Abstract
Purpose
To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations.
Methods
A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: (“arthrofibrosis” OR “stiffness” OR “stiff” OR “complications”) AND (“arthroscopy” OR “arthroscop” OR “ACL” OR “anterior cruciate”) AND (“treat” OR “care” OR “management” AND “knee”). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients.
Results
A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications.
Conclusions
Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications.
Level of Evidence
Level IV, systematic review of Level I-IV studies.
Arthrofibrosis is a common complication in most joints following orthopaedic surgical procedures such as arthroscopy, anterior cruciate ligament reconstruction (ACLR), and total joint replacement (total knee arthroplasty [TKA]).1 ACLR has been identified to be commonly associated with the development of arthrofibrosis of the knee.1,2 Consequently, patients of all ages can suffer from pain and decreased range of motion, which hinders their progress postoperatively, prevents them from performing activities of daily living, and, ultimately, affects their quality of life.3,4 The definition of arthrofibrosis varies widely, as do the approaches for management of this condition. For example, some may define arthrofibrosis based on the loss of flexion and/or extension reported in degrees. Alternatively, arthrofibrosis may be defined based on the presence of scar tissue in compartment(s) of a joint.4 More specifically, the knee is the most commonly affected joint, with arthrofibrosis occurring both post-trauma and postoperatively.2 The importance of early rehabilitation and prevention of arthrofibrosis has been explored extensively, and conclusions have been drawn based on the index surgery performed.5, 6, 7, 8
Previous studies have explored treatment strategies for arthrofibrosis after TKA. A systematic review providing a thorough, comprehensive review has been performed and identified arthrofibrosis following TKA can be improved with manipulation under anesthesia (MUA) and/or arthroscopic lysis of adhesions (LOA).9 Although treatment strategies for arthrofibrosis following TKA have been explored, there are not extensive data exploring treatment options for arthrofibrosis of the knee following knee arthroscopy and ACLR, which are the most common among the general population.9 We sought to focus on the most common etiologies associated with arthrofibrosis of the knee, taking into consideration that these are not the only etiologies that could lead to the development of arthrofibrosis. Other common etiologies include TKA, trauma, and multiligamentous injuries; these were not included in this study, as it would broaden the scope of the conclusions that could be drawn from this study. In addition, there are a variety of options available including but not limited to administration of medical management, MUA, arthroscopic LOA, etc. The purposes of this study were to systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and ACLR and to compare the treatment strategies in pediatric and adult populations. We hypothesized that MUA and LOA would remain the most common treatment methodologies with favorable outcomes in the setting of arthrofibrosis following knee arthroscopy or ACLR in both the adult and pediatric populations.
Methods
Study Design
A systematic search of electronic databases was performed using PubMed, EMBASE, and Cochrane Library Database. The search was performed in March of 2022, in accordance with the most up to date PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify and collect articles describing treatment regimens for arthrofibrosis of the knee following arthroscopy and following ACLR.
Search Strategy
The following search terms were used to identify relevant studies: (“arthrofibrosis” OR “stiffness” OR “stiff” OR “complications”) AND (“arthroscopy” OR “arthroscop” OR “ACL” OR “anterior cruciate”) AND (“treat” OR “care” OR “management” AND “knee”).
Eligibility Criteria
Studies were included if they met the following criteria: written in English, published between the year 2000 to present day, abstracts relating to knee arthroscopy surgical outcomes and ACLR outcomes, and abstracts referring to treatment for arthrofibrosis of the knee within the full text of the paper. The inclusion criteria aimed to capture outcomes status post medical, nonoperative, and operative treatment of arthrofibrosis following knee arthroscopy and/or ACLR. The search was not limited to a specific patient sex. To capture articles with relevant treatment, the search was limited to studies conducted in the United States or non-U.S. countries that offer the same treatment strategies available in the United States. Non-human studies, cadaveric studies, editorials, narrative reviews, systematic reviews, case reports, and published abstracts that did not have a corresponding full-text article were excluded. The remaining exclusion criteria were as follows: studies that discuss arthrofibrosis following TKA rather than knee arthroscopy or ACLR, studies that discuss arthrofibrosis following trauma to the knee that are not treated with arthroscopy or ACLR, and studies that do not include any outcomes.
