- Email: [email protected]
Arthroscopic treatment of flexion deformity after ACL reconstruction
Arthroscopy:
The Journal of Arthroscopic
and Related Surgery
Published by Raven Press, Ltd. 0 1992 Arthroscopy
Arthroscopic
P.
Mariani, M.D.,
8<4):517-521
Association of North America
Treatment of Flexion Deformity After ACL Reconstruction Ferretti,
M.D.,
Conteduca,
M.D.,
C. Tudisco,
Summary: complication
one frequent is restriction the range of motion and of extension. the presence the suprapatellar pouch, it is possible two different pathological findings the intercondylar notch: a misplacement of graft causing the presence from graft that blocks the degrees All patients had range-of-motion restriction ACL procedure. The and at 6 months that good results have been obtained
did remain. all cases, the postoperwas between and lo”, but deficit regressed case necessary the remaining patients. Key Knee joint-ACLStiffness.
The
knee range of motion cessful use
surgical techniques and postoperative physical apy. treatment this complication because vigorous with patient are often ineffecpose some risk graft. Moreover, in joint stiffness after ACL and flexion both may The various procedures described for flexion deformity treatment as posterior release, lengthening are ineffective patients because the the treatment for arthrofibrosis the knee with restriction
the
the treatment the knee ACL surgery This article will report the results obtained with arthroscopic treatment in a series who a restriction ACL procedures. MATERIALS AND METHODS From May until 1989 we treated with knee fibroarthrosis secondary previous open procedures. For study we examined who satisfied the criteria: (a) prior ACL (b) preoperative limitation of extension 15” or more, and (c) failure Our study included (17 were male and was female) with an range of 1746
“La Sapienza,” enza,”
have reported the arthroscope for
and reprint requests to P. P. Mariani, “La SapiMoro 5, I-00185,
All patients had 517
previously treated for
518
P. P. MARIANI ET AL.
an acute or chronic lesion of the ACL. Table 1 shows the different procedures that had been performed. The time elapsing between ACL procedure and arthroscopy ranged from 6 months to 2 years (mean: 13 months). All patients included in the study had a significant loss of extension ranging from 15 to 35” (average 25”). Ten patients also had a significant restriction of flexion that ranged from 60 to 90” (mean: 75”). Eleven patients had undergone a manipulation while they were under general anesthesia, without any benefit. In all cases the physical therapy had been ineffective. Follow-up physical examination consisted of a full evaluation of the operative knee with specific emphasis on range of motion and gait. Patients were checked after 1 month and again after 6 months for a final evaluation. Active and passive pre- and postoperative motion values under anesthesia as well as the active final motion values were recorded. In 12 patients, radiographic examinations before and after surgery were reviewed and the position of the patella was evaluated by the Insall-Salvati method. SURGICAL TECHNIQUE All procedures were performed with patients under general anesthesia and followed a standard protoco1. All cases, even those who had just a deficit of extension, showed the presence of adhesions in the suprapatellar pouch and lateral gutters. These adhesions must first be dissected with a basket and high-speed motorized instrumentation. In the intercondylar notch there are two different pathological findings; we have divided our patients into two different groups according to these findings-Group 1: presence of hypertrophic tissue that arises from the graft and prevents extension by locating itself between femoral condyle and tibia1 plateau (Figs. l-3). Group 2: incorrect placement of graft with intercondylar impingement (Fig. 4). TABLE 1. Previous procedures
of ACL reconstruction in 18 patients in study
Patek tendon Reinsertion of ACL Semitendinosus and gracillis Prosthetic (Dacron) Semitendinosus ACL, anterior cruciate ligament.
Arthroscopy.
