Surgical Treatment of the Arthrofibrotic Knee | Orthopedic Surgeon | Dr. Millett
29
February

By Paul Henry / in , , , , , , , , , , , , /


motion loss continues to be a difficult complication
following ligamentous injury and surgery to the knee a better understanding of the pathoanatomic
causes of motion last can lead to improved prevention
and treatment strategies the purpose of this instructional video is to outline our approach to the surgical management
of the arthofibrotic knee when motion was does occur early recognition
and appropriate treatment can be expected to restore motion and improve function in
the majority of patients treatment options although varied should improve
outcome when implemented appropriately loss of motion may involve loss of flexion extension
or both when patients present with loss of flexion
and extension the loss of flexion is usually better tolerated
and also easier tree motion loss is best avoided through appropriate
prevention strategies which include technical surgical and rehabilitative factors which
are discussed elsewhere it is important to understand the miryad
causes of motion loss so the treatment can be targeted at the specific
cause causes of extension loss include notch impingement
and a c l_ nodules causes of flexion loss include suprapateller adhesions medial/ lateral gutter adhesions causes of both extension and flexion loss include
improper graph position infrapatellar contracture syndrome soft-tissue calcifications and global arthrofibrosis and infection as a general rule causes of loss of extension reside in the
interchodular notch while causes of loss of flexion reside in the
superpatellar pouch and medial and lateral gutters when non-operative measures fail or when there is a discreet surgically correctable
abnormality we advocate arthroscopic surgery when surgery is undertaken we perform a systematic
nine step a valuation regardless of whether the procedures performed arthroscopically
or open first we evaluate and reestablishes superpatellar
pouch second we evaluate and re-establish the medial gutter
followed by re-establishment of the lateral gutter after focusing our attention on the super-
patellar pouch and medial lateral gutters we move our attention to the infrapatellar fat pad on the
pretibial recess this area has also been named the anterior interval we debride and mobilize the infrapatellar fat pad
and reestablish the pretibial recess next we evaluate the lateral and medial
retinacular structures we perform lateral and medial retinacular
releases if they’re tight or scarred our attention is next focused on the
interchodular notch we deride scar tissue in this area and look
for a c l_ nodules or notch impingement in severe cases of graft malposition we may have release the a c l_ or even the pcl next we evaluate motion on the operating table
both extension and flexion if full extension is not achieved we evaluate
the tibial insertion of the posterior capsule inspecting the capsular recess at this point if the capsular recess and posterior
capsular structures are tight medial and possibly lateral capsulotomies
are performed finally we evaluate the femoral insertion of
the posterior capsule if we were unable to obtain full-motion and release this structure
if necessary preoperative workup begins with a careful history
and physical examination usually the correct diagnosis can be made
from the history and physical examination alone although radiographs can be useful to assessed tonal
placement and patellar-femoral alignment important issues such as patella infera and graft malposition can fairly reliably be determined by x_-rays bony nodules on the tibia and calcifications
of the n_c_i_ are readily seen on plain films we always examine for loss of patellar motion
on exam and patella infera by comparison radiographs if questions remain with the diagnosis remains
unclear an mri is obtained to more carefully evaluate the
soft tissues for patients in whom a surgical procedure is
should be performed we advocate the use of regional epidural anesthesia
and in regional epidural catheters for post procedure patient controlled analgesia this type of anesthesia provides better local
pain control and therefore allows more intensive physical
therapy in the immediate post procedure period while arthroscopic debridement and capsular release
are often successful treatments they’re among the most technically challenging
of arthroscopic procedures because of the thicken capsule loss of joint space adhesions
and scarr tissues we have found capsular distension with saline
prior to arthroscopy to be an important adjunct in the arthroscopic treatment of arthrofibrosis
of the knee with the patient under anesthesia and prior
to arthroscopy the knee joint of the patient with arthrofibrosis is palpated often the scarring so severe that it is difficult
to make out the various surface landmarks the extremitiy is prepped and draped in understand
conditions normal saline is injected into the suprapatellar pouch from the lateral side we are careful to watch and feel for joint
distension as the fluid is injected to ensure that the fluid is entering the true joint space we use a sixty cc syringe in eighteen gauge
needle the fluid should flow easily if the needle
is indeed in the true joint space normal knees easily accept one hundred eighty
ccs of saline and we attempt to introduce that volume of fluid
into the arthrofibrotic knee as well has a capsule as the standard of care is taken
not to rupture the true capsule as the fluid is inserted although interarticular
adhesions may be disrupted as the capsule becomes extended the last sixty ccs are inserted slowly to allow
the capsule to stretch over time preservation of the true joint capsule prevents
extravasation of the fluid during arthroscopy and facilitates visualization after the knee is maximally distended with saline
we insert the arthroscopic instruments through standard portals we typically insert the inflow cannula into
the knee for a supramedial portal and then initiate flow this keeps the joint distended
and facilitates insertion of the arthroscope through the
inferior lateral portal and helps with initial visualization of the
joint we then perform our standard arthroscopic debridement
and releases in severe cases it is often difficult to insert the
arthroscope therefore we first reestablish the suprapatellar
pouch and medial and lateral gutters this helps with visualization of the knee joint this is an example of a patient was
suprapatellar adhesions we use electric cautery to lice the adhesions
and release the suprapatellar pouch would prefer to use electric cautery because this minimizes
bleeding which can contribute to postoperative scarring this is at the conclusion of lysis of adhesions
in the suprapatellar pouch notice how large the pouch is depart usually extends three four centimeters
proximal to the patella next we carefully inspect the medial and lateral
gutters it is important to look for adhesions
this region in his first example you can see the adhesions
which have formed between the capsule and the femoral chodral in this next example we’re using the suction
punch to remove adhesions from the lateral gutter these adhesions have formed between the
femorochondial and the capsule we use a high inferior lateral portal originally
described by patel approximately one centimeter proximal to the standard or lateral arthroscopy
portal to provide clear visualization of the anterior
soft tissues in the retrapatellar and pretibial regions this is an example of a normal anterior interval notice how the inner minuscule ligament glides
freely on the anterior surface of the tibia this is an example of anterior interval scarring adhesions in the pretibia recess have been shown an experimental models to increase
patellar femoral joint contact pressures an internal release is performed by releasing the
scar tissue from medial to lateral just anterior to the peripheral limb of the
anterior horn of each meniscus the release is performed with the thermal ablation
device the release is also proceeded from proximal at
the level of the meniscus to approximately one centimeter distal along
the anterior tibial cortex care should be taken to avoid cauterizing
or burning the bone of the anterior tibia particular hemostasis is obtained prior
to completion by cauterizing any bleeding vessels in the
infrapatellar fat pad as a general rule limitations of flexion usually reside in the supra patellar
pouch and gutters while limitations of extension usually reside
in the notch and posterior capsule therefore the notch should be carefully inspected if there is evidence of graft impingement a notchplasty should be performed fiber proliferative a c l_ nodules should
be excised if present if the cruciate graft or native ligaments
are malposition or excessively scarred they may need to be debrided released or
excised altogether this is an example of an a c l_ nodule here we are using a section punch to remove
the scar tissue from the a c l_ the fiberprolipherative nodule has formed an
the anterior a c l_ possibly due to impingement in the notch this is an example of a patient with a bony
nodule in the interchodular notch nodules or osteophytes in this region can
impinge on the interchodular notch and block extension here we are using an arthroscopic burr
to remove the bony nodules to prevent further impingement in this patient overgrowth of the notch
femoral side has led to osteophyte formation which impinges and blocks full extension here
we’re using an osteotome to remove these osteophytes to reestablish full extension the final part of the evaluation involves
the posterior capsule after completing the evaluation of the notch the knee should be placed through a range of motion and flexion and extension should be carefully
assessed if they’re still persistant loss of extension
consideration should be made for a posterior- capsular release steadman has described a limited open procedure
to release the posterior medial on posterior lateral capsules he’s can be added if necessary this is an example of a patient undergoing
a open posterior medial capsulotomy after performing the arthroscopic procedure the knee is re-prepped and a medial incision is carried out on the
posterior medial aspect of the knee care is taken to identify and preserve the
saphenous nerve the dissection is carried anterior to the medial
hamstrings muscles and their tendons and that medial gastric tendon is carefully
identified a retractor is placed anterior to this tendon and the posterior capsules of the knee joint is identified inserting a hemostat interarticularly can aid in
identifying the capsule capsulotomy is them performed using metzenbaum
scissors the incision is carried from medial over to
the lateral side under direct vision extension and flexion are then reassessed if a persistent loss of extension exist tension should then be focused on the lateral
side an incision is carried out just proximal to
the fibril head the dissection is carried out anterior to
the biceps femorous tendon again the gastroc tendon is the key once this is identified it is carefully
retracted posteriorly the capsules carefully freed and identify
it again the use of a hemostat through the
joint to identify the capsule can be an aide a lateral capsulotomy is them performed as
it was on the medial side in our experienced knee motion will not improve
dramatically even surgery therefore if they’ve lost of extension process every time should be made to achieve this
motion before leaving the operating room in summary arthrofibrosis has a variety of causes and for optimal outcomes appropriate treatment
must be targeted at the specific cause this nine step approach allows the surgeon to systematically address all
the pathoanatomy our first three steps are to evaluate and re-establish the suprapatellar
pouch followed by the medial and lateral gutters
next we carefully look at the anterior interval mobilizing the fat pad and
reestablishing the pretibial recess the lateral reticulum and medical retinaculum
are evaluated and releases are performed if necessary the interchodular notch must be careful evaluated as this is often the site of scar tissue acl
modules bony nodules or malposition grafts the final two steps involve evaluation of the posterior capsule at the tibial
and femoral insertions the capsular recess must be carefully inspected and capsulotomies must be performed if
necessary


