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Fibrosis refers to the process that follows chronic inflammation. A fibrotic tissue is like a scar tissue, thick, and rigid due to excessive accumulation of protein below the skin. Knee stiffness, a post -traumatic fibrosis caused disease, which is common in the underdeveloped countries. This is a complication of trauma where an extreme disfigurement tissue response leads to painful restriction of joint movement. Despite exercises and stretches, the scar tissue forms within the joints and within the soft tissues. Symptoms include pain, limping, stiffness, heat swelling and general body weakness. The prime goal of treatment in a stiff knee is restoration of normal motion without inflicting more damage on the adjacent or joint structures. Because forced manipulation of scarred knee could indiscriminate tearing of intra-articular tissue, compression of the tibiofemoral and patellofemoral with risk of chondral damage, rupture of ligament, and femoral fracture.
After a number of cases with patient with stiff knees in my centre, I identified some predominant cases with extra-articular causes. The prospective study consisted of 20 patients, who had stiffness after trauma. A surgical method was used. The patients with spinal anesthesia, tourniquet was used and without a standard leg holder to allow knee flexion and extra leg movements. Standard arthroscopic method using the ante lateral portal of the telescope and the anteromedial portal instruments inspected the knee joint. More medial and lateral suprapatellar portals were used to access joints. The intra-articular part of the procedure involved assessment and management of an existing intra-articular pathology. Arthroscopic lysis process of adhesions in the infrapatellar area was extended into medial and lateral gutters, and into the supra patellar until the patella was letting free of motion. In addition, the extra-articular procedure in the medial and lateral suprapatellar portals for access with the arthroscope and instruments was done alternatively. This made the suprapatellar pouch perforated and discharge of adhesions was done on the medial, anterior and lateral femur, from distal to proximal. The pressure on the fluid was minimized to avoid fluid extravasations, and manipulation into knee flexion periodically assessed to the remaining adhesions.
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Special physiotherapy attention was paid to these patients after surgery in the recovery room, even 48 hrs after the surgery active assisted exercises were encouraged. In addition, physiotherapy twice a day for the first week and physical therapy continued until maximum improvement.
Data Analysis
The range of flexion and extension of the knee joint was measured before and after the operation. Comparison of the effects of arthroscopic adhesion release and arthroscopic aided quadricepsplasty. Follow up was done at 7 weeks, 7months and at lastly one year after the surgery to calculate the degree of correction achieved and to reflect whether the flexion was achieved.
Results
My cohort study had 10 patients, 5 males and 5 females. The range of the patients was 20-59 years; with 14 patients being less than 32 years. Thirteen cases had the problem of knee immobilization for more than 5 months while none had less than two months. The period between the injury and surgery and the arthroscopic aided release was less than 2 years in 14 cases and more than two years in 4 knees.
Reduced patellofemoral glide was found in all of the cases, but with additional wound in the distal quadriceps, in 5 cases. The use of ultrasound revealed that both in intra and extra-articular sites in fifteen cases had limited to the area above the suprapatellar pouch in 5 cases and only 3 cases of intra-articular adhesions while 2 had a fusion of the patella to the anterior femur.
In many underdeveloped countries, in spite advance orthopedic for fracture and management of injury, inadequate techniques, improper rehabilitation and non-availability of medical experts leaves many people with stiff knees.