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Manipulation under anesthesia, lysis of adhesions found effective for arthrofibrosis after trochleoplasty
According to recently published results, manipulation under anesthesia with lysis of adhesions is an effective procedure for patients with arthrofibrosis after sulcus-deepening trochleoplasty.
Researchers identified 62 knees with severe trochlear dysplasia that underwent sulcus-deepening trochleoplasty. The mean follow-up was 32.5 months. Medial patellofemoral ligament reconstruction, lateral retinacular release and tibial tubercle osteotomy were among the concomitant procedures. During the physical examination, investigators collected range of motion outcomes and recurrent patellar instability findings. The primary outcome of the study was range of motion (ROM) after the initial procedure and after manipulation under anesthesia or manipulation under anesthesia with lysis of adhesions.
“Arthrofibrosis was defined as active and passive flexion less than 90° within 3 months of surgery combined with a plateau in progress with physical therapy,” the researchers wrote.
Results showed arthrofibrosis as a complication in 11 patients. These patients underwent manipulation under anesthesia within 3 months of their initial surgery.
Of the 11 patients, nine patients subsequently underwent arthroscopic lysis of adhesions after manipulation under anesthesia. Manipulation alone was not enough for these patients to achieve acceptable ROM. Compared with those without arthrofibrosis, patients with arthrofibrosis had a mean pre-manipulation ROM that was significantly different (133.3° vs. 77.3°, respectively ). Postoperative ROM significantly increased after manipulation under anesthesia and/or lysis of adhesions in patients with arthrofibrosis compared with preoperative ROM (127.3° vs. 77.3°).
The ROM was not significantly different between patients with arthrofibrosis compared to those without it after manipulation under anesthesia with lysis of adhesions (127.3° vs. 133.3°). At the subsequent follow-ups, there were no complications seen after manipulation under anesthesia or lysis of adhesions. – by Monica Jaramillo
Disclosures: Carstensen reports no relevant financial disclosures. Please see the study for a list of all other authors’ relevant financial disclosures.
Perspective
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Sulcus-deepening trochleoplasty is a technically demanding and effective surgical procedure for patella instability caused by severe trochlear dysplasia and can result in complications including arthrofibrosis. Diduch and colleagues report that 11 out of 62 knees treated with trochleoplasty developed arthrofibrosis with an average range of motion (ROM) of 77.3o. They were able to be successfully treated with manipulation and lysis of adhesions to achieve a mean postoperative ROM of 127.3o with comparable functional outcome to the other trochleoplasty patients. Interestingly, the rate of arthrofibrosis in patients with therapy delayed by 2 weeks was 34.6% compared to the 5.6% rate in the group that had therapy initiated within 3 days.
Our preference for early motion after trochleoplasty is consistent with these findings, and we and other groups have had minimal issues with arthrofibrosis. One limitation of this study is that although no patient experienced recurrent instability, the length of follow-up was relatively short and variable ( 32.5+19.3 months), and so conclusions about outcomes are very limited. Additionally, other complications were not reported in this paper, so it is unclear if early motion resulted in other issues (for example, with osteochondral flap healing).
In conclusion, trochleoplasty remains a technically demanding procedure, but the rate of arthrofibrosis can be decreased by early motion. This and other complications will need to be better understood.
University Health System
Evanston, Illinois
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