Arthroscopic lysis of adhesions for the stiff total knee: results after failed manipulation

Postoperative Supine Sleeping Position Following Total Knee Arthroplasty Decreases Knee Flexion Contractures

Background

Total knee arthroplasty (TKA) is an orthopaedic operation that improves quality of life and reduces pain in patients with disabling arthritis of the knee. One commonly recognized postoperative complication is flexion contracture of the knee. While early physical therapy and range of motion (ROM) exercises have helped improve ROM postoperatively, flexion contractures still remain a significant postoperative complication of TKA.This study evaluated postoperative sleeping position and its effect on terminal knee extension and ROM following primary TKA. We hypothesized that patients who slept in the supine position would achieve earlier knee extension and ROM when compared to those in the lateral recumbent position.

Methods

A total of 150 consecutive primary total knee arthroplasties (TKAs) were conducted by a single surgeon (JMC). Prospective data collection included assessments of preoperative range of motion (ROM), postoperative ROM, patient-reported outcome measures, and sleeping positions. Functional outcomes and patient-reported measures were compared between pre- and postoperative phases, as well as across different sleeping position groups.

Results

Postoperative follow up was a mean of 29.6 days. Mean postoperative terminal extension ROM at one month was 2.98 degrees in the supine group versus 6.03 degrees in the lateral group (P < 0.001). Overall, there was significant improvement in patient reported outcome measures (WOMAC, Oxford, and pain) after surgery, but no difference existed between sleeping groups. For knee extension, a two-way ANOVA revealed that there was a statistically significant interaction between the effects of surgery and sleep position (p = 0.0053).

Conclusions

Our results demonstrate that sleeping position does affect initial postoperative knee terminal extension; however, there is no effect on patient reported outcomes. We found a statistically significant difference in extension when comparing patients in the supine versus lateral group. Patients who slept in the lateral position lacked 6.03 degrees of extension which is greater than the 5 degrees threshold needed for normal gait mechanics. Conversely, those in the supine group only lacked 2.98 degrees of extension, allowing for normal gait mechanics. This study identifies an easy, effective means of increasing patient knee range of motion following TKA.

The Effect of Postoperative Sleeping Position on Knee Extension and Range of Motion Following Primary Total Knee Arthroplasty

Total knee arthroplasty (TKA) is an orthopaedic operation that improves quality of life and reduces pain in patients with disabling arthritis of the knee. One commonly recognized complication is flexion contracture of the knee. Early physical therapy helps prevent flexion contracture and improve range of motion (ROM) postoperatively. This study evaluated postoperative sleeping position and its effect on terminal knee extension and ROM following primary TKA. We hypothesized that patients who slept in the supine position would achieve earlier knee extension and greater ROM when compared to those in the lateral recumbent position. A total of 150 consecutive primary TKAs were performed by a single surgeon (J.M.C.) from April 2014 to December 2014. The data were collected prospectively to determine preoperative ROM, postoperative ROM, and sleeping position. Mean postoperative terminal extension ROM at 1 month was 2.9 degrees in the supine group versus 6.0 degrees (p< .001) in the lateral group. No significant demographic differences between the two groups at baseline were found. Our results demonstrate that sleeping position affects initial postoperative terminal extension, however, not overall ROM. We found a statistically significant difference in extension when comparing patients in the supine versus lateral group. Patients who slept in the lateral position lacked 6 degrees of extension which is greater than the 5 degrees needed for normal gait mechanics. Those in the supine group lacked 2.9 degrees of extension, allowing for normal gait mechanics. This study identifies an easy, effective means of increasing patients initial ability to achieve knee extension and satisfaction following TKA.

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.

Effects of application of the clinical nursing pathway on surgical site wound infection and postoperative complication rates in patients with total knee arthroplasty: A meta-analysis

This study aimed to systematically evaluate the effects of clinical nursing on surgical site wound infections and postoperative complications in patients after undergoing total knee arthroplasty (TKA). Computerised searches of Embase, PubMed, Cochrane Library, China National Knowledge Infrastructure, VIP and Wanfang databases were conducted from inception to August 2023 to collect randomised controlled trials (RCTs) on patients with TKA who received clinical nursing pathway interventions. Literature screening, data extraction and quality assessment of the included studies were performed independently by two researchers. The meta-analysis was performed using Stata 17.0. A total of 14 RCTs with 1174 patients were included, including 587 patients each in the intervention and control groups. The meta-analysis results showed that the application of clinical nursing pathways to patients undergoing TKA significantly reduced surgical site wound infections (risk ratio [RR] = 0.28, 95% confidence interval [CI]: 0.15-0.54, p < 0.001) and postoperative complications (RR = 0.25, 95% CI: 0.17-0.37, p < 0.001). Therefore, clinical nursing pathway interventions in patients undergoing TKA should be promoted in clinical practice as they can effectively reduce the incidence of wound infection and postoperative complications.

