Arthrofibrosis Library

"Functional outcomes are dependent on the time lapse between index post-traumatic surgery and arthroscopic lysis of adhesions. The best results are obtained when the procedure is performed within 6-7 mo after the index operation. Therefore, time since first surgical procedure is a prognostic factor, and the expected results may not be provided in cases of chronic stiffness or regional muscle contracture."

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 Apr 11;8(5):e429-e435. doi: 10.1016/j.eats.2019.01.005. PMID: 31194118; PMCID: PMC6554358.

"While arthrofibrosis after TKA can be associated with significant improvements in ROM and KSS, caution is advised given high rates of revisions, reoperations, and complications. "

Revision Total Knee Arthroplasty for Arthrofibrosis.. Rutherford RW, Jennings JM, Levy DL, Parisi TJ, Martin JR, Dennis DA. J Arthroplasty.2018 Mar 23. [Epub ahead of print]

"Arthrofibrosis remains a rare but potentially devastating complication after ACL [anterior cruciate ligament] reconstruction, and roughly 2 % of patients had post-operative stiffness that required intervention. Female patients are at higher risk of arthrofibrosis. However, when patients develop severe motion complications after ACL injury, interventions are generally effective in preventing permanent arthrofibrosis."

Procedural intervention for arthrofibrosis after ACL reconstruction: trends over two decades. Sanders TL, Kremers HM, Bryan AJ, Kremers WK, Stuart MJ, Krych AJ. Knee Surg Sports Traumatol Arthrosc. 2017 Feb;25(2):532-537.

"The issue of arthrofibrosis following ACL [anterior cruciate ligament] 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."

Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review. Ekhtiari S, Horner NS, de Sa D, Simunovic N, Hirschmann MT, Ogilvie R, Berardelli RL, Whelan DB, Ayeni OR. Knee Surg Sports Traumatol Arthrosc. 2017 Mar 4. doi: 10.1007/s00167-017-4482-1. [Epub ahead of print]

"... interventions to regain full extension may include bracing, physical therapy, and open or arthroscopic surgery. Open surgical approaches to restore full motion often demand extensive recovery and promote further adhesions and loss of motion, which has led to the advent of arthroscopic techniques to address these pathologies.

"We present a safe, effective, and reproducible arthroscopic technique for posteromedial capsular release to address knee flexion contractures."

Arthroscopic Posteromedial Capsular Release. Dean CS, Chahla J, Mikula JD, Mitchell JJ, LaPrade RF. Arthrosc Tech. 2016 Jun; 5(3): e495–e500. [Link to full text free article with illustrations]

"CPM [continuous passive motion] following operative fixation for a fracture of the tibial plateau may reduce the risk of the development of arthrofibrosis, particularly in patients who also undergo prolonged provisional external fixation."

Arthrofibrosis of the knee following a fracture of the tibial plateau. Haller JM, Holt DC, McFadden ML, Higgins TF, Kubiak EN. Bone Joint J. 2015. 97-B(1):109-14. 

"Various risk factors for stiffness after TKA [total knee arthroplasty] have been identified, including reduced preoperative knee range of motion, history of prior knee surgery, etiology of arthritis, incorrect positioning or oversizing of components, and incorrect gap balancing.

"Mechanical and associated causes, such as infection, arthrofibrosis, complex regional pain syndrome, and heterotopic ossification, secondary gain issues have also been identified."

Stiffness after total knee arthroplasty. Manrique J, Gomez MM, Parvizi J. J Knee Surg. 2015 Apr;28(2):119-26.

"Post-traumatic knee stiffness is a common condition. It requires an accurate assessment of the injuries. Any CRPS [chronic regional pain syndrome] must be controlled and fracture sites must have healed. A 3 to 6-month wait seems reasonable before any release surgery is carried out, however the final decision is made on a case-by-case basis according to the clinical and imaging findings...

