Results of knee manipulations after anterior cruciate ligament reconstructions* JULIE A. DODDS, MD, JAMES S.
KEENE,† MD, BEN K. GRAF, MD, AND RICHARD H. LANGE, MD
From the Section of Sports Medicine, Division of Orthopedic Surgery, University of Wisconsin Clinical Sciences Center, Madison, Wisconsin
ABSTRACT
manipulations in these patients. Knee manipulations are not benign procedures. Additional anesthesia is required and the manipulation itself may result in supracondylar fractures of the femur, avulsions of the patellar ligament, wound problems, or hemarthrosis.5,Therefore, we examined the results of knee manipulations after ACL reconstructions and evaluated the effect of various factors (time to manipulation, severity of premanipulation motion deficits, and concomitant arthroscopic lysis of adhesions) on the outcome of this procedure.
We analyzed the results of knee manipulations in 42 knees that had persistent flexion or extension deficits after intraarticular ACL reconstructions. All manipulations were done under a spinal or general anesthetic and, in 10 cases, arthroscopic debridement of adhesions also was performed. The average time from reconstruction to manipulation was 7 months (range, 3 to 14 months) and the average followup was 26 months (range, 6 to 56 months). At manipulation, average flexion was increased from 95° to 136° and average extension from 11° to 3°. In no case was motion gained at the expense of joint stability and, at final followup, average flexion and extension were 127° and 4°, respectively. The final range of motion achieved was not affected by the time to manipulation, severity of premanipulation flexion deficit, or concomitant arthroscopic debridement of adhesions. However, knees with premanipulation extension deficits of ≥15° achieved significantly less final extension than knees with lesser premanipulation deficits. Overall, manipulations were a safe and effective method for improving both flexion and extension in 86% of the knees that had restricted motion after ACL reconstructions.
MATERIALS AND METHODS Between 1984 and 1987, three of the authors (JSK, BKG, RHL) performed 336 intraarticular ACL reconstructions in 333 patients. Of the 336 reconstructed knees, 46 (14% ) were manipulated for loss of motion after the operation. Of these 46 knees, 42 were evaluated 6 or more months after manipulation and are the basis of this report. In all 42 knees, the ACL was reconstructed with a patellar tendon graft, as described by Clancy.4The bone blocks of the grafts were secured to the tibia and femur with No. 5 Ethibond sutures that were tied around screws or staples. In 9 knees, the reconstructions were performed arthroscopically and, in 33 knees, they were performed via an arthrotomy. Twenty-three (55%) of the reconstructions were performed within 3 weeks of injury and 19 (45%) were performed after that interval. In 8 knees we performed concomitant meniscal repair; in 19, partial medial or lateral menisectomy; and in 6 knees we performed medial collateral
There are numerous, well-recognized complications associated with intraarticular ACL reconstructions. These include infection, saphenous and peroneal nerve injuries, fractures of the patella and tibia, retropatellar pain, and limited knee action. Although treatment of many of these complications has been addressed in other studies,2, 3, 6,7.9-12,14 to our knowledge, there are no published reports on the results of knee
ligament repair. The rehabilitation protocol after reconstruction was similar for all of the knees that ultimately required manipulation, except for the time to initiation of knee motion. In 11 knees, active-assisted flexion and passive extension were started within 2 weeks of surgery. In the remaining 31 knees, motion was started 6 weeks after surgery. Criteria for manipulation were the inability to achieve
’ Presented at the 15th annual meeting of the AOSSM, Traverse City, 1989 t Address correspondence and repnnt requests to James S Keene, MD, Division of Orthopedic Surgery, 600 Highland Avenue, Madison, Wl 53792
Michigan, June
283
284
120° of active flexion or inability to actively extend the knee within 10° of neutral (0°) by 6 months after reconstruction, or the failure to gain motion at any time (~3 months after surgery) during the rehabilitation process. Based on these criteria, 23 knees were manipulated to gain flexion, 1 to gain extension, and 18 to improve both flexion and extension. The average age of the patients undergoing manipulation was 24 years (range, 15 to 38 years); 19 (47%) were male and 21 (53%) were female. Twenty-four (57%) manipulations involved the right knee and 18 (43%) involved the left knee. Manipulations were performed at an average 7 months (range, 3 to 14 months) after the reconstruction. The average followup was 26 months (range, 6 to 56 months), with 32 of the 42 knees having at least 1 year of