Published in the early days of arthroscopy, this paper presents the authors' experience in a series of 24 patients with restricted flexion due to adhesions and scarring inside the knee joint, and in which arthroscopic surgery was used to try and free up the joint again.
As they continued with this study the authors noted that their patients fell into three groups based upon anatomic criteria -
- Group 1 - the adhesions formed discrete bands or a single sheet
- Group 2 - masses of adhesions completely obliterated the suprapatellar pouch and gutters
- Group 3 - as Group 1 or 2 but with in addition an extracapsular band
The group they called 'Group 1' included those patients who proved amenable to 'arthroscopic lysis of the adhesions' (breaking down the bands of adhesions via keyhole surgery). It frequently took only a sweeping action with closed scissors to break the adhesions, and they discovered that in some cases even just filling the joint space with fluid (which they had done to measure the capacity of the joint space) was enough to do this.
Into the second group ('Group 2') they put the patients who had proved somewhat more challenging - where there were masses of adhesions which made it hard even to move the arthroscopic instruments within the knee. They discovered that they generally needed to first release the scarring around the patellar tendon via a small incision before the tissues were mobile enough to allow adequate arthroscopic visualisation.
They added a 'Group 3' when they found that some patients failed to improve their ROM (range of motion) even after arthroscopic debridement (cleaning up) and it was subsequently found that this was due to the presence of a 1cm wide extracapsular (outside of the fibrous capsule that surrounds the joint) band of scar tissue, and which the surgeons had not met with before nor diagnosed prior to surgery. This band passed in the midline obliquely from the top of the patella to the front of the femur, in the space between the suprapatellar pouch (the extension of the joint space above the patella) and the undersurface of the quadriceps muscles, ie outside the capsule of the knee. Only after the release of this band did the ROM subsequently improve - and they continued with the series of operations they began diligently to look for the presence of this band and to routinely remove it.
Despite improvement in most of the patients in the study there was a small number of patients who showed no appreciable improvement - and who were considered treatment failures. On the plus side, three patients who had their initiating incident 8-27 years earlier nonetheless derived some benefit, with a 15-20 degree improvement in their range of movement. No attempt appears to have been made in this group to specifically address any loss of extension.