TITLE PAGE

Type of Article: Case Report

Arthrofibrosis Following ACL Reconstruction

A Case Report

IB Aditya Wirakarna 1*, IGN Wien Aryana 2, Komang Arie

Trysna Andika 3, IGB Indra Angganugraha 4, Hafidz
Addatuang Ambong 5, Stedy Adnyana Christian 6,
Soehartono Hadi Pranata 7
1
Resident of Orthopaedic and Traumatology Department,
Sanglah General Hospital, Udayana University, Bali, Indonesia
2
Staff Of Orthopaedic and Traumatology Department, Sanglah
General Hospital, Udayana University, Bali, Indonesia
3
Resident of Orthopaedic and Traumatology Department,
Sanglah General Hospital, Udayana University, Bali, Indonesia
4
Resident of Orthopaedic and Traumatology Department,
Sanglah General Hospital, Udayana University, Bali, Indonesia
5 Resident of Orthopaedic and Traumatology Department,
Sanglah General Hospital, Udayana University, Bali, Indonesia
6
Resident of Orthopaedic and Traumatology Department,
Sanglah General Hospital, Udayana University, Bali, Indonesia
7
Resident of Orthopaedic and Traumatology Department,
Sanglah General Hospital, Udayana University, Bali, Indonesia

*Corresponding author:

Dr. IB Aditya Wirakarna

Orthopaedic and Traumatology Department,
Sanglah General Hospital, Udayana University,
Bali, Indonesia
Phone (or Mobile) No.: ++6281353459488
Email: wirakarna@gmail.com
ABSTRACT

Pain and loss of motion of the knee after anterior cruciate ligament
reconstruction remain a challenging dilemma. There are many
causes for this problem that one of it is due to arthrofibrosis.
Arthrofibrosis is a condition where an excessive scar tissue was
formed in the joint that give restriction to the knee motion as well as
pain. A 33 -year-old France male sustained complete torn anterior
cruciate ligament of his left knee. AnatomicaL reconstruction done
four weeks after the injury. Intraoperative was uneventful. After post
operation noted patient was able to perform full active knee
extension. He was very compliant to rehabilitation program and also
performed the exercises at home. However on follow up in clinic,
patient started to loss his active and gradually on subsequent visit
later affected his passive full extension at 2 months post operation.
Regional examination showed diffused firm swelling over the
anteromedial aspect of the the medial joint line which is was very
tender, patellar tap test (-), no warm and redness. Arthrofibrosis can
disrupt the normal knee kinematics and may lead to progressive
degenerative changes in the knee. Although the knee is stable by
objective criteria, the patient is often dissatisfied and frequently
seeks treatment because of persistent symptoms and impairment of
knee function. Application of the treatment algorithm for the
management of arthrofibrosis has simplified our decision-making
process in these complex cases, early detection with early
intervention is very important in determining the outcome of the
treatment.

Keyword : Arthrofibrosis, Loss of motion, ACL Reconstruction,

Arthroscopy

INTRODUCTION
Arthrofibrosisis a restriction of motion of a joint that can result from
injury or surgery. It is a particularly bothersome complication when it
involves the knee, because even small loses of knee extension are
poorly tolerated. Although restrictons of knee motion have resulted
from minor injuries or diagnostic arthroscopy. They are more
common after major ligament or fracture reconstruction. In general,
both the incidence and the severity of postoperative arthrofibrosis are
correlated with the extent of the surgical procedure, any presurgical
limitations of motion, and the duration of postoperative
immobilization. In the treatment of acute anterior cruciate ligament
(ACL) tears, an inverse correlation exists between the time from
injury to surgery and the frequency of arthrotlbrosis.

Restriction of knee motion after injury or surgery has long been a

problem. The advent of arthroscopic surgery, with a resultant
decrease in joint trauma, has helped to decrease the frequency and
severity of motion limitation that may result from surgical
intervention. In the 1940s, Thompson described an extensive open
quadriceps plasty for the problem of arthrofibrosis. Nicoll, in the
1960s, recognized four potential sites of disease that could contribute
to the problem. These included (a) fibrosis of the vastus intermedius
in and just proximal to the suprapatella pouch, (b) intraarticular
adhesions between the patella and the femur, (c) fibrosis of the vastus
lateral is with adhesion to the femoral condyle, and (d) shortening of
the rectus femoris. His recommended treatment was open serial
release of each of the areas, until full motion was restored. These
were extensive, often heroic, associated with significant morbidity.
Sprague et al. were the first to recognize the potential of the
arthroscope in the evaluation and treatment of arthrofibrosis . Since
then, innumerable authors have contributed to our understanding,
evaluation, and treatment of this problem. Most important has been
identification of strategies for prevention.