followup after manipulation. All of the manipulations were performed under a general or spinal anesthetic. After complete muscle relaxation had been obtained, the hip was flexed to 90°, the tibia was grasped proximally, and the ankle was placed under the axilla of the surgeon. The surgeon then placed his ear next to the knee, and gently flexed the knee until there were no further audible or palpable separations of adhesions. Extension was gained by placing the ipsilateral ankle on a bolster and applying a posterior force to the extended knee. Range of motion of the opposite knee was used as a guide for the amount of motion to be gained at the time of manipulation. In 10 (24%) of the 42 knees, arthroscopy was performed before (one knee), immediately after (eight knees), or 6 weeks after (one knee) the manipulation. In all 10 knees, adhesions were debrided; 3 of these knees also required lateral and/or medial retinacular releases and 3 required &dquo;notchplasties&dquo; (widening of the intercondylar notch). In one knee an arthrotomy and debridement of adhesions was performed immediately after manipulation. At the conclusion of the manipulation or the manipulation and arthroscopy, knee stability was assessed with the Lachman and pivot shift tests, passive flexion and extension were measured with a goniometer, and the knee was injected with 40 cc of 0.25% bupivacaine hydrochloride. Ice packs were applied to the knee in the recovery room and physical therapy was initiated under the direction of a physical therapist. Most patients were discharged from the hospital on the day of the procedure. Active and active-assisted motion, performed daily by the patient, was supervised by a physical therapist at least three times per week. We measured maximum flexion and extension and tested joint stability before, immediately after, and at 2, 6, 12, and a24 weeks after manipulation. Range of motion was recorded using the method recommended by the American Medical Association.’ Full extension was thus designated as 0°, and extension deficits and hyperextension were recorded as positive and negative values, respectively. The Mann-Whitney test was used for statistical analysis of the results. Specifically, the effect of premanipulation motion, time to manipulation, and the addition of arthroscopic procedures on the final motion achieved were evaluated.
RESULTS The average maximum flexion and extension before manipulation, at manipulation, and at various intervals after manipulation are shown in Table 1. The severity of the flexion deficit before manipulation did not adversely affect the final flexion achieved. In the 17 knees with s90° of flexion before manipulation, final mean flexion was 125° (range, 70° to 140°) and, in the 25 knees with >90° before manipulation, final flexion averaged 132° (range, 95° to 147°). These differences were not statistically significant (P 0.27). However, the severity of the premanipulation extension deficit did adversely affect the final extension achieved. In the 23 knees with an extension deficit of :::150 before manipulation, final average extension was 1.3° (range, 0° to 7°) and, in the 19 knees with an extension deficit >15° before manipulation, final extension averaged 6.8° (range, 0° to 25°). This differ=
ence was
significant (P
=
0.003).
The length of time from ACL reconstruction to manipulation did not affect the final flexion or extension obtained (Table 2). As shown in Table 2, gains in flexion and extension were inversely related to the length of time from surgery to manipulation. However, the greater gains achieved in knees manipulated early only reflected their larger premanipulation motion deficits; final mean flexion and extension were similar to that of the knees manipulated at later intervals. The effect of time to manipulation was further analyzed by dividing the 42 knees into two groups: those manipulated within 6 months of reconstruction (13 knees) and those manipulated more than 6 months (29 knees) after the reconstruction (Table 2). The knees were grouped in this manner because in the early years of this study, manipulations generally were not performed within the first 6 months for fear of disrupting the reconstruction ligament. Average premanipulation flexion (80° versus 101°) and extension (14° versus 10°) in these two groups were not significantly different (P 0.18). The differences in final flexion and extension for the two groups were not significant (P 0.28) and, in both groups, there were no detectable increases in knee laxity after manipulation. In 10 of the 42 knees we performed an arthroscopic lysis of adhesions in conjunction with the closed manipulation. =
=
TABLE1
Average flexion and extension of the 42 knees before, immediately after, and
at
2, 6, 12, and >_24 weeks (average 26 months) after manipulation
° A negative value indicates hyperextension (i.e., yond neutral) of the knee.
