ICJR REWIND: For Stiffness after TKA, Prevention Is the Best Medicine

    All total knee arthroplasty patients are potentially at risk for stiffness after surgery. The problem is, it is difficult to predict which ones will develop stiffness and which ones won’t, says Dr. Raj Sinha in an article originally published on September 18, 2018.

    Stiffness is one of the primary reasons for patient dissatisfaction with their total knee arthroplasty (TKA). Because stiffness is a challenge to manage, the best treatment option is to prevent it from occurring in the first place, says Raj K. Sinha, MD, PhD, from STAR Orthopaedics in Rancho Mirage, California.

    Speaking at ICJR’s annual Winter Hip & Knee Course, Dr. Sinha said the problem is that all patients are potentially at risk, and it is difficult to predict which ones will develop stiffness and which ones won’t.

    He said that all patients have some modifiable and/or non-modifiable risk factors for stiffness after TKA, such as age, smoking, and prior surgeries. They’re further at risk just from the surgery itself, as errors in the surgical technique – including malpositioning the implant, overstuffing the anterior compartment, and an implant that’s the wrong size (too big or too small) – can lead to stiffness.

    In addition, stiffness, like quality, is hard to define: Surgeons know it when they see it but can’t agree on the parameters that indicate stiffness. Scranton [1] defined stiffness as less than 85° of flexion, while Nicholls and Dorr [2] defined it as flexion contracture greater than 20° or flexion arc less than 45° and Kim et al [3] defined it as flexion contracture of 15° or more and/or less than 75° of flexion. These varying definitions have led to varying reported incidences of stiffness after TKA, ranging from 1.3% to 5.3%. [3-5]

    Dr. Sinha considers 10° of flexion contracture to indicate stiffness. Patients who struggle to get to 90° of flexion typically have functional limitations that require intervention, he said. One piece of advice he has for preventing stiffness is to check that the patient has full extension of the knee during the procedure. His circulating nurse, standing 10 feet away from the table, determines if the knee is in full extension; those who are right at the operating table may get a distorted view of extension.

    If stiffness can’t be prevented, it can be treated. But the treatment options are not always successful. During his presentation, Dr. Sinha reviewed:

    • Manipulation
    • Arthroscopic arthrolysis
    • Open arthrolysis
    • Revision

    To learn more about these options, click the image above and watch Dr. Sinha’s presentation.


    Dr. Sinha has no disclosures relevant to this presentation.


    1. Scranton PE Jr. Management of knee pain and stiffness after total knee arthroplasty. J Arthroplasty. 2001 Jun;16(4):428-35.
    2. Nicholls DW, Dorr LD. Revision surgery for stiff total knee arthroplasty. J Arthroplasty. 1990;5 Suppl:S73-7.
    3. 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.
    4. Yercan HS, Sugun TS, Bussiere C, Ait Si Selmi T, Davies A. Neyret P. Stiffness after total knee arthroplasty: prevalence, management and outcomes. Knee. 2006 Mar;13(2):111-7. Epub 2006 Feb 20.
    5. Gandhi R, de Beer J, Leone J, Petruccelli D, Winemaker M, Adili A. Predictive risk factors for stiff knees in total knee arthroplasty. J Arthroplasty. 2006 Jan;21(1):46-52.