Recommendations for the treatment of arthrofibrosis

• Arthrofibrosis is a serious disease and should be treated by a multidisciplinary team.
• Arthrofibrosis patients must be treated differently to patients who are healing normally.
• Early, modified treatment is essential for preventing arthrofibrosis from becoming chronic. Modified techniques are essential during surgery and physiotherapy.
• Chronic inflammation drives an ongoing, dysfunctional wound healing process.
• Fat pads (such as the IFP) are almost always involved in arthrofibrosis, but proper consideration is often not given to this during surgery and physiotherapy.
• Arthrofibrosis is frequently caused by surgery – it is an inappropriate healing response.
• Symptoms are highly variable and depend on the joint and tissues that are fibrotic.

Surgery Recommendations from Dr Steven Singleton

• Do not over-treat - use as non-traumatic (minimal) surgery as possible, with only the necessary lysis of adhesions, not the removal of all scar tissue – minimise cell damage.
• Do not raise a tourniquet unless absolutely necessary – avoid hypoxia.
• Excellent control of bleeding through the use of a cauterising device and insufflation – avoid inflammatory and fibrotic mediators in blood.
• Minimise pain through the use of anaesthetics, nerve block, or several nerve blocks, placed before surgery – minimalize the contribution of inflamed nerves that release Substance P and other pro-inflammatory, pro-fibrotic mediators, permit therapy such as passive motion.
• Avoid use a rotary cutting tool - minimise cell damage.
• Immediate, continuous, gentle post-op use of a continuous passive motion machine – reduce adhesions and contractions.

Physiotherapy Recommendations from Sebastiano Nutarelli

• Do not try to force improvement, do things little and often to try to regain range of motion - minimise cell damage & inflammation.
• Regaining muscle mass is not the goal anymore - get joint back to some level of homeostasis (normality) first and foremost - minimise cell damage & inflammation.
• Don’t attempt to force flexion or extension using overpressure - minimise cell damage & inflammation.
• In knees, use crutches for at least 6 weeks post-op, then carefully increase load using one crutch, and then none, as tolerated – Minimise damage to the infrapatellar fat pad.
• Extensive post-op use of a continuous passive motion machine, up to 12 to 24 hours a day, with increases of only 1 degree in range of motion at a time to avoid tearing tissue - reduce adhesions and contractions.
• Strengthening of the muscles, for example quadriceps, should Not be attempted until the joint is no longer painful and inflamed. This can come later. Minimise damage to the infrapatellar fat pad.
• Use of biofeedback is helpful.
• Blood flow restriction should only be used well down the track after the joint has recovered, and then extremely carefully since hypoxia can re-stimulate myofibroblasts - minimise cell damage, fibrosis & inflammation.
• Use careful, gentle physiotherapy post-op or injury to avoid arthrofibrosis in the first place – don’t tell patients to push through the pain, listen and adapt the protocol to what their joint is able to tolerate.

Rheumatology Recommendations from Ass. Prof. Rob Will and Dr Kayley Usher

• Have early testing done by a rheumatologist to get the correct diagnosis.
• Evidence of inflammation may be relatively scant in low grade inflammation.
• There may be a systemic inflammatory process that needs to be treated.
• Good control of pain is important, there are many interactions between the nervous system and the immune system, patients may need to see a pain specialist.
• People with auto-inflammatory and auto-immune conditions, including diabetes, are at greatly increased risk of developing arthrofibrosis.
• Early post-op medications to reduce inflammation and fibrosis may prevent the feedback lops that create chronic fibrosis.
• Medications that may assist include metformin, Losartan, Pregabalin as well as a range of modern anti-inflammatory medications including anti-TNF-α antibodies and JAK inhibiters.
• Good sleep, diet and stress reduction are important.
• NSAIDS (other than aspirin) should not be taken for longer than a week to prevent downregulation of the production of resolvins.

See Expert Primers interviews at https://www.arthrofibrosis.info/post/arthrofibrosis-expert-primer