Post-Operative Care
No matter how meticulous and thorough a scar tissue resection
may be, and even if a full range of knee motion is successfully
restored on the operating room table, the biggest challenge is
maintaining that range of motion after surgery. New scar
tissue may rapidly re-form within the joint unless comprehensive
action is taken to avoid this. Unless special post-operative pain
relief measures are taken, attempting to move the joint through
its full range of motion immediately after surgery may simply
be intolerable. Unfortunately, if the patient does not move their
knee through a full arc of motion repeatedly and fairly continuously
in the first 2 to 3 post-operative weeks, they are at risk of
having their knee joint become "frozen" once again.
Aside from knees where only joint extension is lacking
(which are often best held in a maximally extended position in
a full-leg cast for the first several post-op days), the key to
better results following surgical procedures for arthrofibrosis
is to perform them under epidural anesthesia and to maintain
this or a supplemental regional, pain-relieving, anesthetic nerve block for a day or two post-operatively,
so as to allow joint motion without the inhibiting effect of severe
pain. I have been using this anesthetic method following arthrofibrosis
surgery for well over a decade. Taking advantage of the ongoing pain relief afforded by the extended
anesthetic block effect, a program of immediate post-operative
physical therapy is begun and continued, utilizing special, passive
stretching techniques at the extremes of the knee's range of motion.
The patient is also taught how to do their own stretching therapy,
to supplement their supervised treatment. A continuous passive
joint motion (CPM) machine is used in between stretching sessions,
beginning in the recovery room and then continuing at home. This
device is a mechanical leg cradle that gently bends and straightens
the knee while the patient is lying down in bed. Post-operative
medication to inhibit recurrent fibrous scar tissue formation
within the knee is also often helpful. Possibilities include intra-articular
(injected into the joint) hyaluronate (a joint lubricant) and/or
corticosteroid (cortisone) medication administered on one or more
occasions in the first post-operative month or two. Faithful
patient compliance with prescribed outpatient physical therapy
treatment and diligent, self-administered stretching in the post-operative
phase is critical. Supplemental treatment with an oral anti-inflammatory
medication (if the patient's stomach can tolerate it) is helpful.
A severe case of arthrofibrosis can be an extremely difficult challenge
for both patient and knee surgeon alike. In this author's experience,
the comprehensive treatment program described above has met with
good results in most circumstances, including cases of total knee
joint replacement that still demonstrated a restricted range of
motion despite one or more attempts at manipulation under anesthesia
without arthroscopic intervention.
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