What Can Be Done for Patients with a Stiff Knee after TKA?
Research show that knee flexion of between 90° and 100° is needed for most activities of daily living. Following a total knee arthroplasty (TKA), some patients – between 1% and 10%, depending on the study – meet the definition of a stiff knee replacement, which is generally agreed to be failure to achieve 90° of knee flexion 6 to 12 weeks post-operatively.
Managing a patient who presents with a stiff knee after TKA can be challenging. Henry Clarke, MD, from Mayo Clinic in Phoenix, Arizona, discussed the treatment options for these patients in a presentationat the 13th Annual Insall Scott Kelly Institute Sports Medicine and Total Knee & Hip Course in New York. The meeting was supported by the International Congress for Joint Reconstruction.
Dr. Clarke focused on three options:
- Arthroscopic debridement
- Revision TKA
Studies have shown that manipulation under anesthesia (MUA) can achieve an additional 30 to 40 degrees of knee flexion. Dr. Clarke offers this option to patients who do not have 90 degrees of flexion 6 to 12 weeks after TKA.
Typically, Dr. Clarke does this procedure on an outpatient basis, with the patient under general anesthesia with muscle relaxation. He manipulates for flexion only. Dr. Clarke applies pressure over the proximal third of the tibia, with his hand over the knee to feel the arthrofibrotic bands release.
The same patients are offered this option as are offered MUA, with the difference being that Dr. Clarke is more likely to use this modality in a patient who underwent a cruciate-retaining TKA. This, too, is an outpatient procedure that Dr. Clarke will do up to 1 year following the original TKA.
Dr. Clarke combines arthroscopy with manipulation in this procedure. He releases the posterior cruciate ligament (PCL) in patients with a cruciate-retaining TKA, which he says is very helpful in achieving greater knee flexion. Research backs him up, showing that PCL release can be an effective technique in a stiff, cruciate-retaining TKA.
Revision TKA in a patient with a stiff knee is a very challenging procedure. The goal is to correct all technical errors identified in the preoperative evaluation.
Preoperatively, it is important to evaluate the soft tissue to determine if prophylactic tissue expanders or soft tissue flaps will be needed. Dr. Clarke said surgeons at Mayo Clinic have achieved good results with prophylactic muscle flaps. In one study, patients with a prophylactic muscle flap gained 22° of flexion, versus loss of flexion in patients who needed a salvage flap during the procedure.
Dr. Clarke admitted that although some increase in flexion can be achieved with revision TKA, research shows there is often little increase in patient satisfaction. The exception may be the patient who has malrotation of the implant with stiffness. Recent research has shown that if the malrotation is corrected, the patient will typically do fairly well after the revision.
Click the image above to watch Dr. Clarke’s presentation, in which he also discusses patient, surgeon, and post-operative factors associated with a stiff knee following TKA.