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Stiff Total Knee Replacements

Stiff TKR presentation

Anam Jawaid

on 7 February 2018

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Transcript of Stiff Total Knee Replacements


Mr M J Iqbal
Walsall Manor Hospital


Infection work-up
CT Scan for Rotation and slope
Treatment options
EARLY: 3-4 month
MUA & aggressive Physio

No Intrinsic Problem

Arthroscopic Arthrolysis
: upto 1 yr

Less invasive & faster rehab
Med & Lat Release
Suprapatellar Pouch Clearance
Notch Clearance & PCL Release in CR cases
Add MUA too after releases

Component Scratching & hence Increase wear
Limited Gain in ROM :0-42 degree
25% Failure

Intrinsic Problem
A Frustrating Complication of a very successful op
Produces Functional Limitation and often painful

Arc of motion required for activities of daily living and definitions of stiff TKR

Multi Factorial
ROM Expectations have been raised over the time: >95 deg
Stiff TKR: >15 degree FFD & <75 degree flexion

Careful selection of patients and avoiding surgical pitfalls minimizes this problem

Patient factors:

Strong Correlation with Pre-Op ROM Vs Post-Op range

Lower Range gains :
High Range Loses

Surgical factors:
Tight Extension / Flexion Gap
Mis-Sizing of components
Overstuffing of Tibio-Fem J
Overstuffing of PFJ
Left over large post Osteophytes
Tight PCL & Post Capsule
Low Post Tibial Slope

?Surgical Closure NOT in Flexion

Post-Op factors:
Low Grade Infection
Poor Rehab Protocols- Splintage / Pillow
Poor pain Control & RSD
Excessive Hematoma & Anticoagulation Warfarin

Poor Follow-ups & Physio in initial phase
7% of cases experience this
Implant factors
Extended Post Condyle
Restoration of Post Condylar Offset
Single Radius Femoral component
(10-110 degrees as in Triathlon)
Conclusion 2:
Previous Surgery:
Osteotomy/Traumatic OA
Arthrofibrotic tendency
H/O Contralateral stiff TKR
CRPS personality

Intrinsic Problem
SINGLE component Revision:
Smaller femur PS
Tibia with Increased Post Slope
Patellar Under sizing
Patient factors
& Arthrolysis

Open Arthrolysis
- for >1 yr and Arthrofibrotic cases
Quads Snip /
+ V-Y Quadriceps Plasty (Mod Coonse-Adams):1.5 cm Length
+ PCL & POST Capsule Release +- POLY Exchange

More correction of resistant factors like Quads / Post Capsule

More invasive & Slow rehab
still limited gain 20-40 deg, Failure 20 %
Mod Coonse Adams Flap
Results of Operations in Stiff TKR Variable due to various factors

Open Arthrolysis better than Arthroscopic in difficult cases

Some Useful References:
Alejandro Gonza ́lez Della Valle, MD & Alejandro Leali, MD & Steven Haas, MD(2007):Etiology and Surgical Interventions for Stiff Total Knee Replacements HSSJ 3: 182–189
Aglietti P, Windsor RE, Buzzi R, Insall JN (1989) Arthroplasty for the stiff or ankylosed knee. J Arthroplasty 4:1–5
Christensen CP, Crawford JJ, Olin MD, Vail TP (2002): Revision of the stiff total knee arthroplasty. J Arthroplasty 17:409–415
Coonse K, Adams JB (1943): A new operative approach to the knee joint. Surg Gynecol Obstet 77:344–347
Hutchinson JR, Parish EN, Cross MJ (2005) Results of open arthrolysis for the treatment of stiffness after total knee replacement. J Bone Jt Surg Br 87:1357–1360
Nicholls DW, Dorr LD (1990): Revision surgery for stiff total knee arthroplasty. J Arthroplast 5:S73–S77
Ritter MA, Stringer EA (1979): Predictive range of motion aftertotal knee replacement. Clin Orthop Relat Res 143:115–119

1% may never improve despite surgical Tt
Patients with clear causes like overstuffing ,malrotation,tight flexion gap etc achieve best results by revision surgery.

If cause is unclear:result is variable

some patients never improve BUT still are functionally better than Pre TKR disability level
Conclusion 1:
Expectations for more movement is increasing both in patients & surgeons
Minimize prevalence by:
-Careful Patient selection & better
Pre-op Counselling for expectation
-meticulous pre-op planning & surgery
-using modern implants
-having good F/Up mechanism

Must Rule out Infection

In all Cases first do MUA around 3m &
Arthroscopic Arthroysis upto 1 yr
in some cases
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