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Rheumatoid arthritis (RA) and arthrofibrosis (AF) are both chronic synovial hyperplasia diseases that result in joint stiffness and contractures. They shared similar symptoms and many common features in pathogenesis. Our study aims to perform a comprehensive analysis between RA and AF and identify novel drugs for clinical use. Based on the text mining approaches, we performed a correlation analysis of 12 common joint diseases including arthrofibrosis, gouty arthritis, infectious arthritis, juvenile idiopathic arthritis, osteoarthritis, post infectious arthropathies, post traumatic osteoarthritis, psoriatic arthritis, reactive arthritis, rheumatoid arthritis, septic arthritis, and transient arthritis. 5 bulk sequencing datasets and 4 single-cell sequencing datasets of RA and AF were integrated and analyzed. A novel drug repositioning method was found for drug screening, and text mining approaches were used to verify the identified drugs. RA and AF performed the highest gene similarity (0.77) and functional ontology similarity (0.84) among all 12 joint diseases. We figured out that they share the same key pathogenic cell including CD34 + sublining fibroblasts (CD34-SLF) and DKK3 + sublining fibroblasts (DKK3-SLF). Potential therapeutic target database (PTTD) was established with the differential expressed genes (DEGs) of these key pathogenic cells. Based on the PTTD, 15 potential drugs for AF and 16 potential drugs for RA were identified. This work provides a new perspective on AF and RA study which enhances our understanding of their pathogenesis. It also shed light on their underlying mechanism and open new avenues for drug repositioning studies. [ABSTRACT FROM AUTHOR]

Background: Manipulation under anesthesia (MUA) is a well-established treatment for stiffness after total knee arthroplasty (TKA). Risk factors for failure of MUA remain largely unknown. The primary aim of this study was to identify risk factors for failure of MUA after TKA. Methods: We performed a retrospective cohort study including 470 patients who underwent MUA after primary TKA with minimum 2 year follow-up. Patients were grouped into success (n = 412) or failure (n = 58) cohorts; failure was defined as flexion < 90° at most recent follow-up or revision for stiffness. The increase in flexion post-MUA for the cohort was calculated. Several clinical, patient, and surgical factors were analyzed using univariate, followed by multivariable logistic regression models to identify independent risk factors associated with failure. Results: The mean increase in flexion was 42° (range 0–115). BMI 30–35 (p = 0.01, odds ratio (OR) 2.42; 95% CI 1.25–4.68) and poorer pre-MUA flexion (p < 0.01, OR 1.43; 95% CI 1.23–1.67) were risk factors for failure. When considering revision for stiffness only, BMI 30–35 (p = 0.01, OR 3.27; 95% CI 1.41–7.61), lower pre-MUA flexion (p < 0.01, OR 1.43; 95% CI 1.18–1.75), and history of prior knee surgery (p = 0.04, OR 2.31; 95% CI 1.06–5.04) were predictors of failure. Time to MUA (p = 0.48), thromboprophylaxis (p = 0.44), pre-operative opioid use (p = 0.34), depression/anxiety (p = 1.0), and several other factors analyzed were not associated with failure. Conclusion: In this large cohort, elevated BMI and lower pre-MUA flexion were risk factors for failure of MUA. History of prior knee surgery was an additional predictor of requiring revision for stiffness. [ABSTRACT FROM AUTHOR]

Posttraumatic elbow stiffness can have a large impact on the ability of a patient to perform activities of daily living. Following a stepwise approach to treatment helps clinicians in this otherwise difficult-to treat condition. Treatment in adults is based on dealing with the involvement of soft tissue contracture, osseous impingement or both. Unlike adults, posttraumatic elbow stiffness in children has distinctly different causes and the thrust of treatment is primarily non-surgical. In skeletally immature children, the skeletal growth potential should be properly assessed and closely followed, observing either progression or natural correction of the deformity. Early active motion aided by physiotherapy is the first step in treatment for both adults and children. Following physiotherapy, brace therapy is a proven cheap and effective therapy for treatment-resistant stiffness. If adequate conservative treatment is unsuccessful, the next step is surgical arthrolysis. This procedure can be performed either open or arthroscopically, with the decision dependent on multiple factors. Early active mobilization after surgery is equally important, with the addition of bracing or continuous passive motion (CPM) in pending contractures following surgery. This paper provides a review of the current literature and a state-of-the-art guidance on the management of posttraumatic elbow stiffness in adult and paediatric patients. [ABSTRACT FROM AUTHOR]

Abstract Rheumatoid arthritis (RA) and arthrofibrosis (AF) are both chronic synovial hyperplasia diseases that result in joint stiffness and contractures. They shared similar symptoms and many common features in pathogenesis. Our study aims to perform a comprehensive analysis between RA and AF and identify novel drugs for clinical use. Based on the text mining approaches, we performed a correlation analysis of 12 common joint diseases including arthrofibrosis, gouty arthritis, infectious arthritis, juvenile idiopathic arthritis, osteoarthritis, post infectious arthropathies, post traumatic osteoarthritis, psoriatic arthritis, reactive arthritis, rheumatoid arthritis, septic arthritis, and transient arthritis. 5 bulk sequencing datasets and 4 single-cell sequencing datasets of RA and AF were integrated and analyzed. A novel drug repositioning method was found for drug screening, and text mining approaches were used to verify the identified drugs. RA and AF performed the highest gene similarity (0.77) and functional ontology similarity (0.84) among all 12 joint diseases. We figured out that they share the same key pathogenic cell including CD34 + sublining fibroblasts (CD34-SLF) and DKK3 + sublining fibroblasts (DKK3-SLF). Potential therapeutic target database (PTTD) was established with the differential expressed genes (DEGs) of these key pathogenic cells. Based on the PTTD, 15 potential drugs for AF and 16 potential drugs for RA were identified. This work provides a new perspective on AF and RA study which enhances our understanding of their pathogenesis. It also shed light on their underlying mechanism and open new avenues for drug repositioning studies.

