Early Identification of Arthrofibrosis in Adolescents Following Anterior Cruciate Ligament Reconstruction Is Associated With the Need for Subsequent Surgery: A Matched Case–Control Study

Published:February 11, 2022DOI:


      To identify the postoperative characteristics associated with the need for subsequent surgical intervention in pediatric anterior cruciate ligament reconstruction (ACLR).


      Patients ≤18 years old who received operative treatment for arthrofibrosis following ACLR versus age- and sex-matched controls with a satisfactory postoperative course were retrospectively reviewed. The range of knee motion preoperatively and at each postoperative visit was recorded. Based on the typical post-operative protocols, visits were categorized into 3 groups: first (first 4 weeks), second (weeks 5-8), and third (weeks 9-16) visits. The deficit in the total arc of range of motion (ROM) in the operative knee relative to the nonoperative knee and the change in ROM between visits were compared. Receiver operating characteristic analysis was performed to determine the time point in which a diagnosis of arthrofibrosis could be predicted with the greatest accuracy.


      In total, 18 patients with arthrofibrosis (mean age 14.2 ± 2.7 years, 9 male) and 36 control patients were included in the final analysis. Arthrofibrosis patients had significantly larger ROM deficits at all visits, 93° vs 69° for the first, 69° vs 24° for the second, and 56° vs 2º for the third, compared with controls (P < .001 for all). Pairwise comparisons showed that in arthrofibrosis cases, the total ROM did not change significantly between the second and third visits (P = .77), contrary to the controls. Receiver operating characteristic analysis revealed that the total ROM deficit of 50.7° at the second postoperative visit is 89% sensitive and 92.5% specific for development of arthrofibrosis.


      We found that patients who go on to need manipulation of the knee under anesthesia/arthroscopic lysis of adhesions do not experience a significant improvement in ROM after the first 5-8 weeks, and that a ROM deficit of >50° at the 5- to 8-week mark postoperatively, is associated with ultimately needing operative intervention for arthrofibrosis. Based on these findings, it may be appropriate to intervene earlier if a patient still has a ROM deficit exceeding 50° by the second postoperative month.

