Updated: 3/10/2018

TKA Stiffness

Topic
Review Topic
0
0
Questions
9
0
0
Evidence
6
0
0
Videos
1
Techniques
2
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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Technique Guides (2)
Questions (9)

(OBQ13.173) A 60-year-old woman undergoes a total knee arthroplasty for end-stage osteoarthritis. Preoperative knee range of motion is 5 to 100 degrees. Postoperatively, she experiences reduced range of motion. She is scheduled to undergo manipulation under anesthesia. In which of the following scenarios is this procedure best indicated? Review Topic

QID: 4808
1

Knee range of motion 0 to 60 degrees at 2 months postoperatively

83%

(3023/3636)

2

Knee range of motion 0 to 60 degrees at 8 months postoperatively

5%

(180/3636)

3

Knee range of motion 30 to 120 degrees at 2 months postoperatively

8%

(290/3636)

4

Knee range of motion 30 to 120 degrees at 8 months postoperatively

2%

(65/3636)

5

Knee range of motion 30 to 120 degrees at 2 weeks postoperatively

2%

(61/3636)

ML 3

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PREFERRED RESPONSE 1

(SAE07HK.84) A 73-year-old man has stiffness after undergoing primary posterior cruciate ligament-retaining total knee arthroplasty 18 months ago. Extensive physiotherapy, dynamic splinting, and manipulations under anesthesia have failed to result in improvement. Examination reveals range of motion from 30 degrees to 60 degrees of flexion. The components are well fixed, and the evaluation for infection is negative. In discussing the possibility of revision arthroplasty, the patient should be advised that Review Topic

QID: 6044
1

the success of improving range of motion to a functional range of 0 degrees to 90 degrees in the literature is between 75% to 80%.

24%

(21/87)

2

the preoperative arc of motion will not influence the ultimate range of motion after formal component revision.

1%

(1/87)

3

change from a posterior cruciate ligament-retaining to a posterior cruciate ligament-substituting design has a much greater chance of success.

21%

(18/87)

4

manipulation under anesthesia will effectively improve range of motion if postoperative stiffness develops following revision.

1%

(1/87)

5

the major postoperative focus will be to regain near full extension.

52%

(45/87)

ML 3

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PREFERRED RESPONSE 5

(SAE07HK.38) Which of the following statements best describes the outcome of the routine use of continuous passive motion (CPM) machines after total knee arthroplasty (TKA)? Review Topic

QID: 5998
1

CPM is likely to improve early range of motion and final range of motion.

5%

(7/138)

2

CPM may improve early range of motion but is unlikely to improve final range of motion.

93%

(129/138)

3

CPM is likely to decrease postoperative pain.

1%

(1/138)

4

CPM is likely to improve extension but not flexion.

1%

(1/138)

5

CPM is likely to restore quicker ambulatory ability.

0%

(0/138)

ML 1

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PREFERRED RESPONSE 2

(SAE07HK.25) Stiffness can occur following total knee arthroplasty. What is the most appropriate management for a patient who has deteriorating arc of motion after undergoing a revision knee arthroplasty 9 months ago? Review Topic

QID: 5985
1

Aggressive physical therapy

11%

(13/118)

2

Manipulation under anesthesia

22%

(26/118)

3

Investigation for periprosthetic infection

53%

(63/118)

4

Revision knee arthroplasty

7%

(8/118)

5

Resection arthroplasty

2%

(2/118)

ML 3

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PREFERRED RESPONSE 3
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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%

(2187/2575)

2

Cortisone injection followed by physical therapy for quadriceps strengthening

2%

(61/2575)

3

Aspiration to evaluate for septic arthritis

2%

(41/2575)

4

Revise femoral component by downsizing A-P diameter

6%

(161/2575)

5

Revise tibial component and add 5 degrees of posterior tibial slope

5%

(116/2575)

ML 2

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PREFERRED RESPONSE 1
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Topic COMMENTS (1)
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