How to treat the stiff total knee arthroplasty?: a systematic review

A Comparison Between Polyethylene Exchange and Full Revision for Arthrofibrosis Following Total Knee Arthroplasty

BACKGROUND

Arthrofibrosis is a debilitating postoperative complication and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) range of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis.

METHODS

Patients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > .05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = .85), and flexion (81 versus 82 degrees, P = .80) versus extension (11 versus 11 degrees, P = .87) ROM.

RESULTS

The full component revision had higher KOOS, JR (65 versus 55, P = .04), and flexion (102 versus 92 degrees, P = .02), but similar extension (3 versus 3 degrees, P = .80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. The MUA (18.2 versus 18.8%, P = .96) and LOA (2.0 versus 0.0%, P = .32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision.

CONCLUSIONS

The full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, and preoperative indications, as well as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange.

The Chitranjan S. Ranawat Award: Manipulation Under Anesthesia to Treat Postoperative Stiffness After Total Knee Arthroplasty: A Multicenter Randomized Clinical Trial

BACKGROUND

Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes.

METHODS

There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov.

RESULTS

The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points.

CONCLUSIONS

In this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted.

LEVEL OF EVIDENCE

Level 1, RCT.

Postoperative Continuous Passive Motion Does Not Improve the Range of Movement Achieved After Manipulation Under Anesthetic for Stiffness in Total Knee Replacement

Background

Stiffness is a common complication following total knee arthroplasty. Manipulation under anesthesia (MUA) is an intervention that can potentially improve range of motion (ROM). Continuous passive motion (CPM) therapy has been utilized to enhance post-MUA ROM, but its effectiveness remains debated. This study assesses whether CPM therapy after MUA results in superior ROM outcomes compared to MUA alone.

Methods

A retrospective analysis included patients undergoing MUA for stiff primary total knee arthroplasty between 2017 and 2022. Demographics and ROM data were collected. Patients were in 2 groups: those who received inpatient CPM post-MUA and those who received day-case MUA alone. Complications and further interventions were noted.

Results

Of 126 patients, 39 underwent MUA only (day-case group), and 87 received CPM and MUA (inpatient group). Mean preoperative ROM was 69.4° (standard deviation [SD]:18.0°) and 73.9° (SD: 18.1°) for inpatient and day-case groups, respectively. Mean post-MUA ROM improved by 39.4° (SD: 17.7°) and 25.5° (SD: 11.1°) inpatient groups and day-case, respectively. The mean percentage of ROM gained at MUA maintained at final follow-up was 63.7% (40.8%) and 67.0% (47.5%) inpatient and day-case groups, respectively.

Conclusions

This study found no advantage in the routine use of CPM post-MUA for stiff total knee replacement patients, suggesting it may not provide sustained ROM improvements compared to MUA alone. Cost-effectiveness and patient selection merit further investigation.

Outcomes of Early Versus Delayed Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Stiffness following total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA). However, there is debate regarding the timing of MUA, with many recommending against MUA beyond 3 months after TKA. Therefore, the purpose of this systematic review was to evaluate the functional and clinical outcomes of early versus delayed MUA for stiffness following TKA.

METHODS

A search following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was performed in the PubMed, Embase, Scopus, and Cochrane databases in November 2023. Data regarding study characteristics, demographics, knee flexion and extension, patient-reported outcomes, complications, and revisions were collected. A quality assessment was performed using the Methodological Index for Non-randomized Studies. Included were 14 studies analyzing 13,445 knees, 72.1% of which underwent early MUA and 27.8% of which underwent delayed MUA. Of the 14 studies, 10 defined early MUA as being performed within 3 months of the index TKA.

RESULTS

Pre-MUA and post-MUA knee flexion for the early/delayed groups was 71.3°/77.9° and 103.0°/96.1°, respectively. Upon meta-analysis, pre-MUA knee flexion was significantly higher in the delayed group (P = .003), whereas post-MUA flexion was similar in both groups (P = .36). The mean gain in knee flexion for the early and delayed groups was 32.0°/19.2°. The surgical complication and revision TKA rates for the early and delayed groups were 4.9%/10.3% and 5%/9%, respectively. A meta-analysis found the risk of surgical or medical complications and revision TKA to be significantly higher in the delayed MUA group (P < .00001 and = .002, respectively).

