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Dr Gaurav GuptaDNB Orth, Mch Orth, MNAMS
Fellowships: Arthroscopy & Sports injuries (Sweden), Arthroscopy (UK)Knee & Hip (UK), Shoulder & Upper limb (Australia), Joint Replacement (Australia)
Consultant Orthopaedic Surgeon, Kolkata
FORTIS, CMRI, BORRC HOSPITALS
Etiology of Knee Arthrofibrosis
Etiology
• Ligament injuries• Immobilisation post injury / post surgery
» Bracing, Plastering
» Contractures develop – intraarticular & extraarticular
» Poor rehab & poor motivation contribute
Etiology - ACLR
• Reported incidence 4% to 35%
• Incorrect tunnel placement
• Notch impingement – cyclops lesion
• Immobilisation
• Preoperative poor ROM
• Poor rehab
• ?? Timing
Etiology – ACLR
• Randomised 105 patients• 32 month follow up• Lysholm, Tegner, ROM• No difference if ACLR <2wk or 4-6 wks
• PCL Reconstruction» Causes same as ACLR
» Generally more prone to stiffness
» Longer rehab, No consensus on rehab protocols
• Medial & Lateral reconstructions» Risk of “Overtightening”
» Non isometric reconstructions
• Poor rehab & poor pain management contribute to stiffness in ligament surgery
Etiology
• Multiligament Reconstruction• Multiligs are high-energy injuries
• Risk higher than 1 ligament surgery
• Functional outcomes not as good as ACLR
• Prevention by inflammation control and early motion remains the key
Etiology
Multilig reconstruction – interesting case
• Knee dislocation Afghanistan• ACL+PCL+Medial injury• Popliteal artery grafted• Compartment syndrome• Fasciotomy in Dubai – medial, lateral• Got infected• Presented to us June 2013
Etiology - TKA
• Incidence of postoperative stiffness 6%
• Posttraumatic OA
• Prior HTO
• Poor preoperative ROM
• Technical errors» Poor exposure – extensor mechanism trauma
» Oversized femur
» Overstuffing of Patella
» Malrotation of components
» Retained posterior osteophytes
» Gap imbalance
» Varus valgus malalignment
• Poor pain management
• Aggressive anticoagulation therapy
• Poor rehab
• Poor motivation
• Individual propensity» Rapid proliferation of scar tissue
» Genetic factors
» Difficult to identify “at risk” group
Pathology
• Anterior scarring
• Posterior capsular contracture
• Fibrosis of suprapatellar pouch
• Quads adhesions
• Medial and lateral gutter scarring
• Combination of above
Cellular Pathology
• Cellular pathology• Excessive fibrotic healing response with diffuse intra-
articular scarring
• Immune response behind scarring
• T cell mediated immune response plays a crucial role
How to prevent arthrofibrosis
• Avoid immobilisation
• Good surgical technique
• Pain control
• Early good rehab
• Drugs» Intraarticular triamcinolone
» New horizons: Oral montelukast, Intra-articular forskolin, Intra-articular monoclonal antibody - bevacizumab
SUMMARY
• Etiology of arthrofibrosis• Fractures & Ligament injuries
• Post Reconstructive surgery
• Post TKA
• Septic arthritis, RA, OA
• Most cases are preventable