Data Extraction and Assessment of Study Quality
Data were extracted concurrently by 2 reviewers (R.R. and C.B.) using the method as follows: 1 author (R.R.) independently performed the search; 2 authors independently removed duplicates, screened titles, and abstracts for relevance and screened the remaining full-text articles against the eligibility criteria discussed above. Relevant studies referenced by the eligible articles were identified and subsequently screened against the same eligibility criteria. Any discrepancies between reviewers were resolved by the senior author on the team (M.V.) to enhance objectivity to avoid remediable mistakes in this study, and to improve the overall quality of the study.
Once inclusion and exclusion were completed, data were extracted from each article independently by 2 members of the research team (R.R. and C.B.). Any disagreements were resolved by discussion. Unresolved disagreements were resolved by the senior author. Descriptive data were extracted from each article including article demographics, patient demographics, information about the index surgical procedure and treatment methods implemented, and follow-up. Outcome data for each procedure were reported in the following ways: objective examination findings (active and passive range of motion), outcome scores (International Knee Documentation Committee Subjective score, Western Ontario and McMaster Universities Arthritis Index, Lysholm score, Tegner score), and complications. These outcomes were then compared between pediatric and adult populations. Data compilation and comparison were performed manually using Excel (Microsoft, Redmond, WA).
To assess the quality of each study included, a systematic approach was used based on the level of evidence. Level I was assigned to all randomized controlled trials and systematic reviews. Cohort studies were considered Level II. All case–control studies were considered Level III. Case report and case series was considered Level IV; however, case reports were excluded, as previously mentioned in the eligibility criteria. To address the potential for bias, only Levels I through IV were included in the review to limit bias from lesser quality studies.
Results
Search Results
A total of 1,208 articles were identified in the initial search (776 PubMed, 402 Embase, 30 Cochrane Library) (Fig 1). Of these studies, 160 duplicates were removed, leaving 1,048 articles to screen. Following the title abstract screening, 935 studies (77.4%) were excluded, leaving 318 studies (26.3%). Of the 935 studies, 29 (3.10%) were specifically excluded for the reason that they did not report outcomes. Of these 318 studies, 15 (4.72%) were excluded as the full text was unavailable. Based on the predetermined eligibility criteria, a total of 42 studies remained, which are summarized in Table 1.2, 3, 4,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,27,28, 29, 30, 31, 32,33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47
Fig 1.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
Table 1.
Summary of the 42 Included Studies
| Treatment(s) for Arthrofibrosis | Studies |
|---|---|
| MUA only | 142,4,9,18,27,29,30,32,33,36,38,40,44,45 |
| LOA only | 233,4,9,11, 12, 13, 14,16,17,22, 23, 24, 25,27,28, 29, 30, 31, 32,35,37,42,45 |
| MUA and LOA | 142,15,19,20,26,30, 31, 32,34,39,40,43,46,47 |
| Notchplasty | 34,16,43 |
| Other surgical techniques | |
| Open posterior arthrolysis | 133 |
| Total graft resection | 121 |
| LOA and ROH | 310,17,43 |
| Dynamic splinting | 141 |
| Casting in extension | 127 |
| Bracing | 122 |
| Medications (e.g., oral corticosteroids, IL-1 antagonist injection, epidural therapy) | 22,27 |
IL-1, interleukin-1; LOA, lysis of adhesions; MUA, manipulation under anesthesia; ROH, removal of hardware.
Treatment for Arthrofibrosis of the Knee in Adult Patients
Of the 42 included studies, 291, 2, 3,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 (69.0%) primarily focused on treatment for arthrofibrosis of the knee in adults. The index surgeries reported included ACLR (23 studies, 79.3%),2,3,11, 12, 13, 14,16,17,19, 20, 21, 22, 23, 24, 25, 26,28, 29, 30, 31, 32,33,34 other arthroscopic ligamentous surgery (2 studies, 6.89%),12,18 fixation of PCL avulsion fracture (1 study, 3.45%),19 and fixation of tibial spine fracture (3 studies, 10.3%).10,15,35 The most common treatments for arthrofibrosis were MUA and/or LOA (26 studies, 89.6%).3,4,11, 12, 13, 14, 15, 16, 17, 18, 19, 20,22, 23, 24, 25, 26,27,28, 29, 30, 31, 32,33, 34,35 Notchplasty (1 study, 3.45%),16 total graft resection (1 study, 3.45%),21 open posterior arthrolysis (1 study, 3.45%),33 casting or bracing in extension (2 studies, 6.89%),22,27 and medications (2 studies, 6.89%)4,27 were less commonly mentioned. Noyes et al.27 described 2 patients who received continuous epidural anesthesia as a medical therapy, whereas Ekhtiari et al.2 included 31 patients who received oral corticosteroids, epidural therapy in 6 patients, or intra-articular interleukin-1 antagonist injection in 4 patients. All patients included in these 2 studies2,27 exhibited improvement in range of motion. The various treatments for arthrofibrosis for all included studies are summarized in Table 1 and clearly defined in Table 2.3,6,10,12, 13, 14, 15, 16, 17, 18, 19, 20,22,23,25,27,28, 29, 30, 31, 32,33, 34, 35,46,48
Table 2.
