The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 1 suppl 2

Surgical Techniques | September 01, 2005

Stiffness After Total Knee Arthroplasty

Charles L. Nelson, MD¹; Jane Kim, BA¹; Paul A. Lotke, MD¹

¹ Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 2 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104. E-mail address for C.L. Nelson: charles.nelson@uphs.upenn.edu. E-mail address for J. Kim: jane_kim73@hotmail.com. E-mail address for P.A. Lotke: paul.lotke@uphs.upenn.edu

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The line drawings in this article are the work of Jennifer Fairman (jfairman@fairmanstudios.com).

Investigation performed at the Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1479-1484, July 2004

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Sep 01;87(1 suppl 2):264-270. doi: 10.2106/JBJS.E-00345

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Abstract

BACKGROUND:

Stiffness is an uncommon but disabling problem after total knee arthroplasty. The prevalence of stiffness after knee replacement has not been well defined in the literature. In addition, the outcomes of revision surgery for a stiff knee following arthroplasty have not been evaluated in a large series of patients, to our knowledge. The purposes of this study were to define the prevalence of stiffness after primary total knee arthroplasty and to evaluate the efficacy of revision surgery for treatment of the stiffness.

METHODS:

We defined a stiff knee as one having a flexion contracture of 15° and/or <75° of flexion. Two separate groups were evaluated. First, the results of 1000 consecutive primary total knee replacements were reviewed to determine the prevalence of stiffness. Second, the results of fifty-six revisions performed because of stiffness, sometimes associated with pain or component loosening, after primary total knee arthroplasty were evaluated.

RESULTS:

The prevalence of stiffness was 1.3%, at an average of thirty-two months postoperatively. The patients with a stiff knee had had significantly less preoperative extension and flexion than did those without a stiff knee (p < 0.0001). There were no significant differences in age, gender, implant design, diagnosis, or the need for lateral release between the patients with and without stiffness. The second cohort, of knees revised because of stiffness, were followed for an average of forty-three months. The mean Knee Society score improved from 38.5 points preoperatively to 86.7 points at the time of follow-up; the mean Knee Society function score, from 40.0 to 58.4 points; and the mean Knee Society pain score, from 15.0 to 46.9 points. The mean flexion contracture decreased from 11.3° to 3.2°, the mean flexion improved from 65.8° to 85.4°, and the mean arc of motion improved from 54.6° to 82.2°. The arc of motion improved in 93% of the knees, and flexion increased in 80%. Extension improved in 63%, and it remained unchanged in 30%.

CONCLUSIONS:

The prevalence of stiffness in our series of 1000 primary knee arthroplasties was 1.3%. Revision surgery was a satisfactory treatment option for stiffness, as the Knee Society scores improved, the flexion contractures diminished, and 93% of the knees had an increased arc of motion. However, the results suggest that the benefits are modest.

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INTRODUCTION

INTRODUCTION | SURGICAL TECHNIQUE | References

Stiffness is a disabling problem following total knee arthroplasty. Most patients have both pain and diminished functional capacity in association with the knee stiffness. Management requires careful evaluation to determine the etiology of the stiffness as well as precise surgical technique to correct the problem while avoiding complications.

A comprehensive clinical evaluation is performed to exclude or identify extrinsic sources of knee stiffness. These may include severe osteoarthritis of the ipsilateral hip, neurologic injury leading to muscle rigidity, tight quadriceps or hamstring muscles secondary to muscle injury, heterotopic ossification, or long-standing juvenile inflammatory conditions limiting knee range of motion prior to the completion of skeletal growth. When extrinsic sources are identified, revision total knee arthroplasty is unlikely to be associated with a favorable outcome without correction of the extrinsic problem.

Following the exclusion of extrinsic sources of knee stiffness, the goal is to identify a specific intrinsic etiology that can be corrected. Potential intrinsic causes of knee stiffness include (1) overstuffing of the patellofemoral articulation, (2) an excessively tight flexion and/or extension gap, (3) a tight posterior cruciate ligament, (4) femoral and/or tibial malrotation, (5) arthrofibrosis, and (6) limited bearing excursion in association with a highly conforming mobile-bearing prosthetic design.

Overstuffing of the patellofemoral articulation may result from anterior displacement of the anterior flange of the femoral component due to oversizing of the femoral component or from anterior translation of an appropriately sized femoral component. It also occurs after patellar resurfacing if the patellar component composite thickness is increased.