extension be-
285 TABLE 2 Final average flexion and extension compared to the length of time from surgery to the
manipulation
In most cases, arthroscopy was performed when full passive extension was not easily obtained with manipulation alone, or there was a &dquo;springy endpoint&dquo; to the motion achieved with closed manipulation. Thus we performed arthroscopy in four knees to gain flexion, and in six to gain flexion and extension. Table 3 shows the average extension before manipulation and at final followup in the six knees in which arthroscopic lysis of adhesions was performed to gain extension. The average extension in these six knees was 3° (range, -5° to 10°) immediately after manipulation. The extension achieved after arthroscopy was specifically stated in the records of only two of the six knees; the gains in these cases were 0° and 8°, respectively. Twelve knees were manipulated to gain extension (Table 3) and did not undergo arthroscopy; the difference in average final extension between these 12 and the 6 undergoing lysis was not significant (P 0.37). In the 10 knees where arthroscopic debridement was performed to increase flexion, average flexion was 138° (range, 125° to 145°) after manipulation. Table 3 shows the average flexion before manipulation and at final followup. The flexion achieved after arthroscopy could not be determined from the medical records. Thirty-one knees were manipulated to improve flexion, with no lysis deemed necessary. The results show (Table 3) that average final flexion was greater in the knees that only were manipulated, i.e., the groups of 31 and
the first and second manipulations was 7 months (range, 2 to 12 months). The average flexion and extension achieved after each manipulation is summarized in Table 5. Five of the six knees were manipulated a second time because the range of motion achieved after the first manipulation was less than that measured before the manipulation: two lost 5° and 8° of extension, two lost 15° and 22° of flexion, and one knee lost 5° of extension and 15° of flexion. After the second manipulation, four knees achieved acceptable motion and two knees required a third manipulation. Of these latter two knees, one lost 25° of flexion and achieved only 10° to 75° of motion, and the other gained only 10° of flexion and extension and achieved only 10° to 80° of knee motion. In these two knees, the third manipulation, performed 3 to 5 months after the second manipulation, resulted in gains of 50° and 55° of flexion and 0° and 3° of extension. In one knee with an extension deficit of 20° and flexion of 95°, we performed an arthrotomy at the first manipulation, then had to perform a second manipulation. The final flexion and extension achieved was 112° and 20°, respectively.
12, respectively.
No complications from anesthesia or fractures occurred in this series. In the majority of the patients, manipulation did result in hemarthrosis, but in no case did this cause a delay in initiating physical therapy. No clinically detectable ACL laxity developed as a result of manipulation. One knee was found to have posterolateral laxity 6 weeks after the second manipulation. This pattern of instability had not been appreciated before the ACL reconstruction or before the first or second manipulation.
=
In six knees, more than one manipulation was performed. The profile of these 6 knees was not appreciably different from the remaining 36 knees that required only one manipulation, except for that percentage of knees in which reconstruction was performed in the acute stage (
KEENE,† MD, BEN K. GRAF, MD, AND RICHARD H. LANGE, MD
From the Section of Sports Medicine, Division of Orthopedic Surgery, University of Wisconsin Clinical Sciences Center, Madison, Wisconsin
ABSTRACT
manipulations in these patients. Knee manipulations are not benign procedures. Additional anesthesia is required and the manipulation itself may result in supracondylar fractures of the femur, avulsions of the patellar ligament, wound problems, or hemarthrosis.5,Therefore, we examined the results of knee manipulations after ACL reconstructions and evaluated the effect of various factors (time to manipulation, severity of premanipulation motion deficits, and concomitant arthroscopic lysis of adhesions) on the outcome of this procedure.
We analyzed the results of knee manipulations in 42 knees that had persistent flexion or extension deficits after intraarticular ACL reconstructions. All manipulations were done under a spinal or general anesthetic and, in 10 cases, arthroscopic debridement of adhesions also was performed. The average time from reconstruction to manipulation was 7 months (range, 3 to 14 months) and the average followup was 26 months (range, 6 to 56 months). At manipulation, average flexion was increased from 95° to 136° and average extension from 11° to 3°. In no case was motion gained at the expense of joint stability and, at final followup, average flexion and extension were 127° and 4°, respectively. The final range of motion achieved was not affected by the time to manipulation, severity of premanipulation flexion deficit, or concomitant arthroscopic debridement of adhesions. However, knees with premanipulation extension deficits of ≥15° achieved significantly less final extension than knees with lesser premanipulation deficits. Overall, manipulations were a safe and effective method for improving both flexion and extension in 86% of the knees that had restricted motion after ACL reconstructions.
