Arthrofibrosis is an inflammatory proliferation of connective tissue cells in a joint. The phenomenon is most commonly observed after knee joint reconstruction, making it a postoperative complication. Treatment involves arthroscopic revision and physical as well as physiologic therapies.
What is arthrofibrosis?
Fibrocytes are cells of the connective tissue. They are located between the individual fibers of the extracellular matrix and thus stabilize the connective tissue. In shape, they are spindle-shaped and equipped with long-branched cell processes that allow them to form tight networks. When connective tissue pathologically proliferates, this clinical picture is called fibrosis in reference to fibrocytes. Arthrofibrosis is specifically characterized by a pathological proliferation of fibrocytes that occurs on the basis of inflammatory processes within a joint. Two different forms of arthrofibrosis are distinguished: primary and secondary arthrofibrosis. In the primary form, there is a massive proliferation of connective tissue as part of scarring in a joint. Secondary arthrofibrosis is probably caused by mechanical factors. The most important disease from this group is cyclops syndrome. Arthrofibrosis occurs after anterior cruciate ligament reconstructions with an incidence between 4 and 35 percent. Arthrofibrosis has been observed particularly frequently in the context of arthroscopic interventions on the knee joint and especially reconstruction of the anterior cruciate ligament.
Causes
The causes of primary arthrofibrosis are largely unknown. However, joint reconstruction appears to be associated with the phenomenon. Therefore, decreased locomotor activity after or before surgery is now considered a risk factor. Too short a time interval between reconstruction and an irritable condition in the joint can also be described as a risk factor. The same applies to perioperative pain, which is countered with physiotherapeutic treatment. Postoperative muscle training too early or infections and bleeding into the joint can also cause arthrofibrosis. The same applies to rheumatoid arthritis and diabetes mellitus. Secondary arthrofibrosis, on the other hand, is usually preceded by incorrect graft placement or entrapment symptoms. The pathogenesis for both forms assumes the development of granulation tissue and interstitial edema. Thus, inflammatory mediators are released. Because of pathologically increased collagen synthesis, the fluid in the interstitial space is exchanged with extracellular matrix. Type VI collagen is mediately involved in fibroblast proliferation. Some authors also refer to arthrofibrosis as pathologic wound healing, which triggers a cytokine response through dysregulation of cytokines.
Symptoms, complaints, and signs
The clinical picture of arthrofibrosis is extremely complex. Although the symptoms can vary greatly in individual cases, painful and permanent movement restrictions of the affected joint are considered characteristic. In most cases, there is redness and overheating of the corresponding area on the skin. Swelling is also common. Often, an effusion forms in addition or there is entrapment symptomatology with scar impingement. Apart from these leading symptoms, no uniform picture can be described for arthrofibrosis. Sometimes the more or less severe restriction of movement of the affected joint even occurs completely without pain symptoms. As a compelling clinical symptom, a persistent restriction of mobility is described that includes more than ten degrees of extension and more than 125 degrees of flexion. In extreme cases, complete loss of function of the joint occurs in the course of arthrofibrosis. In most cases, this phenomenon affects the knee joint. Swelling or redness and effusions on the skin do not necessarily accompany the problem. Heating of the corresponding part of the body, on the other hand, is present in most cases.
Diagnosis and course
Prompt diagnosis of arthrofibrosis can be difficult because of the heterogeneous clinical picture. Postoperative complications may also occur in the setting of other clinical pictures. Differentially, postoperative lack of motion or immobilization and persistent restriction of motion may also be due to shrinkage of the associated joint capsule.To support a suspected anamnetic diagnosis of arthrofibrosis, CRPS can be performed. However, this can only detect symptoms of arthrofibrosis in the rarest of cases. The course of arthrofibrosis depends strongly on the time of diagnosis. In extreme cases, for example, if the diagnosis is made too late, patients may permanently lose joint function and have to live with a persistent limitation of mobility.
Complications
Arthrofibrosis is itself a complication, which can occur especially after surgical interventions on the knee joint. Due to arthrofibrosis, most movements are usually associated with severe pain for the patient. Due to this pain, the patient’s movement is relatively limited. This person may be dependent on the help of others. The affected area is often reddened and somewhat swollen. In the worst case, the joint may completely lose its function due to arthrofibrosis. In this case, the patient can no longer move without walking aids, which leads to a severe reduction in quality of life. Due to these limitations, arthrofibrosis can also lead to psychological problems. Treatment usually takes place surgically. Its success depends strongly on the severity of the arthrofibrosis and cannot be universally confirmed. In most cases, however, the pain subsides and the joint can be moved again. Special complications do not occur if the treatment is performed early. In addition to the surgical intervention, treatment with the help of heat and cold are also possible in case of arthrofibrosis. These likewise do not lead to further discomfort.
When should one go to the doctor?
