stiffness of the knee—mixed arthroscopic and subcutaneous technique: results of 67 cases

Arthroscopy: The Journal of Arthroscopic and Related Surgery 9(6):685-690 Published by Raven Press, Ltd. © 1993 Arthroscopy Association of North America

Stiffness of the Knee Mixed Arthroscopic and Subcutaneous Technique: Results of 67 Cases

Jose Achalandabaso, M.D., and Javier Albillos, M.D.

Summary: This study is an analysis of the treatment for mixed-cause stiffness of the knee: intraarticular and extraarticular. We examined 67 patients. The cause of stiffness was mostly ligamentous surgery, found in 51 cases (76%). Preoperative range of motion was 11 ° extension and 89 ° flexion. In 14 cases extension was complete. In the remaining 53 cases, extension was limited. Results achieved with arthroscopic arthrolysis were generally excellent. The ideal time to perform the operation is within the first 9 months after injury. The best results were obtained in the 7th month. Results deteriorate notably after 1 year. The age of the patient does not seem to affect the end result. Key Words: Arthrofibrosis--Knee.

There are many possible causes of stiffness in the knee joint. In this study, we refer to arthrofibrosis of traumatic origin, which causes adhesions between the different articular and periarticular elements.

Until the present time, intraarticular causes (1,2) and extraarticular causes (3,4) that limit articular motion have been described. Diverse techniques for achieving the elimination of the adhesions has been proposed. Smillie described the technique of manipulation under anesthetic, finding numerous problems according to bone quality and the existence of inflammation. Moreover, injuries to the cartilage due to such manipulations have been described (5,6).

Numerous investigators have recommended surgical arthrolysis using open surgery (7-11) or arthroscopic surgery (2,7,12). In addition, techniques to eliminate adhesions of the quadriceps muscle to the femur have been proposed (3,4).

The presence of numerous complications result- ing from the Judet method and the improvement in

From the Servicio de Artroscopia, Policlinica Guipuzcoa, San Sebastian, Gtfipuzcoa, Spain.

Address correspondence and reprint request to Dr. Jose Achalandabaso, Servicio de Artroscopia, Policlinica Guipuzcoa, Alto de Miramon, San Sebastian, Guipuzcoa, Spain.

results obtained from arthroscopic techniques en- couraged us to use this form of treatment.

MATERIALS AND METHODS

Between 1986 and 1992, 67 patients with stiffness of the knee have been treated. In 62 patients arthroscopic arthrolysis was performed to eliminate intraarticular adhesions. In five cases, the above treatment was combined with an extraarticular technique for the elimination of adhesions between the quadriceps and the femur. The surgical procedures preceding arthrofibrosis are listed in Table 1.

We examined 67 patients (44 men and 23 women) with ages ranging from 18 to 53 years. The average age was 31, and most of the patients (64.5%) were 20-40 years of age.

After the initial surgery, the patients received a monthly check-up and were tested goniometrically for range of motion (ROM). One of the problems in a patient with arthrofibrosis is identifying at what point surgery will be required because ROM will not improve further. When patients record the same ROM on two consecutive monthly visits, the problem is discussed with them, and an attempt is made to discover the reason (pain, swelling, anxiety, etc.) for their lack of progress in order to prescribe ap- propriate treatment. If the limitation of motion con-

685

686 J. A C H A L A N D A B A S O A N D J. A L B I L L O S

TABLE 1. Surgical procedures preceding arthrofibrosis

Procedure n

ACL reconstruction (arthroscopic) 23 ACL reconstruction (open) 12 ACL and MCL repair (open) 10 Femur fracture 5 Patellofemoral surgery 4 Open repair of dislocated knee 4 Tibial plateau fracture 4 Meniscal (open) 3 PCL 2

tinues for another month, arthrolysis is recommended.

