Stiffness after Total Knee Arthroplasty

H.Makhmalbaf MDConsultant Orthopaedic Surgeon

Assistant Professor Mashad University

Manipulation

Functional problem & arthrofibosis following total Knee Arthroplasty

• Thorsten M. Seyler Et al JBJS Am. 2007• Small number of patients with persistent

dysfunction that is difficult to treat• Persistent pain, Instability • & limitation of ROM• Decreased ROM ,quality of life• Decreased patient satisfaction

Functional problems

• Continued dysfunction despite initial rehab.• Noninvasive & invasive treatment• Revision surgery• If well-fixed, well-aligned prosthetic

components will not benefit from a complete revision

Non operative

• Rehabilitation protocols• Static or dynamic splinting• Injections • Application of serial casts• MUA

Invasive procedues

• Arthroscopic debridment• Open debridement with or without PE

exchange• Complete component revision

• Careful radiographic & clinical evaluation• Component loosening, malalignment• Retained bone cement• Indicated the need for revision surgery• Infection: aspiration & culture• Diagnosis & identify organism• Proper antibiotic therapy & timely surgical

treatment

Stiffness : AAOS

• Is a debilitating complication of TKA• Is inadequate or smaller than expected ROM• If ROM is between 10-90 & no pain or

functional difficulties it is not a stiff knee• Difficulty getting out of a chair• Pain when climbing stairs• An observable stiff-knee gait

Stiffness: AAOS instructional course Lectures

• Is closely related to pain• Patient’s experience in attempting to move

the knee• Is closely related to patient’s motivation• Tolerate the pain to achieve the goal• No better results with CPM• Physiotherapy & Supervision lower risk

Preoperative Risk Factors

• Limitation of range of motion• Underlying diagnosis• History of prior surgery

Stiffness after TKA: Laskin RsJ arthroplasty 2004 Jun

• Improper flexion-extension gap balancing• Oversizing or malpositioning of components• Inadequate femoral or tibial resection• Excessive joint line elevation• Creation of anterior tibial slope• Inadequate resection of posterior osteophytes• Tight posterior cruciate ligament

Postoperative Factors

• Poor patient motivation• Arthrofibrosis • Infection• Complex regional pain syndrome• Heterotopic ossification

Management

• Mobilizing the patient &• Instituting physical therapy• If fails:• Manipulation • Lysis of adhesions• Revision arthroplasty

Management:

• Closed manipulation is successful within 3 m.• Arthroscopic or open lysis after 3 months• Revision arthroplasty is preferred for stiffness

from malpositioned or oversized components• If flexion is good initially but stiffness develops

later ,should be assessed for intrinsic as well as extrinsic causes .

Prevention & treatment of stiffness following TKA

• Current Opinion in Orthopaedics Jan 2008 • Range 1-6%• Poor preopeative ROM• Poor intraoperative ROM• Patella infera• The best treatment is avoidance

Prevention of stiffness:Current Op. in Orth. 2008

• Proper patient motivation• Physical therapy• Careful surgical technique• Careful ligamentous balancing• Flexion-extension gap equalization• Maintenance of posterior condylar offset

Management of Stiffness Following TKA J. Parvizi et al. JBJS Am 2006

• Stiffness is a disabling complication• Exact etiology can not found in most cases • Prevalence 1.3% to 12%• Preoperative ROM• Contracture of extensor mechanism &• Capsular structure

Management of stiffness

• Lack of patient compliance • Patient threshold for pain• Technical factors such as:• Overstuffing of the PFJ• Mismatch of the flexion & extension gaps• Inaccurate ligament balancing

Management of stiffnessJ.Parvizi et al

• Component malpositioning• Use of oversized components• Joint-line elevation• Excessive tightening of the extensor mechan.• Underresection of the patella• Anti-oxidants Or high dose of Vit. C

Stiffness & operation scars

stiff knee ,sever OA

Sever 3 compartment OA

Stiffness after TKAMaloney

• The most important factor is pre-op ROM• Design of prosthesis• Evaluate patients X-ray• Malrotation of components• Stuffing of the PFJ• Balance the PCL• MUA up to 3mo• Open release of arthrofibrosis, PCL, med & lat gut• Revision surgery

Previous operation & patellectomy

Severe OA

Sever pain & Stiffness

30 deg. ROM pre-op.

Sever OA & synovitis

PS Prosthesis 100 deg ROM

• Osteoprotic bone• Adhesions in the

suprapatella pouch• Patella subluxating• Release of adhesions• Patella realigned

ROM after closure

Post op X-ray

Causes of stiff Knee: Hofmann

• ROM between 20-70• Infection, Trauma, deformity, RA, HTO• Fixed extensor mechanism• Scarred recesses, patella ankylosis• Patella baja, avulsion lig. patella• Disruption quad. tendon.• Patella fracture

Surgical technique:

• Synovectomy• Release recesses• Release lig. Patella• Optional distal femur cut• Quadriceps snip• Sliding patella• Tuberosity osteotomy

Stiff Knee post OP

• Sufficient analgesia– Epidural catheter– PCA– Opioids & NSAID

• Immediate CPM 0-90• Intensive physiotherapy

The best treatment is through Avoidance

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