CHALLENGING CASES: Addressing Stiffness Post-Knee Replacement

    The surgeon’s goal with total knee arthroplasty (TKA) is to achieve a multi-planar, rotational, slide-glide motion.

    Yet even if the surgeon judges that the patient has a well-functioning knee after the procedure, the patient may report that the knee feels “stiff,” “tight,” or “woody.”

    The key is the postoperative range of motion (ROM), according to William J. Long, MD, FRCSC, who presented on stiffness following TKA at the ICJR South/RLO Spring Hip & Knee Course. ROM is significantly associated with improved functional outcome and patient satisfaction, [1] he said, with the definition of stiffness tied to functional requirements such as 65° to 105° of flexion for activities of daily living.

    Studies have shown that patient-specific risk factors for stiffness after TKA include: [2-5]

    • Prior surgery
    • Non-white race
    • Age under 65 years
    • Diabetes
    • High cholesterol
    • Smoking
    • Osteonecrosis
    • Preoperative ROM < 100°
    • Preoperative stiffness
    • Gender

    Intraoperative factors correlated with the ability to obtain good postoperative ROM include:

    • Component sizing
    • Bone resection
    • Osteophyte removal
    • Component alignment and rotation
    • Soft tissue balancing

    Treatment options for patients who present with stiffness include:

    Static stretching. The literature shows that static stretching increases ROM, particularly in extension, and provides good patient satisfaction.

    Manipulation under anesthesia (MUA). There is a time limit on MUA, however:  In a study by Dzaja et al [6], patients who underwent MUA less than 12 weeks after their TKA surgery had significantly better flexion gain, ROM and Knee Society Scores than those patients who underwent MUA more than 12 weeks post TKA. In addition, MUA has been associated with supracondylar fracture, instability, and extensor mechanism disruption.

    Arthroscopic lysis of adhesions. This is an option for patients who have either failed MUA or who are further out from their surgery than is ideal for MUA. In the literature, arthroscopic lysis of adhesions generally results in an improvement in ROM of about 26°.

    Revision TKA. Reported outcomes vary. Studies have reported increased ROM of 16° to 50°, along with a failure rate of 14.3%.

    The bottom line, Dr. Long said, is that stiffness after TKA is a common complication, and the group of patients who develop stiffness is fairly predictable. Multi-modal pain management at the time of surgery, along with use of tranexamic acid, can help prevent stiffness.

    Dr. Long recommends seeing patients early postoperatively; those who are not progressing as expected will need physical therapy to focus on ROM, as well as good pain management. Early MUA and arthroscopic lysis of adhesions have shown good results, but revision TKA for stiffness has had only moderate outcomes.

    Click the image above to watch Dr. Long’s presentation and learn more about his pre-emptive approach to managing patients after TKA to avoid stiffness.


    Dr. Long has disclosed that he is a consultant and speaker for Zimmer Biomet, Ortho Development, and Pacira Pharmaceuticals and that he receives royalties from Elsevier.


    1. Ha CW, Park YB, Song YS, Kim JH, Park YG. Increased Range of Motion Is Important for Functional Outcome and Satisfaction After Total Knee Arthroplasty in Asian Patients. The Journal of Arthroplasty 31 (2016) 1199-1203
    2. Rothermich MA, Nam D, Brophy RH, et al. The Impact of Prior Surgery after Total Knee Arthroplasty J of Knee Surgery; Issue 01, 2017
    3. Issa K, Rifai A, Boylan MR, Pourtaheri S, McInerney VK, Mont MA. Do Various Factors Affect the Frequency of Manipulation Under Anesthesia After Primary Total Knee Arthroplasty? Clin Orthop Relat Res (2015) 473:143–147
    4. Kim J, Nelson CL, Lotke PA. Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am. 2004 Jul;86-A(7):1479-84.
    5. Bourne RB. Knee Society Interim Meeting, 2006
    6. Dzaja I, Vasarhelyi EM, Lanting BA. Knee manipulation under anaesthetic following total knee arthroplasty. Bone Joint J 2015;97-B:1640–4.