The Cost of Stiffness After Total Knee Arthroplasty

BACKGROUND

Stiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact.

METHODS

An observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options.

RESULTS

The prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA.

CONCLUSION

Patients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.

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.

Intra-articular celecoxib improves knee extension regardless of surgical release in a rabbit model of arthrofibrosis

Aims

Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release.

Methods

A total of 24 rabbits underwent contracture-forming surgery with knee immobilization followed by remobilization surgery at eight weeks. At remobilization, one cohort underwent capsular release (n = 12), while the other cohort did not (n = 12). Both groups were divided into two subcohorts (n = 6 each) – one receiving IA injections of celecoxib, and the other receiving injections of vehicle solution (injections every day for two weeks after remobilization). Passive extension angle (PEA) was assessed in live rabbits at 10, 16, and 24 weeks, and disarticulated limbs were analyzed for capsular stiffness at 24 weeks.

Results

IA celecoxib resulted in greater mean PEA at ten weeks (69.6° (SD 4.6) vs 45.2° (SD 9.6), p = 0.004), 16 weeks (109.8° (SD 24.2) vs 60.9° (SD10.9), p = 0.004), and 24 weeks (101.0° (SD 8.0) vs 66.3° (SD 5.8), p = 0.004). Capsular stiffness was significantly reduced with IA celecoxib (2.72 Newton per cm (N·cm)/° (SD 1.04), p = 0.008), capsular release (2.41 N·cm/° (SD 0.80), p = 0.008), and capsular release combined with IA celecoxib (3.56 N·cm/° (SD 0.99), p = 0.018) relative to IA vehicle (6.09 N·cm/° (SD 1.64)).

Conclusion

IA injections of a celecoxib led to significant improvements in passive extension angles, with reduced capsular stiffness, when administered to rabbit knees with established experimental contracture. Celecoxib was superior to surgical release, and the combination of celecoxib and a surgical release did not provide any additional value.

Cite this article: Bone Joint Res 2022;11(1):32–39.

[Surgical treatment of arthrofibrosis of the knee joint]

Die Arthrofibrose des Kniegelenks ist eine schwerwiegende Komplikation nach Trauma und Operation, da die Funktion des Gelenks häufig dauerhaft beeinträchtigt wird. Es werden nach wie vor frühzeitige Mobilisierungstechniken und die Anästhesie eingesetzt, ohne dass die zugrunde liegenden Prozesse ausreichend aufgeklärt wurden. Während die Frühphase der Arthrofibrose gut auf konservative Maßnahmen zur Schmerzreduktion und zur Wundheilungsregulation anspricht, ist in der Spätphase häufig straffes kollagenes Narbengewebe vorhanden, das die Beweglichkeit dauerhaft einschränkt. In dieser Phase ist eine Verbesserung der Beweglichkeit ohne chirurgische Maßnahmen in der Mehrzahl der Fälle aussichtslos. Bei einer chirurgischen Therapie sollte zwischen der lokalisierten (zumeist sekundären) Arthrofibrose (z. B. Kreuzbandoperation) und einer generalisierten Arthrofibrose (primär, in der Mehrzahl der Fälle nach einer Knietotalendoprothese [Knie-TEP]) unterschieden und die Behandlung entsprechend geplant werden. Begleitende pathologische Veränderungen (Transplantatposition, Instabilität der TEP, Implantatverschleiß, „Low-grade“-Infektion, patellofemorale Instabilität oder „maltracking“, Patella baja) müssen bei der Behandlung berücksichtigt werden. Eine multimodale Begleitbehandlung (Physiotherapie, Schmerztherapie, Psychosomatik) ist zur Sicherung des Behandlungserfolgs notwendig.

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.

Ultrasound-Assisted Posterior Knee Arthroscopy: A Description of the Technique

Entering the posterior knee with arthroscopy can be difficult. Scar tissue, a tumor, and the obese patient can make instrument placement difficult and risk iatrogenic injury. Ultrasound can be used to visualize the posterior knee and provide direct guidance of instrumentation. We describe the technique and indications for using ultrasound during arthroscopy. Accurate and atraumatic insertion of instruments can be performed with no damage to total knee components or the knee joint. Ultrasound guidance should be considered during difficult posterior knee arthroscopy.

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.

Lysis of Adhesion for Arthrofibrosis After Total Knee Arthroplasty Is Associated With Increased Risk of Subsequent Revision Total Knee Arthroplasty

BACKGROUND

The aim of this study is to determine incidence of lysis of adhesion (LOA) for postoperative arthrofibrosis following primary total knee arthroplasty (TKA), patient factors associated with LOA, and impact of LOA on revision TKA.

