Functional Problems and Arthrofibrosis Following Total Knee

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Functional Problems and Arthrofibrosis Following Total Knee
Arthroplasty
Thorsten M. Seyler, David R. Marker, Anil Bhave, Johannes F. Plate, German A. Marulanda, Peter M. Bonutti,
Ronald E. Delanois and Michael A. Mont
J Bone Joint Surg Am. 2007;89:59-69. doi:10.2106/JBJS.G.00457
This information is current as of December 29, 2007
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Seyler.fm Page 59 Monday, September 10, 2007 1:59 PM
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COPYRIGHT © 2007
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Functional Problems and Arthrofibrosis
Following Total Knee Arthroplasty
By Thorsten M. Seyler, MD, David R. Marker, BS, Anil Bhave, PT, Johannes F. Plate, BS,
German A. Marulanda, MD, Peter M. Bonutti, MD, Ronald E. Delanois, MD, and Michael A. Mont, MD
Introduction
mproved surgical techniques and multidisciplinary rehabilitation protocols that involve coordination among surgeons, physical therapists, anesthesiologists, and social
services personnel have led to excellent knee function and
range of motion in a large percentage of patients following total knee arthroplasty. Nevertheless, there remains a small
number of patients with persistent dysfunction that is difficult
to treat1-4. Functional problems following total knee arthroplasty may be incapacitating as a result of persistent pain5,
instability6, and a limited range of motion7. It has been shown
recently that there is a direct correlation between a decreased
range of motion following surgery and a lower perceived quality of life as evaluated with use of the Short Form-36 health
survey questionnaire8. Continued dysfunction for any reason
ultimately leads to decreased patient satisfaction.
There is controversy about treatment methods for patients for whom initial rehabilitation efforts are unsuccessful
following total knee arthroplasty. The reported efficacy of
both noninvasive and invasive treatment modalities has been
variable, with the percentage of patients obtaining improvement ranging from 0% to 90%3,9-12. Patients who have continued dysfunction despite initial rehabilitation efforts may
require revision surgery. However, patients who have wellaligned, well-fixed prosthetic components will likely not
benefit from a complete revision. Treatment of arthrofibrosis,
scarring, soft-tissue contractures, and/or other soft-tissue dysfunction should involve less invasive treatment protocols before surgical options are considered. Nonoperative treatment
modalities for restoring the range of motion include intensive
rehabilitation protocols, static or dynamic splinting, injections, and application of serial casts13. Manipulation with the
patient under anesthesia and invasive procedures, including
arthroscopic débridement, open débridement with or without
polyethylene exchange, and complete component revision,
have been utilized when initial nonoperative rehabilitation efforts have failed.
I
As a result of the variability in the functional limitations
experienced by patients and the inconsistency in the success of
present, commonly used rehabilitation modalities, additional
treatment options need to be considered and evaluated. We
are reporting our experience with diagnosing the underlying
causes of dysfunction following total knee arthroplasty and
the level of success that we have had with use of various rehabilitation and treatment modalities.
Materials and Methods
Diagnostic Methods
atients for whom initial rehabilitation efforts following
total knee arthroplasty were considered to have failed
because of continued pain and/or functional limitations underwent a careful radiographic and clinical evaluation. Radiographic studies were used to identify component loosening,
malalignment, or other problems (for example, retained
bone cement) that indicated the need for revision surgery.
When infection was suspected, aspiration and cultures were
utilized to verify the diagnosis and to identify the organism,
thus ensuring proper antibiotic therapy and timely surgical
treatment14.
Patients for whom standard rehabilitation efforts had
been unsuccessful and who had no evidence of radiographic
abnormalities were thoroughly assessed to identify any underlying soft-tissue problems associated with their dysfunction (Fig. 1). The range of motion was assessed at all clinical
evaluations prior to and following the total knee arthroplasty. Standard flexion and extension measurements were
performed with use of a goniometer. Limb length was measured with a tape measure when a limb-length discrepancy
was suspected.
