Management of arthrofibrosis of the knee

OVERVIEW

Chapter synopsis

Arthrofibrosis of the knee is a preventable complication that presents many challenges to the treating physician. Effective treatment involves working closely with rehabilitation staff, with the overall objective being to regain symmetrical knee extension, knee flexion, and strength. A classification system for arthrofibrosis, step-by-step treatment methods, and results of this treatment approach are presented in this chapter.

Important points

Prevention is the best treatment for arthrofibrosis.
Preoperative and postoperative rehabilitation is a critical aspect of treatment.
Do not attempt to work on knee extension and flexion range of motion (ROM) at the same time. Restore symmetrical knee extension first, then work on knee flexion second.
Patients with contracture of the patellar tendon may demonstrate some improvement of knee flexion but will not regain full symmetry.

Clinical and surgical pearls

Surgical intervention depends on the classification and should focus on the following:
- 1.
  Eliminating impingement of the anterior cruciate ligament (ACL) or ACL graft in the intercondylar notch
- 2.
  Removal of extrasynovial scar tissue anterior to the tibia and within the infrapatellar fat pad (if present)
- 3.
  Medial and lateral retinacular release to restore patellar mobility (if needed)
- 4.
  Knee manipulation to regain knee flexion (if needed)
The use of a passive knee extension device is more effective than casting in conjunction with surgical treatment.
Early postoperative care should focus on the prevention of hemarthrosis to avoid a quadriceps muscle shutdown.

Clinical and surgical pitfalls

Good quadriceps muscle control is needed so that the hamstring muscles do not go unopposed and pull the knee into flexion, making extension difficult to maintain. Also, contraction of the quadriceps stretches the patellar tendon to full length and prevents shortening of the patellar tendon.
There is no specific timeframe for surgical intervention or how long patients should take to complete preoperative rehabilitation. Rehabilitation can be a lengthy process, but it is imperative that patients fully maximize knee extension and flexion before surgery.
It is counterproductive to work on knee extension and flexion ROM at the same time. Similarly, it is counterproductive to work on strengthening and ROM at the same time.

Arthrofibrosis is the proliferation of fibrotic tissue within and surrounding a joint. It results in decreased range of motion (ROM), pain, decreased function, and subsequent strength loss secondary to disuse. In the knee joint, arthrofibrosis is a potential complication after fracture treatment or intra-articular surgery, including arthroscopy, anterior cruciate ligament (ACL) reconstruction, and total knee arthroplasty. Arthrofibrosis is a difficult condition to treat, and precautionary measures should be taken to prevent this potential postoperative complication.

Arthrofibrosis of the knee results in the loss of extension, and in some patients, loss of knee flexion also occurs. Loss of knee extension is usually more symptomatic compared with loss of flexion.

Arthrofibrosis is most effectively treated via a multidisciplinary approach, with the physician, rehabilitation staff, and patient working closely together. The treatment should be viewed as a process that includes intensive rehabilitation, followed by arthroscopic scar resection when needed and postoperative rehabilitation. In addition, patients often require a lot of emotional support and encouragement throughout this process and must be well informed and actively involved in their own care.

Preoperative considerations

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