We had the opportunity to interview Dr. Luca Deabate about his surgical practice regarding the treatment of arthrofibrosis. Dr. Deabate is an orthopaedic surgeon specializing in knee surgery, sports medicine, degenerative joint disease, and knee stiffness. He is a head of knee surgery in Lugano, Switzerland, and coordinates the surgical team that works with the European Knee Arthrofibrosis Center in Lugano. Here is our edit.
Can you tell us about the importance of treating knee arthrofibrosis as part of your surgical practice?
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LD: Arthrofibrosis of the knee has become an important part of my weekly surgical practice. This realization came about through the work of my colleague, Sebastiano, who highlighted the lack of knowledge and skills in treating this pathology. With the growing number of knee surgeries, complications such as arthrofibrosis have become more prevalent, necessitating specialized treatment.
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Questions from another Orthopaedic Surgeon
What are the most important aspects of knee replacement technique to consider when trying to prevent arthrofibrosis?
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LD: Preventing arthrofibrosis entirely is almost impossible, but there are three key aspects I focus on:
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Balancing the TKA: Achieving a good balance between joint stability and soft tissue flexibility is crucial. This prevents mechanical stiffness and allows space for rehabilitation.
Minimal Soft Tissue Release: Keeping soft tissue release minimal prevents significant changes in the knee’s biomechanics.
Proper Haemostasis: Most important is to achieving proper haemostasis. I pay very close attention to haemostasis throughout the procedures.
If you need to perform a scope and manipulate a knee replacement to clear tissue for arthrofibrosis post-surgery, do you use any special techniques?
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LD: In most cases, I perform this arthroscopically and pay attention to a few details. I don't use a tourniquet, avoid high pressure in the water pump, and absolutely do not use a shaver in order to minimize bleeding. Instead, I use radiofrequency or a cauteriser device to burn and cut tissue, and I always perform a 10-minute haemostasis at the end of the procedure to prevent post-operative bleeding.Â
You don't use a tourniquet during arthrofibrosis surgery. How about using a tourniquet in total knee replacement to help with cement preparation and the implant stage?
LD:Â I don't use a tourniquet during most of the total knee replacement procedure, including the preparation, cuts, and trial procedure. I only use the tourniquet for the cementation process, keeping the pressure as low as possible and trying to stay under 20 minutes.
Many patients want to know what they can do to reduce their risk of developing arthrofibrosis. Do you have any tips to give to them?
LD: Patient education is vital. Patients need to recognize the onset of arthrofibrosis early. Timing is critical, so I spend time discussing potential complications before surgery. If patients are aware, they can seek early treatment with physiotherapy or nonsteroidal medications, which can significantly mitigate the severity of arthrofibrosis.
Questions from the IAA committee
What is your approach to operating on patients with arthrofibrosis in general?
LD: I try to avoid surgery for these patients unless absolutely necessary. Exhausting all physical therapy options is crucial before considering surgery. When surgery is indicated, it’s important to operate on non-reactive knees to avoid rebound stiffness. Timing is key; selecting the right moment to intervene surgically can greatly influence outcomes.
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How important is post-operative pain control in your plan?
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LD: Post-operative pain control is crucial. We have an excellent pain service where anaesthesiologists follow the patient for 48 hours post-surgery. Effective pain management is essential for early mobilization and to prevent other complications.
What is your philosophy on how to approach knee arthrofibrosis in terms of physiotherapy, pain management, and psychological care for complex patients and their caregivers?
LD:Â One of the most profound lessons I learned is the importance of listening to the patient, believing in their experiences, and, most importantly, explaining the nature of their condition and the potential outcomes. Many of these patients have endured years of pain and multiple surgeries, so empathetic listening and clear communication about their treatment journey are crucial.
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How do you approach the treatment of patella baja in your patients?
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LD: Patella baja is a major issue due to the shortening of the patellar tendon. Although lengthening the tendon makes sense theoretically, I avoid it due to the risk of complications. Instead, I prefer tibial tubercle transfer (TTT) as it has a higher success rate and fewer complications, preserving the integrity of the tendon. I think it is one of the most important tendon in the body and I don't want to have a problem with that.
Can you explain the procedure and indications for sagittal partial patellectomy?
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LD: In cases of hyper-pressure, arthrosis, or other issues constraining the knee, the patella often enlarges, particularly on the lateral side. A sagittal partial patellectomy involves removing a small portion of the lateral patella to provide more space for movement. This is often combined with a lateral release to ensure smoother patellar motion.
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What message would you like to give to medical students and residents about treating arthrofibrosis?
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LD: Treating arthrofibrosis is challenging. The most important advice is to trust the patient. They often have a long, painful history. This condition is a biological problem for which we currently have mainly mechanical solutions. It’s a long journey, and the patient's perspective and experiences are crucial.
Questions from patients
What are the success rates of treating patella baja, and can it get worse post-treatment?
LD: Success rates vary depending on the individual case and the quality of rehabilitation. While achieving 100% success is rare, significant improvements in mobility, stiffness, and pain control are common when patients are managed by a multidisciplinary team. It's rare for a patient to be worse off post-treatment.
Are there any promising developments in the pipeline for those who are seeking more successful treatments?
LD:Â We are investigating the use of quercetin, a treatment already utilized by cardiologists for pericardial fibrosis, with initial positive outcomes. Another area of interest involves cytokine panels, which could provide valuable insights into individual patient responses. Collaborating with rheumatologists and specialists proficient in cytokine analysis will be crucial in advancing this aspect of treatment. Furthermore, increasing awareness and involvement of physiotherapists in arthrofibrosis management holds promise for optimizing patient care.
How do you address extension deficits surgically?
LD: Addressing extension deficits is tricky as they can stem from anterior interval problems or posterior issues. Understanding the exact cause is essential for effective treatment, whether it involves anterior interval release or posterior capsular release.
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Is there any treatment to reduce pain from long-term arthrofibrosis?
LD: Yes, involving a pain specialist is key. They have the most effective tools for managing chronic pain in these patients. Each case is unique, but pain specialists can often find ways to improve the patient’s condition.
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Can you tell us more about your interdisciplinary team at the European Knee Arthrofibrosis Center in Lugano?
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LD: Our team includes skilled physiotherapists who are the frontline in patient care. I also have an assistant, Marco, who is crucial during long and demanding procedures. Our pain specialist is invaluable for managing post-operative pain. We also collaborate with a rheumatologist for differential diagnosis and treatment planning. Lastly, my empathetic secretary manages patient histories and scheduling, which is essential given the demanding nature of these cases.
Note from the IAA:
This interview has been edited for clarity and brevity. Watch the full interview below.
Feel free to use this checklist for both a list of questions to ask your surgeon and to help building an international database of surgeons who treat arthrofibrosis.
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