Arthrofibrosis Following Anterior Cruciate Ligament Reconstruction

@#Introduction: Anterior cruciate ligament (ACL) tear is a frequent injury and its reconstruction is among the most commonly performed orthopaedic surgical procedures. ACL reconstruction generally yields good results. However, its recovery can be hampered by the development of postoperative complications. The aim of this study was to review complications following arthroscopic ACL reconstruction done in Hospital Raja Permaisuri Bainun, Ipoh and Hospital Teluk Intan, Perak with the emphasis on arthrofibrosis. Arthrofibrosis is defined as a loss of 15 degrees extension or more, with or without flexion loss compared to the contralateral knee. Materials and Methods: The study is based on a series of retrospective cases, on which medical records of 200 patients who underwent ACL reconstruction surgeries between March 2007 and December 2014 were reviewed. Follow-up treatment records were available for 166 patients (83%). The data was analysed to identify the risk factors for developing complications with an emphasis on arthrofibrosis. Results: Eight patients (5%) developed arthrofibrosis in the post-operative period. Early surgical intervention, preoperative limited range of motion and female gender are the risk factors correlate with arthrofibrosis. However, the type of graft used and meniscal procedure do not have a significant correlation with the development of arthrofibrosis. Other complications encountered are local infections, hypertrophic scar and chronic regional pain syndromes. Conclusion: The 5% incidence of arthrofibrosis following an ACL reconstruction in our centres can be reduced with proper preventive measures which include thorough preoperative evaluation, proper patient selection, restoration of ROM prior to surgery and proper timing of surgery.

Rigidez en cirugía de reconstrucción del ligamento cruzado anterior / Knee stiffness in anterior cruciate ligament reconstruction

La rigidez de rodilla en cirugía de Reconstrucción del Ligamento Cruzado Anterior (R-LCA) es una complicación devastadora, alcanzando una incidencia variable entre el 4% y el 38%. La definición de artrofibrosis es aún poco clara, lo que ha llevado a distintos esquemas terapéuticos. Conocer la etiopatogenia es clave para entender los procesos y las posibles alternativas de tratamiento. Distintas clasificaciones han sido descritas, siendo la de Shelbourne la más usada, debido a su valor pronóstico asociado. El objetivo del tratamiento en una rodilla estable es mejorar la movilidad articular, la satisfacción del paciente, y disminuir el riesgo de artrosis a largo plazo. El tratamiento se puede dividir en quirúrgico y conservador. Ese último, se enfoca principalmente en buscar la causa y lograr una prevención e intervención temprana, siendo el manejo que con mayor frecuencia se realiza. El tratamiento quirúrgico es una opción cuando el tratamiento conservador falla. Se realizó una revisión de la literatura y de 150 pacientes sometidos a R-LCA, de los cuales 4 presentaron artrofibrosis a un seguimiento de 2 años. Además, presentamos nuestro algoritmo de manejo terapéutico.

Knee stiffness in Anterior Cruciate Ligament Reconstruction (ACL-R) is a devastating complication, with a variable incidence of 4% to 38%. The definition of arthrofibrosis is still unclear, which has led to different therapeutic schemes. Knowing the etiopathogenesis is key to understanding the processes and possible treatment alternatives. Different classifications have been described, with Shelbourne being the most used, due to its associated prognostic value. The aim of treatment in a stable knee is to improve joint mobility, patient satisfaction, and decrease the risk of long-term osteoarthritis. The treatment can be divided into operative and non-operative. The latter focuses mainly on finding the cause and achieving prevention and early intervention, being the management that is most frequently performed. Surgical treatment is an option when conservative treatment fails. A review of the literature and of 150 patients undergoing R-LCA was performed, of which 4 presented arthrofibrosis at a 2-year follow-up. In addition, we present our therapeutic management algorithm.

