Review Article Arthroscopic Releases for Arthrofibrosis of the

Abstract Michael R. Chen, MD Intra-articular inflammation or fibrosis may lead to decreased soft- Jason L. Dragoo, MD tissue and capsular compliance, which may result in or loss of motion within the knee. Etiology of intra-articular fibrosis may include isolated anterior interval scarring and posterior capsular contracture, as well as fibrosis that involves the suprapatellar pouch or arthrofibrosis that involves the entire synovial space. Initial nonsurgical management, including compression, elevation, and physical therapy, can decrease knee pain and inflammation and maintain range of motion. Surgical management is indicated in the patient who fails conservative treatment. Surgical options include arthroscopic releases of the anterior interval, posterior capsule, and peripatellar and suprapatellar regions. Recent advances in arthroscopic technique have led to improved outcomes in patients with intra-articular fibrosis of the knee.

nee stiffness is a common compli- management of these disorders may Kcation associated with trauma or lead to improved outcomes in this surgery and has been extensively patient population. studied.1-3 Risk factors include injury severity, timing of surgery, delayed Pathophysiology of postoperative rehabilitation, pro- longed immobilization, infection, Arthrofibrosis complex regional pain syndrome, The exact etiology of intra-articular From the Department of and technical errors during intra- tissue fibrosis is unknown, but sev- Orthopaedic Surgery, Stanford articular and extra-articular recon- eral theories exist. Platelet-derived Hospital and Clinics, Redwood City, structive procedures. Extra-articular CA. growth factor and transforming stiffness may be caused by muscular growth factor-beta 1 are inflamma- Dr. Dragoo or an immediate family fibrosis and contracture, heterotopic member serves as a paid consultant tory cytokines produced by the in- to Genzyme and Össur and has ossification, or myositis ossificans. flamed synovium that promote the received research or institutional The inflammatory response to in- proliferation of fibroblasts and ex- support from ConMed Linvatec and ″ jury or surgery can cause fibrosis, re- tracellular matrix proteins, the inhi- Ossur. Neither Dr. Chen nor any sulting in restricted knee motion. An- immediate family member has bition of proteolytic enzymes, and received anything of value from or terior interval scarring, contracture the production of collagen. These cy- has stock or stock options held in a of the posterior capsule or suprapa- tokines are present in intra-articular commercial company or institution tellar pouch, and diffuse arthrofibro- scar tissue and in the synovial fluid related directly or indirectly to the subject of this article. sis may contribute to knee stiffness, of patients with joint trauma, as well lead to alterations in the biomechan- as in fibrosis in the kidney, liver, and J Am Acad Orthop Surg 2011;19: 4-6 7-9 709-716 ics of the joint, and cause pain. lung. Additionally, vascular en- Specific releases can be performed dothelial growth factor is present in Copyright 2011 by the American 8 Academy of Orthopaedic Surgeons. for each fibrotic region. Familiarity the infrapatellar fat pad. This factor with the diagnosis and arthroscopic is released after injury to the fat pad

