arthroscopic management of postoperative arthrofibrosis of the knee joint: indication, technique,...

Arthroscopy: The Journal of Arthroscopic and Related Surgery 10(6):591-597 Published by Raven Press, Ltd. © 1994 Arthroscopy Association of North America

Arthroscopic Management of Postoperative of the Knee Joint: Indication, Technique,

Arthrofibrosis and Results

Wilhelm Klein, M.D., Nilesh Shah, M.D., and Andreas Gassen, M.D.

Summary: From October 1987 through March 1991, 58 patients with postoperative joint stiffness underwent arthroscopic fibroarthrolysis. Forty-six knees in 46 patients were followed. The indication for arthroscopic management was decreased range of motion after surgery. Eighty-seven percent had been treated by arthrotomy. Thirteen percent had been managed by arthroscopic surgery. The indication for primary surgery was a torn anterior cruciate ligament in 74%. The mean interval between arthroscopic fibroarthrolysis and follow-up was 22.1 months. The average age was 32.7 years. A modified Blauth and J/iger score was used for classification of fibroarthrosis: grade I (mild 17.4%), grade II (moderate 63%), grade III (severe 15.2%), and grade IV (bad 4.3%). The gain in range of motion was evaluated by the Cauchoix index: the results were excellent in 54.5%, good in 21.7%, and fair and poor in 23.8%. Pain was evaluated according to a modification of the Lysholm score: 80.4% of the patients experienced a reduction in pain. The sports activity level in the Tegner activity scale increased from 2.3 to 4.8. Patient satisfaction was excellent or good in 56.5% (n = 26), fair in 39.1% (n = 18), and poor in 4.3% (n = 2). On the basis of our retrospective study, we feel that arthroscopic fibroarthrolysis is of benefit to the patients with postoperative joint stiffness even after a prolonged period. Key Words: Postoperative arthrofibrosisw Arthroscopic fibroarthrotysis---Cauchoix index--Technique.

Arthrofibrosis linked with soft-tissue problems, pain and loss of knee function, prolonged mobilization, and formation of scar tissue after knee ligament surgery have been described by several inves- tigators (1-13). In Germany, postoperative joint stiffness is still treated by open fibroarthrolysis by a great majority of surgeons. The obvious disadvan- tages of this treatment are the renewed surgical t rauma with new scar tissue and prolonged rehabilitation (14-16). Initially diagnostic arthroscopy ap- peared to be useless in a joint with reduced space. However, some causes of fibroarthrosis were first identified by arthroscopic means (1,8-11).

Hypertrophic fibrous tissues located near the fat

From the Department of Rheumatology and Arthroscopic Sur- gery, Diisseldorf, Germany (W.K.A.G.), and the Sangini Bone and Joint Clinic, Ellisbridge, Ahamedabad, India (N.S.).

Address correspondence and reprint requests to Dr. Wilhelm Klein, St. Swidbert 17, 40489 Diisseldorf, Germany.

pad associated with loss of motion and patella entrapment had been described earlier as intrapatellar contracture syndrome (9,11,17). Fischer saw dras- tic improvement after arthroscopic excision of this "extens ion b lock" (11). In I977, O 'Connor described for the first time a scar band reaching from the suprapatellar pouch to the infrapatellar region that was responsible for loss of flexion (10).

Today ar throscopic surgical techniques have reached a degree of effectiveness that permits ade- quate f ibroarthrolysis without a r thro tomy. The minimal joint trauma guarantees early mobilization and rapid rehabilitation. Postoperative pain is dras- tically reduced. The diagnosis, indication, operative technique, and results of arthroscopic fibroarthrolysis already have been published (16-27). We performed arthroscopic arthrolysis on 58 patients who had undergone diverse surgical procedures in other departments and experienced pain and loss of range

591

592 W. KLEIN ET AL.

of motion between October 1987 and March 1991. We report here our experience and results of arthroscopic arthrolysis of 46 patients we were able to follow. Improvement in range of motion was documented in degrees of flexion and extension. Besides the gain in range of motion, the relative range of motion amplitude was documented using the Can- choix index. We modified parts of the Lysholm score for pain evaluation. The Tegner activity scale and subjective assessment of the surgical success were documented in this follow-up study.

INDICATIONS AND CONTRAINDICATIONS

The indication for arthroscopic fibroarthrolysis was postoperative loss of motion not responding to physiotherapy within 6 months. Contraindications for the arthroscopic procedure were arterial occlu- sion disease, degenerative joint disease grade III, axis deviation of >5 ° , and sympathetic reflex dys- trophy. Relative contraindications were hemo- philia, excessive obesity, noncompliant patients, and patients seeking compensation.

