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 MANAGEMENT FACTORIALS IN TKA
The stiff total knee arthroplasty
CAUSES AND CURES
K. G. Vince
From Whangarei
Hospital, Kamo,
New Zealand
 K. G. Vince, MD, FRCS(C),
Consultant Orthopedic
Surgeon
Whangarei Hospital , Northland
District Health Board, 118 Crane
Rd. RD 1, Kamo, 0185, New
Zealand
Correspondence should be sent
to K. G. Vince e-mail:
kellyvince@mac.com
©2012 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.94B11.
30793 $2.00
J Bone Joint Surg Br
2012;94-B, Supple A:103–11.
Seven stiff total knee arthroplasties are presented to illustrate the roles of: 1) manipulation
under general anesthesia; 2) multiple concurrent diagnoses in addition to stiffness; 3) extraarticular pathology; 4) pain as part of the stiffness triad (pain and limits to flexion or
extension); 5) component internal rotation; 6) multifactorial etiology; and 7) surgical
exposure in this challenging clinical problem.
Technical skill is mastery of complexity,
but creativity is mastery of simplicity
The Cambridge mathematician and topologist
Christopher Zeeman, known for the term
‘arthrofibrosis’ and his contributions to ‘catastrophe theory’ said ‘technical skill is mastery of
complexity while creativity is mastery of simplicity.’ Successful revision of the stiff total knee
arthoplasty (TKA) will require the greatest technical skill and the ability to reduce complex failure (catastrophe) to a complete roster of simple
problems: technical skill and creativity.
These are seven concise case presentations,
each one illustrating a facet of the complex
problems that come under the heading of the
stiff TKA. Knee motion combined with stability epitomises the successful arthroplasty surgery. Satisfactory surgery requires a stable joint
that extends fully with strength, and bends
comfortably to a degree that permits normal
activities. Ultimately, the limit of flexion in any
TKA will be how far the quadriceps muscle can
stretch. Accordingly, pre-op flexion is the
major, but not the only, determinant of postoperative flexion.1
When surgeons describe an arthroplasty as
stiff they mean that either extension or flexion
fails to reach a certain expected point; usually
full extension and some arbitrary amount of
flexion, usually in excess of 90°. By contrast,
patients often use the word stiff to describe the
feeling of moving the joint. For example two
doors may open and close fully. The one with
rusted hinges requires greater force to reach
the same point. Accordingly, a patient with full
extension and flexion to 110°, may yet
describe their TKA as stiff if motion is difficult.
Every complex mechanism requires all subsystems to function, for overall success. It is
VOL. 94-B, No. 11, NOVEMBER 2012
dangerous to accept stiffness in a TKA without
analysis. This implies that the stiff TKA is one
entity and implying further that everyone
understands exactly what it is. Worse still is the
use of arthrofibrosis, sounding as it does erudite
and insightful, as a synonym for stiffness.
Arthrofibrosis implies that stiffness results from
the patient’s tendency to form scar tissue, and
not in the arthroplasty. Obviously, if a surgeon
believes that arthrofibrosis is the cause of stiffness, (as it may be in a minority of cases) then
revision surgery should not be contemplated.
Won’t that same unnatural tendency to form
scar tissue simply make the revision stiff as well?
Case one: manipulation under general
anaesthetic
A 68-year-old female presented for right TKA.
She was pleased with her left TKA but had
required a manipulation under general anaesthesia (MUGA) to achieve functional flexion.
(Fig. 1a) The indications for both arthroplasties were painful osteoarthritis, in knees with
reasonable flexion prior to surgery. The right
TKA was performed uneventfully (Figs. 1b, 1c
and 1d). The patellae tracked centrally, indicating correct rotational position of all components. She progressed slowly after surgery and
a MUGA was performed eventually resulting
in 115° of flexion. This case was straightforward: a patient, unwilling or unable to participate in effective physical therapy following
TKA who benefited from MUGA. Having performed the surgery, I was confident that the
TKA was mechanically capable of superior
motion and proceeded with MUGA. Nascent
scars stretched easily while the patient
was anaesthetised, and recovery returned to
schedule.