The time between the first injury and arthrolysis in our study averaged 8 months. This evolution time was grouped as follows: <6 months, 26 cases; 6-12 months, 29 cases; >12 months, 12 cases. Preoper- ative ROM was 11 ° extension and 89 ° flexion. In 14 cases, extension was complete. In the remaining 53 cases, extension was limited.

Although the majority of our patients had mixed stiffness, i.e., limited flexion and extension, for di- dactic reasons we divided their descriptions and their treatments into two separate groups: stiffness in extension and bent knee.

STIFFNESS IN EXTENSION

Stiffness in extension is the term used to describe the inability to flex the knee completely.

Causal elements In almost all cases, the cause is frontal tension

scar bands that are too tight to allow flexion. Al- though theoretically posterior limits may exist, they are seldom found in clinical practice. These unions or frontal scar bands are normally adhesions of the quadriceps expansions to lateral recesses, adhesions of the subquadricipital bursa, adhesions of the quadriceps muscle to the femur, or shortening of the rectus femoris muscle. The first two causes are intraarticular, whereas the latter two are extraarticular. Any one of these adhesions would hamper flexion because they would produce a functionally shortened extensor apparatus and therefore must be progressively eliminated.

Occasionally posterior limits are caused by loose bodies or posterior osteochondral fragments and os- teochondromas of the popliteal cavity, sometimes so serious that they prevent flexion due to compression against the neighboring bone during range of motion.

Suggested technique We use a double technique, both under arthro-

scopic control and subcutaneous section. The small volume we often find initially in the

interior of the knee makes it difficult to perform the beginning steps of the technique until enough volume is obtained. We use our regular equipment with double fluid entrance through the arthroscopy sleeve. In these cases, we cannot use the accessory portal into the suprapatellar pouch as the first step. During the operation, after we obtain enough volume we can insert a cannula into the suprapatellar pouch.

The following steps are then performed: 1. The section of the adhesions at the suprapa-

tellar pouch is performed by means of the arthroscopic technique. High-powered motors are extremely helpful for performing this task. Cutting and motorized instruments normally are used until the cavity comes into sight.

2. The section of the lateral quadriceps expansion is performed subcutaneously. We also section the remaining adhesions at the suprapatellar pouch while making a gentle attempt at bending the knee, which can only be effective in a slightly stiff condi- tion with lightly fixed adhesions.

3. The section of the medial quadriceps expansion is performed by means of the same technique. We cut away fibrous remains medially.When the stiffness is only intraarticular, the knee will flex when we push it, meaning that we will have fulfilled our aim. We then install drainage and apply a compression bandage.

When the stiffness is extraarticular, the following steps are performed. First, the quadriceps is sharply dissected from the bone (Fig. 1). This im- pressive maneuver is performed through the arthro-

FIG. 1. Diagram of the technique used for the dissection of the quadriceps.

Arthroscopy, VoL 9, No. 6, 1993

S T I F F N E S S OF THE K N E E 687

scopic portals, cutting through the upper area of the suprapatellar pouch and moving upward. The same set of instruments usually used for removing ce- ment from a hip prosthesis is used due to the lack of more specific instruments for this purpose. Dissec- tion may be continued upwards to the groin, although we avoid proceeding more than four finger breadths from the groin itself. We continue laterally until reaching the external intermuscular wall or posterior edge of the fascia lata, which normally can be felt easily. No resistance is usually found on the medial aspect unless there is significant scarring. We avoid going further than the medial edge of the femur.

After performing a manipulation, these opera- tions often result in good flexion. We then install a drainage system in the knee and apply a compression bandage. In cases that were unsuccessful, we move the hip to 90 ° of flexion to see if this maneuver makes the knee flexion easier. If it appears to do so, we continue by sectioning the rectus femoris muscle from the iliac spine. This section can be performed subcutaneously. When in extension, the rectus femoris muscle is usually extremely taut. Once this has been done, we complete the knee flexion movement and install the drains in the knee and the area of the rectus recession. In Table 2 we see how many of these procedures were performed on each of the 67 patients.