Muscle strength was measured with use of manual isokinetic strength testing and graded on a scale of 0 to 515. A grade
of 0 corresponded to no contraction of the muscle and 100%
loss of strength, whereas a grade of 5 indicated active movement against gravity with full resistance and no loss of strength.
P
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the
authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment
or agreement to provide such benefits from a commercial entity (Joint Active Systems, Effingham, Illinois). No commercial entity paid or directed, or
agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization
with which the authors, or a member of their immediate families, are affiliated or associated.
J Bone Joint Surg Am. 2007;89(Suppl 3):59-69 • doi:10.2106/JBJS.G.00457
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BONE & JOINT SURGER Y · JBJS.ORG
VO L U M E 89-A · S U P P L E M E N T 3 · 2007
OF
FU N C T I ON A L PROBL EM S A N D AR TH ROFI BROS I S
F O L L O W I N G TO T A L K N E E A R T H RO P L A S T Y
Fig. 1
A standardized algorithm was used to diagnose and treat functional problems following total knee arthroplasty. CKD = customized knee device,
JAS = Joint Active Systems, and NMES = neuromuscular electrical stimulation.
All measurements were made by two of us (A.B. and T.M.S.),
who agreed with each other regarding the grade assessments
>95% of the time.
Video gait analysis was conducted with use of an eightcamera motion analysis system (Motion Analysis, Santa Rosa,
California) combined with two central force-plates (Advanced
Mechanical Technology, Watertown, Massachusetts). This system was utilized to measure body kinematics, muscle activation, and ground reaction force along a 10-m, level-surface
walkway. Twenty-six reflective markers (Helen Hayes marker
set) were placed on both sides of the patient at the hip, knee,
ankle, and foot. After the setup of markers for movement recording, electrodes were placed for surface electromyography.
The force-plates and electromyography system were synchronized with the motion analysis system to measure ground reaction forces and activities of the lower-extremity muscles.
The subjects were instructed to walk several passes at a selfselected speed until ten consistent force-plate recordings were
collected for each side. Throughout the observation period,
the sampling rate for the data points was 60 Hz. The data were
processed with use of standard OrthoTrak software (Motion
Analysis). The analyzed parameters were walking velocities,
ground reaction vectors, joint moments, power, knee flexion,
and ranges of ankle dorsiflexion during the stance phase as
well as during the loading response.
Patient Cohort
On the basis of a thorough clinical evaluation performed with
use of the previously mentioned diagnostic methods, functional problems and stiffness of the knee after total knee arthroplasty were diagnosed in 106 patients (108 knees). Initial
rehabilitation efforts, which included manipulation under anesthesia in some cases, had failed for all of these patients. The
patients had shown minimal improvement in terms of both
function and pain relief at a minimum of two months postoperatively. Common symptoms included quadriceps fatigue
pain, anterior knee pain, abnormal gait, back pain, limp, difficulty with walking long distances, and an inability to participate in non-strenuous sports or recreational activity. Patients
also reported difficulty with sitting in and rising from a chair,
descending and ascending stairs, and sexual relations. There
were sixty-four women and forty-two men, and the mean age
was fifty-three years (range, nineteen to seventy-seven years).
Seventeen of the patients had the functional problems following revision total knee arthroplasty, and all others had them
after primary total knee arthroplasty.
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regimens lasted for three to six months (mean, 4.6 months)
(Fig. 2). All rehabilitation efforts failed for seven patients, who
subsequently received surgical treatment, including arthroscopic débridement, open débridement with or without polyethylene exchange, and complete component revision.
Results
Nonoperative Treatment
onnective tissue is viscoelastic in nature, and under tension it responds by reaching either the elastic or plastic
deformation state. In elastic deformation, tissue can revert to
its original length after the force is removed. In the plastic deformation state, tissue will maintain the newly elongated
length after elimination of the force. The goal of therapeutic
stretching is to achieve permanent length changes without requiring new tissue growth by plastically deforming tissues that
have stiffened or shortened16.
