellar tendon-bone (BTB) autograft in female basketball players is higher in African American players than in White players.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Using a computerized relational database, the authors identified competitive female basketball players who underwent primary ACL reconstruction with BTB autograft by the senior author over a 13-year period. Data previously entered from examinations and surgical findings were reviewed retrospectively. Univariate statistics and multivariable logistic regression were used to assess the relationship between undergoing subsequent MUA and/or LOA and study predictors.

RESULTS

A total of 186 knees (114 African American knees and 72 White knees) met inclusion criteria. The overall rate of MUA and/or LOA was 8.6%. Thirteen African American knees (11.4%) and 3 White knees (4.2%) underwent MUA and/or LOA for treatment of arthrofibrosis. No study predictor was found to have a statistically significant relationship with the rate of MUA and/or LOA on univariate analysis. However, when controlling for body mass index and previously described risk factors (age <18 years, time from injury to surgery ≤28 days, and concomitant meniscal repair) in the logistic regression model, the authors found that MUA and/or LOA was more likely in African American (odds ratio, 4.01 [95% CI, 1.01-15.92]; P = .049) than in White female players and in patients who underwent ACL reconstruction within 28 days of injury (odds ratio, 4.01 [95% CI, 1.18-13.57]; P = .026) compared with those with surgery delayed beyond 28 days.

CONCLUSION

In female basketball players, the present study found a statistically significantly increased risk for undergoing MUA and/or LOA after primary ACL reconstruction with BTB autograft in African American females compared with White females and in patients who underwent ACL reconstruction within 28 days of injury.

Uncommon, foreign-body induced knee arthrofibrosis in a pediatric patient

Arthrofibrosis is defined as an excessive fibrotic tissue response within a joint leading to a painful loss of motion. This pathological scar formation process with dysregulated, inordinate extracellular matrix formation, especially collagen, may occur in any joints, although is frequently localized in the knee. Different etiologies have been described and most of them are related to trauma, infection or recent surgical procedure. Although arthrofibrosis affects people of all ages, it is unusual in pediatric population. We present a case report of an uncommon, foreign body induced knee arthrofibrosis in a 14-year old boy. We also review the current literature regarding diagnostic procedures and treatment rationale for arthrofibrosis of the knee.

Risk Factors and Outcomes for Preoperative Stiffness Requiring Intervention Before Anterior Cruciate Ligament Reconstruction

Background

To date, there is a scarcity of literature related to the incidence of prolonged stiffness after an anterior cruciate ligament (ACL) tear that requires manipulation under anesthesia/lysis of adhesions (MUA/LOA) in the preoperative period before ACL reconstruction (ACLR) and how preoperative stiffness influences outcomes after ACLR.

Hypothesis

Preoperative stiffness requiring MUA/LOA would increase the risk for postoperative stiffness, postoperative complications, and the need for subsequent procedures after ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

The PearlDiver Research Program was used to identify patients who sustained an ACL tear and underwent ACLR using their respective International Classification of Diseases, 9th or 10th Revision, and Current Procedure Terminology (CPT) codes. Within this group, patients with preoperative stiffness were identified using the CPT codes for MUA or LOA. Significant risk factors for preoperative stiffness were identified through univariate and multivariate logistic regression analyses. Outcomes after ACLR were analyzed between patients with and without preoperative stiffness using multivariate logistic regression, controlling for age, sex, and Elixhauser Comorbidity Index.

Results

Between 2008 and 2018, 187,071 patients who underwent ACLR were identified. Of these patients, 241 (0.13%) underwent MUA/LOA before ACLR. Patients with preoperative stiffness began preoperative physical therapy significantly later than patients without stiffness (P = .0478) and had a delay in time to ACLR (P = .0003). Univariate logistic regression demonstrated that female sex, older age, anxiety/depression, obesity, and anticoagulation use were significant risk factors for preoperative stiffness (P < .05 for all). After multivariate regression, anticoagulation use was the only independent risk factor deemed significant (odds ratio, 6.69 [95% CI, 4.01-10.51]; P < .001). Patients with preoperative stiffness were at an increased risk of experiencing postoperative stiffness, deep vein thrombosis, pulmonary embolism, surgical-site infection, and septic knee arthritis after ACLR (P < .05 for all).

Conclusion

Although the risk of preoperative stiffness requiring an MUA/LOA before ACLR is low, the study findings indicated that patients with preoperative stiffness were at increased risk for postoperative complications compared with patients with no stiffness before ACLR.

Effect of Prior Knee Arthroscopy on Midterm Outcomes After Medial Opening-Wedge High Tibial Osteotomy: A Propensity Score-Matched Analysis

Background

Knee arthroscopy is frequently performed to improve joint function and relieve pain. However, there is no consensus regarding the effect of prior arthroscopy on outcomes following medial opening-wedge high tibial osteotomy (MOWHTO).

Purpose

To compare midterm clinical outcomes and survival rates after MOWHTO between patients with and without a history of knee arthroscopy.

Study Design

Cohort study; Level of evidence, 3.

Methods

We enrolled patients who underwent MOWHTO between March 2008 and February 2017 and had ≥4 years of follow-up. Patients who had undergone knee arthroscopy were included in an arthroscopy group, and those who had not were included as controls. After propensity score matching based on age, sex, body mass index, and lesion size, 80 patients in each group were included. Clinical outcomes were assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS), 36-Item Short Form Health Survey, and Tegner Activity Scale. Furthermore, survival rates and relevant risk factors that affected joint survivorship were analyzed, wherein conversion to total knee arthroplasty was considered the endpoint.

Results

Although the pre- to postoperative improvement in clinical outcomes did not differ significantly between the groups, there were significant between-group differences in final postoperative scores on the KOOS-Activities of Daily Living (arthroscopy vs control, 78.1 ± 10.6 vs 81.0 ± 9.8; P = .031), KOOS-Sport and Recreation (45.4 ± 12.8 vs 48.7 ± 13.5; P = .045), 36-Item Short Form Health Survey Physical Component Summary (65.1 ± 12.7 vs 69.3 ± 11.8; P = .017), and Tegner Activity Scale (4.1 ± 1.1 vs 4.5 ± 1.0; P = .007). The survival rate was 96.8% at a mean follow-up of 8 years, and survival was not associated with a history of arthroscopy (P = .697; log-rank test).