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K. G. VINCE
Fig. 1
Figure 1a – antero-posterior (AP) standing radiographs of the arthritic right knee (viewed on our left) and the successful left TKA. Motion on the left
was satisfactory only after a MUGA (manipulation under general anesthesia). Figure 1b – AP standing radiograph of right TKA. Figure 1c – merchant
patellofemoral radiograph showing central tracking of the patella and indicating that rotational position of the tibial and femoral components is satisfactory. Figure 1d – lateral radiograph of the right TKA with the limb slightly rotated, so that the posterior condyles are seen separately and the
fixation lugs do not lineup correctly. This may give the illusion of a larger than ideal femoral component. Tibial slope is satisfactory. Knee motion
was 0° to 75° before and 0° to 115° after manipulation under general anesthesia. Figure 1e – diagram showing that if the increase in the AP dimension
of the femoral condyles by more than 12% was a critically independent variable leading to the need for MUGA. Reprinted from Daluga D, Lombardi
AV Jr, Mallory TH, Vaughn BK. Knee manipulation following total knee arthroplasty: analysis of prognostic variables. J Arthroplasty 1991;6:119-1282,
with permission from Elsevier.
Daluga2 and colleagues remind us that the recommendation for MUGA is not always straightforward. They compared 60 TKAs that required MUGA with 41 that achieved
motion routinely. They found that an AP (antero-posterior)
dimension of femoral prosthesis more than 12% greater
than the patient’s femur was a critically independent variable that predisposed to manipulation, i.e. to stiffness. An
oversized femoral component usually makes the TKA
tighter in flexion and therefore stiff. Of all the TKA’s that
undergo MUGA, some will be perfectly balanced and benefit, while others may have some mechanical impediment to
motion that MUGA cannot overcome.
The first lesson to learn from this case is that a TKA has
either been performed adequately in all respects and so can
permit motion up to the limit imposed by quadriceps flexibility or there is some inherent feature that mechanically
limits motion. The second lesson to learn is that arthrofibrosis may be one cause of stiffness, but the two terms are
not synonymous. If a TKA is stiff there will be scar. It
doesn’t mean that the scar caused the stiffness.
Case two: systematic and comprehensive
diagnosis
Stiffness may result from more serious problems, in which
case manipulation alone will fail. In this case a 74-year-old
male presented with a stiff TKA. Radiographs indicated a
prior tibial tubercle transfer, as treatment for a dislocating
patella (Fig 2). Our approach to every problem TKA is 1)
systematic and 2) comprehensive.3,4 Systematic means that
the same disciplined evaluation should be followed for each
case. We use a worksheet that lists the eight indications for
revision on the left, and on the right (Fig 2d), the necessary
data that must be collected to confirm the diagnosis and
plan corrective surgery. Infection tops the list, as it must be
considered in every case. Simple diagnoses follow, some of
which can be identified even over the telephone. The most
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Fig. 2
Figure 2a – radiographs of a 74 year old male patient who presented with a stiff primary TKA, where two screws are evidence of a tibial tubercle
transfer to treat a patellar dislocation not long after the TKA had been performed. Figure 2b – lateral radiograph of a stiff TKA demonstrating an
oblique image of the patella, normal patellar height, good tibial component slope and an appropriate size of femoral component. The tubercle osteotomy is apparent. This is maximum flexion, approximately 35°. Figure 2c – merchant patella-femoral radiograph demonstrating oblique position of
a re-surfaced patella, suggesting that it wants to dislocate, but has been strapped into the trochlear groove by the tubercle osteotomy. Figure 2d –
problem TKA worksheet listing the reasonable indications for revision TKA on the left column (1 to 8) and # 9: no diagnosis, where further evaluation
is mandatory and surgery should be avoided. Figure 2e – lateral radiograph of a non-articulating, antibiotic impregnated, methyl-methacrylate spacer
as part of a two-stage re-implantation protocol for infection. Figure 2f – AP radiograph of non-articulating spacer, with removal of all foreign material,
including screws. Figure 2g – AP radiograph of reimplanted TKA: the second stage after control of infection. Cement fixation has been employed with
fixation augmented by diaphyseal engaging press-fit stems; straight on the femur and with an offset on the tibia. Figure 2h – lateral radiograph of
re-implanted TKA. Figure 2i – partial full length radiograph showing press fit stems engaged in the diaphysess of tibia and femur with restoration of
neutral mechanical axis. Figure 2j – centrally tracking patella in an arthroplasty without infection, significant pain relief and flexion improved to 90°.
