The procedure of arthroscopically removing internal
knee joint scar is often long and tedious. Sometimes the joint
is packed so thickly with scar tissue that removing it is akin
to a slow, meticulous archeological excavation process. The normal
internal joint anatomy must be carefully exposed, millimeter by
millimeter, as the scar tissue is gradually cut away and removed.
All of the internal joint spaces that are normally present should
be opened up and restored in this fashion prior to attempting
knee manipulation (see FIGURES 1a, 1b, 1c).
The lateral retinaculum (capsular envelope ligament just to the
outer side of the kneecap) is often especially contracted and
tight, and usually must be surgically released (divided) at the
1a -Arthroscopic view during an early stage of a scar
resection procedure in a patient with severe knee arthrofibrosis.
This patient's entire internal joint space was filled up with
tough, fibrous scar tissue (the white, fluffy/fibrous material
seen in this photo), which is nearly all that can be seen
here! An arthroscopic tissue resector instrument has removed
some scar already, creating a small, open "working space",
which is where the lens of the arthroscope was situated when
this picture was taken. The resector is then used to progressively
remove more and more scar tissue, gradually enlarging the
working space, until an anatomic landmark (such as one of
the femoral condyles) is uncovered.
1b - Arthroscopic view of the same patient's knee,
but further along in the procedure. In the background you
can see that the arthroscopic scar resector (shiny metal object
to the left) has uncovered a portion of the smooth, white
femoral condylar surface, marked with an "F". Once
such a landmark is identified, the surgeon can then more safely
and effectively "excavate" the rest of the knee
joint's anatomy out from the mass of scar tissue that has
engulfed it. The goal is to open up all of the internal joint
spaces to normal or near-normal dimensions, fully exposing
the normally free and unencumbered intra-articular joint structures.
- Arthroscopic view of the same patient's medial joint compartment
at the conclusion of the case. The normal, internal joint
space has been restored and the medial femoral condyle has
been completely released from its enveloping scar tissue
cocoon. Similar work has also been done in other knee compartments,
in combination with a retinacular release. At this point,
the knee is tested to see what free range of motion it has,
and if necessary, joint manipulation and stretching are
performed to restore the range of motion to normal. With
almost all of the internal scar tissue that was formerly
restricting the joint removed, the joint manipulation procedure
will require significantly less applied force to regain
the same range of motion, thus reducing the chance of an
inadvertent femoral or tibial fracture.
In severe cases where the posterior (rear) capsule of the knee
is also tightly contracted, thus restricting full knee extension
(straightening) despite attempted knee manipulation,
an open (non-arthroscopic) posterior capsular surgical release
may be required. A technique using a small lateral knee incision
may be utilized to minimize surgical dissection trauma directly
behind the knee as well as skin scarring.