Conclusion

Although patients with prior arthroscopy had some inferior patient-reported outcome scores after MOWHTO, the overall clinical improvements were similar in the arthroscopy and control groups.

Comparison of Physical Therapy Utilization and Motion-Related Re-operations Between Isolated Anterior Cruciate Ligament and Multi-Ligament Knee Injuries

The increased prevalence of postoperative arthrofibrosis after multi-ligament knee injuries (MLKI) compared to isolated anterior cruciate ligament (ACL) injuries has been proposed to be due, in part, to patient factors limiting physical therapy utilization. The purpose of this study was to compare demographic factors, pre- and postoperative physical therapy utilization, and the need for motion-restoring surgery between MLKI and ACL-injured patients. Using the PearlDiver Mariner 151 database, two cohorts matched by age and sex were identified using current procedural terminology (CPT) codes and included those age 16 or greater that underwent isolated ACL (n=3801) vs. MLKI reconstruction (n=3801). The number of pre- and postoperative physical therapy visits was recorded, as was the need for motion-restoring surgery (arthroscopic lysis of adhesions or manipulation under anesthesia). Demographic factors, physical therapy utilization, and the prevalence of motion-restoring surgery were compared between the MLKI and ACL groups using t-tests or chi-square tests, as appropriate. A significantly greater proportion of those with MLKI underwent subsequent motion-restoring surgery (MLKI=412/3081 (13.4%) vs. ACL=84/3081 (2.7%), p<0.001; odds ratio = 5.5 (95% CI: 4.3, 7.0), p<0.0001). Following surgery, less than half of those with MLKI that underwent subsequent motion-restoring surgery attended physical therapy, which was significantly lower than those who did not require motion-restoring surgery (p<0.0001). The prevalence of motion-restoring surgery was significantly greater after MLKI when compared to an isolated ACL injury. While the etiology of arthrofibrosis after MLKI is likely complex, the current results suggest that demographic factors and physical therapy utilization are not solely responsible for the increased risk of arthrofibrosis after MLKI.

Arthrofibrosis is a common but poorly defined complication in multiligament knee injuries: a systematic review

PURPOSE

The purpose of this study is to systematically review multiligament knee injury (MLKI) outcome studies to determine definitions of arthrofibrosis (AF) and provide information about incidence, management as well as potential risk factors.

METHODS

A systematic literature search was performed (PubMed and Cochrane library) following the PRISMA guidelines of operatively treated MLKI (Schenck II-IV) studies reporting the incidence of AF. Twenty-five studies met the inclusion criteria. Injury pattern, timing of surgery, surgical technique, treatment of AF, rehabilitation programs and PROMS were inquired. Risk of bias and quality of evidence were assessed using the Coleman methodological score.

RESULTS

Twenty-five studies with a total of 709 patients with a mean age of 33.6 ± 4.8 years were included and followed 47.2 ± 32.0 months. The majority of studies (22/25) used imprecise and subjective definitions of AF. A total of 86 patients were treated for AF, resulting in an overall prevalence of 12.1% (range 2.8-57.1). Higher-grade injuries (Schenck III-IV), acute treatment and ROM (range of motion) limiting rehabilitation programs were potential risk factors for AF. The time from index surgery to manipulation anesthesia (MUA) and arthroscopic lysis of adhesions (LOA) averaged at 14.3 ± 8.8 and 27.7 ± 12.8 weeks. Prior to MUA and LOA, the ROM was 51.7° ± 23.5 and 80.2° ± 17.0, resulting in a total ROM gain after intervention of 65.0° ± 19.7 and 48.0° ± 10.6, respectively; with no reports of any complication within the follow-up. The overall methodological quality of the studies was poor as measured by the Coleman score with average 56.3 ± 12.5 (range 31-84) points.

CONCLUSIONS

AF is a common but poorly defined complication particularly in high-grade MLKI. Early postoperative and intensified physiotherapy is important to reduce the risk of AF. MUA and LOA are very effective treatment options and result in good clinical outcome. Prospective studies with bigger study population are needed to optimize treatment algorithms of further patients after MLKI. The protocol of this systematic review has been prospectively registered with PROSPERO (CRD42021229187, January 4th, 2021).

Efficacy of non-operative treatment of patients with knee arthrofibrosis using high-intensity home mechanical therapy: a retrospective review of 11,000+ patients

Background

Recovery from knee surgery or injury can be hindered by knee arthrofibrosis, which can lead to motion limitations, pain and delayed recovery. Surgery or prolonged physical therapy are often treatment options for arthrofibrosis, but they can result in increased costs and decreased quality of life. A treatment option that can regain lost motion without surgery would help minimize risks and costs for the patient. The purpose of this study was to determine treatment efficacy of high-intensity home mechanical stretch therapy in patients with knee arthrofibrosis.

Methods

Records were reviewed for 11,000+ patients who were prescribed a high-intensity stretch device to regain knee flexion. Initial and last recorded knee flexion and days between measurements were available for 9842 patients (Dataset 1). Dataset 2 was a subset of 966 patients from Dataset 1. These 966 patients had separate more rigorous measurements available from physical therapy notes (Dataset 3) in addition to data from the internal database (Dataset 2). Within and between dataset statistics were calculated using t tests for comparison of means and Cohen’s d for determination of effect size.

Results

All dataset showed significant gains in flexion (p < 0.01). Mean initial flexion, last recorded flexion and flexion gain were 79.5°, 108.4°, and 29.9°, respectively in Dataset 1. Differences between Datasets 2 and 3 had small effect sizes (Cohen’s d < 0.17). The were no significant differences when comparing workers’ compensation and non-workers’ compensation patients. The average last recorded flexion for all datasets was above the level required to perform activities of daily living. Motion gains were recorded in under 60 days from device delivery.

Conclusions

High-intensity home mechanical stretch therapy was effective in restoring knee flexion, generally in 2 months or less, and in avoiding additional surgery in severe motion loss patients regardless of sex, age, or workers’ compensation status. We believe high-intensity stretching should be considered in any patient who is at risk for a secondary motion loss surgery, because in over 90% of these patients, the complications and costs associated with surgery can be avoided.