CONCLUSIONS

Although post-MUA knee flexion was similar in patients undergoing early and delayed MUA following TKA, the mean gain in flexion for early patients was nearly double that of delayed patients. Delayed patients also had significantly higher risks of surgical or medical complications and revision TKA following MUA.

Manipulation Under Anesthesia and Lysis of Adhesions Are the Most Commonly Reported Treatments for Arthrofibrosis of the Knee After Arthroscopy or Anterior Cruciate Ligament Reconstruction in Both Pediatric and Adult Patients

Purpose

To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations.

Methods

A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: ("arthrofibrosis" OR "stiffness" OR "stiff" OR "complications") AND ("arthroscopy" OR "arthroscop" OR "ACL" OR "anterior cruciate") AND ("treat" OR "care" OR "management" AND "knee"). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients.

Results

A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications.

Conclusions

Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications.

Level of Evidence

Level IV, systematic review of Level I-IV studies.

Low-Dose Irradiation and Rotating-Hinge Revision for the Treatment of Severe Idiopathic Arthrofibrosis Following Total Knee Arthroplasty: A Review of 60 Patients With a Mean 6-Year Follow-Up

BACKGROUND

Severe idiopathic arthrofibrosis after total knee arthroplasty (TKA) is a challenging problem to treat. Low-dose irradiation may decrease fibro-osseous proliferation, while rotating-hinge (RH) revision allows for distal femur shortening and collateral ligament sacrifice. This study reports the clinical outcomes and implant survivorship in patients treated with low-dose irradiation and RH revision for severe idiopathic arthrofibrosis following TKA.

METHODS

A retrospective review was performed on 60 consecutive patients. Patients who had greater than 80° arc of knee motion or less than 15° flexion contracture were excluded. Mean follow-up was 6 years (range, 2 to 14). Kaplan-Meier survivorship analyses were performed, and logistic regressions were used to determine associations between preoperative patient characteristics and clinical outcomes.

RESULTS

Median flexion contracture and median terminal flexion at presentation were 20 and 70°, respectively; at final follow-up, 59 of 60 patients (98%) had ≤10° flexion contracture and 49 of 60 patients (82%) had ≥90° of flexion. The 10-year survivorship free from reoperation for any reason, revision for any reason, and revision for aseptic loosening were 63, 87, and 97%, respectively. There were 27% percent of patients who underwent a manipulation under anesthesia postoperatively, which was the most common reason for return to the operating room. A greater number of prior surgeries was significantly associated with worse range of motion at the final follow-up (P = .004). There were no known radiation-associated complications.

CONCLUSIONS

Patients with severe idiopathic arthrofibrosis following TKA treated with low-dose irradiation and RH revision maintained a gain in knee range of motion of 60° with reliable flexion contracture correction at a mean 6-year follow-up. A manipulation under anesthesia was common in the postoperative period. Survivorship free from revision for aseptic loosening was excellent at 10 years.

Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review

» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.

Effect of Low-Level Laser Therapy on Knee Range of Motion and Functional Abilities After Total Knee Arthroplasty

OBJECTIVE

The aim of this study was to determine the effectiveness of combined low-level laser therapy (LLL) and rehabilitation in patients following recent total knee replacement (TKR).

METHODS

A double-blind randomized controlled study was conducted at the Orthopedic Department of Mansoura University Hospital. Forty-four patients were chosen from a total of 58 patients who met the inclusion criteria and were assigned randomly into control and experimental groups of equal size. Ultimately, 40 patients completed the study (20 from each group). Both groups participated in an intensive functional rehabilitation program, and the experimental group also received LLL therapy around the knee at the incisional line, the medial and lateral intra-articular space, above and below the patella, and at the popliteal fossa at low fluence (6 J/cm2, 650 nm continuous wave) and 60 s per point with a total dose of 48 J per session over 12 treatment sessions for six weeks. Knee range of motion (ROM) was measured with a digital goniometer, and functional abilities were assessed with the Arabic version of the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index.

RESULTS

There were significant differences in all variables pre- and post-treatment within each group. Before treatment, there was no significant difference in any of the measured variables between the groups (P>0.05). After treatment, there were significant differences in knee flexion ROM and WOMAC index (P<0.05) but no significant difference in knee extension ROM between the groups (P>0.05).

