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Sapre V, Dhanwani Y, Saluja N, Jaiswal AM, Chandanwale R. Clinical Outcomes of Arthroscopic Adhesiolysis: A Case Series of 40 Patients With Postoperative Knee Stiffness. Cureus 2024; 16:e63378. [PMID: 39070427 PMCID: PMC11283807 DOI: 10.7759/cureus.63378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Introduction Restricted range of motion over the knee joint is a known complication following the surgical procedure. Aggressive rehabilitation protocols can initially manage knee stiffness due to arthrofibrosis. If conservative management fails, surgical (open or arthroscopic) release is the preferred modality of management. We present a series of 40 patients with postoperative knee stiffness who were treated with arthroscopic adhesiolysis. Material and methods This is a retrospective study conducted at Phoenix Orthopedic Superspeciality Hospital, Nagpur, India, from 2017 to 2021. Our study included 40 patients with postoperative knee joint stiffness, of whom 27 were males and 13 were females. The study considered the duration of stiffness, which ranged from six months to five years. All patients underwent arthroscopic knee release. A rigorously supervised physical therapy program followed this procedure. Patients were examined at three months, six months, and one year to assess improvement in knee range of movement. Results Out of 40 patients, six were classified as Shelbourne type 4, and the remaining were Shelbourne type 3. Twenty-three of 40 patients developed arthrofibrosis following intra-articular or peri-articular fracture fixation surgery; 11 patients were operated on arthroscopically for anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction. Three patients developed stiffness following total knee replacement, one following patellectomy, and three following infection after fracture fixation. The mean pre-op knee range of motion (ROM) was 48.875 degrees. Following arthroscopic release, the mean improvement in ROM was 60 degrees intra-operatively. The average postoperative range was 108.25 degrees. Conclusion Arthroscopic adhesiolysis and quadriceps release are reliable methods for dealing with postoperative knee stiffness. It prevents wound complications and increases the chances of surgical site infection due to smaller incisions. Postoperatively, we achieved an average increase of 60 degrees in ROM over the knee joint.
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Affiliation(s)
- Vikram Sapre
- Orthopedics, N.K.P. Salve Institute of Medical Science and Research Center and Lata Mangeshkar Hospital, Nagpur, IND
| | - Yash Dhanwani
- Orthopedics and Traumatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Navneet Saluja
- Orthopedics, Mata Gujri Memorial Medical College, Kishanganj, IND
| | - Ankit M Jaiswal
- Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Rohan Chandanwale
- Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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2
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Faust TF, Castañeda PG. Arthrofibrosis of the knee in pediatric orthopedic surgery. ACTA ORTOPEDICA MEXICANA 2024; 38:179-187. [PMID: 38862148 DOI: 10.35366/115813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
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.
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Affiliation(s)
- T F Faust
- Department of Research, Alabama College of Osteopathic Medicine. Alabama, USA
| | - P G Castañeda
- Baylor School of Medicine, Department of Pediatric Orthopedic Surgery, Texas Children's Hospital. USA
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3
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Gálvez-Sirvent E, Ibarzábal-Gil A, Rodríguez-Merchán EC. Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management. EFORT Open Rev 2022; 7:554-568. [PMID: 35924649 PMCID: PMC9458943 DOI: 10.1530/eor-22-0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.