      Level of Evidence

      Level III, retrospective comparative prognostic trial.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mayr H.O.
        • Weig T.G.
        • Plitz W.
        Arthrofibrosis following ACL reconstruction—reasons and outcome.
        Arch Orthop Trauma Surg. 2004; 124: 518-522
        • Magit D.
        • Wolff A.
        • Sutton K.
        • Medvecky M.J.
        Arthrofibrosis of the knee.
        J Am Acad Orthop Surg. 2007; 15: 682-694
        • Kalson N.
        • Borthwick L.
        • Mann D.
        • et al.
        International consensus on the definition and classification of fibrosis of the knee joint.
        Bone Joint J. 2016; 98: 1479-1488
        • Su A.W.
        • Storey E.P.
        • Lin S.-C.
        • et al.
        Association of the graft size and arthrofibrosis in young patients after primary anterior cruciate ligament reconstruction.
        J Am Acad Orthop Surg. 2018; 26: e483-e489
        • Nwachukwu B.U.
        • McFeely E.D.
        • Nasreddine A.
        • et al.
        Arthrofibrosis after anterior cruciate ligament reconstruction in children and adolescents.
        J Pediatr Orthop. 2011; 31: 811-817
        • Wang B.
        • Zhong J.-L.
        • Xu X.-H.
        • Shang J.
        • Lin N.
        • Lu H.-D.
        Incidence and risk factors of joint stiffness after anterior cruciate ligament reconstruction.
        J Orthop Surg Res. 2020; 15: 1-10
        • Shelbourne K.D.
        • Patel D.V.
        • Martini D.J.
        Classification and management of arthrofibrosis of the knee after anterior cruciate ligament reconstruction.
        Am J Sports Med. 1996; 24: 857-862
        • Sanders T.L.
        • Kremers H.M.
        • Bryan A.J.
        • Kremers W.K.
        • Stuart M.J.
        • Krych A.J.
        Procedural intervention for arthrofibrosis after ACL reconstruction: Trends over two decades.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 532-537
        • Mauro C.S.
        • Irrgang J.J.
        • Williams B.A.
        • Harner C.D.
        Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence and etiology using IKDC criteria.
        Arthroscopy. 2008; 24: 146-153
        • Eckenrode B.J.
        • Sennett B.J.
        Arthrofibrosis of the knee following anterior cruciate ligament reconstruction.
        J Orthop Sports Phys Ther. 2011; 41 (32-32)
        • Huleatt J.
        • Gottschalk M.
        • Fraser K.
        • et al.
        Risk factors for manipulation under anesthesia and/or lysis of adhesions after anterior cruciate ligament reconstruction.
        Orthop J Sports Med. 2018; 6 (2325967118794490)
        • Sullivan J.P.
        • Huston L.J.
        • Zajichek A.
        • et al.
        Incidence and predictors of subsequent surgery after anterior cruciate ligament reconstruction: A 6-year follow-up study.
        Am J Sports Med. 2020; 48: 2418-2428
        • Cruz A.I.
        • Fabricant P.D.
        • McGraw M.
        • Rozell J.C.
        • Ganley T.J.
        • Wells L.
        All-epiphyseal ACL reconstruction in children: Review of safety and early complications.
        J Pediatr Orthop. 2017; 37: 204-209
        • DeFrancesco C.J.
        • Storey E.P.
        • Shea K.G.
        • Kocher M.S.
        • Ganley T.J.
        Challenges in the management of anterior cruciate ligament ruptures in skeletally immature patients.
        J Am Acad Orthop Surg. 2018; 26: e50-e61
        • Pennock A.
        • Murphy M.M.
        • Wu M.
        Anterior cruciate ligament reconstruction in skeletally immature patients.
        Curr Rev Musculoskelet Med. 2016; 9: 445-453
        • Barlow S.E.
        Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report.
        Pediatrics. 2007; 120: S164-S192
        • Kocher M.S.
        • Garg S.
        • Micheli L.J.
        Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents: Surgical technique.
        J Bone Joint Surg Am. 2006; 88: 283-293
        • Gandhi J.S.
        • Patel N.M.
        • Leska T.M.
        • Ganley T.J.
        General considerations and complications for pediatric anterior cruciate ligament reconstruction.
        in: Thompson S. Schmitz M. Complications in orthopaedics: Sports medicine. Elsevier, Philadelphia2019: 98-110
        • Thompson R.
        • Novikov D.
        • Cizmic Z.
        • et al.
        Arthrofibrosis after total knee arthroplasty: Pathophysiology, diagnosis, and management.
        Orthop Clin North Am. 2019; 50: 269-279
        • Usher K.M.
        • Zhu S.
        • Mavropalias G.
        • Carrino J.A.
        • Zhao J.
        • Xu J.
        Pathological mechanisms and therapeutic outlooks for arthrofibrosis.
        Bone Res. 2019; 7: 1-24
        • Issa K.
        • Kapadia B.H.
        • Kester M.
        • Khanuja H.S.
        • Delanois R.E.
        • Mont M.A.
        Clinical, objective, and functional outcomes of manipulation under anesthesia to treat knee stiffness following total knee arthroplasty.
        J Arthroplasty. 2014; 29: 548-552
        • Yercan H.S.
        • Sugun T.S.
        • Bussiere C.
        • Ait Si Selmi T.
        • Davies A.
        • Neyret P.
        Stiffness after total knee arthroplasty: Prevalence, management and outcomes.
        Knee. 2006; 13: 111-117
        • Ekhtiari S.
        • Horner N.S.
        • Simunovic N.
        • et al.
        Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 3929-3937
        • Cheuy V.A.
        • Foran J.R.
        • Paxton R.J.
        • Bade M.J.
        • Zeni J.A.
        • Stevens-Lapsley J.E.
        Arthrofibrosis associated with total knee arthroplasty.
        J Arthroplasty. 2017; 32: 2604-2611
        • Fabricant P.D.
        • Tepolt F.A.
        • Kocher M.S.
        Range of motion improvement following surgical management of knee arthrofibrosis in children and adolescents.
        J Pediatr Orthop. 2018; 38: e495-e500