Clinical Editor
Dr Sheila Strover is the Founder and previous Clinical Editor of the KNEEguru website.Her medical studies were completed at the University of the Witwatersrand in South Africa - BSc(Hons) (1968) and MBBCh (1974). She emigrated to the United Kingdom in 1983 and worked as an anaesthetist (anaesthesio…
An 'interpretation' of a paper published in 2000 which discusses the critical importance of competent rehabilitation in preventing arthrofibrotic scarring inside the knee after cruciate ligament reconstruction.
Noyes FR, Berrios-Torres S, Barber-Westin SD, and Heckmann TP. Knee Surg, Sports Traumatol, Arthros 8:196-206;2000.
This paper reports the research results of a group of researchers from the Cincinatti Sportsmedicine and Orthopaedic Center. The research relates to a consecutive group of patients (443 knees) with cruciate ligament reconstruction - alone or combined with associated procedures (about 50:50). Half of these patients were subject to a 'delayed' rehabilitation programme (the more traditional approach) while the other half were subject to a 'progressive' rehabilitation programme (the more modern approach). In all of them, though, if the patient was found to be progressing inadequately with mobilisation of the knee then the team 'intervened' early with the kind of rehabilitation or surgical programme relevant to arthrofibrosis.
What the team was appraising here was the question - "To what extent is early intervention really significant in minimising the complication of limitation of motion, and also how significant is the early rehabilitation programme?" This work followed previous studies looking at the effect of both the complexity of the ligament problem and the effect of the speed of the rehabilitation programme, and in which they had already identified that about 10% of patients needed intervention for problems with limitation of knee motion, of whom 1% required re-operation for this problem.
By following a consecutive series of patients one eliminates considerable bias in choosing the population group. 445 consecutive patients were followed, but two were eliminated from the study (one patient died of unrelated problems, and one already had arthrofibrosis before the cruciate surgery was undertaken). Thus 443 patients were entered into the study (443 knees). 294 were men, and 149 were women, and the average age was 29 ((range 14 to 62). Approximately two-thirds of cruciate tears were 'chronic', ie the surgery was being performed at least 12 weeks after the injury.
All of the reconstructions were done using patellar-tendon autograft. A tourniquet was used only briefly for the initial graft harvest. Femoral notchplasty (widening the bony roof over the cruciates) was performed where indicated to allow the graft adequate room to function.
| Instruction | Progressive | Delayed |
|---|---|---|
| Range of motion |
0-90° by 1st post-op day. 135° by 4th post-op week. |
0-90° by 1st post-op day. 120° by 6th post-op week. 135° at 7-8th post-op week (except postero-lateral repairs which are taken even more slowly). |
| Weight-bearing |
25% weight-bearing for the first post-op week. Full weight-bearing by the 4th post-op week. |
Toe-touch only for 1st three post-op weeks. 25% weight-bearing from the 4th post-op week. Full weight-bearing by the 7th-8th post-op week. |
| EMS | Use for fair/poor quads tone during the first 4 post-op weeks. | Use for fair/poor quads tone during the first 6 post-op weeks. |
| Biofeedback | Use with EMS | Use with EMS |
| Patellar mobilisation | Patellar mobilisation was encouraged in all four planes, with ROM exercises at home 4 times a day for the first 6 post-op weeks. | Patellar mobilisation was encouraged in all four planes, with ROM exercises at home 4 times a day for the first 6 post-op weeks. |
| Cryotherapy | Begun immediately after surgery, and continued as needed. | Begun immediately after surgery, and continued as needed. |
The knee was wrapped in a double compression dressing for 24 hours, and drains used when indicated. The leg was kept elevated for the first week and compression, anti-embolism (anti blood clot) stockings and ice were used for the first 10 days, and normal school or work duties forbidden. This regime was to prevent swelling of the joint and surrounding tissues. If there was bleeding into the joint (haemarthrosis), this was aspirated and elevation, compression and ice continued as before, and non-steroidal anti-inflammatory medication was prescribed.
Patients were then divided into those undergoing the progressive regime (the less complicated knees) and the delayed regime (the more complicated knees). Patients were instructed on their own rehabilitation regime:
The paper goes on to give pretty comprehensive details of the full exercise regime for each programme, as well as details of bracing, and anyone interested in these should ask their librarian to obtain a reprint of the original paper.
Any patient who was not regaining extension as expected - even by just a few degrees - was started on a regime where the leg was extended with a rolled-up towel under the foot and ankle and 5-9 kg weights placed on the bottom part of the thigh for 10-15 minutes 6-8 times a day.
A cylinder cast was applied from the upper thigh to the ankle, split and wedged progressively every 12-24 hours to allow gradual improvement in extension - the cast was applied for 36-48 hours, and removal was followed by ROM exercises.
Once full extension was regained a night splint was used for 7-10 nights to maintain extension. Any regression led to renewal of the extension casting.
Seated on a stool with wheels, patients were instructed to fix their feet on the ground and roll the stool forwards, forcing the knee into flexion to the point of mild discomfort and holding it there for 1-2 minutes, then advancing it further to achieve a bit more flexion without severe discomfort, and holding it there again. This was continued for 10 minutes in all, and the whole sequence repeated 6-8 times a day.
Patients who were not responding adequately to the overpressure flexion programme were brought in for gentle manipulation under anaesthesia. Emphasis here is on the word 'gentle' - if the surgeon felt that there was a hard 'end-point' then this was discontinued on the understanding that there was already real scar tissue developing and limiting flexion, and the patient was progressed to an arthroscopic release.
Under arthroscopic vision the surgeon surgically removed adhesions and scar tissues in a systematic way throughout the joint. Where the patella and its surrounding tissues were involved scar tissue was removed above and below the patella, and medial and lateral releases performed, to allow freeing of the patella. If there was scar tissue in the notch above the cruciate ligaments it was cleared out and the bony canal widened (femoral notchplasty). A gentle MUA was then performed and compressive dressings applied, a drain used for 24 hours and an ice-and-compression programme instituted after return to the ward.
Good pain relief was considered essential for 3-4 days, and in difficult cases continuous epidural anaesthesia was used to ensure that mobilisation could continue without the limitation of pain. One patient was found to have developed reflex sympathetic dystrophy, which delayed rehabilitation but went on to be successfully managed.
Both the progressive and delayed programmes showed an extremely low incidence of arthrofibrosis and re-operation. Only 0.7% of the 443 entering the study had such limitation of motion as to require re-operation. 98% of the 443 regained normal ROM, and no knee (0%) developed permanent arthrofibrosis.
The authors point out that in the early weeks after surgery any arthrofibrosis is transient if correctly managed and it should be successfully resolved with a programme like that described in this paper. The authors feel, though, that after 1-3 months arthrofibrosis is frequently established - but thay nonetheless emphasise that significant motion gains can still be made with appropriate surgery and further rehabilitation.