Arthroscopic lysis of adhesions for stiff total knee arthroplasty

Low-Dose Irradiation and Rotating-Hinge Revision for the Treatment of Severe Idiopathic Arthrofibrosis Following Total Knee Arthroplasty: A Review of 60 Patients With a Mean 6-Year Follow-Up

BACKGROUND

Severe idiopathic arthrofibrosis after total knee arthroplasty (TKA) is a challenging problem to treat. Low-dose irradiation may decrease fibro-osseous proliferation, while rotating-hinge (RH) revision allows for distal femur shortening and collateral ligament sacrifice. This study reports the clinical outcomes and implant survivorship in patients treated with low-dose irradiation and RH revision for severe idiopathic arthrofibrosis following TKA.

METHODS

A retrospective review was performed on 60 consecutive patients. Patients who had greater than 80° arc of knee motion or less than 15° flexion contracture were excluded. Mean follow-up was 6 years (range, 2 to 14). Kaplan-Meier survivorship analyses were performed, and logistic regressions were used to determine associations between preoperative patient characteristics and clinical outcomes.

RESULTS

Median flexion contracture and median terminal flexion at presentation were 20 and 70°, respectively; at final follow-up, 59 of 60 patients (98%) had ≤10° flexion contracture and 49 of 60 patients (82%) had ≥90° of flexion. The 10-year survivorship free from reoperation for any reason, revision for any reason, and revision for aseptic loosening were 63, 87, and 97%, respectively. There were 27% percent of patients who underwent a manipulation under anesthesia postoperatively, which was the most common reason for return to the operating room. A greater number of prior surgeries was significantly associated with worse range of motion at the final follow-up (P = .004). There were no known radiation-associated complications.

CONCLUSIONS

Patients with severe idiopathic arthrofibrosis following TKA treated with low-dose irradiation and RH revision maintained a gain in knee range of motion of 60° with reliable flexion contracture correction at a mean 6-year follow-up. A manipulation under anesthesia was common in the postoperative period. Survivorship free from revision for aseptic loosening was excellent at 10 years.

Polyethylene exchange versus full component revision for arthrofibrosis following total knee arthroplasty: A retrospective cohort analysis

Introduction

Arthrofibrosis occurs in up to 10% of patients who undergo total knee arthroplasty (TKA). For cases that are not amenable to manipulation under anesthesia (MUA), there is little consensus on how many components should be revised. We compared outcomes of polyethylene exchanges, when doing lysis of adhesions (LOA) versus full component revision. Specifically, we assessed: (1) re-operation rates at one and two years; (2) rates of surgical complications at one year; and (3) associated risk factors for requiring a LOA.

Methods

A database queried all patients who underwent revision TKA for arthrofibrosis. A total of 2410 patients were identified, 1120 (46.5%) of which underwent all-component knee revision, while the remaining 1290 (53.5%) underwent polyethylene spacer revision. Multivariate logistic regressions assessed re-operation rates and risk factors for requiring LOA.

Results

The incidence and odds of re-operation within one year following polyethylene exchange was not significantly different than full component revision (10.9 versus 12.9%, odds ratio (OR) 0.83, 95% confidence interval (CI) [0.64-1.06], p = 0.145). However, the adjusted models for re-operation within one- and two-years following LOA in the form of polyethylene exchange revision was significantly higher than the full component revision cohort (OR 1.52 CI [1.07-2.17], p = 0.022 and OR 1.44 CI [1.06-1.97] p = 0.022). Risk factors associated with the need for lysis of adhesions included age less than 60 years, depression, fibromyalgia, and anxiety.

Conclusions

Full component revision TKA for arthrofibrosis was associated with lower two-year re-operation rate than polyethylene exchange. Risk factors for LOA include younger age and fibromyalgia.