Treatment Trends in Meniscal Pathology in the Setting of Concomitant ACL Injuries in Pediatric and Young Adult Patients: An Insurance Database Study

BACKGROUND

Meniscal pathology is commonly encountered in the setting of anterior cruciate ligament (ACL) rupture and is increasingly common in the pediatric and adolescent population. Studies have shown that over half of individuals presenting with ACL rupture will have concurrent meniscal pathology.

PURPOSE

To define trends in the utilization of meniscal procedures (ie, meniscus repair vs partial meniscectomy) and short-term complications in pediatric and young adult patients with meniscal pathology in the setting of a concurrent ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The IBM MarketScan Commercial Database was utilized to identify ACL reconstruction procedures performed between 2006 and 2018 for individuals aged 5 to 30 years. Annual proportions of meniscectomy and meniscal repair were analyzed, and short-term complications were compared between pediatric/adolescent patients (aged 5-17 years) and young adults (aged 18-30 years).

RESULTS

An overall 40,736 records of individuals <18 years old with ACL tears were included. The pediatric/adolescent population had a significantly lower proportion of concomitant meniscal procedures (56.8%; 23,149/40,736) than the young adult population (59.7%; 33,764/56,515; P < .01). From 2006 to 2018, utilization of meniscal repair in the setting of ACL reconstruction steadily increased (20.1% to 35.1% [+15 percentage points], P < .01), while the proportion with meniscectomy decreased (34.4% to 21.3% [-13.1 percentage points], P < .01). There was no difference in rate of reoperation for repeat meniscal repair or meniscectomy in the pediatric/adolescent population for those undergoing meniscal repair versus meniscectomy within 180 days of primary surgery (1.7% [188/10,766] vs 1.5% [186/12,383]; P = .14).

CONCLUSION

From 2006 to 2018, the proportion of patients receiving ACL reconstruction with concomitant meniscal repair increased (20.1% to 35.1%) while the proportion with meniscectomy decreased (34.4% to 21.3%) in the pediatric/adolescent population. Meniscal repair was not associated with a higher 180-day rate of reoperation for repeat meniscal repair or meniscectomy than meniscectomy in the setting of ACL reconstruction.

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.

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 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.

Aseptic Revision and Reoperation Risks After Meniscectomy at the Time of Anterior Cruciate Ligament Reconstruction

BACKGROUND

An intact meniscus is considered a secondary stabilizer of the knee after anterior cruciate ligament reconstruction (ACLR). While loss of the meniscus can increase forces on the anterior cruciate ligament graft after reconstruction, it is unclear whether this increased loading affects the success of the graft after ACLR.

PURPOSE

To identify the risk of subsequent knee surgery when meniscectomy, either partial or total, is performed at the time of index ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We conducted a matched cohort study using data from the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry. Patients were identified who had a primary ACLR performed between January 1, 2005 and December 31, 2016, with up to 12 years of follow-up. The study sample comprised patients with ACLR who had a lateral meniscectomy (n = 2581), medial meniscectomy (n = 1802), or lateral and medial meniscectomies (n = 666). For each meniscectomy subgroup, patients with ACLR alone were matched to patients with a meniscectomy on a number of patient and procedure characteristics. After the application of matching, Cox proportional hazards regression was used to evaluate the risk of aseptic revision, while competing risks regression was used to evaluate the risk of cause-specific ipsilateral reoperation between meniscectomy and ACLR alone. Analysis was performed for each meniscectomy subgroup.

RESULTS

After the application of matching, we failed to observe a difference in aseptic revision risk for patients with ACLR and a meniscectomy-lateral (hazard ratio [HR], 0.80; 95% CI, 0.63-1.02), medial (HR, 0.95; 95% CI, 0.70-1.29), or both (HR, 1.25; 95% CI, 0.77-2.04)-as compared with ACLR alone. When compared with patients who had ACLR alone, patients with a lateral meniscectomy had a higher risk for subsequent lateral meniscectomy (HR, 1.89; 95% CI, 1.18-3.02; P = .008), and those with a medial meniscectomy had a lower risk for manipulation under anesthesia (HR, 0.13; 95% CI, 0.02-0.92; P = .041).

CONCLUSION

No difference in aseptic revision risk was observed for patients undergoing primary ACLR between groups with and without meniscectomy at the time of index surgery. Partial lateral meniscectomy at the time of index ACLR did associate with a higher risk of subsequent lateral meniscectomy.

Pharmacologic Thromboprophylaxis Other Than Aspirin Is Associated With Increased Risk for Procedural Intervention for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare rates of procedural intervention for arthrofibrosis following anterior cruciate ligament reconstruction (ACLR) among patients who were not prescribed any pharmacologic thromboprophylaxis compared with patients who were prescribed aspirin and to patients who were prescribed other agents.

METHODS

A search of a national insurance claims database was performed to identify all patients who underwent ACLR from 2007 to 2017 who were active within the database at a minimum of 6 months before and 18 months after their surgery. The primary outcome studied was a subsequent procedure for arthrofibrosis, manipulation under anesthesia, and lysis of adhesions (MUA/LOA). Patients who filled a prescription for aspirin, low-molecular weight heparin, direct factor Xa inhibitors, fondaparinux, and warfarin within 2 days after their surgery were included and those who filled a prescription within 3 months before surgery were excluded. Thromboprophylaxis status was defined as no thromboprophylaxis, aspirin, and any agent other than aspirin. Logistic regression analysis was performed to determine the association between prophylaxis status and MUA/LOA.

RESULTS

Of the 14,081 patients in our final surgical population, 191 patients had MUA/LOA and 13,890 patients did not. In total, 499 patients were prescribed pharmacologic prophylaxis. Rates of MUA/LOA across groups were 1.3% in the group with no thromboprophylaxis, 1.9% in the group prescribed aspirin, and 4.3% in the group prescribed any agent other than aspirin. Only the group prescribed an agent other than aspirin was significantly associated with subsequent procedure for arthrofibrosis (odds ratio 2.6, 95% confidence interval 1.3-4.8, P = .004).