CONCLUSION

The addition of low-level laser therapy to a rehabilitation program post-TKR resulted in substantial enhancements in knee flexion range of motion and the WOMAC index.

Manipulation under Anesthesia Following TKA with Persona IQ: A Case Series

Introduction

Although surgical devices and techniques continue to improve, regular post-operative monitoring of patients is required to ensure the best outcomes. New technological advances have allowed physicians to monitor the daily recovery of total knee arthroplasty (TKA) patients. This report is the first to describe the utilization of an implantable gait monitoring device and its capacity to detect poor early post-operative outcomes.

Case Report

Two patients, a 78-year-old male and a 34-year-old female, were assessed post-TKA utilizing remote gait kinematics and clinical evaluations and determined to need manipulation under anesthesia due to severely limited range of motion. One patient, a 51-year-old female, with good clinical outcomes, was used for comparison.

Conclusion

Remote monitoring may provide an earlier indication than clinical evaluations in identification of TKA patients at risk of poor outcomes and may who need intervention. The use of remote kinematic gait data in earlier identification of patients at risk has the potential to help improve outcomes for the broader population of TKA patients.

Sex-based differences and relationship with the restricted knee flexion angle due to aging: a comparative study

BACKGROUND

The relationship between inferior patellar mobility (IPM) and knee flexion angle has yet to be elucidated. This study aimed to develop quantitative IPM measurement methods and clarify the relationship between IPM and knee flexion angle in community-dwelling older females.

METHODS

This was a cross-sectional study. Overall, 128 healthy older women (age 65-79 years) were recruited from the community to evaluate the relationship between IPM and knee flexion angle. This study was performed between May 2015 and December 2017. The reference value of and sex differences in IPM were evaluated in 205 healthy young adults aged between 19 and 21 years. IPM was compared between healthy older and young women and was objectively measured using our specially designed patellofemoral arthrometer (PFA). Patellar mobility was calculated by normalization to body height. IPM reliability was assessed before all measurements.

RESULTS

Intraclass correlation coefficients for intratester and intertester reliabilities varied from 0.87 to 0.99. The normal range based on two standard deviations of inferior patellar displacement/body height was 5.9-13.5% (young men), 5.1-14.3% (young women), and 1.2-8.8% (older women). IPM was significantly lower in older than young women (P < 0.001). There was a significant positive correlation (r = 0.72 and P < 0.01) between IPM and knee flexion angle in healthy older women unable to flex the knee joint fully.

CONCLUSIONS

Our PFA has good intratester and intertester reliability. The results suggest that IPM decreases with aging in women. IPM and knee flexion angle are correlated among older women unable to flex the knee joint fully.

CLINICAL TRIAL REGISTRATION

Not applicable.

Role of non-ASA VTE prophylaxis in risk for manipulation following primary total knee arthroplasty

INTRODUCTION

Stiffness and decreased range of motion frequently lead to hindrance of activities of daily living and dissatisfaction follow total knee arthroplasty (TKA). This study aims to evaluate the effect of non-aspirin (ASA) chemoprophylaxis and determine patient-related risk factors for stiffness and need for manipulation under anesthesia (MUA) following primary TKA.

MATERIALS AND METHODS

A review of all patients undergoing primary TKA from 2013 to 2019 at a single academic orthopedic hospital was conducted. The primary outcome measure was MUA performed post-operatively. Chi-square analysis and Mann-Whitney U test were used to determine statistically significant relationships between risk factors and outcomes. Significance was set at p < 0.05. Univariate logistic regression was performed to control for identified independent risk factors for MUA.

RESULTS

A total of 11,550 patients undergoing primary TKA from January 2013 to September 2019 at an academic medical center were included in the study. Increasing age and Charlson Comorbidity Index were associated with statistically significant decreased odds of MUA (0.93, 95% CI: 0.92-0.94, p < 0.001, OR 0.71, 95% CI 0.63-0.79, p < 0.001). Active smokers had a 2.01 increased odds of MUA (OR 2.01, 95% CI 1.28, 3.02, p < 0.001). There was no significant difference in rates of MUA between ASA and non-ASA VTE prophylaxis (p 0.108).