commonly made diagnosis ‘loosening’ is held in reserve
to force us to consider all others first, and not jump to
conclusions.
‘Comprehensive means’ that we consider every possible diagnosis, even having identified one compelling
problem in a TKA. This patient presented with stiffness.
It would be foolhardy to leave the assessment at that
point. A systematic approach required that infection be
considered first and indeed ESR and CRP were elevated,
indicating the importance of an aspiration of synovial
fluid.5 White cell count, differential and culture all confirmed the diagnosis of sepsis. Our comprehensive
approach forced us to consider patellar tracking problems and their ineluctable association with internal
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rotation of tibia and or femoral components.6 The final
assessment was an infected TKA, with a failed tibial
tubercle transfer for patellar dislocation because the
basic problem was internal rotation of tibial and femoral
components. Incidentally, because of pain, scarring and
patellar dislocation, the TKA was stiff.
The patient was treated with a two-stage re-implantation
protocol for infection7-10 (Figs 2e & 2f). The re-implantation was performed with careful attention to rotational
position of the tibial and femoral components, yielding a
centrally tracking patellar with increased comfort and flexion (Figs 2g to 2j).
This case teaches us that poor motion may be the result of
another more fundamental problem with the arthroplasty
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K. G. VINCE
Fig. 3a
Fig. 3b
Fig. 3c
Figure 3a – AP radiograph of failed, loose, stiff TKA in a super obese patient. Serial MUGA’s eventually lead to aseptic loosening with a peri-prosthetic
fracture, seen here. Figure 3b – lateral radiograph showing proximal tibial fracture, that one can visualise resulting from forced flexion during a
MUGA. The femoral component has been implanted in an undesirably flexed position that encroaches on the flexion gap, making the correct sized
implant function like one that is too large. Figure 3c – AP radiograph of the pelvis demonstrating a severely arthritic hip (arrow) ipsilateral to the
painful stiff TKA.
and that no matter what else is wrong with the arthroplasty
it may also be infected. Each TKA must be evaluated with a
disciplined system and completely.
Case three: extra-articular problems
This 56 year old female patient was referred to our unit
with a painful, stiff TKA. Her body mass index placed her
in the super obese category.11 Several MUGA’s had been
performed elsewhere. The last one resulted in a tibial fracture and loose component (Figs 3a & 3b). A systematic and
comprehensive evaluation yielded a normal ESR and CRP,
with low white cell count and differential in aspirated
synovial fluid. Cultures of the fluid were negative, effectively eliminating infection as a cause of the failure.12 Radiographs of the pelvis, which we perform routinely prior to
revision of the stiff TKA revealed extensive hip arthropathy
(Fig.3c).
That knee symptoms may arise from hip pathology has
been understood for many years, and not just by orthopedic
surgeons.13,14 Nonetheless, the diagnosis can be missed,
perhaps because the patient is difficult to assess. The surgeons in this case were presumably so focused on stiffness,
which they may have attributed to the obvious obesity that
they neglected to fully evaluate the patient. While there are
many demands on a clinician’s time, this diagnosis cannot
be missed. This stiff TKA was interpreted as a nothing more
complicated than a condition requiring manipulation. No
aetiology was considered, and causes outside the knee joint
were overlooked.
