Lateral Extraarticular Procedures Increase Risk of Arthrofibrosis After Anterior Cruciate Ligament Reconstruction in
Christopher D Hamad1, Joshua Wiener1,2,3, Soroush Shahamatdar1
1Department of Orthopaedic Surgery, University of California, Los Angeles, CA, USA.
Background:
Loss of range of motion following anterior cruciate ligament reconstruction (ACLR) is a clinically significant complication that may lead to delayed recovery, arthrofibrosis, and secondary procedures. Lateral extraarticular procedures (LEAPs) are increasingly performed to reduce anterolateral instability and minimize graft failure but their impact on postoperative stiffness and arthrofibrosis remains unclear.
Methods:
The TriNetX Research Network was queried for patients aged 12-21 years who underwent primary ACLR between 2015 and 2023, with or without concomitant LEAP. Patients with inflammatory arthropathies were excluded. Propensity score matching was performed based on demographics and comorbidities, resulting in 2 balanced cohorts (n = 1,140 each). Outcomes within 1 year included arthrofibrosis, manipulation under anesthesia or lysis of adhesions (MUA/LOA), physical therapy (PT) utilization, opioid prescriptions, and chronic knee pain. Risk ratios (RRs), odds ratios (ORs), 95% confidence intervals (CIs), and Kaplan-Meier survival estimates were calculated.
Results:
Arthrofibrosis occurred in 5.7% of patients undergoing ACLR with LEAP compared with 2.8% of those undergoing isolated ACLR (RR: 2.02, OR: 2.08, 95% CI: 1.35-3.20, P = .001). MUA/LOA rates were higher with LEAP (3.3% vs 2.1%) but not statistically significant (OR: 1.57, 95% CI: 0.93-2.64, P = .088). LEAP patients had greater PT utilization (48.2% vs 38.8%, OR: 1.47, 95% CI: 1.24-1.73, P < .001) and higher short-term opioid use (26.1% vs 19.5%, OR: 1.46, 95% CI: 1.20-1.78, P < .001).
Conclusions:
In this large, multi-institutional cohort, the addition of LEAP to ACLR in adolescents was associated with an increased risk of arthrofibrosis, as well as greater PT and opioid utilization at 1 year. While this is a database study with unmeasured variables and cannot definitively prove causation, surgeons should balance graft protection benefits with the higher risk of postoperative stiffness and emphasize careful patient selection, counseling, and early rehabilitation to reduce complications.
Key Concepts:
(1)The addition of lateral extraarticular procedures is associated with a 2-fold increase in arthrofibrosis compared with isolated anterior cruciate ligament (ACL) reconstruction.(2)Lateral extraarticular procedure (LEAP) patients demonstrate increased early resource utilization, including physical therapy and opioid prescriptions.(3)Increased postoperative pain and delayed range of motion may contribute to stiffness after LEAP procedures.(4)Surgeons should counsel patients on the graft-protective benefits of LEAP in the context of increased knee stiffness risk.(5)Careful patient selection and early range-of-motion-focused rehabilitation are essential when performing LEAP in adolescent ACL surgery.
Level Of Evidence:
III; Retrospective Cohort Study.
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