Decreased flexion may be associated with a tight flexion gap. This occurs when the amount of posterior femoral condylar bone that is resected is less than the thickness of the posterior condyles of the femoral component. Decreased extension may result from a tight extension gap when the distal femoral resection is too distal or the tibial insert is too thick. Radiographs of the ipsilateral knee that are made before knee replacement or radiographs of the contralateral knee allow for the assessment of optimal sizing and bone resection.

When a posterior cruciate ligament-preserving knee design is utilized, limited knee flexion may result if the posterior cruciate ligament is too tight. Williams et al. reported improved flexion and good results following arthroscopic release of the posterior cruciate ligament in these patients¹.

Femoral or tibial malalignment or malrotation may lead to pathologic tightness of soft-tissue structures about the knee. Malalignment tends to lead to asymmetry of the extension gap. Malrotation may result either in asymmetry of the flexion gap or patellar tracking problems, both of which may lead to diminished flexion.

Arthrofibrosis involves excessive pathologic postoperative scarring, which directly inhibits flexion and/or extension. It is one of the most unresponsive causes of stiffness.

Finally, bone impingement resulting from osteophytes or postoperative heterotopic bone also can limit motion.

SURGICAL TECHNIQUE

INTRODUCTION | SURGICAL TECHNIQUE | References

Intravenous prophylactic antibiotics are administered preoperatively. Optimally, we prefer the use of an epidural and/or femoral nerve catheter to facilitate immediate range of motion postoperatively. The tourniquet may or may not be inflated, according to the preference of the surgeon.

The prior anterior skin incision is excised and extended as necessary. Safe and adequate exposure is the key element to the surgical approach. Patellar tendon avulsion is a disastrous complication of revision total knee arthroplasty and can be avoided with good exposure. We prefer to utilize a medial parapatellar arthrotomy for these patients as this approach affords the best exposure, is extensile, and allows for modifications to minimize the risk of patellar tendon avulsion. Following the arthrotomy, the first step is to reestablish medial and lateral gutters, making certain that the extensor mechanism moves independently from the synovium, scar tissue, and femur. Most patients require a formal synovectomy, with excision of the synovium along with the dense scar tissue that encapsulates the entire joint.

A medial sleeve is developed around the medial aspect of the tibia in the plane of the semi-membranosus bursa. This sleeve may be extended subperiosteally around the posterior aspect of the tibia. The creation of this sleeve allows for marked external rotation of the tibia, which moves the tibial tubercle laterally and allows subluxation of the patella with less tension on the patellar tendon. Occasionally, dense adhesions will need to be released in order to allow sufficient tibial external rotation.

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FIG. 1: Illustration depicting a medial parapatellar arthrotomy (solid line) and quadriceps snip modification (blue dashed line). It is important to keep the longitudinal incision in the tendon and to extend it proximally to the top of the tendon before creating an oblique incision (quadriceps snip) at the proximal extent of the tendon. A transverse or oblique incision across the quadriceps tendon closer to the patella (black dashed line) must be avoided as this may be associated with postoperative extensor mechanism disruption.

During surgery, we prefer patellar subluxation to eversion. Patellar tendon avulsion is more likely when its fibers are twisted following eversion. If the patella cannot be mobilized laterally because of excessive tension on the patellar tendon, a lateral retinacular release is performed. The retinaculum is incised between 1 and 2 cm from the lateral border of the patella.

In cases in which there is excessive tension on the patellar tendon, particularly when a tight quadriceps muscle interferes with lateral mobilization of the patella, a quadriceps snip may be performed as described by Insall^2,3 (Fig. 1). This approach releases the proximal tether on the patella. It is performed by transecting the quadriceps tendon obliquely, well proximal to the patella. The quadriceps snip surgical approach has the advantage of allowing normal postoperative rehabilitation and range-of-motion exercises. When incising the quadriceps tendon proximally, it is important to stay within the fibers of the tendon so that a secure side-to-side closure can be accomplished.