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Affiliation(s)
- Elena Gálvez-Sirvent
- Department of Orthopaedic Surgery, "Infanta Elena" University Hospital, Valdemoro, Madrid, Spain.,Faculty of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Aitor Ibarzábal-Gil
- Department of Orthopaedic Surgery, "La Paz" University Hospital, Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Department of Orthopaedic Surgery, "La Paz" University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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4
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Ebisz M, Mostowy M, Góralczyk A, Hirschmann MT, Skowronek P, LaPrade RF, Malinowski K. Both arthroscopic and open posterior knee capsulotomy are effective in terms of extension recovery and functional improvement-systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:1443-1452. [PMID: 34117895 DOI: 10.1007/s00167-021-06634-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To assess the recovery of extension and improvement in functional scores after an arthroscopic or open posterior knee capsulotomy in the setting of an extension deficit. METHODS A systematic search of articles published between 1980 and 2020 was performed in the MEDLINE/PubMed database, EMBASE/Ovid database and Web of Science database. The inclusion criteria consisted of patients with primary extension deficits > 5° who underwent an arthroscopic or open posterior knee capsulotomy. The assessed outcomes were preoperative and postoperative range of motion and functional outcome scores. Randomized controlled trials, cohort studies and case series with a follow-up longer than 6 months were included. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for case series. The certainty of evidence was assessed using the GRADE approach. RESULTS Of 226 records identified through database searching, 7 studies were included in the final analysis. The outcomes of 107 patients with a mean age of 34.1 (range 15-63) years were available. In all the included studies, a posterior capsulotomy resulted in the restoration of knee extension to normal or nearly normal values (mean postoperative extension deficit: 0.4-4.2 degrees) with a significant increase in functional outcome scores. No neurovascular complications were reported within the studies. Due to the diverse methodology of studies, the direct comparison of arthroscopic versus open approaches was not possible. Concerning the risk of bias assessment, the greatest concerns raised the selection of participants among the included studies and the methods of outcome measurement. The certainty of evidence was very low according to the GRADE. CONCLUSIONS Both arthroscopic and open posterior capsulotomy of the knee results in restoration of normal or nearly normal knee extension and significant improvement in functional outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michał Ebisz
- Artromedical Orthopaedic Clinic, Antracytowa 1, 97-400, Belchatow, Poland
| | - Marcin Mostowy
- Orthopedic and Trauma Department, Veteran's Memorial Teaching Hospital in Lodz, Medical University of Lodz, Zeromskiego 113, 90-549, Lodz, Poland
| | | | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland.,University of Basel, CH-4051, Basel, Switzerland
| | - Paweł Skowronek
- Department of Orthopaedic, Trauma Surgery S. Zeromski Hospital, Os. Na Skarpie 66, 31-913, Krakow, Poland
| | - Robert F LaPrade
- Twin Cities Orthopedics, 4010 W 65th St Edina, Minnesota, 55435, USA
| | - Konrad Malinowski
- Artromedical Orthopaedic Clinic, Antracytowa 1, 97-400, Belchatow, Poland.
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5
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Lee DR, Therrien E, Song BM, Camp CL, Krych AJ, Stuart MJ, Abdel MP, Levy BA. Arthrofibrosis Nightmares: Prevention and Management Strategies. Sports Med Arthrosc Rev 2022; 30:29-41. [PMID: 35113841 PMCID: PMC8830598 DOI: 10.1097/jsa.0000000000000324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathologic periarticular fibrosis and symptomatic joint stiffness. The knee, elbow, and shoulder are particularly susceptible to AF, often in the setting of trauma, surgery, or adhesive capsulitis. Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss. Reliable nonoperative modalities exist and outcomes are improved when etiology, joint involved, and level of dysfunction are considered in the clinical decision making process. Surgical procedures should be reserved for cases recalcitrant to nonoperative measures. The purpose of this review is to provide an overview of the current understanding of AF pathophysiology, identify common risk factors, describe prevention strategies, and outline both nonoperative and surgical treatment options. This manuscript will focus specifically on sterile AF of the knee, elbow, and shoulder.
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Affiliation(s)
- Dustin R. Lee
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Erik Therrien
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bryant M. Song
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L. Camp
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J. Krych
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J. Stuart
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Mathew P. Abdel
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bruce A. Levy
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
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6
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Ibrahim IO, Nazarian A, Rodriguez EK. Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook. JBJS Rev 2021; 8:e1900223. [PMID: 32618740 DOI: 10.2106/jbjs.rvw.19.00223] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
* 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.
