ARTHROSCOPIC ARTHROLYSIS OF KNEE ARTHROFIBROSIS …applications.emro.who.int/imemrf/egypt_rheum... · ARTHROSCOPIC ARTHROLYSIS OF KNEE ARTHROFIBROSIS AFTER ANTERIOR ... Orthopedic

Egypt Rheumatol Rehab Vol. 28, No. 4, October 2001

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ARTHROSCOPIC ARTHROLYSIS OF KNEE ARTHROFIBROSIS AFTER ANTERIOR

CRUCIATE LIGAMENT RECONSTRUCTION HESHAM AL-KADY*, HASSAN M. ALI*, EIMAN HAMED OMRAN**, MOOTAZ AL-SABROUT*

AND MAHER AL-ASSAL*

*Arthroscopy Unit, Orthopedic Department, ** Rheumatology & Rehabilitation Department, Assiut University Faculty of Medicine

KEY WORDS: ANTERIOR CRUCIATE LIGAMENT, KNEE ARTHROFIBROSIS, ARTHROSCOPIC ARTHROLYSIS CONTINUOUS PASSIVE MOTION.

ABSTRACT Hypothesis: Arthrofibrosis following anterior cruciate

ligament (ACL) reconstruction may result in a greater functional deficit than the original ACL deficiency especially when both flexion and extension may be limited. Arthroscopic arthrolysis for such cases is the treatment of choice because the pathology is intraarticular.

Methodology: This study represents the results of arthroscopic arthrolysis followed by immediate utilization of continuous passive motion (CPM) in 16 male patients who presented with knee stiffness after ACL reconstruction. The mean age was 27 years (range 19-34), and the mean interval between ACL reconstruction and arthrolysis was 6.2 months (ranged 3-11). In all cases arthrolysis included cutting of the intraarticular adhesions followed by handling of other associated pathology, like excision of cyclops fibrous nodule, notchplasty or partial release of tight misplaced graft. The last step was forced manipulation of the knee into flexion. CPM was used immediately after arthrolysis for 2 hours 4 times daily interrupted by isometric quadriceps and hamstring setting exercises, and leg lifts in the first postoperative 4 days, then active and active assistive exercises, were allowed.

Results: According to the criteria of Parisien we had 14 excellent and 2 good cases. The average flexion range improved from 97° preoperatively to 133° postoperatively. One

Knee Arthroscopic Arthrolysis After ACL Reconstruction Hesham Al-Kady et al.

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complication occurred in this series in the form of avulsion of the inferior pole of the patella that occurred during the final manipulation of the knee into flexion after arthrolysis. Internal fixation using tension band wiring was done and this patient went to a final quite satisfied range of motion (0°-125°) at 5 months follow up.

Conclusion: Arthroscopic arthrolysis for knee arthrofibrosis after ACL reconstruction is a safe effective procedure with low morbidity that sequentially facilitates an accelerated postoperative intensive physiotherapy of passive (CPM), active assistive and active exercises.

INTRODUCTION Arthrofibrosis following anterior cruciate ligament (ACL)

reconstruction is a well recognized and disturbing complication. It may result in a greater functional deficit than the original ACL deficiency. In spite of improved surgical techniques and postoperative physical therapy, this complication is still present and is difficult to be treated. Vigorous physical therapy or manipulation with the patient under anesthesia are often ineffective and possess some risk for the graft. Moreover, in arthrofibrosis after ACL reconstruction, both extension and flexion may be limited.

The various procedures described for the flexion deformity, such as posterior capsular release lengthening of flexor tendons, or corrective supracondylar osteotomy is ineffective because the pathology is intraarticular. Arthroscopic arthrolysis is the treatment of choice for arthrofibrosis of the knee as reported by several authors (Sprague et al., 1982; Del Pizzo et al., 1985; Parisien, 1988; Richmond & Assal, 1991; Vaquero et al., 1993; Lindenfeld et al., 1999), and also for cases after ACL reconstruction (Richmond & Assal, 1991; Mariani et al., 1992; Reider et al., 1995; Lindenfeld et al., 1999).

This article reports the results obtained with arthroscopic treatment in a series of 16 patients who had restriction of knee motion after ACL reconstruction (Table 1).


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Table (1): Clinical data and results of the studied cases.

