O2065: To Manipulate or Not: Management of Arthrofibrosis in Tibial Spine Fractures: A Preliminary Study

Background: Operative management of tibial spine fractures (TSF) carries a moderate risk of complications of which arthrofibrosis, and resultant decreased knee range of motion (ROM), is one of the most frequently reported. The decision for who, and when to consider manipulation under anesthesia (MUA) or non-operative treatment for arthrofibrosis is variable and the literature lacks recommendations regarding optimal management. Therefore, we compared patients treated non-operatively versus with MUA to determine if each treatment could result in satisfactory outcomes in the management of arthrofibrosis.

Methods: We performed a multicenter retrospective cohort study for patients with TSFs. Patients 25 years and younger treated operatively for TSFs and later diagnosed with arthrofibrosis were included. Arthofibrosis was defined as loss of knee extension ≥ 5.0° and/or knee flexion ≥ 15.0°. Those lost to follow up prior to resolution of arthrofibrosis were excluded.

Patients were organized into two cohorts: non-operative treatment and MUA. Data was collected for sex, race, injury date, fracture classification, concomitant injuries, surgery dates, follow up duration, knee ROM, and return to the operating room. Descriptive statistics were compiled for each group and were compared.

Results: There were 12 and 22 patients in the non-operative and MUA groups respectively. Patient demographics and concomitant injuries were similar between groups. The 1-2 week postoperative median flexion for the MUA group was 45.0° and extension was 12.5°. Median 1-2 week postoperative flexion in the non-operative group was 60.0° and extension was 0.0°. The median one-year postoperative flexion for the MUA group was 137.5° and the extension was 0.0°. The median one-year postoperative flexion for the non-operative group was 130.0° and median extension was 0.0°.

In the MUA group, the median time to return for MUA was 2.4 months. At 2 months postoperatively, the MUA group had a median flexion and extension of 80.0° and 8.0° respectively. The non-MUA group had a median flexion and extension of 85.0° and 10.0° respectively at this time. The median pre-MUA flexion and extension angles were 90.0° and 5.0° respectively. The post-MUA median flexion and extension angles were 130.0° and 3.0° respectively.

Conclusion: The MUA group had decreased ROM compared to the non-MUA group initially after surgery. At the time of MUA decision making, however, the ROM between cohorts was similar. This may imply MUA decision making is a result of surgeon preference rather than ROM value. Irrespective of treatment, both MUA and non-MUA effectively treated arthrofibrosis to a similar degree of flexion and extension at terminal evaluation. Additionally, both groups had similar incidence of concomitant injuries which may imply severity of injury does not affect the treatment outcomes for arthrofibrosis. While this study improves understanding of treatment outcomes for arthrofibrosis, large prospective studies are needed to elucidate which treatment, if any, is optimal.