CONCLUSIONS

Patients who were prescribed a pharmacologic agent other than aspirin had a 2.6 times greater likelihood of requiring a procedural intervention for arthrofibrosis following ACLR compared with patients who were not prescribed a thromboprophylaxis agent LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

A New Procedure for Ultrasound-Guided Hydrorelease for the Scarring After Arthroscopic Knee Surgery

Postoperative scarring is one of the complications after arthroscopic knee surgery, which is usually treated with manual therapy or arthroscopic debridement. The incidence of symptomatic scarring requiring surgery within six months postoperatively has been reported to be approximately 0.06-6.00%. We treated a patient after arthroscopic surgery with a new "ultrasound-guided hydrorelease" procedure and we describe it. A 50-year-old woman with a history of arthroscopic anterior cruciate ligament reconstruction of the right knee presented to our clinic 10 months ago with a complaint of right anterior knee pain. Ultrasound imaging showed an infrapatellar fat pad (IPFP) scarring and sliding defects. The pre-treatment Kujala scale was 62 points and the visual analogue scale was 72. The inferolateral side of the patella was palpated to identify the scarring after arthroscopy at the IPFP area. An ultrasound probe was applied vertically to identify the site of adhesion of interest. Ultrasound-guided hydrorelease was performed using 7.0mL saline injected by needle (22G, 60mm) directed at the site with hypoechoic changes in the IPFP. After the procedure, the normalization of the IPFP sliding was confirmed by an ultrasound image. Four weeks after this procedure, the patient improved, with a Kujala scale of 82 points and a visual analogue scale of 28. The most important finding from this patient's course is that her chief complaint of anterior knee pain improved by ultrasound-guided hydrorelease into the IPFP scarring after arthroscopic knee surgery. The procedure should be considered as a treatment for scarring after arthroscopic knee surgery.

Arthroscopic Posterior Capsular Release for Loss of Knee Extension

Arthrofibrosis, as a result of osteoarthritis, after trauma, or after knee surgery, can have significant implications for patient function, satisfaction, and outcomes. When extensive conservative management fails to achieve satisfactory results, surgical intervention may be necessary. Arthroscopic techniques to release anterior adhesions are often viewed as easier and safer than posterior releases required for flexion contractures. We present our technique of a safe, effective, and reproducible arthroscopic complete posterior capsulotomy.

Incidence and risk factors of joint stiffness after Anterior Cruciate Ligament reconstruction

Background

Joint stiffness is a common complication after anterior cruciate ligament (ACL) reconstruction, which seriously affects the efficacy of the operation and patient satisfaction. After ACL reconstruction, the identification of joint stiffness’ risk factors can help its prevention. This meta-analysis was conducted to evaluate joint stiffness’ risk factors and incidence after ACL reconstruction and provide guidance on its prevention.

Methods

PubMed, Embase, and Cochrane Library were searched to obtain relevant studies. The odds ratios (ORs) with 95% confidence intervals (CIs) for all potential risk factors were analyzed using fixed or random-effects meta-analysis in RevMan 5.2.

Results

In total, there were 37 studies and 113,740 patients that were included in this study. After ACL reconstruction, joint stiffness’ incidence negatively correlated with the studies publication time (R = −0.62, P = 0.0094). After ACL reconstruction, the joint stiffness overall pooled incidence was 3% (95% CI, 3-4%). Gender (OR, 0.51; 95% CI, 0.38-0.68; P < 0.00001) was identified as a risk factor. Potential risk factors, such as trauma to surgery time interval, graft type, and concomitant surgery with meniscus injury, have no significant correlation with joint stiffness after ACL reconstruction.

Conclusion

This study indicated that joint stiffness’ incidence after ACL reconstruction is 3% and that gender is a risk factor for joint stiffness after ACL reconstruction.

Prior knee arthroscopy effects on subsequent total knee arthroplasty: A protocol of match-controlled study

BACKGROUND

Currently, there exists a paucity of literature about the impact of prior knee arthroscopy on subsequent total knee arthroplasty (TKA). The purpose of this study was to compare outcomes of patients undergoing TKA after prior knee arthroscopy with a matched cohort of control subjects with primary osteoarthritis and no history of arthroscopy.

METHODS

We reviewed patients who underwent primary TKA at our academic center from January 2011 to December 2017. Of these, we included 68 patients (70 knees) that were performed TKA following knee arthroscopy. The groups were split by sex, age to within 6 years, and body mass index within 5 kg/m. A 1:2 matching algorithm was applied. Outcome measures included surgical time, intraoperative estimated blood loss, Oxford Knee Score, range of movement, complications, and revision rate.

RESULTS

This study had limited inclusion and exclusion criteria and a well-controlled intervention.

CONCLUSION

This clinical trial is expected to determine whether prior knee arthroscopy is associated with reduced functional outcomes or increased risks of revision and complications following TKA.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5413).

Manipulation Under Anesthesia With Lysis of Adhesions Is Effective in Arthrofibrosis After Sulcus-Deepening Trochleoplasty: A Prospective Study

Background

Sulcus-deepening trochleoplasty has been established as an effective treatment for patellar instability due to trochlear dysplasia. However, arthrofibrosis is a known complication following trochleoplasty, which may require manipulation under anesthesia (MUA) with or without lysis of adhesions (LOA) to increase the knee range of motion (ROM), especially flexion.

Purpose

To prospectively follow patients for ROM improvements and subsequent complications after undergoing MUA with or without LOA in the setting of sulcus-deepening trochleoplasty.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 76 knees with severe trochlear dysplasia were prospectively enrolled and underwent sulcus-deepening trochleoplasty, with a mean (±SD) follow-up of 32.5 ± 19.3 months. Concomitant procedures included medial patellofemoral ligament reconstruction, lateral retinacular release, and tibial tubercle osteotomy. Physical examination including ROM and findings of recurrent patellar instability were collected for all patients. Arthrofibrosis was defined as active and passive flexion less than 90° within 3 months of surgery combined with a plateau in progress with physical therapy. Paired-samples and independent-samples t tests were used. A P value less than .05 was considered significant.