Case code

Age in

years

Surgical procedure for ACL

reconstruction

Interval between surgery and lysis

Pre-operative

ROM (degrees)

Duration of

follow up /months

Final ROM

(degrees)

AF 34 Open reconstruction "Pat. B.T.B." 7 months 30-100 10

months 0°-135°

SE 22

Open "Pat. B.T.B." and PLCI reconst. by

advancement of arcuate ligament

complex.

6 months

10°-90°

8 months

0°-140°

1A 34 Arthorscopic "Pat. B.T.B." 8 months 10°-35° 8 months 0°-130°

TR 23 Open reconstruction "Pat. B.T.B." 6 months 15°-120° 28

months 0°-140°

AS 21

Open reconstruction "Pat. B.T.B." and

PLCI reconstruction by advancement of arcuate ligament

complex.

11 months

5°-115°

8 months

0°-135°

ME 32 Open reconstruction

"Pat. B.T.B." and MCL repair acutely.

8 months 10°-120° 8 months 0°-140°

MM 26 Open reconstruction "Pat. B.T.B." 8 months 10°-90° 10

months 0°-140°

SH 32 Open reconstruction "Pat. B.T.B." 7 months 15°-115° 9 months 0°-140°

OF 32 Open reconstruction "Pat. B.T.B." 6 months 20°-90° 20

months 0°-130°

HB 28 Open reconstruction "Pat. B.T.B." 3 months 0°-30° 5 months 0°-125°

AM 27 Open reconstruction "Pat. B.T.B." 4 months 5°-110° 4 months -5°-135°

HR 23 Open reconstruction "Pat. B.T.B." 8 months 5°-110° 4 months -5°-135°

HA 20 Open reconstruction "Pat. B.T.B." 3 months 10°-120° 8 months 5°-130°

KA 24 Open reconstruction "Pat. B.T.B." 4 months 5°-90° 5 months 0°-120°

MS 19 Open reconstruction "Pat. B.T.B." 5 months 10°-110° 4 months 0°-130°

KM 34 Open reconstruction "Pat. B.T.B." 5 months 5°-110° 3 months 0°-130°

ACL, Anterior cruciate ligament; PLCI, posterolateral corner injury; MCL, medial collateral ligament; Pat. B.T.B., patellar bone-tendon-bone-autograft.


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MATERIALS AND METHODS From May 1996 until March 2001 we treated 38 patients with knee

arthrofibrosis secondary to previous intraarticular surgery. For this study we examined those patients who satisfied the following three criteria: (a) Prior ACL intraarticular reconstruction, (b) Prearthroscopic flexion deformity of 10 degrees of more and/or limitation of flexion to less than 120 degrees, (c) Failure of conventional physical therapy for 3 months after ACL reconstruction to restore the normal knee range of motion.

Our study included 16 patients; all were males with age range of 19-34 years (mean, 27 years). The right knee was involved in 10 patients and the left in 6.

All patients had been previously treated for chronic injury of the ACL but only two were treated acutely, one immediately after injury to repair the associated injured medial collateral ligament, and the other on the 10th day post-injury. Thirteen patients had isolated ligamentous injury of ACL alone, 2 patients had combined ACL and PLCI "posterolateral corner injury" and one patient had a combined injury of ACL and MCL "medial collateral ligament". The patellar bone-tendon-bone autograft was used in all cases. Reconstruction of PLCI in the two cases was performed with advancement of the arcuate ligament complex as described by (Hughston & Jacobson, 1985).

All patients were treated with open reconstruction but only in one patient arthroscopic reconstruction have been used. Post-reconstruction immobilization cast was used in 8 patients including the 3 of combined ligamentous injury, the cast continued for average 5 weeks. The other 8 patients used posterior splint in extension postoperatively and started passive flexion 20°-90° from the second postoperative day. The interval between ACL reconstruction and arthroscopic arthrolysis ranged from 3-11 months (mean 6.2).

Clinical preoperative evaluation, included patellar mobility, passive and active range of motion, stability of the knee, and gait.

Preoperative plain x-rays (anteroposterior and lateral) views were routine in all cases for assessment of the location of the tibial and the femoral tunnels and screws. In two cases the tibial tunnel was anterior and in one case the femoral tunnel was anterior. These 3 patients were told that a portion (or whole) of the graft might be sacrificed.


