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Stiff Total Knee Replacements

Stiff TKR presentation
by

Anam Jawaid

on 28 November 2013

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Transcript of Stiff Total Knee Replacements

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STIFF TKR

Mr M J Iqbal
Walsall Hospital

Investigations:
X-Rays AP,TRUE Lat & SKYLINE

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

No Intrinsic Problem


Arthroscopic Arthrolysis


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
Produces Functional Limitation and often painful



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

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:
Mal-Alignment:Coronal/sagittal/Rotation
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 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
?Obesity

Intrinsic Problem
Mostly
SINGLE component Revision:
Smaller femur PS
Tibia with Increased Post Slope
Patellar Under sizing
Patient factors
TOTAL COMPONENT REVISION
PS / TS
Open Arthrolysis
- Quads Snip /
+ V-Y Quadriceps Plasty (Mod Coonse-Adams):1.5 cm Length
+ POLY Exchange + PCL & POST Capsule Release

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

If no Intrinsic cause-
-Open Arthrolysis better than Arthroscopic

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 cause 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
Stiffness prevalence can be decreased by:
-Careful Patient selection & better
Pre-op explanation
-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
Advantageous
in some cases
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