9 thoughts on “Surgical Treatment of the Arthrofibrotic Knee | Orthopedic Surgeon | Dr. Millett

  1. Thanks for posting  this. I cant seem to find allot of information on scared tissue or adhesions to the Patella or Quad tendon. I have a quad tear and have undergone surgery 4 months ago. I can only flex my leg 104 degrees with out pain after months of pt. I was told that I need a Arthroscopy  due to scared tissue under the superior patella which will not allow me to fully flex.

  2. Hi, I did have arthroscopic/ Lysis surgery to the right knee. They also found that I had an old tear as well. They cleaned out all of it about 2 moths ago. After a few hurdles my flexion is about 125 degrees and its getting better and stronger each day. I have before and after pictures of both tears. They would not allow me to video because i had not given them time to set anything up.

  3. peter milet is a piece of shit. a piece of dog shit to be exact. It's ok though, God has told me that I am due justice and this piece of shit named peter will pay for doing the wrong procedure to me. Surgical detachment of the kneecaps? Really peter? Fuck you you piece of shit.

  4. Just to hear this POS's voice upsets me. Despite your millions peter, you will get your comeuppance. I guarantee that.

  5. I just had this surgery done june 3 2019 went good came out walking same day. It was to clean out scar tissue and more space in between knee cap due to a previously ACL surgery in a different hospital.

  6. Advising surgery when surgery itself is the main fuckin cause of arthrofibrosis FUCK THAT dooooo nott get a 2nd surgery aggressive therapy and scar tissue massage is what you need this is a serious frustrating condition

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