November 2011, Vol 19, No 11 709 Arthroscopic Releases for Arthrofibrosis of the Knee and may lead to vascular ingrowth iofemoral and patellofemoral com- the knee is fully extended. Increased and scarring.4 Another theory posits pression with the risk of chondral pain in the fat pad with knee exten- that injury, whether induced by damage or fracture, rupture of the sion indicates a positive result. Pa- trauma or surgery, produces hemor- , distal femoral frac- tients may also have pain in this area rhage and subsequent fibrosis due to ture, and complex regional pain syn- with forceful hyperextension of the 12,13 the maturation of localized clotting drome. knee. The patellar tendon and patella and induction of progenitor cells. should be carefully examined to rule out other causes of anterior knee Surgical Management pain. Nonsurgical Management Scarring in the fat pad can be visual- Anterior Interval Release ized on standard T1- and T2-weighted Prevention is the most effective The anterior interval is the space be- magnetic resonance images. On sagit- means of avoiding motion loss fol- tween the infrapatellar fat pad and tal T1- and T2-weighted magnetic res- lowing knee injury or surgery. Ini- patellar tendon anteriorly, and the onance images, anterior interval scar- tially, modalities such as ice, com- anterior border of the tibia and ring is indicated by a low signal pression, elevation, aspiration of transverse meniscal ligament posteri- coursing from the posterior portion of effusion, electrical stimulation, phys- orly.4 Trauma or previous surgery the fat pad to the anterior surface of ical therapy, nonsteroidal anti- may cause hemorrhage or inflamma- the tibia and/or transverse meniscal lig- inflammatory drugs, and a short- tion of the fat pad (ie, Hoffa syn- ament. term course of oral corticosteroids drome), which may result in fibrosis. can be used to decrease knee pain Fibrosis that occurs between the fat Surgical Technique and inflammation and maintain mo- pad and the transverse meniscal liga- Arthroscopic management of ante- tion.10 Flexion is more easily ob- ment or the anterior tibia leads to rior interval scarring begins by estab- tained than extension, thus, efforts dysfunction of anterior knee struc- lishing a modified anterolateral should be directed toward maintain- tures (eg, decreased excursion of the viewing portal. The portal is created ing extension. Isometric strengthen- patellar tendon) and results in slightly more lateral and proximal ing of the quadriceps helps to restore stretching of the surrounding syno- than standard arthroscopic portal extension and prevents atrophy. vial tissue, which may cause pain or placement to allow better visualiza- Early patellar mobilization prevents loss of knee extension.4 Fibrosis tion of the anterior interval struc- adhesion formation and contracture within the anterior interval has a tures (Figure 2). The anterior interval of the patellar tendon. Surgery for an spectrum of severity. Paulos et al1 de- can be viewed with a 30° arthro- acute injury is best performed after scribed infrapatellar contracture syn- scope; scarring is indicated by de- inflammation, edema, and pain have drome, which is a severe form of fi- creased opening of the interval with decreased and range of motion brosis of the fat pad and patellar knee extension as well as fibrosis of (ROM) has normalized. Preoperative tendon that severely limits ROM. the infrapatellar fat pad. and postoperative immobilization Fibrosis can be released using a 70° should be kept to a minimum; early History and Physical electrothermal probe inserted via a knee mobilization following surgery Examination modified anteromedial portal (Figure is recommended. Patients with anterior interval scar- 2). Systematic release begins anterior Additional intervention is indicated ring report anterior knee pain and to the transverse ligament, starting in patients who fail initial nonsurgi- frequently describe a sense of fullness just anterior to the anterior horn of cal treatment. Several authors have within the knee, especially with ex- the medial meniscus and proceeding recommended isolated manipulation tension. Physical examination may laterally and anterior to the anterior of the knee under anesthesia within 6 demonstrate a small flexion contrac- horn of the lateral meniscus (Figure to 12 weeks postoperatively in pa- ture, decreased proximal excursion 3). The release continues until the tients who have not regained full of the patella, and a positive Hoffa anterior tibial cortex is encountered ROM following surgery.10,11 How- test.4 This test is performed with the or until normal fat pad tissue is seen. ever, this modality has recently fallen knee in 30° of flexion; the thumbs Adequate release is confirmed by vi- out of favor due to the risk of intra- are placed at the medial and lateral sualization of interval widening with articular hemorrhage and subsequent margins of the infrapatellar fat pad knee extension and closing with flex- postoperative scarring, as well as and patellar tendon (Figure 1). Pres- ion. Care is taken to avoid disrupting complications such as excessive tib- sure is applied with the thumb, and the anterior meniscal attachments or

