Surgical Controversies & Best Practices in Managing Knee Arthrofibrosis

In Part 1 of this series, we explored how Dr. Marco Valoroso approaches the diagnosis of knee arthrofibrosis after total knee replacement (TKR), as well as the imaging tools and clinical reasoning that guide his evaluations. In this second half of our conversation, we turn to the surgical aspects of treatment — from manipulation under anesthesia to surgical strategies, revision decisions, and best practices to prevent recurrence.

Our next topic is a highly controversial topic: manipulation under anesthesia, or MUA for short. This involves forcing the knee to bend or straighten while the patient is under general anesthesia, and it's often performed without a surgical lysis of adhesions first. Some clinicians use it to try to improve range of motion, but others have concerns that forcefully tearing tissues in a knee could actually worsen arthrofibrosis due to tissue damage, bleeding, or even bone fractures. In your practice, do you perform MUA at all? What are your thoughts on this topic?

Dr. Valoroso: In my clinical protocol, I never perform manual manipulation under anesthesia without first conducting a surgical release of adhesions. This ensures that any fibrotic bands or capsule contractures are released under direct visualization, minimizing the risk of uncontrolled tissue damage. Attempting to force motion through dense fibrosis without pre-surgical release can lead to unpredictable tearing, bleeding, and further inflammatory response, which may worsen the fibrotic process. It's very dangerous.

Specifically for patients with a TKR, are MUAs especially risky? Have you seen certain injuries from MUAs on TKR knees?

Dr. Valoroso: When performed without prior surgical release of adhesions, MUAs can lead to significant complications, especially when fibrosis is present. Literature describes several significant complications, such as patellar tendon rupture, which is one of the most serious complications, often resulting from excessive traction during forced flexion and may require surgical reconstruction, significantly delaying rehabilitation. Periprosthetic fractures, particularly in osteoporotic patients, can occur when force causes fractures around the femoral or tibial components, necessitating complex revision surgery. Component damage or loosening can result because excessive manipulation may compromise the fixation of the prosthesis, especially if micromotion is already present, leading to early loosening or instability. Hemarthrosis, or bleeding within the joint, following this maneuver can exacerbate inflammation and promote further fibrotic response, worsening the very condition the procedure aims to treat. Capsular tears and soft tissue injury have also been described. Forceful stretching of a fibrotic capsule can result in uncontrolled tearing, leading to pain, swelling, and delayed recovery. For this reason, I do not perform MUA in TKR patients without first surgically releasing adhesions, either arthroscopically or via a mini-open approach. This allows for controlled restoration of motion, minimizes trauma, and reduces the risk of injury. In my practice, precision and tissue respect are crucial, especially in the context of a prosthetic joint.

Moving on to surgery — when you operate on an arthrofibrotic knee, what techniques or approaches do you typically use?

Dr. Valoroso: In my clinical practice, I prioritize arthroscopic lysis of adhesions whenever feasible, as it allows for precise visualization and targeted release of fibrotic bands with minimal soft tissue trauma. This is typically combined with capsule release to restore range of motion and flexibility. In more advanced cases, particularly when fibrosis is extensive or involves deep posterior compartments after a posterior arthroscopic release, open posterior surgery becomes necessary to achieve an adequate mechanical release and restore range of motion.

And what precautions do you take to reduce the risk of arthrofibrosis returning?

Dr. Valoroso: Given the high risk of recurrence following surgical intervention, I implement a multimodal arthrofibrotic protocol postoperatively. This includes early mobilization - initiating passive range of motion exercises within hours of surgery is critical. I always use a continuous passive motion (CPM) device and closely monitor physiotherapy to prevent capsular retightening. I also use nonsteroidal anti-inflammatory drugs, such as ibuprofen and celecoxib, to help reduce postoperative inflammation and pain, indirectly limiting fibroblast activation and collagen deposition. I also use gabapentin, which may help manage neuropathic pain in postoperative patients. While it doesn't affect fibrosis itself, it can improve pain control, sleep quality, and tolerance to rehabilitation in selected cases.

Are there differences in your approach when performing lysis of adhesions on a TKR compared to a non-TKR knee?

Dr. Valoroso: Yes, absolutely. My approach differs significantly when performing a lysis of adhesions on a TKR versus a non-TKR knee due to the presence of prosthetic components that alter the joint anatomy. In TKR patients, the stakes are higher—any suspicion of low-grade infection must be thoroughly ruled out before proceeding. There is also navigational complexity because the prosthetic components alter the joint’s spatial relationships and limit visibility. In non-TKR knees, anatomical landmarks are intact and more predictable, while in TKR, for example, the intercondylar notch is occupied by the femoral component. The polyethylene insert can obscure access to posterior compartments, and the scar tissue may be denser and more widespread due to prior surgical trauma. This makes arthroscopic navigation more challenging, increases the risk of incomplete release. And raises the risk to physical structures, because in TKR knees, there is a higher risk of damaging several structures such as the patellar tendon - especially if with a prior surgeon an MUA was attempted - or the collateral ligaments, which may be tattered by fibrosis, if instruments are misdirected or excessive force is applied.