High Complication Rate Associated With Arthroscopic Lysis of Adhesions Versus Manipulation Under Anesthesia for Arthrofibrosis After Total Knee Arthroplasty

BACKGROUND

Arthrofibrosis after total knee arthroplasty (TKA) is often treated by arthroscopic lysis of adhesions (ALAs) or manipulation under anesthesia (MUA). This study compared the 2-year complication rates of ALA and MUA and range-of-motion (ROM) outcomes for ALA, early MUA (<3 months after TKA), and delayed MUA (>3 months after TKA).

METHODS

This retrospective cohort study included 425 patients undergoing ALA or MUA after primary TKA from 2001 to 2018. Demographics, clinical variables, and complication rates were collected from clinical records and compared using Student t -tests and Kaplan-Meier log-rank tests. Multivariable logistic regressions were used for adjusted analysis. ROM data were analyzed using fixed and mixed-effects models.

RESULTS

ALA patients were younger (55.2 versus 58.9 years, P < 0.001) and underwent surgery later from the index TKA (12 versus 1.9 months, P < 0.001). The Charlson Comorbidity Index was higher in the MUA group. Preoperative ROM was significantly worse in the MUA cohort, but did not differ between groups after the procedure (117°, P = 0.27) or at 2 years. Demographics and ROM outcomes were equivalent between early MUA and delayed MUA ( P = 0.75). The incidence of repeat arthrofibrosis (7.1%) and revision arthroplasty (2.4%) was similar between ALA and MUA cohorts while ALA patients had significantly more surgical site infections (3.8%) compared with MUA patients (0.47%, P = 0.017).

DISCUSSION

Equivalent ROM outcomes were seen between ALA, early MUA, and delayed MUA for the treatment of arthrofibrosis after TKA. However, this study demonstrated a markedly higher complication rate, particularly surgical site infection, after ALA, suggesting that MUA may be the preferred option for treating arthrofibrosis at both early and late time points.

Knee Arthroscopy After Prior Total Knee ArthroplastyType of Study: Narrative Review

Total knee arthroplasty (TKA) results in substantial improvement for most patients with end-stage arthritis of the knee; however, approximately 20% of patients have an unsatisfactory result. Although many problems contributing to an unsatisfactory result after TKA are best addressed by revision TKA, some problems may be effectively addressed with arthroscopic treatment. The categories of pathology that can be addressed arthroscopically include peripatellar soft-tissue impingement (patellar clunk syndrome and patellar synovial hyperplasia), arthrofibrosis, and popliteus tendon dysfunction. Recognizing these disease entities and the role of arthroscopic surgery in the treatment of these lesions may be helpful in achieving a good outcome in certain patients who are unsatisfied with their knee arthroplasty.

Pseudomeniscus after knee arthroplasty: A case series for arthroscopic management of this problem and systematic review of literature

Introduction

Most patients undergoing total knee arthroplasty (TKA) experience favorable outcomes. Some patients, however, experience prolonged post-operative knee pain and tenderness at the joint line. This has been attributed in some cases to soft tissue impingement due to pseudomeniscus. The purpose of this study is to evaluate patient outcomes for arthroscopic excision of pseudomeniscus for persistent knee pain after TKA and to perform a review of literature for pseudomeniscus after knee arthroplasty.

Methods

A retrospective analysis of patients undergoing arthroscopy to remove soft tissue causing persistent knee pain after previous TKA was performed. Outcome scores were asked at three time points: prior to knee arthroplasty, prior to arthroscopy, and post-arthroscopy at final follow-up. Subjective satisfaction with surgery and willingness to repeat procedures were also recorded. A two-tailed distribution paired t-test was used to determine statistical significance (p < 0.05). We also performed a review of the literature for pseudomeniscus complications for comparison.

