Clinical Article National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 36-40

Arthroscopic arthrolysis for arthrofibrosis after Tension
Band Wiring Patella
D R GalfatA, Manoj NagarB
A–
Professor & Head, Department of Orthopaedics, Chirayu Medical College and
Hospital, Bhopal
B–
Assistant Professor, Department of Orthopaedics, Chirayu Medical College and
Hospital, Bhopal
Abstract:

Manuscript Reference
Number: Njmdr_2411_14

Early mobilisation is the aim of surgery after patellar fracture and the goal is to achieve
pre injury knee movements but this cannot be accomplished in every case because
of the variety of reasons. Some patients therefore would end up with some loss of
knee movements which is refractory to physiotherapy. We analysed our results of
arthroscopic arthrolysis in 10 patients with significant loss of knee flexion following
tension band wiring for patellar fracture. The patients included 9 males and 1 female.
The average age was 34.7 years. Initial rehabilitation efforts had failed. Arthroscopic
arthrolysis was performed to release intra articular adhesions and fibrous bands in the
supra patellar pouch. Intensive physiotherapy and continuous passive motion began
immediately post-operatively. Patients were followed every 2 weeks in physiotherapy
clinic till 8 weeks. Average flexion achieved at the time of surgery was 130 degrees
(range 120-140). All patients lost some flexion in follow up. The average loss was 20
degrees (range 10-30). Mean flexion at 8 weeks was 110 degrees (average 120-95).
There was no change in knee ROM between 4-8 weeks. Arthroscopic management
can be beneficial for patients suffering from arthrofibrosis following patellar fracture
surgery.
Key Words: Patella Fracture, Arthrofibrosis, Arthroscopic Arthrolysis

Introduction:

Date of submission: 27 June 2014
Date of Editorial approval: 04 July 2014
Date of Peer review approval: 19 September 2014
Date of Publication: 30 September 2014
Conflict of Interest: Nil; Source of support: Nil
Name and addresses of corresponding author:
Dr D R Galfat
B-94, Akriti Gardens, Nehru Nagar
Bhopal, M.P.
Pin – 462003
Mobile - +91-7772014400

Patellar
fractures
account
for
approximately 1% of all fractures [1],
present a higher prevalence within the
age group of 20 to 50 years old [1,2]
and males are more commonly affected
than female [3]. Loss of knee flexion
following surgical fixation of fractured
patella is fairly a common problem. To
achieve satisfactory knee movements,
physiotherapy should be started early and
patients should be allowed unrestricted
knee movements. Despite commencing
early physiotherapy, some patients would
end up with a stiff knee. The reason could
be noncompliance or patient not coming
for regular follow-up. Sometimes surgeon
is not confident about the stability of

36

fixation or the fracture was so comminuted
that stable fixation could not be achieved.
Even few days of immobilization makes
it difficult to achieve full knee movements
even with intensive physiotherapy later
on. Manipulation under anaesthesia is
not possible until the fracture has healed
satisfactorily and by the time fracture
heals it is too late to attempt MUA. Strong
adhesions are difficult break without
causing damage to articular cartilage
and
meniscoligamentous
structures.
Arthroscopic arthrolysis is a safer option
as adhesiolysis is done under direct vision.
In this retrospective review, we present our
results of arthroscopic arthrolysis for stiff
knee following tension band wiring patella.

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 36-40

Material and Method:
10 patients with knee stiffness following tension band
wiring for patella fracture underwent arthroscopic
adhesiolysis between October 2013 to april 2014. There
were 9 males and 1 female [Table 1]. Average age was 34.7
(range 25-45). Surgery was offered only after the fracture
was radiologically healed and improvement in knee
ROM reached a plateau after a supervised physiotherapy
programme with no improvement for 4 weeks. All patients
had loss of flexion. None had loss of extension. Average
preoperative flexion was 30 degrees (range 25-40).

is allowed. Patient is discharged on 3rd to 4th postoperative
day. Sutures are removed on 12th postoperative day. Followup was done in physiotherapy clinic every 2 weeks to asses
knee ROM with the final follow-up at 2 month.

Technique:
All cases were done under spinal anaesthesia in supine
position with a thigh tourniquet. Single dose of antibiotic
is given at the time of induction. Trochar is inserted from
standard anterolateral portal and swiped around the joint to
break patellofemoral adhesions and free medial and lateral
retinaculum from femoral condyles. A medial portal is
then made under direct vision and intraarticular adhesions
were released with a soft tissue shaver. Care was taken to
identify menisci and cruciate ligaments and protect them.
All shaving was done under direct vision. Arthroscope is
then pushed in supra patellar pouch. A radio frequency
probe is then introduced through superolateral portal and
adhesions released under direct vision. Soft tissue shaver
was used to remove the scar tissue after morselisation with
arthroscopic punch and scissor if radio frequency probe
is not available (in 4 cases). Tourniquet is then released.
This is followed by gentle manipulation of knee. Implant is
removed if k wires are impinging upon quadriceps tendon
(5 patients). Circlage wire was not removed in any of the
patient although it could be removed as well if patient
complaints of prominent hardware. Knee joint are injected
with 80 mg methyl prednisolone at the end of the procedure
after closure of the portals. No drain is used. A bulky but
loose dressing is given. Postoperative rehabilitation begins
in the recovery room, displaying the motion gain to the
patient and family while the patient’s pain is still controlled.
Patient is commenced on Immediate CPM in the recovery
room. Multimodal analgesia is used in postoperative
period (opiates, NSAID’s, ice packs). No antibiotics are
given postoperatively. On first postoperative day, dressing
is changed and light dressing (band aids) given. Patient is
commenced on knee ROM exercises and analgesics are
adjusted as per the severity of pain. Early weight bearing

