Female Sex, Older Age, Earlier Surgery, Anticoagulant Use, and Meniscal Repair Are Associated With Increased Risk of Manipulation Under Anesthesia or Lysis of Adhesions for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Purpose To determine what patient or surgical factors are associated with an increased risk of arthrofibrosis requiring manipulation under anesthesia (MUA) or lysis of adhesions (LOA) after anterior cruciate ligament reconstruction (ACLR). Methods A systematic review was performed in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Cochrane, Embase, and Medline databases were searched for studies published through February 2023. Inclusion criteria were studies that identified risk factors for MUA and/or LOA after ACLR. Studies investigating arthrofibrosis after multiligamentous knee injuries or ACL repair were excluded. Results Eleven studies including a total of 333,876 ACLRs with 4,842 subsequent MUA or LOA (1.45%) were analyzed. Increasing age was associated with an increased risk in three studies (p<0.001, p<0.05, p<0.01), but was found to have no association another two. Other factors that were identified by multiple studies as risk factors for MUA/LOA were female sex (four studies), earlier surgery (five), use of anticoagulants other than aspirin (two), and concomitant meniscal repair (four). Conclusions 1.45% of the ACLR patients included in this systematic review had to undergo a subsequent MUA/LOA treat arthrofibrosis. Female sex, older age, earlier surgery, use of anticoagulants other than aspirin, and concomitant meniscal repair were associated with increased risk of MUA/LOA. The modifiable risks, including use of anticoagulants and time between injury and surgery, can be considered when making treatment decisions. Level of Evidence IV (systematic review of level III/IV evidence)