A tibial tubercle osteotomy may be required in cases of extreme stiffness combined with patella infera (Fig. 2). The short contracted patellar tendon interferes with lateral mobilization of the patella. Tibial tubercle osteotomies were described in detail by Whiteside⁴. We prefer a minimum 6-cm-long tubercle osteotomy to allow a large surface area for healing. The optimal thickness is approximately 1 cm. The osteotomy is performed with use of an oscillating saw or osteotome from medial to lateral, with care being taken to maintain the lateral soft-tissue attachment and vascularity from the tibialis anterior. The superior and inferior aspects of the osteotomy are completed with a curved osteotome. The proximal extent of the osteotomy should be transverse (Fig. 3) to provide a mechanical block to proximal migration. The distal aspect of the osteotomy should be oblique to minimize the stress-riser effect, which may predispose to a tibial shaft fracture (Fig. 3)⁵. The osteotomy site is repaired with use of either screws or stainless steel wire. Screws allow more rigid fixation; however, the drill-holes weaken the osteotomy fragment and may be associated with fracture of the tibial tubercle fragment. In addition, bicortical fixation may not be possible in patients with a long, canal-filling tibial component stem. When cerclage wires are utilized, they should be placed at an angle from distal-medial to proximallateral to minimize proximal migration of the osteotomy fragment. A minimum of two cerclage wires should be utilized.

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FIG. 2: Intraoperative photograph showing the site of a tibial tubercle osteotomy. The tibialis anterior remains attached to the osteotomy fragment. The tibial tubercle and the patella are outlined in methylene blue. Note the short, contracted patellar tendon.

CRITICAL CONCEPTSINDICATIONS:Before revision total knee arthroplasty is considered, the patient should have sufficient pain and/or functional limitations to warrant the risks of the procedure. If the patient and surgeon agree that the pain and functional limitations are sufficient, the surgeon's comprehensive evaluation must rule out extrinsic sources of knee stiffness before revision total knee arthroplasty is planned. Preoperative identification of a correctable intrinsic etiology of knee stiffness leads to a more favorable risk:benefit ratio than is the case when no intrinsic problem is identified preoperatively.CONTRAINDICATIONS:Revision total knee arthroplasty is contraindicated whenever there is an unresolvable extrinsic cause of knee stiffness. The extrinsic problem should be addressed before or during the revision knee procedure. Extrinsic causes include decreased range of motion of the hip secondary to arthrodesis or severe arthritic involvement, neurologic disorders leading to extrinsic muscle contractures, and long-standing extrinsic muscle tightness without neurologic abnormalities, particularly in the setting of juvenile inflammatory arthritic conditions. These disorders will benefit minimally from revision total knee arthroplasty unless the underlying extrinsic pathologic condition is addressed first. Surgery is also contraindicated for ill or severely infirm patients in whom the surgical risks are too great. The overriding principle determining whether revision total knee arthroplasty is indicated is whether the patient and surgeon reasonably believe that the surgical risk is less than the anticipated benefit.PITFALLS:The major pitfalls associated with revision total knee arthroplasty in the setting of knee stiffness may be divided into problems that are associated with the preoperative evaluation and problems that are encountered during surgery.The prevention of problems is best accomplished by appropriate sizing and prosthetic positioning during the index arthroplasty procedure. In patients who lose motion immediately postoperatively, as noted above, manipulation with the patient under anesthesia, optimally within the first six weeks, may help to restore functional knee motion.Successful revision of a stiff knee is predicated on ruling out extrinsic sources of stiffness that are uncorrectable with revision total knee arthroplasty. Identifying the etiology of knee stiffness preoperatively or intraoperatively and assessing whether the problem was corrected following placement of the new prosthesis is associated with the best results. In the uncommon case of idiopathic arthrofibrosis, care is taken to release soft tissues adequately and to position and size components appropriately to allow good stability and range of motion on the operating table. An aggressive analgesic and rehabilitation protocol is then instituted on the presumption that early range of motion retards scar formation. In patients with previous heterotopic ossification, the use of low-dose radiation therapy⁷ or a four to six-week course of indomethacin⁸ may prevent recurrence and minimize stiffness.The major pitfalls related directly to the surgical procedure include the challenge of optimizing the fixation, soft-tissue balance, and component positioning while avoiding complications. Because of the difficulty in exposing the stiff knee, care must be taken to avoid patellar tendon avulsion. Patients with long-standing marked flexion contracture, particularly when associated with valgus deformity of the knee, also are at increased risk for peroneal nerve or popliteal vessel injury.

