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The Stiff Total Knee Replacement: Causes, Treatment, and Prevention


The Stiff Total Knee Replacement: Causes, Treatment, and Prevention N. Johanson, M.D. I.C.L. Ch. 46, 1997 Reviewed by: K. Ikram, D.O. Introduction Stiffness is ... – PowerPoint PPT presentation

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Title: The Stiff Total Knee Replacement: Causes, Treatment, and Prevention

The Stiff Total Knee Replacement Causes,
Treatment, and Prevention
  • N. Johanson, M.D.
  • I.C.L. Ch. 46, 1997
  • Reviewed by K. Ikram, D.O.

  • Stiffness is observer dependent
  • From surgeons perspective, it is inadequate or
    less than expected ROM
  • Pt who has 90 deg flexion, and within 10 deg of
    full ext and no complaints of pain or fxnal
    difficulties in not considered to have a stiff

  • If after 1 yr post op, pt has following problems,
    must evaluate for underlying knee problems
  • C/o knee stiffness
  • Difficulty getting out of chair
  • Pain on climbing stairs
  • Stiff knee gait

  • Stiffness is closely related to the pts own
    motivation to gain a fxnal ROM, and his or her
    willingness to endure pain to achieve that goal.
  • Stiffness is nearly always present during early
    postop period, gradually dec over time, and is a
    valuable marker of improvement throughout the
    recovery period
  • Surgical pain is the most imp cause of early knee

  • Both quads and hamstrings guard
  • Passive flexion and extension is difficult to
  • Theoretical basis for implementation of in-hosp
  • CPM has not conclusively demonstrated to shorten
    the hosp stay or provide significantly increased
  • Its value in early post op period is questionable
    in view of its cost

  • Post op knee stiffness usually subsides within
    6-8 wks
  • Knee ROM improves steadily thru the first 3
    months, then less rapid progress seen in next 9
  • If a limited or deteriorating ROM occurs,
  • Infection
  • Mechanical complications related to soft tissue
    or implant
  • Impending arthrofibrosis
  • RSD

  • Late onset knee stiffness following a relatively
    symptom-free period may be suggestive of one of
    the following
  • Infection
  • Overuse synovitis or tendonitis (esp. in younger
  • Synovitis secondary to rheumatoid arthritis,
    particulate wear debris or recurrent hemarthrosis
  • Implant loosening or breakage

  • Early infection (within first 6 wks) is
    characterized by swelling, erythema, and
    generalized pain, with or without drainage.
  • Late infection more easily recognized b/c it
    follows a relatively asymptomatic period
  • Aspiration and culture required to distinguish an
    indolent infection from other cuases of synovitis

Mechanical Problems (Implant/Soft Tissue)
  • B/c of the wide variety of available implant
    designs and rarity of severely stiff TKRs in
    published series, overall problem remains
  • Dorr found that pts who had obtained excellent
    clinical results following either PCL retaining
    or sacrificing designs continued to walk with a
    stiff knee gain 2 yrs post op
  • Suggest that TKR rarely produce a completely
    normal gait

  • The right balance b/n motion, strength, and
    stability is the surgical goal for a good fxnal
  • Inadequate bone resection combined with
    persistent lig imbalance or tightness may result
    in knee stiffness
  • If tightness is recognized, correct by either
    revising bone cuts, releasing ligaments, or a
  • If flexion contracture, more distal femur removed
    or post capsular release

  • Approach to bone resection in TKA is dependent on
    plan to preserve or sacrifice PCL
  • If PCL preserved, femur is cut first to preserve
    the level of the jt line and more closely
    approximate the normal kinematics of the knee
  • A potentially dangerous pitfall is reversing tilt
    of the tibia in the sagittal plane thus causing
    tightening of PCL in flexion if rollback mech
    fxns according to design

  • Inadequate release of tight capsular and
    ligamentous structures is an important cause of
    stiff TKA
  • Poor flexion and extension may result from
    inadequate release or recession of a tight PCL
  • Medial collateral lig in varus deformities and
    LCL and iliotibial band in valgus deformities
    often require release to prevent asymmetric
    implant wear and promote optimal range of knee

  • Patellofemoral dysfxn may cause pain that may
    promote stiffness b/c of disuse.
  • Following patellar conditions should be
    considered when evaluating stiff TKA
  • 1. patella not resurfaced
  • 2. inadequate lateral release
  • 3. Asymmetrical cutting of patella
  • 4. Excessive elevation of jt line
  • 5. Int rotation of fem comp
  • 6. Formation of intra-art adhesions
  • 7. Patella fx or comp loosening

  • Excessive wear debri over a given period of time
    causes synovitis, pain, stiffness, and swelling
  • Causative factors include
  • Poor quality polyethylene
  • High pt wt and activity level
  • Failure to remove cement and bone debris from
    knee jt
  • Implant design factors (contract stresses, poly

Patient Related factors
  • Availability and efficiency of in-hosp P.T. has a
    significant impact on outcome of TKA
  • With shorter hosp stays, an increasing reliance
    on outpt and home P.T. services
  • An important factor is the pts willingness to
    undergo a rigorous rehab program
  • Pt preferences, expectations, and satisfaction
    are important indicators as to the likelihood of
    obtaining good outcomes from surgery.