Background: The optimal timing of anterior cruciate ligament (ACL) reconstruction (ACLR) remains a controversial topic. Previous reviews have demonstrated that there are no differences between early and delayed ACLR; however, these studies have been limited by heterogeneous definitions of acute ACL injury. Purpose: To evaluate postoperative patient functional outcomes and risk for arthrofibrosis after acute arthroscopic ACLR performed ≤10 days after injury. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using multiple medical databases. Inclusion criteria were studies that evaluated postoperative range of motion outcomes for patients undergoing ACLR ≤10 days after initial ACL injury. For included comparative studies comparing patient groups undergoing ACLR ≤10 days and patients undergoing "delayed" ACLR after ≥3 weeks of initial injury, quantitative analysis was performed to assess for differences in postoperative arthrofibrosis, reoperation rates, and patient-reported outcomes between groups. DerSimonian-Laird binary random-effects models were constructed to quantitatively describe the association between the ACLR time period and patient outcomes by generating effect estimates in the form of odds ratios with 95% CIs. Qualitative analysis was performed to describe variably reported patient outcomes and the risk of arthrofibrosis after ACLR for noncomparative studies. Results: Screening yielded 6 full-text articles with 448 patients who underwent ACLR (296 ACLR <10 days, 152 ACLR >3 weeks), with a pooled mean age of 28.1 years. For studies amenable to quantitative analysis, there were no significant differences between ACLR performed ≤10 days and ACLR performed at the 3-week point or after in terms of postoperative stiffness (3 studies; odds ratio, 1.27; P =.508), Tegner scores (2 studies; mean difference, –0.056; P =.155), or reoperation for stiffness (3 studies; odds ratio, 0.869; P =.462). The overall incidence of postoperative arthrofibrosis after 12 months of follow-up was 11 of 296 (3.7%) for ACLRs performed ≤10 days versus 6 of 152 (3.9%) for those performed at the 3-week point or after. Conclusion: ACLR performed ≤10 days after the inciting injury does not increase the risk of postoperative arthrofibrosis and demonstrates similar patient-reported outcomes compared with ACLR performed at the 3-week point or after. [ABSTRACT FROM AUTHOR]

There are limited data documenting the safety and clinical outcomes following outpatient total shoulder arthroplasty (TSA) and reverse TSA (RTSA) compared to inpatient shoulder arthroplasty. It was hypothesized that there would be no significant differences in complication and emergency room (ER) visit rate between outpatient TSA and RTSA. A prospectively maintained institutional registry was retrospectively queried for all patients undergoing primary TSA or RTSA between September 2016 and April 2019 and confirmed as having undergone outpatient surgery, defined as surgery performed at an ambulatory surgery center. Ninety-day complications, readmissions, and ER visits were analyzed for outpatient TSA and RTSA. The 90-day complications included infection, thromboembolic disease (pulmonary embolism, deep venous thrombosis), neurovascular injury, revision surgery, and inflammatory processes. A total of 140 patients were identified who underwent outpatient TSA or RTSA from 2016 to 2019. Four complications (3.7%) were reported in the TSA cohort, compared to 4 complications (12.9%) reported in the RTSA cohort (P =.060). Three ER visits occurred in the RTSA group compared to 0 in the TSA group (P =.001). Patients who experienced a complication had significantly higher body mass index (TSA: P =.049, RTSA: P =.035). In addition, there were no readmissions or reoperations in either TSA or RTSA patients. Overall, the rate of complications, ER visits, and readmission rates in outpatient TSA and RTSA was found to be relatively low given the sample size of this study and minor complications reported. In addition, there were no readmissions or reoperations in either TSA or RTSA patients. Elevated body mass index may significantly increase the risk of complications after both a TSA and RTSA. This study suggests that outpatient TSA and RTSA are safe in selected patients. [ABSTRACT FROM AUTHOR]

Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR). Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively. Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P <.001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P =.133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P =.012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P =.059) demonstrated a similar statistical trend. PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness. [ABSTRACT FROM AUTHOR]

Abstract Background Arthrofibrosis is a joint disorder characterized by excessive scar formation in the joint tissues. Vitamin E is an antioxidant with potential anti‐fibroblastic effect. The aim of this study was to establish an arthrofibrosis rat model after joint replacement and assess the effects of vitamin E supplementation on joint fibrosis. Methods We simulated knee replacement in 16 male Sprague–Dawley rats. We immobilized the surgical leg with a suture in full flexion. The control groups were killed at 2 and 12 weeks (n = 5 per group), and the test group was supplemented daily with vitamin E (0.2 mg/mL) in their drinking water for 12 weeks (n = 6). We performed histological staining to investigate the presence and severity of arthrofibrosis. Immunofluorescent staining and α2‐macroglobulin (α2M) enzyme‐linked immunosorbent assay (ELISA) were used to assess local and systemic inflammation. Static weight bearing (total internal reflection) and range of motion (ROM) were collected for functional assessment. Results The ROM and weight‐bearing symmetry decreased after the procedure and recovered slowly with still significant deficit at the end of the study for both groups. Histological analysis confirmed fibrosis in both lateral and posterior periarticular tissue. Vitamin E supplementation showed a moderate anti‐inflammatory effect on the local and systemic levels. The vitamin E group exhibited significant improvement in ROM and weight‐bearing symmetry at day 84 compared to the control group. Conclusions This model is viable for simulating arthrofibrosis after joint replacement. Vitamin E may benefit postsurgical arthrofibrosis, and further studies are needed for dosing requirements.

Stiff joints formed after trauma, surgery or immobilization are frustrating for surgeons, therapists and patients alike. Unfortunately, the study of contracture is limited by available animal model systems, which focus on the utilization of larger mammals and joint trauma. Here we describe a novel mouse-based model system for the generation of joint contracture using 3D-printed clamshell casts. With this model system we are able to generate both reversible and irreversible contractures of the knee and ankle. Four- or 8-month-old female mice were casted for either 2 or 3 weeks before liberation. All groups formed measurable contractures of the knee and ankle. Younger mice immobilized for less time formed reversible contractures of the knee and ankle. We were able to generate irreversible contracture with either longer immobilization time or the utilization of older mice. The contracture formation translated into differences in gait, which were detectable using the DigiGait® analysis system. This novel model system provides a higher throughput, lower cost and more powerful tool in studying the molecular and cellular mechanisms considering the large existing pool of transgenic/knockout murine strains.

Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions. This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years). Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P >.05). Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA. This is a level III prognostic study. [ABSTRACT FROM AUTHOR]