TECHNIQUE OF ARTHROSCOPIC FIBROARTHROLYSIS

Diagnostic and operative arthroscopy of fibroarthrosis were performed in a supine position. A tourniquet and a leg holder were used. Distension of the joint space was provided by gravity flow 1 m above the operating table through an additional suprapatellar in-flow portal. An anterolateral standard portal for diagnostic arthroscopy was used. When vi- sualization problems were created by scar tissue or complete obliteration of joint compartments, motorized instruments introduced through an antero- medial portal were used (4.5- or 5.5-mm synovial resector or meniscus cutter). Single fibrous bands were cut with a punch. The cartilaginous areas cov- ered with fibrous tissue were cleaned with nonag- gressive hand and motorized instruments. The scar tissue covering the cartilage surface was peeled off whenever possible. In nearly all cases it was nec- essary to change portals several times. Sometimes the arthroscopic work was handicapped by unwel- come adherence stick of scar tissue to the mouth or tube of the motorized suction device. The majority of the cases required arthroscopic fibroarthrolysis in the anterior compartment and the suprapatellar pouch. We did not use electrocautery or epineph- rine to reduce bleeding. When the operative proce-

dure was finished, the tourniquet and leg holder were released, leaving the draping and operative field sterile. Then the affected knee was gently moved under anesthesia to full flexion and extension whenever possible. Ten milliliters of bupiva- caine 0.5% was instilled, drains were inserted, and a wound dressing was applied.

POSTOPERATIVE TREATMENT

On the first postoperative day the drains were removed. The still open arthroscopic portal inci- sions were dosed with sterile strips. The affected knees were treated by continuous passive motion, and isometric exercises were started. The degree of range of motion was adjusted to the patient's pain. A constant passive motion exerciser was used on an outpatient basis for 4 weeks (28). Partial weight bearing with 30% of the patient's body weight was allowed for the next 3 weeks according to the patient's postoperative pain. In addition, physiotherapy for active quadriceps and hamstrings muscle exercise were performed. We did not use any night splints.

MATERIALS AND METHODS

From October 1987 through March 1991 arthroscopic surgery was performed in 58 patients with postoperative knee stiffness. Forty-six patients could be followed. The time from the day of arthroscopic arthrolysis to follow-up was 9-24 months (average 22.1). Joint stiffness was present in the right knee in 26 cases (57%), and the left knee was affected in 20 cases (43%). No bilateral stiffness occurred in our patients.

Age range The age range was 20-50 years (average 32.7):

30.5% of the patients were 20-29 years of age, 26% were 30-39, 32.6% were 40--49, and 10.9% were >50.

Time between previous surgery and subsequent arthroseopic management of arthrofibrosis

The average time between the previous surgical procedure and the following arthroscopic arthrolysis was 22.8 months (range 4-105). The time intervals varied widely because all patients but one [arthroscopic anterior cruciate ligament (ACL) replacement by the author] were sent to us by

Arthroscopy, Vol. 10, No. 6, 1994

MANAGEMENT OF POSTOPERATIVE ARTHROFIBROSIS OF THE KNEE 593

different physicians and underwent the first opera- tion in different departments.

Trauma and indication for previous surgery Rupture of the ACL due to contact sports was the

most common pathology, with 73.9% of the patients (n = 34) so affected. Others were meniscus lesions (8.7%, n = 4) and patellofemoral disease (6.5%, n = 3). One combined lesion of ACL and posterior cruciate ligament (2%) and one case of tibial plateau fracture occurred (2%). In one case a high tibial osteotomy had been performed (2%). One case of cancellous bone grafting in grade IV osteochondri- tis dissecans (2%) and one stiff knee was seen after exploratory arthrotomy. Eighteen patients (39.1%) had undergone immediate surgery on the day of trauma. The majority (60.9%, n = 28) had intervals from initial trauma to surgery of >4 weeks. In 87% arthrotomy of the injured knee was performed: 68.7% once and 18.3% more than once. Only 13% underwent arthroscopic procedures. None of the patients had experienced purulent arthritis. All patients but one who had undergone ACL surgery were treated by open methods. In five patients a mini-arthrotomy was used, the others were treated with an anterior approach from 7 to 12 inches in length. In 85.3% (n = 29) the patellar tendon was used. In 14.7% (n = 5) hamstring tendons for the reconstruction of the ACL were used. None of our patients had undergone replacement using an al- lograft or artificial ligaments.