CONCLUSIONS

Younger age, lower CCI, and history of smoking are associated with a higher rate, while different chemical VTE prophylaxis does not influence rate of MUA after TKA. Arthroplasty surgeons should consider these risk factors when counseling patient preoperatively. Understanding each patients' risk for MUA allows surgeons to appropriately set preoperative expectations and reasonable outcome goals.

Revision total knee arthroplasty for arthrofibrosis improves range of motion

PURPOSE

Arthrofibrosis after primary total knee arthroplasty (TKA) is a significant contributor to patient dissatisfaction. While treatment algorithms involve early physical therapy and manipulation under anaesthesia (MUA), some patients ultimately require revision TKA. It is unclear whether revision TKA can consistently improve these patient's range of motion (ROM). The purpose of this study was to evaluate ROM when revision TKA was performed for arthrofibrosis.

METHODS

A retrospective study of 42 TKA's diagnosed with arthrofibrosis from 2013 to 2019 at a single institution with a minimum 2-year follow-up was performed. The primary outcome was ROM (flexion, extension, and total arc of motion) before and after revision TKA, and secondary outcomes included patient reported outcomes information system (PROMIS) scores. Categorical data were compared using chi-squared analysis, and paired samples t tests were performed to compare ROM at three different times: pre-primary TKA, pre-revision TKA, and post-revision TKA. A multivariable linear regression analysis was performed to assess for effect modification on total ROM.

RESULTS

The patient's pre-revision mean flexion was 85.6 degrees, and mean extension was 10.1 degrees. At the time of the revision, the mean age of the cohort was 64.7 years, the average body mass index (BMI) was 29.8, and 62% were female. At a mean follow-up of 4.5 years, revision TKA significantly improved terminal flexion by 18.4 degrees (p < 0.001), terminal extension by 6.8 degrees (p = 0.007), and total arc of motion by 25.2 degrees (p < 0.001). The final ROM after revision TKA was not significantly different from the patient's pre-primary TKA ROM (p = 0.759). PROMIS physical function, depression, and pain interference scores were 39 (SD = 7.72), 49 (SD = 8.39), and 62 (SD = 7.25), respectively.

CONCLUSION

Revision TKA for arthrofibrosis significantly improved ROM at a mean follow-up of 4.5 years with over 25 degrees of improvement in the total arc of motion, resulting in final ROM similar to pre-primary TKA ROM. PROMIS physical function and pain scores showed moderate dysfunction, while depression scores were within normal limits. While physical therapy and MUA remain the gold standard for the early treatment of stiffness after TKA, revision TKA can improve ROM.

LEVEL OF EVIDENCE

IV.

High Complication Rate Associated With Arthroscopic Lysis of Adhesions Versus Manipulation Under Anesthesia for Arthrofibrosis After Total Knee Arthroplasty

BACKGROUND

Arthrofibrosis after total knee arthroplasty (TKA) is often treated by arthroscopic lysis of adhesions (ALAs) or manipulation under anesthesia (MUA). This study compared the 2-year complication rates of ALA and MUA and range-of-motion (ROM) outcomes for ALA, early MUA (<3 months after TKA), and delayed MUA (>3 months after TKA).

METHODS

This retrospective cohort study included 425 patients undergoing ALA or MUA after primary TKA from 2001 to 2018. Demographics, clinical variables, and complication rates were collected from clinical records and compared using Student t -tests and Kaplan-Meier log-rank tests. Multivariable logistic regressions were used for adjusted analysis. ROM data were analyzed using fixed and mixed-effects models.

RESULTS

ALA patients were younger (55.2 versus 58.9 years, P < 0.001) and underwent surgery later from the index TKA (12 versus 1.9 months, P < 0.001). The Charlson Comorbidity Index was higher in the MUA group. Preoperative ROM was significantly worse in the MUA cohort, but did not differ between groups after the procedure (117°, P = 0.27) or at 2 years. Demographics and ROM outcomes were equivalent between early MUA and delayed MUA ( P = 0.75). The incidence of repeat arthrofibrosis (7.1%) and revision arthroplasty (2.4%) was similar between ALA and MUA cohorts while ALA patients had significantly more surgical site infections (3.8%) compared with MUA patients (0.47%, P = 0.017).

