June 19, 2024 • 46 mins
On this episode, we cover arthrofibrosis following ACL reconstruction.
We kick off with a general overview of what arthrofibrosis is, its causes, and its implications for both surgeons and physical therapists. Dr. Benner shares his extensive experience and insights learned from working alongside Dr. Shelbourne, an internationally known expert in this condition.
The discussion progresses to cover the importance of prevention, early detection, and the critical role of achieving and maintaining full knee extension before and after surgery. We explore the factors that contribute to arthrofibrosis, the significance of preoperative and postoperative care, and the differences in how this condition presents in patients.
The episode also highlights a recent study on arthrofibrosis classification and outcomes, which will be presented at the AOSSM annual meeting. The study, co-authored by Dr. Benner, Scot Bauman, Bill Claussen, and Dr. Shelbourne, categorizes patients based on their range of motion deficits and evaluates their postoperative improvements and subjective scores.
Stay connected with us on social media: (X) and Instagram at @theskcpodcast, and on our YouTube and Facebook pages. You can also reach out via email at theskcpodcast@gmail.com.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Music.
(00:12):
This is Dr. Benner, and I'm here with Scott Bauman tonight to discuss another
great topic, some more content for those of you out there who want to learn more about knees.
Last week, we talked about early predictors of return to sport after ACL reconstruction.
That was a really good topic, talking about some physical therapy parameters
and some other variables that are at play as athletes get back from ACL reconstruction.
(00:34):
I would encourage you to go check that one out. We have a lot of great content.
We have almost 40 episodes up now. Now, if you'd like to go back and learn from
all of those, make sure you follow to not miss any of our subsequent content.
And if you'd like to leave us a five-star review and some comments for those
that come behind you, we'd appreciate that as well.
You can find us on social media, on our Facebook and YouTube pages,
(00:55):
the Shelburne E-Center Podcast.
You can find us on Twitter and Instagram at the SKC Podcast.
And you can also email us at theskcpodcast at gmail.com.
And tonight's going to be another good episode. We're talking about arthrofibrosis
following ACL reconstruction, and I think this is going to be a good discussion.
We're going to start talking about just generally what arthrofibrosis is,
(01:16):
what causes it, those types of things.
And I think it's going to be important for many different clinicians,
not only the surgeons out there that are operating on this condition,
but the physical therapists that are seeing these patients both before and after
surgery to see what type of results we're getting with this type of surgery in this condition.
And then we're eventually going to get into a project that we worked on,
(01:36):
and it actually is going to be at the AOSSM summer meeting this July in Denver, Colorado.
And those that worked on that were myself and Dr. Benner, along with Bill Klaassen,
physical therapist in our office, and Dr.
Shelbourne. So before we get to that study, Dr.
Benner, I just wanted to have a brief conversation here to start,
just to give some more details on arthrofibrosis, specifically following anterior
(01:57):
cruciate ligament reconstruction in general.
So can you speak to how often you see this, what it presents like in the early
time point after surgery, and maybe your thoughts on what types of things causes this?
Well, I'm fortunate now that I've been able to learn from Dr.
Shelbourne's legacy in treating this condition and ultimately really focusing
on not treating this condition, but how do we avoid this condition?
(02:20):
So luckily, I see this very little in my own practice because we very rarely
have stiffness after ACL surgery,
but we do see a fair amount of revision surgeries or complications from people
who've had surgery elsewhere that have come to see us.
And because of that, I feel like this is something that we're in a unique position
to really make some comments on as Dr.
(02:43):
Shelbourne is an internationally known expert in this condition.
You know, I feel like I've been able to learn a lot from Dr.
Shelbourne as well as his techniques and been able to apply them myself to the
point where I feel like we can get equivalent results regardless of who the surgeon is.
But I can tell you, this is one condition. And when I watched Dr.
Shelbourne do these surgeries where, you know, he's very, very good at this
(03:06):
and something I don't think I'm anywhere near as good at treating surgically as he is.
But more importantly, the concepts that I've been able to learn over the years working with Dr.
Shelbourne about this specific complication after ACL surgery has been really great.
And I feel like we have a unique perspective on this and a setup in our office
(03:27):
that really allows us to prevent this complication from happening and to also
handle it when it pops up. A lot of this goes back to Dr.
Shelbourne's work that he's done for the last 40 years, specifically our longer-term
studies that talk about what factors lead to long-term success and avoidance of failure.
(03:48):
You know, functional problems and also avoidance of arthritis in the long term.
And Dr. Shelbourne and Tinker Gray, who was in Scott's position previously,
have shown over and over and over again the importance of maintaining range
of motion and how much worse you can make somebody if you allow them to get stiff after surgery.
Of course, you know, when we do a surgery for instability, we're going to be
(04:09):
focused on how do we stabilize the knee.
However, what we found over time is that the stability, while it is,
of course, important, is not as important as patients getting full range of
motion back afterwards.
And I think it's become pretty clear that if you have a knee that's relatively
loose after a surgery, but you have full range of motion, you can still have a pretty good outcome.
(04:32):
However, if you have perfect stability and your knee is rock solid stable and
you lose range of motion in the long term, that's probably worse than the loose
knee that you had to begin with.
And so I think just right off the jump here, as we start talking about this,
I think it's important for listeners to go back and review Dr.
Shelbourne's previous literature on factors that make a difference in the long-term
(04:54):
after ACL surgery and review our previous content on this podcast that speak to that specifically,
because that's really the foundation on which we really build avoiding this
complication and treating it once it arises.
I like that you said prevention, and that's something that I really speak to
when I talk about this topic with others, especially physical therapists.
(05:15):
And the question is, well, if you are successfully preventing it,
obviously you don't have this problem, but how do you prevent it?
And that question typically comes up, like I said, especially in the rehab world.
As far as the tips for preventing it, what's your thought on that?
And talking to maybe a group of rehab professionals that are seeing these patients
(05:37):
and hopefully before surgery, but is it as simple as get the motion back before surgery?
And the second question would be, when you're seeing this after surgery,
are you seeing the ones that you always see in case studies where you're seeing
these patients that are 15 degrees short of zero and really a life-altering case?
Or is it sometimes just a two or three degree deficit that may be more symptomatic
(06:00):
than you might think it is?
Well, I think from the very beginning, it's important to understand how debilitating this can be.
And I think that it's also important to understand that strategies for dealing
with arthrofibrosis are far inferior to strategies for preventing arthrofibrosis.
And it's important for the surgeon, it's important for the patient,
(06:20):
and it's important for the physical therapist,
all three of those participants in the, you know, kind of care protocol for
this patient understand that that job of avoiding stiffness begins long before surgery.
This is not a post-surgical complication. This is something that starts to happen
from the very beginning when the patient first gets injured.
(06:44):
I was at a meeting once at the Campbell Clinic where I did my training and one
of our former fellows, I was talking a little bit about stiffness after ACL
surgery and arthrofibrosis.
And he asked the question, well, so, you know, let's say that you've done everything,
everything that you can and it happens anyway.
You know, we all have these patients that, you know, you do everything right
(07:05):
and they still develop stiffness.
So what do you do? So I started talking a little bit about it.
He's like, I know, but let's say you've done everything right and they've had a problem.
Now, what are you going to do about it?
So I had to stop there for a minute. I said, okay, when I say we've done everything
right and you say we've done everything right, I think we have to understand what those things are.
(07:26):
To me, doing everything right means we do not do the surgery until the patient
has full, symmetric, perfect extension to the opposite side.
Until that happens, patient does not get a surgery almost under any circumstances.
Or if they can't get their extension back, then sometimes we've even gone as
far as to to do a scope, to take out the stump, to treat meniscus tears that
(07:48):
may be flipped over in the notch or whatever it is that's keeping the knee from
getting all the way straight.
It's that important that we would even go to the measure of doing a scope to
improve the patient's extension pre-ACL reconstruction to make sure that we
don't have surgery until they're all the way ready.
And then secondly, we have to have them understand, their physical therapist
and the patient, understand that keeping the extension perfect is going to be
(08:11):
a priority throughout the entirety of the process.
We need the surgeon to understand that when we do the surgery,
we have to do it in a way that does not impinge the knee in full extension and
keep it from getting full hyperextension symmetric to the opposite side.
Back. So in the operating room, we have to make sure that we don't impinge upon
the roof of the notch. We don't put the graft to anterior.
(08:34):
We don't put too much graft material in there that it blocks extension in any way.
And then we have to get the knee extension perfect the day of surgery,
the day after surgery, two days after surgery, a week out of surgery,
two weeks out of surgery, and forever more going forward.
We have to do that. So when we talk about what are are all those things that
(08:55):
we have to do? What's doing everything?
Those are the things that it goes into. And if you haven't done all of those
things, if you skipped even one of those steps, then in my opinion,
you're not doing everything to avoid arthrofibrosis.
So that's an important thing to realize.
The other one is what's our goal with extension?
I think people say, well, sometimes I hear people say, well,
it's close and we'll get it over time and it'll come back over time.
(09:19):
And unfortunately, the data doesn't bear that out. The data says that if you
don't get it by the time you're discharged from initial physical therapy,
whether that be six months or a year or however long it is, that it is not coming
back and that that does increase your functional limitations and it does make
it more likely for you to get arthrofibrosis.
I think it's also important to keep in mind what our goals are in that our goal
(09:42):
is the IKDC criteria is what we really use as our guide, as the goalposts on
what we're trying to achieve.
And IKDC criteria says that normal is full symmetric hyperextension,
symmetric to the opposite side with a two-degree or less side-to-side difference.
So if someone has seven degrees of hyperextension on the uninvolved knee and
(10:05):
on the ACL reconstructed knee, they have four degrees of hyperextension.
That patient, in our opinion, has arthrovibrosis. They are not getting full
symmetric perfect extension symmetric to the opposite side. And it's important
to understand that even the minute differences can make a big difference in their outcome later on.
