Current Concepts Motion Loss after Ligament Injuries to the Knee Part II: Prevention and Treatment

This is the second part of a two-part review on motion problems after ligament injuries to the knee. The first part, published in the September/October 2001 issue, discussed normal and abnormal knee motion, terminology, risk factors, and pathoanatomy. The purpose of this article is to review current concepts on prevention and treatment of motion problems, summarizing the recent and pertinent studies that discuss this complicated clinical problem. The first part of this article will discuss the different classification schemes that have been published on motion loss of the knee. Prevention strategies will be discussed next, followed by early recognition. Finally, a discussion of the various treatment options and published results will be presented in detail, together with the authors’ nine-step systematic surgical approach to the stiff knee. CLASSIFICATION OF MOTION LOSS Del Pizzo et al., Blauth and Jaeger, and Shelbourne et al. have all outlined classification schemes for patients with motion loss. Del Pizzo et al. were the first authors to divide patients into groups according to preoperative range of motion and severity of fibrosis. They found a positive correlation between severity of motion loss and degree of fibrosis, using the system of pathoanatomic findings developed by Sprague et al. Blauth and Jaeger described a similar four-part classification scheme for patients with motion loss that ranged from mild to extreme, based on the range of motion of the affected knee. The four-part classification scheme that Shelbourne et al. described for patients with arthrofibrosis is useful in that it provides both a descriptive and prognostic guide (Table 1). Seventy-two patients with arthrofibrosis of the knee after previous ACL reconstruction were treated surgically to remove scar tissue. In patients with the most severely affected knees (type 4), 16 had patella infera, greater than 30° of flexion loss, and greater than 10° of extension loss. Not surprisingly, patients with type 4 arthrofibrosis also had less predictable results: five patients failed to regain full extension and in one patient the treatment failed altogether. As a group, however, they still managed an average gain of 18° of extension and 42° of flexion. These various classification schemes are useful in that they are both descriptive and prognostic. We believe it is essential for the clinician to identify the specific cause of the motion loss so that appropriate management can be initiated. Very often the cause is multifactorial and the surgeon must be prepared to address all problems at the time of surgery. Research studies are of great importance as they provide a basis to discuss possible outcomes with patients and give them a measure of risk or benefit of additional surgery.