**2. Anterior interval release**

### **2.1 History and physical examination**

The anterior interval has been defined as the space between the infrapatellar fat pad and patellar tendon anteriorly, and the anterior border of the tibia and transverse meniscal ligament posteriorly.1 Trauma or previous surgery may cause hemorrhage or inflammation of the fat pad (Hoffa's Syndrome), which may be followed by fibrosis. If fibrosis occurs between the fat pad and transverse ligament or anterior tibia, it will lead to dysfunction of the anterior knee structures, such as decreased excursion of the patellar tendon and result in stretching of the surrounding synovial tissue, which may lead to pain or even loss of knee extension. 1 Fibrosis within the anterior interval can exist on a spectrum of severity. Paulos et al. described infrapatellar contracture syndrome, a severe form of anterior interval scarring, with fibrosis of the fat pad and severe limitations in range of motion. 5

Patients with anterior interval scarring complain of anterior knee pain, and frequently describe a sense of fullness within the knee, especially with extension. Physical examination may demonstrate a small flexion contracture, decreased proximal excursion of the patella, as well as a positive Hoffa's test 1. Hoffa's test is performed by placing the thumb at the margin of the infrapatellar fat pad and patellar tendon medially and laterally with the knee flexed at 30o (Figure 1). Pressure is applied with the thumb, and the knee is fully extended. Increased pain in the fat pad with knee extension indicates a positive result. Patients may also have pain in the fat pad with forceful hyperextension of the knee. The patellar tendon and patella should also be carefully examined to ensure they are not also causes of the anterior knee pain.

Scarring in the fat pad can be visualized on standard T1- and T2-weighted magnetic resonance imaging (MRI). Low T1- and T2- signal identified on sagittal images coursing from the posterior portion of the fat pad to the anterior surface of the tibia and/or transverse meniscal ligament indicates anterior interval scarring.

Arthroscopic Soft Tissue Releases of the Knee 259

Arthroscopic treatment of anterior interval scarring begins with establishment of a modified anterolateral viewing portal. The portal is established slightly more lateral and proximal to the standard placement to allow easier visualization of the anterior interval structures (Figure 2). Viewing of anterior interval scarring with the 30o arthroscope will demonstrate decreased opening of the interval with extension as well as fibrosis of the infrapatellar fat

Fibrosis can be released with use of a 70o electrothermal probe via a modified anteromedial portal (Figure 2). Systematic release begins anterior to the transverse ligament, starting just anterior to the anterior horn of the medial meniscus, and proceeding laterally and anterior to the anterior horn of the lateral meniscus (Figure 3). The release is continued until the anterior tibial cortex in encountered or until normal fat pad tissue is seen. Adequate release is confirmed by visualization of interval widening with knee extension and closing with flexion. Care is taken to avoid disrupting the anterior meniscal attachments or the transverse meniscal ligament. Meticulous hemostasis is obtained to prevent postoperative bleeding and

A B Fig. 2. Modified arthroscopic portals for anterior interval release. A, Standard arthroscopic portals. B, The modified anterolateral portal established slightly more lateral and proximal to the standard placement to allow easier visualization of the anterior interval and the modified anteromedial portal established more medial to allow instrumentation of the anterior interval.

**2.2 Anterior interval release** 

pad.

recurrent scarring 1.

Figure 1A

Figure 1B

Fig. 1. Demonstration of Hoffa's test. A, The thumb is placed at the margin of the infrapatellar fat pad and the patellar tendon with the knee in 30o of flexion. B, Pressure is applied with the thumb and the knee and then brought into full extension. Increased pain in the fat pad indicates a positive result.

#### **2.2 Anterior interval release**

258 Modern Arthroscopy

Fig. 1. Demonstration of Hoffa's test. A, The thumb is placed at the margin of the

infrapatellar fat pad and the patellar tendon with the knee in 30o of flexion. B, Pressure is applied with the thumb and the knee and then brought into full extension. Increased pain

Figure 1A

Figure 1B

in the fat pad indicates a positive result.

Arthroscopic treatment of anterior interval scarring begins with establishment of a modified anterolateral viewing portal. The portal is established slightly more lateral and proximal to the standard placement to allow easier visualization of the anterior interval structures (Figure 2). Viewing of anterior interval scarring with the 30o arthroscope will demonstrate decreased opening of the interval with extension as well as fibrosis of the infrapatellar fat pad.

