Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review.

PURPOSE: Arthrofibrosis is the most common post-operative complication of anterior cruciate ligament (ACL) reconstruction. Risk factors and management strategies for arthrofibrosis remain unclear. The purpose of this review was to: (a) describe existing definitions of arthrofibrosis, and (b) characterize the management strategies and outcomes of arthrofibrosis treatment. METHODS: MEDLINE, EMBASE, and PubMed were searched from database inception to search date (March 21, 2016) and screened in duplicate for relevant studies. Data regarding patient demographics, indications, index surgery, management strategy, and outcomes were collected. RESULTS: Twenty-five studies of primarily level IV evidence (88%) were included. A total of 647 patients (648 knees) with a mean age of 28.2 ± 1.8 years (range 14-62 years) were treated for arthrofibrosis following ACL reconstruction and followed for a mean 30.1 ± 16.9 months (range 2 months-9.6 years). Definitions of arthrofibrosis varied widely and included subjective definitions and the Shelbourne classification system. Patients were treated by one or more of: arthroscopic arthrolysis (570 patients), manipulation under anaesthesia (MUA) (153 patients), oral corticosteroids (31 patients), physiotherapy (81 patients), drop-casting (17 patients), epidural therapy combined with inpatient physiotherapy (six patients), and intra-articular interleukin-1 antagonist injection (four patients). All studies reported improvement in range of motion post-operatively, with statistically significant improvement reported for 306 patients (six studies, p range <0.001 to =0.05), and one study (18 patients) reporting significantly better results if arthrofibrosis was treated within 8 months of reconstruction (p < 0.03). The greatest improvements for extension loss were seen with drop-casting (mean 6.2° ± 0.6° improvement), whereas MUA produced the greatest improvement for flexion deficit (mean 47.8° ± 3.3° improvement). CONCLUSIONS: Arthrofibrosis is poorly defined and outcome measures range varies widely. Amongst the studies included in this review, arthrofibrosis was most commonly managed surgically by arthroscopic arthrolysis, and most patients showed at least some improvement, including six studies that reported statistically significant change in ROM. In studies that used a step-wise approach to treating arthrofibrosis, more than half of patients were successfully treated without an operation. A more well-defined concept of arthrofibrosis, along with large, prospective studies will provide a clearer understanding of how to describe and manage this complication. The issue of arthrofibrosis following ACL reconstruction is clinically relevant as it represents a common complication of a commonly performed operation that nonetheless remains poorly defined and without clear treatment guidelines. LEVEL OF EVIDENCE: Systematic Review of Level III and IV Studies, Level IV.

Maximum load to failure and tensile displacement of an all-suture glenoid anchor compared with a screw-in glenoid anchor.

PURPOSE: The purpose of this study was to evaluate the biomechanical behavior of an all-suture glenoid anchor in comparison with a more conventional screw-in glenoid anchor, with regard to maximum load to failure and tensile displacement. METHODS: All mechanical testing was performed using an Instron ElectroPuls E1000 mechanical machine, with a 10 N pre-load and displacement rate of 10 mm/min. Force-displacement curves were generated, with calculation of maximum load, maximum displacement, displacement at 50 N and stiffness. Pretesting of handset Y-Knots in bone analog models revealed low force displacement below 60 N of force. Subsequently, three groups of anchors were tested for pull out strength in bovine bone and cadaver glenoid bone: a bioabsorbable screw-in anchor (Bio Mini-Revo, ConMed Linvatec), a handset all-suture anchor (Y-Knot, ConMed Linvatec) and a 60 N pre-tensioned all-suture anchor (Y-Knot). A total of 8 anchors from each group was tested in proximal tibia of bovine bone and human glenoids (age range 50-90). RESULTS: In bovine bone, the Bio Mini-Revo displayed greater maximum load to failure (206 ± 77 N) than both the handset (140 ± 51 N; P = 0.01) and the pre-tensioned Y-Knot (135 ± 46 N; P = 0.001); no significant difference was seen between the three anchor groups in glenoid bone. Compared to the screw-in anchors, the handset all-suture anchor displayed inferior fixation, early displacement and greater laxity in the bovine bone and cadaveric bone (P < 0.05). Pre-tensioning the all-suture anchor to 60 N eliminated this behavior in all bone models. CONCLUSIONS: Handset Y-Knots display low force anchor displacement, which is likely due to slippage in the pilot hole. Pre-tensioning the Y-Knot to 60 N eliminates this behavior. LEVEL OF EVIDENCE: I.