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Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Arthrofibrosis is the most common post-operative complication of anterior cruciate ligament (ACL) reconstruction. Risk factors and management strategies for arthrofibrosis remain unclear. The purpose of this review was to: (a) describe existing definitions of arthrofibrosis, and (b) characterize the management strategies and outcomes of arthrofibrosis treatment.

Methods

MEDLINE, EMBASE, and PubMed were searched from database inception to search date (March 21, 2016) and screened in duplicate for relevant studies. Data regarding patient demographics, indications, index surgery, management strategy, and outcomes were collected.

Results

Twenty-five studies of primarily level IV evidence (88%) were included. A total of 647 patients (648 knees) with a mean age of 28.2 ± 1.8 years (range 14–62 years) were treated for arthrofibrosis following ACL reconstruction and followed for a mean 30.1 ± 16.9 months (range 2 months–9.6 years). Definitions of arthrofibrosis varied widely and included subjective definitions and the Shelbourne classification system. Patients were treated by one or more of: arthroscopic arthrolysis (570 patients), manipulation under anaesthesia (MUA) (153 patients), oral corticosteroids (31 patients), physiotherapy (81 patients), drop-casting (17 patients), epidural therapy combined with inpatient physiotherapy (six patients), and intra-articular interleukin-1 antagonist injection (four patients). All studies reported improvement in range of motion post-operatively, with statistically significant improvement reported for 306 patients (six studies, p range <0.001 to =0.05), and one study (18 patients) reporting significantly better results if arthrofibrosis was treated within 8 months of reconstruction (p < 0.03). The greatest improvements for extension loss were seen with drop-casting (mean 6.2° ± 0.6° improvement), whereas MUA produced the greatest improvement for flexion deficit (mean 47.8° ± 3.3° improvement).

Conclusions

Arthrofibrosis is poorly defined and outcome measures range varies widely. Amongst the studies included in this review, arthrofibrosis was most commonly managed surgically by arthroscopic arthrolysis, and most patients showed at least some improvement, including six studies that reported statistically significant change in ROM. In studies that used a step-wise approach to treating arthrofibrosis, more than half of patients were successfully treated without an operation. A more well-defined concept of arthrofibrosis, along with large, prospective studies will provide a clearer understanding of how to describe and manage this complication. The issue of arthrofibrosis following ACL reconstruction is clinically relevant as it represents a common complication of a commonly performed operation that nonetheless remains poorly defined and without clear treatment guidelines.

Level of evidence

Systematic Review of Level III and IV Studies, Level IV.

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Abbreviations

ACL :

Anterior cruciate ligament

ROM :

Range of motion

MUA :

Manipulation under anaesthesia

PRISMA :

Preferred reporting items for systematic review and meta-analysis

AOSSM :

American Orthopaedic Society for Sports Medicine

ISAKOS :

International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine

ESSKA :

European Society for Sports, Traumatology, Knee surgery and Arthroscopy

AAOS :

The American Academy of Orthopaedic Surgeons

MINORS :

Methodological Index for Non-Randomized Studies

ICC :

Intraclass correlation coefficient

CI :

Confidence intervals

TKA :

Total knee arthroplasty

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Acknowledgements

The authors thank Mr. Andrew Duong for his help with manuscript preparation and submission.

Authors’ contributions

SE and CEH carried out the search, screening process, and assessment of study quality. SE drafted the manuscript. CEH edited the manuscript. ORA and DD conceived the study, and provided key expert input and editing throughout the process. MTH, RO, and DBW edited the manuscript and provided key expert input. DBW and RLB carried out a comprehensive search of recent orthopaedic meetings to minimize publication bias. NS provided feedback on methodological and statistical aspects. All authors read and approved the final manuscript.

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Authors and Affiliations

  1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

    Seper Ekhtiari

  2. Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St W, Room 4E15, Hamilton, ON, L8N 3Z5, Canada

    Nolan S. Horner, Darren de SA, Rick Ogilvie & Olufemi R. Ayeni

  3. Department of Clinical Epidemiology and Biostatistics, Centre for Evidence Based Orthopaedics, McMaster University, Hamilton, ON, Canada

    Nicole Simunovic

  4. Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Basel, Switzerland

    Michael T. Hirschmann

  5. St. Michael’s Hospital, University of Toronto Orthopaedic Sports Medicine, Toronto, ON, Canada

    Rebecca L. Berardelli &  Danny B. Whelan

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  1. Seper Ekhtiari
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Correspondence to Olufemi R. Ayeni.

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Ekhtiari, S., Horner, N.S., de SA, D. et al. Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review. Knee Surg Sports Traumatol Arthrosc 25, 3929–3937 (2017). https://doi.org/10.1007/s00167-017-4482-1

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