This case reminds us that stiffness can result from pain
and that pain may originate outside of the knee joint.
Case four: pain
A 42-year-old woman presented with pain and stiffness in a
TKA that had been performed for premature osteoarthritis
in association with previous athletic injuries. She had
wanted to remain reasonably active, but the results of surgery were disappointing (Fig 4). The TKA had a fixed flexion deformity of 15° and further flexion to 95°, which
many surgeons might not consider stiff. She had difficulty
bending the knee and it was painful. There was no evidence
of infection12 and neither radiographs of the pelvis and
lumbo-sacral spine, or a technetium bone scan, could locate
a cause outside the knee. No findings other than pain indicated chronic regional pain syndrome.
Critical evaluation of the radiographs revealed that the
femoral component was of an appropriate size, but had
been implanted posteriorly, making the flexion gap smaller
and tighter. Effectively, this component functions like one
of a larger size, replicating the effect noted above and
reported by Daluga.2 CT scanning revealed internal rotation positioning of the tibial component.
The patient described pain and stiffness, but had 95° of
flexion. Revision arthroplasty with careful component sizing
according to soft-tissue tension, balancing of flexion and
extension gaps15 and rotational positioning of components
was successful. The flexion contracture was eliminated but
flexion increased only modestly from 95° to 110°. The
patient, however, was pleased with decreased pain.
The stiff knee is usually a triad of flexion contracture,
poor flexion and pain. We learned in 2001 from Barrack’s
elegant case-control study16 comparing satisfied TKA
patients with those suffering anterior knee pain, patients
with otherwise unexplained anterior knee pain, had more
internal rotation of femoral and in particular, tibial component position. If we identify the underlying problems in the
TKA that presents primarily with stiffness and correct
them, we stand a good chance of improving pain which is
usually a very important part of the procedure. In other
words, success may have more to do with reducing a feeling
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Fig. 4d
Fig. 4
Figure 4a – Lateral radiograph of 42-year-old athletic mother of two boys who was profoundly disappointed with pain and stiffness after a TKA for
arthritis following sports injuries and ligamentous reconstructions. The arrow indicates a notch in the anterior femur and posterior positioning of an
appropriately sized femoral component, translating it into the flexion gap and functioning like an oversized component. Figure 4b – AP radiograph
showing subtle evidence of an internally rotated femoral component. A reasonably symmetric image of the tibia component appears only when the
limb has been externally rotated by the radiology technician. This posture of the limb moves the proximal fibula (dotted outline) behind the tibia.
Figure 4c – the patella has been resurfaced, but cut asymmetrically sand seems to be tethered in the trochlear groove. Figure 4d – the stiff TKA may
manifest with one or all of the three constituents: 1) fixed flexion contracture, 2) poor flexion and 3) pain. Figure 4e -– AP radiograph of the revision
with one size smaller femoral component to accommodate a tighter, scarred soft tissue envelope. The tibial component appears symmetrically and
the proximal fibula is not overlapped as much by the tibia indicating better rotational position of the component. Figure 4f -– lateral radiograph showing the one size smaller femoral component and an anterior augment which brings the femoral component back into the desired position relative to
the anterior femoral cortex. Figure 4g –- long AP radiograph depicting diaphyseal press fit stems, using offset to manage anatomic asymmetry, fixation and alignment. Figure 4h – the patella was not revised given the compromised residual bone stock. It is tracking centrally. The flexion contracture was eliminated, modest gains were made in flexion, but the patient was most grateful for pain reduction.
of painful tightness in a stiff TKA than with dramatic
increases in the motion. Component rotational positioning
is very important in understanding these arthroplasties.
This case illustrates the triad of the stiff TKA: 1) flexion
contracture; 2) poor flexion; and 3) pain. There are usually
several mechanical features that predispose to stiffness and
pain. While the total amount of flexion provided by revision
may be modest, function improves with elimination of flexion
contractures and patients are grateful if the knee is more comfortable and moves more freely, even within a limited arc.
