Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St W, Room 4E15, Hamilton, ON, L8N 3Z5, Canada.
Knee Surg Sports Traumatol Arthrosc. 2017 Dec;25(12):3929-3937. doi: 10.1007/s00167-017-4482-1. Epub 2017 Mar 4.
Arthrofibrosis is the most common post-operative complication of anterior cruciate ligament (ACL) reconstruction. Risk factors and management strategies for arthrofibrosis remain unclear. The purpose of this review was to: (a) describe existing definitions of arthrofibrosis, and (b) characterize the management strategies and outcomes of arthrofibrosis treatment.
MEDLINE, EMBASE, and PubMed were searched from database inception to search date (March 21, 2016) and screened in duplicate for relevant studies. Data regarding patient demographics, indications, index surgery, management strategy, and outcomes were collected.
Twenty-five studies of primarily level IV evidence (88%) were included. A total of 647 patients (648 knees) with a mean age of 28.2 ± 1.8 years (range 14-62 years) were treated for arthrofibrosis following ACL reconstruction and followed for a mean 30.1 ± 16.9 months (range 2 months-9.6 years). Definitions of arthrofibrosis varied widely and included subjective definitions and the Shelbourne classification system. Patients were treated by one or more of: arthroscopic arthrolysis (570 patients), manipulation under anaesthesia (MUA) (153 patients), oral corticosteroids (31 patients), physiotherapy (81 patients), drop-casting (17 patients), epidural therapy combined with inpatient physiotherapy (six patients), and intra-articular interleukin-1 antagonist injection (four patients). All studies reported improvement in range of motion post-operatively, with statistically significant improvement reported for 306 patients (six studies, p range <0.001 to =0.05), and one study (18 patients) reporting significantly better results if arthrofibrosis was treated within 8 months of reconstruction (p < 0.03). The greatest improvements for extension loss were seen with drop-casting (mean 6.2° ± 0.6° improvement), whereas MUA produced the greatest improvement for flexion deficit (mean 47.8° ± 3.3° improvement).
Arthrofibrosis is poorly defined and outcome measures range varies widely. Amongst the studies included in this review, arthrofibrosis was most commonly managed surgically by arthroscopic arthrolysis, and most patients showed at least some improvement, including six studies that reported statistically significant change in ROM. In studies that used a step-wise approach to treating arthrofibrosis, more than half of patients were successfully treated without an operation. A more well-defined concept of arthrofibrosis, along with large, prospective studies will provide a clearer understanding of how to describe and manage this complication. The issue of arthrofibrosis following ACL reconstruction is clinically relevant as it represents a common complication of a commonly performed operation that nonetheless remains poorly defined and without clear treatment guidelines.
Systematic Review of Level III and IV Studies, Level IV.
关节纤维性强直是前交叉韧带（ACL）重建术后最常见的术后并发症。关节纤维性强直的风险因素和管理策略仍不清楚。本综述的目的是：（a）描述现有的关节纤维性强直定义，以及（b）描述关节纤维性强直治疗的管理策略和结果。
从数据库建立到 2016 年 3 月 21 日（搜索日期），对 MEDLINE、EMBASE 和 PubMed 进行了搜索，并对相关研究进行了重复筛选。收集了患者人口统计学、适应证、指数手术、管理策略和结果的数据。
共纳入 25 项主要为 IV 级证据（88%）的研究。共 647 例（648 膝）患者，平均年龄 28.2±1.8 岁（范围 14-62 岁），在 ACL 重建后因关节纤维性强直接受治疗，并平均随访 30.1±16.9 个月（范围 2 个月-9.6 年）。关节纤维性强直的定义差异很大，包括主观定义和 Shelbourne 分类系统。患者接受了一种或多种治疗方法：关节镜下松解术（570 例）、麻醉下手法松解（MUA）（153 例）、口服皮质类固醇（31 例）、物理治疗（81 例）、滴注（17 例）、硬膜外治疗联合住院物理治疗（6 例）和关节内白细胞介素-1 拮抗剂注射（4 例）。所有研究均报告术后关节活动度改善，6 项研究中有 306 例（p 范围 <0.001 至 =0.05）报告统计学显著改善，1 项研究（18 例）报告如果在重建后 8 个月内治疗关节纤维性强直（p<0.03），结果显著更好。在治疗关节活动度丧失方面，滴注的效果最好（平均改善 6.2°±0.6°），而 MUA 对改善屈曲缺陷的效果最好（平均改善 47.8°±3.3°）。
关节纤维性强直的定义不明确，且结果测量指标差异很大。在本综述纳入的研究中，关节纤维性强直最常通过关节镜下松解术进行手术治疗，大多数患者至少有一定程度的改善，包括 6 项报告关节活动度 ROM 有统计学显著改善的研究。在采用逐步治疗关节纤维性强直的研究中，超过一半的患者无需手术即可成功治疗。更明确的关节纤维性强直概念，以及更大规模的前瞻性研究，将有助于更清楚地了解如何描述和管理这种并发症。ACL 重建后关节纤维性强直是一个临床相关的问题，因为它是一种常见手术的常见并发症，但目前仍未明确界定，也没有明确的治疗指南。
三级和四级研究的系统评价，四级。