With arthrofibrosis after TKR, do you usually plan an open or arthroscopic approach?

Dr. Valoroso: In my practice, I generally prefer an arthroscopic approach as the first-line surgical strategy for managing arthrofibrosis after total knee replacement. Arthroscopy offers several advantages: its minimal invasiveness allows for precise lysis of adhesions and facilitates capsule release with reduced soft tissue trauma. It also enables faster recovery and lowers the risk of wound complications. I opt for an open or mini-open approach in the following scenarios: when there is extensive posterior fibrosis, meaning the fibrotic tissue is too dense or widespread, particularly in the posterior compartment, arthroscopy becomes technically limited, and open surgery allows for complete visualization and a true release. Additionally, I may choose an open approach when I suspect that polyethylene overstuffing is contributing to stiffness. If the insert is excessively thick and limiting flexion and extension, I may decide, in selected cases, to replace it with a thinner polyethylene component to restore joint balance and improve range of motion. This decision is always based on joint gap assessment and overall implant stability.

Another controversial topic: TKR revision to treat arthrofibrosis. We hear that worldwide, many patients are offered TKR revision even when their scans don’t show any clear problem with the existing prosthesis. In your view, what’s the rationale behind this?

Dr. Valoroso: My opinion: revising a total arthroplasty without identifying a clear mechanical or infectious issue is not justified. Replacing a well-positioned and stable implant in the absence of objective findings introduces a significant inflammatory insult to the joint, which may paradoxically exacerbate the arthrofibrotic process rather than resolve it.

In rare cases where revision is necessary due to issues with the prosthesis — for example, mechanical failure, loosening, or infection — is a hinged prosthesis always required, or are there alternatives?

Dr. Valoroso: In rare cases where revision is necessary due to mechanical failure, loosening, or infection, a hinged prosthesis is not always required. In clinical practice, I have never implanted a fully constrained prosthesis in patients with arthrofibrosis. Instead, I opt for a highly stabilized implant, such as a posterior-stabilized or semi-constrained design, which offers stability without the excessive constraints of a hinge. This approach allows for better soft tissue balance while minimizing mechanical stress transfer to the bone-implant interface. We must always remember that the more constrained a prosthesis is, the higher the risk of aseptic loosening over time. Therefore, I reserve this design only for cases with severe ligament insufficiency or major bone loss, which are rarely present in isolated arthrofibrosis.

Finally, are there situations where a tibial tuberosity transfer is indicated after TKR?

Dr. Valoroso: Tibial tuberosity transfer after TKR is rarely indicated, but in very select cases, it may be considered, typically when there is significant dysfunction of the extensor mechanism or persistent patellar instability that cannot be corrected through soft tissue procedures alone. In my practice, I do not routinely perform tibial tuberosity transfer in patients with arthrofibrosis because this procedure is not appropriate for stiffness alone, as it does not address intra-articular fibrosis or capsular contracture. Moreover, tibial tuberosity transfer can act as a significant inflammatory trigger, potentially reactivating the fibrotic process. For this reason, I approach such procedures with extreme caution and reserve them only for cases where extensor mechanism alignment is absolutely necessary and cannot be achieved through less invasive means.

Before we finish, is there one key piece of advice you’d like to give patients or clinicians dealing with this condition?

Dr. Valoroso: Thank you. It’s been a pleasure to share my perspective. If I had to offer one key piece of advice, it would be this: never underestimate the importance of early recognition and targeted intervention. Arthrofibrosis is a complex and multifactorial condition, but if addressed promptly with accurate diagnostics, minimally invasive techniques, and a structured rehabilitation plan, we can often prevent it from becoming chronic and debilitating. For clinicians, I would say: resist the urge to rush into aggressive procedures like revision unless there is a clear mechanical or infectious indication. Avoid manipulation under anesthesia. Precision matters more than force. And for patients: stay engaged in your recovery, communicate openly with your care team, and understand that stiffness doesn’t always mean failure. It can often be reversed with the right strategy.

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Disclaimer

Arthrofibrosis is a controversial subject and the views expressed by the clinicians do not necessarily represent the views of the International Arthrofibrosis Association (IAA). The materials presented on this website are provided voluntarily as a public service. It is of a general nature, based on the scientific literature. The information and advice provided is made available in good faith but is provided solely on the basis that readers will be responsible for managing their own assessment of the matters discussed herein and that they should verify all relevant representations, statements and information. Please consult your doctor.