Results of knee manipulations after anterior cruciate ligament reconstructions

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.

Outcomes of Arthroscopic Lysis of Adhesions for the Treatment of Postoperative Knee Arthrofibrosis: A Systematic Review

Background:

Postoperative knee arthrofibrosis is a common and potentially detrimental complication affecting knee function and gait. Several cohort studies have reported good outcomes after arthroscopic lysis of adhesions (LOA) with manipulation under anesthesia (MUA).

Purpose:

To review the literature assessing the efficacy and complications of arthroscopic LOA and MUA for postoperative arthrofibrosis of the knee and evaluate whether any relevant subgroups are associated with different clinical presentation and outcomes.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies published from January 1, 1990, to April 1, 2021, were identified through a search of the US National Library of Medicine (PubMed/MEDLINE), EMBASE, and Cochrane databases. All studies included in this analysis included pre- and postoperative range of motion measurements for their treated patients. Studies reporting outcomes for patients with isolated cyclops lesions after anterior cruciate ligament reconstruction were excluded.

Results:

Eight studies comprising 240 patients were included. The mean time from index surgery to arthroscopic LOA and MUA was 8.4 months, and the mean postoperative follow-up was at 31.2 months. All studies demonstrated a significant improvement (41.6°) in arc of motion after arthroscopic LOA. Clinically significant improvements in outcome measures, including the International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score, were reported after arthroscopic LOA across all applicable studies. Of 240 patients, a single complication (synovial fistula) occurred after LOA and MUA, which resolved without intervention.

Conclusion:

The results of this review indicated that arthroscopic LOA and MUA is a safe and efficacious treatment for postoperative arthrofibrosis of the knee.

Clinical results after very early, early and late arthroscopic arthrolysis of the knee

Purpose

Impaired patient outcome can be directly related to a loss of motion of the knee following surgical procedures. If conservative therapy fails, arthroscopic arthrolysis is an effective procedure to improve range of motion (ROM). The purpose of this study was to evaluate the outcome of patients undergoing very early (< 3 months), early (3 to 6 months), and late (> 6 months) arthroscopic arthrolysis of the knee.

Methods

With a follow-up on average at 35.1 ± 15.2 (mean ± SD, 24 to 87) months, 123 patients with post-operative motion loss (> 10° extension deficit/ < 90° of flexion) were included between 2013 and 2018 in the retrospective study, while eight patients were lost to follow-up. A total of 115 patients were examined with a minimum follow-up of two years. Twenty percent (n = 23) of patients of this study population had a post-operative motion loss after distal femoral fracture, 10.4% (n = 12) after tibial head fracture, 57.4% (n = 66) after anterior/posterior cruciate ligament (ACL/PCL) reconstruction, 8.7% (n = 10) after infection of the knee, and 3.4% (n = 4) after patella fracture. Thirty-seven patients received very early (< 3 months, mean 1.8 months) arthroscopic arthrolysis, and 37 had early (3 to 6 months, mean 4.3 months) and 41 late (> 6 months, mean 9.8 months) arthroscopic arthrolysis after primary surgery.

Results

The average ROM increased from 73.9° before to 131.4° after arthroscopic arthrolysis (p < 0.001). In the group of very early (< 3 months) arthroscopic arthrolysis 76% (n = 28) of the patients had a normal ROM (extension/flexion 0/140°), in the group of early (3–6 months) arthrolysis 68% (n = 25) of the patients and in the group of late arthrolysis 41.5% (n = 17) of the patients showed a normal ROM after surgery (p = 0.005). The total ROM after arthrolysis was also significantly increased in the group of very early and early arthrolysis (136.5° and 135.3° vs. 123.7°, p < 0.001). A post-operative flexion deficit occurred significantly less in the group of very early and early arthroscopic arthrolysis compared to the late arthroscopic arthrolysis (3.9° and 4.2° vs. 16.6°, p < 0.001). Patients treated with very early (< 3 months) and early (3 to 6 months) showed a significantly increased post-operative Tegner score of 4.8 ± 1 and 4.7 ± 1.1 compared to 3.8 ± 1.1 in the group of late arthroscopic arthrolysis (> 6 months, p < 0.001).