Vol. 8. No. 4, 1992
8 6 2
1 1
In the first group, complete extension is accomplished by removing the hypertrophic tissue but leaving the graft intact. In the second group it is necessary to perform an accurate and wide notchplasty with curette or motorized abrader, and then remove the adhesions between the graft and the medial surface of lateral condyle. When the femoral tunnel is too anterior (which happens frequently), these procedures alone are ineffective. Therefore, it is necessary to remove the most anterior tendon fibers. Furthermore, a small transverse incision of the tendon can be performed to stretch the graft without compromising joint stability. Once sufficient space is the intercondylar notch has been created, it is possible to examine the posterior compartments from an anterior portal. A subsequent manipulation of the knee is not necessary when there is just a deficit of extension because it does not further increase the extension obtained by the arthroscopic release. Two hemovac drains were placed into the joint under direct vision. A compressive dressing was applied and the patient’s knee was immediately placed on a continuous passive motion machine. The next day, the compressive dressing was replaced by a lighter one and the patient began the exercise program involving quadriceps tightening and hamstring stretching. RESULTS Our results fall into two categories (group 1 and group 2) along the same lines as the pathological findings. The postoperative and final motion value of both groups are shown in Table 2. Group 1 is composed of 8 patients (44.4%) with a mean preoperative value of 20” of loss of extension. In this group, flexion is modestly impaired and the mean is 100”. This group had the best results because in all cases a full or almost full range of motion was obtained. Group 2 contained 10 patients (55.6%) in whom the graft had been incorrectly placed. This group showed a more marked restriction of joint motion with a mean value of flexion equal to 75” and extension equal to 30”. In this group, no patient regained full range of motion as compared with the opposite knee. The mean postoperative value was 108” for flexion and 3” for extension. There were two patients who did not regain complete extension. One patient refused any other
FLEXION
FIG. View cated ment,
1. of at at
DEFORMITY
AFTER ACL RECONSTRUCTION
519
Anterior impingement. hypertrophic tissue, loanteromedial compart60” of flexion.
treatment, because he was satisfied with the final postoperative extension of - 5”. The other patient, who had a Dacron prosthetic replacement with over-the-top technique for an acute ACL tear, underwent a second arthroscopic release for a residual extension lack of 12”, but no further benefit was obtained. The patient refused the removal of the prosthetic ligament to get complete extension of the knee. Immediately after the arthroscopic surgery, all patients had extension of between 5 and 10”. On the final evaluation, however, this deficit regressed in 12 patients (66.6%) after physical therapy. In the remaining six cases a dropout cast for 20 days was sufficient to obtain the complete extension.
We were able to examine the posterior compartments in just 11 cases, detecting some bands of adhesions that in our judgment do not affect the range of motion. It is impossible to state whether in the remaining cases the posterior compartments were obliterated by adhesions or whether there was a pathological retraction of the capsule. At any rate, the final result was not affected by the missing view and excision of adhesive bands in the posterior compartments. The evaluation of patellar position was carried out by the Insall-Salvati method in 12 patients (7 from group 1 and 5 from group 2) as shown in Table 3. We have not found any correlation between the height of the patella and cause of stiffness: of the
FIG. View cated ment,
2. of at at
Anterior impingement. hypertrophic tissue, loanteromedial compart30” of flexion.
Arthroscopy.
Vol. 8. No. 4, 1992
520
P. P. MARIANI ET AL.
FIG. 3. High-power microscopic section of resected specimen: presence of fibrocartilage that surrounds an area of trabecular bone.
four cases showing a Salvati-Insall index lower than 1, two belonged to group 1 and two to group 2. In comparison to the preoperative examination, the radiograph performed 6 months after surgery did not show any variation of patellar position, although patients had obtained a complete recovery of extension. In addition, we treated by arthroscopy one patient with patella infera with a marked limitation of extension and flexion (range of motion between 35 and 60”). After arthroscopic treatment, the patient achieved complete extension while the flexion showed a limitation at 95”.
DISCUSSION In years past, the flexor tendon contracture was considered to be the main cause of loss of extension after surgery. The posterior release was commonly selected as the treatment of choice. Except for neuromuscular disease, the hamstring tendon contracture does not require a surgical treatment because it can improve after physical therapy. In fact, we have noticed that after arthroscopic treatment in patients with flexion deformity, an extension deficit still remains but it regresses after physical therapy or with the use of an extension (dropout) cast.
4A,B
FIG. 4. Intercondylar
Arthroscopy,
Vol. 8, No. 4, 1992
impingement.