Summary of Included Articles—Adult Population
| Article | Level of Evidence | Index Surgery | Treatment(s) for Arthrofibrosis (Number of Patients) | Outcomes | Complications |
|---|---|---|---|---|---|
| Mayr et al.,3 2004 | IV | ACLR | LOA (223) | Mean ROM improved from 93.65° to 130.06°. 3.2% had >10° loss ROM after LOA. | In one case the original ACL graft was replaced. |
| Eckenrode et al.,14 2018 | IV | ACLR | LOA (3) | Mean AROM improved from 122.7° to 128°. Mean pain rating improved from 2.7 to 0.7 | None |
| Calloway et al.,13 2018 | IV | ACLR | LOA, MUA (32) | IKDC scores improved from 49.6 to 69.4. WOMAC scores improved from 74 to 85.3 | None |
| Robertson et al.,30 2009 | III | ACLR | LOA (5) | Successful restoration of knee hyperextension with LOA. | None |
| Mayr et al.,23 2017 | IV | ACLR | LOA (141) | Mean ROM improved from 99.47° to 127.98°. Mean pain rating was 1.34 with everyday life at 18.7 years’ follow-up. | In 65% of cases, notchplasty was required. At 18.7 years after LOA, 56% and 38% of patients had abnormal or severely abnormal IKDC objective scores, respectively |
| Mauro et al.,22 2008 | III | ACLR | LOA (28) | Following LOA, only 4 patients continued to have loss of ROM between 6° and 10°. | 64.3% of patients with decreased ROM were noted to have reduced quadriceps tone and 46.4% had reduced patellar mobility. |
| Bodendorfer et al.,12 2019 | III | ACLR, PCLR, LCLR | LOA (17) | Mean ROM improved by 38.8°. Mean KOOS composite score improved by 47.5 points following LOA. Mean WOMAC score improved by 50.5% postoperatively. Mean IKDC scores improved by 47.3 points postoperatively. | 12 of 17 patients returned to preinjury level of activity. Of the 4 who did not fully return, one was a competitive athlete that was able to play recreationally. Another competitive athlete could only return to a minimal level of activity. |
| Thaunat et al.,35 2016 | IV | Tibial spine avulsion fracture arthroscopic bone suture repair | LOA (1) | 10° extension lag reduced to 3° extension lag | After anterior joint release, intraoperative assessment showed persistence of 10° deficit. Posterior release of joint capsule through 2 retro-ligamentous approaches was required. |
| Sanders et al.,32 2017 | III | ACLR | MUA (4), MUA and LOA (19) | Mean ROM improved from 91° to 129° | None |
| Hasan et al.,16 2000 | III | ACLR | MUA and LOA (13) | Mean preoperative extension deficit improved from 10° to 3° following MUA and LOA. Passive knee flexion improved from 123° to 131° postoperatively. Mean postoperative Lysholm score was 89 and mHSS knee score was 90. | None |
| Worsham et al.,34 2019 | III | ACLR | LOA (29) | Mean ROM deficit was 6.7° for extension and 19.8° for flexion. After LOA, ROM deficit was 3.5° for extension and 6.1° for flexion | None |
| Robertson et al.,31 2011 | IV | ACLR | LOA (10), MUA and LOA (8) | 14 patients experienced substantial improvement in knee extension with an average change of 6°. This left a mean extension deficit of 1°. Patients in the severe extension deficit group underwent LOA and MUA and showed mean improvement of 10°. 12 patients experienced substantial knee flexion improvement with an average change of 6°, leaving a mean flexion deficit of 2°. Patients in the severe flexion deficit group underwent LOA and MUA and showed mean improvement of 12°. | LOA was proven to be optimally performed within 8 months of the index procedure. LOA greater than >12 months after the index procedure had poorer outcomes. |
| Heusdens et al.,17 2020 | II | ACL Repair | LOA and hardware removal (4) | “Regained natural knee movement” | None |
| Ibrahim et al.,20 2013 | IV | ACLR, PCLR, and posterolateral corner reconstruction | MUA and LOA (4) | All patients improved their range of motion except one who had persistently >10° flexion deficit | None |
| LaPrade et al.,19 2019 | IV | ACLR | MUA and LOA (18) | 5 had knee extension deficits and 13 had flexion deficits | None |
| Panisset et al.,28 2017 | IV | ACLR | MUA (2), LOA (4) | All knees were grade 1 flexion deficit at 1-year postoperatively. No extension deficits reported at 1-year postoperatively. | MUA for flexion deficit patients. LOA for extension deficit patients only. |