Conclusions

An arthroscopic arthrolysis is highly effective and leads to good to excellent mid-term results. An early arthroscopic arthrolysis within 6 months after primary surgery leads to significantly improved ROM and functional scores compared to the late arthrolysis (> 6 months).

Arthroscopic lysis of adhesions improves knee range of motion after fixation of intra-articular fractures about the knee

BACKGROUND

Post-traumatic stiffness after open reduction and internal fixation of fractures about the knee can have dramatic effects on function. Traditionally, open quadricepsplasty has been the treatment of choice, but is associated with significant morbidity.

PURPOSE

The purpose of this study is to examine the immediate and sustainable range of motion (ROM) changes after surgical arthroscopic lysis of knee adhesions (SALKA) for post-traumatic knee stiffness after open reduction internal fixation (ORIF).

METHODS

We retrospectively reviewed a consecutive series of patients at a single institution who underwent SALKA for knee stiffness after intra-articular fractures about the knee treated with ORIF from 2009 to 2015. Pre-operative and immediate post-operative total ROM was assessed while patients were sedated during the SALKA procedure. Total ROM was assessed in the office pre-operatively and compared to the latest post-operative follow-up visit. Immediate post-operative ROM was also compared to the latest post-operative follow-up visit. Two-tailed paired Student's t test was calculated for analysis.

RESULTS

Of the 14 patients included in the study, 10 (71 %) had tibial plateau ORIF, 3 (21 %) had patella ORIF, and 1 (8 %) had intra-articular distal femur ORIF. The mean time between ORIF and SALKA was 244 days. The mean follow-up time after SALKA was 135 days. Under sedation during SALKA, the mean total ROM increased from 72° to 127° immediately post-operatively (p < 0.01). The mean pre-operative in-office total ROM was 73° and increased to 104° at the latest follow-up visit (p < 0.01). The mean immediate post-operative ROM was 127° and decreased to 104° at the latest follow-up visit (p = 0.01).

CONCLUSION

Lysis of adhesions utilizing SALKA after ORIF about the knee improves knee ROM immediately post-operatively and in the short-term follow-up. However, there is a decrease in the gains in the range of motion over time. Patients should be counseled as such. Lysis of adhesions utilizing arthroscopic techniques may provide a favorable alternative to open quadricepsplasty.

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

BACKGROUND

Arthrofibrosis after knee arthroscopy is a challenging complication. Previous studies reporting incidences of manipulation under anesthesia (MUA) or lysis of adhesions (LOA) after knee arthroscopy are limited by confounders such as small sample size and regional sampling bias.

PURPOSE

To investigate the incidence of MUA or LOA after common arthroscopic knee procedures.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

A national insurance database was retrospectively queried for arthroscopic knee procedures from 2007 to 2011. The incidence of postoperative MUA and LOA within 3 and 6 months postoperatively was determined for each of 13 common arthroscopic knee surgeries, including ligamentous reconstructive procedures, cartilage restoration procedures, and meniscal procedures.

RESULTS

A total of 330,714 unique patients who underwent knee arthroscopy were included in the study. The overall incidence of MUA was 0.06% to 6.00% by 3 months and 0.11% to 8.00% by 6 months postoperatively. The incidence of LOA was somewhat less, ranging from 0.04% to 4.00% by 3 months and 0.06% to 6.00% by 6 months postoperatively. Isolated arthroscopic partial meniscectomy had the lowest incidence of postoperative MUA and LOA, while multiligament reconstructions and meniscal transplants had the highest incidences.

CONCLUSION

The overall incidence of MUA and LOA after arthroscopic knee procedures is low but rises significantly as the number of concomitant procedures or complexity of the procedures increases. This information may be useful in counseling patients on the likelihood of MUA or LOA based on the type of arthroscopic knee procedure that is planned.