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Case five: internal rotation
A 41-year-old athletic male, developed arthritis after an
anterior cruciate ligament reconstruction and underwent a
TKA complicated by pain and very poor motion. The knee
lacked 10° of extension and flexed to only 45°. The pain
was disabling. Good quality radiographs were impossible.
When the prosthesis was imaged symmetrically, the limb is
externally rotated (Figs 5a & 5b). When the limb was
rotated correctly, the prosthesis could not be viewed well.
The tibia was implanted in internal rotation and facilitated
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K. G. VINCE
Fig. 5d
Fig. 5a
Fig. 5c
Fig. 5b
Fig. 5e
Fig. 5f
Fig. 5g
Fig. 5h
Figure 5a – radiograph of a painful stiff TKA cannot depict the limb and both components in a true AP rendering simultaneously, because of problems
with the rotational position of the components. In this image the limb is reasonably well positioned, but the tibial (more prominent later tibial fixation
flange) and femoral (more prominent lateral femoral condyle) components are internally rotated. Figure 5b – the difficulty continues with the lateral
radiograph which shows non-overlapping posterior femoral condyles as well as patella alta. Figure 5c – lateral radiograph showing maximum flexion,
with a femoral component that is probably slightly larger AP than the native bone. Figure 5d - patella is almost dislocated and certainly tracking poorly
related to rotational positioning of tibial and femoral components.19 Figure 5e – CT scan of TKA according to a validated protocol to quantify rotational
position of components,6,17 showing the most proximal of three cuts on the tibia, establishing the tibial component angle, and illustrated by the line
at 90° to the line passing through the posterior tibial condyles and projected to the upper left (arrow head). Its relation to the proximal tibia is established by two additional, more distal cuts. Figure 5f – the most distal CT scan cut (third of three) through the level of the tibial tubercle. TCA is reproduced from figure 5e and the “geometric center” (see label and arrow at the right of the image) was established on a CT cut just below the component.
A line has been drawn from the geometric center through the center of the tibial tubercle. Figure 5g – figures 5e and 5f have been overlaid. It is clear
the tibial component has been positioned internally, 42° to where it might have been aligned with the tubercle. Figure 5h -– a patella has been added
to figure 5g, showing how internal rotation of the tibial component delivers the patella, not to the central trochlear groove, but to the condyle with
resultant maltracking and perhaps dislocation.
by patella alta, the patella was subluxing and would probably dislocate if the knee was flexed further (Figs 5c & 5d).
CT scanning is very useful in evaluating the stiff TKA
and essential in this case. A validated protocol quantifies
the rotational position of tibial and femoral components,
with four cuts: one through the femoral epicondyles and
three through the proximal tibia.17 Tibial CT cuts image
the component, the geometric center of the proximal
tibia and the tibial tubercle. Given the asymmetry of the
proximal tibia, upto 18° of internal rotation of the tibial
component is permissible.6 This patient had a tibial
component oriented at 42° of internal rotation. (Figs
5e to 5g).
By the time of revision arthroplasty, the knee had been so
stiff over a prolonged period of time that the quadriceps
had difficulty stretching. Gains in flexion were modest, correction of flexion contracture complete and the improvement in pain gratifying. Our experience with revision TKA
demonstrated that one of the most consistent findings in the
stiff TKA is internal rotation of the tibial component,18
usually the result of limited exposure and a desire to maximise coverage of the asymmetric tibia. It is difficult to discuss the stiff TKA now without quantitative CT scan data
on rotational positioning of the components.
