From the Complex Joint Reconstruction Center, Hospital for Special Surgery, New York NY (Gu, Malahias, and Sculco), the Department of Orthopedic Surgery, George Washington Hospital, Washington DC (Gu, Agarwal, McDaniel, Knapp, Mathur, and Doerre), the Department of Orthopedic Surgery, Hospital for Special Surgery (Wessel and Richardson), the Department of Sports Medicine, Hospital for Special Surgery (Rodeo), New York, NY, and the Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO (Kaar).
J Am Acad Orthop Surg. 2023 Jun 1;31(11):574-580. doi: 10.5435/JAAOS-D-20-01358. Epub 2022 Nov 9.
Arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) is a notable but uncommon complication of ACLR. To improve range of motion after ACLR, aggressive physical therapy, arthroscopic/open lysis of adhesions, and revision surgery are currently used. Manipulation under anesthesia (MUA) is also a reasonable choice for an appropriate subset of patients with inadequate range of motion after ACLR. Recently, the correlation between anticoagulant usage and arthrofibrosis after total knee arthroplasty has become an area of interest. The purpose of this study was to determine whether anticoagulant use has a similar effect on the incidence of MUA after ACLR.
The Mariner data set of the PearlDiver database was used to conduct this retrospective cohort study. Patients with an isolated ACLR were identified by using Current Procedural Terminology codes. Patients were then stratified by MUA within 2 years of ACLR, and the use of postoperative anticoagulation was identified. In addition, patient demographics, medical comorbidities, and timing of ACLR were recorded. Univariate and multivariable analyses were used to model independent risk factors for MUA.
We identified 216,147 patients who underwent isolated ACLR. Of these patients, 3,494 (1.62%) underwent MUA within 2 years. Patients who were on anticoagulants after ACLR were more likely to require an MUA (odds ratio [OR]: 2.181; P < 0.001), specifically low-molecular-weight heparin (OR: 2.651; P < 0.001), warfarin (OR: 1.529; P < 0.001), and direct factor Xa inhibitors (OR: 1.957; P < 0.001).
In conclusion, arthrofibrosis after ACLR is associated with the use of preoperative or postoperative thromboprophylaxis. Healthcare providers should be aware of increased stiffness among these patients and treat them aggressively.
前交叉韧带重建（ACLR）后发生的关节纤维性僵直是 ACLR 的一种显著但不常见的并发症。为了改善 ACLR 后的活动范围，目前常采用积极的物理治疗、关节镜下/开放粘连松解术和翻修手术。对于 ACLR 后活动范围不足的合适患者群体，关节内手法松解术（MUA）也是一种合理的选择。最近，抗凝剂的使用与全膝关节置换术后关节纤维性僵直之间的相关性成为研究热点。本研究旨在确定抗凝剂的使用是否对 ACLR 后 MUA 的发生率有类似的影响。
本研究采用 PearlDiver 数据库中的 Mariner 数据集进行回顾性队列研究。使用当前操作术语（Current Procedural Terminology，CPT）代码识别接受单纯 ACLR 的患者。然后，根据 ACLR 后 2 年内是否接受 MUA 将患者分层，并确定术后抗凝的使用情况。此外，还记录了患者的人口统计学特征、合并症和 ACLR 的时间。使用单变量和多变量分析来建立 MUA 的独立危险因素模型。
我们共确定了 216147 例接受单纯 ACLR 的患者。其中 3494 例（1.62%）在 2 年内接受了 MUA。术后使用抗凝剂的患者更有可能需要接受 MUA（优势比[OR]：2.181；P < 0.001），具体而言，低分子肝素（OR：2.651；P < 0.001）、华法林（OR：1.529；P < 0.001）和直接因子 Xa 抑制剂（OR：1.957；P < 0.001）。
总之，ACL 重建后发生的关节纤维性僵直与术前或术后血栓预防的使用有关。医疗保健提供者应该意识到这些患者存在僵硬增加的情况，并积极进行治疗。