View of patellar tendon, incorrectly placed, at 60” (A) and 30” (B) of flexion.
FLEXION
DEFORMITY
TABLE 2. Mean motion values Preoperative Group I (8 patients) Group 2 (10 patients)
20-100 30-75
Postoperative (1 mo)
Postoperative
(6 mo)
5-l IO IO-98
O-11.5 3-108
Another cause of loss of extension was attributed to the formation of adhesions in the posterior compartment. However, when it was possible to examine the posterior compartment through an anterior or posterior portal these adhesions were not always visible. After ACL reconstructive surgery, flexion deformity is often attributed to other causes. In most of our cases an error in the placement of the graft caused by a too-anterior femoral tunnel resulted in an intercondylar impingement. In these circumstances an arthroscopic notchplasty is done to increase the extension. Care must be taken not to damage the graft when dissecting it free. In rare instances it may be necessary to cut the most anterior tendon fibers. In some cases there was hypertrophic tissue located between the femur and tibia blocking the last degrees of extension. We have defined this occurrence as “anterior impingement” to distinguish it from flexion deformity due to the nonisometric placement of the graft. We do not know the precise origin of this tissue, because we have not found any correlation with the substitute tendon, nor do we know the exact cause of these changes. Several factors can be hypothesized but not proven: adhesions with the fat pad, osteocartilagineous debris and fragments close to the tibia1 tunnel, or too-vigorous physical therapy. Such alterations are characterized by new collagen formation with fibrocartilage and osseous metaplasia and are different from those described by Paulos et al. (6). In the infrapatellar contracture syndrome, there is an abnormal fibrosclerosis of the TABLE 3. Height of patella and stiffness Normal Low Patella infera
7 (5 group 1 + 2 group 2) 4 (2 group 1 + 2 group 2) I (group 2)
521
AFTER ACL RECONSTRUCTION
fat pad, patellar retinacula, and anterior capsular tissues. In Paulos’ opinion these changes are due to immobility and injury associated with inflammation. The hypertrophic tissue we have observed does not cause any patellar entrapment or a patellar tendon contracture. Actually, we have not found any correlation between patellar height and stiffness, and only one case showed a patella infera. The low position of patella can just account for a limitation of flexion but not necessarily a limitation of extension. All patients with patella baja, even the case with patella infera, regained complete extension after the arthroscopic release; on the other hand, the more severe the alteration of patella position the more limited the flexion remained. CONCLUSIONS In patients with loss of extension after ACL reconstructive surgery, this study has shown the following. (a) Restriction of flexion and extension is caused by intercondylar impingement due to incorrect placement of the graft. If the impingement stems from a poorly placed graft, then these patients will generally do poorly even after attempts at release. (b) At the time of the placement of the graft, it is imperative that the drill holes be cleared of any osteocartilaginous debris that may cause impingement later. (c) Arthroscopic treatment seems to produce good results and is an effective tool to treat this not-infrequent and problematic complication of ligamentous surgery. REFERENCES 1. Sprague NF, O’Connor
2.
3. 4.
5. 6.
RL, Fox JM. Arthroscopic treatment of postoperative knee fibroarthrosis. Clin Orrhop 1982; 166:165-72. Del Pizzo W, Fox JM. Friedman M, Snyder S, Terkel R. Operative arthroscopy for the treatment of fibroarthrosis of the knee. Contemp Orthop 1985;10:6.5-73. Parisien JS. The stiff knee. In: Parisien JS, ed. Arthroscopic surperv. McGraw-Hill. 1988: 163-71. Ch&tel P. Herman Sl Benoit S. Witvoet J. Percutaneous arthrolysis under arthroscopic control and manipulation under anesthesia in the treatment of postoperative stiffness of the knee. Rev Chir Orthop 1988;74:517-25. Mariani PP. Gigli C, Ferretti C. Arthroscopic arthrolysis of the knee. Itnl J Orthop Traumarol 1988;14:149-56. Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbott P. Infrapatellar contracture syndrome. Am J Sports Med 1987;15:33141.