DISCUSSION

Equivalent ROM outcomes were seen between ALA, early MUA, and delayed MUA for the treatment of arthrofibrosis after TKA. However, this study demonstrated a markedly higher complication rate, particularly surgical site infection, after ALA, suggesting that MUA may be the preferred option for treating arthrofibrosis at both early and late time points.

Knee Arthroscopy After Prior Total Knee ArthroplastyType of Study: Narrative Review

Total knee arthroplasty (TKA) results in substantial improvement for most patients with end-stage arthritis of the knee; however, approximately 20% of patients have an unsatisfactory result. Although many problems contributing to an unsatisfactory result after TKA are best addressed by revision TKA, some problems may be effectively addressed with arthroscopic treatment. The categories of pathology that can be addressed arthroscopically include peripatellar soft-tissue impingement (patellar clunk syndrome and patellar synovial hyperplasia), arthrofibrosis, and popliteus tendon dysfunction. Recognizing these disease entities and the role of arthroscopic surgery in the treatment of these lesions may be helpful in achieving a good outcome in certain patients who are unsatisfied with their knee arthroplasty.

Pseudomeniscus after knee arthroplasty: A case series for arthroscopic management of this problem and systematic review of literature

Introduction

Most patients undergoing total knee arthroplasty (TKA) experience favorable outcomes. Some patients, however, experience prolonged post-operative knee pain and tenderness at the joint line. This has been attributed in some cases to soft tissue impingement due to pseudomeniscus. The purpose of this study is to evaluate patient outcomes for arthroscopic excision of pseudomeniscus for persistent knee pain after TKA and to perform a review of literature for pseudomeniscus after knee arthroplasty.

Methods

A retrospective analysis of patients undergoing arthroscopy to remove soft tissue causing persistent knee pain after previous TKA was performed. Outcome scores were asked at three time points: prior to knee arthroplasty, prior to arthroscopy, and post-arthroscopy at final follow-up. Subjective satisfaction with surgery and willingness to repeat procedures were also recorded. A two-tailed distribution paired t-test was used to determine statistical significance (p < 0.05). We also performed a review of the literature for pseudomeniscus complications for comparison.

Results

Nine out of eleven patients were considered eligible to be assessed for post-operative satisfaction. Seven out of nine patients reported complete satisfaction and eight participants stated they would undergo the procedures again if they have to. Among 9 included patients, five patients have successfully completed the clinical score evaluation survey. The mean age of the patients with clinical score evaluation at the time of TKA was 61 years (range, 53-72) and the time between TKA and undergoing arthroscopy was 8 months (range, 5-13). The average follow-up period for patient-determined assessment after the arthroscopic procedure was 71 months (range, 16-115). All 5 patients reported improved Oxford Knee Scores (p=0.017), Western Ontario and McMaster Universities Osteoarthritis Index (p=0.023), and pain scores (p=0.018) comparing pre-arthroscopy to post-arthroscopy at follow-up.

Conclusion

Arthroscopic removal of pseudomeniscus after TKA provides promising results in patients who experience persistent knee joint line pain and tenderness. Considering our results and review of literature, we recommend including pseudomeniscus in the differential for post arthroplasty knee pain.

Study design

Case series with a review of literature.

Early manipulation under anaesthesia for stiffness following total knee arthroplasty is associated with a greater gain in knee flexion

PURPOSE

This study aimed to identify the risk factors for manipulation under anaesthesia (MUA) following total knee arthroplasty (TKA) and whether performing an 'early' MUA within 3 months leads to a greater improvement in range of motion.

METHODS

Primary TKAs performed between 2013 and 2018 at three tertiary New Zealand hospitals were reviewed with a minimum follow-up of 1 year. Clinical details of patients who underwent MUA were reviewed to identify the knee flexion angle prior to and following MUA. Multivariate analysis identified the risk factors for undergoing MUA and compared flexion angles between 'early' (< 3 months) and 'late' MUA (> 3 months).

RESULTS

A total of 7386 primary TKAs were analysed in which 131 underwent an MUA (1.8%). Patients aged < 65 years were two times more likely to undergo MUA compared to patients aged ≥ 65 years (2.5 versus 1.3%, p < 0.001; adjusted HR = 2.1, p < 0.001). There was no difference in the final flexion angle post-MUA between early and late MUA (104.7° versus 104.1°, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3° versus 79.6°, p = 0.012), and subsequently had a greater overall gain in flexion compared to those who underwent late MUA (mean gain 33.1° versus 24.3°, p < 0.001).