"There is practically no role for isolated manipulation under anaesthesia. Arthroscopic and open techniques can be used in combination within a well thought-out surgical plan to treat the various components of the stiffness in a single procedure. Drainage, control of postoperative pain and rehabilitation (early, daily, extensive and monitored) are essential to the success of this procedure."

Post-traumatic knee stiffness: surgical techniques. Pujol N, Boisrenoult P, Beaufils P. Orthop Traumatol Surg Res. 2015 Feb;101(1 Suppl):S179-86. doi: 10.1016/j.otsr.2014.06.026. Epub 2015 Jan 9. [Link to full illustrated article and free pdf download]

Between 2010 and 2014, 16 patients were treated by arthroscopic arthrolysis. Extension deficit decreased more than 10° from 13.6° to 3°, while flexion increased over 26° from 91.6° to 117.8°.

Surgery involved "arthroscopic release of scar tissue and removal of the fibrotic Hoffa fat pad".

[Arthroscopic arthrolysis for the treatment of movement disorders of the knee.] [Article in German] Tröger M, Holschen M. Oper Orthop Traumatol. 2014 Aug;26(4):361-8.

This was a study of patients with "(p)rolonged knee motion restriction after anterior cruciate ligament (ACL) reconstruction, persistent decreased patella mobility, or extension deficit".

The original paper is in German. The abstract does not go into detail about the improvement in range of motion.

They noted that despite surgery to release the restricted tissues, and a prolonged rehab, "78% of patients develop knee osteoarthritis within 5 years".

[Arthroscopic treatment of arthrofibrosis after ACL reconstruction. Local and generalized arthrofibrosis.] [Article in German] Mayr HO, Stöhr A. Oper Orthop Traumatol. 2014 Feb;26(1):7-18.

"Patients can reliably expect an improvement after arthroscopic lysis of adhesions for a stiff TKA [total knee arthroplasty] using a standardized arthroscopic approach; however, patients achieved approximately half of the improvement that was obtained at the time of surgery."

Arthroscopic lysis of adhesions for the stiff total knee: results after failed manipulation. Tjoumakaris FP, Tucker BC, Post Z, Pepe MD, Orozco F, Ong AC. Orthopedics. 2014 May;37(5):e482-7.

"MUA [manipulation under anaesthesia] for a stiff primary TKA [total knee arthroplasty] is an efficacious procedure to restore range of motion. Early gains in motion appear to be maintained at long term, and in some cases patients may gradually improve further at mid-term follow-up. The risk of periprosthetic fracture is low, making MUA a safe option for improving knee range of motion."

Long-term outcomes of MUA for stiffness in primary TKA. Pivec R, Issa K, Kester M, Harwin SF, Mont MA. J Knee Surg. 2013 Dec;26(6):405-10.

"Revision knee data from six joint arthroplasty centers were compiled for 2010 and 2011 to determine mechanism of failure and time to failure. Aseptic loosening was the predominant mechanism of failure (31.2%), followed by instability (18.7%), infection (16.2%), polyethylene wear (10.0%), arthrofibrosis (6.9%), and malalignment (6.6%)."

Why are total knees failing today? Etiology of total knee revision in 2010 and 2011. Schroer WC, Berend KR, Lombardi AV, Barnes CL, Bolognesi MP, Berend ME, Ritter MA, Nunley RM. J Arthroplasty 2013 28(8 Suppl):116–119.

The authors state that ".... Postoperative care is crucial for the successful outcome of arthroscopic adhesiolysis. For example, an ROM gain may be lost due to a prolonged period of immobility caused by postoperative pain."

They also found "...no association between the cause of arthrofibrosis and the increase in postoperative ROM [range of motion]. The duration of disease was significantly related to the postoperative recovery of ROM. Age had no significant influence on the postoperative recovery of ROM".

The first point, about pain management, to be a really critical statement, and a major factor in why the secondary referral centers succeed more often - they really focus on this matter of post operative pain prevention and management to allow the ROM exercises and stretches to continue without pain being a major inhibitor.