37

Table 1 Patient Data
Patients

Age

Sex

Pre-op
ROM

Final ROM
(4weeks)

1

42

M

25

115

2

45

M

30

95

3

28

M

25

120

4

35

M

40

110

5

32

M

35

105

6

40

M

40

110

7

25

M

25

120

8

38

F

25

110

9

35

M

25

105

10

27

M

30

110

Figure 1 - 4 month post TBW for patellar fracture

Figure 2 - Examination under anaesthesia

Figure 3 - Arthroscopic trochar used to release patellofemoral adhesions and medial and lateral retinaculi

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 36-40

at 6 and 8 weeks. There were no procedure related
complications.

Discussion:
Loss of motion or stiffness after Tension Band Wiring for
patella fracture is frustrating for the patient and surgeon.
Stiffness results in pain and loss of range of movement.
This decreased range of movement can severely affect the
patient’s ability to perform activities of daily living such
as walking, climbing stairs, or getting up from a seated
position. Biomechanical studies and gait analysis have
shown that patients required 67° of knee flexion during
the swing phase of gait, 83° of flexion to climb stairs, 90–
100° of flexion to descend stairs, and 93° of flexion to stand
from a seated position [3]. Fibrosis and contractures in
different parts of the knee contribute to different types of
motion loss. Adhesions in the suprapatellar pouch typically
limit patellar mobility and can restrict knee flexion. The
proximal extent of the pouch should be approximately 3.5
cm from the superior pole of the patella. A foreshortened
pouch can lead to a further loss of knee flexion [4]. Other
structures of the knee that contribute to a loss of flexion
are the medial and lateral gutters, and the anterior interval.
The anterior interval is the region of the knee posterior to
the patellar fat pad and anterior to the antero superior tibial
plateau. This interval is an under recognized source of knee
flexion loss [5].

Figure 4 - Releasing intra articular adhesions while
preserving normal structures

Figure 5 - Recreating suprapatellar pouch, shaver
from superolateral portal

Arthrofibrosis has been treated with physical therapy,
manipulation under anesthesia, and open or arthroscopic
debridement with varying degrees of success. With
aggressive physical therapy, flexion increases slightly over
time and then reaches a plateau where range of movement
can no longer be increased. Manipulation is theoretically
designed to produce disruption of immature, early adhesions
[6]. Manipulation under anesthesia cannot be attempted till
fracture union is achieved which usually takes about 10-12
weeks. By this time adhesions become very dense and any
attempt to forcefully bend knee carries risk of fracturing
tibia and femur and tear of tendons, muscles, or ligaments.

Figure 6 - Final Knee flexion achieved

Figure 7 - CPM started in recovery

Results:
Average flexion achieved on operation table was 130
degrees (range 120-140). All patients lost some flexion in
follow up. At 4 weeks, the average loss was 20 degrees
(range 10-30). Mean flexion at 4 weeks was 110 degrees
(average 120-95). There was no further loss of flexion

Chriestel.P et al. [7] compared the results of arthroscopic
arthrolysis and manipulation under anesthesia for treatment
of postoperative knee stiffness and concluded that
arthroscopic releases and manipulations under anaesthesia
made before the end of the third month after operation
gave better results than those performed later. However,

