Welcome to the inaugural international panel discussion on the surgical treatment of arthrofibrosis. Kayley Usher, representing the International Arthrofibrosis Association, is excited to moderate this important conversation. Joining her are esteemed experts: Dr. Kristoffer Barfod from Denmark, Dr. Ralf Rosenberger from Austria, and Dr. Jason Dragoo from the USA.
This article is a summarized version of a conversation, created using AI assistance for clarity and brevity. It is not a verbatim transcript, and some details have been rephrased for readability.
Arthrofibrosis is a common complication following joint injuries and surgeries, and is characterized by stiffness, reduced range of motion, and pain. While pain is a significant concern in active arthrofibrosis, a residual form likely exists where pain is less prominent. It arises from excessive scar tissue formation and the activation of special cells called myofibroblasts, affecting various joints and often referred to by names like Frozen Shoulder or Stiff Elbow. Early intervention and treatment modification are crucial for patient recovery. In this panel discussion, the group will explore modified surgical treatments for arthrofibrosis.
This is a controversial subject and the views expressed by the panellists do not necessarily represent the views of the IAA.
Dr. Dragoo, do you agree with the IAA Advisor's preference for using cauterizing tools instead of mechanical shavers in arthrofibrosis surgery, and if so, why?
Dr. Jason Dragoo: I wholeheartedly agree with the use of cauterizing tools in arthrofibrosis surgery. In my experience, the more invasive we are and the more we alter the joint, the higher the chance of bleeding occurring during the procedure. Bleeding can set the stage for the scar tissue process to begin again, which is particularly problematic for patients who tend to be 'super healers.' While some patients have minimal healing responses, others exhibit excessive healing, which can complicate recovery.
As we've honed our techniques over the years, we first observed that patients undergoing arthrofibrosis surgery with mechanical shavers had poor recovery outcomes. We noticed that these patients often experienced swelling, which we believed was due to bleeding that required aspirations to remove excess fluid from the knee.
About 15 years ago, we began exploring radiofrequency ablation devices in arthroscopic surgery. Initially, these devices were met with skepticism within our profession due to their misuse in other contexts, but we started to recognize their potential benefits. These tools allow us to release tissues and make necessary cuts while simultaneously cauterizing and preventing bleeding. This approach has provided us with the best of both worlds.
Over time, we’ve refined our techniques to emphasize the importance of limiting bleeding during surgery. We’ve adopted a philosophy of striving for 'bloodless' surgery, or at least minimizing bleeding as much as possible. Whenever we see bleeding during the procedure, we make it a point to cauterize it.
Now, when dealing with arthrofibrosis, I focus on systematic releases rather than extensive dissection. I’ve learned that it's more advantageous to make targeted cuts in areas that require mobility, allowing the joint to maintain its natural function. While there are exceptions for particularly thick scar tissue regions, generally, we aim for minimal dissection combined with effective releases. This way, we can encourage the joint to remodel naturally over time, which is critical for achieving optimal results.
Would you recommend cauterising all the scar tissue or do you mainly make a cut to release the joint and leave the rest of the scar tissue to be broken down by the joint itself?
Dr Jason Dragoo: What a great question. And I would love to hear all of your thoughts on it, because we all wrestle with this. I think as time has gone by, I've learned that minimizing the surface area of our surgical procedure is really important. Theoretically, it would be beneficial to use these devices to dissect away all of the scar tissue visible. But in reality, that hasn’t held true. What we’ve found is that targeted, systematic releases at key areas—places where the joint needs to have natural motion—work better than removing large sections of scar tissue just for the sake of it. For example, in the knee, if we don’t allow for that motion, it can restrict movement of the patella.
Now, in some cases, we do find regions where the scar tissue is very thick. You might have a segment with really dense scar tissue in one area, while the rest is more manageable. In those cases, simple releases might not be enough, and I consider doing a bit more work to reduce the bulk of the thicker areas to help the overall joint become more flexible. Still, I try to avoid going back in for a second or third procedure, as those follow-ups often don’t yield much improvement. I aim to achieve our motion goals and get those releases right in the first surgery so we can avoid additional procedures that may only aggravate the joint.