[Note: Arthroscopic adhesiolysis is the surgical procedure performed under keyhole surgery of breaking down the adhesions in a structured way, starting with a portal above the patella on the lateral side (superolateral portal) freeing the adhesions, and then changing portals as the tissue frees up until all areas are freed.]

Prognostic factors of arthroscopic adhesiolysis for arthrofibrosis of the knee. Kim YM, Joo YB. Knee Surg Relat Res. 2013 Dec;25(4):202-6. [Link to full text free article with images]

"The authors recommend arthroscopic lysis of adhesions as a treatment option for stiff knees after TKA [total knee arthroplasty] that fails after at least 3 months of nonoperative treatment."

Arthroscopic lysis of adhesions for stiff total knee arthroplasty. Schwarzkopf R, William A, Deering RM, Fitz W. Orthopedics. 2013 Dec;36(12):e1544-8.

"Though the precise function of the IFP [infrapatellar fat pad] is unknown, studies have shown that it may play a role in the biomechanics of the knee or act as a store for reparative cells after injury. Inflammation and fibrosis within the IFP, caused by trauma and/or surgery can lead to a variety of arthrofibrotic lesions including Hoffa's disease, anterior interval scarring and infrapatellar contracture syndrome."

Evaluation and treatment of disorders of the infrapatellar fat pad. Dragoo JL, Johnson C, McConnell J. Sports Med. 2012 Jan 1;42(1):51-67.

"....there is a connection between BMP-2 concentration and soft-tissue density in arthrofibrosis after TKA [total knee arthroplasty]. This opens up the possibility of conducting a prophylaxis against arthrofibrosis in risk patients by influencing the BMP-2 pathway."

BMP-2 Dependent Increase of Soft Tissue Density in Arthrofibrotic TKA. Pfitzner T, Röhner E, Krenn V, Perka C, Matziolis G. Open Orthop J. 2012;6:199-203.

"...arthroscopic lysis of adhesions should be considered in the treatment of patients with pain and poor range of motion after TKR [total knee replacement]. Conditions such as infection, loosening or improper component sizing, and malalignment should be sought before arthrofibrosis is diagnosed and arthroscopic management prescribed."

Arthroscopic arthrolysis for arthrofibrosis of the knee after total knee replacement. Hegazy AM, Elsoufy MA. HSS J. 2011 Jul;7(2):130-3. [Link to free full text article]

"The average volume of the human knee in this study was between 65 and 110 mL (±1 standard deviation of mean of 87.5 mL). Although patients with chronic knee pain may have pain from multiple sources, some may have diminished knee volume, and selected arthroscopic releases can restore knee volume to near-normal levels."

Restoration of knee volume using selected arthroscopic releases. Dragoo JL, Miller MD, Vaughn ZD, Schmidt JD, Handley E. Am J Sports Med. 2010 Nov;38(11):2288-93. [Link to free full text article.]

"Perioperative rehabilitation that emphasizes restoration of normal knee range of motion appears to improve outcomes in patients with arthrofibrosis who undergo arthroscopic scar resection. In support of our hypothesis, patients who achieved greater knee range of motion had better subjective knee scores."

Perioperative rehabilitation using a knee extension device and arthroscopic debridement in the treatment of arthrofibrosis. Biggs-Kinzer A, Murphy B, Shelbourne KD, Urch S. Sports Health. 2010 Sep;2(5):417-23. [Link to free full text article]

"Patients treated with HIS [high intensity stretch] mechanical therapy demonstrated significantly reduced rates of re-hospitalization which corresponded to reduced knee-attributable medical costs."

Knee-attributable medical costs and risk of re-surgery among patients utilizing non-surgical treatment options for knee arthrofibrosis in a managed care population. Stephenson JJ, Quimbo RA, Gu T. Curr Med Res Opin. 2010 May;26(5):1109-18.