710 Journal of the American Academy of Orthopaedic Surgeons Michael R. Chen, MD, and Jason L. Dragoo, MD

Figure 1

Clinical photographs demonstrating the Hoffa test of the knee. A, The thumb is placed at the lateral margin of the infrapatellar fat pad and patellar tendon with the knee in 30° of flexion. B, Pressure is applied with the thumb as the knee is brought into full extension. (Reproduced with permission from Steadman JR, Dragoo JL, Hines SL, Briggs KK: Arthroscopic release for symptomatic scarring of the anterior interval of the knee. Am J Sports Med 2008;36[9]:1763-1769.) the transverse meniscal ligament. Figure 2 Meticulous hemostasis must be ob- tained to prevent postoperative bleeding and recurrent scarring.4 Postoperatively, the goal of rehabil- itation is to prevent scar reformation while preserving joint mobility. Initially, rehabilitation focuses on establishing full ROM and patellar and patellar ten- don mobility. Patients are limited to touch-down weight bearing for 2 weeks to limit inflammation and to maximize interval excursion.14 Typi- cally, patients are prescribed a 4- to 6-week course of anti-inflammatory medication following surgery. After 6 weeks, the goal is the return of functional strength; sports-specific Illustration demonstrating modified placement of arthroscopic portals for exercise is begun to facilitate gradual anterior interval release. A, Standard placement of arthroscopic portals. B, The modified anterolateral portal (arrow) is established slightly more return to sport. lateral and proximal than the standard portal to improve visualization of the anterior interval. The modified anteromedial portal (arrow) is created more Results medial than the standard portal to allow exploration of the anterior interval. Steadman et al4 described the results The shaded areas denote the infrapatellar fat pad. of isolated anterior interval release in a series of 25 consecutive patients with scarring of the anterior interval. average Lysholm score significantly to 70 (P < 0.0001 and P < 0.001, re- Patients failed a minimum of 6 improved from 59 preoperatively to spectively). Four patients with failed months of physical therapy and non- 81 postoperatively, and the average results required a second surgical re- steroidal anti-inflammatory drugs. International Knee Documentation lease. Ogilvie-Harris and Giddens15 Following arthroscopic release, the Committee score improved from 49 described arthroscopic resection of

November 2011, Vol 19, No 11 711 Arthroscopic Releases for Arthrofibrosis of the Knee

2 Figure 3 limb-length discrepancy. Contrac- draping for the creation of a postero- ture of the posterior capsule is the medial and/or posterolateral portal primary cause of extension loss; (Figure 4). Use of an arthroscopic however, anterior interval scarring, pump is recommended to maintain patellar entrapment, anterior cruci- constant intra-articular pressure and ate ligament graft malposition, and ensure distension of the posterior hamstring tightness can also contrib- capsule. Anterolateral and anterome- ute to loss of extension.1,2,16,17 dial arthroscopic portals are created near the edge of the patellar tendon History and Physical to allow instrumentation to be used Examination in the posterior compartment. Patients with an extension deficit The posteromedial compartment is should be systematically evaluated visualized by placing a 30° arthro- for the causes of flexion contracture. scope between the medial femoral A thorough history should be ob- condyle and posterior cruciate liga- Illustration demonstrating anterior tained, and any trauma and/or surgi- ment via the anterolateral portal.20 interval release. The release is cal procedures should be noted. Knee Often, a blunt arthroscopic obtura- made anterior to the transverse ROM should be carefully measured, tor must first be used to break meniscal ligament and proceeds laterally and anterior to the anterior and the quality of the end point through scar tissue or adhesions be- horn of the lateral (L) meniscus. should be recorded. Flexion contrac- fore inserting the arthroscope.20 Un- ACL = anterior cruciate ligament, tures exhibiting a firm end point der direct visualization, a spinal nee- M = medial meniscus. (Reproduced tend to involve the posterior capsule, with permission from Steadman JR, dle is inserted into the skin through Dragoo JL, Hines SL, Briggs KK: whereas a spongy end point typically the posteromedial capsule to localize Arthroscopic release for indicates involvement of the patello- the posteromedial arthroscopic por- symptomatic scarring of the femoral mechanism or anterior inter- tal (Figure 4). The portal is then cre- anterior interval of the knee. Am J val. Sports Med 2008;36[9]:1763-1769.) ated under direct visualization by MRI is the radiographic imaging making a small incision and advanc- modality of choice. Thickening or ing an arthroscopic cannula through the infrapatellar fat pad in patients scarring of the posterior capsule, the incision into the posteromedial with Hoffa syndrome. Patients had which is indicated by a low signal on compartment. Similarly, the arthro- marked improvement in symptoms T1- and T2-weighted magnetic reso- scope may be placed between the an- and function after surgery at an aver- nance images, may sometimes be ob- terior cruciate ligament and lateral age follow-up of 76 months. Con- served. femoral condyle to visualize the pos- versely, patients with severe scarring terolateral compartment. A postero- or infrapatellar contracture syn- Surgical Technique lateral portal can be created in a sim- drome had symptoms of patellofem- Surgical intervention is indicated af- ilar manner; however, care must be oral arthritis and tibiofemoral arthri- ter failed nonsurgical treatment in taken to avoid the peroneal nerve, tis and could not return to a the patient with a flexion contracture which lies on the posteromedial bor- preinjury level of sport or work de- of 10° to 15° and an unyielding end der of the biceps femoris tendon. The spite improvement in ROM after ar- point.18 However, even smaller de- incision must be made anterior to 1 throscopic and open treatment. grees of contracture may not be tol- this tendon, and blunt dissection erated in the elite athletic popula- must be performed during portal Posterior Capsular Release tion. Open17-19 and arthroscopic20,21 placement. Flexion contractures are one of the posterior capsular releases have been Two methods of arthroscopic cap- main factors that adversely affect pa- described, but arthroscopic releases sular release have been described in tient outcome and knee function fol- are more technically demanding. the literature. LaPrade et al20 de- lowing surgery.1,2,16 A 5° loss of ex- The patient is positioned for stan- scribed an isolated posteromedial re- tension can cause a noticeable limp dard arthroscopy with the contralat- lease for flexion contractures. They during ambulation as well as patello- eral leg placed in a well-leg holder recommended separating the pos- femoral irritability, and a deficit of and the foot of the bed dropped. A teromedial capsule from the postero- 10° is poorly tolerated.6 Extension tourniquet should be carefully placed medial structures, including the me- deficit >20° results in substantial high on the thigh to allow adequate dial gastrocnemius tendon and

