Arthroscopic Posteromedial Capsular Release

Abstract

Post-traumatic or postsurgical flexion contractures of the knee can significantly limit function and lead to gait abnormalities. In this setting, interventions to regain full extension may include bracing, physical therapy, and open or arthroscopic surgery. Open surgical approaches to restore full motion often demand extensive recovery and promote further adhesions and loss of motion, which has led to the advent of arthroscopic techniques to address these pathologies. We present a safe, effective, and reproducible arthroscopic technique for posteromedial capsular release to address knee flexion contractures.

Fig 1

Intraoperative photographs after placing the patient in the supine position on the operating table with the operative leg secured in a leg holder. Range of motion is assessed, and the affected right knee shows maximum flexion (A) and extension (B) from 23° to 102° as measured by a goniometer.

Fig 2

Intra-articular space of the right knee viewed through the anterolateral portal. Extensive adhesions are seen in the anterior interval and anterior to the medial femoral condyle (MFC).

Fig 3

Subpatellar space of the right knee viewed through the anterolateral portal. Significant peripatellar adhesions are seen and released with the aid of an arthroscopic shaver placed through the anteromedial portal. (MFC, medial femoral condyle.)

Fig 4

Medial gutter of the right knee viewed through the anterolateral portal. Medial gutter adhesions are noted and are released with a radiofrequency (RF) probe placed through the anteromedial portal.

Fig 5

Intraoperative and arthroscopic views of the right knee maintained in flexion in a knee holder. The arthroscope is placed in the anterolateral portal and carefully guided into the posterior compartment of the knee. With the arthroscope in the posterior compartment, a spinal needle is placed between the posterior oblique ligament, the medial head of the gastrocnemius, and the semimembranosus tendon. The spinal needle is then removed, and a small incision is made using a No. 11 blade in the posteromedial (PM) capsule.

Fig 6

Intraoperative and arthroscopic views of the right knee maintained in flexion in a knee holder. After a small incision is made in the posteromedial capsule and while the posteromedial capsule is viewed directly through the anterolateral portal, a blunt obturator or small periosteal elevator is used to gently separate the posteromedial (PM) capsule from the medial gastrocnemius muscle and tendon.

Fig 7

Intraoperative and arthroscopic views of the right knee maintained in flexion in a knee holder. While the posteromedial capsule is viewed directly through the anterolateral portal, an arthroscopic biter is used to release the posteromedial capsule in a medial-to-lateral direction until the midline is reached.

Fig 8

Intraoperative and arthroscopic views of the right knee maintained in flexion in a knee holder. While the posteromedial capsule is viewed directly through the anterolateral portal, an arthroscopic shaver is used to clear any remaining debris or fibrous tissue. When using the shaver, the surgeon should always keep the blade facing anteriorly to avoid damaging the posterior neurovascular bundle.

Fig 9

Intraoperative photograph with the patient in the supine position on the operating table. After completion of the posteromedial capsular release, range of motion is again assessed using a goniometer and compared with the preoperative state as well as the contralateral knee. To ensure that full extension can be attained in the operative knee, the distal thigh is held to the table while the heel is lifted.