Effect of surgical scope on postoperative fibrosis of knee joints / 中国骨伤

Knee arthrofibrosis is a common complication after surgery, which is one of the key factors affecting the surgical outcome. It often causes the decrease of joint activity, chronic arthralgia, degeneration of cartilage tissues and joint disuse change, which seriously affects the daily life of the patients. How to reduce the occurrence of knee arthrofibrosis is the key to improve the expected effect of surgery, which is also an important problem to solve in clinical medicine; with our team's previous and recent research, we found that the degree of knee arthrofibrosis is closely related to the rang of the surgical. The use of minimally invasive and arthroscopic treatment can reduce the damage to synovial, cartilage and fat pad tissue, at the same time, combining with early postoperative rehabilitation training is the future effective prevention of postoperative arthrofibrosis of knee.

Incidencia de artrofibrosis en reconstrucción primaria del ligamento cruzado anterior (LCA) con autoinjerto del tendón del cuádriceps / Incidence of arthrofibrosis in primary reconstruction of the anterior cruciate ligament (ACL) using quadriceps tendon graft

Introducción La artrofibrosis de rodilla es una complicación importante que se puede presentar en cirugía de reconstrucción primaria del ligamento cruzado anterior (LCA) y afecta negativamente a los resultados por pérdida de flexoextensión de la rodilla. El objetivo del estudio es establecer la existencia de artrofibrosis en reconstrucción primaria del LCA en pacientes en los cuales se utilizó técnica de autoinjerto de tendón del cuádriceps. Materiales y métodos Se realizó un estudio retrospectivo, una serie de casos, en que se incluyó a todos los pacientes con lesión del LCA a quienes se practicó cirugía durante un período de observación de 4 años, en los cuales se utilizó autoinjerto de tendón del cuádriceps sin taco óseo rotuliano. Resultados Se encontró a 127 pacientes con cirugía primaria del LCA con autoinjerto de tendón del cuádriceps sin bloqueo óseo rotuliano durante el período de observación. Cinco pacientes (3,9%) presentaron artrofibrosis que se clasificaron, de acuerdo con la clasificación de Shelbourne, como un paciente de tipo I, tres pacientes de tipo II y un paciente de tipo III. A todos los pacientes se les realizó artrólisis artroscópica total y un plan agresivo de rehabilitación. Todos recuperaron los rangos de movilidad y retornaron a su actividad deportiva. Discusión Mejoras en la técnica quirúrgica, en instrumental quirúrgico, en los protocolos de rehabilitación acelerada y en minimizar los factores de riegos asociados han disminuido considerablemente esta complicación. Nivel de evidencia clínica Nivel IV.

Background Knee arthrofibrosis is a significant complication that can occur in primary reconstruction surgery of the anterior cruciate ligament (ACL), and adversely affects the results due to loss of flexion-extension of the knee. The aim of this study is to establish the presence of arthrofibrosis in primary ACL reconstruction in patients in whom a quadriceps tendon autograft reconstruction technique was performed. Materials and methods A retrospective case series study was conducted over a four-year observation period on all patients with ACL lesion who were subjected to surgery, in which autograft of the tendon quadriceps without patellar bone block was used. Results A total of 127 patients underwent primary ACL surgery with quadriceps tendon autograft without patellar bone block during the observation period. The five (3.9%) patients that presented with arthrofibrosis were classified according to the Shelbourne classification as one type I patient, three type II patients, and one type III patient. All patients underwent total arthroscopic arthroscopy and aggressive rehabilitation. They all regained mobility ranges and returned to their sporting activity. Discussion Improvements in surgical technique, surgical instruments, accelerated rehabilitation protocols, and minimisation of associated risk factors have significantly reduced the incidence of arthrofibrosis. Evidence level Level IV.

