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tendons was necessary 6 months after
arthrolysis. The three other patients who had
ACL graft resections during the arthrolysis did
not complain of knee instability.
DISCUSSION
The most important finding of the present study
was that open posterior release is a safe and
efficient additional procedure for treating
persistent flexion contracture after anterior
arthroscopic release. Indeed, all the patients
except one (93%) had a complete post-
operative extension and all patients were
satisfied. Subjective functional results after
posterior release were close to outcomes seen
from primary ACLR [16].
Loss of range of motion remains a problematic
complication after ACLR [17]. Strum
et al.
[18] reported 35% of ROM loss after acute
ACLR two decades ago. However, with a
better understanding of risk factors, surgical
timing, improved surgical technique and
advanced rehabilitation protocols, this ROM
loss had markedly decreased to 0.49 to 11% [1,
11, 19, 20].
The aetiology of motion loss after ACLR is
variable. As opposed to just the timing of
surgery [21, 22], other factors should be
analysed closely preoperatively, including the
severity of the initial soft-tissue or bony injury,
MRI documented bone bruising [23] and
ROM. Other causes can lead to loss of motion
after ACLR such as delayed rehabilitation,
technical errors [24, 25], Cyclops lesions [11,
26], patellar entrapment or infrapatellar
contracture syndrome (IPCS) [27], infection,
complex regional pain syndrome and genetic
factors [28].
Despite these preventative strategies, a few
patients do develop ROM loss after knee
surgery. In most cases, conservative treatment
with enhanced rehabilitation or manipulation
under anaesthesia should suffice to solve the
deficit. On rare occasions, a surgical
debridement is necessary to obtain complete
extension. It remains difficult to know when to
intervene surgically. It is fundamental to
identify the cause of knee stiffness as soon as
possible. At the beginning of the third month
following the index operation, should there be
no gain in ROMdespite intensive rehabilitation,
a surgical solution should be envisioned. In
cases where an obvious cause is idenfied, such
as a “Cyclops” lesion or an intra-articular
screw, then a surgical solution should be
executed rapidly. Where the pathology is more
of a global deficit with associated inflammatory
syndrome, the decision is more difficult. Paulos
et al.
[29] recommended avoiding surgery until
the inflammatory state has become quiescent.
Occasionally, a vicious cycle is present:
intensive rehabilitation causes pain and
inflammation, which in turn cause knee
stiffness. In these cases, anti-inflammatories
and restriction of painful rehabilitation is
useful, and at 6 months, surgical intervention
should be considered [30].
The structured release procedure for treating
ROM deficit has always included a systematic
anterior arthroscopic release [3, 31-33].
Sometimes, when the initial ACL graft is
malpositioned and conflicts with the
intercondylar notch, it has to be removed to
obtain full extension. In these cases, the patient
should be informed that an iterative ACLR
could be necessary in the case of knee
instability. No extension deficit, even a few
degrees, should be tolerated at the end of the
arthroscopic step. If there is still a residual
flexion contracture, a second open posterior
step must be performed [34].
Various studies have reported post-operative
outcomes following knee stiffness treatment
procedures [9, 19, 35-37]. Nonetheless, these
series were heterogeneous with a large variety
of different treatments, with a systematic
anterior release associated in a few cases to a
posterior release. None of these studies detailed
separately the specific outcomes of the
posterior open release because of the rarity of
this procedure.
Only four studies specifically report their
posterior open release results but none include
a systematic posteromedial and posterolateral
approach (Table 3).