Intraarticular fibrous nodule as a cause of loss of extension following anterior cruciate ligament reconstruction

Loss of motion is a well-known complication following anterior cruciate ligament (ACL) reconstruction. We have found that loss of extension is more disabling than loss of flexion, and is a more common problem following arthroscopic assisted ACL reconstruction. We are reporting on a group of 21 patients who have developed restricted knee extension following ACL reconstruction utilizing either the central one-third of the patellar ligament or the hamstring tendons as an autogenous graft. The patients presented at an average of 4 months postoperatively with a clinical syndrome of loss of extension associated with pain at terminal extension, crepitus, and grinding with attempted extension beyond their limit. The consistent finding at arthroscopy was a fibrous nodule occupying the intercondylar notch, varying in size from 1 × 1 to 2 × 3 cm, and presenting a mechanical block to full extension. It appears that anterior placement of the graft, particularly on the tibia, results in injury to the graft and subsequent nodule formation. Removal of the nodule resulted in improvement of an average preoperative loss of extension of 11°, to 3° at surgery, and 0° at 1 year follow-up. The average side-to-side difference in terminal extension at final examination, using the uninvolved limb for comparison, was 3°. Histology was available for review on 19 of the 21 patients operated on. The consistent microscopic finding within the nodule was the presence of disorganized dense fibroconnective tissue that, with time, underwent modulation to fibrocartilage. It is postulated that this occurs in response to compressive loading of the nodule.