| Tardy et al.,33 2016 | IV | ACLR | LOA (9), MUA, and LOA (3) | Mean ROM improved from 96° preoperatively to 143° postoperatively. | One patient had postop flexion deformity of 5°. One patient had ACL graft resected to achieve full extension. |
| Noyes et al.,27 2000 | II | ACLR with or without partial meniscectomy | LOA (3), MUA (9), extension casting (9) | In the extension casting group, all patients achieved at least 0° extension. In the MUA group, mean preoperative flexion was 92°. All MUA patients achieved at least 135° after intervention. LOA produced full ROM in all 3 patients. | None |
| Millett et al.,6 2004 | IV | ACLR with concomitant MCL injury | LOA (1) | Following LOA, patient regained motion and function. Postoperative Lysholm and Tegner scores were 97 and 10, respectively. | None |
| Faivre et al.,15 2014 | IV | Tibial spine fracture fixation with Tightrope device | MUA and LOA (2). | One patient had 10° flexion and 5° extension deficit. The other patient had full ROM | None |
| Prodromos et al.,29 2005 | IV | ACLR | LOA and Hardware removal (1), MUA (1) | Full ROM following LOA. Full extension and nearly full flexion following MUA | None |
| Mariani,48 2010 | IV | Tibial plateau and supracondylar femoral fracture ORIF | LOA (18) | Preoperative flexion and extension were 85° and 34°. Postoperative flexion and extension were 100° and 3°. | One patient developed synovial fistula at posterior portal site |
| Aderinto et al.,10 2008 | III | Anterior tibial spine fixation | LOA and hardware removal (6), MUA (1) | LOA and hardware removal was successful in 2 of 6 cases. MUA resolved ROM limitations. | None |
| Meister et al.,25 2018 | IV | ACL repair with dynamic intraligamentary stabilization | LOA (5) | No patient with LOA had normal ROM postoperatively. At 1-year follow-up, 2 patients had persistent extension deficit of 6-10° and 2 patients had >10°. A flexion deficit of 6-15° was present in 1 and 3-5° in another patient at 1-year follow-up. | 3 patients complained about persistent VAS scores >3 at 1-year follow-up. |
| Tibial Spine Research Group et al,46 2021 | III | Type II tibial spine fractures | LOA and MUA (4), LOA (1), MUA (1), hardware removal alone (1), none (4) | 6 patients had full ROM, 3 had functional ROM, and 2 had unknown final ROM. Patients treated with LOA and MUA had mean ROMs of 122.5°. The patient treated with LOA had 140° ROM. The patient with hardware removal had 140° ROM. Patients with no treatment had a mean ROM of 102.5°. | None |
| Lamoria et al.,18 2020 |
IV | Isolated tibial spine avulsion fractures | MUA (3) | One patient ended with 110° of flexion and 2 ended with 120° of flexion at final follow-up. | None |
ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; AROM, active range of motion; IKDC, International Knee Documentation Committee; KOOS, Knee Injury and Osteoarthritis Outcome Score; LCLR, lateral collateral ligament; LOA, lysis of adhesions; MCL, medial collateral ligament; mHSS, modified Hospital for Special Surgery; MUA, manipulation under anesthesia; ORIF, open reduction and internal fixation; PCLR, posterior cruciate ligament reconstruction; ROM, range of motion; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
Comparing Treatment for Arthrofibrosis of the Knee in the Pediatric Population
Of the 42 included studies, 13 studies4,36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47 (31.0%) focused on the treatment for arthrofibrosis following ACLR or arthroscopic surgery in the pediatric population, which was defined as a patient younger than the age of 18 years. Ten studies4,29,36, 37, 38,40,42,45, 46, 47 (76.9%) described patients who underwent either MUA or LOA, whereas 5 studies39, 40, 41,46,47 (38.5%) included patients who underwent both MUA and LOA for treatment. Less-common treatments for arthrofibrosis in the pediatric population were described in 4 studies4,39,41,46 (30.8%), which included removal of hardware, notchplasty, bracing in extension, dynamic splinting. Six studies4,37,39,41,43,47 (46.2%) mentioned complications resulting from treatment for arthrofibrosis of the knee. Among these 6 studies, 3 studies4,41,43 (23.1%) reported motion deficit as the complication. The remaining 3 studies37,39,47 (23.1%) reported the following complications: instability in the knee following LOA, requirement of revision surgery following MUA/LOA and extension brace, or distal femoral fracture following MUA with subsequent growth arrest requiring further treatment. The treatments for arthrofibrosis among the pediatric population are summarized in Table 3.4,36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47
