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Nonrevision Surgery
CASE STUDY
A 52-year-old white man presented with minimal pain but limited range of motion (ROM) after a total knee arthroplasty (TKA) that was performed 8 months earlier. His medical history was significant for type 2 diabetes and smoking tobacco products daily. He had undergone an open meniscectomy in his early 20s and had a ROM of 5 to 120 degrees preoperatively. After the primary TKA, he had significant swelling and periincisional blisters, which delayed and limited early postoperative physical therapy. At 3 weeks, the staples were removed, and his ROM was documented at 5 to 65 degrees. Manipulation under anesthesia (MUA) was discussed but was refused by the patient. Progression with physical therapy was slow, and he was forced to minimize his use of pain medications because of constipation and nausea. By 2 months, he had progressed to 5 to 80 degrees of active assisted ROM. On presentation for a second opinion 8 months after TKA, he had regressed to 8 to 65 degrees of active motion. Radiographs taken at that time ( Fig. 15.1 ) revealed good component alignment in the sagittal and coronal planes with a neutral mechanical axis. Infection parameters, including erythrocyte sedimentation rate (ESR), C-reactive protein level (CRP), and synovial cell count, were negative on preoperative testing. Computed tomography (CT) using a standard protocol to determine component rotation showed that the femoral and tibial components were within the normal limits of external rotation.
Surgical management of the patient’s knee stiffness was discussed, and all options were considered. The cause of his stiffness was reviewed, and poor tolerance to pain medications was assessed by a team of anesthesiologists. The essential components of this case, including the procedure ultimately performed and its outcome, are reviewed in this chapter.
Algorithm
Algorithm for surgical management of the stiff TKA. Dichotomous paths ensue from determination of component alignment, rotation, and sizing ( MUA , manipulation under anesthesia).
Chapter Preview
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Stiffness after total knee arthroplasty (TKA) is a common complication. Depending on the definition, it can affect 1% to 60% of cases. It is a significant cause for patient dissatisfaction after surgery.
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Specific numeric criteria for stiffness after TKA vary, but loose criteria usually suggest a range of motion of 5 to 95 degrees. Stricter criteria describe a range of 15 to 75 degrees. It is generally agreed that an arc of motion of less than 70 degrees qualifies as a stiff TKA.
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Nonoperative management of these difficult cases starts with aggressive physical therapy and dynamic braces.
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Surgical management consists of revision and nonrevision techniques (e.g., manipulation under anesthesia [MUA], arthroscopy-assisted MUA, open lysis of adhesions).
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This chapter reviews nonrevision options in treating knee stiffness after TKA, such as arthroscopic lysis of adhesions, MUA, and tunneled epidural anesthesia.
Introduction
Stiffness after total knee arthroplasty (TKA) is a common, disabling condition that occurs in up to 60% of cases. Although more stringent reviews have found the incidence to range from 1% to 12%, complete fibrous ankylosis has been described in only 0.1% of cases. Stiffness has been defined as a limited range of motion (ROM) that affects the ability to perform routine activities of daily living. Limited knee motion is a common cause for patient dissatisfaction after surgery, and it can negatively influence outcomes and return to preoperative levels of function.
Typically, flexion contractures greater than 5 to 8 degrees are poorly tolerated because a standard gait pattern becomes difficult to achieve. This situation leads to poorer functional scores, greater levels of pain, and difficulty with walking and stair climbing. Several factors may contribute to this deformity, such as adaptive muscle shortening, a longer extremity requiring knee flexion to functionally equalize leg lengths, inadequate soft tissue balancing, and tight hamstring or gastrocnemius muscles. Terminal flexion plays a similar role in functional outcome, with 67 degrees required for the swing phase of walking, 100 degrees to descend stairs, and 105 degrees to arise from a low chair.
Stiffness after TKA may result from preoperative, intraoperative, or postoperative conditions ( Table 15.1 ). In a well-fixed, properly aligned TKA, several factors may contribute to the development of arthrofibrosis, including the number of prior operations, preoperative ROM, tendency for scar tissue formation, complex regional pain syndrome, heterotopic ossification, poor pain tolerance, and inability to participate in postoperative therapy. Depression can also impair a patient’s motivation to participate in physical therapy, and it is often encountered as patients cope with the pain and concept of having a new knee.
Table 15.1
Factors Contributing to Stiffness After Total Knee Arthroplasty
| Preoperative Period | |
| Preoperative range of motion Preoperative diagnosis (e.g., obesity) Prior open surgical procedures |
Keloid or hypertrophic scar formation Medical or physical conditions that may preclude participation in postoperative therapy Patient’s personality |
| Intraoperative Period | |
| Poor gap balancing Component malpositioning or rotation Joint line elevation (e.g., patella baja) |
Inadequate bony resection Anterior tibial slope Retained posterior osteophytes Oversizing of components Retained cement |
| Postoperative Period | |
| Poor motivation and compliance Deep infection Arthrofibrosis |
Complex regional pain syndrome Heterotopic ossification Clinical depression |
In our case study, the patient presented after delayed entry into physical therapy and with a medical history significant for diabetes, smoking, and a prior open procedure on the operative knee. Management of complex cases ranges from aggressive physical therapy to nonrevision surgical options to complete revision TKA. This chapter focuses on the nonrevision options for managing knee stiffness after TKA, including manipulation under anesthesia (MUA) and arthroscopic or open lysis of adhesions with MUA.
