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

• Know the diverse causes

• Understand the pathology

• Prevent arthrofibrosis

Etiology

• Fractures• Treatment in plaster

• Immobilization post surgery

• Inadequate rehab

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

• Six papers, 370 ACLRs

• No difference if ACLR within 3 wks or after 6 wks

Etiology – ACLR

• 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

• Treated infection

• Rehab – got ROM

• PCLR + ACLR

• Rehab to keep ROM

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

Other etiology

• Inflammatory arthropathy eg: RA

• Osteoarthritis - rarely

• Septic Arthritis

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

We want all multiligs like this !!ACLR + MCLR

SUMMARY

• Etiology of arthrofibrosis• Fractures & Ligament injuries

• Post Reconstructive surgery

• Post TKA

• Septic arthritis, RA, OA

• Most cases are preventable

THANK YOU

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