Results

Nine out of eleven patients were considered eligible to be assessed for post-operative satisfaction. Seven out of nine patients reported complete satisfaction and eight participants stated they would undergo the procedures again if they have to. Among 9 included patients, five patients have successfully completed the clinical score evaluation survey. The mean age of the patients with clinical score evaluation at the time of TKA was 61 years (range, 53-72) and the time between TKA and undergoing arthroscopy was 8 months (range, 5-13). The average follow-up period for patient-determined assessment after the arthroscopic procedure was 71 months (range, 16-115). All 5 patients reported improved Oxford Knee Scores (p=0.017), Western Ontario and McMaster Universities Osteoarthritis Index (p=0.023), and pain scores (p=0.018) comparing pre-arthroscopy to post-arthroscopy at follow-up.

Conclusion

Arthroscopic removal of pseudomeniscus after TKA provides promising results in patients who experience persistent knee joint line pain and tenderness. Considering our results and review of literature, we recommend including pseudomeniscus in the differential for post arthroplasty knee pain.

Study design

Case series with a review of literature.

Efficacy of Arthroscopic Arthrolysis in the Treatment of Arthrofibrosis: A Systematic Review

Stiffness after total knee arthroplasty (TKA) remains a clinical challenge for health care professionals. Historically, arthroscopic arthrolysis is a treatment modality that has been reserved for patients that have failed other conservative modalities, including manipulation under anesthesia. However, a systematic review of the literature evaluating the clinical efficacy and complications of arthroscopic arthrolysis for stiffness after TKA has not been performed. A systematic review of medical databases (PubMed, EMBASE, Cochrane Library) was undertaken for articles published from January 1980 to October 2018. A descriptive and critical analysis of the results was performed. From 1,326 studies, 7 studies met the inclusion criteria for this study. A total of 160 patients who underwent arthroscopic arthrolysis for arthrofibrosis following TKA were included for analysis. The quality of the evidence for the included studies ranged between moderate and high. Overall, patients had significant increased range of motion and flexion by 32.5 and 26.7 degrees, respectively following arthroscopic arthrolysis. Functional outcome scores also significantly improved for patients who underwent arthroscopic arthrolysis after TKA. Arthroscopic arthrolysis is an efficacious modality for treatment of stiffness following TKA. The greatest benefit is seen among patients that present with significant loss of flexion. Arthroscopic arthrolysis should be reserved for patients that have previously failed more conservative modalities.

Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook

* Arthrofibrosis is a pathologic condition that is characterized by excessive periarticular scar-tissue formation. Arthrofibrosis may occur secondary to injury, surgical trauma, hemarthrosis, or infection, or it may occur idiopathically.* The pathogenesis of arthrofibrosis is incompletely understood but involves the dysregulation of normal reparative pathways, with transforming growth factor-beta (TGF-[beta]) as a principal mediator.* Current treatment options for arthrofibrosis primarily involve physiotherapy, operative manipulation, and surgical debridement, all with imperfect results.* Currently, there are no pharmacologic treatment options for arthrofibrosis. This has prompted increased investigational interest in the development of antifibrotic intra-articular therapies.

Patients with Dupuytren's Contracture, Ledderhose Disease, and Peyronie's Disease are at higher risk of arthrofibrosis following total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a successful treatment for patients with late stage osteoarthritis, yet arthrofibrosis remains a consistent cause of TKA failure. Dupuytren's, Ledderhose and Peyronie's Diseases are related conditions of increased fibroblast proliferation. The aim of this study was to identify whether an association exists between these conditions and arthrofibrosis following TKA.

METHODS

Patient records were queried from 2010 to 2016 using an administrative claims database to compare the rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with independent chart diagnoses of Dupuytren's Contracture, Ledderhose, or Peyronie's Diseases versus those without. Complications were queried and compared using multivariate logistic regression.

RESULTS

Patients with Dupuytren's (n = 5,232) and Ledderhose (n = 50,716) had a significantly higher rate of ankylosis following TKA: 30-days (OR, 1.54; OR, 1.23), 90-days (OR, 1.20; OR, 1.24), 6-months (OR, 1.23; OR, 1.23), and 1-year (OR, 1.28; OR, 1.23), while patients with Peyronie's (n = 1,186) had a higher rate of diagnosis at 6-months (OR, 1.37) and 1-year (OR, 1.35). Patients with diagnoses of any of the fibroproliferative diseases had a statistically higher risk of MUA at 90-days, 6-month, and 1-year following primary TKA. These cohorts did not have a significantly higher rate of revision TKA.