C
Custom Knee Devices
Seventy-eight patients (seventy-nine knees) followed a daily
outpatient rehabilitation algorithm using a fitted custom knee
device (Fig. 3)17. The device is hinged at the knee and has elastic bands (Thera-Band; The Hygenic Corporation, Akron,
Ohio), which produce a flexion moment. The patients were
instructed how to position the brace for maximum tolerated
force and were expected to utilize the custom knee device for
Fig. 2
Taping was utilized to medialize the patella in patients with atrophy
of the vastus medialis obliquus, increased activity of the vastus lateralis muscle, and tightness of the iliotibial band during isokinetic
strengthening.
All individuals demonstrated gait abnormalities that
were associated with one or more biomechanical dysfunctions. The six most prevalent categories of dysfunction were
flexion contracture, knee flexion deficit, quadriceps weakness,
limb-length discrepancy, peroneal nerve entrapment, and
functional malalignment of the distal joints. Sixty-six patients
(sixty-eight knees) were diagnosed as having a knee flexion
contracture; forty-three patients (forty-four knees), muscle
tightness; twenty-eight patients (twenty-eight knees), quadriceps muscle weakness; seven patients (seven knees), a limblength discrepancy of 1 to 2.5 cm; four patients (four knees),
functional malalignment; and fourteen patients (fourteen
knees), peroneal nerve dysfunction. Some of the patients had
more than one functional problem.
The specific rehabilitation and physical therapy modalities were customized for each patient, and treatments with
these modalities were not mutually exclusive. Some of these
treatments included the use of a customized knee device (seventy-nine knees), a JAS device (Joint Active Systems, Effingham, Illinois) (thirty knees), botulinum toxin injections (nine
knees), electrical stimulation (forty-one knees), and peroneal
nerve release (fourteen knees). In general, the physical therapy
Fig. 3
The custom knee device was used to improve knee flexion in patients
who had limited flexion (<90°). The patient sits at the end of a treatment table while a prolonged flexion stretch is applied two or three
times per day.
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thirty to forty minutes two or three times a day. The brace was
removed at all other times.
All patients who were treated with the custom knee device had a knee flexion deficit, which was defined as a flexion
angle of <90° and which resulted in functional deficits in the
ability to rise from and sit in a chair, sit for prolonged periods
of time, ascend and descend stairs, and engage in sexual activities. These problems were mainly related to tightness of the
rectus femoris muscle, patellar tracking problems, and tightness or inflammation of the patellar tendon. In addition to the
patients’ use of the custom knee device, physical therapists supervised inferior patellar, patellar tendon, quadriceps tendon,
rectus femoris, and knee joint mobilization efforts to further
increase knee flexion (Fig. 4).
Patients with a knee flexion contracture used a customized device to increase knee extension, which was similar to
the custom knee device used to increase flexion and which was
also applied for thirty to forty minutes three times a day (Fig.
5). Knee flexion contracture leads to problems with walking,
anterior knee pain, extensive patellar wear, and patellar tendinitis. An overall excellent result was obtained in seventy-one
knees (90%) treated with the custom knee device. The mean
Knee Society score at the time of final follow-up was 91 points
(range, 55 to 100 points), and the total arc of motion improved by a mean (and standard deviation) of 24.7° ± 18.3°.
After obtaining minimal improvement with use of the custom
knee device, three patients required arthroscopic lysis of adhesions, one patient had an open débridement with polyethylene
exchange, and one patient had complete component revision.
Some patients chose not to undergo additional surgery and
ended their rehabilitation efforts despite continued range-ofmotion deficits.
