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ILL Document Delive: REG-14365762 BRXBIR NLM -- W1 JO9O7XCK (Gen) Bireme Organizacac Pan Americana Da Saude Rua Botucatu 862 - Vila Clementino Sao Paulo 4023-901 BRAZIL ATIN: SUBMITTED: 2008-03-19 08:44:14 PHONE: 011-5S-11-5576-9835 PRINTED: 2008-03-19 11:57:33 FAX: 011-55-11-5571-1919 REQUEST NO REG- 14365762 E-MAIL: SENT VIA: DOCLINE DOCLINE NO 24510197 REG. Copy Journal TITLE JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS PUBLISHER/PLACE American Academy of Orthopaedic Surgeons Rosemont, IL : VOLUME/ ISSUE PAGES: 2007 Nov; 15(11):682-94 682-94 DATE: 2007 AUTHOR OF ARTICLE Magit D;Wolff A;Sutton K:Medvecky M TITLE OF ARTICLI ARTHROFIBROSIS OF THE KNEE. ISSN: 1067-151X OTHER NUMBERS/LETTERS: Unigue ID.: 9417468 24510197 17989419 SOURCE: PubMed MAX COST: $16.00 COPYRIGHT COMP. Guidelines CALL NUMBER: W1 JO907XCK (Gen) NOTES: 080316-23 DELIVERY: E-mail: REPLY Mail: KEEP THIS RECEIPT TO RECONCILE WITH BILLING STATEMENT For problems or questions, contact NLM at http://wwwcf-nlm.nih. gov/ill/ill_web_form.cfm or phone 301-496-5511. Include LIBID and request number. NOTE:-THIS MATERIAL MAY BE PROTECTED BY COPYRIGHT LAW (TITLE 17, U.S. CODE) NLM Collection Access Section, Bethesda, MD Arthrofibrosis of the Knee David Magit, MD Andy Wolff, MD Karen Sutton, MD Michael J. Medvecky, MD Abstract Better understanding of surgical timing, improved surgical technique, and ativanced rehabilitation protocols has led to decreased incidence of motion loss after anterior cruciate ligament injury and reconstruction. However, motion loss from high-energy, multiligament injuries continues to compromise functional outcome, Prevention, consisting of control of inflammation and carly motion, remains the key element in avoiding motion loss. However, certain techniques, such as manipulation under anesthesia in conjunction with arthroscopic lysis of adhesions, are seliable treatment options. Open surgical débridement is rarely necessary and should be considered only as a salvage procedure. A greater understanding of the pathogenesis of arthrofibrosis and related inflammatory mediators may result in novel therapies for Dr Magi is Orthopaesic Sursean, The Greenwich Spovis and Shoulder Senice, Onhopaodic and Nevrosuroery, Speciale PC, Greenwich, CF Os Woite Folow, Staagan Hawking sim, Val, CO. Dr Sutton ia Deparment of Orthopaedic and Rehabilitation, Yala University Schoo of Maekcin, New Haven, CT. Dr Medieaty 1 Assistant Protoesos, Department of (Orthopacdios and Rehabil, Ya Inversty School of Medicine Nope ofthe fallowing authote cc 2 rmambsr of ernie fries has ‘ceived enyhing of value tem ar cur stocs i a commercial comaany oF inatiution lated deaety or inet 1S the abject of thie stile: Dr. Magi Br Welt Dr. Sulton ad Dr. Mececy. Reprint queers: Dr Magi. The Grrenyics Sports wd Shoulder ‘Service, Onhapasdc and Nevrosugery ‘Spocilets 0:8 Greerwien Orice Pak 1D Valley Ds cae Ortop Sey 2007.18 682 oot Cob 2607 by he Amerioan Acianiy oF Uthopteds Suind, os2 Material may be protected by copyright law (Title 17, U.S. Code) _ ‘treating the patient w ‘Lott ofknce motion i devasa ng consequence of both sit and multiligamentous iniury and beir reconstruction. Increased recog nition of this problem in the decades has led to better prevention and improved management of these injuries. Despite these advances, however, motion loss remains a prob- lematic ‘consequence of knee lige- ment injury ‘The incidence of motion loss var ies according to the degree of injury ‘Motion loss is less severe after single- ligament, low-energy injury than af- ter high-energy, multiligament in- jury. The etiology of motion loss is mnultifactorial, involvi ina- tion of mechanical and biologic fac- tors. Major risk factors include tech- nical errors during intra-articular ligament reconstruction and extra- articular procedures, injury severity, timing of surgery, delayed postoper. ative physical rehabilitation, hesero- topic ossification, prolonged immo- Dilization, infection, and complex regional pain syndrome. Recently, authors have begun to exatnine pos- sible genetie