Dr. Kristoffer Barfod: I completely agree with you, Jason. I’ve moved from trying to dissect away all the scar tissue to being more conservative—to removing as little as possible while still maintaining full function and motion. So yes, I’m focused on making small incisions as needed.
Dr. Ralf Rosenberger: It’s the same with me, Kristoffer. For me, releasing the tissue is much more important than removing all of it.
Do you aim for a single surgery to perform releases during trauma and arthroplasty, or is it routine to plan for multiple surgeries for patients with arthrofibrosis? Additionally, are there patients for whom it would be unwise to attempt further surgery due to poor responses from their first surgery?
Dr. Kristoffer Barfod: We strive for a single surgery when possible, but it's not always achievable. Sometimes we accept minor motion deficits to avoid multiple procedures. I've found that returning too soon for a second surgery can lead to poor outcomes.
Dr. Ralf Rosenberger: Most cases are single-step surgeries for us. If complications arise, such as an improperly placed implant after arthroplasty, I may consider a revision surgery. However, I usually aim to resolve issues in one procedure.
Dr. Jason Dragoo: I also aim for single surgeries but inform patients that additional procedures might be needed for full restoration. However, the number of patients requiring repeat surgeries is low. I believe in allowing time for inflammation to subside before considering further surgery, ideally waiting at least six months for better results.
Dr. Kayley Usher: That's an interesting point, Dr. Dragoo, about waiting and not operating on a very inflamed knee. From my research, inflammation significantly contributes to fibrosis. There are powerful feedback loops between immune cells, inflammation, and myofibroblasts that create scar tissue. If we proceed with surgery when myofibroblasts are already activated, we may worsen the situation by perpetuating that feedback loop.
What is the role of medications in the management of arthrofibrosis? Do you have specific strategies for patients whose conditions are regressing?
Dr. Jason Dragoo: I believe in an active management approach rather than relying solely on surgery. After surgery, we often achieve the desired motion, but we must manage the body's response to prevent stiffness. This is crucial because surgical success doesn't guarantee long-term outcomes; the body's set point tends to revert to its pre-surgery state. Celecoxib (Celebrex) is our primary anti-inflammatory because it doesn’t affect platelet function, minimizing bleeding risks. Corticosteroids are used cautiously. While they can help control inflammation and scar tissue formation, we must be careful due to increased infection risks. Dosing and timing are critical, with intra-articular injections sometimes being necessary. Losartan has shown potential in animal studies, although its clinical impact in humans remains uncertain. It may help reduce fibrosis. Doxycycline is used for its anti-inflammatory properties and as an adjunct for patients at risk of infection, although it is not the primary antibiotic for surgery. For patients who are not responding well post-surgery, I often refer them to rheumatology for additional management, including more aggressive immunosuppressive treatments.
Dr. Ralf Rosenberger: I emphasize comprehensive pain management and the importance of collaboration with physiotherapists. After surgery, patients receive oral pain medications, and we ensure they continue rehabilitation with physiotherapists who communicate regularly with us. Adequate pain control is vital for recovery. Patients should not experience pain during rehabilitation, so we work closely with anesthesiologists to manage this effectively. I personally avoid using corticosteroids in most cases, as I have not observed significant benefits from them. The focus is on collaboration and communication to ensure a tailored recovery approach for each patient.
What are your thoughts on the need for more research and evidence-based approaches in the management of arthrofibrosis?
Dr. Jason Dragoo: I agree that we need to shift towards evidence-based practices, and I find it concerning because we don't have clarity on whether our current strategies are effective. It would be preferable to move towards something more grounded in research. However, we also need to consider if we are prepared to conduct randomized trials to create scientific algorithms that can help us understand what really works. For me, the challenge lies in the randomization aspect. Treating patients with a protocol that might not suit their individual needs raises significant ethical concerns. The variation in cases complicates matters further. For instance, in sports medicine, even a loss of 2 degrees of extension can mean the end of an athlete’s career. Conversely, some patients may have a total arc of motion of only 40 degrees, and this discrepancy makes it difficult to establish a one-size-fits-all approach. While I agree with the need for more robust data, our discussions often become anecdotal reflections based on our personal experiences rather than grounded in high-level evidence.