  • Pre op education is an important tool for guiding
    the pt to understanding the goals and risks and
    benefits of surgery
  • Educ process gives the surgeon an opportunity to
    recognize pts with unrealistic expectations or
    lack of motivation
  • Host factors that promote arthrofibrosis about
    the knee jt are not well understood
  • Inflammatory connective tissue dz have increased
    incidence of arthrofibrosis

Diagnostic Considerations
  • Most important diagnostic tool in the eval of the
    stiff TKA is the physical exam
  • 2 exams should be performed within the first 6
    wks to assure acceptable progress with ROM and
    fxnal status
  • Plain x-rays should be ordered within the first 6
    wks and repeated if stiffness and pain increase.
  • X-ray findings may include Inadequate bone
    resection, oversized fem component, evidence of
    lig imbalance resulting from asymmetric cement
    pressurization, or gross maltracking or
    subluxation of patella

  • Bone scan is indicated in late cases of stiffness
  • Less useful during early recovery period and
    throughout first year post op
  • Cementless implants tend to increase bone scan
    activity up to 2 yrs
  • Infection should be ruled out with an aspiration
    and culture of jt fluid
  • Neg culture does not absolutely r/o infection
  • If suspicion high, arthrotomy may be necessary to
    obtain tissue sample

Treatment Alternatives
  • In a stiff, non infected, radiographically
    satisfactory TKA, most imp initial treatment is
    an adequately supervised course of sustained
    intensive P.T., lasting 3-6 months
  • If, during the first 3 months, a plateau is
    reached, manipulation under anesthesia should be
  • Fox Poss found a group of pts manipulated 2 wks
    post op and could not see any difference from
    control at 1 yr post op
  • Pre op ROM is an imp predictor of post op motion

  • Parsley and assoc reported 17 knees lt 75 deg
    flexion pre op, gained 16 deg post op
  • 257 knees had gt 95 deg flexion and lost a mean of
    6 deg of flexion
  • So knowledge of pre op flexion should assist the
    surgeon and pt with goals for motion post op
  • If manipulation does not obtain acceptable ROM,
    an exploration and debridement may be performed,
    using open or arthroscopic techniques
  • Arthroscopy good for localized tethering of
    patella or patellar clunk syndrome
  • Results of arthroscopic tx of gen arthrofibrosis
    have not been as good

Revision Surgery
  • Exchange of modular tibial polyethylene space in
    conjunction with capsular or ligamentous release
    may provide improvement of ROM
  • Deformity should be completely corrected with a
    new trial spacer in place
  • If correction not complete, revise tibial and/or
    femoral components after making new bone cuts.

  • During revision for TKA stiffness, fully release
    all structures that may have contributed to
    condition including
  • Quadriceps tendon and vastus intermedius adhesion
    to femur and suprapatella pouch
  • Medial and lateral gutters
  • Collateral ligaments
  • Lateral patellar retinaculum

Prevention of Stiff TKA
  • The most fundamental consideration for prevention
    of TKA complications in general is the selection
    of an implant and instrumentation sytem that is
    complex enough to allow flexibility, yet simple
    enough to minimize chance for technical error
  • Based on a published track record of performance
    over 5-10 yrs
  • Technical difficulty should be compatible with
    proficiency and experience of surgeon

  • A design with less inherent stability or
    constraint will require more exacting bone cuts
    and ligament balancing to deliver an acceptable
  • Applies to many PCL retaining designs
  • Cemented cruciate substituting designs have more
    inherent stability and will better tolerate the
    aggressive ligament releases required to correct
    severe varus or valgus deformities
  • Elevation of jt line is also better tolerated in
    PCL substituting implants

  • Knowledge of pt expectations, goals, and
    motivations is essential for early detection of
    potential problems with stiffness following TKA
  • A poorly motivated pt with little or no pre op
    education combined with a short hosp stay and
    marginally delivered home or outpt P.T.
    constitutes a dangerous mix that may result in a
    less than optimal surgical result.
  • More research is needed on this issue.