الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Loss of knee motion is a consequence of both single and multi-ligamentous injury and their reconstruction. Increased recognition of this problem in the past two decades has led to better prevention and improved management of these injuries. Despite these advances, however, motion loss remains a problematic consequence of knee ligament injury.
The incidence of motion loss varies according to the degree of injury.
Motion loss is less severe after single-ligament low-energy injury than after high-energy, multi-ligament injury.
The etiology of motion loss is multi-factorial, involving a combination of mechanical and biologic factors. Major risk factors include technical errors during intra-articular ligament reconstruction and extra-articular procedures, injury severity (supracondylar femoral fracture), timing of surgery, delayed postoperative physical rehabilitation, heterotopic ossification, prolonged immobilization, infection, and complex regional pain syndrome. Recently, authors have begun to examine possible genetic differences among patients with arthrofibrosis.
Arthrofibrosis represents a wide spectrum of disease, ranging from localized to diffuse involvement of all compartments of the knee (synovium, menisci, curicate ligament and articular surfaces of femur, tibia and patella) and of the extra-articular soft tissues (capsule and collateral ligaments).
Transforming growth factor-B (TGF-B), which is released by platelets, plays a critical role in the process of tissue repair. At the site of injury, TGF-B and platelet-derived growth factor initiate a cascade of events resulting in the production of extracellular matrix proteins and protease inhibitors as well as inhibition of proteolytic enzyme production.
Formation of extracellular matrix occurs at the site of injury, consisting of an aggregation of collagen, fibronectin, and proteoglycans. With an increase in local concentration, the autoregulatory mechanism of TGF-B results in feed back inhibition.
An ACL nodule is a fibroproliferative scar nodule that occurs after ACL reconstruction with bone-patellar tendon-bone autograft. It is most commonly located anterolateral to the tibial tunnel. The nodules called a “cyclops lesion.” are typically attached to the graft as well as to the soft tissue overlying the tibia.
Evaluation of the patient with a stiff knee must follow a thorough and logical progression. A detailed history of the index trauma and a medical history are necessary. The patient’s complaint should be explored in detail to assess the nature of the pain as well as any functional problems. A complete physical examination of the affected knee and adjacent joints is necessary, and the patient is observed walking and getting up from a chair. Basic radiographs are obtained to evaluate malposition, and fracture as a cause of the patient’s symptoms. Specialized radiographic views and computed tomography (CT) scans are ordered based on the history and physical examination. When infection is suspected, laboratory tests for the erythrocyte sedimentation rate (ESR) and C-reactive protein level are indicated. Further workup for infection can include aspiration and nuclear scans.
Prevention of motion loss remains essential to successful outcome.
Adequate reduction of femoral fracture, Postponed ACL reconstruction if the knee is swollen and warm. Early post operative mobilization with use of CPM is important.
Treatment options include static or dynamic bracing, manipulation under anesthesia, and arthroscopic or open débridement. A review of the literature shows that arthroscopic débridement, open arthrotomy, open qudricepsplasty and percutaneous knee lysis can provide success in many cases. However, the goal should be to avoid these additional operations if possible. In patients who have various soft-tissue dysfunctions and for whom standard rehabilitation protocols were unsuccessful, botulinum toxin injections, use of a custom knee device or a JAS device, can improve the range of motion and enhance the clinical outcome Furthermore, many of these techniques do not have to be delayed for two or three months but rather can be initiated at an earlier time.