Stiffness after Total K nee Arthroplasty

1. Stiffness after Total Knee Arthroplasty H.Makhmalbaf MD Consultant Orthopaedic Surgeon Assistant Professor Mashad University

2. Manipulation

8. 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

9. 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

10. Non operative • Rehabilitation protocols • Static or dynamic splinting • Injections • Application of serial casts • MUA

11. Invasive procedues • Arthroscopic debridment • Open debridement with or without PE exchange • Complete component revision

12. 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

14. 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

15. 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

16. Preoperative Risk Factors • Limitation of range of motion • Underlying diagnosis • History of prior surgery

17. 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

18. Postoperative Factors • Poor patient motivation • Arthrofibrosis • Infection • Complex regional pain syndrome • Heterotopic ossification

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

20. 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 .

21. 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

22. 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

23. 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

24. 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

25. 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

26. Stiffness & operation scars

27. stiff knee ,sever OA

28. Sever 3 compartment OA

29. 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

30. Previous operation & patellectomy

31. Severe OA

32. Sever pain & Stiffness

33. 30 deg. ROM pre-op.

34. Sever OA & synovitis

35. PS Prosthesis 100 deg ROM • Osteoprotic bone • Adhesions in the suprapatella pouch • Patella subluxating • Release of adhesions • Patella realigned

36. ROM after closure

37. Post op X-ray

38. 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

39. Surgical technique: • Synovectomy • Release recesses • Release lig. Patella • Optional distal femur cut • Quadriceps snip • Sliding patella • Tuberosityosteotomy

40. Stiff Knee post OP • Sufficient analgesia • Epidural catheter • PCA • Opioids & NSAID • Immediate CPM 0-90 • Intensive physiotherapy

41. The best treatment is through AvoidanceTHANK YOU