Updated: 3/10/2018

TKA Stiffness

Topic
Review Topic
0
0
Questions
9
0
0
Evidence
15
0
0
Techniques
3
Introduction
  • Definition
    • flexion contracture 10-15 degrees
    • flexion < 90 degrees
  • Incidence
    • 1.3%-12%
  • Risk factors
    • preoperative factors
      • poor preoperative ROM 
        • most important factor
      • patella baja 
      • increased medical comorbidities
      • low pain tolerance
    • technical factors
      • overstuffing patellofemoral joint
      • malrotation
      • tight flexion and/or extension gaps
      • joint line elevation
      • excessive tightening of extensor mechanism during closure
        • closure in flexion (as opposed to extension) may limit this complication
      • tight PCL in cruciate-retaining prosthesis
    • postoperative factors
      • delayed rehabilitation
      • infection
      • HO
      • hamstring spasms
      • usually resolves within 6 months
Presentation
  • Symptoms
    • difficulty kneeling
  • Physical exam
    • check preoperative ROM from records
Imaging
  • Radiographs
    • rule out prosthesis malposition or alignment
  • CT scan
    • rule out prosthesis malposition or alignment
Studies
  • Serum labs
    • ESR/CRP
      • must rule-out infection
Treatment
  • Nonoperative
    • manipulation under anesthesia 
      • indications
        •  flexion <90 degrees within first 12 weeks of operation (timing is controversial)     
          • over aggressive manipulation
            • fracture
            • extensor mechanism disruption
      • contraindications
        • stiffness >3 months postoperatively 
        • manipulation associated with greater risk and lower benefit
  • Operative
    • arthroscopic lysis of adhesions with manipulation under anesthesia
      • indications
        • persistent late stiffness
    • revision total knee arthroplasty
      • indications
        • identifiable technical cause for stiffness
 

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(OBQ11.250) A 64-year-old male underwent the procedure shown in Figures A and B 7 weeks ago. He complains of difficulty with going down stairs. He reports no pain and denies constitutional symptoms. On examination the incision is well healed and no effusion is present. He is able to perform a straight leg raise with 5/5 strength. He lacks 2 degrees of terminal extension and has 80 degrees of active flexion. The knee is stable to varus and valgus stress testing at extension and mid flexion. His C-reactive protein and erythrocyte sedimentation rate are normal. What is the next most appropriate step in management? Review Topic

QID: 3673
FIGURES:
1

Manipulation under anesthesia

85%

(2044/2398)

2

Cortisone injection followed by physical therapy for quadriceps strengthening

2%

(56/2398)

3

Aspiration to evaluate for septic arthritis

2%

(38/2398)

4

Revise femoral component by downsizing A-P diameter

6%

(144/2398)

5

Revise tibial component and add 5 degrees of posterior tibial slope

4%

(107/2398)

ML 2

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