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Affiliation(s)
- Ishaq O Ibrahim
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Ara Nazarian
- Harvard Medical School Orthopedic Trauma Initiative, Boston, Massachusetts.,Center for Advanced Orthopaedic Studies (A.N.), and Orthopaedic Trauma Service (E.K.R.), Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
| | - Edward K Rodriguez
- Harvard Medical School Orthopedic Trauma Initiative, Boston, Massachusetts.,Center for Advanced Orthopaedic Studies (A.N.), and Orthopaedic Trauma Service (E.K.R.), Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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7
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Flick TR, Wang CX, Patel AH, Hodo TW, Sherman WF, Sanchez FL. Arthrofibrosis after total knee arthroplasty: patients with keloids at risk. J Orthop Traumatol 2021; 22:1. [PMID: 33403515 PMCID: PMC7785621 DOI: 10.1186/s10195-020-00563-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/17/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without. METHODS Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant. RESULTS Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9). CONCLUSION Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study. LEVEL OF EVIDENCE Level III retrospective comparative study.
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Affiliation(s)
- Travis R Flick
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Cindy X Wang
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Akshar H Patel
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Thomas W Hodo
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Fernando L Sanchez
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
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8
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Vaish A, Vaishya R, Bhasin VB. Etiopathology and Management of Stiff Knees: A Current Concept Review. Indian J Orthop 2020; 55:276-284. [PMID: 33927806 PMCID: PMC8046887 DOI: 10.1007/s43465-020-00287-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Knee stiffness after trauma, fracture fixation, arthroscopic surgery, infection, and knee arthroplasty is a known complication, which is challenging to manage and causes significant disability to the patients. METHODS We did a comprehensive search on the stiff knees, in the last week of May 2020, from the search engines of PubMed, SCOPUS, Google Scholar, and Research Gates using the appropriate keywords. RESULTS We found two types of articles related to knees stiffness: (a) following trauma, internal and external fixation of fractures and arthroscopic surgery, and (b) following total knee arthroplasty. Arthroscopic surgery was found to be a favored mode of management of stiff knees in both of the above groups. The Manipulation under Anesthesia (MUA) was also found effective if done carefully and in the early course of the stiffness. CONCLUSION Knee stiffness due to any cause is a trouble proposition to both patients and treating surgeons. Various methods of management have been described to deal with knee stiffness. Amongst the operative treatment, MUA and arthroscopic surgery were found to be the most effective. Arthroscopic surgery offers a good option of release stiff knees in the majority of cases, and it is most valuable and effective if done earlier in the course of the stiffness (preferably between 3 and 6 months).
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Affiliation(s)
- Abhishek Vaish
- grid.414612.40000 0004 1804 700XDepartment of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076 India
| | - Raju Vaishya
- grid.414612.40000 0004 1804 700XDepartment of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076 India
| | - Vishwa Bandhu Bhasin
- grid.415985.40000 0004 1767 8547Department of Orthopaedics, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 1100060 India
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9
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Wang MM, Feng YS, Xing Y, Dong F, Zhang F. Mechanisms involved in the arthrofibrosis formation and treatments following bone fracture. J Back Musculoskelet Rehabil 2020; 32:947-954. [PMID: 31403938 DOI: 10.3233/bmr-191499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Arthrofibrosis is a common complication for patients with bone fracture following external and internal fixation. In this review, we summarize the related factors and significant pathways for joint adhesion following fracture surgery. Moreover, the different types of treatments and related preventive measures are also discussed. Many factors related to the development and treatment of arthrofibrosis are discussed in this review in order to provide possible clues for the prospective targets to develop new medication or treatments for preventing or reducing the joint adhesion following orthopedic surgery.