If arthrofibrosis is suspected, the appropriate physician should be consulted immediately. This is especially true if symptoms such as redness, swelling or increasing pain in the joints are added. If the affected joint is suddenly no longer as mobile as before, an immediate visit to the doctor is recommended. People who are prone to pronounced scarring are particularly susceptible to arthrofibrosis. Other risk factors include: poor joint and bone mobility prior to surgery, arthrofibrosis of other joints, and autonomic nervous system disorders. Rarely, scarring may also have genetic causes. If one or more of these pre-existing conditions exist, a quick visit to the doctor is recommended. The physician will diagnose the arthrofibrosis and can directly initiate the appropriate treatment measures. If the disease is not treated, the scarring can spread to other joints. At the latest, if mobility continues to decrease, the cause must be medically clarified. If new problems occur after therapy, this should be reported to the responsible physician.
Treatment and therapy
The route of therapy depends on the type of arthrofibrosis. In secondary arthrofibrosis, surgical revision is usually used. For example, such revision can be performed by arthroscopic removal of scar strands or excessive connective tissue. On the other hand, if the movement restriction is due to an incorrectly fitting implant, a graft adjustment is performed. This can be done at the knee joint, for example, as part of cruciate ligament surgery, which creates an extension of the knee axis. Primary arthrofibrosis is difficult to treat. Arthroscopic revisions can also be considered for this form of arthofibrosis, but usually show little success. In the case of a primary form of arthofibrosis, conservative treatment methods include physiotherapy to restore mobility. NSAIDs or physical therapies with heat or cold can also be used. The same applies to electrotherapy and ultrasound therapies. Depending on the individual case, manual lymphatic drainage can bring improvements in the symptoms. If arthrofibrosis persists despite the countermeasures, therapy is by anesthetic mobilization and open arthrolysis. In individual cases, persistent arthrofibrosis may also require replacement of the endoprosthesis.
Outlook and prognosis
The prognosis of arthrofibrosis depends on the possible start of treatment. The earlier this occurs, the better the chances of recovery. Without treatment, there will be progression of the disease and thus of the symptoms.In addition, psychological problems often occur, resulting in a further reduction in well-being and quality of life. With an early diagnosis and an immediate start of treatment, the various therapy options usually lead to a rapid alleviation of the symptoms. Within a few weeks, the patient can achieve complete freedom from symptoms. This is true if there are no further complications. Arthrofibrosis often develops as a secondary disease. Regardless of the existing underlying disease, arthrofibrosis must be treated separately. The start of treatment depends on the patient’s health stability. Delays may occur, leading to an increase in pain. If the underlying disease cannot be cured to a sufficient degree, arthrofibrosis may develop again. The prognosis of recurrent arthrofibrosis is also good under normal conditions and can be achieved within a short time in people with a stable immune system. If the arthrofibrosis is already in an advanced stage, the prognosis deteriorates significantly. Despite various treatment options, success is usually only moderate and freedom from symptoms is not achieved.
Prevention
If more than three weeks elapse between cruciate ligament rupture and reconstruction, arthofibrosis of the knee can usually be prevented, according to recent studies. With respect to other procedures or joints, no promising preventive measures are available to date.
Follow-up
Direct aftercare is usually not possible for arthrofibrosis. The affected person is dependent on purely symptomatic treatment, since causal treatment is usually not possible in this case. However, early diagnosis and treatment of arthrofibrosis have a very positive effect on the further course of this disease and can prevent further complications and complaints. In many cases, surgical interventions are necessary to alleviate the symptoms. After such an operation, the patient must rest and take care of his body. Above all, the affected joint should not be subjected to unnecessary stress. Sporting activities should also be avoided. As a rule, the patient is also dependent on physiotherapy measures to increase the mobility of the joint again. The exercises can often be performed in the patient’s own home, thus accelerating the healing of the arthrofibrosis. Since the quality of life of the affected person is significantly limited by the disease, he or she is often dependent on the help of others in everyday life. Loving care has a positive effect on the course of the disease. Contact with other sufferers of arthrofibrosis can also prove useful in exchanging helpful information.
Here’s what you can do yourself
Primary or secondary arthrofibrosis mainly affects knee joints after surgery – including minimally invasive arthroscopy. Whereas in secondary arthrofibrosis the causative agent can be identified and usually corrected by surgical intervention, the reasons for the development of primary arthrofibrosis are more in the realm of speculation. What appears to be certain is that joint irritation triggers inflammatory reactions that cause the formation of connective tissue (scar tissue) as a counter-reaction. If it is known that a surgical or arthroscopic procedure is to be performed on a joint, it is recommended that self-help measures be incorporated into daily life to prevent arthrofibrosis. The most important self-help measures involve determining the optimal time for surgery. For example, it helps to wait at least six weeks before cruciate ligament replacement surgery for a cruciate ligament tear in the knee, since shorter periods between cruciate ligament tear and surgery significantly increase the risk of developing arthrofibrosis. Another preoperative preventive measure consists of targeted physiotherapy to keep the affected joint as mobile as possible. An immobile phase over a longer period would also increase the risk of arthrofibrosis. Targeted, individually tailored physiotherapy should also be started immediately after surgery. Physiotherapy can be performed independently at home as a self-help measure in addition to the therapy in the therapist’s office.
