**2. Arthrofibrosis**

240 Modern Arthroscopy

Fig. 4.1. Painful TKR without any clinically identifiable cause. O Arthroscopy synovium

Fig. 4.3. Same knee implant at the time of revision. The knee was a part of global recall. Note

Fig. 4.2. Note the scratches on the metal surface of the same knee.

showed signs of metallosis.

the scratches on the tibial base plates

The incidence of arthrofibrosis or stiffness following TKR varies considerably and has been cited to be between 1 and 11%. Arthrofibrosis or knee stiffness is clinically defined as an inadequate range of movement that results in functional limitations affecting activities of daily living. The cutoff range of motion (ROM) for which stiffness requires surgical treatment is defined as having a flexion contracture of 15 degrees or flexion of less than 75 degrees. This decreased range of movement can severely affect the patient's ability to perform tasks of daily living such as walking, climbing stairs, or getting up from a seated position. Biomechanical studies and gait analysis have shown that patients required 67 degrees of knee flexion during the swing phase of gait, 83 degrees of flexion to climb stairs, 90- 100 degrees of flexion to descend stairs, and 93 degrees of flexion to stand from a seated position

Fig. 5. Adhesion in suprapatellar pouch.

**2.1** 

Arthrofibrosis may be secondary to numerous factors, including limited preoperative range of motion, faulty surgical technique, incorrect sizing, inappropriate implant placement, or inadequate postoperative rehabilitation and limiting motion until wound healing occurs. It could be also due to a biological predilection as some patients may be predisposed to

**2.3** 

lateral gutters.

**Study** 

Nicholls &

Ries &

Babis et al 7 (7)

**Number of Patients (Knees)** 

Scranton et al 4 (4) Modified

**Technique** 

Williams et al 9 (10) PCL release 29 30° 20 Campbell 8 (8) Lysis 11.6 16.5° 12 Diduch et al 8 (8) Lysis 7.4 26° 20 Bae et al 11 (13) Lysis 20 42° 12 Sprague et al 1 (1) Lysis 12 23° 3 Scranton et al 7 (7) Lysis N/A 31° 12

Dorr 12 (13) Revision N/A 33° N/A

Badalamente 5 (6) Revision 20 50° 33

Open Lysis with Tib. Insert Exchange

**Time from TKA to Secondary Surgery (Months)** 

Open N/A 62° 12

**Total Gain in Range of Motion (Degrees)** 

12 28° 50

**Time to Follow-up (Months)** 

Arthroscopy Following Total Knee Replacement 243

Performing arthroscopy for arthrofibrosis however may be a technically demanding. Insertion of the arthroscope into a markedly stiff knee with an arthro-fibrotic patellofemoral compartment can be challenging and one posing potential risk of damaging the prosthesis. Arthroscopic debridement of adhesions in combination with manipulation has been shown to substantially improve knee range of movement in patients with postoperative arthrofibrosis resulting from surgical procedures other than TKA. However, arthroscopic lysis of adhesions after TKA has not been as successful as lysis after procedures other than TKA. Bocell et al observed that only two of seven patients maintained pain-free improvements in range of movement after arthroscopic debridement of arthrofibrosis and manipulation after TKA. Campbell observed an increase in flexion of only 11° and an increase in extension of only 5.5° in eight patients 1 year after arthroscopy. Others have reported more marked improvements in range of movement. After arthroscopic debridement and manipulation, Diduch et al reported a 26° improvement in mean flexion in eight patients, and Scranton observed a 31° gain in mean range of movement; however, neither study examined the effect of arthroscopy on flexion contractures. Bae et al reported a mean improvement of 42° in the total arc of motion at 1-year follow-up in 13 knees; the improvement in flexion contractures was less clear. Patients with flexion limitations who receive a PCL-retaining total knee component may benefit from arthroscopic release of the PCL. Williams et. al observed an increase in mean flexion of 30° and an improvement in mean knee extension from 4° to 1.5° at 20-month follow-up in 10 knees after arthroscopic PCL release. When adhesions are more extensive, electro-cautery, arthroscopic scissors, and large-radius shavers can be used to debride the supra-patellar pouch and the medial and

extensive scar tissue formation as a response to the tissue trauma itself, which occurs during total knee replacement.