Severe idiopathic arthrofibrosis after total knee arthroplasty (TKA) is a challenging problem to treat. Low-dose irradiation may decrease fibro-osseous proliferation, while rotating-hinge (RH) revision allows for distal femur shortening and collateral ligament sacrifice. This study reports the clinical outcomes and implant survivorship in patients treated with low-dose irradiation and RH revision for severe idiopathic arthrofibrosis following TKA. A retrospective review was performed on 60 consecutive patients. Patients who had greater than 80° arc of knee motion or less than 15° flexion contracture were excluded. Mean follow-up was 6 years (range, 2 to 14). Kaplan-Meier survivorship analyses were performed, and logistic regressions were used to determine associations between preoperative patient characteristics and clinical outcomes. Median flexion contracture and median terminal flexion at presentation were 20 and 70°, respectively; at final follow-up, 59 of 60 patients (98%) had ≤10° flexion contracture and 49 of 60 patients (82%) had ≥90° of flexion. The 10-year survivorship free from reoperation for any reason, revision for any reason, and revision for aseptic loosening were 63, 87, and 97%, respectively. There were 27% percent of patients who underwent a manipulation under anesthesia postoperatively, which was the most common reason for return to the operating room. A greater number of prior surgeries was significantly associated with worse range of motion at the final follow-up (P =.004). There were no known radiation-associated complications. Patients with severe idiopathic arthrofibrosis following TKA treated with low-dose irradiation and RH revision maintained a gain in knee range of motion of 60° with reliable flexion contracture correction at a mean 6-year follow-up. A manipulation under anesthesia was common in the postoperative period. Survivorship free from revision for aseptic loosening was excellent at 10 years. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to identify the rate and risk factors for a reoperation for arthrofibrosis following primary anterior cruciate ligament (ACL) reconstruction. Methods: Prospective data recorded in the New Zealand ACL Registry were cross‐referenced with data from the Accident Compensation Corporation (ACC). Primary ACL reconstructions performed between April 2014 and May 2021 were analysed. The ACC database was used to identify patients who underwent a reoperation for a diagnosis of arthrofibrosis. Multivariable survival analysis was performed to compute adjusted hazard ratios (aHR) and 95% confidence intervals. Results: A total of 12,296 primary ACL reconstructions were analysed, of which 230 underwent a reoperation for arthrofibrosis (1.9%) at a mean follow‐up of 3.6 years. A higher risk of arthrofibrosis was observed in females (aHR = 1.76, p = 0.001), patients with a history of previous knee surgery (aHR = 1.82, p = 0.04) and when a transtibial drilling technique was used (aHR = 1.53, p = 0.03). ACL reconstruction >6 months after injury had the lowest rate of arthrofibrosis (1.3%, aHR = 0.45, p = 0.01). There was no difference in risk between early surgery within 6 weeks versus delayed surgery between 6 weeks and 6 months after injury (2.9% versus 2.1%, aHR = 0.78, not significant). Conclusion: Female sex, previous knee surgery and a transtibial drilling technique increased the risk of reoperation for arthrofibrosis. Early surgery within 6 weeks of injury was not associated with an increased risk when compared with surgery between 6 weeks and 6 months after injury. Level of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Purpose: It has been suggested that low-grade infections could be the cause of arthrofibrosis. However, this hypothesis has not been conclusively proven. The aim of this study is to assess the incidence of unexpected positive cultures (UPC) in patients undergoing revision total joint arthroplasty for a diagnosis of arthrofibrosis. Methods: A retrospective single-centre review was performed. All patients who underwent an aseptic revision due to histologically confirmed arthrofibrosis (based on the synovial-like interface membrane (SLIM) criteria) were included. The incidence of UPC was then calculated. Results: A total of 147 patients were included. Of these, 100 underwent a total knee arthroplasty (TKA) procedure and 46 a total hip arthroplasty (THA) surgery. One patient had a periprosthetic joint infection and was therefore excluded. Of the 146 included patients, 6 had confirmed UPC (4.08%). The following bacteria were identified: Anaerococcus octavius, Staphylococcus epidermidis, Enterobacter cloacae, Staphylococcus hominis, Streptococcus pluranimalium, Staphylococcus pettenkoferi. Conclusions: Our results suggest that the incidence of UPC in patients with arthrofibrosis is low. It is lower than that of UPC in patients that undergo a revision for other causes. There is no proven relationship between histologically confirmed arthrofibrosis following total joint arthroplasty and prosthetic joint infection. [ABSTRACT FROM AUTHOR]

Arthrofibrosis, which causes joint motion restrictions, is a common complication following total knee arthroplasty (TKA). Key features associated with arthrofibrosis include myofibroblast activation, knee stiffness, and excessive scar tissue formation. We previously demonstrated that adiponectin levels are suppressed within the knee tissues of patients affected by arthrofibrosis and showed that AdipoRon, an adiponectin receptor agonist, exhibited anti‐fibrotic properties in human mesenchymal stem cells. In this study, the therapeutic potential of AdipoRon was evaluated on TGFβ1‐mediated myofibroblast differentiation of primary human knee fibroblasts and in a mouse model of knee stiffness. Picrosirius red staining revealed that AdipoRon reduced TGFβ1‐induced collagen deposition in primary knee fibroblasts derived from patients undergoing primary TKA and revision TKA for arthrofibrosis. AdipoRon also reduced mRNA and protein levels of ACTA2, a key myofibroblast marker. RNA‐seq analysis corroborated the anti‐myofibrogenic effects of AdipoRon. In our knee stiffness mouse model, 6 weeks of knee immobilization, to induce a knee contracture, in conjunction with daily vehicle (DMSO) or AdipoRon (1, 5, and 25 mg/kg) via intraperitoneal injections were well tolerated based on animal behavior and weight measurements. Biomechanical testing demonstrated that passive extension angles (PEAs) of experimental knees were similar between vehicle and AdipoRon treatment groups in mice evaluated immediately following immobilization. Interestingly, relative to vehicle‐treated mice, 5 mg/kg AdipoRon therapy improved the PEA of the experimental knees in mice that underwent 4 weeks of knee remobilization following the immobilization and therapy. Together, these studies revealed that AdipoRon may be an effective therapeutic modality for arthrofibrosis. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the functional outcomes of patients undergoing arthroscopic arthrolysis of the knee and find the ideal timing for arthrolysis to achieve maximum range of motion (ROM) of the knee. Methods: All patients who underwent arthroscopic arthrolysis for post-operative joint stiffness following surgery for injuries around knee joint at a tertiary care centre from 2009 to 2023 were included in this study. The patients’ details such as primary injury, time interval between the index surgery and arthrolysis, improvement in knee range of ROM and Lysholm score from prior to arthrolysis to last follow-up post arthrolysis were retrieved from hospital database and analysed. Results: Total of 42 patients who underwent arthroscopic arthrolysis of knee from 2009 to 2023 were included in this study. Follow-up range was 6 months to 6 years. ROM after arthrolysis significantly improved in the early and delayed arthrolysis groups as compared to late arthrolysis groups (mean 126.25 and 115.62 vs 106.3, p < 0.05). Patients treated with early arthroscopic arthrolysis (within 3 months) showed significant increase in post operative Lysholm score compared to other groups (p < 0.05). ROM of 120° and beyond was achieved in 75% of cases in early arthrolysis group compared to 62.8% and 39% in delayed and late arthrolysis group (p < 0.05). Conclusions: Arthroscopic arthrolysis done within 6 months (with maximum effect when done within 3 months) after the primary surgery leads to significant improvement in ROM and functional scores as compared to those with late arthrolysis group. [ABSTRACT FROM AUTHOR]