Now, one thing you talked about in there when you're talking about,
(10:26):
you know, kind of covering these incidence rates, if you will,
getting into more of the causes, you mentioned some type of impingement.
When you look at this postoperatively and you see these patients come in,
what's your thought on as to the cause of this?
Is it more of a graft tunnel mismatch and there is some type of physical impingement
or is there some type of overgrowth due to some healing potential of the graft?
(10:51):
And that leads to the second question. And are you seeing these more with patellar
tendongraphs, quad tendongraphs, hamstring grafts? And if you are,
really, what's that reason or what do you think the cause is for this condition?
Well, there's a lot of different factors at play. One of them is just understanding
what our goals are, as I described them before,
and the fact that everybody is educated on what makes the difference on patients
(11:15):
getting their full extension back.
If the patient doesn't understand that they have to get their knee perfectly
straight before surgery, and they have to keep it that way throughout the whole
process if the therapist doesn't understand it, and especially if the surgeon doesn't understand,
because, you know, a lot of us, in my opinion, probably don't understand the
critical importance of full hyperextension symmetric to the opposite side.
And even something as simple as how do you measure range of motion?
(11:38):
You know, I got one time corrected at my fellowship because I was reporting
hyperextension to the degree, and they said, why don't you just look at it in
gradations by five degrees? So someone has hyperextension, say they have five degrees.
I don't want to hear they have one or they have four or they have seven.
And to me, that leads to an illustration of a misunderstanding how important
(12:01):
every degree is and that symmetry is really our goal.
So those are presurgical and education factors.
In surgery, you know, we're big believers that the tibial tunnel has to be placed
in a location where the knee, when put into full hyperextension,
that the tibial tunnel stays posterior to the roof of the intercondylar notch.
(12:24):
And you can see that on x-ray as Blumensat's line, the roof of the intercondylar notch.
So we like to see post-surgically that our tibial tunnel in full hyperextension
is parallel and posterior to Blumensat's line.
That way, We can have a radiographic way to show that we're not causing impingement.
We also check that passively in the operating room.
After we're done with surgery, we extend the knee into full hyperextension,
(12:47):
symmetric to the opposite side, and we watch that the graft fits perfectly in
the intercontinental notch.
And if it doesn't, then we take some bone away, do a notchplasty until it can
allow full hyperextension.
And then post-surgically, it's just about understanding what our goals are.
Again, that the surgeon, the patient, and the physical therapist all understands
(13:07):
that perfect extension is the ultimate goal.
As it relates to graft types, you know, we use patella tendons and the reason
is that we get early bone-to-bone healing so we don't worry as much about fixation
because the healing happens pretty early with patella tendon grafts.
And with that, we don't restrict hyperextension at all in the early time after surgery.
(13:27):
We tension the graft in a way that makes sure that you can get the graft into
full hyperextension without putting too much tension on the graft.
With hamstring grafts, I think there's some concerns with early healing and
with early adequate fixation with hamstring grafts.
And because of that, a lot of times they will tell you to not go into full hyperextension
early on after surgery for fear of stretching out the graft or losing fixation.
(13:51):
And then there's some concern around quadriceps tendon grafts, at least in my opinion.
I saw a study at a meeting last year where they talked about arthrofibrosis
rates with quadriceps tendongraphs are approaching 6% to 7%.
And that, of course, is concerning since we know that that has long-term effects
on function as well as development of arthritis down the road.
(14:15):
So in my opinion, you know, when you can go back to our previous episodes to
hear why I think patella tendongraphs are the best graft, but in my opinion,
those are the best grafts that we can use.
And I think they have some specific advantages in that we can get good early
fixation no problems with impingement due to too much graft material which could
(14:37):
be a problem with quadriceps tendinographs and no early restrictions on full
hyperextension due to fixation like we do have in hamstrings.
So knowing your thoughts on the causes of arthrofibrosis following surgery what
are some of the treatment options that you typically go with when you see these
patients post-operatively?
Well once you identify that a patient has any degree of extension loss I think
(14:59):
it's important to realize this is not a small problem. This is a big problem.
In our office, it's a five-alarm fire if somebody comes in a month after surgery
and they're three degrees off on their extension.
That's a big, big problem, and everybody in the office understands that that can't happen.
So just early recognition and proper
(15:20):
appreciation of the
gravity of that potential problem is a
big early bear is a big barrier in the early time after
surgery when we get these patients further out which is usually
where we get them when we see them from elsewhere by then usually
the patient has pretty is a lot further out from surgery and has had more long-standing
(15:40):
more long-standing problems and in that case we're always starting with non-surgical
treatment it's important to try to control pain in whatever way you need to
or treat pain we don't use Use narcotics usually,
but an anti-inflammatory medicine or steroid dose pack,
something to decrease pain and hopefully...
(16:01):
Relieve some of that pressure in the front of the knee in order to get things
under control, allow them to tolerate physical therapy.
And another important thing early on is to recognize symptomatically the differences
in posterior stretching pain versus anterior impingement type pain.
Pain in the back of the knee with arthrofibrosis is usually related to hamstring
(16:24):
and posterior capsular tightness versus anterior pain and a feeling of impingement
in full extension is usually due to the graft actually impinging the roof of
the intercontinental notch and having too much soft tissue on the front of the graft,
something like a cyclops lesion, for example, or fat pad fibrosis from the passage
of instruments with arthroscopic technique that then adheres the fat pad to
(16:48):
the soft tissues in front of the ACL.
So it's important to know the difference between those. The
posterior pain that happens with hamstring tightness and posterior your capsular
tightness usually will resolve or at least improve significantly with extension
stretching versus if the patient hurts anteriorly and feels pinching in the
(17:09):
front of the knee when they fully extend the knee.
Unfortunately, a lot of times you won't be able to smash that down enough in
order to be able to get the patient out to full extension.
So when a patient comes in with mostly posterior pain and stiffness,
then I feel like the early time period is really focused on And can we get their
pain under control and make them more comfortable?
And then can we do some physical therapy for posterior capsular and hamstring stretching?
(17:33):
Eventually, they may get to the point where they say the posterior tightness
resolved as their extension improved, but now they've kind of plateaued where
they're no longer getting improvements and now they feel that anterior impingement type pain.
That's where we think that we may need to intervene surgically when they have
anterior pain limiting extension.
(17:55):
Attention. Now, going back to the
acute phase, and you talked about the difference between when you or Dr.
Shelburne's operating on these patients and how we see them in our office versus
seeing somebody that's more in the chronic stage, and they say,
I had surgery six, eight months ago, and I've been stiff since day one.
You talked about it being a five-alarm fire, and everybody needs to be on the
same page to recognize the problem in order to properly treat the problem.
(18:17):
When would you say that starts to be a concern to the point where maybe we need
to get this patient in more often to really get on top of this knee extension deficit?
And second question, but still dealing with the timeframe is when do you decide it's too late now?
We need to start talking about either changing the course of treatment or we
need to start looking at surgical interventions for the extension deficit.
(18:40):
So what are those timeframes for both of those examples?
I'd say by the two-week visit, if they come in at two weeks and they don't have
full extension symmetric to the opposite side, we're already thinking this is a big problem.
And especially if we get out to the one-month visit and the patient doesn't
have full symmetric extension, now we're really starting to think this is an issue.
And those are some times where we will increase the frequency of therapy visits
(19:04):
just to lay eyes on them a little bit more and have the therapist working on
them a little more hands-on in a little more hands-on fashion.
You know, as far as when it's too late and when we start to think about surgical
intervention, I don't actually think there's a specific timeframe in which I
would say, if it's not better by this time, then you got to move on.
(19:24):
I think that's more about progression and less about specific criteria and time.
That if a patient is, you know, four months out from surgery and they have a
10 degree flexion contracture and they come in at six months and their flexion
contracture has gone from 10 degrees to four degrees,
I don't think that necessarily means we have to intervene as long as we've seen progression.
(19:47):
So if their flexion contraction has gone from 12 degrees to nine degrees to
six degrees to four degrees to two degrees,
then I think visit over visit, then I think we need to keep going versus if
they have 15 degree extension loss and it goes from 15 to 12 and the next visit
they're at 12 degrees loss and the next visit they're at 12 degrees loss and
(20:09):
the next visit that they're at 12 degrees loss,
eventually you have to figure out we're not progressing and things are in a
bad place and they're not getting better.
One more question on this acute phase. I've had patients over the years where,
and I think arthrofibrosis can feel different.
If you have somebody, let's say in subacute or even chronic phase where maybe
they're only five degrees off, some patients come in and they're five degrees
(20:32):
off and you put them in some extension devices,
you really work diligently on maximizing their extension and you can get it
and then they come back and they're still four degrees off.
You can get it on the table and at the end of the session, you say,
yeah, I did a great job. They have full extension. They come back and they're stiff again. in.
And you take that and you compare it and contrast it to somebody else who has
a five degree extension loss.
And some of those just come to a hard stop. And the infield of terminal extension,
(20:56):
and let's call terminal extension five degrees off, for the first person I talked
about, I always describe it as kind of a spongy or springy feeling where you
can get it there, but just kind of pops back and forth versus that person that
really comes to a hard stop.
Is there a difference between those from an anatomy standpoint or a physiologic
standpoint, Or is that just person-to-person differences in how their infields are?
(21:17):
Yeah, I don't know that it's necessarily an anatomic or structural problem that's different.
I just think that it's important to understand that those situations both happen.
That if you say, you know, this patient came in with a six-degree flexion fracture
and they're just not budging at all,
then that's probably something we need to get an MRI scan, look for impingement,
(21:40):
soft tissue in front of the graft,
et cetera, versus I think sometimes if somebody has a six degree flexion contracture
and you push them down and they can get to one degree contracture,
then the next time they come in six degrees, you can get them to two,
six degrees, you can get them to two, six degrees, you can get them to one.