#### **2.2**

Managing stiff knee involve a thorough clinical exam to rule out any extrinsic contributing factor, ruling out infection and revisiting the surgical notes to identify any surgery related causes. One of the important aspects is identifying or excluding low grade infections. Initial step in managing these cases is a step by step incremental rehabilitation program. If this fails, a closed manipulation may be the next step. Recalcitrant cases may require arthroscopic or open arthrolysis. Arthroscopic management allows minimally invasive access to focal lesions (e.g. nodules, loose bodies) and is helpful in addressing cases of severe diffuse arthrofibrosis refractory to closed methods as well as in avoiding potential catastrophic complications associated with manipulation alone. Arthroscopic treatment of painful knee arthroplasty provides reliable expectations for improvement in function, decrease in pain, and improvement in knee scores.

Flowchart for management of Arthrofibrosis after TKR

#### **2.3**

242 Modern Arthroscopy

extensive scar tissue formation as a response to the tissue trauma itself, which occurs during

Managing stiff knee involve a thorough clinical exam to rule out any extrinsic contributing factor, ruling out infection and revisiting the surgical notes to identify any surgery related causes. One of the important aspects is identifying or excluding low grade infections. Initial step in managing these cases is a step by step incremental rehabilitation program. If this fails, a closed manipulation may be the next step. Recalcitrant cases may require arthroscopic or open arthrolysis. Arthroscopic management allows minimally invasive access to focal lesions (e.g. nodules, loose bodies) and is helpful in addressing cases of severe diffuse arthrofibrosis refractory to closed methods as well as in avoiding potential catastrophic complications associated with manipulation alone. Arthroscopic treatment of painful knee arthroplasty provides reliable expectations for improvement in function,

total knee replacement.

decrease in pain, and improvement in knee scores.

Flowchart for management of Arthrofibrosis after TKR

**2.2** 

Performing arthroscopy for arthrofibrosis however may be a technically demanding. Insertion of the arthroscope into a markedly stiff knee with an arthro-fibrotic patellofemoral compartment can be challenging and one posing potential risk of damaging the prosthesis. Arthroscopic debridement of adhesions in combination with manipulation has been shown to substantially improve knee range of movement in patients with postoperative arthrofibrosis resulting from surgical procedures other than TKA. However, arthroscopic lysis of adhesions after TKA has not been as successful as lysis after procedures other than TKA. Bocell et al observed that only two of seven patients maintained pain-free improvements in range of movement after arthroscopic debridement of arthrofibrosis and manipulation after TKA. Campbell observed an increase in flexion of only 11° and an increase in extension of only 5.5° in eight patients 1 year after arthroscopy. Others have reported more marked improvements in range of movement. After arthroscopic debridement and manipulation, Diduch et al reported a 26° improvement in mean flexion in eight patients, and Scranton observed a 31° gain in mean range of movement; however, neither study examined the effect of arthroscopy on flexion contractures. Bae et al reported a mean improvement of 42° in the total arc of motion at 1-year follow-up in 13 knees; the improvement in flexion contractures was less clear. Patients with flexion limitations who receive a PCL-retaining total knee component may benefit from arthroscopic release of the PCL. Williams et. al observed an increase in mean flexion of 30° and an improvement in mean knee extension from 4° to 1.5° at 20-month follow-up in 10 knees after arthroscopic PCL release. When adhesions are more extensive, electro-cautery, arthroscopic scissors, and large-radius shavers can be used to debride the supra-patellar pouch and the medial and lateral gutters.


Arthroscopy Following Total Knee Replacement 245

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.
