Perspective

Optimizing range of motion may prevent a stiff knee after TKA

When knee stiffness is confirmed, it can be treated with manipulation under anesthesia, which is successful 85% of the time.

Knee stiffness following total knee arthroplasty is a rare complication, which is multifactorial and can be prevented with techniques that help optimize knee range of motion, according to a presenter.

“[Knee stiffness is] a vexing problem that, with manipulation, we can treat with success 85% of the time,” Peter K. Sculco, MD, assistant attending orthopedic surgeon at Hospital for Special Surgery, told Orthopedics Today. “For those resistant types, it can lead to surgical treatments which have their own varying success rates, but, in essence, it is a problem we still need to work on, as a field, to improve both its prevention and also how we better treat it.”

Sculco noted the etiology of knee stiffness depends on patient factors, surgical factors and postoperative factors. These factors can make identifying the cause of stiffness complicated.

Peter K. Sculco, MD
Peter K. Sculco

“Patient-related factors ... are demographic and related to comorbidities,” Sculco said in a related presentation. “You have knee-related factors, most significantly previous surgical procedures or having preoperative stiffness. You have mental health-related factors, and you have nerve-related factors. So, there is a long list of things that can lead to a postoperative stiff knee.”

Prevention is the best treatment, according to Sculco. This can be obtained through surgical techniques, such as limiting pouch dissection and keeping debris out of the knee.

“But, what is most important, is having balanced, rectangular flexion and extension gaps with correct component rotation and avoid over-stuffing the patellofemoral joint and overstuffing your extension and flexion gaps,” Sculco said at the meeting.

If a patient presents with a stiff total knee, evaluation should involve determining when the stiffness occurred and when the initial surgery was performed. Infection should be ruled out appropriately with plain radiographs and CT or MRI, he said.

Once stiffness is confirmed, Sculco said it can be treated with manipulation under anesthesia (MUA) with arthroscopic lysis, open lysis with or without polyethylene exchange in revision TKA.

“For a patient who is stiff within 3 to 6 months after surgery who presents with less than 9° flexion, that is a good indication for MUA,” he said. “You want to see that patient has a soft endpoint rather than a hard endpoint, that they do not have an isolated flexion contracture that does not respond as well to manipulation and, ... they want to be within 6 months from surgery.” – by Casey Tingle

Disclosure: Sculco reports no relevant financial disclosures.

Knee stiffness following total knee arthroplasty is a rare complication, which is multifactorial and can be prevented with techniques that help optimize knee range of motion, according to a presenter.

“[Knee stiffness is] a vexing problem that, with manipulation, we can treat with success 85% of the time,” Peter K. Sculco, MD, assistant attending orthopedic surgeon at Hospital for Special Surgery, told Orthopedics Today. “For those resistant types, it can lead to surgical treatments which have their own varying success rates, but, in essence, it is a problem we still need to work on, as a field, to improve both its prevention and also how we better treat it.”

Sculco noted the etiology of knee stiffness depends on patient factors, surgical factors and postoperative factors. These factors can make identifying the cause of stiffness complicated.

Peter K. Sculco, MD
Peter K. Sculco

“Patient-related factors ... are demographic and related to comorbidities,” Sculco said in a related presentation. “You have knee-related factors, most significantly previous surgical procedures or having preoperative stiffness. You have mental health-related factors, and you have nerve-related factors. So, there is a long list of things that can lead to a postoperative stiff knee.”

Prevention is the best treatment, according to Sculco. This can be obtained through surgical techniques, such as limiting pouch dissection and keeping debris out of the knee.

“But, what is most important, is having balanced, rectangular flexion and extension gaps with correct component rotation and avoid over-stuffing the patellofemoral joint and overstuffing your extension and flexion gaps,” Sculco said at the meeting.

If a patient presents with a stiff total knee, evaluation should involve determining when the stiffness occurred and when the initial surgery was performed. Infection should be ruled out appropriately with plain radiographs and CT or MRI, he said.

Once stiffness is confirmed, Sculco said it can be treated with manipulation under anesthesia (MUA) with arthroscopic lysis, open lysis with or without polyethylene exchange in revision TKA.

“For a patient who is stiff within 3 to 6 months after surgery who presents with less than 9° flexion, that is a good indication for MUA,” he said. “You want to see that patient has a soft endpoint rather than a hard endpoint, that they do not have an isolated flexion contracture that does not respond as well to manipulation and, ... they want to be within 6 months from surgery.” – by Casey Tingle

Disclosure: Sculco reports no relevant financial disclosures.

    Perspective
    Ran Schwarzkopf

    Ran Schwarzkopf

    One of the leading causes of dissatisfaction after TKA is limited range of motion (ROM). Patients who achieve at least 110° flexion are able to negotiate most stairs and obstacles. Full or nearly full knee extension is needed to stand and ambulate without early quadriceps fatigue. Postoperative stiffness, as defined well by Sculco, has varied degrees and etiologies. Patient education prior to surgery, with matching expectations as to the amount of pain to be expected especially during and after therapy, is fundamental in avoiding postoperative knee stiffness. Patients should expect postoperative discomfort during exercises and especially at night when going to sleep. I explain to patients that when they go to sleep they will have increased throbbing because they are no longer distracted and are fully aware of their knee. Another important point is to explain that physical therapy sessions are not sufficient to achieve a good outcome. Patients need to dedicate a few hours a day to ROM exercises, with an emphasis on extension and flexion. Sculco does a good job summarizing the causes of stiffness. As surgeons, we should give extra time to patient education and preparation, as well as our surgical technique.

    • Ran Schwarzkopf, MD
    • NYU Langone Medical Center New York

    Disclosures: Schwarzkopf reports he is a consultant for Smith & Nephew and Intellijoint; receives stock from Intellijoint and Gauss Surgical; and receives research funding from Smith & Nephew.