I think it's important to understand, even though those may seem like they're
different from a progression standpoint, that the problem is likely the same.
(22:04):
And really both those, those are just, you know, a little bit different different
presentations of essentially the same entity.
That something's up in the front of the knee that's keeping the knee from going
all the way straight and staying there.
So take that same example we were just talking about, five or six degree flexion
contracture, you start being concerned about it at the two-week point.
(22:24):
At the four-week point, you start making some more decisions.
When does the imaging come into play? Is that something you're going to order
around that time? And if so, what type of imaging are you getting on these patients.
From an imaging perspective, anytime somebody comes to see us with arthrofibrosis
that's in surgery that's done elsewhere, we always get just standard x-rays, bilateral PA view,
lateral views, and a merchant's view just to get kind of a general screening
(22:49):
type x-ray series of the patient.
Four that we give on pretty much all knee problems. But we also get an extension lateral view.
We ask the patient to fully contract their quad, extend their knee as far as
they can, and then we take a lateral view in that position.
In that position, we want to see the tibial tunnel be parallel and posterior to Blumensat's line.
(23:09):
And if with the knee in full hyperextension, the tibial tunnel is anterior to
that line, then that probably is telling us that that the ACL graft is impinging
on the roof of the endocrine of the notch in full extension,
and that that's probably blocking things from moving forward.
If we don't see that on regular x-ray, then we have to move on to some advanced
imaging, and MRI scans are really the best that we have.
(23:31):
They're looking for a cyclops lesion, some soft tissue in front of the main
portion of the ACL graft that when the knee is fully extended is going to impinge
upon the roof of the endocrine of the notch.
The other thing that we've seen a lot of is a lot of fat pad scarring and just
thick cords of scarring going from the fat pad all the way into the anterior
(23:51):
portion of the ACL graft.
And this can really tether the fat pad and because of that cause range of motion
loss by that fat pad really getting stuck down.
And in our opinion, the arthroscopic technique is worse for this than open technique.
I know people think open technique is old school and archaic and things like that,
(24:11):
but by opening up the knee to do the ACL surgery and sewing it back together
pretty gently, I think we are able to avoid a lot of that fat pad scarring versus
when you do arthroscopic technique.
A lot of times you're passing sharp instruments back and forth repeatedly through
those arthroscopic portals,
(24:32):
and we can really see some pretty profound scarring of the fat pad into the
front of the intercontinental notch, into the front of the ACL.
So we usually start with plain x-rays and then moving on to MRI scan as needed
to look for any kind of impinging soft tissues up in the front of the knee.
So now when you have these patients, you get the imaging done and you decide
that a surgical intervention is going to be the best course of action for this particular patient.
(24:56):
What's your surgical plan and what are you seeing intraoperatively and how does that go?
So surgically, there's a question in the literature, if you read about this,
on whether this is an anterior problem or a posterior problem or both.
And I think it was Dick Steadman in the past that's talked about anterior interval
release, trying to release that anterior scarring to the front of the ACL graft
(25:22):
and trying to free things up that way.
And then I've read other things about people making posterior portals,
removing scar from the posterior compartment, maybe even releasing the hamstrings
in severe cases, things like that.
In our hands, that has not been necessary.
We believe this is an all anterior problem, that the posterior problems will
(25:43):
stretch out with physical therapy versus the anterior impingement and, you know.
The mechanical block that we have for the knee getting into full extension is
not something that will get better with physical therapy.
So if we've had the patient make initial progress and it eventually develops
anterior pain that's not getting better, then we go on to an MRI scan,
we find some scarring in the front of the knee, and we choose to go ahead with surgery.
(26:06):
A couple of technical pearls on this. We usually make our portals a little bit wider.
The scar can be a little bit further, not just in front of the intercontinental
notch, but also from the anterior horn of the medial and lateral menisci where
the anterior horns insert.
It can really spread that entire anterior portion of the knee.
So we'll kind of get down on, and once we've made those portals,
(26:28):
a medial and a lateral portal that are wider than average, then we'll try to
get to the front of one meniscus.
Now, I guess it doesn't really matter either side, but either one.
Get on the front of the meniscus and get into the scar tissue and take that
down all the way to the attachment of the anterior horn of the meniscus and
find the tibia in the front.
I think that's an important thing to do is get through that soft tissue all
(26:52):
the way down onto the tibia at the level of either the anterior attachment of
the medial or the lateral meniscus.
And then once you do that, then you kind of start to work your way along the
tibia over to the opposite side until you reach the anterior horn of the other meniscus.
And that kind of develops a plane between the back of the fat pad and the tibia
(27:13):
and the soft tissues that are on the front of the ACL.
And then once we do that, then we start staying along the tibia and moving further
posterior until we get to the anterior portion of the ACL graft.
This is where it gets, for me, it gets really difficult and pretty nervy,
is when then you have to come kind of, once you get underneath all the way up
to the front of the ACL graft, Now you can't keep going any further posteriorly
(27:36):
or you'll be getting into your ACL graft.
So now you have to get up on top of the ACL where there's with a bunch of soft
tissue stuck to the front of it.
And we use an arthrocare wand for this as opposed to a shaver just because it
allows us to develop those planes a little more cleanly and it doesn't generate
as much debris, things like that.
So that's when we start to take that arthrocare wand and start going through
(27:57):
soft tissue on the front of the ACL until you start to see ACL fibers and then you got to stop.
And that's where I get nervous and I've seen Shelbourne do this
a lot and he's peeling away and he's he's going going away
at the at this soft tissue in the front of the ACL and I'm
in the back watching biting my fingernails because I'm worried that we're going
to get into the ACL graft but once you find the front of the ACL graft then
(28:18):
you're starting to peel that stuff away from the front of the ACL until you
get down to the tibia so now you develop those medial lateral planes you take
it all the way across the front and separate it from the fat pad and then you get in front of the ACL,
take that all the way down to tibia and then you're kind of isolated this soft
tissue in the front of the knee.
And then you can either take the ArthroCare wand and smaller lesions and just...
(28:40):
Kind of burn through all that all the way down to the tibia as it all kind of
evaporates and goes away.
Or you can actually try to remove it in mass as almost like a loose body removal
and remove it from the front of the ACL.
That's the soft tissue portion. So once you've done that, hopefully before you
started, you extended the knee fully to see where the ACL or the soft tissue
(29:04):
on the front of the ACL impinges upon the intercondylar notch and that you get
all that soft tissue away,
and then you extend the knee again to see if the ACL is fitting up into the
roof of the intercondylar notch.
Sometimes you do even have to peel a few fibers of the anterior portion of the ACL away.
Now, does that put your ACL graft at risk? Of course it does.
However, if the ACL graft is impinging in full extension, you know,
(29:27):
as we've talked about before, having an ACL graft that impinges an extension
resulting in extension loss is a bad long-term prognosis.
So if that's what it takes to take even just a little bit of the anterior fibers of the ACL,
then i then i think that's something that probably needs to be done the
next thing you have to do is to assess whether or
not there's any bony impingement from the intercondylar notch
(29:48):
so a lot of times you can actually see a color change between the edge of the
native intercondylar notch where it's kind of glistening white cartilage and
then the osteophytes or kind of bony overgrowth that will that will be kind
of overhanging the wall of the intercondylar notch sometimes it'll It'll be
a little pinkish, like an osteophyte.
And sometimes you do have to do some bony work as well.
(30:09):
Some people use a burr for this. We like to use a small osteotome.
You just really can get a sharp edge.
And, you know, so you're not, you know, buzzing away, you know,
cell layer by cell layer, just trimming away a little bit of bone at a time.
You can put that osteotome, just a skinny one through an arthroscopic portal,
get right on the edge of the bone that you want to take off,
give it a little bit of a tap, move down a little bit, give it a little bit
(30:31):
of a tap and remove it as one big piece.
Rather than shaving away a little bit at a time. And then again,
reassessing as you take more and more bone away until the ACO graft fits perfectly
into the intercondylar notch with the knee into full hyperextension.
And then another thing is you got to realize this is not a short surgery.
You know, I watched Dr. Shelbourne do, you know, medial meniscectomies and the
(30:52):
tourniquet times, you know, 14 minutes, you know, it's pretty,
pretty fast or sometimes even less.
With arthrofibrosis cases, sometimes even though it's a knee scope,
there can be tourniquet times reaching 45 minutes,
60 minutes, 70 minutes of meticulously getting this soft tissue out of the front
of the knee, off the front of the ACO graft,
(31:13):
removing it completely from anterior horn of one meniscus to the other,
and then also going away and removing some bone until you're,
and you do not leave the operating room until you have the knee into full hyperextension
without impingement in the front of the knee.
Well, as you had mentioned, this is something that especially Dr.
Shelburne has seen for a long time now and seen a high volume of them.
(31:34):
And at one point, he decided to classify these patients into certain categories.
So can you touch on that a little bit in terms of how you classify these patients post-operatively?
A quick word about classification systems. I think everybody wants to have their
name on a classification system of whatever that That is, whether it's the Schatzer
(31:56):
classification or the, you know, the Loggie Hansen classification for ankle fractures, et cetera.
We have all these classification systems, but it's important to keep in mind
what these classification systems can really do.
They can really facilitate communication is a big part of it.
And they can also help to guide research into these topics and give us a way
(32:17):
of separating them as we study them.
And then also, hopefully, if you have a good classification system,
it can guide your ultimate treatment patterns.
And we kind of touched on this in a, you know, you mentioned earlier a research
study that we are going to be presenting at the AOSSM annual meeting in Denver this summer.
So let's just get right into that. This study is called Results Following Arthroscopic
(32:38):
Scar Resection for Arthrofibrosis Post-Anterior Cruciate Ligament Reconstruction.
And the lead author on that is Bill Clausen, one of the therapists from our office.