Arthroscopic f'mdings in postoperative arthrofibrosis The most common additional finding in our pa-

tients was chondromalacia grade II and III (91.3%,

n = 42). Synovial and capsular fibrosis was present 25 times (54.3%) (Figs. 1A and B and 2A-C). There were five case of cyclops disease (10.9%), all following open ACL reconstruction using the patellar tendon. In four cases and in the only ACL replacement by arthroscopic means, two of these had a cyclops lesion as the only pathology (one underwent open surgery, the other arthroscopy) (Fig. 3A-C). A symptomatic O'Connor band under the knee cap was present in two knees (Fig. 4A and B). Four patients had complete obliteration of the suprapatellar pouch (Fig. IA and B).

Subgroups A and B Because our patients presented with varied

causes of their joint stiffness, we formed a subgroup that was more homogeneous (group B). This group was composed of the 34 patients who underwent reconstruction of the ACL. Two patients were ex- cluded from group B because their only pathology was a cyclops lesion. These two patients were the only ones that showed a pure lack of extension. One of these two patients had undergone arthroscopic replacement of the ACL by hamstring tendon in our department; the other had undergone ACL replacement via miniarthrotomy using patellar tendon. Of the remaining 32 patients, three underwent ACL replacement by hamstring tendon (9.4%), and in the other 39 cases (90.6%) patellar tendon was used.

Complications The complication rate was 4.3% (n = 2). In one

case rearthroscopy was performed due to postoperative bleeding. In the second case, with seven pre-

1A--C

/ FIG. 1. A: Schematic illustration of scar tissue in the suprapateltar groove and in the medial gutter causing impingement and range of motion problems. B and C: Arthroscopic view of scar bands and partial scar covering on the cartilage surface of the medial femoral condyle.


594 W. KLEIN ET AL.

2A,B

FIG. 2. A: Schematic illustration of scar tissue in the suprapatellar pouch. Flexion contracture after acute ACL repair. B: Arthroscopic view of scar tissue with small foramen in the suprapatellar pouch (artefacts are air-bubbles).

vious surgical procedures in his history, the knee again showed a dramatic loss of motion within 12 months postoperatively. No severe complications such as infections or neurovascular damage were seen.

Follow-up scoring system We used a modified Blauth und J~iger score. Due

to the extension in indication for arthroscopic arthrolysis, the scale became more rigid (4). This score rates the range of motion (Table 1).

According to this score, two cases (4.3%) were grade IV decrease in range of motion preoperatively, seven (15.2%) were grade III (severe), 29 (63%) were grade II (moderate), and eight (17.4%) were grade I (mild).

Range of motion Two patients (4.3%), showing only a cyclop's le-

sion intraoperatively, experienced pure loss of extension, and 24 (52.2%) had a combined loss of ex-

tension and flexion. Twenty patients (43.5%) had loss of flexion with full extension. The average loss of extension was 10.38 ° preoperatively, and the average loss of flexion was 31.16 ° .

Gain in range of motion For each individual patient we ascertained the

motion gain according to Cauchoix in relation to the individual knee situation. This score relates the individual postoperative profit in range of motion to the maximal possible gain. Cauchoix (5) defined this gain as the ratio of range of motion benefit to the greatest range of motion benefit (5) (Table 2). The average range of motion pre- and postoperatively was compared.

RESULTS

We present results of two groups. Group A represents all 46 patients for whom follow-up was ac-

3A-C

FIG. 3. Schematic illustration of cyclop's disease.

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MANAGEMENT OF POSTOPERATIVE ARTHROFIBROSIS OF THE KNEE 595

~ O'Connor 's b~md

FIG. 4. Schematic illustration of O'Connor 's band under the patella in arthrofibrosis of the knee.

4A,B

complished; group B represents the subgroup of patients who underwent ACL repair and additional pathology.

In group A the relative gain in range of motion according to Cauchoix was excellent or good in 76% in this retrospective follow-up study. In 23.8% the results were fair or poor.

Group B rated even better, with 78% excellent (46.9%, n = 15) and good results (31.1%, n = 10), 12.5% (n = 4) fair, and 9.4% (n = 3) poor (Table 3).

Improvement of range of motion The average range of motion improved from

103.9 ° preoperatively to 132.7 ° at the time of follow- up in group A. Group B showed an improvement from 98.8 ° preoperatively to 133 ° at the time of follow-up.

