Knee Surgeon
Dr Peter Millett is an orthopaedic surgeon and partner at the internationally renowned Steadman Clinic in Vail, Colorado. Ranked among the top 1% of orthopaedic surgeons by U.S. News & World Reports, Dr Millett specializes in disorders of the shoulder, elbow and knee as well as all sports-related i…
Dr Peter Millett chats about arthrofibrosis, and why patients with established arthrofibrosis need to seek out a surgeon who is expert in this potentially devastating complication.
It usually occurs in post-traumatic and post-surgical settings and can manifest itself in many different ways. The severity can range from small amounts of scar tissue in certain locations within the knee that may only cause symptoms with certain activities to diffuse scarring that is chronically painful and completely restricts all motion of the knee.
Non-operative measures such as rest, ice, anti-inflammatory agents, and subsequent physical therapy are the usual first lines of treatment. When these measures are unsuccessful, surgery may be indicated. Historically, forceful manipulation of the knee by the surgeon has been used to break up the scar tissue. In my opinion, there are now better treatment techniques available, particularly since manipulation has significant risks of complication such as fracture of the bone, rupture of tendons, and injury to the cartilage.
It is my preference to release the scar tissue in arthrofibrosis using specific surgical methods, as surgery is generally more precise and safer. In most instances, the surgery can be performed using a minimally-invasive arthroscopic approach. Arthroscopy is a technique in which a camera and small instruments are placed into the knee through small holes (portals). While this type of surgery has significant advantages (less pain, less scarring, better visualization), it does, in cases of arthrofibrosis, require an experienced knee surgeon with advanced surgical skills, primarily because of the altered tissue planes and scarring which distort the normal anatomy. Arthroscopic surgical release and excision of scar tissue does provide a powerful and effective method for treating individuals with arthrofibrosis. Furthermore, it can be used to treat both focal areas of scar tissue as well as more global or generalized arthrofibrosis.
After surgery, patients are typically hospitalized for 48 hours to control pain and to initiate the rehabilitation. Appropriate rehabilitation is essential to success. Motion machines and manual stretching by skilled physical therapists are key components in the early hours and days after surgery. Dynamic bracing can also be used to help maintain extension of the knee. The knee cap (patella) and all the tendons to which it attaches must be kept mobile and supple. After discharge from the hospital, daily outpatient physical therapy visits start and may continue for 6 to 8 weeks.
Arthrofibrosis usually restricts knee motion and causes pain, and it invariably poses a very difficult clinical problem to treat. Early recognition and appropriate treatment can be expected to restore motion and improve function in the majority of individuals who develop this problem. Whenever possible, it is important to identify the specific cause and target the treatment accordingly.
When an individual develops arthrofibrosis, it is important for them to seek a knee specialist who understands the many causes of the problem so that treatment can be targeted at the specific cause. Arthroscopic treatment of knee arthrofibrosis is definitely effective in improving knee range of motion and restoring function, assuming that the surgery is performed properly and with skill.
Arthroscopic surgical treatment can be very complex and technically challenging, and it is generally most effective when the underlying problem is predominately within the joint. When the scarring is also outside the joint, a combined approach that includes both arthroscopic and open techniques may be indicated. Careful diagnostic evaluation, skillful surgery, and appropriate rehabilitation can be expected to eliminate pain, improve motion, and restore motion in the vast majority of individuals with this problem.
1. Kim D, Gill TJ, Millett PJ. Arthroscopic management of the arthrofibrotic knee. Arthroscopy 2004, Jul;20 Suppl 2:187-94.
2. Millett PJ, Johnson B, Steadman JR. Rehabilitation of the arthrofibrotic knee. American Journal of Orthopaedics, 2003 Nov;32(11):531-8.
3. Millett PJ, Steadman JR: The role of capsular distention in the arthroscopic management of arthrofibrosis of the knee: A technical consideration. Arthroscopy 2001;17:E31.
4. Millett PJ, Warren RF, Wickiewicz TL. Management of motion loss following knee ligament surgery. In Simonian and Wickiewicz (eds). The Adult Knee. Philadelphia: Lippincott, Williams & Wilkins, 2003.
5. Millett PJ, Wickiewicz TL, Warren RF. Motion loss after ligament injuries to the knee. Part II: prevention and treatment. Am J Sports Med 2001; 29:822-8.
6. Millett PJ, Wickiewicz TL, Warren RF. Motion loss after ligamentous injuries to the knee. Part I: Causes. Am J Sports Med 2001; 29:664-75.
7. Millett PJ, Williams RJ 3rd, Wickiewicz TL. Open debridement and soft tissue release as a salvage procedure for the severely arthrofibrotic knee. Am J Sports Med 1999;27:552-61.