Dr. Ralf Rosenberger: I agree with Jason.
Dr. Kristoffer Barfod: I also see the importance of moving to evidence-based approaches and away from eminence-based (reputation-based). Our field would benefit from more rigorous studies.
How do you approach discussions with patients who are upset about the possibility of postponing surgery for arthrofibrosis?
Dr. Jason Dragoo: It’s definitely a challenging situation. I often encounter patients who have undergone numerous surgeries and come in hopeful that the next one will finally resolve their issues. Initially, they may feel better, but as time goes on, they often find themselves back in the same cycle, asking for another procedure. I try to explain that we are not ignoring their concerns; instead, we are focusing on a coordinated approach that includes physical therapy and medical management. It’s crucial to educate patients about the appropriate timing for surgery. I emphasize that there may be times when surgery is not the best option, and this understanding can help mitigate difficult conversations. Patients can feel neglected or that care is being withheld, especially after years of frustration. Open communication about the potential need to explore different avenues before considering another surgery is vital.
Dr. Kayley Usher: Yes, these conversations are incredibly tough. It might be beneficial to prepare patients before surgery by discussing the possibility that, if their knee reacts negatively post-op, they may need to delay any additional procedures until things settle down. Preparing them in advance can help ease the situation if it arises.
Dr. Ralf Rosenberger: I agree with Jason and Kayley. It’s important to foster an individualized approach. The experience of the surgeon plays a significant role in these discussions. There’s often a gut feeling that comes from treating numerous patients. It’s crucial to have honest conversations.
What is your approach regarding the use of tourniquets in surgery for arthrofibrosis, including during primary total knee arthroplasty? In the scientific literature there's pretty good evidence that tourniquets increase hypoxia, inflammation and post-operative bleeding and can have other negative side effects like nerve damage. And all of these are powerful drivers of fibrosis.
Dr. Ralf Rosenberger: In my practice, we never use tourniquets during knee surgeries. If we have to open the knee, I want to see where any bleeding is occurring so I can address it directly. Using a tourniquet can increase trauma to the knee, which is not beneficial. We start with the tourniquet turned off, and while there may be instances where we need to use it due to excessive bleeding, in most cases, it's unnecessary. Avoiding tourniquets helps reduce complications like thrombosis, embolism, and infections, which can contribute to fibrosis. Regarding blood pressure management, we collaborate with anesthesiologists to keep it low during surgery, which has made a noticeable difference in minimizing bleeding.
I stopped using tourniquets in primary total knee arthroplasties back in 2012. In my experience, they are not needed and can complicate matters. I have never encountered any problems with cement setting without a tourniquet, and avoiding their use reduces the risk of complications.
Dr. Kristoffer Barfod: I don’t perform total knee arthroplasties, so my insights are anecdotal, but I agree with Dr. Rosenberger's approach. I primarily perform arthroscopic surgeries and seldom use tourniquets. My experience in Melbourne involved not using pumps to increase water pressure in knee procedures, relying instead on elevation. However, with modern pumps, the need for a tourniquet has significantly decreased.
Dr. Jason Dragoo: I also don’t perform total knee arthroplasties, so my perspective is limited, but I fully support avoiding tourniquets during arthrofibrosis surgery. But I don't want to say that's across the board. Tourniquets are commonly used in arthroscopic procedures, and I find that visualization can be hindered without the torniquet. In cases involving bone transplantation, using a tourniquet can expedite surgery and reduce trauma, but in arthrofibrosis, our focus is on ensuring hemostasis and effectively managing post-operative pain.
What is your experience with continuous passive motion (CPM) in the management of arthrofibrosis, and how do you incorporate it into postoperative care? There is evidence that CPM reduces reduces inflammation and helps maintain range of motion, especially in the immediate postoperative period.