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In the lateral, or better the axial view (if possible), the patella is assessed for the morphology "length and depth" of the trough harvest site. This weak point is exposed to tensile forces during manipulating the knee in flexion. In two cases a transverse 4 mm lag screw was used to fix a longitudinal fissure in the patella.

Operative technique

After anesthesia (general, spinal, or epidural), the patient is examined for limitation of flexion and extension, and for patellar mobility concerning medial-lateral glide, superior-inferior glide and patellar tilt. In all cases a tourniquet was applied to the thigh with the knee in maximum possible flexion position to minimize capturing of the quadriceps femoris muscle. This tourniquet should always be deflated prior to final manipulation to allow free glide of the quadriceps.

The leg was prepared and draped, and then the knee joint was distended through a superior-medial inflow cannula. Standard anterior-lateral and anterior-medial portals were used for arthroscopic visualization and instrumentation. An initial diagnostic examination was performed with particular attention to search for one or more of the characteristic pathologic findings: (1) Adhesions in the suprapatellar pouch and gutters, (2) misplacement of the graft causing an intercondylar impingement, (3) narrow intercondylar notch, (4) hypertrophic fibrous nodule in front of the ACL graft "Cyclops" blocking the last degrees of extension.

All cases, even those with extension deficit showed adhesions in the suprapatellar pouch and the gutters. These adhesions were firstly cut by basket forceps or the knife of lateral retinacular release, and then resected entirely using a motorized full radius resector. Lysis now is directed to the anterior compartment and the notch. A cyclops lesion: a hypertrophic tissue originating from the graft or from the drilling debris is now resected (in 3 cases) until exposing the ACL graft. If the grafts impinged in full extension, anterior notch plasty was performed using burr or acrominizer or a curette (done in 13 cases). Now you can evaluate the graft placement. If femoral or the tibial tunnel was anterior, the most anterior graft fibers were sectioned if restoration of flexion was still unsatisfactory (done in two cases), and even the whole misplaced graft was sacrificed in two patients.

Finally, the tourniquet was deflated to free the quadriceps for the final manipulation to the maximum possible flexion. Manipulating the knee


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into extension to improve the extension deficit obtained by notchplasty or excision of cyclops is ineffective intraoperatively and should be avoided.

A suction drain was placed under direct vision and a compressive dressing was applied.

Postoperative care:

Maintaining the acquired range of motion (ROM) with arthrolysis is very important and is only possible through meticulous supervised postoperative care.

All patients in this study were subjected to a standard postoperative physiotherapy program composed of continuous passive motion (CPM) interrupted with therapeutic assisted active exercises.

The CPM machine was instituted immediately postoperatively from 0° extension to 120° flexion for 2 hours 4 times daily for the first two postoperative days using adjusted slow speed to suit the patient’s comfort. In all patients, heavy analgesia using parental NSAIDs and/or tramadol HCL was used for the first 2-3 days followed by oral NSAIDs for the next 2 weeks according to the patient's need. Indomethacin (injectable or oral) was routinely given in the first 2-4 days. In the interval between the CPM sessions the patient was instructed to perform isometric quadriceps exercises every hour for a few minutes. In the next following two days (third and fourth postoperative days), the CPM was used for half an hour 3 times daily at a higher speed, interrupted with isometric quadriceps and hamstring setting exercises, leg lifts.

Active assisted and active ROM exercises were allowed for 15 minutes 3 times daily on the bed's firm edge. The suction drain was removed in the second or third postoperative day and if considerable effusion developed after that it was aspirated as it inhibits the quadriceps and limits the ROM. After removing the suction drain and the bulky circular dressing, a very thin anterior dressing was applied to be held in place by adhesive plaster applied with the knee in maximum possible flexion. In this stage of thin dressing, cryotherapy in the form of ice packs can be used to control pain and effusion. Weight bearing was allowed partially using crutches or walker from the third-fourth day to be increased gradually as tolerated. The average hospitalization time was 4 days, ranging from 3 to 6 days.


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Follow-up:

In this study each patient was evaluated thoroughly every week for the first 3-4 weeks postoperatively. The knee was inspected, tense effusion was aspirated, and making sure that the patient is performing the rehabilitation physiotherapy program properly. Measurement of the ROM goniometrically was performed. The average follow up period was 8.9 months (ranged from 3 to 28 months).