BackgroundPostoperative knee arthrofibrosis is a common and potentially detrimental complication affecting knee function and gait. Several cohort studies have reported good outcomes after arthroscopic lysis of adhesions (LOA) with manipulation under anesthesia (MUA).PurposeTo review the literature assessing the efficacy and complications of arthroscopic LOA and MUA for postoperative arthrofibrosis of the knee and evaluate whether any relevant subgroups are associated with different clinical presentation and outcomes.Study designSystematic review; Level of evidence, 4.MethodsThis review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies published from January 1, 1990, to April 1, 2021, were identified through a search of the US National Library of Medicine (PubMed/MEDLINE), EMBASE, and Cochrane databases. All studies included in this analysis included pre- and postoperative range of motion measurements for their treated patients. Studies reporting outcomes for patients with isolated cyclops lesions after anterior cruciate ligament reconstruction were excluded.ResultsEight studies comprising 240 patients were included. The mean time from index surgery to arthroscopic LOA and MUA was 8.4 months, and the mean postoperative follow-up was at 31.2 months. All studies demonstrated a significant improvement (41.6°) in arc of motion after arthroscopic LOA. Clinically significant improvements in outcome measures, including the International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score, were reported after arthroscopic LOA across all applicable studies. Of 240 patients, a single complication (synovial fistula) occurred after LOA and MUA, which resolved without intervention.ConclusionThe results of this review indicated that arthroscopic LOA and MUA is a safe and efficacious treatment for postoperative arthrofibrosis of the knee.

With the growing number of primary arthroscopies performed, patients requiring revision hip arthroscopies for various issues is high including postoperative adhesion formation, a source of pain, mechanical symptoms, range of motion limitation, stiffness, and microinstability. Adhesions are a consequence of biological pathways that have been stimulated by injury or surgical interventions leading to an increased healing response. Preventative efforts have included surgical adjuncts during/after primary hip arthroscopy, biologic augmentation, and postoperative rehabilitation. Treatment options for adhesion formation includes surgical lysis of adhesions with or without placement of biologic membranes aimed at inhibiting adhesion reformation as well as systemic medications to further reduce the risk. Postoperative rehabilitation exercises have also been demonstrated to prevent adhesions as a result of hip arthroscopy. Ongoing clinical trials are further investigating pathways and prevention of adhesion formation.

Excessive posttraumatic scarring in orthopedic tissues, such as joint capsules, ligaments, tendons, muscles, and peripheral nerves, presents a significant medical problem, resulting in pain, restricted joint mobility, and impaired musculoskeletal function. Current treatments for excessive scarring are often ineffective and require the surgical removal of fibrotic tissue, which can aggravate the problem. The primary component of orthopedic scars is collagen I-rich fibrils. Our research team has developed a monoclonal anti-collagen antibody (ACA) that alleviates posttraumatic scarring by inhibiting collagen fibril formation. We previously established the safety and efficacy of ACA in a rabbit-based arthrofibrosis model. In this study, we evaluate the utility of a well-characterized thermoresponsive hydrogel (THG) as a delivery vehicle for ACA to injury sites. Crucial components of the hydrogel included N-isopropylacrylamide, poly(ethylene glycol) diacrylate, and hyaluronic acid. Our investigation focused on in vitro ACA release kinetics, stability, and activity. Additionally, we examined the antigen-binding characteristics of ACA post-release from the THG in an in vivo context. Our preliminary findings suggest that the THG construct exhibits promise as a delivery platform for antibody-based therapeutics to reduce excessive scarring in orthopedic tissues. [ABSTRACT FROM AUTHOR]

Joint contractures after anterior cruciate ligament (ACL) reconstruction are a serious problem. Given the uncertain effects of weight bearing after ACL reconstruction on contractures, this study was conducted to examine such effects. To control the amount of weight bearing, ACL-reconstructed rats were reared with either untreated (small weight bearing; weight bearing during locomotion was 54% of pre-surgery at minimum), hindlimb unloading (non-weight bearing), or sustained morphine administration (large weight bearing; weight bearing during locomotion was maintained at 80% or more of pre-surgery) conditions. Untreated rats were used as controls. Knee extension range of motions (ROMs) before (includes myogenic and arthrogenic factors) and after myotomy (includes arthrogenic factor only) and fibrotic reactions in the joint capsule were assessed 7 and 14 days post-surgery. ACL reconstruction significantly reduced ROMs both before and after myotomy and induced fibrosis in the joint capsule accompanying upregulation of fibrosis-related genes (i.e., type I and III collagens and transforming growth factor-β1) at both time points. Morphine administration increased the ROM before myotomy, but not after myotomy 7 days post-surgery. Unloading after ACL reconstruction improved ROMs both before and after myotomy at both time points. In addition, unloading after ACL reconstruction attenuated fibrotic reactions in the joint capsule. Our results suggest that morphine administration improves myogenic contractures in parallel with an increase in the amount of weight bearing. Unloading after ACL reconstruction is effective in reducing both myogenic and arthrogenic contractures. [ABSTRACT FROM AUTHOR]

Arthrofibrosis occurs in up to 10% of patients who undergo total knee arthroplasty (TKA). For cases that are not amenable to manipulation under anesthesia (MUA), there is little consensus on how many components should be revised. We compared outcomes of polyethylene exchanges, when doing lysis of adhesions (LOA) versus full component revision. Specifically, we assessed: (1) re-operation rates at one and two years; (2) rates of surgical complications at one year; and (3) associated risk factors for requiring a LOA. A database queried all patients who underwent revision TKA for arthrofibrosis. A total of 2410 patients were identified, 1120 (46.5%) of which underwent all-component knee revision, while the remaining 1290 (53.5%) underwent polyethylene spacer revision. Multivariate logistic regressions assessed re-operation rates and risk factors for requiring LOA. The incidence and odds of re-operation within one year following polyethylene exchange was not significantly different than full component revision (10.9 versus 12.9%, odds ratio (OR) 0.83, 95% confidence interval (CI) [0.64–1.06], p = 0.145). However, the adjusted models for re-operation within one- and two-years following LOA in the form of polyethylene exchange revision was significantly higher than the full component revision cohort (OR 1.52 CI [1.07–2.17], p = 0.022 and OR 1.44 CI [1.06–1.97] p = 0.022). Risk factors associated with the need for lysis of adhesions included age less than 60 years, depression, fibromyalgia, and anxiety. Full component revision TKA for arthrofibrosis was associated with lower two-year re-operation rate than polyethylene exchange. Risk factors for LOA include younger age and fibromyalgia. [ABSTRACT FROM AUTHOR]

Proximal humerus fractures (PHFs) have an estimated annual incidence of 25 per 10 000 people in the United States (1). Treatment of these fractures varies depending on patient-related factors and fracture characteristics. For patients 65 years old, due to high rates of failure with open reduction and internal fixation, generally either conservative treatment or arthroplasty is preferred.