CASE REPORT

History and Examination

33 -year-old male sustained isolated complete torn anterior cruciate
ligament of his left knee. Anatomical single bundle reconstruction
done four weeks after the injury. Intraoperative was uneventful.
After post operation noted patient was able to perform full active
knee extension. He was very compliant to rehabilitation program
and also performed the exercises at home. However on follow up in
clinic, patient started to loss his active and gradually on subsequent
visit later affected his passive full extension (10 degrees extension
lag) at 4 months post operation. Regional examination showed
diffused firm swelling over the anteromedial aspect of the knee just
above the medial joint line that was very tender.

DISCUSSION

The optimal period for ACL reconstruction was within the first few
weeks after injury. Early ACL reconstruction as a significant risk
factor for postoperative arthrofibrosis. If surgical treatment is delayed
until nearly full motion has been recovered, quadriceps control
allows full active extension, and acute hemarthrosis has resolved,
then the risk of postsurgical arthrofibrosis necessitating arthroscopy
or manipulation will be substantially reduced (Shelbourne et al. and
Mohtadi et al, 1991 ). It is possible to achieve good results with ACL
reconstruction with in the first 3 weeks after injury, if an aggressive
rehabilitation protocol is used. This approach, however, results in
6% of patients' requiring additional surgical procedures to regain
motion. Both the magnitude and the timing of the surgical treatment
in these cases contribute to a potentially high rate of postoperative
stiffness requiring manipulation or arthroscopy (Hunter et al, 1994)

ACL reconstruction remains the most frequent cause of arthrofibrosis

in virtually all series responing on the treatment of Arthrofibrosis.
Although biologically induced arthrofibrosis may occur after ACL
reconstruction, particularly when the procedure is done early after
injury, the condition more commonly occurs as a result of a
mechanical issue.

This is typically the result of suboptimal graft positioning or

excessive tensioning of a nonanatomically positioned graft. Common
positioning errors include: anterior placement of the femoral drill
hole leading to a shortened intraarticular graft and anterior
placement of the tibial drill hole resulting in impingement on the roof
of the notch. There is a definite interplay between the placement of
ACL drill holes and the tensioning technique. Optimal tensioning
technique is one that results in reproducibly stable knees, with full
range of motion. Several authors have recommended techniques that
rely on high tensioning forces applied with the knee in full extension
and fixation with the knee at or near full extension. This approach
ensures that the graft will not limit extension. Which ever tensioning
technique is employed, it is critical that the knee comes to full
extension intraoperatively, because anything less markedly increases
the risk of extension loss. Postoperative limitation of extension
(either mechanical from technical error or by rehabilitation protocol)
may result in the formation of a cyclops lesion, which is a
proliferative nodule of fibrovascular scar that forms anterior to the
ACL graft. This scar may be caused by organization of the hematoma
anterior to the graft. Immobilization has been eliminated from the
postoperative rehabilitation protocols after ACL reconstruction, but it
continue to be recommended after other surgical procedures.

lmmobilization after other surgical procedures also lead to an

increased risk of arthrofibrosis when compared with early
mobilization. This problem has been identified with numerous
procedures including meniscal repair, patellar realignment, posterior
cruciate ligament reconstruction, repair of tibial spine fractures, and
multiligament recontructions. Although immobilization for short
periods may offer protection of various structures from excessive
stress, one must be cognizant of the potential harm of immobilization
when considering its use. The myriad deleterious effects of longer
periods of immobilization include not only stiffness but also loss of
strength of ligaments and muscle, calcium loss from bone, and
articular cartilage injury.