MATERIALS AND METHODS Between 1984 and 1987, three of the authors (JSK, BKG, RHL) performed 336 intraarticular ACL reconstructions in 333 patients. Of the 336 reconstructed knees, 46 (14% ) were manipulated for loss of motion after the operation. Of these 46 knees, 42 were evaluated 6 or more months after manipulation and are the basis of this report. In all 42 knees, the ACL was reconstructed with a patellar tendon graft, as described by Clancy.4The bone blocks of the grafts were secured to the tibia and femur with No. 5 Ethibond sutures that were tied around screws or staples. In 9 knees, the reconstructions were performed arthroscopically and, in 33 knees, they were performed via an arthrotomy. Twenty-three (55%) of the reconstructions were performed within 3 weeks of injury and 19 (45%) were performed after that interval. In 8 knees we performed concomitant meniscal repair; in 19, partial medial or lateral menisectomy; and in 6 knees we performed medial collateral
There are numerous, well-recognized complications associated with intraarticular ACL reconstructions. These include infection, saphenous and peroneal nerve injuries, fractures of the patella and tibia, retropatellar pain, and limited knee action. Although treatment of many of these complications has been addressed in other studies,2, 3, 6,7.9-12,14 to our knowledge, there are no published reports on the results of knee
ligament repair. The rehabilitation protocol after reconstruction was similar for all of the knees that ultimately required manipulation, except for the time to initiation of knee motion. In 11 knees, active-assisted flexion and passive extension were started within 2 weeks of surgery. In the remaining 31 knees, motion was started 6 weeks after surgery. Criteria for manipulation were the inability to achieve
’ Presented at the 15th annual meeting of the AOSSM, Traverse City, 1989 t Address correspondence and repnnt requests to James S Keene, MD, Division of Orthopedic Surgery, 600 Highland Avenue, Madison, Wl 53792
Michigan, June
283
284
120° of active flexion or inability to actively extend the knee within 10° of neutral (0°) by 6 months after reconstruction, or the failure to gain motion at any time (~3 months after surgery) during the rehabilitation process. Based on these criteria, 23 knees were manipulated to gain flexion, 1 to gain extension, and 18 to improve both flexion and extension. The average age of the patients undergoing manipulation was 24 years (range, 15 to 38 years); 19 (47%) were male and 21 (53%) were female. Twenty-four (57%) manipulations involved the right knee and 18 (43%) involved the left knee. Manipulations were performed at an average 7 months (range, 3 to 14 months) after the reconstruction. The average followup was 26 months (range, 6 to 56 months), with 32 of the 42 knees having at least 1 year of followup after manipulation. All of the manipulations were performed under a general or spinal anesthetic. After complete muscle relaxation had been obtained, the hip was flexed to 90°, the tibia was grasped proximally, and the ankle was placed under the axilla of the surgeon. The surgeon then placed his ear next to the knee, and gently flexed the knee until there were no further audible or palpable separations of adhesions. Extension was gained by placing the ipsilateral ankle on a bolster and applying a posterior force to the extended knee. Range of motion of the opposite knee was used as a guide for the amount of motion to be gained at the time of manipulation. In 10 (24%) of the 42 knees, arthroscopy was performed before (one knee), immediately after (eight knees), or 6 weeks after (one knee) the manipulation. In all 10 knees, adhesions were debrided; 3 of these knees also required lateral and/or medial retinacular releases and 3 required &dquo;notchplasties&dquo; (widening of the intercondylar notch). In one knee an arthrotomy and debridement of adhesions was performed immediately after manipulation. At the conclusion of the manipulation or the manipulation and arthroscopy, knee stability was assessed with the Lachman and pivot shift tests, passive flexion and extension were measured with a goniometer, and the knee was injected with 40 cc of 0.25% bupivacaine hydrochloride. Ice packs were applied to the knee in the recovery room and physical therapy was initiated under the direction of a physical therapist. Most patients were discharged from the hospital on the day of the procedure. Active and active-assisted motion, performed daily by the patient, was supervised by a physical therapist at least three times per week. We measured maximum flexion and extension and tested joint stability before, immediately after, and at 2, 6, 12, and a24 weeks after manipulation. Range of motion was recorded using the method recommended by the American Medical Association.’ Full extension was thus designated as 0°, and extension deficits and hyperextension were recorded as positive and negative values, respectively. The Mann-Whitney test was used for statistical analysis of the results. Specifically, the effect of premanipulation motion, time to manipulation, and the addition of arthroscopic procedures on the final motion achieved were evaluated.
RESULTS The average maximum flexion and extension before manipulation, at manipulation, and at various intervals after manipulation are shown in Table 1. The severity of the flexion deficit before manipulation did not adversely affect the final flexion achieved. In the 17 knees with s90° of flexion before manipulation, final mean flexion was 125° (range, 70° to 140°) and, in the 25 knees with >90° before manipulation, final flexion averaged 132° (range, 95° to 147°). These differences were not statistically significant (P 0.27). However, the severity of the premanipulation extension deficit did adversely affect the final extension achieved. In the 23 knees with an extension deficit of :::150 before manipulation, final average extension was 1.3° (range, 0° to 7°) and, in the 19 knees with an extension deficit >15° before manipulation, final extension averaged 6.8° (range, 0° to 25°). This differ=
ence was
significant (P
=
0.003).