Results

A total of 62 knees met inclusion and exclusion criteria and were included in the study. Of these patients, 11 experienced arthrofibrosis as a complication and underwent MUA within 3 months of their index procedure. Of these 11 patients, 9 subsequently underwent arthroscopic LOA following MUA because acceptable ROM could not be achieved with manipulation alone. Patients with arthrofibrosis had a premanipulation mean ROM that was significantly different from those without arthrofibrosis (77.3° ±18.6° vs 133.3° ± 12.7°, respectively; P < .001). In the arthrofibrotic group, postoperative ROM increased significantly after MUA and/or LOA compared with the preoperative ROM (127.3° ± 12.5° vs 77.3° ± 18.6°, respectively; P < .001). ROM in the arthrofibrotic group after MUA/LOA was not significantly different from that in the nonarthrofibrotic group (flexion, 127.3° ± 12.5° vs 133.3° ± 12.7°, respectively; P = .156). No complications from the MUA or LOA were reported at subsequent follow-up visits.

Conclusion

When indicated in the setting of severe trochlear dysplasia, sulcus-deepening trochleoplasty is a treatment for disabling recurrent patellar instability with a known complication of arthrofibrosis. Initiation of postoperative physical therapy within 3 days of surgery may reduce the incidence of arthrofibrosis. If arthrofibrosis is encountered after a sulcus-deepening trochleoplasty, MUA without LOA is not as effective as when following other procedures of the knee, whereas MUA with LOA is an effective procedure likely to result in ROM and patient outcome scores similar to those of a nonarthrofibrotic knee after the same procedure. Both MUA and LOA appear to be safe based on the limited number of patients in this study without complication.

Subsequent Surgery for Loss of Motion After Anterior Cruciate Ligament Reconstruction Does Not Influence Function at 2 Years: A Matched Case-Control Analysis

BACKGROUND

Loss of motion (LOM) remains a common complication after anterior cruciate ligament (ACL) reconstruction and can be detrimental to patient outcomes after surgery. LOM is multifactorial, but nonsurgical and surgical solutions to this complex problem are available. A paucity of quality data exists evaluating clinical outcomes after the surgical treatment of patients with LOM after ACL reconstruction.

HYPOTHESIS

Patients undergoing surgical lysis of adhesions and manipulation under anesthesia for LOM after ACL reconstruction will exhibit decreased function, lower outcome scores, and delayed time of release to play when compared with matched controls without LOM.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A database of 1572 patients undergoing ACL reconstruction was sampled from 2013 to 2017 to identify a total of 58 patients (LOM group [n = 29] vs matched control group [n = 29]). Group comparisons were examined for patients requiring a second surgical procedure for LOM versus matched controls after ACL reconstruction for differences in surgical timing, self-reported International Knee Disability Committee scores, objective function at release to play, and subjective knee function at 2 years with the Single Assessment Numeric Evaluation. The risk of a type I error was set at α = .05 for all statistical analyses.

RESULTS

Patients who underwent lysis of adhesions and manipulation under anesthesia for LOM after ACL reconstruction exhibited no differences in Single Assessment Numeric Evaluation knee function at 2 years when compared with matched controls (85.8 ± 14.9 vs 88.0 ± 10.8, P = .606). All patients met release-to-play criteria. Only International Knee Disability Committee scores (P = .046) and single-legged hop testing (P = .050) reached statistically significant differences, with higher scores in the control group. There was no difference in the time to release to play (P = .034) or level of participation (P = .180) between the control and surgical groups. Subjective function scores at 2 years were not significantly different between groups. Tourniquet time during the index ACL reconstruction was shorter in the control group (P = .034).

CONCLUSION

The findings of this study suggest that patients who undergo surgical treatment for LOM after ACL reconstruction can release to play at similar times but display relative deficits in single-legged-hop symmetry and lower self-reported function when compared with matched controls. Longer surgical times may increase the risk for LOM after ACL reconstruction.

REGISTRATION

NCT03704376 (ClinicalTrials.gov identifier).

Open posterior capsular release with an osteotome in total knee arthroplasty does not place important neurovascular structures at risk

PURPOSE

Posterior capsular contracture is a potential consequence of osteoarthritis, post-traumatic arthritis, and surgical procedures of the knee. Many patients who undergo TKA will be found to have some degree of flexion contracture intraoperatively, which necessitates posterior capsular release. There is no information in the literature about the safety of posterior capsular release done during TKA. The present cadaveric study investigates the safety of posterior capsular release during TKA.

METHODS

This study involved ten fresh-frozen cadaver specimens, each of which underwent three successive releases of the posterior capsule medially, laterally, and in the midline. One senior joint surgeon performed this procedure with a 1.27 cm curved osteotome, hugging the bone posteriorly on the distal aspect of the femur until the osteotome moved freely behind the bone without resistance. The distance from the distal aspect of the femur to the tip of the osteotome was then measured. Finally, the popliteal fossa was dissected, and the course of the neurovascular bundle was followed to assess for any macroscopic injury.

RESULTS

The capsule was penetrated at a median depth of 13.6 cm (range 10.3-17.6). Even at this depth, no injuries to the popliteal artery, tibial nerve, or popliteal vein occurred in any of the 30 penetrating events.

CONCLUSION

This study suggests that posterior capsular release can be performed safely with this technique.

Identifying candidates for arthroscopic primary repair of the anterior cruciate ligament: A case-control study

INTRODUCTION

There has been a recent resurgence of interest in arthroscopic primary repair of proximal anterior cruciate ligament (ACL) tears. Patient selection is critical but not much is currently known on what predicts the possibility of repair. Goal of this study was therefore to assess predictive factors for the possibility of arthroscopic primary ACL repair.

METHODS

In this retrospective case-control study, all patients undergoing ACL surgery in a ten-year interval were included. Patients were treated with primary repair if there was a proximal tear and good tissue quality, or otherwise underwent ACL reconstruction. Collected data were age, gender, BMI, injury-to-surgery delay, injury mechanism and concomitant injuries. Receiver operating characteristic curves were used to find cutoff values, and all significant dependent variables were used in multivariate logistic analysis to assess independent predictors for the possibility of primary repair.