Arthroscopy.
Vol. 8. No. 4. 1992
The Journal of Arthroscopic
and Related Surgery
Published by Raven Press, Ltd. 0 1992 Arthroscopy
Arthroscopic
P.
Mariani, M.D.,
8<4):517-521
Association of North America
Treatment of Flexion Deformity After ACL Reconstruction Ferretti,
M.D.,
Conteduca,
M.D.,
C. Tudisco,
Summary: complication
one frequent is restriction the range of motion and of extension. the presence the suprapatellar pouch, it is possible two different pathological findings the intercondylar notch: a misplacement of graft causing the presence from graft that blocks the degrees All patients had range-of-motion restriction ACL procedure. The and at 6 months that good results have been obtained
did remain. all cases, the postoperwas between and lo”, but deficit regressed case necessary the remaining patients. Key Knee joint-ACLStiffness.
The
knee range of motion cessful use
surgical techniques and postoperative physical apy. treatment this complication because vigorous with patient are often ineffecpose some risk graft. Moreover, in joint stiffness after ACL and flexion both may The various procedures described for flexion deformity treatment as posterior release, lengthening are ineffective patients because the the treatment for arthrofibrosis the knee with restriction
the
the treatment the knee ACL surgery This article will report the results obtained with arthroscopic treatment in a series who a restriction ACL procedures. MATERIALS AND METHODS From May until 1989 we treated with knee fibroarthrosis secondary previous open procedures. For study we examined who satisfied the criteria: (a) prior ACL (b) preoperative limitation of extension 15” or more, and (c) failure Our study included (17 were male and was female) with an range of 1746
“La Sapienza,” enza,”
have reported the arthroscope for
and reprint requests to P. P. Mariani, “La SapiMoro 5, I-00185,
All patients had 517
previously treated for
518
P. P. MARIANI ET AL.
an acute or chronic lesion of the ACL. Table 1 shows the different procedures that had been performed. The time elapsing between ACL procedure and arthroscopy ranged from 6 months to 2 years (mean: 13 months). All patients included in the study had a significant loss of extension ranging from 15 to 35” (average 25”). Ten patients also had a significant restriction of flexion that ranged from 60 to 90” (mean: 75”). Eleven patients had undergone a manipulation while they were under general anesthesia, without any benefit. In all cases the physical therapy had been ineffective. Follow-up physical examination consisted of a full evaluation of the operative knee with specific emphasis on range of motion and gait. Patients were checked after 1 month and again after 6 months for a final evaluation. Active and passive pre- and postoperative motion values under anesthesia as well as the active final motion values were recorded. In 12 patients, radiographic examinations before and after surgery were reviewed and the position of the patella was evaluated by the Insall-Salvati method. SURGICAL TECHNIQUE All procedures were performed with patients under general anesthesia and followed a standard protoco1. All cases, even those who had just a deficit of extension, showed the presence of adhesions in the suprapatellar pouch and lateral gutters. These adhesions must first be dissected with a basket and high-speed motorized instrumentation. In the intercondylar notch there are two different pathological findings; we have divided our patients into two different groups according to these findings-Group 1: presence of hypertrophic tissue that arises from the graft and prevents extension by locating itself between femoral condyle and tibia1 plateau (Figs. l-3). Group 2: incorrect placement of graft with intercondylar impingement (Fig. 4). TABLE 1. Previous procedures
of ACL reconstruction in 18 patients in study
Patek tendon Reinsertion of ACL Semitendinosus and gracillis Prosthetic (Dacron) Semitendinosus ACL, anterior cruciate ligament.
Arthroscopy.