Arthrofibrosis of the knee following a fracture of the tibial plateau

The aim of this study was to report the incidence of arthrofibrosis of the knee and identify risk factors for its development following a fracture of the tibial plateau. We carried out a retrospective review of 186 patients (114 male, 72 female) with a fracture of the tibial plateau who underwent open reduction and internal fixation. Their mean age was 46.4 years (19 to 83) and the mean follow-up was16.0 months (6 to 80). A total of 27 patients (14.5%) developed arthrofibrosis requiring a further intervention. Using multivariate regression analysis, the use of a provisional external fixator (odds ratio (OR) 4.63, 95% confidence interval (CI) 1.26 to 17.7, p = 0.021) was significantly associated with the development of arthrofibrosis. Similarly, the use of a continuous passive movement (CPM) machine was associated with significantly less development of arthrofibrosis (OR = 0.32, 95% CI 0.11 to 0.83, p = 0.024). The effect of time in an external fixator was found to be significant, with each extra day of external fixation increasing the odds of requiring manipulation under anaesthesia (MUA) or quadricepsplasty by 10% (OR = 1.10, p = 0.030). High-energy fracture, surgical approach, infection and use of tobacco were not associated with the development of arthrofibrosis. Patients with a successful MUA had significantly less time to MUA (mean 2.9 months; sd 1.25) than those with an unsuccessful MUA (mean 4.86 months; sd 2.61, p = 0.014). For those with limited movement, therefore, performing an MUA within three months of the injury may result in a better range of movement. Based our results, CPM following operative fixation for a fracture of the tibial plateau may reduce the risk of the development of arthrofibrosis, particularly in patients who also undergo prolonged provisional external fixation.

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.

Arthrofibrosis after anterior cruciate ligament reconstruction in children and adolescents

INTRODUCTION

Arthrofibrosis is a known complication after anterior cruciate ligament (ACL) reconstruction. ACL reconstruction is being performed with increased frequency in the pediatric population. The purpose of this study was to determine the prevalence of arthrofibrosis in children and adolescents and to identify risk factors for arthrofibrosis.

METHODS

The study design was a retrospective case series. Medical records for 1016 consecutive ACL reconstructions in patients aged 7 to 18 years old between 1995 to 2008 at a major tertiary care children's hospital were reviewed to identify cases of postoperative arthrofibrosis. Arthrofibrosis was defined as a loss of 5 degrees or more extension compared with the contralateral knee that required a follow-up procedure or a loss of 15 degrees or more flexion compared with the contralateral knee that required a follow-up procedure. Patient data were recorded and analyzed using bivariate models to identify predictors for arthrofibrosis. Further, we reviewed the clinical course of patients with treated arthrofibrosis to assess functional outcomes of this complication.

RESULTS

Nine hundred two patients with 933 knees met the inclusion criteria for this study, of which 60% were female. The mean age at the time of surgery was 15 years (range, 7 to 18 y), and the average follow-up from original ACL reconstruction was 6.3 years (range, 1.6 to 14.2 y). The overall prevalence of arthrofibrosis in our cohort was 8.3%, with 77 of the 933 knees had at least 1 procedure to treat arthrofibrosis after ACL reconstruction. Risk factors for arthrofibrosis were female sex (11.1% females, P = 0.0001), patients aged 16 to 18 years [11.6%; odds ratio (OR) 3.51; P = 0 .007], patellar tendon autograft (OR, 1.7; P = 0.026), and concomitant meniscal repair (OR, 2.08; P = 0.007). Prior knee surgery and ACL reconstruction within 1 month of injury were not significantly associated with arthrofibrosis after ACL reconstruction. Fifty-three patients had a minimum of 6 months clinical follow-up after the procedure for arthrofibrosis. Of these, 46 patients (86.8%) had full range of motion at follow-up. Thirty-two patients (60.4%) were asymptomatic at final follow-up. Eleven patients (20.8%) complained of some persistent pain.

CONCLUSIONS

The rate of arthrofibrosis after ACL reconstruction in children and adolescents is 8.3%. Risk factors for arthrofibrosis are female sex, older adolescents, concurrent meniscal repair, and reconstruction with patellar tendon autograft. Surgical treatment for arthrofibrosis after ACL reconstruction in pediatric patients can satisfactorily regain motion in the reconstructed knee; however functional outcome may be compromised.

LEVEL OF EVIDENCE

Level 4.