Complications

Avulsion of the inferior pole of the patella occurred in one case (HB). It happened during final manipulation of the knee into flexion after arthroscopic arthrolysis. Tension band wiring was done for this avulsion fracture (Figure 1), and the postoperative rehabilitation program in concern of flexion was decided to be calm until 3 weeks post-arthroscopy after which more aggressive exercises were allowed to increase the flexion range. This patient had a final ROM of 0°-125° at 5 months follow up and he was quite satisfied with the end result.

Fig. (1): Anteroposterior and lateral X-ray views of the knee showing tension band wiring for the avulsion fracture of the inferior pole of the patella following forced flexed manipulation at the end of arthroscopic arthrolysis. Complete

healing of the fracture was shown 4 months after fixation.


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RESULTS According to the criteria of Parisien (1988) shown in Table (2) we

had 14 excellent cases and 2 good cases (Figs. 2, 3). Table (2) Treatment results of arthrofibrosis (Parisien, 1988)

Result Criteria Excellent Patient pleased, ROM is full, no pain, no functional impairment. Good Patient pleased, ROM is double the preoperative level, no pain, no

functional impairment. Fair Patient pleased, ROM improved, some pain and some functional

impairment. Poor ROM unchanged from preoperative level, patient not satisfied.

The mean preoperative flexion deformity was 10.3° (ranged 0°-30°);

the mean preoperative maximum flexion ROM (flexion limitation) was 97° (ranged 30°-120°). The final mean postoperative flexion ROM was 133° (ranged 120°-140°). Suprapatellar adhesions obliterating the pouch were present in 6 cases. Cyclops lesion was found and excised in 3 cases. Anterior notchplasty was necessary in 12 patients. Partial sacrifice of the anterior tightest fibers of the graft was done in 2 cases while total sacrifice of a non isometric graft was mandatory in 2 cases in order to gain full flexion. These 2 cases had another ACL reconstruction surgery 2 months later using hamstring tendons autograft and went to full ROM.

DISCUSSION The normal knee ROM has been described as 0 degrees of extension

to 135 degrees of flexion, although hyperextension is frequently present to varying degrees. So the best way to ascertain the normal full ROM is to examine the normal contralateral knee (Lindenfeld et al., 1999). In some tall patients with a thin long thigh a ROM of flexion of 145° or even more can be found. Maintaining a full ROM requires congruent healthy articular surfaces; adequate muscle function; a capsule with suitable capacity and flexibility effective space in the medial and lateral articular recesses, intercondylar notch, and suprapatellar pouch, and sufficient meniscal motion (Enneking & Horowitz, 1972).

There are three different means for treatment of knee joint stiffness: manual mobilization under anesthesia, arthroscopic arthrolysis, or open arthrolysis.


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A- Pre-arthrolysis extension range.

B- Pre-arthrolysis flexion range.

C- Pre-arthrolysis plain X-ray views.


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D- Full extension range, 14 months after arthrolysis.

E- Full flexion range, 14 months after arthrolysis.

Fig. (2): A male patient treated with arthroscopic arthrolysis for stiffness of the right knee 6 months after ACL reconstruction.


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A- Pre-arthrolysis extension range (-10o).

B- Pre-Arthrolysis flexion range (90o).

C- Pre-arthrolysis plain X-ray.


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D- Full extension range, 10 months after arthrolysis.

E- Full flexion range, 10 months after arthrolysis.

Fig. (3): A male patient aged 26 years treated with arthroscopic arthrolysis for

stiffness of the right knee 8 months after ACL reconstruction.

The totally atraumatic nature of arthroscopy and the more accurate lysis of adhesions permits passive and active kinesiotherapy from the moment the patient recovers from anesthesia.

The treatment of arthrofibrosis may be difficult, particularly if the patient has a loss of both extension and flexion. Closed manipulation may be successful when performed early after the open surgical procedure and followed by aggressive regimen of rehabilitation. But if performed late the forceful manipulation may lead to tearing of articular cartilage, rupture of patellar tendon and even femoral fractures.


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The open release is extensive with high morbidity and often requires initial immobilization followed by vigorous efforts at rehabilitation (Sprague et al, 1982). On the other hand, arthroscopic arthrolysis is a relatively simple technique, the duration of hospitalization is brief, the morbidity is low, no immobilization is required and immediate range of motion exercise can be instituted (O’Connor, 1977; Sprague et al, 1982; Parisien, 1988).