Vol. 8. No. 4, 1992
8 6 2
1 1
In the first group, complete extension is accomplished by removing the hypertrophic tissue but leaving the graft intact. In the second group it is necessary to perform an accurate and wide notchplasty with curette or motorized abrader, and then remove the adhesions between the graft and the medial surface of lateral condyle. When the femoral tunnel is too anterior (which happens frequently), these procedures alone are ineffective. Therefore, it is necessary to remove the most anterior tendon fibers. Furthermore, a small transverse incision of the tendon can be performed to stretch the graft without compromising joint stability. Once sufficient space is the intercondylar notch has been created, it is possible to examine the posterior compartments from an anterior portal. A subsequent manipulation of the knee is not necessary when there is just a deficit of extension because it does not further increase the extension obtained by the arthroscopic release. Two hemovac drains were placed into the joint under direct vision. A compressive dressing was applied and the patient’s knee was immediately placed on a continuous passive motion machine. The next day, the compressive dressing was replaced by a lighter one and the patient began the exercise program involving quadriceps tightening and hamstring stretching. RESULTS Our results fall into two categories (group 1 and group 2) along the same lines as the pathological findings. The postoperative and final motion value of both groups are shown in Table 2. Group 1 is composed of 8 patients (44.4%) with a mean preoperative value of 20” of loss of extension. In this group, flexion is modestly impaired and the mean is 100”. This group had the best results because in all cases a full or almost full range of motion was obtained. Group 2 contained 10 patients (55.6%) in whom the graft had been incorrectly placed. This group showed a more marked restriction of joint motion with a mean value of flexion equal to 75” and extension equal to 30”. In this group, no patient regained full range of motion as compared with the opposite knee. The mean postoperative value was 108” for flexion and 3” for extension. There were two patients who did not regain complete extension. One patient refused any other
FLEXION
FIG. View cated ment,
1. of at at
DEFORMITY
AFTER ACL RECONSTRUCTION
519
Anterior impingement. hypertrophic tissue, loanteromedial compart60” of flexion.
treatment, because he was satisfied with the final postoperative extension of - 5”. The other patient, who had a Dacron prosthetic replacement with over-the-top technique for an acute ACL tear, underwent a second arthroscopic release for a residual extension lack of 12”, but no further benefit was obtained. The patient refused the removal of the prosthetic ligament to get complete extension of the knee. Immediately after the arthroscopic surgery, all patients had extension of between 5 and 10”. On the final evaluation, however, this deficit regressed in 12 patients (66.6%) after physical therapy. In the remaining six cases a dropout cast for 20 days was sufficient to obtain the complete extension.
We were able to examine the posterior compartments in just 11 cases, detecting some bands of adhesions that in our judgment do not affect the range of motion. It is impossible to state whether in the remaining cases the posterior compartments were obliterated by adhesions or whether there was a pathological retraction of the capsule. At any rate, the final result was not affected by the missing view and excision of adhesive bands in the posterior compartments. The evaluation of patellar position was carried out by the Insall-Salvati method in 12 patients (7 from group 1 and 5 from group 2) as shown in Table 3. We have not found any correlation between the height of the patella and cause of stiffness: of the
FIG. View cated ment,
2. of at at
Anterior impingement. hypertrophic tissue, loanteromedial compart30” of flexion.
Arthroscopy.
Vol. 8. No. 4, 1992
520
P. P. MARIANI ET AL.
FIG. 3. High-power microscopic section of resected specimen: presence of fibrocartilage that surrounds an area of trabecular bone.
four cases showing a Salvati-Insall index lower than 1, two belonged to group 1 and two to group 2. In comparison to the preoperative examination, the radiograph performed 6 months after surgery did not show any variation of patellar position, although patients had obtained a complete recovery of extension. In addition, we treated by arthroscopy one patient with patella infera with a marked limitation of extension and flexion (range of motion between 35 and 60”). After arthroscopic treatment, the patient achieved complete extension while the flexion showed a limitation at 95”.
DISCUSSION In years past, the flexor tendon contracture was considered to be the main cause of loss of extension after surgery. The posterior release was commonly selected as the treatment of choice. Except for neuromuscular disease, the hamstring tendon contracture does not require a surgical treatment because it can improve after physical therapy. In fact, we have noticed that after arthroscopic treatment in patients with flexion deformity, an extension deficit still remains but it regresses after physical therapy or with the use of an extension (dropout) cast.
4A,B
FIG. 4. Intercondylar
Arthroscopy,
Vol. 8, No. 4, 1992
impingement.