METHODS

Patients who underwent primary TKA were identified in the Humana and Medicare databases. Patients who underwent LOA within 1 year after TKA were defined as the "LOA" cohort. Multiple binomial logistic regression analyses were performed to identify patient factors associated with undergoing LOA within 1 year after index TKA, and identify risk factors including LOA on risk for revision TKA within 2 years of index TKA.

RESULTS

In total, 58,538 and 48,336 patients underwent primary TKA in the Medicare and Humana databases, respectively. Incidence of LOA within 1 year after TKA was 0.56% in both databases. Age <75 years was a significant predictor of LOA in both databases (P < .05 for both). Incidence of revision TKA was significantly higher for the "LOA" cohort when compared to the "TKA Only" cohort in both databases (P < .0001 for both). LOA was the strongest predictor of revision TKA within 2 years after index TKA in both databases (P < .0001 for both). Additionally, age <65 years, male gender, obesity, fibromyalgia, smoking, alcohol abuse, and history of anxiety or depression were independently associated with increased odds of revision TKA within 2 years after index TKA (P < .05 for all).

CONCLUSION

Incidence of LOA after primary TKA is low, with younger age being the strongest predictor for requiring LOA. Patients who undergo LOA for arthrofibrosis within 1 year after primary TKA have a substantially high risk for subsequent early revision TKA.

LEVEL OF EVIDENCE

III, Retrospective Cohort Study.

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.

Anti-fibrotic effects of the antihistamine ketotifen in a rabbit model of arthrofibrosis

Aims

Arthrofibrosis is a relatively common complication after joint injuries and surgery, particularly in the knee. The present study used a previously described and validated rabbit model to assess the biomechanical, histopathological, and molecular effects of the mast cell stabilizer ketotifen on surgically induced knee joint contractures in female rabbits.

Methods

A group of 12 skeletally mature rabbits were randomly divided into two groups. One group received subcutaneous (SQ) saline, and a second group received SQ ketotifen injections. Biomechanical data were collected at eight, ten, 16, and 24 weeks. At the time of necropsy, posterior capsule tissue was collected for histopathological and gene expression analyses (messenger RNA (mRNA) and protein).

Results

At the 24-week timepoint, there was a statistically significant increase in passive extension among rabbits treated with ketotifen compared to those treated with saline (p = 0.03). However, no difference in capsular stiffness was detected. Histopathological data failed to demonstrate a decrease in the density of fibrous tissue or a decrease in α-smooth muscle actin (α-SMA) staining with ketotifen treatment. In contrast, tryptase and α-SMA protein expression in the ketotifen group were decreased when compared to saline controls (p = 0.007 and p = 0.01, respectively). Furthermore, there was a significant decrease in α-SMA (ACTA2) gene expression in the ketotifen group compared to the control group (p < 0.001).

Conclusion

Collectively, these data suggest that ketotifen mitigates the severity of contracture formation in a rabbit model of arthrofibrosis.

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.

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.

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.

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.

A mini-invasive technique for severe arthrofibrosis of the knee: A technical note

PURPOSE

In this article, a mini-invasive technique is described, which consists of arthroscopic adhesiolysis and quadriceps pie-crusting lengthening basing on pre-operative sonographic examination. Sonographic diagnostic value of quadriceps tendon fibrosis is also evaluated.

METHODS

Pre-operative sonographic examination was performed to make an accurate location diagnosis of quadriceps fibrosis. After arthroscopic adhesiolysis, percutaneous pie-crusting release was performed basing on preoperative sonographic examination. An 18-gauge needle was used to puncture the stiff fibrous band of the distal and lateral quadriceps tendon under maximum knee flexion. The contractural quadriceps tendon is gradually released after 60-100 needle punctures.

RESULTS

This technique was performed in five post-traumatic stiff knees and three stiff knees after previous infection. The contractural rectus femoris tendon is average 22% thinner than contralateral parts according to sonographic measurement. Mean maximum flexion increased from 35° preoperatively to 80° after arthroscopic adhesiolysis and 120° after pie-crusting.

CONCLUSIONS

This technique is a simple, effective and mini-invasive method, allowing an immediate, aggressive rehabilitation postoperatively. Pre-operative sonographic location of quadriceps tendon fibrosis could potentially improve the efficacy and accuracy of percutaneous pie-crusting procedures.