Bae et al, in 1993, reported that the results of arthroscopic arthrolysis are better if the procedure was performed 6-12 months after the arthrofibrosis, than those performed later.

Arthrofibrosis after ACL reconstruction may result in a greater functional deficit than the original ACL deficiency. It is commoner with open than arthroscopic reconstruction (O’Connor, 1977) also it is commoner with reconstructions done less than 2 weeks post-injury (Mohtadi et al, 1990).

The possible findings in such cases include adhesions in the suprapatellar pouch and gutters, cyclops fibrous nodule, misplacement of the graft within the intercondylar notch, and even a narrow intercondylar for which notchplasty was not properly done in the primary surgery. In such situation, arthroscopic arthrolysis is the procedure of choice for handling of these intraarticular causative pathology, as it allows lysis of the adhesions under direct visualization with lowest morbidity that sequentially facilitates early postoperative rehabilitation physiotherapy.

Arthroscopic arthrolysis for these cases includes cutting and excision of the adhesions, excision of the cyclops lesion, notchplasty. Then manipulating the knee gently to flexion, which if not fully achieved arthroscopic reevaluation of the graft itself for tightness due to misplacement. Partial excision of the tight anterior most fibers, and if this is not sufficient, you may sacrifice the whole graft.

Kettlekamp et al (1970) have shown that 110° of flexion is necessary in both knees to get up from a sitting position, and 70° of flexion is necessary for a normal gait, so the aim of surgery is to achieve flexion of 110°-120°. Accordingly most of the western literatures (Kettlekamp et al, 1970; Richmond and Assal, 1991; Mariani et al, 1992; Lindenfeld et al, 1999), stressed on improving the extension ROM, but can be satisfied with a flexion range around 125°. In the eastern community and especially in our locality full flexion into squatting is very important in most patient’s daily


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activities, so improving the extension ROM as well as the full flexion range is our aim.

One complication occurred in this study, of having an avulsion transverse fracture of the inferior pole of the patella, for which internal fixation using tension hand wiring was done and this sequentially decelerated the post-arthrolysis rehabilitation program.

This complication occurred, in particular, in this weak part of the patella, which is the harvest site for the patellar-bone-tendon-bone autograft. This site will obviously exposed to high tensile forces during forceful manipulation of the knee into flexion. Thorough pre-arthrolysis axial x-ray view or CT scan can study the patellar harvest site morphology thus you can avoid this complication by postponing the arthrolysis until full consolidation and healing of the harvest site.

Conclusions:

Arthroscopic arthrolysis for knee arthrofibrosis following ACL reconstruction is a safe effective procedure with low morbidity that sequentially facilitates the accelerated postoperative physiotherapy rehabilitation program.

REFERENCES Bae DK, Cho YJ and Kim JJ (1993): Arthroscopic adhesiolysis of partial knee

ankylosis Orthopedics International Edition, Jan-Feb-March, 1993, Vol 1, No 2.

Del Pizzo W, Fox JM, Friedman M, Snyder Z and Ferkel R (1985): Operative arthroscopy for the treatment of fibroarthrosis of the knee. Contemp Orthap, 10:65-73.

Enneking WF and Horowitz M (1972): The intraaticular effects of immobilization on the human knee. J Bone Joint Surg 54:973-85.

Gogus A and Lobehoffer P (1993): Arthroscopic therapy of arthrofibrosis of the knee joint: Arthroscopy, 9(6): 685-90.

Hughston JC and Jacobson KE (1985): Chronic posterolateral rotatory instability of the knee. J Bone Surg, 67-A: 351-359.

Kettlekamp DB, et al., (1970): An electrogoniometric study of knee motion in normal gait. J Bone Joint surg 52A: 775-90.

Lindenfeld TN, Edward CM, Wojty S, Michigan A and Husain A (1999): Operative treatment of arthrofibrosis of the knee. J Bone and Joint surg, 81-A:1772-84.


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Mariani P, Ferretti A, Conteduca F and Tudisco C (1992): Arthroscopic treatment of flexion deformity after ACL reconstruction. Arthroscopy 8(4)517-521.

Mohtadi NG, Webster-Bogoret S and Fowler PJ (1990): Limitation of motion following anterior cruciate Ligament reconstruction-A case control study. Orthopade 19 (6) 388-99.