BENT KNEE

Bent knee is the term used when the knee cannot be completely extended.

Causal elements Causes of bent knee include anterior extension

limits and posterior tension. Etiology is a lmost never extraarticular. Theoretically, femoral posterior adhesions could be considered a reason for bent knee, but in clinical practice, intraarticular reasons are always found.

TABLE 2. Surgical procedures performed for stiffness in extension

Cases Procedure (n)

Section of the adhesions at suprapatellar pouch 67 Section of the lateral quadriceps expansion 67 Section of the medial quadriceps expansion 19 Sharp dissection of the quadriceps from the bone 5 Section of the rectus femoris muscle from the bone 1

Anterior limits are usually caused by meniscal fragments, cartilaginous fragments, or any type of fragment in front of the area of the femoral condyles; or a narrow interchondytea fossa that is incapable of housing its contents. Its upper edge blocks itself against the ligamentous and synovial contents, thereby preventing extension.

Posterior tensions are usually caused by a reduc- tion in the functioning of posterior capsules, which for whatever reason are not long enough to allow extension.

Proposed technique Our aim is to eliminate anterior limits and

lengthen posterior tension. The following steps are arthroscopically performed:

1. The obstacles preventing movement of the condyles--bucket handles or chondral fragments from the anterior partmare eliminated. When this is the only cause, the operation is finished. In this study, bent knee caused by isolated meniscus has been excluded.

2. The intercondylar region is widened. 3. The bone of the intercondylar region is

opened. Sometimes the osseous upper border of the intercondylar region hits against its contents, preventing extension. If the contents were a good quality ligament or fibrous and resistant plasty, our per- formance would be exclusively directed toward the osseous opening, avoiding mutilating action of im- portant elements. The notchplasty is continued until the extension of the knee has been achieved. This is tested by performing an extension along a direct line of vision in which in the maximum extension achieved the fibrous contents do not come into con- tact with the upper edge of the intercondyle. Notch- plasty was performed in all cases. When it was unsuccessful, the following steps were performed.

The contents in the intercondyle were reduced. On different occasions, we found other fibrous elements in the intercondylar area that had to be removed. In all cases, ligaments were carefully re- spected. We noted in almost all cases a large fibrous mass in front of the intercondylar notch that had to be removed. In five cases a rounded and vascular fibroma occluded the recess. Cyclops Syndrome (12,13). We also noted adhesions of the posterior cruciate ligament to the lateral condyle, causing loss of extension. In these cases, it was easy to make the mistaken diagnosis of a narrow osseous intercondyle. However, simple osseous enlarge- ment does not solve this problem because the ad-

Arthroscopy, Vol. 9, No. 6, 1993

688 J. ACHALANDABASO AND J. ALBILLOS

hesions must be sectioned in order to obtain extension.

The careful implementation of these techniques is usually sufficient to obtain immediate improved extension. However, it may also be necessary to separate the posterior capsules. On occasion, posterior arthroscopic incisions have been used to guide a curved osteotome in an attempt to separate the posterior capsules by means of movement along the length of its insertion into the condyle. On more than one occasion, this maneuver has given the au- thors the impression of improved extension.

Once we have arrived at this point, two situations can occur:

1. Upon placing the knee on the table, extension is obtained spontaneously. A compression bandage should be applied.

2. Extension is not achieved spontaneously, but it is obtained by leaning heavily on the knee. In this case, a cast should be applied in the maximum extension obtained.In 63 cases, arthrolysis was performed under epidural anesthesia, administered as necessary by means of a catheter. Initially, plaster casts of maximum flexion and extension that were changed every 6 h were used. However, the appear- ance of complications led us to abandon the technique after six cases. At the present time, physical therapy commences the day after surgery. The catheter remains in place to administer local anes- thetics when pain hampers motion. Patients re- mained in the hospital for several days until it was possible to remove the catheter. They were then sent home with daily physical therapy. In two cases, a plaster cast was used for a period of 2 weeks to control the extension.