View of patellar tendon, incorrectly placed, at 60” (A) and 30” (B) of flexion.
FLEXION
DEFORMITY
TABLE 2. Mean motion values Preoperative Group I (8 patients) Group 2 (10 patients)
20-100 30-75
Postoperative (1 mo)
Postoperative
(6 mo)
5-l IO IO-98
O-11.5 3-108
Another cause of loss of extension was attributed to the formation of adhesions in the posterior compartment. However, when it was possible to examine the posterior compartment through an anterior or posterior portal these adhesions were not always visible. After ACL reconstructive surgery, flexion deformity is often attributed to other causes. In most of our cases an error in the placement of the graft caused by a too-anterior femoral tunnel resulted in an intercondylar impingement. In these circumstances an arthroscopic notchplasty is done to increase the extension. Care must be taken not to damage the graft when dissecting it free. In rare instances it may be necessary to cut the most anterior tendon fibers. In some cases there was hypertrophic tissue located between the femur and tibia blocking the last degrees of extension. We have defined this occurrence as “anterior impingement” to distinguish it from flexion deformity due to the nonisometric placement of the graft. We do not know the precise origin of this tissue, because we have not found any correlation with the substitute tendon, nor do we know the exact cause of these changes. Several factors can be hypothesized but not proven: adhesions with the fat pad, osteocartilagineous debris and fragments close to the tibia1 tunnel, or too-vigorous physical therapy. Such alterations are characterized by new collagen formation with fibrocartilage and osseous metaplasia and are different from those described by Paulos et al. (6). In the infrapatellar contracture syndrome, there is an abnormal fibrosclerosis of the TABLE 3. Height of patella and stiffness Normal Low Patella infera
7 (5 group 1 + 2 group 2) 4 (2 group 1 + 2 group 2) I (group 2)
521
AFTER ACL RECONSTRUCTION
fat pad, patellar retinacula, and anterior capsular tissues. In Paulos’ opinion these changes are due to immobility and injury associated with inflammation. The hypertrophic tissue we have observed does not cause any patellar entrapment or a patellar tendon contracture. Actually, we have not found any correlation between patellar height and stiffness, and only one case showed a patella infera. The low position of patella can just account for a limitation of flexion but not necessarily a limitation of extension. All patients with patella baja, even the case with patella infera, regained complete extension after the arthroscopic release; on the other hand, the more severe the alteration of patella position the more limited the flexion remained. CONCLUSIONS In patients with loss of extension after ACL reconstructive surgery, this study has shown the following. (a) Restriction of flexion and extension is caused by intercondylar impingement due to incorrect placement of the graft. If the impingement stems from a poorly placed graft, then these patients will generally do poorly even after attempts at release. (b) At the time of the placement of the graft, it is imperative that the drill holes be cleared of any osteocartilaginous debris that may cause impingement later. (c) Arthroscopic treatment seems to produce good results and is an effective tool to treat this not-infrequent and problematic complication of ligamentous surgery. REFERENCES 1. Sprague NF, O’Connor
2.
3. 4.
5. 6.
RL, Fox JM. Arthroscopic treatment of postoperative knee fibroarthrosis. Clin Orrhop 1982; 166:165-72. Del Pizzo W, Fox JM. Friedman M, Snyder S, Terkel R. Operative arthroscopy for the treatment of fibroarthrosis of the knee. Contemp Orthop 1985;10:6.5-73. Parisien JS. The stiff knee. In: Parisien JS, ed. Arthroscopic surperv. McGraw-Hill. 1988: 163-71. Ch&tel P. Herman Sl Benoit S. Witvoet J. Percutaneous arthrolysis under arthroscopic control and manipulation under anesthesia in the treatment of postoperative stiffness of the knee. Rev Chir Orthop 1988;74:517-25. Mariani PP. Gigli C, Ferretti C. Arthroscopic arthrolysis of the knee. Itnl J Orthop Traumarol 1988;14:149-56. Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbott P. Infrapatellar contracture syndrome. Am J Sports Med 1987;15:33141.
Arthroscopy.
Vol. 8. No. 4. 1992