CONCLUSION

Younger age was the only patient risk factor for MUA. Patients who underwent early MUA had similar post-MUA flexion, but had poorer pre-MUA flexion compared to those who underwent late MUA. Subsequently, a greater overall gain in flexion was achieved in those who underwent early MUA.

LEVEL OF EVIDENCE

III.

Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty

Background

Arthroscopic lysis of adhesions is a treatment option for patients with painful, stiff knees as a result of arthrofibrosis following knee arthroplasty, in whom prior manipulation under anesthesia (MUA) has failed. Typically, nonoperative treatment in these patients has also failed, including aggressive physiotherapy, stretching, dynamic splinting, and various pain-management measures or medications. Range of motion in these patients is often suboptimal, and any gains in flexibility will likely have hit a plateau over many months. The goal of performing lysis of adhesions is to increase the range of motion in patients with knee stiffness following total knee arthroplasty, as well as to reduce pain and restore physiologic function of the knee, enabling activities of daily living.

Description

This is a straightforward surgical technique that can be performed in a single stage. The preoperative range of motion is documented after induction of general anesthesia. The procedure begins with the establishment of standard medial and lateral parapatellar arthroscopic portals. A blunt trocar is introduced into the knee, and blunt, manual lysis of adhesions is performed in the suprapatellar pouch and the medial and lateral gutters with use of a sweeping motion after piercing and perforating the scarred adhesive bands or capsular tissue. Next, the arthroscope is inserted into the knee, and a diagnostic arthroscopy is performed. Bands of fibrous tissue are released and resected with use of electrocautery and a 4.0-mm arthroscopic shaver. Next, the posterior cruciate ligament (PCL) is visualized in full flexion. If PCL tightness is observed, the PCL can be released from its femoral origin until the flexion gap is increased. This portion of the procedure can include either partial or full release of the PCL, as indicated. Next, the arthroscope is removed and the ipsilateral hip is flexed to 90° for a standard MUA. Gentle force is applied to the proximal aspect of the tibia, and the knee is flexed. After completing the MUA, immediate post-intervention range of motion of the knee is documented, and the patient is provided with a continuous passive motion (CPM) machine set to the maximum flexion and extension achieved in the operating room.

Alternatives

Nonoperative treatment of a stiff knee following total knee arthroplasty is well documented in the current literature. Range of motion has been shown to increase in patients undergoing proper pain management, aggressive physical therapy, and closed MUA in the acute postoperative setting. Additionally, more severe cases of established arthrofibrosis despite prior MUA can be treated with an open lysis of adhesions1-3.

Rationale

Arthroscopic lysis of adhesions with PCL release versus resection has been well described previously. This procedure has been shown to benefit patients in whom initial nonoperative treatment has failed. Additionally, this procedure is not limited to the immediate acute postoperative period like standard MUA3. To our knowledge, no technique video has been published outlining arthroscopic lysis of adhesions for a stiff knee following total knee arthroplasty.

Expected Outcomes

This procedure has been shown to provide an immediate and lasting improvement in the flexion and extension arc of the knee, as well as improved functional outcomes. Patients should be educated that improvements gained in the operating room must be sustained through physical therapy. In a study of 32 patients who underwent arthroscopic lysis of adhesions for moderately severe arthrofibrosis following a total knee arthroplasty, Jerosch and Aldawoudy reported a mean postoperative flexion of 119° in the operating room and 97° at the time of the latest follow-up. Eight patients with extensor lag showed improvement from 27° to 4°. Average Knee Society scores improved from 70 points preoperatively to 86 points at the time of the latest follow-up4. Their article showed that arthroscopic treatment of stiffness following total knee arthroplasty is a safe and effective form of treatment.