Reduction of the average loss of extension and flexion

The average loss of extension was reduced from 10.4 ° preoperatively (range 5-20 °) to 1.7 ° postoperatively (range 0-15°). In 20 cases (43.5%) the loss of extension was completely eliminated. The average loss of flexion improved from 31.6 ° (range 5-100 °) preoperatively to 7.9 ° (range 0-50 °) at the time of

TABLE 1. Modified Blauth and Jiiger Rating for arthroscopic fibroarthrolysis

Grade Range of motion Severity

I > 120 ° Mild II 80-120 ° Moderate III 40-80 ° Severe IV <40 ° Extreme

follow-up. In 18 cases (39.1%) the loss of flexion was completely eliminated.

Pain index On the basis of the Lysholm score, we set up a

rating system for pain at rest and under stress. The degree of pain was accorded a certain number of points (27). The scores for pain at rest and under stress were summed to form the pain index. The best possible score was 0 (no pain), the worst 8 points (no pain = 0, occasionally/nondisturbing = 1, moderate/disturbing = 2, severe/permanent = 4). In most of our patients pain was reduced signif- icantly. The pain index improved in 80.4%, but no change in pain intensity was seen in 19.6%. The mean pain index improved from 3.62 points preoperatively to 1.32 points at the time of follow-up in group A and from 3.92 to 1.52 in group B.

Activity level The activity level was rated by the Tegner score

(29). Comparing the preoperative level of activity with the activity at the time of follow-up showed a

T A B L E 2. Relative gains in ROM

Gain (%) Rating

Group A 54.3 Excellent 21.7 Good 13 Fair 10.8 Poor

Group B 46.9 Excellent 31.1 Good 12.5 Fair 9.4 Poor


596 W. KLEIN ET AL.

TABLE 3. ROM gain for each individual knee situation defined by Cauchoix, Ratio of actual ROM benefit to greatest pre-op ROM. Outcome of relative

ROM gain (%).

actual ROM - pre-operative ROM x 100 140 × pre-operative ROM

= relative ROM gain in %

relative ROM gain rating system

>80% excellent 61-80% good 41-60% fair

>40% poor

significant improvement from an average of 2.3 to 4.8 in group A. In group B activity increased from 1.9 to 4.6.

Subjective assessment of arthroscopic flbroarthrolysis

Assessment of success of the surgical procedure at the time of follow-up by the patients showed 34.8% (n = 16) excellent, 21.7% (n = I0) good, 39.1% (n = 18) fair, and 4.3% (n = 2) poor results in group A. Subjective assessment of arthroscopic fibroarthrolysis of the patients in group B was excellent in 37.5% (n = 12), good in 25% (n = 8), and fair in 34.4% (n = 11). Only one patient (3.1%) was completdy disappointed by the results of the arthroscopic procedure.

Overall results in group B (n = 32), excluding patients who only showed up with a solitaire cyclops lesion, were similar to the results in group A with different etiologies.

DISCUSSION

In the literature a distinction is generally made between restriction of extension and flexion of the knee joint due to intraarticular or to extraarticular pathology (2,4,18,24). Arthrofibrosis is usually ac- companied by a combined loss of extension and flexion with greater or lesser degree of pain. Iso- lated loss of extension is relatively rare and a typi- cal symptom of cylcops disease (8). Isolated loss of flexion occurs more frequently due suprapatellar pouch pathology. The methods of treatment vary from conservative treatment linked with physiotherapy to mobilization under anesthesia and operative treatment by either arthrotomy or arthroscopy (1-23). The increase in effectiveness of endoscopic arthrolysis over the past years and the increasing experience of surgeons with these methods have led

to an extension in the indication for operative treatment of posttraumatic joint stiffness. Increasing numbers of patients benefit from this development today. Arthroscopic management of joint stiffness can render arthrotomy with its negative side effects. In our experience arthroscopic treatment of fibroarthrosis in the knee joint is a successful procedure. Subjectively, patients assess the procedure's result as excellent or good in 56.5%, fair in 39.1%, and poor in 4.3%. The goal of arthroscopic fibroarthrolysis is primarily to provide normal everyday activity and not to put the patient back into cutting or contact sports. It is hardly possible to restore max- imum performance because most patients have a history of severe traumas. Removal of a cyclops lesion may lead to full range of motion within the first days postsurgery. The outcome of complex cases of knee stiffness is difficult to predict. How- ever, our experience showed that the function of the joint can be improved even in cases with complex pathologies and after a prolonged interval between treatments. The results can be compared with studies with shorter terms between previous surgery and fibroarthrolysis (30). The activity level, compared with the preoperative situation, is improved in most cases. Our experience in this retrospective study showed that arthroscopic arthrolysis is an effective method for handling stiffness of the knee joint. It has a low rate of morbidity and a high degree of patient satisfaction.

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