712 Journal of the American Academy of Orthopaedic Surgeons Michael R. Chen, MD, and Jason L. Dragoo, MD muscle, with a blunt arthroscopic Figure 4 obturator or a small periosteal eleva- tor. The posteromedial capsule is then released using an arthroscopic basket punch and shaver, with the shaver blade facing anteriorly. The procedure starts medially and pro- ceeds laterally to the midline in line with the posterior cruciate ligament at the mid level of the capsule. The gastrocnemius muscle and tendon become visible as the capsule is re- leased. Mariani21 described posteromedial A, Clinical photograph of the knee demonstrating the location of a and posterolateral arthroscopic cap- posteromedial arthroscopic portal used for posterior capsular release. Inset, Arthroscopic image demonstrating the position of the posteromedial portal. sular releases in which the arthro- The entry site (1) is located between the posterior medial femoral condyle (2) scope can be placed in either the pos- and the posterior medial tibial plateau. (3) and is created under direct teromedial or posterolateral portal to visualization. B, Arthroscopic view from the posterolateral portal toward the visualize the contralateral compart- posteromedial aspect of the knee during capsular release. MFC = medial femoral condyle, MTP = medial tibial plateau. (Panel A reproduced with ment. Often, the posterior septum permission from Louisia S, Charrois O, Beaufils P: Posterior “back and forth” must be released before the capsular approach in arthroscopic surgery on the posterior knee compartment. release can be performed. A blunt Arthroscopy 2003;19[3]:321-325. Panel B reproduced with permission from trocar can be used to perforate the Pace JL, Wahl CJ: Arthroscopy of the posterior knee compartments: Neurovascular anatomic relationships during arthroscopic transverse septum, and a shaver or radiofre- capsulotomy. Arthroscopy 2010;26[5]:637-642.) quency probe can then be used to ex- pand the perforation. Posterior adhe- sions are removed until the femoral phylaxis to prevent deep vein throm- Peripatellar and condyles become visible. A punch or bosis. After discharge, patients con- Suprapatellar Releases radiofrequency probe is directed to- tinue with outpatient physical In general, arthrofibrosis in the su- ward the superior capsular attach- therapy and nighttime extension prapatellar pouch of the knee causes ments at the condyle, and the capsule splinting for at least 6 weeks. loss of flexion, whereas scarring of is then progressively released. The the posterior structures can cause gastrocnemius tendon can be visual- Results loss of extension. Scarring and adhe- 20 ized and released to allow for a LaPrade et al reported the results of sions lead to loss of capsular compli- greater posterior release. 15 patients who underwent isolated ance and pain.22 Postoperatively, patients may be arthroscopic posteromedial release. admitted to the hospital for pain Preoperative knee extension aver- History and Physical management and initial physical aged 15° and significantly improved Examination therapy. Placement of an indwelling to 0.07° at final follow-up (average, Physical examination begins with in- epidural catheter, in addition to oral 24 months). Mariani21 reported the spection of patellar glide or excur- and intravenous analgesics, is often results of 18 patients with extension sion, which should be examined in beneficial for pain management. deficits that averaged 34° (range, 16° all directions.23 Typically, the patella Early, aggressive physical therapy is to 44°) who were treated with poste- exhibits decreased excursion in all begun on the first postoperative day. rior capsular release. Extension defi- directions in patients with arthrofi- A continuous passive motion ma- cits averaged 3° (range, 0° to 5°) at brosis. Patellar tilt should be care- chine is used and is alternated in cy- final 1-year follow-up. Patients with fully assessed.23 The inability to ele- cles with extension splinting. Pa- more severe preoperative flexion vate the lateral aspect of the patella tients are advanced to weight bearing contracture require more aggressive to neutral with the knee in full exten- as tolerated and weaned from releases of both the posteromedial sion and with the patella centered in crutches when they are able to am- and posterolateral capsule and, if re- the trochlea indicates a tight lateral bulate without pain. Patients are also sults are inadequate, may require re- retinaculum and possible overcon- prescribed a 2-week course of pro- lease of the gastrocnemius tendon. straint of the patellar mechanism