CONCLUSION

There is an increased odds risk of arthrofibrosis and MUA in patients who have undergone TKA and have a diagnosis of Dupuytren's Contracture, Ledderhose, or Peyronie's Diseases. Improvements to frequency and application of post-operative treatment should be considered in these cohorts to improve outcomes.

Kinematic versus mechanically aligned total knee arthroplasty: no difference in frequency of arthroscopic lysis of adhesions for arthrofibrosis

Arthrofibrosis is a condition that can cause excessive scar tissue formation, leading to painful restriction of joint motion. Following total knee arthroplasty (TKA), significant arthrofibrosis can result in permanent deficits in range of motion (ROM) if not treated. Although arthroscopic lysis of adhesions (ALOA) reliably improves post-TKA ROM if performed in a timely fashion, it exposes patients to additional anesthesia, heightens the risk of infection, and increases overall medical expenses. Kinematically aligned TKA has emerged as an alternative method to mechanically aligned, basing bony cuts off of the patient's pre-arthritic anatomy while limiting need for soft tissue and ligamentous releases. This study aimed to determine whether there is a difference in the frequency of post-TKA arthrofibrosis requiring ALOA between kinematic and mechanically aligned TKA. Between 2012 and 2019, a retrospective analysis was conducted based on a single surgeon's experience. Two cohorts were made based on alignment technique. Postoperatively, patients were diagnosed with arthrofibrosis and indicated for ALOA if they had functional pain with < 90 degrees of terminal flexion at 6 weeks postoperatively despite aggressive physical therapy. Frequency of ALOA was recorded for each cohort and was regressed using independent samples t-test. The results showed no significant difference between the mechanical and kinematic cohorts for frequency of ALOA following TKA (13.2% vs. 7.3%; p = 0.2659). However, the kinematic cohort demonstrated significantly greater post-ALOA ROM compared to the mechanical group (129° vs. 113°; p = 0.0097). Future higher-powered, prospective studies are needed to clarify whether a significant difference in rates of MUA/ALOA exists between the two alignment techniques.

Arthroscopic Lysis of Adhesions With Manipulation for Management of Late-Presenting Stiffness After Total Knee Arthroplasty

Background

Arthrofibrosis is a known complication of total knee arthroplasty (TKA). Closed manipulation is the treatment of choice for arthrofibrosis within 90 days of TKA. Treatment for arthrofibrosis that has failed prior interventions remains controversial, and the role for arthroscopic lysis of adhesions has not been examined for late-presenting arthrofibrosis.

Methods

A retrospective analysis of patients who underwent arthroscopic lysis of adhesions (LOAs) with manipulation for post-TKA arthrofibrosis was performed. Chart review included patient characteristics, time from TKA, prior interventions, and range of motion (ROM) data. Knee extension, flexion, and total ROM were recorded preoperatively, intraoperatively, and throughout follow-up. Knee ROM was compared at the different time intervals using Wilcoxon signed-rank tests.

Results

A total of 13 patients (6 male and 7 female) with a mean age of 66.3 years were included. Average time since index TKA was 57.2 months (3.7-209.5). Ten of 13 patients had undergone prior interventions for arthrofibrosis, which included closed manipulation under anesthesia, open LOA, and revision arthroplasty. The mean preoperative knee flexion and extension values for the cohort were 76.5 ± 17.4 and −4.6 ± 6.1 degrees, respectively. Postoperative improvements in knee ROM were significant at all time points, with mean improvements of 17.2 ± 16.3 degrees at 1 week (P = .022), 17.2 ± 13.2 degrees at 4 weeks (P = .001), 19.2 ± 16.0 degrees at 8 weeks (P = .004), and 25.2 ± 13.1 degrees at 12 weeks (P = .005). No complications were recorded.