JAS (Joint Active Systems) Device
Twenty-nine patients (thirty knees) with a soft-tissue contracture after total knee arthroplasty or trauma to the joint used
the JAS (Joint Active Systems) knee device to treat both flexion and extension limitations (Fig. 6). The JAS device is a
patient-directed, bidirectional orthosis that can be used conveniently in a home setting. It incorporates stress relaxation
and static progressive stretch, while simulating some of the
manual techniques used by physical therapists in the clinical
setting. Patients with heterotopic ossification, peroneal nerve
palsy, or true osseous blocks were not treated with this device.
Fifteen men and fourteen women with a mean age of fifty-two
years began using the JAS device at a mean of 14.1 ± 9.7 weeks
after the index surgery or injury.
Patients were instructed regarding the application of the
device and the protocol for its use as described by Bonutti et
al.18. After they placed the orthosis on the affected limb at the
current limit of motion, the patients were directed to increase
the stretch to the extent that they could tolerate by turning the
ratchet on the device and holding that position for a period of
five minutes. They then increased the stretch to the extent that
they could tolerate and held the new position for another five
minutes. Patients were instructed to stretch to the extent that
Fig. 4
Knee flexion stretch with hip extension was used to treat tightness of
the rectus femoris.
they could tolerate, without causing excruciating pain, and
they continued this incremental stretching for the entire
thirty-minute treatment session.
All but two patients who underwent rehabilitation with
use of the JAS device had a favorable outcome, with an increase in the range of motion, and two patients made no
progress in at least one direction. The patients gained a mean
of 7.4° ± 8.1° of additional extension and 15.1° ± 12.3° of
additional flexion. The total mean increase in the flexionextension arc was 22.5° ± 16.3°, from a mean of 85.4° ± 22.2°
before utilization of the JAS orthosis to a mean of 107.9° ±
16.8° after a mean of 9.4 ± 7.8 weeks (range, three to thirtythree weeks) of treatment. Of the two patients who did not
have an improvement in the range of motion, one required arthroscopic lysis of adhesions and one had an open débridement without polyethylene exchange.
Botulinum Toxin Injections
Eight patients (nine knees) who had rigidity of the hamstring
and/or gastrocnemius muscle as the primary cause of a con-
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Fig. 5
Use of a custom knee device to treat a knee flexion contracture. A black Thera-Band is
used with the custom knee device to impart an extension moment. The heel is propped
up to maximize the extension moment. Patients were encouraged to wear the custom
knee device for a minimum of thirty to forty minutes three times a day. When the patient
did not respond to this therapy regimen, night-time use of the custom knee device was
recommended.
tinued flexion contracture despite initial physical therapy were
treated with botulinum toxin type-A injections. These injections produce a neuromuscular blockade for approximately
three months. The underlying mechanism of action of botulinum toxin is at the cellular level. By acting selectively on
peripheral cholinergic nerve endings, it leads to chemodenervation and local paralysis19. The temporary paralysis and reduction in functional muscle spasticity or muscle tone
provided by botulinum toxin promote better motor balance
across joints; improve walking ability; and, when combined
with intensive physical rehabilitation, allow the therapists to
progress the range of motion beyond previous limitations20,21.
The decision regarding which muscles to inject was
based on the patient’s reported feeling of tightness and spasm
as well as on the findings of the clinical examination. Patients
who lost knee extension as the hip joint was being flexed to
45° were considered candidates for botulinum injections into
the hamstring muscles. The hamstring muscles were palpated
as the knee was extended to determine whether the medial or
lateral hamstrings required treatment. The decision to inject
the gastrocnemius muscle was based on a loss of the range of
knee extension as the ankle was dorsiflexed compared with the
range in the plantigrade position.
The mean time from the index surgery to treatment
with botulinum toxin injections was eighteen months (range,
three to eighty-one months). Following the primary total knee
arthroplasties, we injected the medial hamstrings in eight
cases (seven patients) and both the medial and the lateral
hamstrings in one patient. Two patients also received injections into both heads of the gastrocnemius muscle. All injections were administered by one of us (M.A.M.). The patient
was placed in a prone position, and a 25-gauge needle was
used to inject the muscle belly with a dilution of 50 units/mL.