Scott is a, Scott Bauman, who's on the podcast with me here,
is an author on that as well, as well as Dr. Don Shelbourne and myself.
So Scott, kind of lead into, I guess we've already done a lot of introduction
(32:58):
on this, so tell us a little bit about the classification system and how that
leads into the methods of this study.
Yeah, as you mentioned, we kind of hit the background already,
and the purpose was to just do that, was to define certain categories and see
about a classification system for these patients after surgery.
And then second step of this study was to take that classification system and
(33:21):
then look at their postoperative outcomes as it pertains to range of motion
and subjective scoring.
So what we did was we ended up with 166 patients that we've seen postoperatively
after ACL reconstruction that had a scar resection, and we did exclude patients
that had an ACL on the other side.
Just to keep things equal when it comes to range of motion.
And we put them into four categories. And we based these categories off of the
(33:43):
range of motion that they have after their ACL reconstruction and prior to their scar resection.
So category one was those with minimal range of motion loss,
all the way to category four, which
is your more severe cases with pretty extensive range of motion loss.
So category one were patients that had an extension deficit of less than or
equal to 10 degrees, as well as a flexion deficit less than or equal to five
(34:07):
degrees. So pretty minimal on both of those scales.
And then it goes more severe from there. So category two is less than or equal
to 10 degrees of extension, just like the first category.
The difference is these patients have a more than five degree flexion deficit.
And then category three jumps up with the extension deficit as those that are
more than 10 degrees off on their extension, and then a minimal flexion deficit
(34:31):
of less than or equal to 25.
And then category four is going to be the more severe cases.
And those patients have greater than 10 degree extension deficits,
as well as greater than 25 degrees flexion deficits.
And keep in mind with these categories, they are deficits compared to the other side.
As you mentioned, Dr. Benner earlier, that you got to have a goal for these patients.
And the goal, not only in the operating room, preoperatively and postoperatively,
(34:55):
the goal is to have their extension and their flexion equal to the other side.
And if it's seven degrees on the non-involved side.
We want these patients being seven degrees on the involved side postoperatively.
So that is how we categorize these patients. And to round out the methodology for this study,
From an outcome standpoint, we want to look at their preoperative and postoperative
difference in range of motion and see how that compared between these categories
(35:17):
and what their progressions were, as well as having the rate of quote-unquote normal range of motion.
And again, at our office, we consider normal to be within the IKDC objective
form criteria of two degrees or less from an extension deficit standpoint.
And then the last outcome we wanted to look at was the IKDC scores and see if
there were any differences across these categories. worries.
(35:40):
Yeah, that classification system, I think, is really a good one in trying to
separate, is this an extension-only problem? Is this a flexion-only problem?
Is it a flexion and extension problem?
And is it a more severe flexion and extension problem?
And it takes into account not only severity of range of motion loss,
but whether it's an extension or flexion or both.
(36:01):
So again, a classification that helps to facilitate communication and eventually,
hopefully, guide treatment.
Tell us about the results of this study. What did we find?
So first and foremost, we want to look at the frequency distribution of patients
that were normal preoperatively as well as being normal postoperatively.
And this shows pretty drastic differences here.
For the Category 1s, again, these are those patients that have pretty minimal range of motion loss.
(36:25):
We had 82% of these patients preoperatively to have normal extension,
and then postoperatively, they were able to improve
upon that to be 97% of those patients had
normal extension for category two only 48 percent
of patients had normal extension compared to 95 percent after surgery and then
categories three and four none of them had normal extension because their third
(36:47):
category really graduated them out of that that level but then a hundred percent
of these patients uh in groups three and four were able to have normal extension after surgery.
On the extension note, another pretty interesting finding, and one thing that
we really strived to find out with this study was, are there differences in
postoperative extension deficits depending on what your preoperative motion looks like?
(37:12):
And this is really what drove some of the clinical questions before this study
started was, you know, going back to that example we were talking about when
we were covering the background here is a patient that has a pretty severe case.
They have, let's call it a 15-degree flexion contracture. they're really struggling.
This is a pretty life-altering condition for them versus somebody that may only
have a two or three degree flexion contracture,
(37:34):
and they're more of that spongy type that's just springing back and forth,
but it's enough of a deficit to cause them to have some symptoms to the point
where they're going to pursue this scar resection.
So you have a scar resection surgery for patients that are seemingly in two
different buckets here as a category one with minimal range of motion loss preoperatively
compared to the more severe case in a category So we really strive to see,
(37:57):
is there a difference postoperatively between these cases and in a sense between these categories?
And we found from an extension deficit standpoint, there really was not.
So the difference in post-operative extension was not different based on your
pre-operative category, with all four categories having a mean or an average
(38:17):
of zero degrees from an extension standpoint,
meaning that no matter what your deficit was pre-operatively,
post-operatively following your SCAR section.
The average was a zero-degree extension loss, which I think is pretty tremendous
and something that was, in our opinion, a pretty remarkable finding considering
some of the cases we've seen.
Tell us about the subjective scores as well.
(38:38):
This is where this data gets even more interesting, in my opinion.
Yeah, I would agree. When we look at the preoperative scores for the IKDC,
which is the measure that we collected on these patients,
the IKDCs were statistically significantly different preoperatively,
with the worst scores being towards the more severe cases or the higher categories.
(38:59):
For example, preoperatively on the IKDC, Category 1 had an average of 63 compared
to 45 for Category 2, 16 for Category 3, and 32 for Category 4.
So you look at those categories threes and fours, which per our classification
system was greater than 10 degree extension deficit prior to their scar section,
(39:19):
these patients are really struggling.
And not to say that the 45s and the 63s for the categories ones and two are
not struggling either because I really think they are.
But like I said, with these more
extreme cases, it can be pretty life-altering and a score of 16 to 32.
These patients are usually young and healthy patients having an ACL reconstruction,
and then their mobility really takes a big hit when they have an extension deficit
(39:43):
of more than 10 degrees, which is evident as per their low IKDC score preoperatively.
And then postoperatively, there was not a statistically significant difference
between the postoperative IKDC scores across the four groups,
with Category 1 having an average score of 81.
Category 2 also 81, Category 3, 83, and Category 4, 100.
(40:03):
So when you look at the change over time from preoperative to postoperative in terms of
pre-scar resection and post-scar resection, there's some pretty drastic and
pretty, again, talking about life-altering, pretty difference or pretty big
increases in the IKDC scores.
And again, another interesting note from a statistical standpoint is there is
not a statistically significant difference in post-operative scores after surgery,
(40:26):
similar to that of the extension deficit.
So no matter what category you're in pre-operatively before your scar resection,
post-operatively, you're going to be doing the same across the four classifications
when it comes to extension deficit as well as IKDC scores.
I mean, it's really remarkable how bad some of these people are.
And I think the point that you made about the fact that these are mostly young,
(40:47):
healthy people is really an important one.
You know, young, healthy people should have IKDC scores at or very near 100.
And we're talking about some of these people that, you know,
maybe, you know, 18, 19 years old that are reporting knee function scores that
are in the teens or in the 30s versus, you know, where they should be 100.
(41:07):
Hundred. So really, really significant reductions in their overall,
in their overall functional capacity.
And then post-surgery, the interesting thing is no difference in their post-surgical
scores, regardless of which group they were in.
So, you know, whether they had relatively mild degrees of range of motion loss
or more severe degrees of range of motion loss, they, uh, they still got better
(41:27):
and got to about the same, the same level.
The thing that's important to, to realize, and this goes back to that for prevention
piece is that these people, these people get
back to ikdc scores hovering in the
low 80s the type ones and twos average about 81
on the ikdc the type threes are
83 and the type fours even though that we have an
(41:49):
average ikdc score of 100 that's a pretty
small group so in in general the patients end up with about a low 80s ikdc score
and while that's much better than it was pre pre-arthroscopy for arthrofibrosis
it's It's still not as good as these patients would have gotten if they had
just a primary ACL reconstruction and did well.
(42:11):
In that case, they're more like the mid to high 80s, sometimes even into the
90s. So unfortunately, a lot of times we have to counsel these patients.
We can make you better, but we can't necessarily make you as good as we would
have had we not had this complication in the first place.
So I still think that's an important piece of things to realize that the prevention,
(42:31):
you know, an ounce of prevention is worth a pound of cure when it comes to this problem.
That even if we have a good outcome, it would have been better if we can just
prevent this problem from the beginning.
So as we start to wrap up here, Dr. Benner, do you have any final thoughts or
take-home messages for any of the clinicians listening, whether it be orthopedic
surgeons or physical therapists, when it comes to arthroscopics management for
(42:54):
arthrofibrosis after surgery?
Yeah, absolutely. The first one is that just remembering what our goals are.
Our goal is absolutely perfect extension, symmetric to the opposite side,
including hyperextension.
And the uninvolved knee tells us what our goals are when it comes to extension.
Extension secondly we have to get that before surgery we
have to get it during the surgery we have to get it early after the
(43:16):
surgery and late after the surgery we can't ever allow extension range of motion
loss to really creep in and we definitely can't let it get out of hand in the
early time after surgery the next part is if you're seeing these patients in
the post-surgical phase and they've had this complication recognizing the difference
between posterior stretching pain
and anterior impingement pain is a really important one.
(43:39):
Do the physical therapy up until you feel like the posterior pain is resolved
and the anterior impingement becomes the issue.
If that never happens and you get them all the way back to full range of motion, then great.
But if you eventually start to have anterior impingement pain and no progression
with the extension, you think that they have a mechanical block,
get an MRI scan, look and see where that scar tissue is located.
(44:00):
And then if you end up progressing onto surgery, this is an anterior problem.
Make sure that you do both the soft tissue and the bony work to free up the
ACL graft to be able to fit perfectly in the intercondylar notch.
And then from a results standpoint, that unfortunately is as good as we can
make these patients compared to where they were before.