RESULTS

Three hundred sixty-one patients were included, of which in 158 patients (44%) primary repair was possible. Multivariate analysis (R² = 0.340, p < 0.001) showed that age > 35 years (Odds ratio [OR] 4.2, 95% CI 2.4-7.5,p < 0.001), surgery within 28 days (OR 3.3, 95% CI 1.9-5.7, p < 0.001), and BMI <26 (OR 1.9, 95% CI 1.1-3.3,p = 0.029) were predictive for the possibility of primary repair, and lateral meniscus injury presence decreased the likelihood of repair (OR 0.5, 95% CI 0.3-0.8, p = 0.008).

CONCLUSION

In this large cohort study, it was noted that 44% of patients had repairable ACL tears. Primary repair was more likely to be possible in older patients, patients with lower BMI and when surgery was performed within four weeks of injury.

Pathological mechanisms and therapeutic outlooks for arthrofibrosis

Arthrofibrosis is a fibrotic joint disorder that begins with an inflammatory reaction to insults such as injury, surgery and infection. Excessive extracellular matrix and adhesions contract pouches, bursae and tendons, cause pain and prevent a normal range of joint motion, with devastating consequences for patient quality of life. Arthrofibrosis affects people of all ages, with published rates varying. The risk factors and best management strategies are largely unknown due to a poor understanding of the pathology and lack of diagnostic biomarkers. However, current research into the pathogenesis of fibrosis in organs now informs the understanding of arthrofibrosis. The process begins when stress signals stimulate immune cells. The resulting cascade of cytokines and mediators drives fibroblasts to differentiate into myofibroblasts, which secrete fibrillar collagens and transforming growth factor-β (TGF-β). Positive feedback networks then dysregulate processes that normally terminate healing processes. We propose two subtypes of arthrofibrosis occur: active arthrofibrosis and residual arthrofibrosis. In the latter the fibrogenic processes have resolved but the joint remains stiff. The best therapeutic approach for each subtype may differ significantly. Treatment typically involves surgery, however, a pharmacological approach to correct dysregulated cell signalling could be more effective. Recent research shows that myofibroblasts are capable of reversing differentiation, and understanding the mechanisms of pathogenesis and resolution will be essential for the development of cell-based treatments. Therapies with significant promise are currently available, with more in development, including those that inhibit TGF-β signalling and epigenetic modifications. This review focuses on pathogenesis of sterile arthrofibrosis and therapeutic treatments.

Factors Associated With a Delay in Achieving Full Knee Extension Before Anterior Cruciate Ligament Reconstruction

Background:

Arthrofibrosis commonly occurs after an acute anterior cruciate ligament (ACL) injury and following ACL reconstruction and can lead to poor outcomes. Preoperative stiffness has been shown to be associated with postoperative stiffness; however, few studies have examined predictors of preoperative delay in obtaining full knee extension.

Purpose:

To examine demographic and injury factors as predictors of time required to achieve full knee extension preoperatively in patients with an acute ACL injury.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

A total of 172 patients with an acute ACL tear at presentation (defined as ≤3 weeks from injury) who underwent magnetic resonance imaging (MRI) within 6 weeks of the injury were included in this analysis. Preoperative data included date of injury, age at injury, sex, body mass index, mechanism of injury (noncontact/contact), time from injury to surgery (days), time to achieve full extension prior to surgery (weeks), and bone bruising on MRI. Time to achieve full extension was categorized as <3 or ≥3 weeks. Unadjusted and adjusted logistic regression was used to examine predictors of delayed time to achieve full extension (≥3 vs <3 weeks). Odds ratios and 95% CIs were reported.

Results:

Time to achieve full extension was early (<3 weeks) in 98 patients and delayed (≥3 weeks) in 74 patients. The average time to achieve full extension was 7 days in the early group and 32.5 days in the delayed group. Delayed time to achieve full extension was associated with increased lateral femoral condyle (LFC) bruising compared with early time to achieve extension (82.8% vs 66.7%, respectively; P = .03). No other statistically significant predictors were found after adjustment for age, sex, body mass index, and mechanism of injury.

Conclusion:

Acute ACL injuries associated with LFC bone bruising seen on MRI are more likely to result in reduced extension prior to ACL reconstruction. These injuries should be identified and addressed by an appropriate preoperative rehabilitation program, and surgery should be delayed to avoid risking arthrofibrosis postoperatively by reconstructing a knee with less than full extension.

Adductor Canal Nerve Versus Femoral Nerve Blockade for Pain Control and Quadriceps Function Following Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft: A Prospective Randomized Trial

PURPOSE

To compare femoral nerve blockade (FNB) versus adductor canal nerve blockade (ACB) for postoperative pain control and quadriceps muscle function in patients undergoing anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft.

METHODS

A randomized therapeutic trial of 90 patients undergoing ACL reconstruction with patellar tendon autograft was conducted comparing ACB versus FNB at 24 hours, 2 and 4 weeks, and 6 months postsurgery. Early outcome measures included average pain score and morphine equivalent units (milligrams) consumed, quadriceps surface electromyography, straight leg raise, and ability to ambulate without assistive devices. The 6-month outcome measures included knee range of motion (ROM), isokinetic knee extension peak torque, single-leg squat, and single-leg hop performance. Complications were recorded throughout the study for the development of anterior knee pain, knee extension ROM loss, deep vein thrombosis, and graft failure. Mixed-model analysis of variance and Mann-Whitney U tests were performed using an alpha of .05.

RESULTS

Quadriceps surface electromyography deficits were higher for FNB at 24 hours (P < .001) and 2 weeks (P < .001) when compared with the ACB group. There were no between-groups difference for subjective pain (P = .793) or morphine consumption (P = .358) within the first 24 hours of surgery. A higher percentage of patients in the ACB group met the full ambulation criteria at 4 weeks compared with the FNB group (100% vs 84.2%, P < .001). No between-group differences were observed at 6 months; however, the rate of knee extension ROM loss was higher for the FNB group versus the ACB group (21.1% vs 5.0%, P = .026), respectively.

