Arthroscopic Lysis of Adhesions for Treatment of Post-traumatic Arthrofibrosis of the Knee Joint

Abstract

Normal knee range of motion varies slightly between individuals and measures approximately 0° to -5° of extension to 140° of flexion. A full arc of motion is required for normal gait and knee function. Loss of normal joint range of motion may occur after a traumatic knee injury and may contribute to increased pain, lower functional outcome scores, and decreased patient satisfaction. Although multiple factors may contribute to the development of motion loss, the occurrence of intra-articular scar tissue adhesions, or post-traumatic arthrofibrosis, may limit the patient's knee motion in the early postoperative period. Once motion loss has been identified, it can be a challenging complication to manage. Arthroscopic lysis of adhesions with manipulation under anesthesia is a reliable surgical technique that can improve range of motion in patients with knee stiffness due to post-traumatic arthrofibrosis.

Fig 1

The patient is positioned supine, with the right knee held in an arthroscopic leg positioner. A sterile skin marker is used to show the anatomic landmarks and portal placement used to perform arthroscopic lysis of adhesions, followed by manipulation under anesthesia. Anterior (A) and medial (B) views of the knee show portal placement. One should note that the prior surgical incision has been marked, which was a lateral approach used to perform open reduction–internal fixation for a fracture of the tibial plateau. For this procedure, standard anteromedial (AM) and anterolateral (AL) portals are used, in addition to accessory posteromedial (PM), accessory medial suprapatellar (AcSM), and accessory lateral suprapatellar (AcSL) portals, as shown in these preoperative photographs.

Fig 2

In the right knee, the arthroscope is placed in the anterolateral portal, viewing the suprapatellar region and the medial retinaculum. (A) Capsular adhesions are identified in the medial recess, which restrict patellar mobility. (B) The same arthroscopic field of view is shown, after lysis of adhesions has been performed, showing the medial capsular release. This release is being performed with a 4.0-mm arthroscopic shaver.

Fig 3

With the arthroscope placed in the anterolateral portal of the right knee and visualizing the suprapatellar region, the capsular release is continued superiorly. (A) The suprapatellar region is visualized before debridement and clearly shows significant adhesions between the quadriceps tendon and suprapatellar fat pad. (B) The same arthroscopic field of view is shown after debridement and capsular release. One should note the quadriceps tendon and fibers of the vastus medialis oblique (VMO), which serve as the anatomic landmarks for the superior extent of capsular release. Debridement should continue superiorly until the undersurface of the quadriceps tendon and the VMO are clearly visualized.

Fig 4

In the right knee, the arthroscope is placed in the anteromedial portal and the arthroscopic shaver is placed in the anterolateral portal to visualize the lateral recess. (A) Arthroscopic field of view before debridement and capsular release. (B) Continuation of the superior capsular release into the lateral capsular recess. Adhesions of the lateral retinaculum are debrided, and a lateral release is performed. The lateral release completes what is a nearly circumferential capsular release in the suprapatellar region, resulting in improved patellar excursion and greater knee flexion.

Fig 5

The arthroscope is placed in the anterolateral portal of the right knee, visualizing the intercondylar notch. (A) Arthroscopic field of view before debridement. One should note the hypertrophic ligamentum mucosum. Significant debridement may be required in this region, and an arthroscopic ablator can be used to coagulate the highly vascular scar tissue found in this region. (B) The intercondylar notch is visualized after extensive arthroscopic debridement. The tibial attachment of the anterior cruciate ligament (ACL) and femoral attachment of the posterior cruciate ligament (PCL) can now be clearly visualized. (C) Insertion of the arthroscopic shaver beneath the femoral attachment of the PCL to perform a “limited” notchplasty. Debridement beneath the femoral insertions of the ACL and PCL will facilitate access into the posteromedial and posterolateral joint spaces.

Fig 6

In the right knee, the arthroscope is placed in the anterolateral portal and passed beneath the posterior cruciate ligament insertion on the medial femoral condyle, allowing visualization of the posteromedial joint space. (A) An outside-in technique has been used to establish a posteromedial working portal, and the arthroscopic shaver has been inserted into the posteromedial joint space. One should note the position of the shaver with the blade held facing the posterior femoral cortex while debridement of adhesions is performed. (B) The same arthroscopic field is shown after initial debridement of adhesions. One should note the significant increase in capsular space. After lysis of adhesions is performed, the medial gastrocnemius is palpated deep to the capsule adjacent to its insertion onto the posterior femoral cortex. The posterior capsule is released at the level of attachment on the posterior femur, which allows visualization of the medial gastric tendon insertion.

Fig 7

(A, B) An arthroscopic debridement has been completed in this right knee. A manipulation under anesthesia was performed, and improved range of motion was documented with the arthroscope.