Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty Jerome G. Enad, M.D.
Abstract: The management of the stiff knee after total knee arthroplasty is controversial. Manipulation under anesthesia and open lysis of adhesions are techniques that can theoretically address the fibrous scar tissue, but their efficacy has been shown to be variable. We describe the technique of arthroscopic lysis of adhesions for the stiff knee after total knee arthroplasty. The advantages of this technique include minimally invasive debridement of scar tissue within defined compartments of the knee and evaluation for the presence and treatment of focal lesions (e.g., loose bodies or impinging synovial or soft tissue). The total arc of motion can be improved with a systematic arthroscopic approach.
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rthrofibrosis of the knee can be debilitating to patients who have undergone total knee arthroplasty (TKA). It occurs in 3% to 6% of patients undergoing TKA and can be painful and disabling.1 Excessive scarring of the joint causes dense fibrous connective tissue to build up intra-articularly, resulting in decreased range of motion.2,3 Stiffness of the knee joint and limited flexion can interfere with walking and the patient’s activities of daily living. Nonoperative treatment options include pain management, physical therapy, and manipulation under anesthesia. When these options fail, operative treatments include lysis of adhesions (open or arthroscopic), explantation of components, and revision surgery.1,3,4 Arthroscopic lysis of adhesions is a less invasive surgical procedure that can be used to address both focal and diffuse arthrofibrosis.5 Adhesions typically form between the capsule and femoral condyles, as well as in the anterior interval, the infrapatellar fat pad, and the pretibial recess. The arthroscopic approach allows release of adhesions throughout the suprapatellar pouch, the intercondylar notch, and the lateral and medial gutters. Typically, sharp punch and motorized
From the Uniformed Services University of the Health Sciences, Bethesda, Maryland, and West Florida Orthopaedic Surgery, Pensacola, Florida, U.S.A. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received April 8, 2014; accepted July 3, 2014. Address correspondence to Jerome G. Enad, M.D., West Florida Orthopaedic Surgery, 2130 E Johnson Ave, Ste 130, Pensacola, FL 32514, U.S.A. E-mail:
[email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14296/$36.00 http://dx.doi.org/10.1016/j.eats.2014.07.001
shaver instruments and a radiofrequency device are needed to debride the dense fibrous tissue. Lateral patellar retinacular release can also be performed to improve patellar tracking if patellar mobility is tight with the patellar tilt test or if the capsular closure is deemed to be too tight. (This is best examined with a 70 arthroscope in the superolateral portal). Although posterior capsular adhesions are difficult to address with the arthroscopic approach,6 an arthroscopic posterior cruciate ligament (PCL) recession can be performed in cruciate-retaining knees that show PCL tightness (e.g., 1 year postoperatively).7 Intra-articular loose bodies and focal soft-tissue lesions can also be addressed during arthroscopy.1,4,8
Fig 1. Arthroscopic view of right knee, infrapatellar pouch, with arthroscope in inferolateral portal and shaver in inferomedial portal. Granulation tissue and scar tissue are being debrided to expose the femoral component (one should note the reflection of the shaver on the femoral arthroplasty component).
Arthroscopy Techniques, Vol 3, No 5 (October), 2014: pp e611-e614
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J. G. ENAD Table 1. Key Points to Arthroscopic Lysis of Adhesions for Stiff TKA
Fig 2. Arthroscopic view of right knee, suprapatellar pouch, with arthroscope in inferomedial portal and shaver in inferolateral portal. Scar tissue is debrided up to and including the deep quadriceps fascia.
Relatively few studies have been published on the surgical outcome after arthroscopic lysis of adhesions, but recent studies have shown promising results regarding improvements in patients’ knee motion.3,4,6,8,9 Studies comparing total motion regained after arthroscopic lysis compared with manipulation under anesthesia have shown modest improvement with arthroscopic intervention.3,8
Surgical Technique The technique is demonstrated in Video 1. After induction of general anesthesia, an examination under anesthesia is performed to document the true total arc of knee motion. Standard inferomedial, inferolateral, and superolateral arthroscopic portals are used. The inflow cannula is inserted through the superolateral portal, and the knee is maximally distended with saline solution. All instruments are inserted carefully so as not to scratch the femoral component or polyethylene insert surfaces. Optional 5-mm plastic cannulas (5 76emm Universal Cannula; Smith & Nephew, Andover, MA) can be used to safely maintain the working portals if
Fig 3. Arthroscopic view of right knee, intercondylar notch, with arthroscope in inferolateral portal and radiofrequency probe in inferomedial portal. Scar tissue is being debrided to expose the PCL.
Tips Perform pre-procedure manipulation under anesthesia with the distal fulcrum at the tibial tubercle to avoid fracture or disruption of the extensor mechanism. Use all portals (and accessory portals) interchangeably for optimum access. Use a plastic cannula to maintain the portals and protect the prosthetic surface from scratches. Prescribe immediate physical therapy or continuous passive motion machine use postoperatively. Pearls Loss of flexion indicates scar tissue in the suprapatellar pouch, anterior interval/pretibial recess, or intercondylar notch or a tight PCL. Loss of extension indicates a tight posterior capsule, posterior osteophytes, or PCL stump scarring (difficult to adequately treat arthroscopically). Sharp punch and motorized shaver instruments are needed to debride the dense fibrous tissue, but one must be careful not to damage the prosthetic surfaces with the instruments. Mirror images on the femoral component may make proper orientation difficult. Pitfalls Not using inflow to distend the tight capsule Scratching the metal prosthesis or polyethylene insert Failing to release tight scar tissue in all involved compartments Indications Painless stiff knee arthroplasty (