(44:20):
You can never really make them as good as you could had you avoided this complication
from the very beginning.
So always trying to get this thing right from the very beginning.
Excellent. Well, I appreciate you taking the time tonight to go over some of
the details of this condition from the incidents to the causes all the way through
what I thought was really some of the most important aspects of tonight's episode
(44:41):
was the surgical details and what that looked like. So I appreciate you going
over that as well as the study.
So if you want to get in contact with us, we are on all the social media platforms
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Music.
Music.
(00:12):
This is Dr. Benner, and I'm here with Scott Bauman tonight to discuss another
great topic, some more content for those of you out there who want to learn more about knees.
Last week, we talked about early predictors of return to sport after ACL reconstruction.
That was a really good topic, talking about some physical therapy parameters
and some other variables that are at play as athletes get back from ACL reconstruction.
(00:34):
I would encourage you to go check that one out. We have a lot of great content.
We have almost 40 episodes up now. Now, if you'd like to go back and learn from
all of those, make sure you follow to not miss any of our subsequent content.
And if you'd like to leave us a five-star review and some comments for those
that come behind you, we'd appreciate that as well.
You can find us on social media, on our Facebook and YouTube pages,
(00:55):
the Shelburne E-Center Podcast.
You can find us on Twitter and Instagram at the SKC Podcast.
And you can also email us at theskcpodcast at gmail.com.
And tonight's going to be another good episode. We're talking about arthrofibrosis
following ACL reconstruction, and I think this is going to be a good discussion.
We're going to start talking about just generally what arthrofibrosis is,
(01:16):
what causes it, those types of things.
And I think it's going to be important for many different clinicians,
not only the surgeons out there that are operating on this condition,
but the physical therapists that are seeing these patients both before and after
surgery to see what type of results we're getting with this type of surgery in this condition.
And then we're eventually going to get into a project that we worked on,
(01:36):
and it actually is going to be at the AOSSM summer meeting this July in Denver, Colorado.
And those that worked on that were myself and Dr. Benner, along with Bill Klaassen,
physical therapist in our office, and Dr.
Shelbourne. So before we get to that study, Dr.
Benner, I just wanted to have a brief conversation here to start,
just to give some more details on arthrofibrosis, specifically following anterior
(01:57):
cruciate ligament reconstruction in general.
So can you speak to how often you see this, what it presents like in the early
time point after surgery, and maybe your thoughts on what types of things causes this?
Well, I'm fortunate now that I've been able to learn from Dr.
Shelbourne's legacy in treating this condition and ultimately really focusing
on not treating this condition, but how do we avoid this condition?
(02:20):
So luckily, I see this very little in my own practice because we very rarely
have stiffness after ACL surgery,
but we do see a fair amount of revision surgeries or complications from people
who've had surgery elsewhere that have come to see us.
And because of that, I feel like this is something that we're in a unique position
to really make some comments on as Dr.
(02:43):
Shelbourne is an internationally known expert in this condition.
You know, I feel like I've been able to learn a lot from Dr.
Shelbourne as well as his techniques and been able to apply them myself to the
point where I feel like we can get equivalent results regardless of who the surgeon is.
But I can tell you, this is one condition. And when I watched Dr.
Shelbourne do these surgeries where, you know, he's very, very good at this
(03:06):
and something I don't think I'm anywhere near as good at treating surgically as he is.
But more importantly, the concepts that I've been able to learn over the years working with Dr.
Shelbourne about this specific complication after ACL surgery has been really great.
And I feel like we have a unique perspective on this and a setup in our office
(03:27):
that really allows us to prevent this complication from happening and to also
handle it when it pops up. A lot of this goes back to Dr.
Shelbourne's work that he's done for the last 40 years, specifically our longer-term
studies that talk about what factors lead to long-term success and avoidance of failure.
(03:48):
You know, functional problems and also avoidance of arthritis in the long term.
And Dr. Shelbourne and Tinker Gray, who was in Scott's position previously,
have shown over and over and over again the importance of maintaining range
of motion and how much worse you can make somebody if you allow them to get stiff after surgery.
Of course, you know, when we do a surgery for instability, we're going to be
(04:09):
focused on how do we stabilize the knee.
However, what we found over time is that the stability, while it is,
of course, important, is not as important as patients getting full range of
motion back afterwards.
And I think it's become pretty clear that if you have a knee that's relatively
loose after a surgery, but you have full range of motion, you can still have a pretty good outcome.
(04:32):
However, if you have perfect stability and your knee is rock solid stable and
you lose range of motion in the long term, that's probably worse than the loose
knee that you had to begin with.
And so I think just right off the jump here, as we start talking about this,
I think it's important for listeners to go back and review Dr.
Shelbourne's previous literature on factors that make a difference in the long-term
(04:54):
after ACL surgery and review our previous content on this podcast that speak to that specifically,
because that's really the foundation on which we really build avoiding this
complication and treating it once it arises.
I like that you said prevention, and that's something that I really speak to
when I talk about this topic with others, especially physical therapists.
(05:15):
And the question is, well, if you are successfully preventing it,
obviously you don't have this problem, but how do you prevent it?
And that question typically comes up, like I said, especially in the rehab world.
As far as the tips for preventing it, what's your thought on that?
And talking to maybe a group of rehab professionals that are seeing these patients
(05:37):
and hopefully before surgery, but is it as simple as get the motion back before surgery?
And the second question would be, when you're seeing this after surgery,
are you seeing the ones that you always see in case studies where you're seeing
these patients that are 15 degrees short of zero and really a life-altering case?
Or is it sometimes just a two or three degree deficit that may be more symptomatic
(06:00):
than you might think it is?
Well, I think from the very beginning, it's important to understand how debilitating this can be.
And I think that it's also important to understand that strategies for dealing
with arthrofibrosis are far inferior to strategies for preventing arthrofibrosis.
And it's important for the surgeon, it's important for the patient,
(06:20):
and it's important for the physical therapist,
all three of those participants in the, you know, kind of care protocol for
this patient understand that that job of avoiding stiffness begins long before surgery.
This is not a post-surgical complication. This is something that starts to happen
from the very beginning when the patient first gets injured.
(06:44):
I was at a meeting once at the Campbell Clinic where I did my training and one
of our former fellows, I was talking a little bit about stiffness after ACL
surgery and arthrofibrosis.
And he asked the question, well, so, you know, let's say that you've done everything,
everything that you can and it happens anyway.
You know, we all have these patients that, you know, you do everything right
(07:05):
and they still develop stiffness.
So what do you do? So I started talking a little bit about it.
He's like, I know, but let's say you've done everything right and they've had a problem.
Now, what are you going to do about it?
So I had to stop there for a minute. I said, okay, when I say we've done everything
right and you say we've done everything right, I think we have to understand what those things are.
(07:26):
To me, doing everything right means we do not do the surgery until the patient
has full, symmetric, perfect extension to the opposite side.
Until that happens, patient does not get a surgery almost under any circumstances.
Or if they can't get their extension back, then sometimes we've even gone as
far as to to do a scope, to take out the stump, to treat meniscus tears that
(07:48):
may be flipped over in the notch or whatever it is that's keeping the knee from
getting all the way straight.
It's that important that we would even go to the measure of doing a scope to
improve the patient's extension pre-ACL reconstruction to make sure that we
don't have surgery until they're all the way ready.
And then secondly, we have to have them understand, their physical therapist
and the patient, understand that keeping the extension perfect is going to be
(08:11):
a priority throughout the entirety of the process.
We need the surgeon to understand that when we do the surgery,
we have to do it in a way that does not impinge the knee in full extension and
keep it from getting full hyperextension symmetric to the opposite side.
Back. So in the operating room, we have to make sure that we don't impinge upon
the roof of the notch. We don't put the graft to anterior.
(08:34):
We don't put too much graft material in there that it blocks extension in any way.
And then we have to get the knee extension perfect the day of surgery,
the day after surgery, two days after surgery, a week out of surgery,
two weeks out of surgery, and forever more going forward.
We have to do that. So when we talk about what are are all those things that
(08:55):
we have to do? What's doing everything?
Those are the things that it goes into. And if you haven't done all of those
things, if you skipped even one of those steps, then in my opinion,
you're not doing everything to avoid arthrofibrosis.
So that's an important thing to realize.
The other one is what's our goal with extension?
I think people say, well, sometimes I hear people say, well,
it's close and we'll get it over time and it'll come back over time.
(09:19):
And unfortunately, the data doesn't bear that out. The data says that if you
don't get it by the time you're discharged from initial physical therapy,
whether that be six months or a year or however long it is, that it is not coming
back and that that does increase your functional limitations and it does make
it more likely for you to get arthrofibrosis.
I think it's also important to keep in mind what our goals are in that our goal
(09:42):
is the IKDC criteria is what we really use as our guide, as the goalposts on
what we're trying to achieve.
And IKDC criteria says that normal is full symmetric hyperextension,
symmetric to the opposite side with a two-degree or less side-to-side difference.
So if someone has seven degrees of hyperextension on the uninvolved knee and
(10:05):
on the ACL reconstructed knee, they have four degrees of hyperextension.
That patient, in our opinion, has arthrovibrosis. They are not getting full
symmetric perfect extension symmetric to the opposite side. And it's important
to understand that even the minute differences can make a big difference in their outcome later on.
Now, one thing you talked about in there when you're talking about,
(10:26):
you know, kind of covering these incidence rates, if you will,
getting into more of the causes, you mentioned some type of impingement.
When you look at this postoperatively and you see these patients come in,
what's your thought on as to the cause of this?
Is it more of a graft tunnel mismatch and there is some type of physical impingement
or is there some type of overgrowth due to some healing potential of the graft?
(10:51):
And that leads to the second question. And are you seeing these more with patellar
tendongraphs, quad tendongraphs, hamstring grafts? And if you are,
really, what's that reason or what do you think the cause is for this condition?