Indications and Contraindications
Manipulation Under Anesthesia
Closed MUA is typically indicated for patients with a stiff TKA as an early intervention to get them back on track to a full recovery. Timing of the manipulation varies, with some authorities advocating the procedure within the first 2 weeks, at 2 weeks, or at any time within the first 6 weeks in a patient with less than 90 degrees of flexion. Because of soft tissue concerns and healing requirements for the surgical incision, MUA often is delayed for a minimum of 3 weeks but not more than 12 weeks after surgery. Beyond 12 weeks, the fibrous or scar tissue becomes quite strong, increasing the risk of fracture or extensor mechanism injury with a forceful closed MUA.
Adequate pain control is cited as a crucial part of the MUA procedure, and many advocate the use of an epidural anesthetic for a minimum of 24 to 48 hours in the hospital. Although general anesthesia may be used for MUA, it is relatively contraindicated in those with poor pain tolerance. Many investigators have reported improvements in the ROM of up to 30 or 40 degrees after closed manipulation. We advocate the use of MUA for all patients with less than 90 degrees of flexion or greater than 10 degrees of flexion contracture within the first 12 weeks after TKA. Earlier treatment correlates with superior outcomes.
MUA is better for improving knee flexion than for restoring extension. Cates and co-workers reported on their series of thirty-seven manipulations; only 67% of patients with a flexion contracture gained full extension, and the average improvement was 4 degrees. However, 87% of patients who lacked 90 degrees of flexion at the time of MUA were able to achieve greater than 90 degrees of flexion at 1-year follow-up. The authors concluded that the most important factors for a successful MUA were manipulation within 8 weeks of TKA, full extension and less than 90 degrees of flexion before MUA, and a lateral release during TKA. Stiffness persisting longer than 3 months after surgery or after a failed MUA is considered a contraindication for further closed manipulation procedures. Other relative contraindications include osteoporotic bone, preexisting wound complications, flexion contracture greater than 10 to 15 degrees, and a history of poor preoperative ROM.
Aggressive Physical Therapy and Bracing
Aggressive physical therapy is suggested for early postoperative stiffness, particularly within the first 6 weeks after surgery. It typically consists of stretching, electrical stimulation, deep heating, soft tissue mobilization, and aggressive ROM therapy three to four times per week. Dynamic and progressive-stretch bracing also may play a role in enhancing ROM in the early period after TKA. Flexion and extension bracing or splints are available to improve on the direction of motion that is lacking. Beyond 12 weeks after surgery, the use of aggressive physical therapy or bracing is relatively contraindicated in managing a stiff TKA, because it is unlikely to improve the situation and has the potential to exacerbate pain symptoms during this period.
Aggressive physical therapy and bracing to treat early TKA stiffness is indicated in a compliant patient with a good preoperative ROM, smaller contractures (i.e., 5- to 10-degree flexion contractures and >90 degrees of motion), and good pain control. Relative contraindications are prohibitive cost, poor knee flexion (<80 degrees), large flexion contractures (>15 degrees), noncompliant patient, and poor pain tolerance. Although these modalities are often successful for correcting smaller contractures, they may require prolonged treatment ranging from 2 months to more than 1 year.
Arthroscopic Lysis of Adhesions
Arthroscopic débridement of scar tissue coupled with knee manipulation and aggressive physical therapy is a successful means for managing knee stiffness after primary or revision TKA. A consensus for indications does not exist, but most agree that the first line of management is an attempt at closed management, followed by open operative techniques. The indications for arthroscopic lysis of adhesions to treat arthrofibrosis of a well-positioned TKA are failure of physical therapy and bracing, recurrent stiffness after MUA, and failure to respond appropriately to closed management more than 3 months after TKA. The best outcomes can be anticipated for patients with a painless, stiff TKA. Patients with a significant component of pain are likely to have another underlying diagnosis associated with their knee stiffness. Relative contraindications include component malpositioning, infection, and poor wound healing.
Open Lysis of Adhesions
Indications for open lysis of adhesions are similar to those for arthroscopic lysis. They include severe knee stiffness (<90 degrees of flexion, >10 degrees of flexion contracture) in the setting of good component alignment and fixation; a failed attempt at closed MUA, bracing and physical therapy or arthroscopy; and presenting symptoms persisting more than 3 months after the index procedure. Relative contraindications include component malpositioning, infection, and poor wound healing.
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