Continuous passive motion (CPM) has been recommended as a

modality to reduce the risk of motion-limiting arthrofibrosis after
surgery. The use of CPM after several different procedure has been
studied. Although it has proven to be of significant value with some
procedures, it is not universally beneficial. Total knee arthroplasty is
the procedure in which CPM has demonstrated the most benefit; it
reduce the risk of arthrofibrosis requiring manipulation substantially
(from lOI.ilo to 0% in one study). The risk of arthrofibrosis after
patella realignment is also reduced with the use of CPM. The risk of
motion limitation after ACL reconstruction, however, has not been
altered by the use of postoperative CPM. Quadriceps weakness with
a resulting extensor lag may also inadvertenly result in a limitation of
extension. There is a complex intermingling of this with the issues of
timing of surgery after injury. Inability of the patient actively to
extend the knee fully before the surgical procedure substantially
increases the risk of extension loss postoperatively.

Hyaluronic acid films have proven of benefit in the reduction of

intraabdominal adhesions after bowel surgery. Hyaluronic acid films
or gels may, in the future, offer a mechanical means to reduce
intraarticular adhesions by acting as a barrier to their formation after
surgical procedures.

Any patient who fails to gain knee motion at the expected rate after
injury or surgical treatment may be developing arthrofibrosis.
Mechanical blocks to motion need to be identified early in the
treatment of the motion-limited knee. After acute injury, failure to
gain expected range of motion

May result from a displaced bucket-handle meniscal tear. Magnetic

resonance imaging should be used to identify potential soft tissue
blocks to motion. Displaced articular fracture fragments are best
assessed with plain radiographs or computed tomography scanning.

Malpositioned ACL grafts are still one of the most common causes of
postoperative stiffness. Often routine radiographs are adequate to
identify the misplaced bone tunnels, although magnetic resonance
imaging is occasionally helpful to visualize the graft impinging on
the notch. Identifying and treating a mechanical block motion can
prevent the more serious consequences that can develop.

The identification of a malpositioned ACL drill hole can be a

difficult issue to confront, because the best treatment depends on
early elimination of the mechanical block to motion. This may
necessitate early surgical treatment, either to expand the notch when
anterior placement of the Tibial drill hole leads to impingement of
the graft on the roof of the notch or to remove a graft that is too
anterior on the femur. Delaying surgical correction by even a few
months may be ill advised, because even a few months of a bent knee
gait can result in significant patella femoral arthrosis.

It is better to remove a misplaced ACL graft early, to regain full

motion, and then perform a revision ACL reconstruction in the
correct location than it is to continue with a program of physical
therapy and serial casting if this is destined to fail because of a
technical error.

Pain is often a prominent component of arthrofibrosis. Complex

regional pain syndromes should be included in differential diagnosis,
and they can be difficult to differentiate from arthrofibrosis.
Stiffness, with associated warm hand swelling, is typically the most
prominent symptom of a developing arthrofibrosis. These symptoms
should also alert the clinician to consider sympathetically mediated
pain syndromes and to take the necessary steps, such as lumbar
sympathetic blockade, to rule them out, when appropriate.

Although numerous patterns of arthrofibrosis have been identified, a

simple scheme with four classes, based on motion limitation and
patella mobility, is adequate for treatment planning.

Based on this schema, we have developed a straight forward

treatment algorithm for the management of arthrofibrosis (Figure 4).
Limitation of patella mobility, especially superior glide, can often be
elicited in IPCS. Although this may occur secondary to a timing,
mechanical, or rehabilitative issue, this is often the beginning of
primary arthrofibrosis, which can be particularly bother some to treat.
Not infrequently, patients who develop IPCS are keloid formers.

Using the classification scheme and treatment algorithm presented

earlier will facilitate the management of arthrofibrosis. Early
recognition of the peripatella inflammation that portends the
development of IPCS allows prompt treatment. I believe that a short
course of high-dose oral corticosteroids offers a good chance to treat
this early inflammatory phase successfully and to reduce or prevent
the major problems associated with a full blown IPCS. Oral NSAIDs
may also be of value, but my experience suggests that corticosteroids
work better. Aggressive streeching in this early inflammatory phase
seems to exacerbate the inflammation in many patients, and it is
usually counter productive. Perhaps the reason is the paradoxic
increase in scar formation that can occur when abnormal fibroblasts
are stretched, as noted earlier in the discussion of pathology. The best
rehabilitation program at this juncture is gentle, nonforceful
mobilization performed actively by the patient. This seems to allow
some patients conditions atleast to stabilize, if not improve, early in
the course of IPCS.

