Arthrofibrosis is the consequence of fibrotic tissue that occurs as a result of knee injury or surgery of some sort. It is most commonly associated with Anterior Cruciate Ligament (ACL) reconstruction, but may occur with any invasive procedure of the knee such as Total Knee Replacement.
Authored by Ms Michelle Boucher in 2017 and reviewed in September 2023 by Dr Sheila Strover (Clinical Editor)
More aggressive “salvage procedures” are reserved for more severe cases of arthrofibrosis (Freihling, 2006). These procedures may include quadricepsplasty, typically involving releasing the back of the rectus femoris part of the quads muscle where it becomes adherent to the vastus intermedius part behind it. Where the patellar tendon has become stuck and contracted causing the patellar to be too low for proper functioning of the joint, it may be released and an osteotomy performed to reposition the attachment of the tendon higher up the tibia (eg DeLee osteotomy). Another procedure to release tight tissues to the side of the patella is a “Z-plasty” of the reticula.
Despite the acceptance and increased understanding of arthrofibrosis, rates of this complication still range from 4-33%, depending on the literature reviewed (Majit, 2007). Factors that affect the development of the problem include technical error on the part of the surgeon, timing of the surgery, high versus low velocity trauma, physiotherapy complications, and the development of Complex Regional Pain Syndrome or CRPS. This latter creates a “vicious cycle” of sorts involving impaired autonomic nerve function with severe pain posing a detriment to necessary physiotherapy and impaired healing. Other factors include impaired healing due to inflammation from a variety of causes and host factors such as genetics.Indications for surgical correction include extension deficits which result in 10 degrees or more of extension lag (Freihling, 2009) or a flexion contracture, limiting mobility. Despite surgical correction the same patient is exposed to the same factors that caused the initial complication, so rates of recurrence after corrective surgical procedures are difficult to come by and not often cited in the literature.
There have been some studies that have demonstrated statistically significant positive results at 2 and even 4 year follow up - however sample sizes have been small so these results have to be interpreted with caution. So while the American Academy of Orthopedics recommends that most cases of arthrofibrosis may be adequately corrected using Lysis of Adhesions and Manipulation under Anesthesia procedures, more severe cases may require the more invasive “salvage” measures, although there is little research to ascertain if these measures are going to result in an adequate functional result for the patient.
While most research involving the treatment of arthrofibrosis is decades old, some more current studies for the more severe “salvage” cases of arthrofibrosis in which the functional impairment of the patient is severe, often meeting Sprague’s 3 criteria, have utilized a combination of intra-articular and extra-articular procedures. For example, Wang, in 2006, in the treatment of arthrofibrosis patients with severe flexion contractures, incorporated intra-articular arthroscopic lysis of adhesions procedure with an extra-articular (outside the joint) minimally invasive quadricepsplasty with favorable outcomes, even at 24 months follow-up. In his study of patients with severe flexion contractures, with an average degree of knee flexion of 27 degrees preoperatively to an impressive 115 degrees of knee flexion postoperatively, the results remained stable at two years. Now the study only involved 22 patients, so the small sample size impacts our interpretation of results, but they were statistically significant with 16 patients reporting their postoperative functional outcome as “excellent” and 6 as “good”, even at 2 years, so results appear to have remained stable, without recurrence of arthrofibrosis.
David Majit MD, Andy Wolf MD. Arthrofibrosis of the Knee. Journal of the Academy of Orthopaedic Surgery; American 2007 15 682-694) http://www.wosm.com/wp-content/uploads/2014/11/Arthrofibrosis-of-the-Kne...
D. Freihling MD, P. Lobenhotter MD.The Surgical Treatment of Chronic Extension Deficits of the Knee. Operative Orthopaedic Traumatology; 2009 Dec;21 (6) 545-556)
D. Freihling MD, M. Galla MD, P. Lobenhotter. Arthrolysis for Chronic Knee Flexion Deficits of the Knee: An Overview of Indications and Techniques of Vastus Intermedius Muscle Resection, Transposition and the Tibial Tuberosity and Z-plasty of the Patellar Tendon. Trauma Surgery, 2006; April 109 (4) 285-296).
Jian Wang MD, Jin Zhua MD, Y. He MD. A Knew Treatment Strategy for Severe Arthrofibrosis of the Knee. Journal of Bone and Joint Surgery 2006 June; 88 (6) 1245-1250.