"...the patient received placement of a silicone interpositional membrane with the goal of minimizing scar formation. Arthrofibrosis recurred, ..."

Failure of interpositional membrane to prevent recurrent arthrofibrosis. Meehan JP, Abbi G. J Knee Surg. 2010 Sep;23(3):175-9.

"Marked limitations in knee flexion range of motion and quadriceps activity were addressed using the Graston Technique to deal with soft-tissue adhesions; traditional physical therapy care was also provided. Clear improvement in range of motion and quadriceps activity and function was noted..."

Treatment of knee arthrofibrosis and quadriceps insufficiency after patellar tendon repair: a case report including use of the graston technique. Black DW. Int J Ther Massage Bodywork. 2010 Jun 23;3(2):14-21.

"Stiffness after TKA is a common problem that can be improved with MUA and/or arthroscopic lysis of adhesions with few complications"

How to treat the stiff total knee arthroplasty?: a systematic review. Fitzsimmons SE, Vazquez EA, Bronson MJ. Clin Orthop Relat Res. 2010 Apr;468(4):1096-106.

"...hypoxia and associated oxidative stress are potential therapeutic targets for fibrosis and metaplastic progression of idiopathic arthrofibrosis after TKA."

Mast cells and hypoxia drive tissue metaplasia and heterotopic ossification in idiopathic arthrofibrosis after total knee arthroplasty. Freeman TA, Parvizi J, Dela Valle CJ, Steinbeck MJ. Fibrogenesis Tissue Repair. 2010 Sep 1;3:17. [Link to free full text article]

"Children with tibial spine fractures are at risk for arthrofibrosis. Stabilization of the fracture is important to allow early postoperative rehabilitation. Should stiffness occur, manipulation of the knee should be performed only in conjunction with lysis of adhesions."

Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents. Vander Have KL, Ganley TJ, Kocher MS, Price CT, Herrera-Soto JA. Am J Sports Med. 2010 Feb;38(2):298-301.

"Fibrosis represents a major global disease burden, yet a potent antifibrotic compound is still not in sight. Part of the explanation for this situation is the difficulties that both academic laboratories and research and development departments in the pharmaceutical industry have been facing in re-enacting the fibrotic process in vitro..."

"In order to appreciate the task which in vitro screening of antifibrotics is up against, we will first review the fibrotic process..."

Focus on collagen: in vitro systems to study fibrogenesis and antifibrosis state of the art. Chen CZ, Raghunath M. Fibrogenesis Tissue Repair. 2009 Dec 15;2:7. [Link to free full text article]

"MUA [manipulation under anaesthesia] has a role in the treatment of early stiffness with excellent immediate outcomes. We advocate that MUA should be the first line of management for stiff knee arthroplasties after failed physiotherapy."

Manipulation under anaesthesia for stiffness following knee arthroplasty. Mohammed R, Syed S, Ahmed N. Ann R Coll Surg Engl. 2009 Apr;91(3):220-3. [Link to free full text article]

"Based on our current findings, we suggest that ROS/RNS [reactive oxygen and nitrogen species] initiate and sustain the arthrofibrotic response driving aggressive fibroblast proliferation and subsequent HO. [heterotopic ossification]"

Reactive oxygen and nitrogen species induce protein and DNA modifications driving arthrofibrosis following total knee arthroplasty. Freeman TA, Parvizi J, Della Valle CJ, Steinbeck MJ. Fibrogenesis Tissue Repair. 2009 Nov 13;2(1):5. [Link to free full text article]

"The profibrotic cytokines TGF-beta and PDGF play an important role in the pathogenesis of arthrofibrosis. Both cytokines are key mediators of tissue fibrosis."

[Localisation of TGF-beta and PDGF and their relevance for the pathogenesis of arthrofibrosis]. [In German] Zeichen J, Haeder L, Jagodzinski M, Lobenhoffer P, Bosch U, Brand J. Unfallchirurg. 2008 Feb;111(2):79-84.