The treatment of arthrofibrosis depends both on the type and the time
elapsed from the inciting event. Treatment of each type is discussed
individually. In general, application of the treatment algorithm shown
in figure has simplified our decision-making process in these
complex cases.

In type I arthrofibrosis, the involved knee lacks the full extension

(including physiologic recurvatum) equal to the contralateral knee.
This often results from the early lack of extension and resulting scar
formation anterior in the notch or between the fat pad and the noch.
Although this condition is most frequent after ACL surgery, it is not
limited to ACL reconstructions. Imaging studies, should be
performed to identify any mechanical cause that must be addressed
surgically.

When condition is identified in the first several months after the

index injury or surgery, mechanical stretching technique are often
benefit. Among the technique that have been employed dynamic
extension braces, dropout casts. Extension board because of it
simplicity and ease of use. Serial extension casts are associated with
a risk of articular cartilage injury and must be employed cautiously.
Cartilage damage may occur both from immobilization and from the
pressure on the joint surface from forced extension. If employed,
serial extension cast should be changed at least every 48 hours, to
minimize this risk. The longer the time elapsed from the index
surgery or injury, the less likely these mechanical modalities are to be
effective.

Because flexion deformities from 5 to 8 degrees often result in a

limp or anterior knee pain, these may require surgical treatment. With
flexion contracture more than 10 degrees or more, most patient are
symptomatic. Surgery is indicated for those patient who have pain or
who limp and for who those who have more than a 10 degree loss of
extension. Mostn patient can be treated arthroscopically or with
combination of arthroscopic and limited open technique.

There is usually scarring anterior in the notch or between the

infrapatella fat pad and the notch or proximal tibia. When a nodule of
scar forms anterior to the graft after ACL reconstruction, this variant
is termed cyclops syndrome. This nodule may cause mechanical
symptoms.

It has also been described after total knee arthroplasty. Complete

resection of the nodule, as well as any of additional notch scarring, is
necessary. If impingement on an ACL graft is found, then the notch
plasty must be expanded. Any scarring in the fat pad should be
removed. Rarely is the suprapatella pouch involved in type 1
arthrofibrosis. Any scarring identified in the pouch should be
resected, because this may limit the proximal excursion of the
quadriceps muscle and active extension postoperatively. If full
extension is still limited after all intraarticular scar has been removed,
then attention should be focused on the extra synovial region
between the patella tendon and the tibia. Scar can be resected from
here either arthroscopically or through a small incision. Failure to do
this may result in persistent lack of extension postoperatively, and it
has been shown in cadaver experiments possibly to result in patella
infera.

Immediate postoperative extension splinting or use of an extension

board is recommended. Typically, regaining flexion does not present
a problem, unless extension splinting is employed for a protracted
period. CPM use is typically not required, and it may even be
counterproductive, because full knee hyperextension is often not
reached in CPM. Pain management, although less of an issue than
after surgery in higher grades of arthrofibrosis, is important. Femoral
nerve blocks, single or repetitive, can be important adjuncts in pain
management.

In type 2 arthrofibrosis, only flexion is limited. This typically results

from immobilization in extension and the associated suprapatella
scarring. This can also by the result of extraarticular adhesions
between the quadriceps and the femur. In type 2, the patella is only
limited in inferior excursion and is not entrapped by scar. Early on, in
the first few months after the index injury or surgery, physical
therapy remains the mainstay of treatment. Aggressive manipulative
physical therapy should be avoided, particularly as the interval from
injury or surgery approaches 4 months and there is a risk of avulsion
of articular cartilage by a mature adhesion to the joint surface. Early
manipulation while the patient is under anesthesia has been used
successfully, but it may not be necessary. My preference is to delay
correction until the 4-month anniversary, unless there is a clear lack
of progress after 4 to 6 weeks of supervised physical therapy, and
then to perform arthroscopic lysis of adhesions followed by
manipulation.