Conclusions

Arthroscopic LOAs with manipulation achieves significant improvements in knee ROM for late-presenting arthrofibrosis after TKA.

The stiff total knee arthroplasty: causes, treatment modalities and results

It is clear that the stiff total knee arthroplasty (TKA) is a multifactorial entity associated with preoperative, intraoperative and postoperative factors.

Management of the stiff TKA is best achieved by preventing its occurrence using strategies to control preoperative factors, avoid intraoperative technical errors and perform aggressive, painless postoperative physical medicine and rehabilitation; adequate pain control is paramount in non-invasive management.

Careful attention to surgical exposure, restoring gap balance, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, pain control and adequate physical medicine and rehabilitation (physiotherapy, Astym therapy) all serve to reduce its incidence.

For established stiff TKA, there are multiple treatment options available including mobilization under anaesthesia (MUA), arthroscopic arthrolysis, revision TKA, and combined procedures.

Cite this article: EFORT Open Rev 2019;4:602-610. DOI: 10.1302/2058-5241.4.180105

Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management

Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.

Arthroscopic treatment of total knee arthroplasty complications

The most frequent indications for arthroscopy in patients with total knee arthroplasty (TKA) are soft-tissue impingement, arthrofibrosis (knee stiffness), periprosthetic infection and removal of free bodies or cement fragments.

When performing a knee arthroscopy in a patient with a symptomatic TKA, look for possible free/retained bone or cement fragments, which can be anywhere in the joint.

Patellar tracking should be evaluated and soft-tissue impingement under the patella or between the femoral and tibial prosthetic components should be ruled out.

Current data suggest that knee arthroscopy is an effective procedure for the treatment of some patients with symptomatic TKA.

The approximate rates of therapeutic success vary according to the problem in question: 85% in soft-tissue impingement; 90% in arthrofibrosis; and 55% in periprosthetic infections.

More clinical studies are needed to determine which patients with symptomatic TKA can be the best candidates for knee arthroscopy.

Cite this article: EFORT Open Rev 2019;4:33-43. DOI: 10.1302/2058-5241.4.180035.

Treatment of post-traumatic joint contracture in a rabbit model using pulsed, high intensity laser and ultrasound

Post-traumatic joint contracture induced by scar tissues following a surgery or injury can leave patients in a permanent state of pain and disability, which is difficult to resolve by current treatments. This randomized controlled trial examines the therapeutic effect of pulsed high-intensity laser (PHIL) and pulsed high-intensity focused ultrasound (PHIFU) for post-traumatic joint contracture due to arthrofibrosis. The peak power levels of both PHIL and PHIFU are much higher than that of laser or ultrasound currently used in physical therapy, while short pulses are utilized to prevent damage. To test the effectiveness of these treatments, a rabbit knee model for joint contracture was established. Twenty-one rabbits were split into four groups: untreated control (n  =  5), PHIL (n  =  5), PHIFU (n  =  5), and a PHIL  +  PHIFU group (n  =  6). Maximum extension of the surgically modified rabbit knee was compared to that of the contralateral control knee over the course of 16 weeks. The rabbits in the untreated control group maintained a relatively consistent level of joint contracture, while every rabbit in each of the treatment groups had improved range of motion, eventually leading to a restoration of normal joint extension. Average recovery time was 7.6  ±  1.5 weeks for the PHIL treatment group, 9.8  ±  3.7 weeks for the PHIFU group, and 8.0  ±  2.2 weeks for the combined treatment group. Histopathology demonstrated reduced density and accelerated resorption of scar tissues in the treated knee joints. This study provides evidence that both PHIL and PHIFU are effective in treating post-traumatic joint contracture in rabbits and warrant further investigation into the underlying mechanisms to optimize PHIL and PHIFU based treatments in a larger number of animals.