Table 3.
Summary of Included Articles—Pediatric Population
| Article | Level of Evidence | Index Surgery | Treatment(s) for Arthrofibrosis | Outcomes | Complications |
|---|---|---|---|---|---|
| May et al.,40 2011 | IV | ARIF for ACL tibial spine avulsion | MUA and LOA; arthroscopic scar debridement; MUA | Satisfactory functional and clinical outcomes | None mentioned |
| Cruz, Jr. et al.,38 2017 | IV | All-epiphyseal ACLR | MUA | Statistically significant increase in knee ROM | None mentioned |
| Nwachukwu et al.,4 2011 | IV | ACLR | MUA; LOA; lateral release; notchplasty; debridement of scar tissue | 86.8% of patients had full ROM. 13.2% had reduced ROM (extension deficits and/or flexion deficits) | Persistent motion deficits in 13.2% of patients |
| Pace et al.,41 2018 | IV | ACLR with or without meniscal repair; surgical fixation of tibial spine fracture | DS; DS, MUA, and surgical LOA | 84% treated with DS had improvement and 58% of all patients in the study avoided surgery as a result of DS treatment | 23% of patients had extension deficit, 31% had flexion deficit, and 46% had combined extension and flexion deficits |
| Parikh et al.,43 2014 | III | Arthroscopic reduction and screw fixation for displaced Type II and III tibial spine fractures | SR, debridement if epiphyseal screw; SR, notchplasty if extension deficit; SR, MUA for flexion deficit | 80% of patients achieved 0° of final loss of motion | 1 patient had a 15° extension deficit; 1 patient had a 2° extension deficit, but this patient did not undergo treatment other than screw removal |
| Fabricant et al.,39 2018 | II | ACLR; tibial spine arthroscopic reduction and internal fixation, soft-tissue repair, and multiligament reconstruction | LOA/MUA with patient placed in hinged knee brace locked in extension postoperatively for sleeping and walking | 62.2% reached full ROM, 27.8% reached functional ROM | 10% of patients required revision surgery |
| Bram et al.,36 2019 | III | ACLR with or without continuous passive motion (CPM) | MUA | Required more PT sessions compared with those that did not undergo MUA | None reported |
| Çağlar et al.,37 2021 | IV | Arthroscopic suture fixation technique secondary to type 2, 3, or 4 tibial spine fracture | Arthroscopic synovium debridement | Knee flexion improved from 30° flexion contracture secondary to arthrofibrosis to 10° final flexion contracture | Instability noted in the knee, but patient did not have clinical complaints |
| Su et al.,45 2018 | III | ACLR | MUA or LOA | Mean knee flexion of 134° achieved and full knee extension | None reported |
| Sankar et al.,44 2006 | III | ACLR | MUA | No significant difference in Lysholm scores or report to sport | None reported |
| Pandey et al.,42 2017 | III | Arthroscopic reduction and fixation of tibial spine avulsion using high strength nonabsorbable sutures | Arthroscopic adhesiolysis | No flexion or extension deficit | None reported |
| Tibial Spine Research Group et al.,46 2021 | III | Surgery for tibial spine fractures | LOA and/or MUA; LOA and ROH; LOA, MUA, ROH | 6 patients achieved full ROM, 3 had functional ROM, and 2 had unknown ROM results | None reported |
| Vander Have et al.,47 2010 | IV | Surgical fixation of tibial eminence fracture | MUA; LOA and MUA; 1+ LOA | 90.6% achieved near full ROM within 5° of the contralateral side, 9.4% lacked full extension | In 3 patients, MUA resulted in distal femoral fractures and subsequent growth arrest, requiring further treatment |
ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament rehabilitation; ARIF, arthroscopic reduction internal fixation; DS, dynamic splinting; LOA, lysis of adhesions; MUA, manipulation under anesthesia; PT, physical therapy; ROH, removal of hardware; ROM, range of motion; SR, screw removal.