CONCLUSIONS

ACB was as effective as FNB at providing pain control while eliciting fewer quadriceps muscle activation deficits and fewer postoperative complications. Based on previous evidence and the results of this study, we recommend the use of ACB over FNB for the analgesic management of patients undergoing ACL reconstruction with patellar tendon autograft.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Risk Factors for Manipulation Under Anesthesia and/or Lysis of Adhesions After Anterior Cruciate Ligament Reconstruction

Background:

In the currently published literature, a higher risk for developing arthrofibrosis after anterior cruciate ligament (ACL) reconstruction has been reported for female patients, adolescents, early surgery or concomitant procedures, and the use of a patellar tendon autograft. There is a lack of evidence regarding other graft choices or factors.

Hypothesis:

Multiple risk factors will play a significant role in the development of arthrofibrosis after ACL reconstruction. Specifically, we hypothesized that the risk of manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) would be affected by graft choice and patient demographic factors.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The charts of all patients who underwent ACL reconstruction over a 10-year period at a single academic institution were queried from an electronic medical record database and reviewed at a minimum of 6 months after ACL reconstruction, with the collection of demographic and surgical data. The relative risk for undergoing MUA and/or LOA was calculated for each analyzed risk factor.

Results:

A total of 2424 ACL reconstructions were included, with a chart review at a mean of 56.7 months after surgery (range, 7.6-124.0 months). The rate of MUA and/or LOA for arthrofibrosis was 4.5%. A statistically significantly increased relative risk was found for infection (5.45), hematoma requiring evacuation (3.55), ACL reconstruction with meniscal repair (2.83), use of a quadriceps tendon autograft (2.68), age <18 years (2.39), multiple concomitant procedures (1.69), contact injury (1.62), female sex (1.60), and surgery within 28 days of injury (1.53), and a statistically significantly decreased relative risk was found for revision ACL reconstruction (0.30), age >25 years (0.34), and use of a tibialis anterior allograft (0.36). In the multivariate regression model, the use of a quadriceps tendon autograft (P = .00007), infection (P = .00126), and concomitant meniscal repair (P = .00194) were independent risk factors, whereas revision ACL reconstruction (P = .0024) was an independent protective factor.

Conclusion:

Graft type, infection, concomitant meniscal repair, and primary reconstruction are significant risk factors for undergoing MUA or LOA after ACL reconstruction.

Surgical Technique for Release of Anterior Interval Scarring of the Knee After Anterior Cruciate Ligament Reconstruction

Postoperative scarring is a known complication after arthroscopic anterior ligament reconstruction of the knee. The anterior interval of the knee has been previously identified as a common location for anterior scar formation. The anterior interval is defined as the space between the infrapatellar fat pad and the anterior border of the tibia. Patients with anterior interval scarring often present with lack of terminal knee extension, anterior knee pain, decreased patellar mobility, and quadriceps atrophy. The goal of this paper is to describe the technique for anterior interval release of the knee.

Complications and revision surgeries in two extra-articular tenodesis techniques associated to anterior cruciate ligament reconstruction. A case-control study

INTRODUCTION

Numerous techniques of anterior cruciate ligament (ACL) reconstruction associated to extra-articular tenodesis (EAT) have been described, but there have been few comparative studies, especially in terms of complications and revision procedures. The present study sought to compare two ACL reconstruction techniques using the patellar tendon (KJ): associating EAT by fascia lata (KJL2) or by gracilis (KJG). The study hypothesis was that the KJL2 technique incurs no extra risk of complications or surgical revision compared to the KJG technique.

METHOD

A prospective case-control study compared 41 patients undergoing KJL2 and 41 controls undergoing KJG. Complications, reconstruction failure and revision procedures were assessed at a mean 13 months follow-up (range, 6-20 months).

RESULTS

The KJL2 group showed no extra risk of postoperative complications or reconstruction failure compared to the KJG group: 1 versus 2 re-tears, respectively, not requiring revision. Revision surgery was significantly more frequent in the KJG group (31.7% vs. 7.3%), notably for arthrolysis and meniscectomy.

DISCUSSION

The KJL2 technique is reliable, without greater risk of complications or early revision surgery than the KJG technique.

LEVEL OF EVIDENCE

III - Case-control study.

Dynamic Splinting in Children and Adolescents With Stiffness After Knee Surgery

PURPOSE

The purpose of this study was to investigate the indications and outcomes of dynamic splinting (DS) of the arthrofibrotic knee in the pediatric population.

METHODS

Seventy-four patients (41 males, 33 females) with postoperative arthrofibrosis treated with DS after an index knee surgery were reviewed. Median age was 13 years (range, 4 to 18 y), and median follow-up was 17 months (interquartile range, 10 to 28 mo). Demographics, index surgery procedure, preoperative and postoperative knee range of motion (ROM) measurements, treatment length and subsequent need for manipulation under anesthesia (MUA), and surgical lysis of adhesions (LOA) were evaluated. A ROM deficit was defined as lack of extension ≥10 degrees or lack of flexion <130 degrees. Successful improvement of ROM was defined as an increase of ≥10 degrees in flexion, extension, or both. There were 23 patients with flexion deficit only, 17 with extension deficit only, and 34 with combined flexion and extension deficits. Wilcoxon signed-rank test was used to assess median improvement in ROM. Patients were classified into 4 surgical groups: anterior cruciate ligament (ACL) reconstruction without meniscal repair (n=19), ACL reconstruction with meniscal repair (n=12), tibial spine fracture repair (n=21), and other (n=22). Multivariable logistic regression was used to identify independent predictors of failure of DS requiring MUA and LOA.

RESULTS

A total of 57 patients with flexion deficits showed median improvement of 30 degrees in flexion (95% confidence interval, 0-90 degrees; P<0.001), and 51 patients with extension deficits showed median improvement of 7 degrees in extension (95% confidence interval, 0-60 degrees; P<0.001). DS was associated with ROM improvement in 84% and avoided the need for surgery in 58% of all 74 patients included in the study. Multivariate analysis of the ACL with meniscus repair subgroup revealed that each 1-month delay in DS treatment was associated with a 5-fold increased risk of undergoing a LOA (P=0.007). Thirty-six (63%) patients with flexion deficit avoided need for surgery, whereas 26 (51%) patients with extension deficits avoided surgery.

