Most authors consider that the first step in treating arthrofibrosis “following total knee replacement” is aggressive physical therapy (PT). This could be considered within 6 weeks after total knee replacement. PT has to be started immediately after surgery as soon as possible. PT is used to improve flexion contracture as well as range of flexion. PT should be intensive, rapidly progressive and prolonged. PT under the direct supervision of a trained physical therapist is the more effective. Manual inpatient PT is started immediately after surgery before the patient is discharged from the hospital followed by manual outpatient PT after discharge. Outpatient PT has been considered more effective than home PT but the newer studies indicate that both are equally effective.
The medical literature is a little controversial about physical therapy. Most of the articles published on arthrofibrosis following total knee replacement suggest immediate and aggressive physical therapy. But, for arthrofibrosis following knee arthroscopy, many authors suggest RICE therapy (rest, ice, compression, elevation) and anti-inflammatory medications followed by gentle physical therapy when the pain and inflammation is controlled.
Adequate pain control is extremely important. It prevents muscle spasm due to pain and allows successful physical therapy.
Modern multimodal pain management is ideal. It involves a combination of injection of pain cocktail (a mixture of medications) into the soft tissues in and around the knee at the conclusion of surgery and oral pain medications supplemented as needed with injectable pain medications / intravenous patient controlled anesthesia (IV PCA) in the immediate post-operative period. This is followed by oral narcotic pain medications throughout the rehabilitation period.
Old strategies like prolonged hospitalization and continuous infusion of pain medication through a catheter placed in spine (prolonged and continuous epidural anesthesia), epidural patient controlled anesthesia (epidural PCA), and regional anaesthesia (like femoral block) are less often used in the immediate post-operative period currently.
These are used to improve flexion contracture and limited range of flexion. High-intensity stretch home mechanical therapy device (Flexionator and Extensionator – ERMI, Inc, Atlanta, Georgia) is effective. The Continuous Passive Motion (CPM) has been proven to be clinically ineffective in gaining motion.
In patients with flexion contracture, serial MUA and long leg cast or cylinder cast in extension, static progressive and dynamic progressive extension splints or braces as well as hinged knee brace locked in extension are helpful. In patients with both flexion contracture and limited range of flexion, these extension splints can be removed during range of flexion exercises. Bracing can be alternated with periods of motion.