Key Takeaways

We’ve summarised the key points expressed by experienced arthrofibrosis surgeons, together with references from the scientific literature below. References are indicated at the end of sentences and can be found at the bottom of this page.

• The symptoms of pain and stiffness can begin extremely quickly, with cells reacting rapidly and contracting tissues within minutes[3]. However, symptoms may take weeks or months to develop after surgery.

• Arthrofibrosis is diagnosed by a thorough clinical examination with a finding of pain, limited function and limited range of motion [2,4]. A feeling of stiffness is commonly described.

• A biopsy is not recommended or required for a diagnosis of arthrofibrosis [2]. Taking a biopsy sample requires an invasive procedure that triggers additional inflammation and fibrosis, and the tissue removed may not be from an affected region, potentially leading to a false-negative result.

• It is essential to rule out underlying causes such as low-grade infection or implant loosening (after total knee replacement) that require prompt and specific treatment, as this can significantly alter the outcomes and treatment strategy. See “First Steps” below.

• Closed manipulation under anesthesia (MUA) is frequently prescribed but risks doing serious damage, being associated with fractured bones, internal bleeding, and injury to nerves, tendons, ligaments, and other tissues[5]. “Closed” MUAs are performed without a prior surgical release of adhesions (stuck down tissues). See “Additional Insights” below.

• Surgery is traumatic to the body[6] and risks aggravating the condition. Exhausting all physical therapy options is crucial before considering surgery.

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Surgical Options

• Arthrofibrosis after a total knee replacement (TKR or TKA): a revision should not be performed unless there is a clearly identified problem with the existing prosthesis, such as loosening.

• Patellar tendon lengthening has a high risk of poor outcomes and is avoided by experienced arthrofibrosis surgeons.

• Understanding the exact cause of a lack of range of motion is important for effective treatment.

• Operating on a hot, inflamed joint is not advisable, as the joint is already primed and angry.

• Careful surgical release of adhesions has helped many knees but is never guaranteed. The release of adhesions appears to work by releasing the mechanical tension that maintains the fibrotic pathology[7] (contractions and adhesions), permitting resolution of arthrofibrosis if followed by careful physiotherapy.

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First Steps

• Test for infection with a blood test and using needle aspiration to obtain fluid from the joint*. Infections can be low-grade, and clinical signs and symptoms may not be obvious [8].

• Scans to rule out problems with natural structures, or a graft or prosthesis. These include MRI, ultrasound, and CT[2] *. MRI is the most sensitive modality for detecting fibrosis, and metal artifact suppression is available at some centers for imaging knees post-TKR.

• For surgeons, empathetic listening and clear communication about the treatment journey are crucial*.

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Arthrofibrosis-Appropriate Surgical Methods

For interviews with experienced arthrofibrosis surgeons on the topics below, see the IAA YouTube channel at https://www.youtube.com/@Arthrofibrosis.

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• A tourniquet should not be inflated unless there is a medical emergency.

• Short-duration surgeries that are less invasive are less traumatic to the body and are generally less risky[6]. Surgery should be as minimal as possible and aim to release adhesions rather than remove scar tissue.

• Mechanical shavers are not used during surgery, instead radiofrequency wands are used to cauterise tissue[9].

• Achieving proper hemostasis (stopping bleeding) is a key aspect of surgery to reduce the risk of arthrofibrosis. This takes time and care on behalf of the surgeon.

• Effective post-operative pain management is important.

• The Hoffa’s fat pad (in knees) should be protected and preserved as much as possible, and resection (cutting) should be avoided [10]. This fat pad is an essential organ for knee health, and cutting the fat pad strongly promotes further fibrosis.

• Many of the surgeons listed below prescribe gentle, regular, continuous passive motion (CPM) in the post-operative period. Patients often wake up with their leg already in motion to prevent adhesions and contractions.

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Additional Insights

Closed manipulation under anesthesia (MUA) risks serious damage.

The IAA does not support manipulation under anesthesia (MUA) as a treatment for arthrofibrosis. During a MUA the leg is forcefully bent or straightened to force range of motion (ROM), tearing tissues indiscriminately. In our opinion, this can make arthrofibrosis return with more severe symptoms, especially if important structures are damaged by this procedure. However, some knees may gain ROM from this procedure.