The lesson to learn from this case is that internal rotation
predisposes to stiffness through maltracking. As the patient
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Fig. 6
Figure 6a – AP radiograph of painful stiff TKA which in another era might have been labeled a mystery knee, because of no obvious explanation for
pain. A further diagnosis of arthrofibrosis may have been added because of limited motion. Figure 6b – lateral radiograph shows a thick polyethylene
insert after a reasonable amount of tibial resection, plus neutral tibial slope, a relatively large femoral component and a thick patella construct. None
of these feature by themselves might compromise motion, but together they add up to trouble. Figure 6c – merchant patella-femoral view shows
patellar maltracking, synonomous with internal rotation of tibial and femoral components. Figure 6d – AP radiograph after complete revision arthroplasty with non-linked, constrained implants. A diaphyseal engaging press fit stem has been used on the femur for alignment and fixation, with a
fully cemented stubby stem extension fully cement into the tibia because of relatively small stature. The stem extension has been modified intraoperatively to avoid endosteal impingement. Figure 6e – patella is tracking centrally on the Merchant view indicating that rotational position of tibial
and femoral components has been corrected. Figure 6f – lateral radiographs shows satisfactory joint line height and patellar position. Figure 6g – fish
diagram illustrating the multifactorial nature of the stiff TKA. In particular, rotational positioning of components is of greater significance than has
been appreciated in the past.
flexes the knee and senses that the patella will dislocate,
they become unwilling to flex further and never achieves
functional flexion.19
Case six: multi-factorial
A 47-year-old female, four years after TKA presented with a
stiff, painful TKA since surgery. There was a 5° fixed flexion contracture with flexion limited to 65°. Pain was
severe and constant. The modular tibial polyethylene
insert was thick, probably chosen to balance the extension
gap and eliminate recurvatum in a patient who had a relatively small flexion gap. The posterior slope for this prosthesis is recommended to duplicate normal anatomy, but
VOL. 94-B, No. 11, NOVEMBER 2012
here there was virtually no slope, which tends to tighten
the knee in flexion. The lateral view showed a thick patellar construct and the merchant view showed that the
patella was trying to dislocate, indicating problems with
rotational alignment of the tibial and or femoral components (Figs 6a, 6b and 6c).
Revision surgery that focuses on only one feature of this TKA
will likely fail. The assessment must be analytical and detailed.
Only a complete revision that can modify every variable in
favor of greater motion over greater stability can be expected to
succeed. Even with that, the elasticity of an extensor mechanism
that has not been fully stretched in four years will ultimately
limit motion.
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K. G. VINCE
Fig. 7e
Fig. 7a
Fig. 7b
Fig. 7c
Fig. 7d
Fig. 7g
Fig. 7f
Fig. 7l
Fig. 7k
Fig. 7j
Fig. 7i
Fig. 7h
Fig. 7n
Fig. 7m
Figure 7a –- full-length AP radiographs showing well aligned but extremely stiff TKAs. Figure 7b -– AP radiograph
of the first TKA performed with correction of the extra-articular deformity above. Figure 7c –- AP radiograph of
second TKA also complicated by stiffness that patent has requested help with. Figure 7d –- lateral radiograph of
left TKA stiff but not for revision) with severe patella infer/baja. Figure 7e -– attempted Merchant patella-femoral
view impaired by patients inability to flex past 15°. Figure 7f –- lateral of stiff left TKA for revision. Slope and sizing
are reasonable. It cannot be established whether the contracted patellar tendon contributes to or results from the
stiffness. Figure 7g –- in surgery, immediately prior to revision arthroplasty. Flexion limited to less than 40° with
very hard end point. Figure 7h –- extensive synovectomy, decreases thickness of scar and reveal supple tissue in
the supra-patellar pouch. Figure 7i -– scar on either side of the femur is released longitudinally, to re-establish
the normal para-femoral gutters. This improves the excursion of the extensor mechanism. Figure 7j -– thick wad
of scar on the deep surface of the patellar tendon, which when removed, allows the tendon the stretch and twist
more normally. The tendon is less likely to avulse from its insertion. Figure 7k – a lateral patellar retinacular
release is performed for exposure, not patellar tracking. It allows the entire soft tissue envelope to expand. Figure
Fig. 7o
7l –- long handled scissors are useful to divide scars halfway up the thigh that have stuck the deep extensor to
the femur. Figure 7m –- before any components are removed a gentle manipulation takes advantage of the
Fig. 7p
Fig. 7q
releases that have been performed. Figure 7n –- the quadriceps snip is useful and well known.24 An alternate
maneuver that can be performed first is the quadriceps split whereby the arthrotomy is extended up into the muscle fibers. If this is inadequate, the snip should follow. Figure 7o – the patient under consideration, was still difficult to exposure after all of the above steps had been taken. Ultimately, if a conventional medial release is performed, of the proximal medial and postereromedisal sleeve, as in a a classic
release to correct varus deformity, the tibial can be flexed and externally rotated, driving the tubercle laterally to safely dislocate the knee. This may necessitate a constrained implant, but the exposure is superb
and the extensor is protected. Figure 7p – post revision AP with non-linked constrained implant. Aggressive release of scar usually destabilises a knee like this so that constraint is necessary. Figure 7q – later
radiograph after revision showing press fit stem extensions, anterior augmentation to bring the (smaller sized) femoral component out of flexion and thus decreasing the size and tension in the flexion gap.