November 2011, Vol 19, No 11 713 Arthroscopic Releases for Arthrofibrosis of the Knee

Figure 5 Figure 6

Clinical photographs demonstrating assessment of intra-articular volume. Preoperatively, the knee is injected with 60 mL of sterile saline. After injection, the syringe is removed from the needle to assess the outflow of Illustration of the patellar tilt test. saline. A, Slow egress (drip) indicates normal volume. B, Rapid outflow The patella is centered within the suggests insufficient intra-articular volume. (Reproduced with permission from femoral trochlea with the knee in Dragoo JL, Miller MD, Vaughn ZD, Schmidt JD, Handley E: Restoration of full extension. The medial and knee volume using selected arthroscopic releases. Am J Sports Med lateral aspects of the patella are 2010;38[11]:2288-2293.) stabilized with the thumb and forefinger, and the lateral aspect is elevated with the thumb. Inability to elevate the lateral aspect of the sule; this will prevent extravasation The anterior interval is then reestab- patella to neutral indicates a tight of fluid during arthroscopy.22,24 lished, if necessary.4 lateral retinaculum. (Reproduced Intra-articular volume capacity can Medial and lateral retinacular re- with permission from Dixit S, DiFiori JP, Burton M, Mines B: be assessed by injecting the knee lease may be indicated in patients Management of patellofemoral pain with 60 mL of sterile saline.22,24 After with persistent decreased patellar ex- syndrome. Am Fam Physician injection, the syringe is disconnected cursion after release of the suprapa- 2007;75[2]:194-202.) from the 18-gauge needle. A slow re- tellar pouch. The patellar tilt test can lease of saline indicates that the ar- be used to identify an excessively (Figure 5). Tenderness in the region ticular volume is normal and the tight lateral retinaculum (Figure 5).25 of the suprapatellar pouch and/or in- capsule is under little tension (Figure If the medial and lateral patellar reti- frapatellar fat pad is common, in ad- 6, A). However, if the saline is ex- naculum are scarred, they may be dition to loss of ROM. A systematic pressed from the joint in a stream, partially released to improve patellar evaluation, such as the one described the capsule is under significant pres- mobility and capsular compliance. by Kim et al,3 allows for assessment sure, which indicates insufficient Often, the anterolateral portal is and management of intra-articular capsular volume. The knee should used as the working portal, and the sources of motion loss. then be evaluated for structures anteromedial portal is used for view- Surgical Technique known to reduce intra-articular vol- ing. Placement of the electrothermal Performing capsular distension before ume (eg, anterior interval scarring, probe through a superior portal is 22 arthroscopy is useful because it reestab- complete suprapatellar plica) (Fig- rarely necessary. The retinacular re- lishes effective joint space, allows eas- ure 6, B). leases are performed approximately ier and safer insertion of instruments, Using an electrothermal probe, ad- 1 cm posterior to the border of the enhances visualization, and may dis- hesions are lysed and scarring is re- patella to avoid devascularization. rupt intra-articular adhesions.24 Ster- leased to reestablish the suprapatel- The procedure is performed in layers ile saline should be slowly injected lar pouch. Adhesions between the to prevent an excessive amount of re- into the capsule to allow for stretch- capsule and the femoral condyles are lease. The intercondylar notch can ing and to avoid rupturing the cap- often observed and require release. also be assessed for fibrosis. After

