Aim
To identify patient and perioperative variables independently associated with arthrofibrosis (AF) requiring arthroscopic intervention following primary anterior cruciate ligament reconstruction (ACLR), and to evaluate clinical and functional outcomes following arthroscopic lysis of adhesions (LOA).
Methods
A retrospective matched case-control study was conducted within a single-surgeon cohort from a prospectively maintained database over a 14-year period (2011-2025). Patients who developed AF requiring arthroscopic LOA following primary ACLR were identified as cases (n = 53) and matched 1:5 to controls (n = 265) by date of primary ACLR. Candidate variables included age, sex, BMI, pre-injury Tegner activity level, history of anxiety or depression, graft type and diameter, fixation method, and concomitant procedures. Conditional logistic regression identified variables independently associated with AF. Pre- and post-arthroscopic intervention outcomes (Lysholm score, pain VAS, patient satisfaction) were compared using paired samples t-tests for the AF cohort, with effect sizes calculated using Cohen's d.
Ethical approval for this study was obtained from Bond University Human Research Ethics Committee (BUHREC) Reference LS00235.
Results
From 1,542 primary ACLRs, 53 confirmed AF cases (3.4%) were identified and matched to 265 controls. Two variables were independently associated with AF following multivariable adjustment. A pre-existing history of anxiety or depression was the most strongly associated factor, with affected individuals having approximately 7.5 times the odds of developing AF (OR = 7.500, 95% CI 3.323-16.928, p < .001). Higher pre-injury Tegner activity level (>5) was protective, with greater-activity individuals having 70.7% lower odds of AF (OR = 0.293, 95% CI 0.122-0.708, p = .006). No surgical variables, including graft type, diameter, fixation method, or concomitant procedures, were independently associated with AF in this study. Among the AF cohort, arthroscopic intervention was performed at a mean of 1.3 years post-ACLR and produced large, statistically significant improvements across all outcomes: Lysholm score (+19.6 points, p < .001, d = 1.26), pain VAS (-2.1 points, p < .001, d = 1.06), and patient satisfaction (+1.1 points, p < .001, d = 1.25).
Conclusion
Pre-existing anxiety or depression and lower pre-injury activity level were the primary factors independently associated with AF requiring arthroscopic intervention following ACLR. These findings complement existing evidence implicating surgical variables in AF risk and suggest that patient-level psychological characteristics warrant consideration alongside operative factors when assessing individual risk following ACLR. Arthroscopic LOA produced clinically meaningful improvements in function, pain, and satisfaction, supporting timely surgical intervention in patients with established AF. Routine preoperative psychological screening and integration of psychological risk factors into perioperative care pathways should be considered for patients scheduled for ACLR.
