Insights on Stiffness after Total Knee Arthroplasty

    Why do some total knee arthroplasty (TKA) patients develop knee stiffness after surgery, and what can be done to manage it?

    Preoperative range of motion (ROM) plays a role: A study published in 2004 found that patients with preoperative stiffness were more likely to have postoperative stiffness. [1]

    But that’s just 1 factor of many possibilities, according to Raymond H. Kim, MD, who reviewed the etiology, diagnosis, and treatment of postoperative knee stiffness at the 6th Annual ICJR South Hip & Knee Course.

    Dr. Kim, from The Steadman Clinic in Vail, Colorado, said a complicating issue is that the definition of “stiffness” is not clear cut. In general, “stiffness” means motion restriction in the operated knee that limits daily function. One study reported a prevalence of 1.3% at 32 months after primary TKA, with stiffness defined for the study as flexion contracture of 15° or more and/or flexion of less than 75°. [1]

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    Dr. Kim said the etiologies of knee stiffness fall into 3 categories:

    Patient Factors

    • Preoperative ROM, as mentioned above
    • Inadequate postoperative rehabilitation
    • Socioeconomic status, with African Americans and all patients under age 45 at 2 times the risk for needing manipulation [2]

    Technical Errors

    • Decreased extension: Failure to balance the extension-flexion gap, failure to remove osteophytes, and failure to release a tight posterior capsule
    • Decreased flexion: Overstuffed patellofemoral joint, tight flexion gap, elevation of the joint line, and excessive tightening of the extensor mechanism during arthrotomy closure

    Surgical Complications

    • Indolent infection
    • Subtle component loosening
    • Periprosthetic fracture
    • Reflex sympathetic dystrophy
    • Heterotrophic ossification

    In the early postoperative period (less than 4 weeks after surgery), Dr. Kim recommends more-aggressive physical therapy, with adequate analgesia to reduce pain, and possibly night extension splinting. Patients who present with a stiff knee 4 to 8 weeks after surgery generally undergo closed manipulation. Three to 4 months after surgery, patients with a stiff knee usually require reoperation, such as:

    • Soft tissue expansion
    • Arthroscopic arthrolysis
    • Open debridement and synovectomy
    • Revision of components

    Dr. Kim cautioned that results of these procedures are variable: ROM gains are possible, but they will be modest.

    The best management is prevention, he said, including adequate preoperative education and avoidance of technical errors.

    Click on the image above to hear more from Dr. Kim about knee stiffness after TKA.


    Dr. Kim has no disclosures relevant to this presentation.


    1. 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.
    2. Springer BD, Odum SM, Nagpal VS. Is socioeconomic status a risk factor for stiffness after total knee arthroplasty? A multicenter case-control study. Orthop Clin North Am. 2012 Nov;43(5):e1-7. doi: 10.1016/j.ocl.2012.07.001.