O'Connor RL (1977): Arthroscopy Philadelphia. JB. Lippincott, pp 14-22. Parisien JZ (1988): The role of arthroscopy in the treatment of postoperative

fibroarthrosis of the knee joint: Clinical orthopedics, 229:185-92. Reider B, Belniak RM and Preiskom D (1995): Arthroscopic arthrolysis for

flexion contracture following intraarticular reconstruction of anterior cruciate Ligament. Knee surg sports traumatol Arthrosc 3(2):83-8.

Richmond JC and Assal M (1991): Arthoscopic management of arthrofibrosis of the knee including infrapatellar contracture syndrome. Arthroscopy, 7:144-147.

Sprague NF, O'connor RL and Fox JM (1982): Arthroscopic treatment of postoperative knee fibroarthrosis. Clin Orthop 166:165-72.

Vaquero J, Vidal C, Medina E and Baena J (1993): Arthroscopic lysis in knee arthrofiborsis, Arthroscopy 9:691-694.


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التصاقات الرآبة المتيبسة بعد عملية زالةاستخدام منظار المفاصل إل استصالح الرباط الصليبي األمامي

العسال ماهر ، السبروت معتز ، *عمران إيمان ، علي محمد حسن ، القاضي هشام

جامعة أسيوط- آلية الطب - *الروماتيزم والتأهيلقسمي العظام وقد ينتج تيبس مفصل الرآبة بعد عملية استصالح الرباط الصليبي األمامي عن درجة

إن . ستصالحال قبل عملية ايبيقصور وظيفي أآبر من القصور الناتج عن إصابة الرباط الصليعتبر أجراء مثالي حيث أن هذه استخدام المنظار لعمل تسليك لإللتصاقات في هذه الحاالت

.اإللتصاقات المسببة تكون بحالتها داخل المفصللتصاقات ليفية وتيبس لمفصل با مريضا مصابين 16تم إجراء هذه الدراسة على عدد

ستصالح للرباط الصليبي األمامي حيث تم عالجهم بواسطة تسليك جراحي االرآبة بعد عملية م فوري لماآينة الحرآة السلبية المستمرة وبرنامج تمارين مكثف بمنظار المفاصل متبوع باستخدا

.من التمرينات الساآنة واإليجابية واإليجابية بالمساعدةوآان متوسط الفترة بين ) 34-19متراوحا بين ( عاما 27آان متوسط عمر المرضى

.)11-3متراوحا بين ( شهرا 6.2عملية الرباط الصليبي وعملية التسليك بالمنظار في جميع الحاالت تم عمل تحريك آامل للرآبة بعد اإلنتهاء من تسليك اإللتصاقات

.والزال المريض تحت تأثير المخدراستخدمت ماآينة الحرآة السلبية المستمرة فورا بعد العملية لمدة ساعتين متواصلتين، أربعة مرات يوميا بالتبادل مع التمارين الساآنة للعضلة الرباعية والعضلة الخلفية للفخذ في األربعة

تبادل ثم لمدة نصف ساعة ثالث مرات يوميا بسرعة أآبر بدءا من اليوم الخامس بال. أيام األولى .مع التمارين اإليجابية واإليجابية بالمساعدة

حالة، وجيدة في حالتين طبقا لخصائص 14آانت نتائج هذه الدراسة ممتازة في درجة 133 درجة قبل عملية التسليك إلى 97 من ينالثوآان متوسط زيادة مجال . باريزيان

. شهرا آمتوسط فترات المتابعة8.9بعدها خالل فترة ت نتائج هذه الدراسة إلى أن استخدام المنظار الجراحي للمفاصل لعمل تسليك وقد خلص

لإللتصاقات تليفات الرآبة المتيبسة له دور ملموس في زيادة المجال الحرآي للمفصل آما أن استخدام ماآينة الحرآة السلبية المستمرة له دور ملموس في المحافظة على النتائج التي تم الحصول

.ملية التسليك بالمنظارعليها بعد ع

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ARTHROSCOPIC ARTHROLYSIS OF KNEE ARTHROFIBROSIS …applications.emro.who.int/imemrf/egypt_rheum... · ARTHROSCOPIC ARTHROLYSIS OF KNEE ARTHROFIBROSIS AFTER ANTERIOR ... Orthopedic