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Affiliation(s)
- Man-Man Wang
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Ya-Shuo Feng
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Ying Xing
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Fang Dong
- Department of Clinical Laboratory Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Feng Zhang
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China.,Hebei Provincial Orthopedic Biomechanics key laboratory, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
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10
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Kukreja M, Kang J, Curry EJ, Li X. Arthroscopic Lysis of Adhesions and Anterior Interval Release With Manipulation Under Anesthesia for Severe Post-traumatic Knee Stiffness: A Simple and Reproducible Step-by-Step Guide. Arthrosc Tech 2019; 8:e429-e435. [PMID: 31194118 PMCID: PMC6554358 DOI: 10.1016/j.eats.2019.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/06/2019] [Indexed: 02/03/2023] Open
Abstract
Post-traumatic knee stiffness can present after injuries around the knee and surgery. Management is guided by the type of initial injury, amount of range-of-motion loss, time since injury, and cartilage status. Cases refractory to conservative management may conventionally be treated with manipulation under anesthesia (MUA), arthroscopic lysis of adhesions, or open quadricepsplasty. We describe our arthroscopic technique of lysis of adhesions with anterior interval release and intraoperative MUA, which has been shown to provide sustainable range-of-motion improvement in a subset of patients with severe knee arthrofibrosis. Although technically demanding, this technique benefits from being minimally invasive, allows for direct visualization of intra-articular structures, and allows all-round arthroscopic release of adhesions to improve patellar mobility and decrease the risk of fracture prior to MUA. A rigorous postoperative formal physical therapy protocol and patient compliance are imperative to achieve good outcomes.
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Affiliation(s)
| | | | | | - Xinning Li
- Address correspondence to Xinning Li, M.D., Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, Boston University School of Medicine, Boston Medical Center, 850 Harrison Ave, Dowling 2-North, Boston, MA 02118, U.S.A.
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11
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Arthrofibrosis Associated With Total Knee Arthroplasty. J Arthroplasty 2017; 32:2604-2611. [PMID: 28285897 DOI: 10.1016/j.arth.2017.02.005] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 01/03/2017] [Accepted: 02/05/2017] [Indexed: 02/01/2023] Open
Abstract
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.
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Birjandinejad A, Ebrahimzadeh MH, Sayyed-Hosseinian SH, Tabesh S, Ghanbarifard M. Prognostic Factors Affecting the Results of Modified Thompson Quadricepsplasty for the Treatment of Extension Contracture of the Knee. THE ARCHIVES OF BONE AND JOINT SURGERY 2017; 5:109-113. [PMID: 28497101 PMCID: PMC5410742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 02/20/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Knee extension contracture is a disabling complication after fractures around the knee. In this study we aimed to study factors influencing the outcomes of quadricepsplasty for the treatment of traumatic knee extension contracture. We hypothesized that there is no factor influencing the final range of knee motion. METHODS In this retrospective study, we included 64 patients who underwent modified Thompson quadricepsplasty between 2008 to 2011 with a mean follow-up time of 36 months. RESULTS The mean change in flexion was 66 degrees. Using Judet criteria, results were excellent in 41 patients (64%), good in 15 (23%), fair in 4 (6%) and poor in 4 (6%). Preoperative arc of flexion, duration of extension contracture, number of previous surgeries on the limb, and BMI of the patients were independently influencing the final flexion. CONCLUSION Modified Thompson quadricepsplasty is associated with high number of excellent and good results especially when it is performed earlier in more severe contractures. Preoperative arc of flexion, interval between trauma surgery and quadricepsplasty, the number of prior surgeries, and BMI influence the outcomes of quadricepsplasty.
