DISCLOSURES 3/13/2018. Arthrofibrosis

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1 Center for Cartilage Repair and Arthrofibrosis Christian Lattermann, MD Professor for Orthopaedics and Sports Medicine Vice Chair for Clinical Research Director: Clinical Co-Director: Sports Medicine Research Institute Head Team Physician Eastern Kentucky University Team Physician Center for Cartilage Repair and DISCLOSURES Industry: Vericel: Consultant Cartiheal: Consultant Flexion Therapeutics: Consultant(payments to institution) Smith&Nephew : Institutional Support Current Grant Support: NIH-NIAMS: 1K23AR A1 ( ) Arthritis Foundation ( ) Editorial Board Memberships: Cartilage Journal of Sports Rehabilitation Orthopaedic Journal of Sports Medicine Reviewer for Journals: AJSM, CORR,JKS, O&C, Orthopaedics, OJSM, Cartilage Patents: 09/561,524 ;PCT/EP98/06849 A little background about arthrofibrosis Primary Arthrofibrosis: wound healing aberration MHC Class II fibroblasts are increased Overexpression of Collagen Type IV and VI Overexpression of TGF β 1 and other inflammatory cytokines Overexpression of myofibroblasts (Bosch U, Orthopäde 2002) May be a genetic error of wound healing (Ries MD, CORR 2000) Mast cell overexpression (Monument MJ, JBJS 2010) 1

2 A little more background about arthrofibrosis Secondary Arthrofibrosis: technical issues: Cyclops : misplaced ligament attachments, Meniscus transplant, MPFL malpositioning etc. Extensive post operative hematoma Underrehabilitation : fear of movement Pain control issues Regional pain syndrome or formerly RSD A little more background about arthrofibrosis Primary Arthrofibrosis: possible genetic aspect: Increased incidence of arthrofibrosis in TKA in specific subpopulations Not preventable? wound healing aberration MHC Class II (antigen presenting) fibroblasts are increased Overexpression of Collegen IV and VI Overexpression of TGF β 1 Overexpression of myofibroblasts Secondary Arthrofibrosis: technical issues: misplaced ACL, LCL, Meniscus transplant Extensive post operative hematoma preventable? underrehabilitation : fear of movement Pain control issues Regional pain syndrome or formerly RSD Pre operative Prevention A stiff knee needs to be rehabbed or released prior to any reconstructive/restorative procedure assess pre operative quadriceps strength Rule out pre operative RSD Caveat: extreme tenderness, hair loss, hyperaemia Keep in mind, depending on your practice you may encounter this patient more frequently than the average orthopaedic surgeon 2

3 Intra operative Prevention Love the soft tissues : Reduce bleeding Avoid unnecessary exposure of tissue layers Expose and repair layers anatomically Inflammatory mediators => Try to minimize the soft tissue trauma There is something to be said for minimally invasive surgery Tourniquet use: Quadriceps Post operative bleeding Post operative Prevention (early phase) Patient participation and understanding is key: Try to mobilize early and often CPM Bicycle Early PT Patella mobilization NSAIDS kneeguru Post operative Prevention (late phase) mechanical: Extension: Extension board Prone hangs Quad e stim Dynamic extension splinting Todd Jones Youtube Flexion: Rolling chair Side hangs Flexionator Medical: Medrol Dose Pack B.R. Bach person comm. 3

4 Find the reason(s) for arthrofibrosis: Extension: Anterior adhesions Cyclops Recessi Posterior capsule Flexion: Suprapatellar pouch Recessi Muscular Fat pad contraction Patella baja Patella tendon contracture When does surgery come into play? Indication: If less than 120 at 8 weeks If lacking >5 at 4 6 weeks Manipulation under anaesthesia: Excellent for flexion deficits Not sufficient for flexion contractures Manipulation and Arthroscopic release : Anterior recess release Submuscular release of rectus femoris Open release MUA and arthroscopic release: Typically between 6 8 weeks after original procedure if extension loss >10 or flexion < 120 Manipulation under anaesthesia: short lever arms in my experience very effective for muscular stiffness early adhesions Very effective for lack of flexion and early extension deficits Combine with peripheral block and in house CPM and rehab for 1 2 days or immediate outpatient rehab 4 5x/week 4

5 Open release: Usually for significant extension deficits (>15 20 degrees) Combined arthroscopic and open procedure Technique as described by Lobenhoffer et al: (Lobenhoffer HP et al. KSSTA 1996) Only if still difficulty with extension use drop out cast (watch heel sores!) After surgical arthrolysis: Usually use block (saphenus nerve and popliteal) and retain catheter for hours Use CPM and extension board for the next 2 7 days round the clock Discharge to home once pain under control with sufficient oral pain meds Once discharged PT 4 5x/week for 1 2 weeks See in office or during PT frequently Other interesting ideas: Mast cell inhibitors: The blockade of mast cells reduced the development of post operative stiffness significantly in a rabbit knee stiffness model as well as in other animal models of tissue fibrosis. Mast cells facilitate hypoxia driven fibrosis and tissue metaplasia and go along with increased neuropeptide expression: (Hildebrand KA, JOR 2008) Mast cell inhibitors (Ketotifen) are FDA aproved for the treatment of urtikaria and severe Asthma 5

6 Other interesting ideas: IL 1 blockers: IL 1 receptor antogonist protein (IRAP) can mitigate the IL 1 driven inflammatory response after injury 4 patients with arthrofibrosis showed significant improvement in pain, swelling and ROM after 2 doses of Kineret (150mg) intraarticularly (Birmingham JD, Proceedings Am Col Rheumat, Ann Meeting 2006) What results can we expect? Arthroscopic release: 68 patients with Grade 3 arthrofibrosis undergoing arthroscopic release 90% improved ROM (mean: 48 ) and KOOS pain significantly. (Kim et al, KSRR 2013) 33 patients undergoing arthroscopic release and extension therapy 27/33 normal extension 14/33 normal flexion Improvement of IKDC from 45 to 67 at 14 months Patients with normal extension significantly more likely to have higher IKDC scores (Biggs Kinzer A, Sports Health 2010) What results can we expect? Total knee literature 145/1973 TKA diagnosed with arthrofibrosis and treated with MUA alone Average loss of flexion compared to uncomplicated TKA 11 (114 vs 125 ) (Issa K, J Arthroplasty 2014) 1344 procedures (TKA, revision knee surgery and ligament surgeries) 4.5%, 5.1% and 1.3% with loss of flexion Delayed versus early manipulation was not different Multiple surgeries are risk factor for worse outcomes (Ipach I, Orthop Traumatol Surg Res. 2011) 6

7 Pearls: Keep your friends close but your stiff knees closer i.e. follow up with these patients very frequently This can happen again, believe me! If you do an arthroscopic release close the portals with nylon to prevent fistulas Summary and take home: Arthrofibrosis may be technique related but may also be a disease identify the problem patient Have a very low threshold to use adjunct therapies (mechanical stretching, short term oral steroids) be aggressive with ROM for all large arthrotomies Prevention, prevention prevention When the knee is stiff MUA with scope is effective but may require open for high grade flexion contractures 7