Well, there's a lot of different factors at play. One of them is just understanding
what our goals are, as I described them before,
and the fact that everybody is educated on what makes the difference on patients
(11:15):
getting their full extension back.
If the patient doesn't understand that they have to get their knee perfectly
straight before surgery, and they have to keep it that way throughout the whole
process if the therapist doesn't understand it, and especially if the surgeon doesn't understand,
because, you know, a lot of us, in my opinion, probably don't understand the
critical importance of full hyperextension symmetric to the opposite side.
And even something as simple as how do you measure range of motion?
(11:38):
You know, I got one time corrected at my fellowship because I was reporting
hyperextension to the degree, and they said, why don't you just look at it in
gradations by five degrees? So someone has hyperextension, say they have five degrees.
I don't want to hear they have one or they have four or they have seven.
And to me, that leads to an illustration of a misunderstanding how important
(12:01):
every degree is and that symmetry is really our goal.
So those are presurgical and education factors.
In surgery, you know, we're big believers that the tibial tunnel has to be placed
in a location where the knee, when put into full hyperextension,
that the tibial tunnel stays posterior to the roof of the intercondylar notch.
(12:24):
And you can see that on x-ray as Blumensat's line, the roof of the intercondylar notch.
So we like to see post-surgically that our tibial tunnel in full hyperextension
is parallel and posterior to Blumensat's line.
That way, We can have a radiographic way to show that we're not causing impingement.
We also check that passively in the operating room.
After we're done with surgery, we extend the knee into full hyperextension,
(12:47):
symmetric to the opposite side, and we watch that the graft fits perfectly in
the intercontinental notch.
And if it doesn't, then we take some bone away, do a notchplasty until it can
allow full hyperextension.
And then post-surgically, it's just about understanding what our goals are.
Again, that the surgeon, the patient, and the physical therapist all understands
(13:07):
that perfect extension is the ultimate goal.
As it relates to graft types, you know, we use patella tendons and the reason
is that we get early bone-to-bone healing so we don't worry as much about fixation
because the healing happens pretty early with patella tendon grafts.
And with that, we don't restrict hyperextension at all in the early time after surgery.
(13:27):
We tension the graft in a way that makes sure that you can get the graft into
full hyperextension without putting too much tension on the graft.
With hamstring grafts, I think there's some concerns with early healing and
with early adequate fixation with hamstring grafts.
And because of that, a lot of times they will tell you to not go into full hyperextension
early on after surgery for fear of stretching out the graft or losing fixation.
(13:51):
And then there's some concern around quadriceps tendon grafts, at least in my opinion.
I saw a study at a meeting last year where they talked about arthrofibrosis
rates with quadriceps tendongraphs are approaching 6% to 7%.
And that, of course, is concerning since we know that that has long-term effects
on function as well as development of arthritis down the road.
(14:15):
So in my opinion, you know, when you can go back to our previous episodes to
hear why I think patella tendongraphs are the best graft, but in my opinion,
those are the best grafts that we can use.
And I think they have some specific advantages in that we can get good early
fixation no problems with impingement due to too much graft material which could
(14:37):
be a problem with quadriceps tendinographs and no early restrictions on full
hyperextension due to fixation like we do have in hamstrings.
So knowing your thoughts on the causes of arthrofibrosis following surgery what
are some of the treatment options that you typically go with when you see these
patients post-operatively?
Well once you identify that a patient has any degree of extension loss I think
(14:59):
it's important to realize this is not a small problem. This is a big problem.
In our office, it's a five-alarm fire if somebody comes in a month after surgery
and they're three degrees off on their extension.
That's a big, big problem, and everybody in the office understands that that can't happen.
So just early recognition and proper
(15:20):
appreciation of the
gravity of that potential problem is a
big early bear is a big barrier in the early time after
surgery when we get these patients further out which is usually
where we get them when we see them from elsewhere by then usually
the patient has pretty is a lot further out from surgery and has had more long-standing
(15:40):
more long-standing problems and in that case we're always starting with non-surgical
treatment it's important to try to control pain in whatever way you need to
or treat pain we don't use Use narcotics usually,
but an anti-inflammatory medicine or steroid dose pack,
something to decrease pain and hopefully...
(16:01):
Relieve some of that pressure in the front of the knee in order to get things
under control, allow them to tolerate physical therapy.
And another important thing early on is to recognize symptomatically the differences
in posterior stretching pain versus anterior impingement type pain.
Pain in the back of the knee with arthrofibrosis is usually related to hamstring
(16:24):
and posterior capsular tightness versus anterior pain and a feeling of impingement
in full extension is usually due to the graft actually impinging the roof of
the intercontinental notch and having too much soft tissue on the front of the graft,
something like a cyclops lesion, for example, or fat pad fibrosis from the passage
of instruments with arthroscopic technique that then adheres the fat pad to
(16:48):
the soft tissues in front of the ACL.
So it's important to know the difference between those. The
posterior pain that happens with hamstring tightness and posterior your capsular
tightness usually will resolve or at least improve significantly with extension
stretching versus if the patient hurts anteriorly and feels pinching in the
(17:09):
front of the knee when they fully extend the knee.
Unfortunately, a lot of times you won't be able to smash that down enough in
order to be able to get the patient out to full extension.
So when a patient comes in with mostly posterior pain and stiffness,
then I feel like the early time period is really focused on And can we get their
pain under control and make them more comfortable?
And then can we do some physical therapy for posterior capsular and hamstring stretching?
(17:33):
Eventually, they may get to the point where they say the posterior tightness
resolved as their extension improved, but now they've kind of plateaued where
they're no longer getting improvements and now they feel that anterior impingement type pain.
That's where we think that we may need to intervene surgically when they have
anterior pain limiting extension.
(17:55):
Attention. Now, going back to the
acute phase, and you talked about the difference between when you or Dr.
Shelburne's operating on these patients and how we see them in our office versus
seeing somebody that's more in the chronic stage, and they say,
I had surgery six, eight months ago, and I've been stiff since day one.
You talked about it being a five-alarm fire, and everybody needs to be on the
same page to recognize the problem in order to properly treat the problem.
(18:17):
When would you say that starts to be a concern to the point where maybe we need
to get this patient in more often to really get on top of this knee extension deficit?
And second question, but still dealing with the timeframe is when do you decide it's too late now?
We need to start talking about either changing the course of treatment or we
need to start looking at surgical interventions for the extension deficit.
(18:40):
So what are those timeframes for both of those examples?
I'd say by the two-week visit, if they come in at two weeks and they don't have
full extension symmetric to the opposite side, we're already thinking this is a big problem.
And especially if we get out to the one-month visit and the patient doesn't
have full symmetric extension, now we're really starting to think this is an issue.
And those are some times where we will increase the frequency of therapy visits
(19:04):
just to lay eyes on them a little bit more and have the therapist working on
them a little more hands-on in a little more hands-on fashion.
You know, as far as when it's too late and when we start to think about surgical
intervention, I don't actually think there's a specific timeframe in which I
would say, if it's not better by this time, then you got to move on.
(19:24):
I think that's more about progression and less about specific criteria and time.
That if a patient is, you know, four months out from surgery and they have a
10 degree flexion contracture and they come in at six months and their flexion
contracture has gone from 10 degrees to four degrees,
I don't think that necessarily means we have to intervene as long as we've seen progression.
(19:47):
So if their flexion contraction has gone from 12 degrees to nine degrees to
six degrees to four degrees to two degrees,
then I think visit over visit, then I think we need to keep going versus if
they have 15 degree extension loss and it goes from 15 to 12 and the next visit
they're at 12 degrees loss and the next visit they're at 12 degrees loss and
(20:09):
the next visit that they're at 12 degrees loss,
eventually you have to figure out we're not progressing and things are in a
bad place and they're not getting better.
One more question on this acute phase. I've had patients over the years where,
and I think arthrofibrosis can feel different.
If you have somebody, let's say in subacute or even chronic phase where maybe
they're only five degrees off, some patients come in and they're five degrees
(20:32):
off and you put them in some extension devices,
you really work diligently on maximizing their extension and you can get it
and then they come back and they're still four degrees off.
You can get it on the table and at the end of the session, you say,
yeah, I did a great job. They have full extension. They come back and they're stiff again. in.
And you take that and you compare it and contrast it to somebody else who has
a five degree extension loss.
And some of those just come to a hard stop. And the infield of terminal extension,
(20:56):
and let's call terminal extension five degrees off, for the first person I talked
about, I always describe it as kind of a spongy or springy feeling where you
can get it there, but just kind of pops back and forth versus that person that
really comes to a hard stop.
Is there a difference between those from an anatomy standpoint or a physiologic
standpoint, Or is that just person-to-person differences in how their infields are?
(21:17):
Yeah, I don't know that it's necessarily an anatomic or structural problem that's different.
I just think that it's important to understand that those situations both happen.
That if you say, you know, this patient came in with a six-degree flexion fracture
and they're just not budging at all,
then that's probably something we need to get an MRI scan, look for impingement,
(21:40):
soft tissue in front of the graft,
et cetera, versus I think sometimes if somebody has a six degree flexion contracture
and you push them down and they can get to one degree contracture,
then the next time they come in six degrees, you can get them to two,
six degrees, you can get them to two, six degrees, you can get them to one.
I think it's important to understand, even though those may seem like they're
different from a progression standpoint, that the problem is likely the same.
(22:04):
And really both those, those are just, you know, a little bit different different
presentations of essentially the same entity.
That something's up in the front of the knee that's keeping the knee from going
all the way straight and staying there.
So take that same example we were just talking about, five or six degree flexion
contracture, you start being concerned about it at the two-week point.
(22:24):
At the four-week point, you start making some more decisions.
When does the imaging come into play? Is that something you're going to order
around that time? And if so, what type of imaging are you getting on these patients.