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Affiliation(s)
- Ali Birjandinejad
- Orthopedic Research Center, Shahid Kamyab Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad H Ebrahimzadeh
- Orthopedic Research Center, Shahid Kamyab Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Saman Tabesh
- Orthopedic Research Center, Shahid Kamyab Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Ghanbarifard
- Orthopedic Research Center, Shahid Kamyab Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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13
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Erickson BJ, Campbell K, Cvetanovich GL, Harris JD, Bach BR, Sherman SL. Nonligamentous Soft Tissue Pathology About the Knee: A Review. Orthopedics 2016; 39:32-42. [PMID: 26709560 DOI: 10.3928/01477447-20151218-06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/20/2015] [Indexed: 02/03/2023]
Abstract
Knee pain is one of the most frequent complaints evaluated by orthopedic surgeons. It encompasses a broad range of pathology and can present in a variety of ways. Most of this pain can be attributed to essential structures of the knee, including the menisci, cruciate or collateral ligaments, and articular cartilage. However, there are underrecognized structures in and around the knee that can frequently be a cause of knee pathology and pain. Knee pain stemming from these structures may be missed or incorrectly diagnosed, and these patients often present for second and third opinions because of failure to diagnose and treat the underlying pathology. The synovial plica, suprapatellar pouch, lateral retinaculum, infrapatellar fat pad, and infrapatellar branch of the saphenous nerve are less common but still significant causes of knee pain. Although initial treatment involves various nonoperative modalities, operative treatment is often warranted. Operative and nonoperative management of these soft tissue structures may occur in isolation or with concomitant procedures, including knee ligament reconstruction, total knee arthroplasty, tibial tuberosity osteotomy, or lysis of adhesions. With proper recognition of the role of these structures in knee pain, the orthopedic surgeon can offer a valuable primary or adjunctive treatment option for patients with knee pain, especially those without localizing signs of meniscal, ligamentous, or cartilage damage.
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Shang P, Liu HX, Zhang Y, Xue EX, Pan XY. A mini-invasive technique for severe arthrofibrosis of the knee: A technical note. Injury 2016; 47:1867-70. [PMID: 27346423 DOI: 10.1016/j.injury.2016.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/09/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Ping Shang
- Department of Rehabilitation, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China
| | - Hai-Xiao Liu
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China.
| | - Yu Zhang
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China
| | - En-Xing Xue
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China
| | - Xiao-Yun Pan
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi road, 325027 Wenzhou, China.
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Gwinner C, Märdian S, Schwabe P, Schaser KD, Krapohl BD, Jung TM. Current concepts review: Fractures of the patella. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2016; 5:Doc01. [PMID: 26816667 PMCID: PMC4717300 DOI: 10.3205/iprs000080] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Fractures of the patella account for about 1% of all skeletal injuries and can lead to profound impairment due to its crucial function in the extensor mechanism of the knee. Diagnosis is based on the injury mechanism, physical examination and radiological findings. While the clinical diagnosis is often distinct, there are numerous treatment options available. The type of treatment as well as the optimum timing of surgical intervention depends on the underlying fracture type, the associated soft tissue damage, patient factors (i.e. age, bone quality, activity level and compliance) and the stability of the extensor mechanism. Regardless of the treatment method an early rehabilitation is recommended in order to avoid contractures of the knee joint capsule and cartilage degeneration. For non-displaced and dislocated non-comminuted transverse patellar fractures (2-part) modified anterior tension band wiring is the treatment of choice and can be combined – due to its biomechanical superiority – with cannulated screw fixation. In severe comminuted fractures, open reduction and fixation with small fragment screws or new angular stable plates for anatomic restoration of the retropatellar surface and extension mechanism results in best outcome. Additional circular cerclage wiring using either typical metal cerclage wires or resorbable PDS/non-resorbable FiberWires increases fixation stability and decreases risk for re-dislocation. Distal avulsion fractures should be fixed with small fragment screws and should be protected by a transtibial McLaughlin cerclage. Partial or complete patellectomy should be regarded only as a very rare salvage operation due to its severe functional impairment.
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Affiliation(s)
- Clemens Gwinner
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Germany
| | - Sven Märdian
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Germany
| | - Philipp Schwabe
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Germany
| | - Klaus-D Schaser
- Department of Orthopaedics and Trauma Surgery - University Hospital Dresden, Germany
| | - Björn Dirk Krapohl
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Germany; Department of Plastic and Hand Surgery, St. Marien-Krankenhaus Berlin, Germany
| | - Tobias M Jung
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Germany
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