Fig. 6
The Joint Active Systems (JAS) knee device was used by patients at
home to augment the efforts of their physical therapists in the clinical setting. The JAS device was used for thirty-minute sessions with
progressive stretch at five-minute intervals.
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muscle and the patellar tendon was provided three, four, or five
times per week. The patients who received gastrocnemius injections were encouraged to sleep with the foot in a splint to maintain maximum dorsiflexion stretch on the muscle.
There were no serious complications directly associated
with the botulinum treatment. A transient flu-like condition
developed in one patient and lasted for two days. However, the
patient recovered without additional difficulties and showed
no later effects. Another patient had redness and swelling at
the site of the injection for several days after treatment; this
cleared up by one week.
Eight of the nine knees treated with the botulinum injections achieved extension within 5° of the neutral position.
The range of motion increased by a mean of 42° (range, 10° to
75°; p < 0.001) at a mean of thirty-eight months (range,
twenty-four to fifty-eight months) following the injections.
Fig. 7
Botulinum toxin type A was injected into four sites of a contracted
medial hamstring muscle, three sites of a contracted lateral hamstring muscle, and two sites in each head of a contracted gastrocnemius muscle.
The injections into the medial hamstring muscles consisted of
100 units of botulinum toxin type A distributed evenly among
four sites, those into the lateral hamstrings consisted of 100
units of toxin distributed evenly among three sites, and those
into the gastrocnemius muscle consisted of a total dose of 50
units of toxin injected into two sites in both the medial and
the lateral heads of the muscle belly (Fig. 7).
After receiving the injections, the patients started a rehabilitation regimen that consisted of inpatient and outpatient
treatment for eight continuous weeks. Intensive physical therapy combined with careful knee, quadriceps muscle, and inferior patellar mobilization and stretching of the rectus femoris
Fig. 8
Neuromuscular electrical stimulation (7 to 10-sec on-time, 15 to 20sec off-time, frequency of 70 to 90 pulses/sec, 400-µsec-pulse duration, 90 Hz, and intensity set at the maximum tolerated to produce
a superimposed muscle voluntary contraction) augmented isometric
strengthening at 30° of flexion to treat an extensor lag.
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The Knee Society scores improved by a mean of 35 points
(range, 15 to 53 points; p < 0.001) from the time prior to the
botulinum treatment to the final follow-up examination. All
patients had a good or excellent clinical outcome as indicated
by a Knee Society score of ≥80 points, except for one patient
with a score of 76 points. That patient had a residual knee flexion contracture of 10° but was satisfied with the result and declined further treatment.
Electrical Stimulation
Forty patients (forty-one knees) who had an extension lag
and were included in the previously discussed cohorts (those
treated with botulinum toxin injections and/or a custom
knee device) also received electrical stimulation during their
physical therapy sessions to augment strength training. The
stimulation was administered while the patient underwent
soft-tissue mobilization and exercises with use of a leg-press
to activate the quadriceps and inhibit the flexors (Fig. 8).
Throughout the session, the electrical stimulation was set at a
7 to 10-sec on-time, a 15 to 20-sec off-time, a frequency of 70
to 90 pulses/sec, a 400-µsec pulse duration, and 90 Hz.
Manipulation Under Anesthesia
Patients who had a range of motion of ≤90° at six weeks following the total knee arthroplasty were candidates for manipulation under anesthesia (Fig. 9). These patients showed no
improvement or a reduction in both flexion and extension despite initial rehabilitation efforts. Like the other nonoperative
treatments, manipulations were not utilized for patients who
had component malposition or failure, incorrect component
sizing, joint line displacement, or inadequate bone resection.