Background: Emerging studies have suggested an essential role of fibroblast metabolic reprogramming in the pathogenesis of arthrofibrosis. The metabolic modulator metformin appears to be a therapeutic candidate for fibrotic disorders. However, whether metformin could alleviate arthrofibrosis has not been defined. In this study we have determined if treatment with metformin has beneficial effect on arthrofibrosis and its underlying mechanism. Methods: Articular capsule samples were collected from patients with/without arthrofibrosis to perform gene and protein expression analysis. Arthrofibrosis animal model was established to examine the anti-fibrotic effect of metformin. Cell culture experiments were conducted to determine the mechanism by which metformin inhibits fibroblast activation. Results: We found that glycolysis was upregulated in human fibrotic articular capsules. In an arthrofibrosis animal model, intra-articular injection of metformin mitigated inflammatory reactions, downregulated expression of both fibrotic and glycolytic markers, improved range of motion (ROM) of the joint, and reduced capsular fibrosis and thickening. At the cellular level, metformin inhibited the activation of fibroblasts and mitigated the abundant influx of glucose into activated fibroblasts. Interestingly, metformin prompted a metabolic shift from oxidative phosphorylation to aerobic glycolysis in activated fibroblasts, resulting in the anti-fibrotic effect of metformin. Conclusion: Metformin decreased glycolysis, causing a metabolic shift toward aerobic glycolysis in activated fibroblasts and has beneficial effect on the treatment of arthrofibrosis.The translational potential of this article: The findings of this study demonstrated the therapeutic effect of metformin on arthrofibrosis and defined novel targets for the treatment of articular fibrotic disorders.

The elbow is prone to stiffness due to its unique anatomy and profound capsular reaction to inflammation. The resulting movement impairment may significantly interfere with a patient’s activities of daily living. Trauma (including surgery for trauma), posttraumatic arthritis, and heterotopic ossification (HO) are the most common causes of elbow stiffness. In stiffness caused by soft tissue contractures, initial conservative treatment with physiotherapy (PT) and splinting is advised. In cases in which osseous deformities limit range of motion (e.g. malunion, osseous impingement, or HO), early surgical intervention is recommended. Open and arthroscopic arthrolysis are the primary surgical options. Arthroscopic arthrolysis has a lower complication and revision rate but has narrower indications. Early active mobilization using PT after surgery is recommended in postoperative rehabilitation and may be complemented by splinting or continuous passive motion therapy. Most results are gained within the first few months but can continue to improve until 12 months. This paper reviews the current literature and provides state-of-the-art guidance on the management regarding prevention, evaluation, and treatment of elbow stiffness.

Rheumatoid arthritis (RA), osteoarthritis (OA), and gout are the most prevalent degenerative joint diseases (DJDs). The pathogenesis underlying joint disease in DJDs remains unclear. Considering the severe toxicities reported with anti-inflammatory and disease-modifying agents, there is a clear need to develop new treatments that are specific in their effect while not being associated with significant toxicities. A key feature in the development of joint disease is the overexpression of adhesion molecules, e.g., CD44. Expression of CD44 and its variants in the synovial tissues of patients with DJDs is strongly associated with cartilage damage and appears to be a predicting factor of synovial inflammation in DJDs. Targeting CD44 and its downstream signaling proteins has emerged as a promising therapeutic strategy. PRG4 is a mucinous glycoprotein that binds to the CD44 receptor and is physiologically involved in joint lubrication. PRG4-CD44 is a pivotal regulator of synovial lining cell hemostasis in the joint, where lack of PRG4 expression triggers chronic inflammation and fibrosis, driven by persistent activation of synovial cells. In view of the significance of CD44 in DJD pathogenesis and the potential biological role for PRG4, this review aims to summarize the involvement of PRG4-CD44 signaling in controlling synovitis, synovial hypertrophy, and tissue fibrosis in DJDs. [ABSTRACT FROM AUTHOR]

Background: Arthrofibrosis (AF) after anterior cruciate ligament reconstruction (ACLR) remains a challenge. There is a paucity of data on arthroscopic interventions for AF after ACLR. Purpose: To (1) describe the patient, injury, and surgical characteristics and patient-reported outcomes (PROs) of those requiring an arthroscopic intervention for loss of motion after ACLR and (2) compare outcomes between patients undergoing an early intervention (within 3 months) versus those undergoing a late intervention (after 3 months). Study Design: Case series; Level of evidence, 4. Methods: Patients with a history of ACLR and a subsequent operative procedure for postoperative AF at a single institution between 2000 and 2018 were retrospectively identified. Arthroscopic interventions included lysis of adhesions, capsular release with or without manipulation under anesthesia, and excision of cyclops lesions. Patients were excluded if they had a knee dislocation or multiple-ligament injury, a periarticular fracture, or less than 2-year follow-up from the arthroscopic intervention. PROs including the Tegner activity score, visual analog scale pain score, and International Knee Documentation Committee score as well as knee range of motion (ROM) were recorded. Results: A total of 40 patients were included with a mean age of 27.2 years (range, 11.0-63.8 years) at surgery and a mean follow-up of 10.0 years (range, 2.9-20.7 years). The mean preoperative flexion and extension were 102° (range, 40°-150°) and 8° (range, 0°-25°), respectively. The mean postoperative flexion and extension were 131° (range, 110° to 150°) and 0° (range, –10° to 5°), respectively. After the arthroscopic intervention, the mean ROM improved from 94° (range, 40°-140°) preoperatively to 131° (range, 107°-152°) at final follow-up (P <.001), and the visual analog scale pain score improved from 3.0 preoperatively to 1.2 postoperatively (P =.001). Overall, 13 patients (32.5%) underwent an intervention within 3 months and 27 (67.5%) after 3 months. The early intervention group had a higher postoperative International Knee Documentation Committee score compared with the late intervention group (86.8 vs 71.7, respectively; P =.035). Conclusion: An arthroscopic intervention for AF after ACLR successfully improved knee ROM and pain. Patients who underwent either early or late surgery obtained satisfactory motion and function, although improved PROs were observed when the intervention occurred within 3 months of the primary procedure. [ABSTRACT FROM AUTHOR]

