1. POST ACLR STIFFNESSDR SCHILLER JOSConsultant Orthopedic surgeonBaby Memorial Hospital, Kozhikode 2. Loss of ROM in a joint is a dilemma to bothpatient and doctor. 3. TYPES Localised- Loss of extensionbetter prognosis Generalised/ global- Fibrosis/ capsulitis withsevere stiffnesspoor outcome 4. ETIOLOGY Pre- operative Intra- operative Post- operative 5. RISK FACTORS1. Operating in acute injury period2. Proximal MCL injury3. Poor pre- op ROM4. Error in surgical techique5. Female sex6. Older adolescent7. Concurrent meniscal repair 6. INCIDENCE 4- 35% after ACLR 57% after combined ACL + PCL Reconstruction 7. CYCLOPS LESIONLocalised intra articular fibrous nodule causingloss of knee extension, commonly seen withACLR with anteriorly placed tibial tunnel. 8. Classification of knee stiffness(SHELBOURNE) TYPE 1- normal flexion and 10 deg extensionloss TYPE 3- combined flexion loss > 25 deg andextension loss > 10 deg TYPE 4- extension loss > 10 deg and total flexion< 120 deg combined with patella inferacontracture syndrome 9. MANAGEMENT Prevention is the best treatment. Non-operative supervised therapy rehabilitation. Arthroscopic arthrolysis. Open releases. 10. How to prevent stiffness.1. Avoid acute reconstructions2. Complete ROM prior to surgery3. Achieve quad strength before reconstruction4. Rule out locking due to meniscal tear5. Beware of proximal MCL injury 11. Contd6. Proper tunnel placement7. Tension and fix ACL graft near extension8. Reduce pain, swelling, inflammation inimmediate post op period.9. Achieve full extension, ROM, muscle strength10. If patient has not attained ROM by 14 days,monitor weekly 12. Contd11. Aspirate significant effusion in early post op case12. Early surgical debridement if the patient is notprogressing and has flexion contracture13. Obtain pre op radiographs14. Consider infection and CRPS if there is significantpain15. Counsel the patient regarding realistic goals 13. MANAGEMENT Loss of motionNSAIDSintra articular steroidSupervised physio therapy 14. Pre- op planning Thorough physical examination and history Pain- infectionCRPS (contra indication for surgery) Investigations- blood tests, Plain radiographs,MRI. . Get the previous operative reports 15. Cause of loss of motion.Limitation of extension- intercondylar notchpathologyLimitation of flexion- scar in the lateral/medialgutter, supra patellar pouch 16. INFECTIONarthroscopic irrigation and debridementappropriate I.V antibiotics 17. ARTHROSCOPIC ARTHROLYSIS Leg is positioned without leg holder 6 portals All adhesive bands and fibrotic tissue are excisedfrom supra patellar pouch, med/lateral gutters Intercondylar notch is cleared Notchplasty Partial release of ligaments Manipulation under anaesthesia 18. OPEN RELEASE Medial para patellar arthrotomy Extensive medial release- deep MCL tosemimembranosis Excision of hoffas fat pad. Lataral release Release of residual intra and extra articularadhesions 19. THANK YOU