Manipulations were not performed more than three months
following total knee arthroplasty because of decreased effectiveness and the risk of fracture after that time. Patients who
continued to show a limited range of motion after three
months underwent extensive radiographic and clinical evaluation and were treated with a customized rehabilitation regimen with use of one or more of the previously mentioned
nonoperative treatment modalities.
The criteria used to select candidates for manipulation
under anesthesia in this study differed from those reported in
other studies. Keating et al. selected patients for manipulation as early as two months following total knee arthroplasty,
and the procedure was utilized as late as forty-four weeks
postoperatively12. Fox and Poss treated patients as early as two
weeks after surgery22, and Shoji et al. reported that their patients received manipulations at ten days following surgery23.
The range-of-motion criteria used in other studies also varied. For example, Brassard et al. selected patients with a range
of motion limited to <75°24, and Esler et al. treated patients in
whom flexion had failed to increase to >80° following the initial physiotherapy25.
Fig. 9
Manipulation under anesthesia performed within twelve weeks following total knee arthroplasty
can result in substantial improvement in knee flexion. Manipulation has also been associated
with complications such as femoral supracondylar fracture, avulsion of the patellar tendon,
wound dehiscence, and hemarthrosis.
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The reported outcomes of manipulations under anesthesia have also been variable. In the study by Keating et al.,
patients had a mean increase in flexion of 35° after a mean of
five years of follow-up12. Keating et al. also reported no significant difference in the improvement in flexion between patients who had been treated within twelve weeks following
surgery and those who had had the manipulation at more
than twelve weeks. In contrast, a study by Yercan et al. sug-
gested that the timing of the procedure does affect the final
outcome26. They found the results in patients who had received the manipulations less than three weeks postoperatively
to be better than those in patients who had been treated between three weeks and three months postoperatively. They reported an improvement of 47° in the range of motion at the
time of final follow-up. In contrast to both of these studies,
Fox and Poss22 reported that manipulations ultimately did not
Fig. 10
A five-step surgical technique was utilized for peroneal nerve release to decrease peroneal nerve
symptoms. (Reprinted, with permission of Springer Science and Business Media, from: Paley D.
Principles of deformity correction. New York: Springer; 2002. p 284-5. Also printed with permission of the Rubin Institute for Advanced Orthopaedics. The assistance of Dr. Dror Paley with the
creation of this figure is appreciated.)
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improve the range of motion, which initially increased by 37°
but the increase was only 17° one week later. Furthermore, at
one year, there was no difference in the range of motion between the patients who had received manipulations and those
who had not. As a result of the variability in selection criteria
and outcomes reported in the literature, a prospective study to
further evaluate the efficacy of this procedure is currently being conducted at our institution.
fourteen patients had achieved full extension within 5°. They
were completely symptom-free within six weeks after the surgery. One patient had a persistent knee flexion contracture of
15°. Thirteen patients reported a return to normal gait and
recovery of ankle dorsiflexor function. Also, sensation in the
cutaneous distribution of the superficial and deep peroneal
nerves returned in all cases.
Arthroscopy
Surgical Treatment
Functional problems, persistent pain, and arthrofibrosis after
total knee arthroplasty are debilitating complications. The underlying etiology is often multifactorial, and little information
regarding these problems is known27. Although the etiology of
these complications is poorly understood, several surgical procedures have been proposed as viable treatment modalities.
Open operative procedures such as a complete revision of the
prosthesis or a simple component exchange have been described. More recently, and with the use of arthroscopic surgery,
there have been numerous attempts to address these types of
complications with minimally invasive techniques.
Peroneal Nerve Release
Peroneal nerve release with both proximal and distal decompression at the fibular head was performed after the total knee
arthroplasty in fourteen patients (fourteen knees). All patients
had had constant burning or shooting pain in the dorsum of
the foot, which was made worse by physical therapy. In addition, electromyographic and nerve conduction velocity studies
demonstrated electrophysiological abnormalities of the peroneal nerve in all fourteen patients. The possible causes of the
peroneal nerve palsy appeared to be direct traction on the
nerve or tension on the surrounding soft tissues created during the surgery. Other, indirect mechanisms of injury might
have included compression from tight dressings or possibly a
combination of these factors.