Background: Arthrofibrosis can limit function and return to sport after anterior cruciate ligament (ACL) reconstruction. Previously reported risk factors for developing arthrofibrosis after ACL reconstruction include female sex, age <18 years, time from injury to surgery <28 days, concomitant meniscal repair, prolonged immobilization, and genetic factors. There is a lack of evidence regarding whether race plays a significant role. Hypothesis: The risk of undergoing manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) after primary ACL reconstruction with bone–patellar tendon–bone (BTB) autograft in female basketball players is higher in African American players than in White players. Study Design: Case-control study; Level of evidence, 3. Methods: Using a computerized relational database, the authors identified competitive female basketball players who underwent primary ACL reconstruction with BTB autograft by the senior author over a 13-year period. Data previously entered from examinations and surgical findings were reviewed retrospectively. Univariate statistics and multivariable logistic regression were used to assess the relationship between undergoing subsequent MUA and/or LOA and study predictors. Results: A total of 186 knees (114 African American knees and 72 White knees) met inclusion criteria. The overall rate of MUA and/or LOA was 8.6%. Thirteen African American knees (11.4%) and 3 White knees (4.2%) underwent MUA and/or LOA for treatment of arthrofibrosis. No study predictor was found to have a statistically significant relationship with the rate of MUA and/or LOA on univariate analysis. However, when controlling for body mass index and previously described risk factors (age <18 years, time from injury to surgery ≤28 days, and concomitant meniscal repair) in the logistic regression model, the authors found that MUA and/or LOA was more likely in African American (odds ratio, 4.01 [95% CI, 1.01-15.92]; P =.049) than in White female players and in patients who underwent ACL reconstruction within 28 days of injury (odds ratio, 4.01 [95% CI, 1.18-13.57]; P =.026) compared with those with surgery delayed beyond 28 days. Conclusion: In female basketball players, the present study found a statistically significantly increased risk for undergoing MUA and/or LOA after primary ACL reconstruction with BTB autograft in African American females compared with White females and in patients who underwent ACL reconstruction within 28 days of injury. [ABSTRACT FROM AUTHOR]

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This article provides a narrative review of the risk factors for anterior cruciate ligament reconstruction (ACLR) failures, as well as strategies to prevent such failures. Early timing for ACLR is not a risk factor for arthrofibrosis anymore according to recent studies. Vancomycin-soaked grafts appear to decrease infection rates after ACLR and are cost-effective. Proper tunnel placement is critical for anatomic ACLR to restore knee kinematics and joint stability. The article proposes a reproducible and accurate method for tunnel positioning. Increased sagittal plane tibial slope has been identified as a risk factor for primary ACLR failure. An anterior closing wedge proximal tibial osteotomy is suggested as a viable option for reducing posterior tibial slope. The lateral extra-articular tenodesis procedure in ACLR is effective in restoring both anterior tibial translation and rotatory stability. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to systematically review multiligament knee injury (MLKI) outcome studies to determine definitions of arthrofibrosis (AF) and provide information about incidence, management as well as potential risk factors. Methods: A systematic literature search was performed (PubMed and Cochrane library) following the PRISMA guidelines of operatively treated MLKI (Schenck II–IV) studies reporting the incidence of AF. Twenty-five studies met the inclusion criteria. Injury pattern, timing of surgery, surgical technique, treatment of AF, rehabilitation programs and PROMS were inquired. Risk of bias and quality of evidence were assessed using the Coleman methodological score. Results: Twenty-five studies with a total of 709 patients with a mean age of 33.6 ± 4.8 years were included and followed 47.2 ± 32.0 months. The majority of studies (22/25) used imprecise and subjective definitions of AF. A total of 86 patients were treated for AF, resulting in an overall prevalence of 12.1% (range 2.8–57.1). Higher-grade injuries (Schenck III–IV), acute treatment and ROM (range of motion) limiting rehabilitation programs were potential risk factors for AF. The time from index surgery to manipulation anesthesia (MUA) and arthroscopic lysis of adhesions (LOA) averaged at 14.3 ± 8.8 and 27.7 ± 12.8 weeks. Prior to MUA and LOA, the ROM was 51.7° ± 23.5 and 80.2° ± 17.0, resulting in a total ROM gain after intervention of 65.0° ± 19.7 and 48.0° ± 10.6, respectively; with no reports of any complication within the follow-up. The overall methodological quality of the studies was poor as measured by the Coleman score with average 56.3 ± 12.5 (range 31–84) points. Conclusions: AF is a common but poorly defined complication particularly in high-grade MLKI. Early postoperative and intensified physiotherapy is important to reduce the risk of AF. MUA and LOA are very effective treatment options and result in good clinical outcome. Prospective studies with bigger study population are needed to optimize treatment algorithms of further patients after MLKI. The protocol of this systematic review has been prospectively registered with PROSPERO (CRD42021229187, January 4th, 2021). [ABSTRACT FROM AUTHOR]

Fibrosis is a common and debilitating pathological process that affects many organ systems and contributes to connective tissue disorders in orthopaedics. Tendons heal after acute and chronic injury through a process of fibrovascular scar tissue formation, and soft tissue joint capsules can be affected after traumatic joint injury, leading to arthrofibrosis. Although the precise underlying mechanisms are still being elucidated, fibrosis is thought to be a consequence of dysregulated immune and cytokine signaling that leads to myofibroblast activation and proliferation and subsequent excessive collagen deposition. Current treatments for connective tissue fibrosis include physical therapy and surgery, but there are no therapies that directly target the underlying cellular and molecular mechanisms of fibrosis. Many pharmacological agents have been used to successfully target fibrosis in other tissues and organ systems and thus are a promising treatment option to fill this gap. However, limited evidence is available to guide the use of these agents in musculoskeletal connective tissues. This article provides an overview of pharmacological therapies that have potential to treat connective tissue fibrosis in patients with musculoskeletal conditions, along with the current supporting evidence and future uses of each therapy. [ABSTRACT FROM AUTHOR]

Introduction: A painful, stiff knee after TKA affects the outcome. Various causes have been identified, including heterotrophic ossification (HO), but there is no documented evidence of bone formation between the patella and intercondylar notch of the distal femur in HO. Case report: We present the case of an elderly gentleman who presented with a painful stiff knee after revision TKA due to extensive HO leading to the formation of a bone bridge between the patella and femur. He was treated with repeat revision TKA using a rotating hinge prosthesis and achieved a painless, well-functioning knee at 3 years follow-up. Conclusion: Severe HO following TKA necessitating revision surgery is rare. In most cases, HO is minor and confined to the anterior distal femur without causing any functional compromise. In some cases, it can be widespread and affect all the tissues around the knee joint, causing severe restriction of movement.

