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The tragedy of arthrofibrosis - (part 12 of course on arthrofibrosis)

As you have learned from this course, the permanent loss of knee motion is a disaster. Patients go through months and sometimes years of frustrating, ineffective treatment and eventually wind up with a total knee replacement.

This is especially sad when the condition occurs after a relatively “minor” knee operation, such as a partial meniscectomy that is about a 15-minute operation. Just as frustrating to the medical staff at my office are the cases in which the limitation of knee motion never should have occurred in the first place, or which would have been fairly easily resolved if diagnosed and treated immediately. The vast majority of arthrofibrotic cases are secondary in nature – and that is why most are preventable. The rare cases of true primary arthrofibrosis - caused by an exaggerated inflammatory response to an injury or surgical procedure and not from other factors – are different and should not be confused with the secondary preoperative, intraoperative, and postoperative factors I have discussed in this course.

Patients who suffer from permanent arthrofibrosis never, ever have a knee that resembles normal. The majority sustained the original injury playing sports and were very active individuals. The loss of the ability to participate even in low impact activities brings on depression and tremendous anxiety. In addition, most patients are young, in their 3rd to 4th decade of life, which is far too early to lose the ability to have an active lifestyle.

Trying to deal with arthrofibrosis is extremely time-consuming and affects just about all portions of the patient’s life. Those that are able travel great distances to Centers experienced in treating this condition but even then, no guarantees are ever offered that a solution will be found. This is because usually by the time the patient realizes that they must seek treatment elsewhere, many months have elapsed and the arthrofibrotic condition is well established and often permanent.

One of the problems in the medical community is a lack of agreement of how to recognize an early problem with knee motion, how to treat it, and when to treat it after the injury or surgery. Our review of the published studies found that some authors don’t recommend an extension cast for a limitation of extension until nearly a year postoperative. Our program incorporates this treatment 4-12 weeks after surgery if required. Others recommend a manipulation under anesthesia between 4-8 months postoperative, whereas we will perform a very gentle ranging of the knee under anesthesia as early as 3 weeks postoperative if the patient is delayed in regaining flexion. Aggressive, overzealous motion exercises can cause more harm than good, as they result in tearing of tissues, increased inflammation, and even fractures. An early initiation of gradual stretching of early scar tissue is very effective.

There are many disturbing stories we have seen on various Internet sites of patients describing forceful manipulations done in the surgeon’s office or physical therapy clinic. The belief seems to be to simply break down the scar tissue in whatever manner works, which only of course aggravates the situation.

In two investigations on 650 knees at our Center that underwent ACL reconstruction, 6% required and agreed to treatment intervention for a knee motion problem. At the final follow-up evaluation, 2% lacked normal knee motion (9 knees lacked 5° of extension and 2 had permanent contractures or arthrofibrosis). An extension cast was applied in 2%, gentle manipulation under anesthesia was done in 3%, and arthroscopic debridement was performed in < 1%. So you can see that an early treatment intervention program, combined with knowledge of all of the risk factors for developing arthrofibrosis, is really effective in preventing this disaster.

 

Updated: 22 Apr, 2013
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