RESULTS

We used the Merle D'Aubigne formula (14,15), known as the relative improvement formula, which gives results as shown in Tables 3 and 4. The great advantage of this formula is its capacity to compare

TABLE 3. Evaluation of results according to relative improvement

>60% Excellent 40-60% Good 30--40% Average <30% Poor

The Merle D'Augbigne (7) formula, known as the relative improvement formula, was used: Improvement obtained/Possible improvement × 100 = relative improvement.

TABLE 4. Evaluation of results according to relative improvement

Excellent (56 cases) 83.6% Good (4 cases) 6,0% Average (4 cases) 6.0% Poor (3 cases) 4.4%

final ROM with initial ROM. The absolute gain in degrees is shown in Table 5. Overall, we obtained satisfactory results of 89.6% against poor results of I0.4%.

Results according to age There was no significant difference in the results

according to age. Patients <35 years of age (46 cases) showed a relative improvement of 80%, and those >35 years of age (21 cases) 76%. There also were no significant differences in the analysis by decade.

Results according to evolution time When analyzing our results according to the time

elapsed between injury and arthrolysis, we noted that there was no great difference in the results obtained during the first 9 months. Good results started decreasing around the 1 lth or 12th month, but mainly after 1 year.

Results of extraarticular stiffness Only five extraarticulary caused cases of stiffness

were treated with this technique. The results obtained in these cases were not encouraging (Table 6). Table 6 describes all five cases, observing their evolution time in months and the percentage of relative improvement obtained. These cases involved patients that had either already undergone a long evolution period for stiffness or who had been op- erated on more than once in their centers of origin. One patient had a Guillain-Barr6 syndrome with limited muscular power, and another had an unde- tected drug problem. Complete intraoperative ROM was achieved in all cases. However, we were un- able to maintain this motion. We obtained improvement in all cases, even if moderately so.

TABLE 5, Evaluation of results according to grades of improvement

Preoperative Final Gain

Flexion 89 ° 127 ° 38 ° Extension 11 ° 4 ° 7 °


S T I F F N E S S O F THE K N E E 689

TABLE 6. Evaluation o f results o f extraarticular stiffness

Evolution Relative Case time (mo) improvement Observations

1 20 29 Femur and tibia fracture 2 12 26 Femur fracture and drug

addiction 3 8 35 Comminuted femoral fracture 4 15 33 Femur and tibia fracture 5 12 15 Femur fracture and

Guiltain-Barr6

COMPHCATIONS

We had two septic arthritis cases: one healed with no long-term problems and the other with me- dium results, the cause of which was Staphylococ- cus aureus inoculation in both cases.One neurolog- ical paresis spontaneously resolved. This was felt to be caused by the forced flexion position. This com- plication caused us to stop using this technique.

Four synovial fistulas were medically healed. One of these took 3 months to heal. Rehabilitation continued despite the fistula and finally closed spontaneously.

The partial breakage of a patella tendon corre- sponded to one of our poorer results. Three patients had complications related to their psychiatric back- grounds. One female patient required sedation and group therapy during rehabilitation treatment. An- other patient, one of our poorer results, was found to have a strong addiction to drugs that was discov- ered by chance some months after treatment. One female patient had a serious family problem and immediately" entered postoperative treatment. She was given specific psychiatr ic t reatment that strongly affected her recuperation. She finally achieved an improvement of 60%.

DISCUSSION

The arthroscopic treatment of arthrofibrosis is difficult, especially at the initiation of surgery, due to the small articular cavity that hampers vision. A high degree of technical ability is necessary to perform the surgery. Although they are often present together, defective flexion and extension should be seen as two distinct problems (16). In surgical terms they should be considered as two separate procedures. Stiffness due to extraarticular causes has a poor prognosis, and the risk of complications is high, especially in open surgery (3,4). In our expe- rience subcutaneous dissection of the quadriceps

has afforded the patient improved postoperative comfort with reasonably good results. We believe that the problem lies in the impossibility of performing precise coagulation between the muscle and bone, causing a hematoma that is the source of re- newed adhesions between the two. We are pres- ently working on a new type of instrument that would simultaneously allow mechanical separation and coagulation. Nevertheless, better results would probably be obtained if the stiffness were treated earlier.

