Surgical Techniques   |    
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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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.


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.


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%.


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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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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