From an imaging perspective, anytime somebody comes to see us with arthrofibrosis
that's in surgery that's done elsewhere, we always get just standard x-rays, bilateral PA view,
lateral views, and a merchant's view just to get kind of a general screening
(22:49):
type x-ray series of the patient.
Four that we give on pretty much all knee problems. But we also get an extension lateral view.
We ask the patient to fully contract their quad, extend their knee as far as
they can, and then we take a lateral view in that position.
In that position, we want to see the tibial tunnel be parallel and posterior to Blumensat's line.
(23:09):
And if with the knee in full hyperextension, the tibial tunnel is anterior to
that line, then that probably is telling us that that the ACL graft is impinging
on the roof of the endocrine of the notch in full extension,
and that that's probably blocking things from moving forward.
If we don't see that on regular x-ray, then we have to move on to some advanced
imaging, and MRI scans are really the best that we have.
(23:31):
They're looking for a cyclops lesion, some soft tissue in front of the main
portion of the ACL graft that when the knee is fully extended is going to impinge
upon the roof of the endocrine of the notch.
The other thing that we've seen a lot of is a lot of fat pad scarring and just
thick cords of scarring going from the fat pad all the way into the anterior
(23:51):
portion of the ACL graft.
And this can really tether the fat pad and because of that cause range of motion
loss by that fat pad really getting stuck down.
And in our opinion, the arthroscopic technique is worse for this than open technique.
I know people think open technique is old school and archaic and things like that,
(24:11):
but by opening up the knee to do the ACL surgery and sewing it back together
pretty gently, I think we are able to avoid a lot of that fat pad scarring versus
when you do arthroscopic technique.
A lot of times you're passing sharp instruments back and forth repeatedly through
those arthroscopic portals,
(24:32):
and we can really see some pretty profound scarring of the fat pad into the
front of the intercontinental notch, into the front of the ACL.
So we usually start with plain x-rays and then moving on to MRI scan as needed
to look for any kind of impinging soft tissues up in the front of the knee.
So now when you have these patients, you get the imaging done and you decide
that a surgical intervention is going to be the best course of action for this particular patient.
(24:56):
What's your surgical plan and what are you seeing intraoperatively and how does that go?
So surgically, there's a question in the literature, if you read about this,
on whether this is an anterior problem or a posterior problem or both.
And I think it was Dick Steadman in the past that's talked about anterior interval
release, trying to release that anterior scarring to the front of the ACL graft
(25:22):
and trying to free things up that way.
And then I've read other things about people making posterior portals,
removing scar from the posterior compartment, maybe even releasing the hamstrings
in severe cases, things like that.
In our hands, that has not been necessary.
We believe this is an all anterior problem, that the posterior problems will
(25:43):
stretch out with physical therapy versus the anterior impingement and, you know.
The mechanical block that we have for the knee getting into full extension is
not something that will get better with physical therapy.
So if we've had the patient make initial progress and it eventually develops
anterior pain that's not getting better, then we go on to an MRI scan,
we find some scarring in the front of the knee, and we choose to go ahead with surgery.
(26:06):
A couple of technical pearls on this. We usually make our portals a little bit wider.
The scar can be a little bit further, not just in front of the intercontinental
notch, but also from the anterior horn of the medial and lateral menisci where
the anterior horns insert.
It can really spread that entire anterior portion of the knee.
So we'll kind of get down on, and once we've made those portals,
(26:28):
a medial and a lateral portal that are wider than average, then we'll try to
get to the front of one meniscus.
Now, I guess it doesn't really matter either side, but either one.
Get on the front of the meniscus and get into the scar tissue and take that
down all the way to the attachment of the anterior horn of the meniscus and
find the tibia in the front.
I think that's an important thing to do is get through that soft tissue all
(26:52):
the way down onto the tibia at the level of either the anterior attachment of
the medial or the lateral meniscus.
And then once you do that, then you kind of start to work your way along the
tibia over to the opposite side until you reach the anterior horn of the other meniscus.
And that kind of develops a plane between the back of the fat pad and the tibia
(27:13):
and the soft tissues that are on the front of the ACL.
And then once we do that, then we start staying along the tibia and moving further
posterior until we get to the anterior portion of the ACL graft.
This is where it gets, for me, it gets really difficult and pretty nervy,
is when then you have to come kind of, once you get underneath all the way up
to the front of the ACL graft, Now you can't keep going any further posteriorly
(27:36):
or you'll be getting into your ACL graft.
So now you have to get up on top of the ACL where there's with a bunch of soft
tissue stuck to the front of it.
And we use an arthrocare wand for this as opposed to a shaver just because it
allows us to develop those planes a little more cleanly and it doesn't generate
as much debris, things like that.
So that's when we start to take that arthrocare wand and start going through
(27:57):
soft tissue on the front of the ACL until you start to see ACL fibers and then you got to stop.
And that's where I get nervous and I've seen Shelbourne do this
a lot and he's peeling away and he's he's going going away
at the at this soft tissue in the front of the ACL and I'm
in the back watching biting my fingernails because I'm worried that we're going
to get into the ACL graft but once you find the front of the ACL graft then
(28:18):
you're starting to peel that stuff away from the front of the ACL until you
get down to the tibia so now you develop those medial lateral planes you take
it all the way across the front and separate it from the fat pad and then you get in front of the ACL,
take that all the way down to tibia and then you're kind of isolated this soft
tissue in the front of the knee.
And then you can either take the ArthroCare wand and smaller lesions and just...
(28:40):
Kind of burn through all that all the way down to the tibia as it all kind of
evaporates and goes away.
Or you can actually try to remove it in mass as almost like a loose body removal
and remove it from the front of the ACL.
That's the soft tissue portion. So once you've done that, hopefully before you
started, you extended the knee fully to see where the ACL or the soft tissue
(29:04):
on the front of the ACL impinges upon the intercondylar notch and that you get
all that soft tissue away,
and then you extend the knee again to see if the ACL is fitting up into the
roof of the intercondylar notch.
Sometimes you do even have to peel a few fibers of the anterior portion of the ACL away.
Now, does that put your ACL graft at risk? Of course it does.
However, if the ACL graft is impinging in full extension, you know,
(29:27):
as we've talked about before, having an ACL graft that impinges an extension
resulting in extension loss is a bad long-term prognosis.
So if that's what it takes to take even just a little bit of the anterior fibers of the ACL,
then i then i think that's something that probably needs to be done the
next thing you have to do is to assess whether or
not there's any bony impingement from the intercondylar notch
(29:48):
so a lot of times you can actually see a color change between the edge of the
native intercondylar notch where it's kind of glistening white cartilage and
then the osteophytes or kind of bony overgrowth that will that will be kind
of overhanging the wall of the intercondylar notch sometimes it'll It'll be
a little pinkish, like an osteophyte.
And sometimes you do have to do some bony work as well.
(30:09):
Some people use a burr for this. We like to use a small osteotome.
You just really can get a sharp edge.
And, you know, so you're not, you know, buzzing away, you know,
cell layer by cell layer, just trimming away a little bit of bone at a time.
You can put that osteotome, just a skinny one through an arthroscopic portal,
get right on the edge of the bone that you want to take off,
give it a little bit of a tap, move down a little bit, give it a little bit
(30:31):
of a tap and remove it as one big piece.
Rather than shaving away a little bit at a time. And then again,
reassessing as you take more and more bone away until the ACO graft fits perfectly
into the intercondylar notch with the knee into full hyperextension.
And then another thing is you got to realize this is not a short surgery.
You know, I watched Dr. Shelbourne do, you know, medial meniscectomies and the
(30:52):
tourniquet times, you know, 14 minutes, you know, it's pretty,
pretty fast or sometimes even less.
With arthrofibrosis cases, sometimes even though it's a knee scope,
there can be tourniquet times reaching 45 minutes,
60 minutes, 70 minutes of meticulously getting this soft tissue out of the front
of the knee, off the front of the ACO graft,
(31:13):
removing it completely from anterior horn of one meniscus to the other,
and then also going away and removing some bone until you're,
and you do not leave the operating room until you have the knee into full hyperextension
without impingement in the front of the knee.
Well, as you had mentioned, this is something that especially Dr.
Shelburne has seen for a long time now and seen a high volume of them.
(31:34):
And at one point, he decided to classify these patients into certain categories.
So can you touch on that a little bit in terms of how you classify these patients post-operatively?
A quick word about classification systems. I think everybody wants to have their
name on a classification system of whatever that That is, whether it's the Schatzer
(31:56):
classification or the, you know, the Loggie Hansen classification for ankle fractures, et cetera.
We have all these classification systems, but it's important to keep in mind
what these classification systems can really do.
They can really facilitate communication is a big part of it.
And they can also help to guide research into these topics and give us a way
(32:17):
of separating them as we study them.
And then also, hopefully, if you have a good classification system,
it can guide your ultimate treatment patterns.
And we kind of touched on this in a, you know, you mentioned earlier a research
study that we are going to be presenting at the AOSSM annual meeting in Denver this summer.
So let's just get right into that. This study is called Results Following Arthroscopic
(32:38):
Scar Resection for Arthrofibrosis Post-Anterior Cruciate Ligament Reconstruction.
And the lead author on that is Bill Clausen, one of the therapists from our office.
Scott is a, Scott Bauman, who's on the podcast with me here,
is an author on that as well, as well as Dr. Don Shelbourne and myself.
So Scott, kind of lead into, I guess we've already done a lot of introduction
(32:58):
on this, so tell us a little bit about the classification system and how that
leads into the methods of this study.
Yeah, as you mentioned, we kind of hit the background already,
and the purpose was to just do that, was to define certain categories and see
about a classification system for these patients after surgery.
And then second step of this study was to take that classification system and
(33:21):
then look at their postoperative outcomes as it pertains to range of motion
and subjective scoring.