Dr. Jason Dragoo: During my training, the use of CPM was widespread. While it can have benefits, the literature has not consistently demonstrated its efficacy, and I have transitioned away from using CPM due to several factors. Its high cost, combined with a lack of perceived benefits compared to coordinated physical therapy starting on day one post-surgery, has led to this change. I now prioritize having physical therapists linked with patients before surgery and seeing them frequently in the weeks following. This integrated approach replaces the need for CPM, focusing instead on personalized physical therapy to encourage early motion.
Dr. Kristoffer Barfod: In Scandinavia, our practice is similar; we seldom use CPM machines. They may be employed occasionally for addressing flexion deficits, but we focus heavily on intensive physiotherapy as the primary approach.
Dr. Ralf Rosenberger: Until around 2010-2012, CPM was a standard practice in Austria, especially after total knee arthroplasties (TKAs) and ACL reconstructions. However, as rapid recovery protocols evolved, the use of CPM declined. Interestingly, many patients expressed a desire for it, leading me to reintroduce CPM machines into my practice. I find that they can help with swelling and provide patients reassurance by demonstrating that their knee is moving. However, I only use them for addressing flexion deficits, not extension deficits.
Dr. Kayley Usher: I believe it’s essential to use CPM in a pain-free manner. For patients with flexion deficits, it can help manage inflammation and maintain range of motion without causing additional stress or injury. The goal is to avoid manipulation that causes pain or tears tissues, which is counterproductive. Historical issues with CPM usage stem from misunderstandings about its application. We advocate for its use, particularly in specific patient populations, to help deactivate stress fibers within myofibroblasts and promote recovery.
Dr. Rosenberger, can you tell us about your physiotherapy approaches post-op, and do you advocate for gentle physiotherapy?
Dr. Ralf Rosenberger: Yes, absolutely. When it comes to physiotherapy in arthrofibrosis treatment, aggressive exercise is not appropriate. No force. What works for elite athletes, like Cristiano Ronaldo, is not suitable for patients recovering from arthrofibrosis, it's a total no-go. In this context, it's essential that physiotherapy is focused and gentle. The goal is to avoid any forceful interventions. Instead, we prioritize micro-mobilization techniques, such as gentle movements of the patellofemoral joint and tibial gliding in flexion. The idea is to work with the tissue rather than against it.
Dr. Kristoffer Barfod: In Norway, we are still learning about the best approaches. There is a division among clinics regarding aggressiveness in physiotherapy. Some therapists are more cautious, while others tend to be more aggressive. Personally, I believe we should avoid pushing patients into painful ranges. If they regress and stiffness returns, the question becomes whether to push through discomfort or stay away from pain. I'm still grappling with how best to handle that balance.
Dr. Kayley Usher: I have strong opinions on this subject. From my perspective, it's crucial to keep patients away from pain during therapy. I've experienced the negative consequences of pushing too hard, which can lead to permanent damage. My approach is to advocate for pain-free movement. There is a significant amount of evidence from organ fibrosis research indicating that upsetting nerves and the immune system can lead to increased myofibroblast activity, which exacerbates fibrosis. So, I believe that maintaining a pain-free environment is essential.
Dr. Jason Dragoo: I agree with the need for careful and tailored physical therapy. Our motto is "movement is good; weight-bearing and force are bad." We focus on gentle mobilization of the tibiofemoral and patellofemoral joints while avoiding heavy loading at the beginning. The key is to maintain range of motion achieved during surgery through slow, controlled movements rather than aggressive stretching. While discomfort may occur, we generally avoid pushing into pain, as this can lead to setbacks.
Dr. Kayley Usher: There's a very important distinction in my mind, between discomfort and pain. I believe that a small amount of discomfort is acceptable, maybe even necessary. I liken the feeling of stretch needed to the mild discomfort of stretching a finger backward. It's important that the patient is in control of their therapy, deciding when to stop based on their comfort level. This approach can empower them while still allowing for gentle stretching. It’s also important for patients to be aware that some reduction in range of motion is normal in the postoperative phase due to the inflammation reactivating the myofibroblasts.
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