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Arthrofibrosis after cruciate ligament surgery

Of all the conditions on the list for triggering arthrofibrosis, anterior cruciate ligament surgery used to come tops. But the chance of developing arthrofibrosis after ACL surgery is less nowadays than it used to be.

This is because research into this problem led to surgeons changing their practice, so that one is less likely these days to have an ACL reconstruction complicated by arthrofibrosis than one would have ten years ago.

ACL reconstruction using a free tendon graft is actually itself a relatively new procedure (ref 1). Despite some early experimentation, one can safely say that prior to the 1980s cruciate ligaments were not routinely reconstructed. Surgery in the 1970s revolved around trying to stabilise the knee outside of the joint capsule, rather than tackling the torn cruciate ligament itself within the capsule.

With the advent in the 1980s of synthetic ligament materials and new surgical instrumentation, surgeons offered the first real hope of full restoration of function to patients with torn cruciates. With synthetic ligament surgery there came a big push to educate surgeons in the new surgical techniques, and an increase in the number of patients having cruciate reconstruction followed. It was not long, however, before synthetic ligaments went out of fashion, partly because they had inherent problems of their own and partly because the new techniques advanced to allow fully biological 'autograft' (the patient's own tissue) to be used as a graft material. Of the autografts, the patellar-tendon-graft (PTG) was promoted as 'the gold standard' and surgeons all over the world started to perform PTG cruciate reconstruction surgery.

As the technique shifted from the synthetic graft to the natural graft, which required ingrowth of blood vessels and the formation of new ligament cells, so the surgeons tended to 'protect' the graft by immobilising the patient's knee for a fairly prolonged period of time. Rehab was progressed cautiously. But the outcome was not always as good as expected, and an increasing number of post-surgery cruciate ligament patients started having trouble regaining full range of motion. As these patients started in the 1990s being referred to specialist units for assessment and management, leaders in the field began to publish their findings (ref 2) - that many of these joints were being limited by the presence of scar tissue within the joint cavity. Research was undertaken to find out why, and two of the main reasons were shown to be the timing of the reconstruction surgery after the initial injury and the length of the period of immobilisation after surgery (ref 3). This led to a change of practice amongst surgeons that has resulted in a fall in the percentage of cruciate patients progressing to arthrofibrosis - 

  • the initial surgery is generally delayed for about 3 weeks after injury, and surgery is not undertaken until full range of motion is restored and the joint is not inflamed 
  • the period of immobilisation was decreased and patients were put through an accelerated rehabilitation programme.

Ref 4 is a review of the topic - the last bit gives an overview in fairly easy-to-read language.

REFERENCES

  1. Colombet P, Allard M, Bousquet V, de Lavigne C and Flurin PH. The history of ACL surgery. http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/87_colombet/colo...
  2. Shelbourne, KD. Outpatient Surgical Management of Arthrofibrosis After Anterior Cruciate Ligament Surgery. The American Journal of Sports Medicine 22:192-197 (1994). http://ajs.sagepub.com/cgi/content/abstract/22/2/192 
  3. Shelbourne, KD. Arthrofibrosis in acute anterior cruciate ligament reconstruction - The effect of timing of reconstruction and rehabilitation. The American Journal of Sports Medicine 19:332-336 (1991).
  4. Creighton RA and Bach BR. Arthrofibrosis: Evaluation, Prevention, and Treatment. Techniques in Knee Surgery 4(3):163–172, 2005

 

Updated: 17 Apr, 2013
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