Arthrofibrosis is defined as an excessive fibrotic tissue response within a joint leading to a painful loss of motion. This pathological scar formation process with dysregulated, inordinate extracellular matrix formation, especially collagen, may occur in any joints, although is frequently localized in the knee. Different etiologies have been described and most of them are related to trauma, infection or recent surgical procedure. Although arthrofibrosis affects people of all ages, it is unusual in pediatric population. We present a case report of an uncommon, foreign body induced knee arthrofibrosis in a 14-year old boy. We also review the current literature regarding diagnostic procedures and treatment rationale for arthrofibrosis of the knee.

Introduction: Arthrofibrosis remains a common cause of patient dissatisfaction and reoperation after total knee arthroplasty (TKA). Losartan is an angiotensin receptor blocker (ARB) with inhibitory effects on transforming growth factor beta, previously implicated in tissue repair induced fibrosis, and has been studied to prevent stiffness following hip arthroscopy. This study aimed to evaluate pre- and postoperative range of motion (ROM) and the incidence of manipulation under anesthesia (MUA) following primary TKA in patients taking Losartan preoperatively for hypertension. Materials and methods: A retrospective review of 170 patients from 2012 to 2020 who underwent a primary, elective TKA and were prescribed Losartan at least three months prior to surgery. All patients who were prescribed Losartan and had a preoperative and postoperative ROM in their chart were included and were matched to a control group of patients who underwent TKA and had no Losartan prescription. ROM, MUA, readmissions, reoperations, and revisions were assessed using chi-square and independent sample t tests. Results: Seventy-nine patients met the inclusion criteria. Preoperative ROM was similar between patients on Losartan and the control group (103.59° ± 16.14° vs. 104.59° ± 21.59°, respectively; p = 0.745). Postoperative ROM and ΔROM were greater for patients prescribed Losartan (114.29° ± 12.32° vs. 112.76° ± 11.65°; p = 0.429 and 10.57° ± 14.95° vs. 8.17° ± 21.68°; p = 0.422), though this difference did not reach statistical significance. There was no difference in readmission, rate of manipulation for stiffness, or all-cause revision rates. Conclusion: In this study, we found that the use of Losartan did not significantly improve postoperative ROM, reduce MUA or decrease revision rates. Further prospective studies using Losartan are required to elucidate the potential effects on ROM and incidence of arthrofibrosis requiring MUA. Level III evidence: Retrospective cohort study. [ABSTRACT FROM AUTHOR]

Purpose: To utilise a large cross-sectional database to analyse the effects of time duration between diagnosis of anterior cruciate ligament (ACL) tear and ACL reconstruction (ACLR) on concomitant procedures performed and subsequent surgery within 2 years. Methods: An analysis from 2015 to 2018 was performed using the Mariner PearlDiver Patient Records Database. Current Procedural Terminology (CPT), and International Classification of Diseases (ICD-10) codes identified patients with a diagnosis of ACL tear who underwent subsequent ACLR. Patients were stratified in biweekly and bimonthly increments based on the time duration between initial diagnosis of ACL tear and surgical treatment. Chi-squared analysis was used to compare categorical variables, and trend analysis was performed with Cochran–Armitage independence testing. Results: Of 11,867 patients who underwent ACLR, 76.1% underwent surgery within 2 months of injury diagnosis. Patients aged 10–19 were most likely to undergo surgery within 2 months of injury diagnosis (83.5%, P < 0.0001). As duration from injury diagnosis to ACLR increased from < 2 months to > 6 months, rates of concomitant meniscectomy increased from 9.1% to 20.5% (P < 0.0001). The overall 2-year subsequent surgery rate was 5.3%. The incidence of revision ACLR was highest for patients who underwent surgery > 6 months after diagnosis (P < 0.0001), whilst the incidence of ipsilateral lysis of adhesions and manipulation under anaesthesia (MUA) was highest for patients who underwent surgery < 2 months after diagnosis (P < 0.0001). ACLR at 6–8 weeks after diagnosis demonstrated the lowest risk for concomitant procedures as well as 2-year subsequent surgery. Conclusion: The majority of patients undergo ACL reconstruction within 2 months of initial ACL tear diagnosis. Delayed surgery greater than 6 months after the diagnosis of an ACL rupture leads to increased need for concomitant meniscectomy as well as higher risk for revision ACLR within 2 years, but immediate surgery may increase risk for knee arthrofibrosis. Level of evidence: IV [ABSTRACT FROM AUTHOR]

Purpose: Arthrofibrosis is a common inflammatory complication of joint trauma and surgery. 5lipoxygenase (5-LO) is a key enzyme involved in inflammation. Inhibition of 5-LO has been shown to reduce inflammation in heart and lung models but has not been examined in a joint contracture model. Methods: Twenty-six rats underwent joint contracture. Six rats served as non-surgical controls. A 5-LO inhibitor, caffeic acid (CA), suspended in 10% ethanol was orally administered to 14 rats and ethanol without CA to the remaining 12 rats daily for 21 days. Leukotriene B4 (LTB4) levels were measured, both systemically and locally. 5-LO levels in the posterior capsule were quantified by measuring the ratio of the length of the posterior capsule demonstrating 5-LO immunostaining to the total length of the capsule. Results: Joint contracture was successfully achieved in all rats who underwent manipulation. Levels of 5- LO measured in the posterior capsule were significantly increased in the animals who underwent surgery (56%/44–64) compared to the non-surgical control animals (7%/4–9). LTB4 levels were found to be significantly lower in the non-surgical control animals (107.79 ± 34.08 pg/ml) compared to all surgical animals (157.6 ± 55.3 pg/ml). Conclusion: Surgical intervention resulted in increased 5-LO activity of the synovial surface of the posterior capsule and increased LTB4 levels in the patellar tendon—fat pad. Oral administration of the 5LO inhibitor, CA, was ineffective at reducing systemic and local LTB4 levels and preventing knee joint contracture. Inhibiting 5-LO activity may still be effective in preventing arthrofibrosis and warrants further investigation. [ABSTRACT FROM AUTHOR]

Following anterior cruciate ligament (ACL) injury, 20% of patients will develop osteoarthritis. Despite this, there remains a paucity of data describing outcomes of total knee arthroplasty (TKA) after prior ACL reconstruction. We aimed to describe survivorships, complications, radiographic results, and clinical outcomes of TKA after ACL reconstruction in one of the largest series to date. We identified 160 patients (165 knees) who underwent primary TKA following prior ACL reconstruction between 1990 and 2016 using our total joint registry. The mean age at TKA was 56 years (range, 29-81), 42% were women, and their mean body mass index was 32. Ninety percent of knees were posterior-stabilized designs. Survivorship was assessed using the Kaplan-Meier method. The mean follow-up was 8 years. The 10-year survivorships free of any revision and any reoperation were 92 and 88%, respectively. Seven patients were revised for instability (6 global and 1 flexion), 4 for infection, and 2 for other reasons. There were 5 additional reoperations: 3 manipulations under anesthesia, 1 wound debridement, and 1 arthroscopic synovectomy for patellar clunk. Nonoperative complications occurred in 16 patients, 4 of which were flexion instability. Radiographically, all nonrevised knees were well-fixed. Knee Society Function Scores significantly improved from preoperative to 5 years postoperative (P <.0001). Survivorship of TKA in post-ACL reconstruction knees was lower than expected with instability being the most common reason for revision. In addition, the most common nonrevision complications were flexion instability and stiffness requiring manipulations under anesthesia, indicating that achieving soft tissue balance in these knees may be difficult. [ABSTRACT FROM AUTHOR]