Some investigators (1,2,I6) express serious doubts as to the usefulness and advisability of manipulation under anesthetic. In our opinion, it should be considered with caution. The major factor influencing the results is the time elapsed between the prior surgery and arthrolysis.

CONCLUSIONS

1. Results achieved with arthroscopic arthrolysis were generally excellent.

2. Prophylactic antibiotic treatment is recommended given the high risk of infection with the technique.

3. The ideal time for performing the operation is within the first 9 months after injury. Our best re- suits were obtained in the 7th month. Results deteriorate markedly after I year.

4. The age of the patient does not seem to affect the end result.

5. The detachment of the quadriceps through arthroscopy can constitute alternative surgery that somewhat improves the range of movement. How- ever, extraarticular stiffness is a factor that greatly overshadows the prognosis of the final ROM.

REFERENCES

1. Parisien JS. The role of arthroscopy in the treatment of postoperative fibroarthrosis of the knee joint. Clin Orthop 1988; 229:185-92.

2. Richmond JC, Assal MA. Arthroscopic management of arthrofibrosis of the knee, including infrapatellar contraction syndrome. Arthroscopy 1991;7:144-7.

3. Judet J, Judet R. Raideur du genou sans ankylose osseuse. In: Encyclopddie m~dico-chirurgicale, techniques chirurgi- cales. Vol. 3. Paris: Editions Techniques, 1976:44,840-5.

4. Valenti JR, Cafiadell J. Rigidez de rodilla en extension. Rev Ortop Traum 1984;28:723-8.

5. Enneking WF, Horowitz M. The intra-articular effects of immobilization on the human knee. J Bone Joint Surg 1972; 54:973-85.

6. Evans EB, Eggers GWN, Butler JK, et al. Experimental immobilization and remobitization of rat knee joints. J Bone Joint Surg 1960;42:737-58.

Arthroscopy, Vot. 9, No. 6, 1993

690 J. ACHALANDABASO AND J. ALBILLOS

7. Thompson TC. Quadricepsplasty to improve knee function. J Bone Joint Surg 1944;26:366-79.

8. Ramadier JO. Traitement des ankyloses et des raideurs en extension du genou. Raport de la 38 rdunioon de la Societd Francaise d'Orthop~die. Paris: Masson, 1953.

9. Judet R. Mobilization of the stiff knee. J Bone Joint Surg [Br] 1959;41:856.

10. Judet J, Judet R. Raideurs du genou en flexion. In: Encyclo- p~die m~dico-chirurgicale. Vol. 3. Paris: Editions Tech- niques, 1976:44, 845.

11. Judet R, Judet J, Lagrange J. Une technique de liberation de l'appareil extenseur dans les raideurs du genou. Mere Acad Chit 1956;82:2%30,994-47.

12. Jackson DW. Cyclops syndrome: loss of extension following intra-articular ACL reconstruction. Arthroscopy 1990;6: 171-8.

13. Mariani PP, Ferretti A. Arthroscopic treatment of flexion deformity after ACL reconstruction. Arthroscopy 1992;8: 517-21.

14. D'Augbign6 M. Nouveau trait~ de technique chirurgicale. Paris: Masson, 1981.

15. Ruiz GR, La artrolisis como tratamiento de la rigidez de rodilla. Rev Ortop Traum 1984;28:729-36.

16. Smillie IS. Traumatismos de la articulacion de la rodilla. Barcelona, Spain: Ed JIMS, 1980:310-36.


stiffness of the knee—mixed arthroscopic and subcutaneous technique: results of 67 cases

Documents