CRITICAL CONCEPTS

INDICATIONS:

Before revision total knee arthroplasty is considered, the patient should have sufficient pain and/or functional limitations to warrant the risks of the procedure. If the patient and surgeon agree that the pain and functional limitations are sufficient, the surgeon's comprehensive evaluation must rule out extrinsic sources of knee stiffness before revision total knee arthroplasty is planned. Preoperative identification of a correctable intrinsic etiology of knee stiffness leads to a more favorable risk:benefit ratio than is the case when no intrinsic problem is identified preoperatively.

CONTRAINDICATIONS:

Revision total knee arthroplasty is contraindicated whenever there is an unresolvable extrinsic cause of knee stiffness. The extrinsic problem should be addressed before or during the revision knee procedure. Extrinsic causes include decreased range of motion of the hip secondary to arthrodesis or severe arthritic involvement, neurologic disorders leading to extrinsic muscle contractures, and long-standing extrinsic muscle tightness without neurologic abnormalities, particularly in the setting of juvenile inflammatory arthritic conditions. These disorders will benefit minimally from revision total knee arthroplasty unless the underlying extrinsic pathologic condition is addressed first. Surgery is also contraindicated for ill or severely infirm patients in whom the surgical risks are too great. The overriding principle determining whether revision total knee arthroplasty is indicated is whether the patient and surgeon reasonably believe that the surgical risk is less than the anticipated benefit.

PITFALLS:

The major pitfalls associated with revision total knee arthroplasty in the setting of knee stiffness may be divided into problems that are associated with the preoperative evaluation and problems that are encountered during surgery.

The prevention of problems is best accomplished by appropriate sizing and prosthetic positioning during the index arthroplasty procedure. In patients who lose motion immediately postoperatively, as noted above, manipulation with the patient under anesthesia, optimally within the first six weeks, may help to restore functional knee motion.

Successful revision of a stiff knee is predicated on ruling out extrinsic sources of stiffness that are uncorrectable with revision total knee arthroplasty. Identifying the etiology of knee stiffness preoperatively or intraoperatively and assessing whether the problem was corrected following placement of the new prosthesis is associated with the best results. In the uncommon case of idiopathic arthrofibrosis, care is taken to release soft tissues adequately and to position and size components appropriately to allow good stability and range of motion on the operating table. An aggressive analgesic and rehabilitation protocol is then instituted on the presumption that early range of motion retards scar formation. In patients with previous heterotopic ossification, the use of low-dose radiation therapy⁷ or a four to six-week course of indomethacin⁸ may prevent recurrence and minimize stiffness.

The major pitfalls related directly to the surgical procedure include the challenge of optimizing the fixation, soft-tissue balance, and component positioning while avoiding complications. Because of the difficulty in exposing the stiff knee, care must be taken to avoid patellar tendon avulsion. Patients with long-standing marked flexion contracture, particularly when associated with valgus deformity of the knee, also are at increased risk for peroneal nerve or popliteal vessel injury.

In cases of severe stiffness in which a quadriceps snip is insufficient to allow satisfactory patellar mobilization and a tibial tubercle osteotomy either is insufficient or is not desirable, a medial parapatellar arthrotomy may be modified into a quadriceps V-Y turndown as described by Insall^3,6. This approach allows the extensor mechanism to be reflected laterally and inferiorly if necessary. This procedure can disrupt the entire proximal patellar circulation and may be associated with a greater risk of osteonecrosis of the patella. It also requires a modified postoperative rehabilitation regimen to protect the repaired quadriceps mechanism from rupture or stretch.

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FIG. 3: Illustration depicting a tibial tubercle osteotomy site from the lateral view, emphasizing the transverse nature of the proximal extent of the osteotomy and the oblique nature of the distal extent of the osteotomy.

Following satisfactory exposure, the existing implants are removed with use of standard removal instruments. If a modular tibial component is present, removal of the polyethylene insert will increase space and allow better exposure for removal of the femoral and tibial components. Extra care is taken to preserve bone stock.

In cases of preoperative flexion contracture, posterior capsular release is critical to allow full extension without joint line elevation. If residual osteophytes remain on the posterior aspects of the femoral condyles, they need to be removed as well. Scrutiny of preoperative radiographs, and, if available, prearthroplasty radiographs or radiographs of the contralateral knee, is important in order to make certain that the femoral component is not undersized. Distal and posterior augments will allow placement of an appropriately sized femoral component at the normal joint line.

In cases of loss of flexion, it is important to determine whether flexion is limited by the quadriceps mechanism (extrinsic contracture) or whether flexion is limited by impingement or abnormal tension involving the deep soft-tissue structures around the knee.