The intra operative findings usually include suprapatellar pouch that

contains multiple adhesions. Less often, the pouch has been
obliterated with scar. In the surgical treatment of this isolated lack of
flexion, all visible scar should be removed, and meticulous
hemostasis should be obtained. Traditionally, the motorized shaver is
the instrument of choice, but newer radio frequency devices offer the
ease of resection and cauterization simultaneously.
The dissection should be carried up under the distal quadriceps
muscle to free it from the femoral shaft, to restore the normal volume
to the suprapatella pouch. A blunt obturator or a ¼ inch curved
osteotome can be employed for this purpose. The entire procedure
can often be done without the use of a tourniquet, and this improves
both hemostasis and post operative quadriceps function. If a
tourniquet is required ,it should be deflated before manipulation to
allow free quadriceps excursion. Post operative drainage of the joint
and CPM are of benefit after arthrolysis in patients with type 2
arthrofibrosis. Although the drains can eassily be placed into the
gutters from a suprapatella portal, old incision sites should be
avoided, because this may lead to delayed healing. Persistent
drainage, and an increased risk of infection. The maximum tolerated
range of motion for the CPM should be selected both for flexion and
extension in the immediate postoperative period. The drains may be
removed early if the volume of drainage is limited (more than 75
mL/8 hours) or maintained for up to 48 hours if needed. Post
operative pain management is often an issue after arthrolysis in
patients with any type of arthrofibrosis. The use of femoral nerve
blocks or indwelling epidural catheters can be of marked benefit in
the perioperative period. Patella entrapment syndromes encompass
types 3 and 4 arthrofibrosis and extend to IPCS. Surgical treatment is
almost always required, but it should be delayed until complete
resolution of the inflammatory stage. As previously noted, a short
course of high-dose oral corticosteroids may be of significant
benefit. Aggressive stretching and manipulation while the patient is
under anesthesia are contraindicated, particularly when there is
warmth and inflammation in the fat pad or peripatella region. IPCS
can be recognized by the development of patella infera, in association
with entrapment of the patella. Wide variability exists in the ratio of
patella tendon length to patella length (range 0. 75 to J .46) among
patients, but almost no variation between sides in the same patient.
Flexed-knee lateral Radiographs to compare involved with
uninvolved patella tendon length are indicated to identify patella
infera.

More than 8 mm of shortening of the patella tendon will require

specific attention to this tendon during surgical treatment. This is best
accomplished with a DeLee-type tibial tubercle osteotomy, which not
only restores the patella toward its normal vertical position but also
helps to decrease patella femoral contact pressures by bringing the
insertion of the patella tendon more anteriorly.

Open, arthroscopic, and combined procedures have been employed

and reported on in the treatment of types 3 and 4 arthrofibrosis.
Results have been similar, and the selection depends on the comfort
and skill of the individual surgeon. All intra articular adhesions must
be released. Lateral and medial retinacular releases are necessary, as
is removal of all scar, often including the fat pad, that tethers the
patella to the tibia. The bursa deep to the distal patella tendon must
be completely freed . Notch impingement must be corrected. If a
malpositioned ligament graft is identified, this must be removed,
motion must be regained, and late reconstruction should be
considered if instability develops. In our own series, this was usually
not necessary, because more than 50% of patients who had an ACL
graft resected remained clinically stable through more than 2 years of
follow up. This is in part the result of reduced activity level, because
most patients who develop true patella entrapment have long-term
patella femoral symptoms related to articular surface damage. Extra
articular bands from the patella to the femur have been described, but
direct exposure of these bands may not be necessary, because the
lateral and medial releases are usually adequate to lyse them.
Although the DeLee tibial tubercle slide osteotomy can be used to
restore the patella to a near-normal location, patella femoral
symptoms often remain a long-term issue, as the result of significant
patella chondromalacia And the shortened patella tendon. In some
patients who have been treated with only soft tissue releases,
progressive shortening of the patella tendon in time has been
reported, a finding suggesting an ongoing fibrotic process.