The mean age of the patients was sixty-three years.
None had an underlying neurological disorder. In each case,
the peroneal nerve was released at two possible entrapment
points with use of a standard five-step surgical technique (Fig.
10). First, a short oblique incision was made at the level of the
neck of the fibula in line with the course of the nerve. Next,
the superficial fascia of the leg was incised and divided over
the peroneal nerve. The third step was to divide the fascia over
the muscles medially. At this stage, the underlying fascial band
that passes over the nerve was exposed and then sectioned to
release the first potential entrapment point. The final step involved isolating and then cutting the intermuscular septum
between the anterior and lateral compartments. This last step
releases the second common point of entrapment. In some
patients, the anterior compartment fascia was also released
longitudinally in a subcutaneous fashion.
Following peroneal nerve release, all patients received
intensive physical therapy three, four, or five times a week for
eight weeks, with use of either the custom knee device or the
JAS device. At the end of these eight weeks, thirteen of the
Arthroscopy at the site of a prosthetic knee is a technically
challenging procedure, but various reports have shown promising success rates. Williams et al. reported on arthroscopic release of the posterior cruciate ligament in ten stiff painful
knees that had undergone posterior cruciate ligament-sparing
total knee arthroplasty28. At a mean of twenty months after the
arthroscopic procedure, the mean increase in knee flexion was
30.5° (range, 10° to 50°). Eight patients reported satisfaction
and decreases in pain and stiffness, whereas two patients went
on to have a revision total knee arthroplasty. Diduch et al.
studied the efficacy and safety of arthroscopy for diagnosing
and treating symptoms in forty knees that had undergone total knee arthroplasty29. Arthroscopy was used successfully to
diagnose the cause of the symptoms in 97.5% of the patients,
and arthroscopic treatment included removal of impinging
tissue or loose bodies. At an average of 19.9 months, the rates
of clinical success were 82% for procedures done to treat
“clunks,” 60% for those used to remove impinging synovial or
soft tissue, and 63% for those used to treat arthrofibrosis.
Similarly, Jerosch and Aldawoudy evaluated the efficacy of arthroscopic management of knee stiffness after total knee
arthroplasty30. In their series of thirty-two knees, twenty-five
demonstrated improvements in both the range of motion and
the Knee Society scores. In the present study, four patients underwent arthroscopic removal of scar tissue. These patients
had an improvement in the range of motion ranging between
10° and 20°. At a mean of sixteen months following the arthroscopy, no patient had required an additional surgical procedure and the mean Knee Society score was 89 points.
Arthrotomy and Débridement
When a patient presents with severe stiffness of the knee, an
arthrotomy with synovectomy, removal of scar tissue, lateral
retinacular release, posterior capsular release, posterior cruciate ligament release, and/or exchange of a single component
can be a reasonable approach. Babis et al. reported the results
in seven knees in which stiffness after total knee arthroplasty
had been treated with an arthrotomy, débridement of scar tissue, and isolated exchange of the tibial polyethylene insert9. At
the time of final follow-up, two knees had been revised, four
knees were severely painful, and one knee was moderately
painful. The authors concluded that open débridement and
exchange of the polyethylene insert alone was not an effective
treatment approach in their hands. Conversely, Maloney, in a
comment on the evaluation and management of arthrofibrosis11, pointed out the risk of damage to the articulation
during arthroscopy to remove scar tissue and found open
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débridement and resection of the posterior cruciate ligament
to be a good treatment option. However, he did not report the
actual number of patients in his series. Yercan et al. reported
the results in seven patients who had been treated with an arthrotomy, which had been combined with component exchange in two cases26. Although five of the seven knees showed
improvements both in the range of motion and in terms of
pain relief, the authors concluded that open arthrolysis and
isolated revision of a component does not correct a limited arc
of motion but leads to reliable pain relief. We performed an
arthrotomy with débridement of scar tissue and exchange of
the polyethylene insert to correct oversized components in
two patients. Both patients demonstrated improvements in
the Knee Society scores and the total arc of motion.