Following placement of appropriately sized femoral and tibial trial components in the desired rotation and at the desired joint line, range of motion and stability need to be assessed with the extensor mechanism reduced. If flexion is limited, an extrinsically tight quadriceps muscle is likely to be the cause. Occasionally, the quadriceps is adherent to the femur and requires further release to improve flexion. We try to avoid quadricepsplasty or z-lengthening procedures. Most patients accept diminished flexion in order to avoid more disabling quadriceps weakness and an extensor lag, which may develop following pathologic lengthening of the quadriceps. When the knee is well balanced and flexion is limited only by a tight quadriceps mechanism, it has been our experience that the patient gradually stretches the extensor mechanism and regains more flexion. Finally, if the composite patella-patellar button thickness is excessive, patellar revision with resurfacing is necessary.

Once satisfactory range of motion and stability are demonstrated, the actual femoral and tibial components are fixed in identical position. The knee is closed in a standard fashion, and a sterile dressing applied.

Postoperatively, we institute immediate range of motion in a continuous passive motion machine for most patients. The specific continuous passive motion protocol is patient-dependent. A high-flexion continuous passive motion protocol with a range of 70° to 100° is started in the recovery room, and a protocol with a range of 0° to 100° is started on the next postoperative day. We have found that this routine may be associated with less blood loss and earlier return of good knee flexion; however, care must be taken to ensure that the patient maintains full knee extension. In cases in which the patient had a notable preoperative flexion contracture, a knee immobilizer or cylinder cast may be required and continuous passive motion may not be used. It is important to stress that good knee extension is more important than good knee flexion for gait and function.

Optimizing pain control postoperatively allows the patient to participate more fully with range-of-motion exercises. This early motion is even more important in the setting of arthrofibrosis, in which motion is important for retarding recurrent scar formation. Knee manipulation may be necessary when a patient presents with unacceptable range of motion between two and six weeks postoperatively. However, what constitutes an acceptable range of motion is variable and depends on the patient's body habitus, bone stock, and functional limitations as well as on the range of motion that is achieved intraoperatively. In cases in which flexion is limited by an extrinsic contracture, cases in which there is marked osteopenia, and cases in which manipulation is attempted more than three months postoperatively, the risk of iatrogenic fracture increases with excessively forceful manipulation.

References

INTRODUCTION | SURGICAL TECHNIQUE | References

Williams RJ 3rd, Westrich GH, Siegel J, Windsor RE. Arthroscopic release of the posterior cruciate ligament for stiff total knee arthroplasty. Clin Orthop Relat Res. 1996;331: 185-91.331185 1996 [PubMed][CrossRef]

Garvin KL, Scuderi G, Insall JN. Evolution of the quadriceps snip. Clin Orthop Relat Res. 1995;321: 131-7.321131 1995 [PubMed]

Berger RA, Rosenberg AG. Surgical approaches in revision total knee arthroplasty. In: Lotke PA, Garino JP, editors. Revision total knee arthroplasty. Philadelphia: LipincottRaven; 1999. p. 157-72.157 1999

Whiteside LA. Exposure in difficult total knee arthroplasty using tibial tubercle osteotomy. Clin Orthop Relat Res. 1995;321: 32-5.32132 1995

Ritter MA, Carr K, Keating EM, Faris PM, Meding JB. Tibial shaft fracture following tibial tubercle osteotomy. J Arthroplasty. 1996;11: 117-9.11117 1996 [CrossRef]

Insall JN, editor. Surgery of the knee. New York: Churchill Livingstone; 1984. Surgical approaches to the knee. p 41-54.41 1984

Chidel MA, Suh JH, Matejczyk MB. Radiation prophylaxis for heterotopic ossification of the knee. J Arthroplasty. 2001;16: 1-6.161 2001 [CrossRef]

Bellemans J, Claerhout P, Eid T, Fabry G. Severe heterotopic ossifications after total knee arthroplasty. Acta Orthop Belg. 1999;65: 98-101.6598 1999

Topics

knee joint ; range of motion ; knee replacement arthroplasty ; stiff knee

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Charles L. Nelson, Jane Kim, Paul A. Lotke; Stiffness After Total Knee Arthroplasty. The Journal of Bone & Joint Surgery. 2005 Sep;87(1_suppl_2):264-270.

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