Dissatisfaction occurs in nearly 20% of patients after total knee arthroplasty (TKA); however, there remains only limited understanding of the biologic mechanisms that may contribute to suboptimal postoperative outcomes requiring revision surgery. Expansion of effector T and B cells, could promote an abnormal healing response via local or peripheral immune system mechanisms and contribute to inferior outcomes necessitating revision TKA. In this pilot study, we hypothesized that patients suffering from complications of arthrofibrosis or instability may exhibit differences in adaptive immune function. Patients (n = 31) undergoing revision TKA for an indication of arthrofibrosis or instability were prospectively enrolled. Whole blood and synovial fluid (SF) from the operative knee were collected at time of surgery. Peripheral blood mononuclear cells were isolated and analyzed by flow cytometry. Serum and SF were assessed for immunoglobulin levels by Luminex and antiphospholipid antibodies by enzyme‐linked immunoassay. No significant differences were observed in peripheral blood T/B cell populations or serum immunoglobulins levels between groups. SF analysis demonstrated significant differences between the two groups, with higher levels of immunoglobulin G1 (IgG1) (p = 0.0184), IgG3 (p = 0.0084) and antiphosphatidyl serine IgG (p = 0.034) in arthrofibrosis relative to instability patients. Increased levels of both IgG subclasses and antiphospholipid antibodies in the SF suggest that intra‐articular T‐B cell interactions, potentially triggered by exposure to apoptotic components generated during post‐op healing, could be functioning as a source of immune complexes that fuel fibrous tissue growth in arthrofibrotic patients. [ABSTRACT FROM AUTHOR]

Purpose: Arthrofibrosis after primary total knee arthroplasty (TKA) is a significant contributor to patient dissatisfaction. While treatment algorithms involve early physical therapy and manipulation under anaesthesia (MUA), some patients ultimately require revision TKA. It is unclear whether revision TKA can consistently improve these patient's range of motion (ROM). The purpose of this study was to evaluate ROM when revision TKA was performed for arthrofibrosis. Methods: A retrospective study of 42 TKA's diagnosed with arthrofibrosis from 2013 to 2019 at a single institution with a minimum 2-year follow-up was performed. The primary outcome was ROM (flexion, extension, and total arc of motion) before and after revision TKA, and secondary outcomes included patient reported outcomes information system (PROMIS) scores. Categorical data were compared using chi-squared analysis, and paired samples t tests were performed to compare ROM at three different times: pre-primary TKA, pre-revision TKA, and post-revision TKA. A multivariable linear regression analysis was performed to assess for effect modification on total ROM. Results: The patient's pre-revision mean flexion was 85.6 degrees, and mean extension was 10.1 degrees. At the time of the revision, the mean age of the cohort was 64.7 years, the average body mass index (BMI) was 29.8, and 62% were female. At a mean follow-up of 4.5 years, revision TKA significantly improved terminal flexion by 18.4 degrees (p < 0.001), terminal extension by 6.8 degrees (p = 0.007), and total arc of motion by 25.2 degrees (p < 0.001). The final ROM after revision TKA was not significantly different from the patient's pre-primary TKA ROM (p = 0.759). PROMIS physical function, depression, and pain interference scores were 39 (SD = 7.72), 49 (SD = 8.39), and 62 (SD = 7.25), respectively. Conclusion: Revision TKA for arthrofibrosis significantly improved ROM at a mean follow-up of 4.5 years with over 25 degrees of improvement in the total arc of motion, resulting in final ROM similar to pre-primary TKA ROM. PROMIS physical function and pain scores showed moderate dysfunction, while depression scores were within normal limits. While physical therapy and MUA remain the gold standard for the early treatment of stiffness after TKA, revision TKA can improve ROM. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

This article provides a narrative review of the risk factors for anterior cruciate ligament reconstruction (ACLR) failures, as well as strategies to prevent such failures. Early timing for ACLR is not a risk factor for arthrofibrosis anymore according to recent studies. Vancomycin-soaked grafts appear to decrease infection rates after ACLR and are cost-effective. Proper tunnel placement is critical for anatomic ACLR to restore knee kinematics and joint stability. The article proposes a reproducible and accurate method for tunnel positioning. Increased sagittal plane tibial slope has been identified as a risk factor for primary ACLR failure. An anterior closing wedge proximal tibial osteotomy is suggested as a viable option for reducing posterior tibial slope. The lateral extra-articular tenodesis procedure in ACLR is effective in restoring both anterior tibial translation and rotatory stability.

Background: There are few large studies evaluating total knee arthroplasty (TKA) in young patients. Therefore, we sought to evaluate patients aged 45 years or younger undergoing a primary TKA. Methods: This was a retrospective, single-institution study, from 2003 to 2018, evaluating primary TKA in patients aged 45 years or younger. We identified 162 TKAs with a minimum follow-up duration of 2 years. Common surgical indications were degenerative joint disease (50%), post-traumatic arthritis (21%), and inflammatory arthritis (20%). Forty-nine knees had a prior significant knee surgery. We evaluated survivorship free of revision for any reason and aseptic revision. In addition, we characterized complication rates and risk factors for failure. Results: The mean age was 39 years, 70% were female, and the mean clinical follow-up duration was 7 years. At 8 years, survivorship free of revision for any reason was 82%, and survivorship free of aseptic revision was 87%. Fifty-five knees experienced at least 1 complication, with an overall complication rate of 34%. There were 6 (4%) periprosthetic joint infections (PJIs), and 24 (15%) knees of patients underwent manipulation under anesthesia with or without arthroscopic lysis of adhesions. There were no specific risk factors for revisions identified. Age less than 40 years was associated with PJI (P = .031), and marital status at the time of TKA was associated with arthrofibrosis requiring an intervention (P = .045). Conclusions: TKAs in patients aged 45 years or younger are associated with acceptable survivorship at a mean follow-up duration of 7 years. Patients should be counseled about the elevated risk of complications, specifically PJI and arthrofibrosis.