Novel rabbit model of moderate knee contracture induced by direct capsular damage

The treatment of joint contracture continues to represent a challenging problem in orthopedic surgery and rehabilitation medicine. Existing animal models of knee contracture for evaluating new treatments are mostly created by extensive joint tissue damage with Kirschner-wire immobilization which requires a second surgery to remove Kirschner-wires. This study aimed to develop a less invasive rabbit model of moderate knee contracture through a single surgery. Skeletally mature New Zealand White rabbits had their right knee operated to create surgical damage to the posterior capsule under direct visualization. Operated knees were then held in a flexed position by suturing the superficial flexion muscles with absorbable sutures. The flexion contracture (net extension loss) was determined by comparing the extension angles between the operated and non-operated knees from 8 to 24 weeks post-surgery. The flexion contracture of the operated knees was significantly greater (p < 0.01/0.001) than the non-operated knees at each weekly measurement. The mean flexion contractures were 22° at 8 weeks, 19° at 16 weeks, and 18° at 24 weeks. No significant differences in the severity of flexion contracture were observed between 8-week and each of the following weeks, suggesting that the flexion contracture was essentially stabilized by 8 weeks post-surgery. Histopathologic analyses demonstrated intra-articular and peri-articular scar formation. This less invasive rabbit model of moderate knee contracture is more quickly established through a single surgery with lower risk of surgical complications compared to the previously reported invasive models, and could be an alternative animal model for joint contracture research. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2687-2695, 2018.

Outcomes and Predictors of Success for Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty

A stiff total knee arthroplasty (TKA) can manifest as pain and decreased range of motion (ROM). When conservative management including physical therapy and manipulation under anesthesia fails, arthroscopic lysis of adhesions (LOA) is frequently pursued. The authors examined the efficacy of LOA for the stiff TKA. They retrospectively reviewed the records of 18 patients who underwent LOA for stiff TKA between April 2013 and June 2016 and who failed to meet 90° ROM at 6 weeks postoperatively. They recorded patient demographics, ROM prior to TKA, and incidence of manipulation under anesthesia between initial TKA and LOA as well as pre- and postoperative outcomes of ROM, pain, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The mean time from TKA to LOA was 117 days, with a mean follow-up of 449 days. Mean improvements in ROM flexion contracture, flexion, and arc were 6.11° (P<.05), 29.45° (P<.001), and 35.56° (P<.001), respectively. Range of motion improved for 17 of 18 patients. The WOMAC was completed by 15 of 18 patients, with a mean improvement in scores of 32.23% (P<.001); all 15 patients with available WOMAC scores improved. Pain score improved by a mean of 2.17 (P<.001), with 14 of 18 patients reporting decreased pain. Improvements in flexion contracture, flexion, ROM arc, WOMAC scores, and pain were all statistically significant (P<.05). Age, weight, body mass index, and time to LOA were found to be statistically significant predictors of outcome. Finally, pre-TKA and pre-LOA ROM parameters were found to be statistically significant predictors of post-LOA ROM outcomes. [Orthopedics. 2017; 40(6):e1062-e1068.].

Arthrofibrosis Associated With Total Knee Arthroplasty

BACKGROUND

Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions.

METHODS

In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined.

RESULTS

Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes.

CONCLUSION

Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Arthroscopic lysis of adhesions for the stiff total knee arthroplasty

The management of the stiff knee after total knee arthroplasty is controversial. Manipulation under anesthesia and open lysis of adhesions are techniques that can theoretically address the fibrous scar tissue, but their efficacy has been shown to be variable. We describe the technique of arthroscopic lysis of adhesions for the stiff knee after total knee arthroplasty. The advantages of this technique include minimally invasive debridement of scar tissue within defined compartments of the knee and evaluation for the presence and treatment of focal lesions (e.g., loose bodies or impinging synovial or soft tissue). The total arc of motion can be improved with a systematic arthroscopic approach.