Supracondylar femur fracture after knee manipulation: a report of 3 cases

Supracondylar femur fracture is a rare but devastating complication of knee manipulation following total knee arthroplasty (TKA). Avoidance of this complication can be achieved by careful attention to the indications and contraindications, timing, and technique of closed manipulation. We performed a retrospective chart and radiographic review to identify all patients who underwent closed manipulation under anesthesia for a diagnosis of aseptic arthrofibrosis after TKA. This article presents 3 cases of supracondylar femur fracture following closed knee manipulation of stiff TKAs that occurred at our institution over a 4-year period (1999-2002). Patient age ranged from 44 to 73 years. All patients underwent cruciate retaining TKA. Time from TKA to manipulation ranged from 3 months to 3 years. Two patients sustained an extension type supracondylar fracture. Two of the 3 patients were treated with closed reduction and casting/bracing. At a minimum 8-month follow-up after fracture, range of motion was poor with average flexion to 77 degrees and average flexion contracture of 13 degrees . In our patients, risk factors for fracture included prolonged time from arthroplasty to manipulation, arthrofibrosis, radiographic osteopenia, and rheumatoid arthritis. To our knowledge, this represents the largest case series of iatrogenic supracondylar femur fractures reported in the literature. Two manipulation techniques are described in detail. The alternative manipulation technique is highlighted with no fractures or complications over the same period. We believe that the alternative manipulation technique is a safe and effective technique to manipulate stiff TKA's and has been used for over >10 years by the senior surgeon (J.V.B.).

Arthrofibrosis of the knee

Better understanding of surgical timing, improved surgical technique, and advanced rehabilitation protocols has led to decreased incidence of motion loss after anterior cruciate ligament injury and reconstruction. However, motion loss from high-energy, multiligament injuries continues to compromise functional outcome. Prevention, consisting of control of inflammation and early motion, remains the key element in avoiding motion loss. However, certain techniques, such as manipulation under anesthesia in conjunction with arthroscopic lysis of adhesions, are reliable treatment options. Open surgical débridement is rarely necessary and should be considered only as a salvage procedure. A greater understanding of the pathogenesis of arthrofibrosis and related inflammatory mediators may result in novel therapies for treating the patient with motion loss.

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.

Motion loss after ligament injuries to the knee. Part II: prevention and treatment

This is the second part of a two-part review on motion problems after ligament injuries to the knee. The first part, published in the September/October 2001 issue, discussed normal and abnormal knee motion, terminology, risk factors, and pathoanatomy. The purpose of this article is to review current concepts on prevention and treatment of motion problems, summarizing the recent and pertinent studies that discuss this complicated clinical problem. The first part of this article will discuss the different classification schemes that have been published on motion loss of the knee. Prevention strategies will be discussed next, followed by early recognition. Finally, a discussion of the various treatment options and published results will be presented in detail, together with the authors' nine-step systematic surgical approach to the stiff knee.

MR imaging of cyclops lesions

OBJECTIVE

Localized anterior fibrosis (cyclops lesion) is a known cause of extension loss of the knee after anterior cruciate ligament (ACL) reconstruction. We describe MR imaging as a noninvasive diagnostic tool to examine cyclops lesions.

SUBJECTS AND METHODS

Thirty-three MR studies of 31 patients with residual persistent extension loss after ACL reconstruction using patellar tendon autograft were reviewed and compared with results of second arthroscopy. We used MR imaging to describe the ACL graft signal intensity and course, tibial and femoral tunnel placement. quantitative measurements of notch size and shape, and the presence or absence of cyclops lesions. When a cyclops lesion was revealed on MR imaging, the signal-intensity characteristics, location, and size were documented. Preoperative MR imaging findings were then correlated with findings at arthroscopy.

RESULTS

The sensitivity, specificity, and accuracy of revealing a cyclops lesion on MR imaging were 85.0%, 84.6%, and 84.8%, respectively. We found no statistically significant differences in the size of intercondylar notches for patients with and patients without cyclops lesions.

CONCLUSION

MR imaging was sensitive, specific, and accurate in revealing cyclops lesions in a subgroup of patients with extension loss after ACL reconstruction.