Effects of 5-aza-2-deoxycyfidine on proliferation and activation of myofibroblast in arthrofibrosis of the knee / 实用医学杂志

Objective To investigate the effect of methyltransferase inhibitor 5-Aza-dC (5-aza-2’-deoxycytidine) on proliferation and activation of myofibroblasts in arthrofibrosis of the knee. Methods The model of arthrofibrosis of rat knee was firstly established.Myofibroblasts were isolated and cultured from the posterior capsule of rat knee. Cells were identified by immunofluorescence.Myofibroblasts were treated with 2 μmol/L 5-Aza-dC. The expression levels ofα-SMA、col1A1 mRNA and protein in myofibroblasts before and after the treatment with 5-Aza-dC were detected by RT-PCR and Western blotting,respectively.The proliferation rate of these myofibroblasts were detected by MTT method,and the cell cycle was detected by flow cytometry of DNA content in each phase. Results The extension of rat knee in arthrofibrosis model was significantly decreased. α-SMA protein,the representational protein of myofibroblast,was largely expressed in the isolated cells from model knees. The expression levels ofα-SMA、col1A1 mRNA and protein in myofibroblasts were decreased after the treatment with 5-Aza-dC and the growth of myofibroblasts was also slowed down. Conclusion The methyltransferase inhibitor 5-Aza-dC may become a potential therapeutic drug in the treatment of arthrofibrosis of the knee through inhibiting the proliferation of myofibroblasts.

Prognostic Factors of Arthroscopic Adhesiolysis for Arthrofibrosis of the Knee

PURPOSE: To assess the results of arthroscopic adhesiolysis for arthrofibrosis of the knee and to investigate possible prognostic factors. MATERIALS AND METHODS: Among the patients who developed arthrofibrosis after knee joint surgery, 68 patients who underwent arthroscopic adhesiolysis and were available for at least one-year follow-up were evaluated with regard to the Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee score, patient satisfaction, and range of motion (ROM) of the knee. The influence of possible prognostic factors including the cause of arthrofibrosis, duration of disease, and age of the patient on the postoperative ROM was analyzed. RESULTS: Sixty-one patients (89.7%) obtained an average increase of 48.6degrees in ROM; however, the remaining seven patients (10.3%) did not show any increase at the final follow-up. The Lysholm knee score and IKDC subjective knee score increased significantly at the final follow-up. Patient satisfaction was high or very high in 89.7% of the patients at the final follow-up. There was no association between the cause of arthrofibrosis and the increase in postoperative ROM. The duration of disease was significantly related to the postoperative recovery of ROM. Age had no significant influence on the postoperative recovery of ROM. CONCLUSIONS: We believe that arthroscopic adhesiolysis is effective for the treatment of intraarticular arthrofibrosis. In particular, the duration of the disease had significant influence on the postoperative outcome.

Risk factors of stiff knees after primary total knee arthroplasty / 中国矫形外科杂志

[Objective]To evaluate the incidence and predictors of stiff knees after primary TKA.[Method]A retrospective review was given to the data from 1216 patients undergoing primary total knee arthroplasty between October 1996 and October 2006.Forty-five stiff TKA patients with a 1-year postoperative flexion range of less than 90?was taken as treatment group.Forty-five TKA patients with greater than 90? flexion at 1 year postoperative as control group.The age,sex,body mass index,American Society of Anesthesiologists(ASA) rating,surgeon,implant type,and fixation of the control group were matched to those of the treatment group.A case-control study was conducted to determine predictive factors of stiff TKA.[Result]No significant differences were found with regard to the mean age,ratio of sex and preoperative medical comorbidities.Preoperative flexion and intraoperative flexion were predictive of ultimate postoperative flexion(P=0.001 and P=0.039,respectively).Preoperative and postoperative relatively decreased patellar heightwere significantly correlated with postoperative stiffness(P=0.001).[Conclusion]Stiffness post-TKA is multifactorial,careful attention to surgical exposure,restoring gap kinematics,minimizing surgical trauma to the patellar ligament/extensor mechanism,appropriate implant selection,and physiotherapy may all serve to reduce the incidence of post-TKA stiffness.