**2.4**

Loss of knee flexion often indicates involvement of the supra-patellar pouch, patello-femoral joint or anterior interval. Involvement of the intercondylar notch can affect both flexion and extension. Extension loss can result from intra-articular nodules and arthrofibrosis of the posterior capsule.

Fig. 6. Suprapatellar pouch with adhesion and synovitis

Kim et al (Ref) described a systematic approach when performing arthroscopic debridement of an arthrofibrotic knee. The use of regional anesthesia can effectively manage perioperative pain and facilitate postoperative rehabilitation (Ref: Millet). Prior to portal placement; capsular distention is achieved by saline injection into the supra-patellar pouch. Arthroscopy of prosthetic knees is initially approached through the conventional anteriormedial and anterior-lateral portals. If necessary, additional superolateral or superomedial portals can be utilized. Extreme care must be exercised when trocars and other instruments are inserted or manipulated in the joint, so as not to scratch the metallic surfaces or the polyethylene. Raab et al noted in an in vitro study, that a stainless steel cannulae could produce surface alterations in the femoral component with loads as small as 8 Newton. The supra-patellar pouch is reestablished first, followed by the medial and lateral gutters. The anterior interval is identified by releasing the infra-patellar fat pad from the anterior tibia,

Loss of knee flexion often indicates involvement of the supra-patellar pouch, patello-femoral joint or anterior interval. Involvement of the intercondylar notch can affect both flexion and extension. Extension loss can result from intra-articular nodules and arthrofibrosis of the

**2.4** 

posterior capsule.

Fig. 6. Suprapatellar pouch with adhesion and synovitis

Kim et al (Ref) described a systematic approach when performing arthroscopic debridement of an arthrofibrotic knee. The use of regional anesthesia can effectively manage perioperative pain and facilitate postoperative rehabilitation (Ref: Millet). Prior to portal placement; capsular distention is achieved by saline injection into the supra-patellar pouch. Arthroscopy of prosthetic knees is initially approached through the conventional anteriormedial and anterior-lateral portals. If necessary, additional superolateral or superomedial portals can be utilized. Extreme care must be exercised when trocars and other instruments are inserted or manipulated in the joint, so as not to scratch the metallic surfaces or the polyethylene. Raab et al noted in an in vitro study, that a stainless steel cannulae could produce surface alterations in the femoral component with loads as small as 8 Newton. The supra-patellar pouch is reestablished first, followed by the medial and lateral gutters. The anterior interval is identified by releasing the infra-patellar fat pad from the anterior tibia, allowing for reestablishment of the pretibial recess. Medial and/or lateral retinacular release may be required in the patient with reduced patellar mobility or a tight patello-femoral joint. Once in the intercondylar notch, the surgeon must evaluate notch stenosis. If present, a notchplasty is performed. Scar tissue, bony nodules, and loose bodies are removed. Depending on the severity of the scarring, release or excision is performed. Once complete, the knee should be ranged and motion reassessed. Persistent loss of extension usually indicates posterior capsular involvement. Care needs to be taken, as decreased joint space by intra-articular adhesions bands and hypertrophied synovium, iatrogenic damage to the prosthesis and polyethylene during arthroscopy may be the major disadvantage of arthroscopy following total knee replacement.

Fig. 7. Scar Tissue within joint space.

Arthroscopy Following Total Knee Replacement 247

Fig. 8. Arrow denoting a narrow hair thin lucent line at the superior pole of patella. Also

note that patella at the lower pole is thicker than the upper pole

Fig. 9. Arthroscopic image of the nodule at the superior pole of the patella.

5. Quadriceps Impingement secondary to superior placement of patellar button.

6. Inadequate synovial tissue debridement at superior pole of patella during primary

**3.4 Causes of patellar clunk syndrome** 

1. Poor Patellar Tracking. 2. Peripatellar Fibrosis

procedure.

3. Implant Design Related Issues 4. Implant malpositioning.
