Approach to a Patient with Stiffness After Total Knee Replacement (TKR)
Stiffness following total knee replacement can pose significant challenges for both patients and orthopaedic surgeons. For surgeons, physiotherapists, GPs, and patients it is essential to have a comprehensive approach to effectively prevent, address and manage this postoperative complication.
Definition of Stiffness After TKR: Stiffness after TKR is not clearly defined and definitions alter depending on the patients demands, implants and surgeons philosophy. Acceptable Range of motion is usually from 0-110° and stiffness is often defined as and arc of <75°. Flexion needed for stairs climbing is at least 50° and for rising from chair it is 95°. Usually the range of motion before TKR determines what can be achieved after surgery.
Stiffness can result from various factors, including the formation of scar tissue, adhesions, or suboptimal postoperative rehabilitation, but also surgical technique and implant size and position.
Pre-operative Prevention: Prior to surgery, proactive measures should be taken to minimize the risk of postoperative stiffness. Patient education plays a crucial role in ensuring patients understand the significance of adhering to the prescribed postoperative rehabilitation program. Emphasizing the importance of prehabilitation exercises can help patients strengthen the muscles surrounding the knee joint, potentially improving ROM before surgery and aiding in the recovery process.
Intra-operative Prevention: During the surgical procedure, meticulous attention should be given to accurate implant sizing and alignment. Properly aligning the prosthetic components is essential in reducing the chances of postoperative joint restrictions that can contribute to stiffness. Achieving appropriate soft tissue balancing is equally vital to prevent excessive tension on the joint and minimize the risk of stiffness.
Postoperative Prevention: Following TKR, early mobilization is crucial in preventing adhesions and stiffness. The first six weeks are key here and this is where the physiotherapist can help most! Encouraging patients to initiate gentle range of motion exercises soon after surgery can promote joint flexibility and mitigate the formation of scar tissue. A structured and progressive physical therapy program should be prescribed to patients, focusing on improving knee ROM and functional outcomes. Additionally, the implementation of cryotherapy to reduce inflammation can contribute to facilitating postoperative mobility. In certain cases, the use of dynamic splints during periods of rest may help maintain joint mobility and prevent stiffness.
Incidence of Stiffness: The incidence of stiffness after total knee replacement varies depending on multiple factors, including patient-specific characteristics, surgical technique, and adherence to postoperative rehabilitation. Studies have reported that the overall incidence of post-TKR stiffness ranges from 1% to 23%, with a higher likelihood in patients who have undergone more complex or revision surgeries.
Indications for Surgical Treatment: When conservative measures fail to improve knee stiffness, and patients experience persistent limitations in daily activities, ongoing pain, or functional impairment, surgical intervention may be necessary. Evaluating the patient's overall condition and the severity of the stiffness will help determine the most appropriate surgical approach. The earlier stiffness is noticed and treated the better the changes are to improve outcomes here.
Surgical Approaches to a Stiff Knee Postoperative:
Manipulation Under Anesthesia (MUA): MUA is a non-surgical procedure conducted while the patient is under anesthesia. The surgeon manipulates the knee joint to break up adhesions and improve knee ROM. This procedure is performed to restore joint flexion (bending the knee) mainly, and will likely increase it by around 20° if stiffness is due to early scarring with a failure rate of 15%. It has limited success with achieving more extension (straightening the knee) and as time after surgery has past two to three months.
Arthroscopic Lysis of Adhesions: Arthroscopic lysis of adhesions is a minimally invasive procedure aimed at releasing adhesions and scar tissue within the knee joint. This procedure offers the advantage of visualization, allowing for the assessment and treatment of any intra-articular pathology contributing to stiffness.
Open release and posterior Capsulotomy: Posterior capsulotomy is a surgical release of the posterior capsule of the knee joint. This procedure aims to improve joint mobility by addressing tightness in the posterior soft tissues contributing to stiffness. This is used to target improvement in extension.
Revision Total Knee Replacement: In cases where severe stiffness results from implant malposition or instability, revision total knee replacement may be considered. This surgical approach involves removing the existing components and replacing them with new ones to correct alignment and balance. At times and with extensive scarring collateral ligaments might be affected during debridement surgery and a hinged knee replacement needs to be used as revision implant.
By adopting this comprehensive approach and considering the most appropriate surgical interventions when necessary, we can effectively manage stiffness after TKR, ultimately leading to improved patient outcomes and enhanced overall quality of life.
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