Fibrosis can be released with use of a 70o electrothermal probe via a modified anteromedial portal (Figure 2). Systematic release begins anterior to the transverse ligament, starting just anterior to the anterior horn of the medial meniscus, and proceeding laterally and anterior to the anterior horn of the lateral meniscus (Figure 3). The release is continued until the anterior tibial cortex in encountered or until normal fat pad tissue is seen. Adequate release is confirmed by visualization of interval widening with knee extension and closing with flexion. Care is taken to avoid disrupting the anterior meniscal attachments or the transverse meniscal ligament. Meticulous hemostasis is obtained to prevent postoperative bleeding and recurrent scarring 1.

Fig. 2. Modified arthroscopic portals for anterior interval release. A, Standard arthroscopic portals. B, The modified anterolateral portal established slightly more lateral and proximal to the standard placement to allow easier visualization of the anterior interval and the modified anteromedial portal established more medial to allow instrumentation of the anterior interval.

Arthroscopic Soft Tissue Releases of the Knee 261

Steadman et al 1 described the results of isolated anterior interval release in twenty-five consecutive patients. Patients failed a minimum of six months of physical therapy and nonsteroidal anti-inflammatory medications. Following arthroscopic release, the average Lysholm score significantly improved from 59 preoperatively to 81 postoperatively, while the average International Knee Documentation Committee (IKDC) score improved from 49 to 70. Four patients had failed results, requiring a second surgical release. Ogilvie-Harris and Giddens described arthroscopic resection of the infrapatellar fat pad in patients with Hoffa's syndrome. 6 Patients had significant improvement in symptoms and function after

Conversely, patients with severe scarring, or infrapatellar contracture syndrome, had symptoms of patellofemoral arthritis and tibiofemoral arthritis and could not return to preinjury sport or work despite improvements in range of motion after arthroscopic and open

Flexion contractures are one of the main factors that adversely affect patient outcome and knee function following surgery. 5, 7, 8 A 5o loss of extension can cause a noticeable limp during ambulation and patellofemoral irritability, and a loss of 10o is poorly tolerated. 3 Deficits greater than 20o result in a significant leg-length discrepancy. 8 Contracture of the posterior capsule is the primary cause of extension loss, however anterior interval scarring, patellar entrapment, anterior cruciate ligament (ACL) graft malposition and hamstring

Patients with an extension deficit should be systematically evaluated for the multiple potential causes of a flexion contracture. A thorough history of any trauma or surgical procedures should be obtained. Knee range of motion should be carefully measured and the quality of the endpoint should be recorded. Flexion contractures exhibiting a firm endpoint tend to involve the posterior capsule, while a spongier endpoint typically indicates

MRI is the imaging modality of choice. Thickening or scarring of the posterior capsule,

Surgical intervention is indicated in a patient with a 10-15 degree flexion contracture with an unyielding endpoint that has failed non-operative management, 10 however even smaller degrees of contracture may not be tolerated in the elite athletic population. Both open 9,10,11 and arthroscopic posterior capsular releases 12,13 have been described, however

The patient is positioned for standard arthroscopy, however the contralateral leg is placed in a well-leg holder and the foot of the bed is dropped. Care should be taken to place the tourniquet high on the thigh to allow adequate draping for the creation of a posteromedial and/or posterolateral portal (Figure 4). An arthroscopic pump is generally recommended to maintain a constant intra-articular pressure and ensure distension of the posterior capsule. Anterolateral and anteromedial arthroscopic portals are created near the edge of the patellar

tendon to allow instrumentation to be used in the posterior compartment.

involvement of the patellofemoral mechanism or anterior interval.

indicated by low T1 and T2 signal, may sometimes be observed.

arthroscopic releases are more technically demanding.

**2.3 Results** 

treatment. 5

surgery at an average follow-up of 76 months.

**3. Posterior capsular release** 

**3.1 History and physical examination** 

tightness can also contribute. 5, 7, 8, 9

**3.2 Posterior capsular release** 

Fig. 3. Location of anterior interval release. The release is made anterior to the transverse meniscal ligament and proceeds anterior to the anterior horn of the medial and lateral meniscus.

Postoperatively, the goal is to prevent scar reformation, while preserving joint mobility. Initially, rehabilitation is focused on establishing full range of motion and patellar and patellar tendon mobility. Patients are limited to touch-down weight bearing for 2 weeks to limit inflammation and to maximize interval excursion. 4 Patients are also usually prescribed anti-inflammatory medications for 4 to 6 weeks following surgery. After 6 weeks, the goal is the return functional strength followed by sports specific exercise and gradual return to sport.