Motion improved to about 75° of flexion
The lesson to learn from this case is that stiffness complicating TKA is often a multi-factorial problem.
Accordingly, complete revision arthroplasty is appropriate and lesser interventions are rarely successful.
Although some of the first cases described above were
used to illustrate specific single points, every one of them
was revised with attention to all of the variables that we
have covered.
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THE STIFF TOTAL KNEE ARTHROPLASTY
Case seven: surgical exposure
A 67-year-old male presented with bilateral stiff TKAs with
relatively little pain. His main complaint was that with only
35° of flexion bilaterally, should he fall to the ground, he
would be unable to get up. He was involved in a road traffic
accident that left him with solidly healed femur fractures
and decreased flexion in knees that eventually developed
arthritis. The arthroplasties performed on stiff knees, in
turn, became even stiffer.
The argument can be made that his knees would be limited by the quadriceps muscle stiffness even if revision was
performed. The patient is adamant that he would like to
proceed as the current situation is unmanageable. The surgical team feels that aggressive lysis of scar and revision to
components that permit greater laxity in flexion, (i.e.
smaller femoral component) combined with an assiduous
physical therapy protocol may improve the situation. Even
modest gains would be welcome (Fig. 7).
Many surgeons might recommend a tibial tubercle osteotomy for exposure. I believe that approach is unnecessary
in this situation, as well as limiting and risky for aggressive
physical therapy. In addition, the tubercle osteotomy does
not, in itself, liberate the patient and the knee from extensive scarring. Surgical access might be excellent, but once
the procedure is complete and the tubercle fixed back to the
tibia, the extensor is stiff. The patellar turn-down is
outdated20, the V-Y plasty misguided21-23 (lengthening the
extensor mechanism often leaves the patient with a
disabling lag even if it increases flexion) and the quadriceps
snip is of limited effectiveness.24-27
The surgical approach must include: synovectomy, reestablishment of the parafemoral gutters, quadriceps
liberation from the scarring that adheres to the anterior
femur, scar removal from around the patellar tendon and
sometimes a lateral patellar retinacular release for exposure,
not patellar tracking. Ultimately, release of the proximal
medial capsule and deep collateral ligament permits safe
external rotation of the tibia. This drives the tubercle laterally, dislocating the knee. Non-linked constrained implants
are useful generally in cases like these and will splint or supplant the medial soft-tissue envelope after the exposure. This
has long been my approach for revision arthroplasty and has
evolved concurrently and been reported by others as the,
“Extensor Mechanism Tenolysis”.28
This case brings us full circle to stiffness that is primarily
of soft-tissue origin, a case of arthrofibrosis. It poses specify
and significant challenges in terms of surgical exposure.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.This paper is
based on a study which was presented at the Winter 2011 Current Concepts in
Joint Replacement meeting in Orlando, Florida, 7th – 10th December.
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