In the immediate postoperative period, intraarticular drains are

important to reduce the potential for haemarthrosis. Early motion,
including CPM, cryotherapy, and regional pain management
techniques, such as femoral nerve block or an indwelling epidural
catheter, should all be employed. Daily physical therapy for patella
mobilization, joint motion, and recruitment of the quadriceps is
indicated, often for the first few weeks. There is often a biphasic
improvement in joint motion, with immediate postoperative motion
decreasing over the next 7 to 10 days in the early inflammatory phase
of healing. As the warmth and inflammation fade, motion can again
regained. Oral corticosteroids, in a high-dose tapered course over 3 to
4 weeks, can be of significant benefit for patients with significant
post release inflammation. Because of the significant cortical defect
created just distal to the tibial tubercle by the DeLee osteotomy, even
when grafted, these patients require long-term protection with
crutches and a hinged brace, often up to 12 weeks postoperatively.
This area is also prone to stress reactions or stress fractures if the
patient returns to running, even after complete healing.

As noted earlier, a major factor in reducing the risk of motion loss

after injury or surgery is the rehabilitation protocol. This really
begins preoperatively in many cases, because regaining full motion
after injury and before surgical treatment diminishes the risk of
motion problems postoperatively. If possible, full passive extension
should be encouraged in the immediate postoperative period. This
prevents the accumulation of a hematoma in the notch, which may
lead to an extension-limiting cyclops lesion. This also reduces the
tendency for the fat pad to scar to the notch.

Early recognition by the creating orthopaedic surgeon or physical

therapist of patients who are not regaining flexibility at the expected
rate after injury or surgical treatment is key to reducing the long-term
morbidity of the condition. Greater than anticipated pain is often a
precursor of motion issues and should alert the practitioner to this
issue.

CONCLUSSION

When motion problems are identified, the type of arthrofibrosis

should be categorized, and treatment should be instituted. If the
patient's condition is in an inflammatory stage, mobilization should
be gentle. Oral corticosteroids should be considered important
adjuncts that can reduce inflammation before more aggressive
manipulative or surgical therapy. Early (typically in the first 4
months) after the inciting injury or surgical procedure, nonoperative
treatment is indicated. Surgical intervention should not be delayed,
however, when there is failure to progress or a mechanical block to
motion. Any surgical treatment, whether it be open, arthroscopic, or a
combination, need be based on the following principles: (a) complete
removal of all intraarticular scar; (b) release of any extraarticular
adhesions; (c) elimination of any mechanical block to motion,
including malpositioned grafts; and (d) restoration of patella mobility
and position. Failure to achieve any of these will result in persistent
limitations of motion and the potential for further articular cartilage
injury. After surgical treatment of arthrofibrosis, rehabilitation
protocols should stress early motion(particularly full passive
extension, if it was limited preoperatively), rapid return of quadriceps
function and excursion, and patella mobilization. CPM can be an
important adjunct, if flexion was limited preoperatively. In the future,
the use of hyaluronic acid films or gels or manipulation of the
various growth factors may reduce the incidence of arthrofibrosis in
high-risk situations.

The arthroscopic treatment of types 1 or 2 arthrofibrosis has proven

effective in most cases. Normal or near-normal motion and function
can be anticipated and maintained for the long term. When patella
entrapment or IPCS is encountered , the long-term results are less
satisfactory. In large part, this can be attributed to damage to the
articular surfaces of the patellofemoral joint. Observations of
progressive shortening of the patella tendon after treatment point to
either an ongoing inflammatory process or persistent abnormal
growth factor expression. Substantial motion gains in both flexion
(approximately 30 degrees) and extension (approximately 15
degrees) can be achieved in those patients with patella entrapment
but no patella infera. Functional recovery and return to athletics are
determined, in large part, by the status of the patellofemoral articular
surfaces. Whereas motion gains in those patients with IPCS are
nearly as good as in patients with just patella entrapment, their
function typically remains limited by articular surface damage and
the long term abnormal patellofemoral mechanics related to the
shortened patella tendon. Late loss of patella tendon length with
return to a mechanically suboptimal patella location is a concern.
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Figure 1. Left knee X-ray with Insalvati Ratio 1,2 following ACL
Reconstruction

A. MRI Axial View B. MRI Sagittal View

C. MRI Coronal View

Figure 2. Left knee MRI from A. axial. B. Sagittal, and C. coronal

view showed there is an Arthrofibrosis following ACL
Reconstruction
Figure 3. Type Of Arthrofibrosis Based On Motion Limitation and
Patella Mobility (by Donald Shellborne)

Figure 4. Algorithm for Management of Arthrofibrosis.