714 Journal of the American Academy of Orthopaedic Surgeons Michael R. Chen, MD, and Jason L. Dragoo, MD the anterior and suprapatellar pouch scarring. Posterior capsular release, 10. Noyes FR, Berrios-Torres S, Barber- releases are completed, knee ROM is although technically demanding, is Westin SD, Heckmann TP: Prevention of permanent arthrofibrosis after anterior tested. If persistent extension deficit effective for managing flexion con- cruciate ligament reconstruction alone or remains, then the posterior compart- tracture secondary to contracture of combined with associated procedures: A prospective study in 443 . Knee ment is assessed and released as de- the posterior capsule. Lysis of adhe- Surg Sports Traumatol Arthrosc 2000; scribed previously. sions and retinacular release of the 8(4):196-206. Postoperatively, an indwelling epi- suprapatellar pouch and peripatellar 11. Brassard MF, Scuderi GR: Complications of total knee arthroplasty, dural catheter can help to provide region offer controlled, focused man- in Insall JN, Scott WN, eds: Surgery of adequate pain management, which agement of the intra-articular causes the Knee, ed 3. New York, NY, Churchill allows for immediate intensive physi- of motion loss, with decreased risk Livingstone, 2001, pp 1814-1816. cal therapy. Patients are placed in a of complications. 12. Christel P, Herman S, Benoit S, Bornet D, Witvoët J: A comparison of continuous passive motion machine arthroscopic arthrolysis and immediately, and patellar mobiliza- manipulation of the knee under References anesthesia in the treatment of post- tion and ROM exercises are empha- operative stiffness of the knee. French sized. 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Ogilvie-Harris DJ, Giddens J: Hoffa’s adverse outcome of this procedure is The surgical treatment of arthrofibrosis of the knee. Am J Sports Med 1994; disease: Arthroscopic resection of the infrapatellar fat pad. Arthroscopy 1994; the inability to restore complete 22(2):184-191. 14,26,28 10(2):184-187. ROM. Several authors have also 3. Kim DH, Gill TJ, Millett PJ: 16. Saito T, Takeuchi R, Yamamoto K, noted marked postoperative tenderness Arthroscopic treatment of the Yoshida T, Koshino T: arthrofibrotic knee. Arthroscopy 2004; in the region of the infrapatellar fat Unicompartmental knee arthroplasty for 20(suppl 2):187-194. pad, which resolved with nonsurgical osteoarthritis of the knee: Remaining measures.26,27 Complications of retinac- 4. Steadman JR, Dragoo JL, Hines SL, postoperative flexion contracture Briggs KK: Arthroscopic release for affecting overall results. 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Matsusue Y: Cytokine production in the Arthroscopic posteromedial capsular Arthroscopic techniques provide infrapatellar fat pad: Another source of release for knee flexion contractures. minimally invasive, efficacious alter- cytokines in knee synovial fluids. Ann Knee Surg Sports Traumatol Arthrosc Rheum Dis 2003;62(2):108-112. 2008;16(5):469-475. natives to open procedures. Anterior 9. Border WA, Noble NA: Transforming 21. Mariani PP: Arthroscopic release of the interval release is a simple procedure growth factor beta in tissue fibrosis. N posterior compartments in the treatment for management of anterior interval Engl J Med 1994;331(19):1286-1292. of extension deficit of knee. Knee Surg

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716 Journal of the American Academy of Orthopaedic Surgeons