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 36-40

arthroscopic release can be done very late compared with
manipulation under anaesthesia and avoids the need for
surgical arthrolysis.
Cosgeria et al [8] in their study identified a progressive joint
surface damage due to alteration of the forces though the
knee. Moreover, patients who had their lysis of adhesion
done earlier than 6 month after the trigger accident had
better functional results. We believe arthroscopic arthrolysis
should be done once the fracture is radiologically healed
and an adequate trial of physiotherapy has failed to improve
knee movements further. This rarely needs to be delayed
more than 6 months. Arthroscopy being less traumatic than
open procedure reduces the risk of rescarring and therefore
postoperative loss of movement gained by surgery.
The inclusion criteria for this study were not rigidly defined
by a discrete value of limited flexion as we felt that our
criteria for ‘‘knee stiffness’’ were more personalized to the
patient and thus more clinically relevant.
The arthroscopic treatment of knee arthrofibrosis has been
reported as being effective in improving knee range of
motion and restoring function with minimal complications.
Among the first to report their results were Sprague et al [9]
who described a series of 24 patients with “fibroarthrosis”
who gained an average of 45° of knee flexion with
arthroscopic release of adhesions. Several authors have
since reported similar results with knee range-of-motion
improvements ranging from 45° to 68° [8-17].
There is some loss of movements gained during surgery.
This happens during initial few weeks as evident from the
current study. Loss of extension is less tolerated [8] and
even 10 degree of extension loss leads to visible limp.
There were no patients with extension loss in current study
probably because all patients had their knee immobilised in
full extension postoperatively for varying period.
We recognize several limitations to our study. This is a
retrospective review of a small number of patients. We must
be cautious in rendering generalized recommendations
on this limited experience. The follow-up is short. After
initial few cases we identified that the knee ROM remains
static beyond 4 weeks and therefore longer follow-up was
considered unnecessary. We did not measure the pain and
knee scores in any patient and therefore it is not possible
to comment on the extent of improvement in pain and
function with improved knee ROM but all patients reported

less pain and better quality of life after arthrolysis.
In conclusion, we suggest that arthroscopic lysis of
adhesions should be considered in the treatment of patients
with poor range of motion after patellar fracture surgery
when adequate trial of physiotherapy has failed to improve
function. The arthroscopic approach is a powerful and
controlled method that is effective treating postsurgical
knee stiffness refractory to physical therapy.

References:
1. Eric EJ. Fraturas do joelho. In: Rockwood CAJ,
Green DP, Bucholz RW. Fraturas em adultos. 3rd ed.
Philadelphia: Lippincott; 1991. p.1729 –44.
2. Nummi J. Fracture of the patella: a clinical study of
707 patellar fractures. Ann. Chir Gynaecol. Fenn.
1971; 60(Suppl):179-87
3. Matthew R. Bong M, and Paul E. Di Cesare, MD.
Stiffness after total knee arthroplasty Journal of
American Academy of Orthopaedic Surgeons May/
June 2004 2004;12(3):8.
4. Lindenfeld TN, Wojtys EM, Husain A. Instructional
Course Lectures, the American Academy of
Orthopaedic Surgeons— operative treatment of
arthrofibrosis of the knee. J Bone Joint Surg Am
1999;81:1772-1784.
5. David H. Kim, Thomas J. Gill, Peter J. Millett.
Arthroscopic Treatment of the Arthrofibrotic Knee
Arthroscopy: The Journal of Arthroscopic and Related
Surgery, Vol 20, No 6 (July-August, Suppl 1), 2004:
pp 187-194
6. Stamos VP, Bono JV. Management of the stiff total
knee arthroplasty in revision total knee arthroplasty.
In: Bono JV, Scott RD, eds. Techniques in Total Knee
Arthroplasty. New York, NY: Springer Science +
Business Media, Inc; 2005:251-257.
7. Christel P, Herman S, Benoit S, Bornert D, Witvoët J.
Percutaneous arthrolysis under arthroscopic control
and manipulation under anesthesia in the treatment of
postoperative stiffness of the knee. Rev Chir Orthop
Reparatrice Appar Mot 1988;74(6):517-25.

39

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 36-40

8. Cosgarea AJ, DeHaven KE, Lovelock JE. The surgical
treatment of arthrofibrosis of the knee. Am J Sports
Med 1994;22:184-191.

13. Richmond JC, al Assal M. Arthroscopic management
of arthrofibrosis of the knee, including infrapatellar
contraction syndrome. Arthroscopy 1991;7:144-147.

9. Sprague NF III, O’Connor RL, Fox JM. Arthroscopic
treatment of postoperative knee arthrofibrosis. Clin
Orthop 1982;166:165-172.

14. Achalandabaso J, Albillos J. Stiffness of the knee—
mixed arthroscopic and subcutaneous technique:
results of 67 cases. Arthroscopy 1993;9:685-690.

10. DelPizzo W, Fox JM, Friedman MJ, et al. Operative
arthroscopy for the treatment of arthrofibrosis of the
knee. Contemporary Orthopaedics 1985;10:67-72.

15. Cohen I, Hendel D, Rzetelny V. Arthroscopic
adhesiolysis of the knee joint in arthrofibrosis. Bull
Hosp Jt Dis 1993;53:66-67.

11. Sprague NF III. Motion-limiting arthrofibrosis of the
knee: the role of arthroscopic management. Clin Sports
Med 1987;6:537-549.

16. Vaquero J, Vidal C, Medina E, et al. Arthroscopic lysis
in knee arthrofibrosis. Arthroscopy 1993;9:691-694.

12. Parisien JS. The role of arthroscopy in the treatment
of postoperative fibroarthrosis of the knee joint. Clin
Orthop 1988;229:185-192.

17. Klein W, Shah N, Gassen A. Arthroscopic management
of postoperative arthrofibrosis of the knee joint:
Indication, technique,and results. Arthroscopy
1994;10:591-597.

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