Arthroscopic Lysis of Adhesions Is an Effective Technique to Manage Arthrofibrosis after Total Knee Arthroplasty

Editor’s note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.

Arthrofibrosis after total knee arthroplasty (TKA) can cause notable loss of knee flexion (<90 degrees) and extension (>10 degrees), accompanied by pain with motion, palpable crepitus, and decreased passive motion of the patella. According to the authors of an OVT video, the incidence of arthrofibrosis is about 3 to 10 percent after TKA, accounting for 10 percent of revision cases and 28 percent of readmissions within 30 days of TKA. It is also one of the leading causes of dissatisfaction after TKA. Arthrofibrosis results from uncontrolled inflammatory and proliferative phases of healing, leading to excessive maturation of scar tissue.</90>

If a patient is diagnosed within 3 months of surgery, manipulation under anesthesia (MUA) is a treatment option, with an expected recovery of about a 30-degree arc of motion. However, after 3 months, scar tissue matures and the risk of complications such as periprosthetic fracture and extensor mechanism injury significantly increase. At that point, MUA is not recommended and more invasive intervention is warranted. One such intervention is arthroscopic lysis of adhesions (LOA), a minimally invasive technique with an expected increase in range of motion (ROM) from 24 to 31 degrees.

An OVT video from Thomas Boucher, MD, and colleagues utilizes a patient case to highlight their technique for arthroscopic LOA. The patient was male, was aged 74 years, and had persistent pain and difficulty with ROM after TKA.

At 1 year after surgery, he experienced gradually worsening pain despite consistent physical therapy, with difficulty climbing stairs and squatting. ROM was 0 to 95 degrees. Before TKA, his knee ROM was equivalent to the contralateral nonoperative knee. He was treated with arthroscopic LOA and achieved ROM of 0 to 125 degrees.

The video authors begin with the patient supine and wearing a high thigh tourniquet. Examination under anesthesia assesses ROM. Four working portals are used for the procedure. The superolateral portal is first established with a spinal needle to determine the desired portal placement, followed by insertion of the arthroscopic trocar into the suprapatellar pouch. This is advanced across the knee to tent the skin medially to create a superomedial working portal.

With the camera in the superomedial portal and the shaver in the superolateral portal, the suprapatellar pouch is debrided. TKA components become visible, and radiofrequency ablation is then used to create planes to adequately debride the superior portion of the medial and lateral gutters, as well as to maintain hemostasis (Fig. 1). The authors emphasize that the shaver should be aimed away from the components to avoid damage to metal/polyethylene.

With the knee in extension and the camera in the superolateral portal, the infrapatellar fat pad and adjacent scarring are debrided to mobilize the patellar tendon. This creates space for an anteromedial portal to be created under direct visualization with a spinal needle per standard technique. A shaver is then placed through this anteromedial portal and used to debride the patellofemoral compartment. Scar tissue between the femoral component and polyethylene spacer is mobilized, and this is carried down around the tibial component.

The authors recommend using preoperative lateral radiographs to measure the distance between the tibial component and tibial tubercle, in order to determine a safe zone for debridement. A Cobb elevator is then used to elevate adhesions off the anterior tibia toward the tibial tubercle.

With the camera in the anteromedial portal, an anterolateral portal is made in standard fashion to debride the intercondylar notch and inferior portion of the lateral gutter. Scar tissue deep to the patellar tendon is released. A lateral release is performed to free up the patellar tendon. This is done initially from the superolateral and the anterolateral portals with ablation to release both deep and superficial lateral patellofemoral ligaments.

To complete the procedure, a quadricepsplasty is done with a Cobb elevator through the superolateral and superomedial portals during proximal viewing through the anteromedial portal. After debridement is completed, a gentle manipulation of the knee is performed to break up any remaining bands of scar tissue.

The authors’ postoperative protocol includes immediate weight bearing as tolerated and resumption of physical therapy on postoperative day 1. They utilize a continuous passive ROM machine and recommend physical therapy three times per week in addition to a home exercise program.

Overall, this video is a clear, concise description of a technique that can be used to improve ROM and patient satisfaction after arthrofibrosis develops following TKA.

As the total number of TKA procedures increases with an aging population, the incidence of arthrofibrosis is expected to rise as well. It is reasonable for any surgeon to be able to perform this procedure, and this technique is a good tool for anyone performing TKA to optimize patient outcomes.

Leslie Schwindel, MD, FAAOS, is a general orthopaedic surgeon at Lake Cumberland Regional Hospital in Somerset, Kentucky, and a member of the AAOS Now Editorial Board.

Video details

Title: Arthroscopic Lysis of Adhesions for Arthrofibrosis after Total Knee Arthroplasty
Authors: Thomas Boucher, MD; Joseph Barbera, MD; James N. Gladstone, MD, FAAOS; David Eric Kantrowitz, MD
Published: Jan. 31, 2024
Time: 10:12
Tags: Adult Reconstruction Knee, Revision Total Knee Arthroplasty, Arthroplasty, Complications, Rehabilitation

Visit aaos.org/OVT to view this award-winning title and more than 1,600 other videos from across orthopaedic topics, institutions, practice management, and industry.