Novel Protocol for Knee Mobilization Under Femoral and Sciatic Nerve Blocks for Postoperative Knee Stiffness

The purpose of this study was to evaluate the effectiveness of intermittent femoral and sciatic nerve blocks combined with an in-house physiotherapy protocol for treating postoperative knee stiffness. Sixty-eight patients with postoperative knee stiffness were evaluated for passive knee flexion and extension at different time points, beginning preoperatively and continuing throughout a median 10-month follow-up after mobilization intervention. Sciatic and femoral nerve catheters were activated 1 hour prior to each physiotherapy session, which was performed twice per day and supported by a continuous passive range of motion machine. Median time from admission to catheter removal was 4 days (range, 1-8 days). Mean hospital length of stay was 7 days (range, 2-19 days). Overall mean flexion increased significantly from pretreatment (74°) to discharge (109°; P<.01). There was no significant difference in mean flexion at 6-week follow-up compared with that at discharge (108°; P=.764), but there was a significant increase in flexion at final follow-up (120°; P=.002). Overall mean knee extension lag decreased significantly from pretreatment (5°) to discharge (0.4°; P=.001). There was no significant increase in mean extension lag from discharge to final follow-up (1°; P=.2). Overall, 11 patients underwent revision surgery for persistent stiffness. This novel protocol for continuous knee mobilization under perineural blocks is a valuable alternative to knee manipulation under anesthesia for this select group of procedures. The 2 techniques produced a similar early range of motion gain, but the reported protocol resulted in less range of motion loss at follow-up and fewer possible complications. [Orthopedics. 2016; 39(4):e708-e714.].

Predominance of synovial sensory nerve fibers in arthrofibrosis following total knee arthroplasty compared to osteoarthritis of the knee

BACKGROUND

So far, there exists no golden standard for the treatment of arthrofibrosis (AF) following total knee arthroplasty (TKA). Although pain is a hallmark of AF, nociceptive nerve fibers have never been investigated in affected joint tissue.

METHODS

A total of 24 patients with osteoarthritis (OA) of the knee (n = 12) and post-TKA AF of the knee (n = 12) were included. Along evaluation of typical clinical signs and symptoms by using the Knee Society Clinical Rating System (KSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC index), the innervation of joint tissue was studied by semiquantitative immunofluorescence of nerve fibers.

RESULTS

Patients with AF compared to OA had a lower KSS and lower KOOS. In all compartments (anterior, medial, and lateral recesses), the density of synovial sympathetic nerve fibers was significantly higher in OA compared to AF, which was also true for the density of sensory nerve fibers in the medial and lateral recesses. In synovial tissue of the anterior recess of patients with AF compared to OA, the density of nociceptive sensory nerve fibers was significantly higher relative to sympathetic nerve fibers. This was similarly observed in the neighboring infrapatellar fat pad of the knee.

CONCLUSIONS

Similar as in many painful musculoskeletal diseases, this study indicates that patients with arthrofibrosis of the knee after TKA demonstrate a preponderance of profibrotic sensory nerve fibers over antifibrotic sympathetic nerve fibers. This could serve as a starting point for AF therapy with specific antifibrotic pain medication or regional anesthetic techniques.

Right-Left Differences in Knee Extension Stiffness for the Normal Rat Knee: In Vitro Measurements Using a New Testing Apparatus

Knee stiffness following joint injury or immobilization is a common clinical problem, and the rat has been used as a model for studies related to joint stiffness and limitation of motion. Knee stiffness measurements have been reported for the anesthetized rat, but it is difficult to separate the contributions of muscular and ligamentous restraints to the recorded values. in vitro testing of isolated rat knees devoid of musculature allows measurement of joint structural properties alone. In order to measure the effects of therapeutic or surgical interventions designed to alter joint stiffness, the opposite extremity is often used as a control. However, right-left stiffness differences for the normal rat knee have not been reported in the literature. If stiffness changes observed for a treatment group are within the normal right-left variation, validity of the results could be questioned. The objectives of this study were to utilize a new testing apparatus to measure right-left stiffness differences during knee extension in a population of normal rat knees and to document repeatability of the stiffness measurements on successive testing days. Moment versus rotation curves were recorded for 15 right-left pairs of normal rat knees on three consecutive days, with overnight specimen storage in a refrigerator. Each knee was subjected to ten loading-unloading cycles, with the last loading curve used for analysis. Angular rotation (AR), defined here as the change in flexion-extension angle from a specified applied joint moment, is commonly used as a measure of overall joint stiffness. For these tests, ARs were measured from the recorded test curves with a maximum applied extension moment of 100 g cm. Mean rotations for testing days 2 and 3 were 0.81-1.25 deg lower (p < 0.001) than for day 1, but were not significantly different from each other. For each testing day, mean rotations for right knees were 1.12-1.30 deg greater (p < 0.001) than left knees. These right-left stiffness differences should be considered when interpreting the results of knee treatment studies designed to alter knee stiffness when using the opposite extremity as a control.