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Dynamic Splinting in Children and Adolescents With Stiffness After Knee Surgery

Pace, James, L., MD*; Nasreddine, Adam, Y., MA; Simoni, Michael, MD; Zurakowski, David, PhD†,§; Kocher, Mininder, S., MD, MPH†,‡,∥

Journal of Pediatric Orthopaedics: January 2018 - Volume 38 - Issue 1 - p 38–43
doi: 10.1097/BPO.0000000000000730
Lower Extremity

Purpose: The purpose of this study was to investigate the indications and outcomes of dynamic splinting (DS) of the arthrofibrotic knee in the pediatric population.

Methods: Seventy-four patients (41 males, 33 females) with postoperative arthrofibrosis treated with DS after an index knee surgery were reviewed. Median age was 13 years (range, 4 to 18 y), and median follow-up was 17 months (interquartile range, 10 to 28 mo). Demographics, index surgery procedure, preoperative and postoperative knee range of motion (ROM) measurements, treatment length and subsequent need for manipulation under anesthesia (MUA), and surgical lysis of adhesions (LOA) were evaluated. A ROM deficit was defined as lack of extension ≥10 degrees or lack of flexion <130 degrees. Successful improvement of ROM was defined as an increase of ≥10 degrees in flexion, extension, or both. There were 23 patients with flexion deficit only, 17 with extension deficit only, and 34 with combined flexion and extension deficits. Wilcoxon signed-rank test was used to assess median improvement in ROM. Patients were classified into 4 surgical groups: anterior cruciate ligament (ACL) reconstruction without meniscal repair (n=19), ACL reconstruction with meniscal repair (n=12), tibial spine fracture repair (n=21), and other (n=22). Multivariable logistic regression was used to identify independent predictors of failure of DS requiring MUA and LOA.

Results: A total of 57 patients with flexion deficits showed median improvement of 30 degrees in flexion (95% confidence interval, 0-90 degrees; P<0.001), and 51 patients with extension deficits showed median improvement of 7 degrees in extension (95% confidence interval, 0-60 degrees; P<0.001). DS was associated with ROM improvement in 84% and avoided the need for surgery in 58% of all 74 patients included in the study. Multivariate analysis of the ACL with meniscus repair subgroup revealed that each 1-month delay in DS treatment was associated with a 5-fold increased risk of undergoing a LOA (P=0.007). Thirty-six (63%) patients with flexion deficit avoided need for surgery, whereas 26 (51%) patients with extension deficits avoided surgery.

Conclusions: Our data suggest that DS is an effective method to increase knee ROM and reduce the need for subsequent MUA/LOA in the pediatric and adolescent patient with arthrofibrosis after an index knee surgery.

Level of Evidence: Level IV—retrospective case series.

*Division of Orthopaedic Surgery, Children’s Hospital Los Angeles, Los Angeles, CA

Department of Orthopaedic Surgery


Division of Sports Medicine, Boston Children’s Hospital

Harvard Medical School, Boston, MA

None of the authors have received any external financial reward pertaining to the completion of this study.

The authors declare no conflicts of interest.

Reprints: Mininder S. Kocher, MD, MPH, Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail:

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