plasties in five patients who had had stiffness after the primary
arthroplasty33. The arc of motion increased from a mean of 36°
before the revision surgery to a mean of 86° after it. In a study
of fifty-six knees in fifty-two patients who had undergone revision surgery because of stiffness, Kim et al. reported that the
mean Knee Society pain and functional scores improved from
15 to 47 points and from 39 to 87 points, respectively2. Thirtyfive knees (63%) had a decreased flexion contracture, and
forty-five knees (80%) had increased flexion. Fifty-two knees
(93%) demonstrated a gain in the total arc of motion. Only
one patient underwent revision arthroplasty in our series.
This patient had an improved but still limited range of motion
and reported a high degree of satisfaction because of persistent pain relief.
Revision Total Knee Arthroplasty
Conclusions
lthough total knee arthroplasties performed with modern
surgical techniques and standard rehabilitation protocols
have been shown to provide excellent functional outcomes for
the majority of patients, as many as 15% to 20% of patients
continue to have functional limitations3,34. The sources of these
functional deficits can be identified through a combination of
careful radiographic and clinical examination, three-dimensional gait studies, and isokinetic strength testing17. A review
of the current literature shows that arthroscopic débridement,
open arthrotomy, open arthrolysis as well as replacement of a
polyethylene insert, or a complete revision can provide success
in many cases, especially those involving malaligned or overstuffed components9,10,35,36. However, the goal should be to
avoid these additional operations if possible. The results of the
present study show that botulinum toxin injections, use of a
custom knee device or a JAS device, and peroneal nerve release
can improve the range of motion and enhance the clinical outcome in patients who have various soft-tissue dysfunctions
and for whom standard rehabilitation protocols were unsuccessful. Furthermore, many of these techniques do not have to
be delayed for two or three months after the total knee replacement but rather can be initiated at an earlier time.
Patients with persistent stiffness and pain after total knee arthroplasty who do not benefit from intensive physical therapy
may require a revision total knee arthroplasty. Revision arthroplasty is the preferred treatment for patients with malaligned or oversized components and/or late-onset stiffness.
However, studies of revision arthroplasties performed to treat
stiffness after total knee arthroplasty have yielded mixed results. Haidukewych et al. reported that, of fifteen patients (sixteen knees) with well-fixed and well-aligned components who
had been treated with revision arthroplasty, ten were satisfied
with the outcome and showed modest improvements in the
Knee Society pain and functional scores as well as in the total
arc of motion10. In a study by Christensen et al., eleven patients
who had been treated with revision arthroplasty because of
stiffness after total knee arthroplasty had mean improvements
in the Knee Society pain and functional scores of 39.6 and 53.7
points, respectively, and a mean improvement in the arc of
motion of 43.5°31. Three patients required manipulation under
anesthesia because of recurrent stiffness, and one required revision surgery because of loosening of the femoral component. Nicholls and Dorr reported that, of thirteen revision
arthroplasties (in twelve patients) performed to treat stiffness,
five achieved an excellent or good result, four achieved a fair
result, and four achieved a poor result32. Four knees required
manipulation because of recurrent stiffness postoperatively.
Despite these suboptimal clinical outcomes, eleven of the
twelve patients reported a high degree of satisfaction with the
result of the procedure because of pain relief. Ries and Badalamente reported the results of six revision total knee arthro-
A
Corresponding author:
Thorsten M. Seyler, MD
Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore,
2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address:
[email protected]
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Functional Problems and Arthrofibrosis Following Total Knee

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