The length of time from ACL reconstruction to manipulation did not affect the final flexion or extension obtained (Table 2). As shown in Table 2, gains in flexion and extension were inversely related to the length of time from surgery to manipulation. However, the greater gains achieved in knees manipulated early only reflected their larger premanipulation motion deficits; final mean flexion and extension were similar to that of the knees manipulated at later intervals. The effect of time to manipulation was further analyzed by dividing the 42 knees into two groups: those manipulated within 6 months of reconstruction (13 knees) and those manipulated more than 6 months (29 knees) after the reconstruction (Table 2). The knees were grouped in this manner because in the early years of this study, manipulations generally were not performed within the first 6 months for fear of disrupting the reconstruction ligament. Average premanipulation flexion (80° versus 101°) and extension (14° versus 10°) in these two groups were not significantly different (P 0.18). The differences in final flexion and extension for the two groups were not significant (P 0.28) and, in both groups, there were no detectable increases in knee laxity after manipulation. In 10 of the 42 knees we performed an arthroscopic lysis of adhesions in conjunction with the closed manipulation. =
=
TABLE1
Average flexion and extension of the 42 knees before, immediately after, and
at
2, 6, 12, and >_24 weeks (average 26 months) after manipulation
° A negative value indicates hyperextension (i.e., yond neutral) of the knee.
extension be-
285 TABLE 2 Final average flexion and extension compared to the length of time from surgery to the
manipulation
In most cases, arthroscopy was performed when full passive extension was not easily obtained with manipulation alone, or there was a &dquo;springy endpoint&dquo; to the motion achieved with closed manipulation. Thus we performed arthroscopy in four knees to gain flexion, and in six to gain flexion and extension. Table 3 shows the average extension before manipulation and at final followup in the six knees in which arthroscopic lysis of adhesions was performed to gain extension. The average extension in these six knees was 3° (range, -5° to 10°) immediately after manipulation. The extension achieved after arthroscopy was specifically stated in the records of only two of the six knees; the gains in these cases were 0° and 8°, respectively. Twelve knees were manipulated to gain extension (Table 3) and did not undergo arthroscopy; the difference in average final extension between these 12 and the 6 undergoing lysis was not significant (P 0.37). In the 10 knees where arthroscopic debridement was performed to increase flexion, average flexion was 138° (range, 125° to 145°) after manipulation. Table 3 shows the average flexion before manipulation and at final followup. The flexion achieved after arthroscopy could not be determined from the medical records. Thirty-one knees were manipulated to improve flexion, with no lysis deemed necessary. The results show (Table 3) that average final flexion was greater in the knees that only were manipulated, i.e., the groups of 31 and
the first and second manipulations was 7 months (range, 2 to 12 months). The average flexion and extension achieved after each manipulation is summarized in Table 5. Five of the six knees were manipulated a second time because the range of motion achieved after the first manipulation was less than that measured before the manipulation: two lost 5° and 8° of extension, two lost 15° and 22° of flexion, and one knee lost 5° of extension and 15° of flexion. After the second manipulation, four knees achieved acceptable motion and two knees required a third manipulation. Of these latter two knees, one lost 25° of flexion and achieved only 10° to 75° of motion, and the other gained only 10° of flexion and extension and achieved only 10° to 80° of knee motion. In these two knees, the third manipulation, performed 3 to 5 months after the second manipulation, resulted in gains of 50° and 55° of flexion and 0° and 3° of extension. In one knee with an extension deficit of 20° and flexion of 95°, we performed an arthrotomy at the first manipulation, then had to perform a second manipulation. The final flexion and extension achieved was 112° and 20°, respectively.
12, respectively.
No complications from anesthesia or fractures occurred in this series. In the majority of the patients, manipulation did result in hemarthrosis, but in no case did this cause a delay in initiating physical therapy. No clinically detectable ACL laxity developed as a result of manipulation. One knee was found to have posterolateral laxity 6 weeks after the second manipulation. This pattern of instability had not been appreciated before the ACL reconstruction or before the first or second manipulation.
=
In six knees, more than one manipulation was performed. The profile of these 6 knees was not appreciably different from the remaining 36 knees that required only one manipulation, except for that percentage of knees in which reconstruction was performed in the acute stage (