differences among pa th motion loss. tients with arthrofibrosis, Arthrofibrosis represents « wide spectrum of disease, ranging from ized co diffuse involvement of all compartments of the knee and of the extre-articular soft tissues. Proven. tion of motion loss remains essential to successful outcome. In the patient ‘who experiences motion loss despite preventive measures, tions include static or dynamic bra ing, manipulation under anesthesia, arthroscopic or open dét ‘ment. In recalcitrant cases, arthrode- sis in the older patient or total knee hroplasty may be required Normal Knee Motion Normal knee m combination of longitudinal axial, ro- tation, varus/valgus angulation, and flexion/extension arcs, Flexion and be categorized into three sub-ares: terminal extension, active function, and passive flexion. ‘The ate of cerminal extension, also called “screw home,” begins at the limit of passive extension, This arc flexion to 5° of hy- moves from | Journal ofthe Armrioas Academy o! Ortropaccho Surgeons Fe enone Davie Magi, MD, o eine cterencs Geko Knee motion can be measured by the standard goniometric method (A) or by measuring the hael-heightcitference (B). Panel A reproduced and panel 8 adapted from Schlegel TF, Boublk M, Hawkins RU, Steadman JR: Reliability of heet-height measurement for docume perextension. The arc of terminal ex teasion is rarely used in normal gait but is though to allow for quadziceps ‘muscle relaxation during the stance phase. The are of active function ranges from 10° to approximately 120°, which covers the zange needed activities of daily living, n- cluding sitving and stair climbing The are of passive flexion begins ut approximately 120° and e passive limit ofan applied exter nal force. Typically, passive flexion is 140° in men and 143* in womea. However, flexion to 165° is seen in societies in which full kneeling or squatting is common, such as in Jar pan, India, and che Middlle East. Flexion and Extension Deficits Flexion Loss ‘The functional effects of knee motion loss vary depending on pa: tient activity. In general, flexion to 5° is adequate for completing ac- tivities of daily living and usually docs not adversely affect normal Volume 15, Number 11, November 2007 wait. Without flexion beyond 125°, the patient may report an inability to squat. Smal flexion deficits in the athlete, however, can produce marked changes. in’ pesformance Loss of flexion 210° can affect run ning speed. Severe flexion deficits <90P alfect the ability of even the most sedentary patient to sit or nb stairs, Extension Loss Extension loss is poorly tolerated and can be more difficult to manage than loss of flexion. As little as 5° of extension loss can produce a notice able limp during ambulation, strain the quadriceps muscle, and contrib ute {0 patellofemoral pain, During \weight bearing on a ilexed knee, the quadriceps muscle force required to stabilize the knee is 75% of the load on the femoral head at 15° of flexion, 210% at 30°, and 410% at 60°. With inereased joint contact pressure, the clinical consequences are inereased quadriceps muscle activity and fa tigue, and, ultimately, patellofemo- ral arths g knee extension deficits, Ar J Sports Med! 2002;80:478-482,) Measuring Motion Loss Proper care for the patient with re- cent ligamentous knee injury or fequites accurate de tection of motion loss. The most common method involves placing a goniometer over the lateral knee joint Line in the midsagittal position, asing the greater trochanter and lat. eral malleolus as reference points Figure 1, A). Several studies have demonstrated high inter- and in- troobserver reliability with this method.“ A second method involves measuring the heel-height differ- ence, which is done with the patient in the prone position {Figure 1, 8).Ia general, I cm of heel-height differ- ence correlates to 1° of knee flexion contracture. This technique may be helpful in detecting subtle degrees of motion loss |<10"} Classification of Motion Loss Determining the crue incidence of motion loss can be difficult, given esa _Material may be protected by copyright law (Title 17, U.S. Code)