Quantitative analysis of synovial fibrosis in the infrapatellar fat pad before and after anterior cruciate ligament reconstruction

We performed quantitative analysis of synovial fibrosis in the infrapatellar fat pad in 26 patients who underwent arthroscopically assisted anterior cruciate ligament reconstructions. Twelve patients underwent reconstruction with patellar tendon autografts, and 14 had reconstructions with semitendinosus and gracilis tendon autografts. Synovial samples were obtained at the time of reconstruction from 10 patients and at second-look arthroscopy from all 26 patients. Sections from quick-frozen samples were stained with either hematoxylin and eosin or Fast green and Sirius red. We used sodium hydroxide in absolute methanol to elute the Fast green and Sirius red stains, and the total collagen content of each section was estimated by measuring the optical density of the eluted solution. The volume of each section was determined on a computer using an imaging program, and collagen content per unit of tissue was calculated. Median collagen content was 15.3 micrograms/mm3 for the preoperative samples, 25.1 micrograms/mm3 for the group with patellar tendon autografts, and 27.1 micrograms/mm3 for the group with hamstring tendons autografts. Analysis of preoperative and postoperative paired samples revealed a significant increase in synovial collagen after anterior cruciate ligament reconstruction. We observed increased fibrosis in patients who had pain on exertion or stiffness in squatting after the reconstructive surgery.

Achieving full range of motion after anterior cruciate ligament reconstruction

A review of 119 consecutive anterior cruciate ligament reconstructions showed that the time from injury to surgery (early versus delayed) did not make a difference in obtaining full range of motion. Only patients with late surgery had a slight decrease in range of motion. Followup data were obtained for 111 reconstructions. Twenty-one were early surgeries (1 to 14 days), 22 were delayed surgeries (15 to 28 days), and 68 were late surgeries (more than 28 days). The patients involved in the 21 early surgeries obtained 0 degree of knee extension or better and 135 degrees of knee flexion or better. The patients involved in the 22 delayed reconstructions reached 0 degree of knee extension or better and 135 degrees of flexion or better. Among the patients with the 68 late surgeries, 93% of the knees reached 0 degree of extension or better and all reached at least 135 degrees of flexion. The five patients who did not achieve full knee extension had extension loses less than 4 degrees. All 111 reconstructions were determined stable when full range of motion was achieved based on clinical examination, which included the Lachman test, anterior drawer test, pivot shift, and KT-1000 arthrometer when appropriate.

Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction

Arthrofibrosis resulting in loss of knee extension compromises the results of anterior cruciate ligament reconstructions. We designed a study to clarify the symptoms and to evaluate the results of arthroscopic treatment of this complication. Forty-two patients in a series of 959 consecutive open anterior cruciate ligament reconstructions required further surgical treatment for relief of symptoms related to loss of extension. Arthroscopic examination of these knees confirmed the presence of an extension block caused by hypertrophy of the ligament or abundant tissue formation in the anterior tibiofemoral joint an average of 9 months after anterior cruciate ligament reconstruction. The offending tissues were excised arthroscopically and the patients were followed with an aggressive rehabilitation program. Thirty-five patients were available for followup an average of 28 months after excision of the tissue. Subjective functional status and symptomatic status were scored numerically using identical, patient-completed questionnaires before and after the excision procedure. Range of motion, Cybex, and KT-1000 arthrometer results were also recorded. The results were statistically compared with results from a control group demographically matched and selected at random from the 959 patients. Before excision of the offending tissue, the knee scores of the study group differed significantly from those of the control group. However, after the excision procedure, the knee scores of the 2 groups were nearly identical. Marked improvements in function and symptoms (most notably, activity-related anterior knee pain, crepitus at terminal extension, and knee stiffness) were noted in all patients in the study group after removal of the extension block and resumption of an accelerated rehabilitation program.(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior cruciate ligament reconstruction. The effect of tibial tunnel placement on range of motion

In 111 patients who had anterior cruciate ligament reconstructions, postoperative radiographic measurements of anterior to posterior and medial to lateral location of the tibial tunnels were correlated with the final range of motion achieved. In the 25 patients with extension deficits of 10 degrees or more, placement of the tibial tunnel was more anterior (average, anterior 23% of the tibia) than in the remaining 86 patients with extension deficits of < 10 degrees (average, anterior 29% of tibia). This difference was statistically significant with P < 0.001. Logistic regression analysis revealed that the more anterior the placement of the tibial tunnel, the greater the loss of both flexion (P = 0.01) and extension (P = 0.002). In the 21 patients with full extension but flexion < 130 degrees, placement of the tibial tunnel tended to be more medial (average, medial 40% of the tibia) than in the 65 patients without flexion deficit (average, medial 45% of the tibia). We conclude that placement of the tibial tunnel in the "eccentric," anteromedial position may contribute to the development of flexion and extension deficits after anterior cruciate ligament reconstruction.