CONCLUSIONS

Our data suggest that DS is an effective method to increase knee ROM and reduce the need for subsequent MUA/LOA in the pediatric and adolescent patient with arthrofibrosis after an index knee surgery.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Prior Knee Arthroscopy Does Not Influence Long-Term Total Knee Arthroplasty Outcomes and Survivorship

BACKGROUND

Arthroscopic knee surgery frequently precedes total knee arthroplasty (TKA). There have been mixed data on the effect of prior arthroscopic surgery on results of TKA. The purpose of this study was to compare the 10-year Knee Society Score (KSS), survivorship, and complications of TKA in a cohort of patients who had a previous knee arthroscopy to a control cohort.

METHODS

A retrospective review of 1315 TKAs who underwent a primary TKA between 2003 and 2004 was performed. Of these, 160 TKAs had previous arthroscopy (excluding ligamentous reconstruction). A matched cohort study 2:1 was carried out with a group of 320 controls (no prior surgery). Outcomes were assessed with the original KSS, range-of-motion, complications, and survivorships. Mean follow-up was 9 years.

RESULTS

The mean KSS increased from 36-84 in the arthroscopy group vs 35-86 in the control group (P = .5). The mean preoperative and postoperative range-of-motion was not different between groups (P = .2). The survivorship free of complication at 5 years was similar in both groups (94.3% in arthroscopy group vs. 95.3% in the control; P = .7) with infection in 2 controls and 3 arthroscopy cases (P = .2). The survivorships free of revision for aseptic loosening, revision for any reason, and reoperation were similar at 10 years (96.5%, 94.6%, and 89.2%, respectively, in the arthroscopy group vs 96.2%, 95.9%, and 91.5% in the control group).

CONCLUSION

There were no significant differences between both groups. These data are reassuring and valuable in an era in which many candidates for TKA will have had previous arthroscopic knee surgery.

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.

Extension deficit after anterior cruciate ligament reconstruction: Is arthroscopic posterior release a safe and effective procedure?

BACKGROUND

Postoperative extension deficits following anterior cruciate ligament (ACL) reconstruction can cause major limitation during daily life. The purpose of this study was to evaluate the efficiency of an all-arthroscopic approach and posterior capsule release for the treatment of persistent knee extension deficits following ACL reconstruction.

METHODS

Between 2009 and 2013 a total of 10 patients with knee flexion contractures after ACL reconstruction were assessed following an all-arthroscopic approach and posterior capsulotomy. The clinical outcomes were reviewed using the range of motion (ROM), Tegner Activity Level, Lysholm score and visual analogue pain scale (VAS).

RESULTS

Four women and six men with a median age of 34years (range: 17 to 49years) were included in the study. The median follow-up period was 25months (range: 14 to 69months). The median preoperative extension deficit was 15° (range: 10 to 20°) compared to the normal contralateral knee. Postoperatively at final follow-up the median extension deficit was one degree (range: 0 to five degrees) (P<0.01). The median preoperative Lysholm score improved from 52 (range: 32 to 67) to 92 (range: 84 to 100) postoperatively (P<0.01), while the median Tegner Activity Level improved from three (range: two to six) to six (range: three to seven) respectively (P<0.02). The median VAS status for pain decreased from five (range: one to 10) to one (range: 0 to three) (P<0.01). No complications were observed.

CONCLUSIONS

Arthroscopic posterior capsulotomy is a safe and effective additional procedure in the treatment of persistent knee extension deficits following ACL reconstruction with excellent results regarding ROM and subjective outcomes.

LEVEL OF EVIDENCE

Level IV.

Extension deficit after ACL reconstruction: Is open posterior release a safe and efficient procedure?

BACKGROUND

Extension loss is a potentially devastating consequence of anterior cruciate ligament reconstruction (ACLR). It can often be treated by anterior arthroscopic release. In rare cases, a chronic flexion contracture requires an additional posterior open release. To our knowledge, no study analysing the results of both posteromedial and posterolateral approaches has been performed so far. The purposes of this study were (1) to analyse the midterm outcome and complications of a combined procedure, anterior arthroscopic debridement and posterior open capsulotomy - for the treatment of chronic extension deficits after ACLR and (2) to describe the surgical technique of posterior open release with both posteromedial and posterolateral approaches.

MATERIAL AND METHODS

This is a retrospective clinical cohort study. Twelve patients presenting a chronic flexion contracture of 10° or more after ACLR treated by open posterior arthrolysis with an average follow-up time of 38months (range six to 90) were included. At last follow-up, they underwent both a clinical examination with range of motion analysis, International Knee Documentation Committee (IKDC) and KOOS scores.

RESULTS

At follow-up, all patients except one (93%) achieved complete extension. Only one patient (7%) had a residual post-operative flexion deformity of five degrees. The range of motion (ROM) improved significantly after arthrolysis from 96°±14.3° (SD) to 14.3°±7°(SD)(p<0.001). No post-operative complications were recorded. No patients required further open debridement. The post-operative objective IKDC score was grade A for five patients, B for seven versus C for five patients and D for seven preoperatively. The mean post-operative subjective IKDC score was 86.4±9.7. The post-operative Knee injury and Osteoarthritis Outcome Score (KOOS) distribution was as follows: pain 93.8±5 (SD); symptoms 88±8.6 (SD); ADL 96.8±3.7 (SD); sports activities 83.6±12.3 (SD); and quality of life 82.9±8.8 (SD). Mean patients' satisfaction was 9.25±0.6 (SD) out of 10 after arthrolysis.

CONCLUSIONS

Open posterior release with both posteromedial and posterolateral approaches is a safe and efficient additional procedure in case of persistent flexion contracture after ACLR with good ROM gain, functional scores and patients' satisfaction.

LEVEL OF EVIDENCE

Therapeutic study - Level IV.

Arthroscopic Posteromedial Capsular Release

Post-traumatic or postsurgical flexion contractures of the knee can significantly limit function and lead to gait abnormalities. In this setting, interventions to regain full extension may include bracing, physical therapy, and open or arthroscopic surgery. Open surgical approaches to restore full motion often demand extensive recovery and promote further adhesions and loss of motion, which has led to the advent of arthroscopic techniques to address these pathologies. We present a safe, effective, and reproducible arthroscopic technique for posteromedial capsular release to address knee flexion contractures.