What are the factors that contribute to arthrofibrosis following ACL reconstruction and which measures can counteract this?
"We define arthrofibrosis as any symptomatic loss of extension or flexion in the knee. Arthrofibrosis is a condition that can be prevented in almost all cases. Certainly, it is easier to prevent than it is to treat. One of the main factors causing arthrofibrosis is inadequate preoperative rehabilitation before undergoing ACL reconstruction.
"ACL reconstruction is always an elective surgery, except when the lateral structures are torn, which occurs in less than 1% of patients. Every patient should undergo preoperative rehabilitation to regain full extension and flexion equal to the non-injured leg before undergoing surgery. Furthermore, patients should regain good leg control, have a normal gait, and knee swelling should be resolved. In other words, the knee needs to feel like a normal knee, except for the ACL deficiency, before the patient should undergo ACL reconstruction.
"What is important to recognize is that full extension should include hyperextension (full straightening of the knee), not just to 0° extension. Most people have some degree of hyperextension in their knees. To evaluate knee extension, have the patient lie supine, place one hand above the knee to stabilize the femur (thigh), and use the other hand to lift the heel of the foot off the table so the knee goes into hyperextension. This method allows the evaluator not only to appreciate any difference in extension between knees but also feel any subtle tightness in the joint.
"During surgery, the surgeon should put the knee through full range of motion after the graft has been secured as a means to ensure that the placement and fixation of the graft has not captured the joint.
"After surgery, obtaining full range of motion symmetrical to the normal knee should be the top priority for rehabilitation. The key to achieving full range of motion is to be able to prevent and limit a hemarthrosis (bleeding within a joint) in the knee. I use a Cryo/Cuff (Aircast, Inc.) to obtain both compression and cold on the knee after surgery. The patients use a continuous passive motion machine (CPM) mainly as a means to provide elevation with gentle motion. Furthermore, patients stay in the hospital for a 23-hour stay so we can prevent the hemarthrosis and provide patient education.
"As another means to prevent a hemarthrosis, we have our patients remain at bed rest for the first 5 days after surgery. The patients are able to perform their knee range of motion exercises while in bed. Only gentle strengthening exercises are included as part of the rehabilitation program until the patient has achieved full symmetrical extension and knee flexion. When the patients do begin strengthening exercises, they are reminded to evaluate their range of motion daily to make sure they have not lost any extension or flexion. Aggressive strengthening stimulates the ACL graft to mature and can sometimes affect range of motion if the patient does not continue to monitor and perform full extension and flexion exercises daily.
"If these preoperative and postoperative principles are applied, arthrofibrosis can be prevented."