Discussion
The most important finding of this study was that most studies identified MUA and/or LOA as the treatment for arthrofibrosis of the knee following arthroscopy or ACLR. There was substantial variability in the reported definitions of arthrofibrosis and/or the diagnostic criteria for arthrofibrosis of the knee. Although most of the studies included in our analysis described MUA and/or LOA as the most common treatment options for arthrofibrosis of the knee in both adult and pediatric patients, it is possible that the threshold to report arthrofibrosis and the subsequent treatment was based on how a paper defined arthrofibrosis. For example, arthrofibrosis could have been defined as a motion deficit requiring MUA and/or LUA. In addition, there is a spectrum of care that can be implemented based on the severity of arthrofibrosis of the knee, provider/institution knowledge or preference, resource availability, resulting in a wide variability in the specific treatment given, such as administration of medical management, MUA, LOA, etc., or even a combination of these treatments.
The secondary aim of this systematic was to compare the strategies in pediatric versus adult populations regarding the treatment for arthrofibrosis of the knee following ACLR or following arthroscopic surgery. Similar to the finding of the primary aim of the study, the most common treatments were MUA and/or LOA in the pediatric population. There was no mention of medication use among the pediatric population, whereas 2 studies2,26 involving the adult population were identified to implement medication as treatment. This included oral corticosteroids, epidural therapy, and intra-articular interleukin-1 antagonist injection. Among both the pediatric and adult populations, most studies identified MUA and/or LOA as the treatment. Other variants include notchplasty, open posterior arthrolysis, other surgical techniques, dynamic splinting, casting in extension, and bracing. Future studies should aim to focus on other etiologies that could precede the development of arthrofibrosis of the knee such as trauma, multiligamentous injury, etc. In addition, future studies should aim to focus on the medications used in the treatment for arthrofibrosis of the knee and analyze clinical efficacy of each of these treatments. These future studies can aid in ultimately formulating an algorithm in the treatment for arthrofibrosis, with the goal of ultimately improving patient outcomes and quality of life.
Limitations
This study is not without limitations. As mentioned previously, there was a wide variety of definitions and/or diagnostic criteria for arthrofibrosis of the knee, which poses an inherent challenge of variation in the diagnosis of arthrofibrosis. Taking into consideration this is a systematic review, abstracts are solely searched for the defined terms as outlined in the Methods section. There may have been other studies that could have represented additional treatments for arthrofibrosis that may have not been captured in the full-text articles that were included in this review based on the predetermined eligibility criteria.
Conclusions
Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified MUA and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications.
Disclosure
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: M.K.M. reports personal fees from Arthrex, outside the submitted work; American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North American, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, Ruth Jackson Orthopaedic Society, and The Forum: board or committee member; and American Journal of Sports Medicine-Electronic Media, Arthroscopy, and Ortho Info: editorial or governing board. B.G.V. reports personal fees from Artelon, Spinal Simplicity stock options, Altior stock options, Carbon 22 stock options, American Orthopedic Foot and Ankle Society Board or Committee member. All other authors (R.R., C.B., A.T., T.M., M.L.V.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Footnotes
Investigation performed at the University of Kansas School of Medicine, Kansas City, Kansas, U.S.A.
Supplementary Data
References
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