**5.2 Arthroscopic lysis of adhesions**

266 Modern Arthroscopy

Modern lateral releases are generally performed using an arthroscopic electrothermal probe to aid in hemostasis, since hemarthrosis is the most common complication of this procedure. 23 The anterolateral portal is often used as the working portal and the anteromedial portal as the viewing portal. Placement of the electrothermal probe through a superior portal is possible, but usually unnecessary. The lateral release is performed approximately 1cm posterior to the lateral border of the patella to avoid devascularization. A complete release begins at the level of the proximal pole of the patella and is continued distally to the level of the distal pole. Modified releases begin distal to the vastus lateralis insertion on the patella and are continued distally only far enough to achieve a neutral tilt test. The release is

Complications of lateral releases are common, especially with excessive release, which continues beyond the fat and muscle layers or disrupts the vastus lateralis tendon insertion. Over-release can result in wound complications or medial patellar instability. Hemarthrosis is the most common complication; therefore meticulous hemostasis is required due to the

Weight-bearing is generally limited for several days to decrease the incidence of hemorrhage and inflammation. Bracing after lateral release is not routinely used. Patellar mobilization is begun immediately after surgery in physical therapy, followed by

Several studies have demonstrated 60-90% satisfactory results with arthroscopic lateral release for patellofemoral pain with maltracking and without instability. 22,23,24,25 Increasing amounts of chondromalacia and instability were associated with less favorable results in these studies. When arthroscopic lateral release has been performed for indications other than lateral patellar compression, the results have been poor.

Arthrofibrosis is the development of intra-articular scarring and adhesions due to trauma, previous surgery, prolonged immobilization and infection. In general, arthrofibrosis of the anterior structures of the knee cause of loss of flexion, while scarring of the posterior structures can cause loss of extension. Scarring and adhesions lead to loss of capsular

Physical examination of the patella typically exhibits decreased excursion in all directions. Tenderness in the region of the supra-patellar pouch and/or infrapatellar fat pad is

If arthrofibrosis is recognized early, non-operative measures such as physical therapy modalities, range of motion exercises and anti-inflammatory medications may successfully improve motion. Manipulation under anesthesia has been a commonly performed procedure, however it is falling out of favor due to complications such hemarthrosis, which can predispose to further scar tissue formation, distal femur fractures and patellar tendon rupture. Arthroscopic lysis of adhesions avoids these complications and allows for

performed in layers to prevent over-release.

proximity of the geniculate arteries. 23

quadriceps strengthening.

**4.3 Results** 

19,20,21,22,25,27,28

**5. Lysis of adhesions** 

compliance and pain. 29

controlled, focused treatment.

**5.1 History and physical examination** 

common, along with loss of range of motion.

A systematic evaluation as described by Kim, et al. allows for assessment and treatment of intra-articular sources of motion loss. 30 Capsular distension before arthroscopy is useful, as it re-establishes effective joint space, allows easier and safer insertion of instruments, enhances visualization, and may disrupt intra-articular adhesions. 31 Injection of sterile saline should be performed slowly to allow for capsular stretching and to avoid rupture of the capsule, preventing extravasation of fluid during arthroscopy. 29,31

Intra-articular volume capacity can be assessed by injecting the knee with 60cc's of sterile saline. 29,31 After injection, the 18 gauge needle is disconnected from the syringe. If the saline drips out of the needle, the capsule is under little tension and the intra-articular volume is considered normal (Figure 6B). If, however, the saline is expressed from the joint in a stream (Figure 6A), the capsule is under significant pressure indicating insufficient volume. The knee should then be evaluated for stuctures known to reduce interarticular volume. 29

Fig. 6. Assessment of intra-articular volume. The preoperative knee is injected with 60mL of sterile saline. A, Rapid outflow suggests insufficient intra-articular volume. B, Slow egress (drip) indicates normal volume.

Arthroscopic Soft Tissue Releases of the Knee 269

clicking, or catching varies widely. Provocative meniscal tests and test for patellofemoral pathology are often positive, which further complicates the diagnosis. A thickened medial plica is occasionally palpable medially, just proximal to the joint line, which may be tender and felt to catch with flexion and extension. MRI can often demonstrate the presence of a

A standard diagnostic arthroscopy is always performed to ensure that other more common intra-articular pathologies are not present as the source of pain. Normal plicae appear soft and may be almost translucent at its edge and can be moved freely. In contrast, pathologic plicae often appear thickened and hypertrophic, while having the feel of a tight bowstring. Underlying chondral degeneration of the medial femoral condyle is often present with

When the diagnosis of a symptomatic plica is made, it should be resected along its entire length using an electrothermal probe. Care is taken to ensure that only the plica is resected,

The normal suprapatellar pouch extends to approximately 3-4cm proximal of the proximal pole of the patella. With the arthroscope in the suprapatellar pouch, failure to visualize the quadriceps tendon suggests the presence of a complete suprapatellar plica dividing the suprapatellar pouch. The presence of an incomplete or complete suprapatellar plica can result in a decrease of knee volume, and pain. 29 Thus, suprapatellar plicae can be resected

The majority of results of arthroscopic plica excision have described medial plica excision and mostly been limited to small retrospective reviews. Kent et al. summarized the results of arthroscopic treatment of medial plica in studies published since 1980. 38 In all the studies reviewed, patients had 66% to 98% good to excellent outcomes with plica excision. Weckstrom et al. also recently described retrospective results of military recruits with arthroscopic medial plica resection at median 6-year follow-up. 39 Functional results as determined by the Kujala and Lysholm knee scores were good to excellent in 68% of

Few reports exist of pathologic infrapatellar or suprapatellar plica. Demirag et al. 40 and Boyd et al., 41 in small series described 85% to 91% good or excellent results with arthroscopic resection of symptomatic infrapatellar plica, while Bae et al. 42 reported 90% good or excellent results with excision of a complete, symptomatic suprapatellar plica.

A myriad of inta-articular soft tissue disorders can cause significant morbidity within the knee. Arthroscopic techniques provide minimally-invasive efficacious alternatives to open treatment. Anterior interval release is a simple procedure for treating anterior interval scarring, a fibrotic condition still commonly unrecognized as a cause of anterior knee discomfort. Posterior capsular release, although technically demanding, is effective for treating flexion contractures secondary to scarring and contracture of the posterior capsule. Isolated lateral release provides satisfactory results for patellofemoral pain with maltracking without instability. Arthroscopic lysis of adhesions allows for controlled, focused treatment

plica, but not whether it is pathologic.

while protecting the surrounding structures.

in patients with parapatellar pain with an electrothermal probe.

**6.2 Plica excision** 

**6.3 Results** 

patients.

**7. Summary** 

medial plica impingement.

Using an electrothermal probe, adhesions are lysed and scarring is released to re-establish the suprapatellar pouch. Adhesions between the capsule and the femoral condyles are often observed and require release. The anterior interval is then re-established as necessary. 1 The medial and lateral patellar retinaculum are partially released if they are scarred, which improves patellofemoral mobility and capsular compliance. The intercondylar notch is then assessed for cyclops lesions.

After completing all anterior releases, the knee is then taken through a range of motion. If a persistent extension deficit remains, then the posterior compartment is assessed and released as previously described.

Postoperatively, an indwelling epidural catheter can help provide adequate pain management, which allows for immediate intensive physical therapy. Patients are placed in a continuous passive motion (CPM) machine immediately, and patellar mobilization and range of motion exercises are emphasized.
