Arthrofibrosis after Knee Replacement – Treatment:
At present, there is no universally accepted, effective treatment method available to completely prevent arthrofibrosis or completely cure established arthrofibrosis using medicines (pharmacological or biological agents).
A. Standard Treatment options for Arthrofibrosis after Knee Replacement:
The main treatment approaches currently available to treat arthrofibrosis following total knee replacement include,
(1). Physical Therapy & Rehabilitation
(2). Manipulation under Anesthesia (MUA)
(3). Arthroscopic Removal of Scar Tissue (Arthroscopic Arthrolysis or Arthroscopic Lysis of Adhesions)
(4). Open Removal of Scar Tissue (Open Arthrolysis or Open Lysis of Adhesions)
(5). Revision Knee Replacement (Revision Arthroplasty)
Each treatment approach can be repeated or combined with another one as needed. For example, MUA can be repeated at appropriate time intervals as needed or if the first revision knee replacement fails a second revision knee replacement (re-revision) may be considered as needed. Similarly, MUA may be done in the postoperative period after revision as needed. The timing and the effectiveness of the various currently available treatment methods for arthrofibrosis following total knee replacement are controversial.
Other potential options include accepting the condition, knee fusion (arthrodesis) and amputation but we do not have much literature evidence in favor of these approaches for arthrofibrosis. These options may be considered after the failure of all other treatment options for patients with severe, painful, diffuse arthrofibrosis involving the whole knee with significant flexion contracture along with significantly decreased range of flexion.
B. Other Possible Treatment options for Arthrofibrosis after Knee Replacement:
Treatments like use of biological or pharmaceutical agents inside the knee joint are still in research stage. These include non-steroidal anti-inflammatory drugs like Celecoxib, Colchicin (oral or intra-articular), high doses of vitamin C, Interleukin (IL-1) inhibitors like Anakinra, Rosiglitazone, Rapamycin, Gamma-Interferon, monoclonal antibody against vascular endothelial growth factor (bevacizumab), dicorin and Mitomycin C.
There are published reports on different novel techniques with variable results. These include hydraulic distension of knee, Ilizarov method, Botulinum toxin injection into muscles behind the thigh (hamstrings) for stiffness due to muscle spasm, intra-articular Paralytic Shellfish Poisoning Toxin, amniotic membrane insertion and blocking the nerves with medications (sympathetic block).
Few patients have reported success with augmented soft tissue mobilization techniques and deep tissue massage techniques using Graston Technique, Astym Therapy, Myofascial Releaser Ellipse Pro or even kitchen utensils and rolling pin to accomplish this.
Different patients have tried different treatment approaches. These include losing weight, prolonged bed rest, staying off the affected knee for a prolonged period of time (10-12 months) with continuous passive motion machine on, avoiding aggressive or painful physical therapy, anti-inflammatory diet, NSAID creams like Diclofenac Sodium, anti-inflammatory medicines, anti-gout medicines prescribed by rheumatologist, oral steroids like dosepac, repeated corticosteriod injections into knees, anti-allergy medications, cryotherapy (ice packs or Game Ready), heating pad, aquatherapy (water therapy), swimming, aqua jogging and exercising in pool, ultrasound, laser, shockwave, bike, stationary bike, rowing machine, floor pedal machine, flexion/extension brace like Dynasplint or JAZ brace, needling, acupuncture, chiropractic active release therapy, naturopathy, stem cell therapy, and PRP injection. Other than anectodal positive results, none of them has given consistent and predictable results so that a specific modality could be recommended as a standard treatment approach.
Prognosis of Arthrofibrosis after Knee Replacement:
Exactly when scar tissue matures is variable and remains a topic of debate. Fibrous tissue progressively matures and becomes resistant to more conservative treatment approaches with time.
The severity and duration of scar tissue and the presence of new bone formation within the soft tissue (heterotopic ossification) may affect the prognosis following treatment. But few authors indicate that there is no correlation between the interval between the initial knee replacement and revision and conclude no difference in results between early and late revision.
Generalized arthrofibrosis leads to more severe stiffness and inferior prognosis than localized arthrofibrosis.
Traditionally, the prognosis has been considered better after revision knee replacement in patients with an identifiable cause for stiffness where the cause is corrected. Recent articles indicate similar prognosis after revision knee replacement in patients with and without an identifiable cause for stiffness.
Sometimes, following any type of treatment for arthrofibrosis (Physical Therapy, MUA, arthroscopic or open arthrolysis and revision knee replacement), the pain and stiffness of arthrofibrosis may recur or even worsen after a short period of improvement or rarely immediately.