So what we did was we ended up with 166 patients that we've seen postoperatively
after ACL reconstruction that had a scar resection, and we did exclude patients
that had an ACL on the other side.
Just to keep things equal when it comes to range of motion.
And we put them into four categories. And we based these categories off of the
(33:43):
range of motion that they have after their ACL reconstruction and prior to their scar resection.
So category one was those with minimal range of motion loss,
all the way to category four, which
is your more severe cases with pretty extensive range of motion loss.
So category one were patients that had an extension deficit of less than or
equal to 10 degrees, as well as a flexion deficit less than or equal to five
(34:07):
degrees. So pretty minimal on both of those scales.
And then it goes more severe from there. So category two is less than or equal
to 10 degrees of extension, just like the first category.
The difference is these patients have a more than five degree flexion deficit.
And then category three jumps up with the extension deficit as those that are
more than 10 degrees off on their extension, and then a minimal flexion deficit
(34:31):
of less than or equal to 25.
And then category four is going to be the more severe cases.
And those patients have greater than 10 degree extension deficits,
as well as greater than 25 degrees flexion deficits.
And keep in mind with these categories, they are deficits compared to the other side.
As you mentioned, Dr. Benner earlier, that you got to have a goal for these patients.
And the goal, not only in the operating room, preoperatively and postoperatively,
(34:55):
the goal is to have their extension and their flexion equal to the other side.
And if it's seven degrees on the non-involved side.
We want these patients being seven degrees on the involved side postoperatively.
So that is how we categorize these patients. And to round out the methodology for this study,
From an outcome standpoint, we want to look at their preoperative and postoperative
difference in range of motion and see how that compared between these categories
(35:17):
and what their progressions were, as well as having the rate of quote-unquote normal range of motion.
And again, at our office, we consider normal to be within the IKDC objective
form criteria of two degrees or less from an extension deficit standpoint.
And then the last outcome we wanted to look at was the IKDC scores and see if
there were any differences across these categories. worries.
(35:40):
Yeah, that classification system, I think, is really a good one in trying to
separate, is this an extension-only problem? Is this a flexion-only problem?
Is it a flexion and extension problem?
And is it a more severe flexion and extension problem?
And it takes into account not only severity of range of motion loss,
but whether it's an extension or flexion or both.
(36:01):
So again, a classification that helps to facilitate communication and eventually,
hopefully, guide treatment.
Tell us about the results of this study. What did we find?
So first and foremost, we want to look at the frequency distribution of patients
that were normal preoperatively as well as being normal postoperatively.
And this shows pretty drastic differences here.
For the Category 1s, again, these are those patients that have pretty minimal range of motion loss.
(36:25):
We had 82% of these patients preoperatively to have normal extension,
and then postoperatively, they were able to improve
upon that to be 97% of those patients had
normal extension for category two only 48 percent
of patients had normal extension compared to 95 percent after surgery and then
categories three and four none of them had normal extension because their third
(36:47):
category really graduated them out of that that level but then a hundred percent
of these patients uh in groups three and four were able to have normal extension after surgery.
On the extension note, another pretty interesting finding, and one thing that
we really strived to find out with this study was, are there differences in
postoperative extension deficits depending on what your preoperative motion looks like?
(37:12):
And this is really what drove some of the clinical questions before this study
started was, you know, going back to that example we were talking about when
we were covering the background here is a patient that has a pretty severe case.
They have, let's call it a 15-degree flexion contracture. they're really struggling.
This is a pretty life-altering condition for them versus somebody that may only
have a two or three degree flexion contracture,
(37:34):
and they're more of that spongy type that's just springing back and forth,
but it's enough of a deficit to cause them to have some symptoms to the point
where they're going to pursue this scar resection.
So you have a scar resection surgery for patients that are seemingly in two
different buckets here as a category one with minimal range of motion loss preoperatively
compared to the more severe case in a category So we really strive to see,
(37:57):
is there a difference postoperatively between these cases and in a sense between these categories?
And we found from an extension deficit standpoint, there really was not.
So the difference in post-operative extension was not different based on your
pre-operative category, with all four categories having a mean or an average
(38:17):
of zero degrees from an extension standpoint,
meaning that no matter what your deficit was pre-operatively,
post-operatively following your SCAR section.
The average was a zero-degree extension loss, which I think is pretty tremendous
and something that was, in our opinion, a pretty remarkable finding considering
some of the cases we've seen.
Tell us about the subjective scores as well.
(38:38):
This is where this data gets even more interesting, in my opinion.
Yeah, I would agree. When we look at the preoperative scores for the IKDC,
which is the measure that we collected on these patients,
the IKDCs were statistically significantly different preoperatively,
with the worst scores being towards the more severe cases or the higher categories.
(38:59):
For example, preoperatively on the IKDC, Category 1 had an average of 63 compared
to 45 for Category 2, 16 for Category 3, and 32 for Category 4.
So you look at those categories threes and fours, which per our classification
system was greater than 10 degree extension deficit prior to their scar section,
(39:19):
these patients are really struggling.
And not to say that the 45s and the 63s for the categories ones and two are
not struggling either because I really think they are.
But like I said, with these more
extreme cases, it can be pretty life-altering and a score of 16 to 32.
These patients are usually young and healthy patients having an ACL reconstruction,
and then their mobility really takes a big hit when they have an extension deficit
(39:43):
of more than 10 degrees, which is evident as per their low IKDC score preoperatively.
And then postoperatively, there was not a statistically significant difference
between the postoperative IKDC scores across the four groups,
with Category 1 having an average score of 81.
Category 2 also 81, Category 3, 83, and Category 4, 100.
(40:03):
So when you look at the change over time from preoperative to postoperative in terms of
pre-scar resection and post-scar resection, there's some pretty drastic and
pretty, again, talking about life-altering, pretty difference or pretty big
increases in the IKDC scores.
And again, another interesting note from a statistical standpoint is there is
not a statistically significant difference in post-operative scores after surgery,
(40:26):
similar to that of the extension deficit.
So no matter what category you're in pre-operatively before your scar resection,
post-operatively, you're going to be doing the same across the four classifications
when it comes to extension deficit as well as IKDC scores.
I mean, it's really remarkable how bad some of these people are.
And I think the point that you made about the fact that these are mostly young,
(40:47):
healthy people is really an important one.
You know, young, healthy people should have IKDC scores at or very near 100.
And we're talking about some of these people that, you know,
maybe, you know, 18, 19 years old that are reporting knee function scores that
are in the teens or in the 30s versus, you know, where they should be 100.
(41:07):
Hundred. So really, really significant reductions in their overall,
in their overall functional capacity.
And then post-surgery, the interesting thing is no difference in their post-surgical
scores, regardless of which group they were in.
So, you know, whether they had relatively mild degrees of range of motion loss
or more severe degrees of range of motion loss, they, uh, they still got better
(41:27):
and got to about the same, the same level.
The thing that's important to, to realize, and this goes back to that for prevention
piece is that these people, these people get
back to ikdc scores hovering in the
low 80s the type ones and twos average about 81
on the ikdc the type threes are
83 and the type fours even though that we have an
(41:49):
average ikdc score of 100 that's a pretty
small group so in in general the patients end up with about a low 80s ikdc score
and while that's much better than it was pre pre-arthroscopy for arthrofibrosis
it's It's still not as good as these patients would have gotten if they had
just a primary ACL reconstruction and did well.
(42:11):
In that case, they're more like the mid to high 80s, sometimes even into the
90s. So unfortunately, a lot of times we have to counsel these patients.
We can make you better, but we can't necessarily make you as good as we would
have had we not had this complication in the first place.
So I still think that's an important piece of things to realize that the prevention,
(42:31):
you know, an ounce of prevention is worth a pound of cure when it comes to this problem.
That even if we have a good outcome, it would have been better if we can just
prevent this problem from the beginning.
So as we start to wrap up here, Dr. Benner, do you have any final thoughts or
take-home messages for any of the clinicians listening, whether it be orthopedic
surgeons or physical therapists, when it comes to arthroscopics management for
(42:54):
arthrofibrosis after surgery?
Yeah, absolutely. The first one is that just remembering what our goals are.
Our goal is absolutely perfect extension, symmetric to the opposite side,
including hyperextension.
And the uninvolved knee tells us what our goals are when it comes to extension.
Extension secondly we have to get that before surgery we
have to get it during the surgery we have to get it early after the
(43:16):
surgery and late after the surgery we can't ever allow extension range of motion
loss to really creep in and we definitely can't let it get out of hand in the
early time after surgery the next part is if you're seeing these patients in
the post-surgical phase and they've had this complication recognizing the difference
between posterior stretching pain
and anterior impingement pain is a really important one.
(43:39):
Do the physical therapy up until you feel like the posterior pain is resolved
and the anterior impingement becomes the issue.
If that never happens and you get them all the way back to full range of motion, then great.
But if you eventually start to have anterior impingement pain and no progression
with the extension, you think that they have a mechanical block,
get an MRI scan, look and see where that scar tissue is located.
(44:00):
And then if you end up progressing onto surgery, this is an anterior problem.
Make sure that you do both the soft tissue and the bony work to free up the
ACL graft to be able to fit perfectly in the intercondylar notch.
And then from a results standpoint, that unfortunately is as good as we can
make these patients compared to where they were before.
(44:20):
You can never really make them as good as you could had you avoided this complication
from the very beginning.
So always trying to get this thing right from the very beginning.
Excellent. Well, I appreciate you taking the time tonight to go over some of
the details of this condition from the incidents to the causes all the way through
what I thought was really some of the most important aspects of tonight's episode
(44:41):
was the surgical details and what that looked like. So I appreciate you going
over that as well as the study.
So if you want to get in contact with us, we are on all the social media platforms
on Twitter and Instagram at the SKC podcast.
You can visit the SKC podcast, YouTube or Facebook pages, or you can email us
at the SKC podcast at gmail.com and we will see you.
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