1. POST ACLR STIFFNESS
DR SCHILLER JOS
Consultant Orthopedic surgeon
Baby Memorial Hospital, Kozhikode

2.  Loss of ROM in a joint is a dilemma to both
patient and doctor.

3. TYPES
 Localised- Loss of extension
better prognosis
 Generalised/ global- Fibrosis/ capsulitis with
severe stiffness
poor outcome

4. ETIOLOGY
 Pre- operative
 Intra- operative
 Post- operative

5. RISK FACTORS
1. Operating in acute injury period
2. Proximal MCL injury
3. Poor pre- op ROM
4. Error in surgical techique
5. Female sex
6. Older adolescent
7. Concurrent meniscal repair

6. INCIDENCE
 4- 35% after ACLR
 57% after combined ACL + PCL Reconstruction

7. CYCLOPS LESION
Localised intra articular fibrous nodule causing
loss of knee extension, commonly seen with
ACLR with anteriorly placed tibial tunnel.

9. Classification of knee stiffness
(SHELBOURNE)
 TYPE 1- normal flexion and <10 deg extension
loss
 TYPE 2- normal flexion and > 10 deg extension
loss
 TYPE 3- combined flexion loss > 25 deg and
extension loss > 10 deg
 TYPE 4- extension loss > 10 deg and total flexion
< 120 deg combined with patella infera
contracture syndrome

10. MANAGEMENT
 Prevention is the best treatment.
 Non-operative supervised therapy rehabilitation.
 Arthroscopic arthrolysis.
 Open releases.

11. How to prevent stiffness.
1. Avoid acute reconstructions
2. Complete ROM prior to surgery
3. Achieve quad strength before reconstruction
4. Rule out locking due to meniscal tear
5. Beware of proximal MCL injury

12. Contd…
6. Proper tunnel placement
7. Tension and fix ACL graft near extension
8. Reduce pain, swelling, inflammation in
immediate post op period.
9. Achieve full extension, ROM, muscle strength
10. If patient has not attained ROM by 14 days,
monitor weekly

13. Contd…
11. Aspirate significant effusion in early post op case
12. Early surgical debridement if the patient is not
progressing and has flexion contracture
13. Obtain pre op radiographs
14. Consider infection and CRPS if there is significant
pain
15. Counsel the patient regarding realistic goals

14. MANAGEMENT
 Loss of motion
NSAID’S
intra articular steroid
Supervised physio therapy

15. Pre- op planning
 Thorough physical examination and history
 Pain- infection
CRPS (contra indication for surgery)
 Investigations- blood tests, Plain radiographs,
MRI.
 . Get the previous operative reports

16. Cause of loss of motion.
Limitation of extension- intercondylar notch
pathology
Limitation of flexion- scar in the lateral/medial
gutter, supra patellar pouch

17.  INFECTION
arthroscopic irrigation and debridement
appropriate I.V antibiotics

18. ARTHROSCOPIC ARTHROLYSIS
 Leg is positioned without leg holder
 6 portals
 All adhesive bands and fibrotic tissue are excised
from supra patellar pouch, med/lateral gutters
 Intercondylar notch is cleared
 Notchplasty
 Partial release of ligaments
 Manipulation under anaesthesia

20. OPEN RELEASE
 Medial para patellar arthrotomy
 Extensive medial release- deep MCL to
semimembranosis
 Excision of hoffas fat pad.
 Lataral release
 Release of residual intra and extra articular
adhesions

21. THANK YOU