Important Tips

Perform manual lysis of adhesions with a trocar prior to inserting the arthroscope in order to improve visualization and access.Utilize all portals and accessory portals interchangeably in order to improve access.Prescribe physical therapy with or without CPM machine immediately following surgery in order to maintain correction.Utilize pump inflow in order to help distend the tightened capsule.Protect the prosthetic surface from scratches during portal establishment.Loss of flexion implies scarring in the suprapatellar pouch and/or intercondylar notch, or PCL tightness.Loss of extension implies a tight posterior capsule, posterior osteophytes, or scarring of the PCL stump.A motorized shaver is the best tool for treatment of dense fibrous tissue, but be sure not to scratch metal total knee components.

Acronyms and Abbreviations

TKA = total knee arthroplastyROM = range of motionCT = computed tomographyMRI = magnetic resonance imagingESR = erythrocyte sedimentation rateCRP = C-reactive protein.

Arthrofibrosis is a common but poorly defined complication in multiligament knee injuries: a systematic review

PURPOSE

The purpose of this study is to systematically review multiligament knee injury (MLKI) outcome studies to determine definitions of arthrofibrosis (AF) and provide information about incidence, management as well as potential risk factors.

METHODS

A systematic literature search was performed (PubMed and Cochrane library) following the PRISMA guidelines of operatively treated MLKI (Schenck II-IV) studies reporting the incidence of AF. Twenty-five studies met the inclusion criteria. Injury pattern, timing of surgery, surgical technique, treatment of AF, rehabilitation programs and PROMS were inquired. Risk of bias and quality of evidence were assessed using the Coleman methodological score.

RESULTS

Twenty-five studies with a total of 709 patients with a mean age of 33.6 ± 4.8 years were included and followed 47.2 ± 32.0 months. The majority of studies (22/25) used imprecise and subjective definitions of AF. A total of 86 patients were treated for AF, resulting in an overall prevalence of 12.1% (range 2.8-57.1). Higher-grade injuries (Schenck III-IV), acute treatment and ROM (range of motion) limiting rehabilitation programs were potential risk factors for AF. The time from index surgery to manipulation anesthesia (MUA) and arthroscopic lysis of adhesions (LOA) averaged at 14.3 ± 8.8 and 27.7 ± 12.8 weeks. Prior to MUA and LOA, the ROM was 51.7° ± 23.5 and 80.2° ± 17.0, resulting in a total ROM gain after intervention of 65.0° ± 19.7 and 48.0° ± 10.6, respectively; with no reports of any complication within the follow-up. The overall methodological quality of the studies was poor as measured by the Coleman score with average 56.3 ± 12.5 (range 31-84) points.

CONCLUSIONS

AF is a common but poorly defined complication particularly in high-grade MLKI. Early postoperative and intensified physiotherapy is important to reduce the risk of AF. MUA and LOA are very effective treatment options and result in good clinical outcome. Prospective studies with bigger study population are needed to optimize treatment algorithms of further patients after MLKI. The protocol of this systematic review has been prospectively registered with PROSPERO (CRD42021229187, January 4th, 2021).

A physical therapist-led clinical decision-making program reduced risk of adverse events after total knee arthroplasty over 3 years: A retrospective review

CONTEXT

Reducing adverse events after total knee arthroplasty has implications for newly developed bundled payment models.

OBJECTIVE

To examine the impact of a physical therapist-led clinical decision-making program on the risk of adverse events, function, visits used, or reaching knee range of motion (ROM) goals in patients after total knee arthroplasty.

METHODS

The decision-making program consisted of quarterly meetings and recommendations for early risk identification and evidence-based intervention. A retrospective review of electronic records included adult patients who underwent total knee arthroplasty postoperative rehabilitation in an 18-month baseline period from 2014 to 2015 and an intervention period from 2015 to 2018. Relative risk reduction (RRR) determined whether a reduction in risk had occurred. Discharge function was measured with the Lower Extremity Functional Scale.

RESULTS

A total of 160 patients were included, 69 from the 18-month baseline period and 91 from the 36-month intervention period. Mean (SD) age was 68 (9.2) years in the baseline period and 72 (9.7) years in the intervention period. There was an 8.4% (95% CI, 1.1%-64.9%) RRR in adverse events. The RRR for patients not reaching full knee extension was 70.5% (95% CI, 33.4%-87.0%) and the RRR for patients not reaching 120° of knee flexion was 65.5% (95% CI, 5.4%-87.4%). There was significant improvement in the discharge function score (P = 0.05), but not the number of visits used (P = 0.29).

CONCLUSION

The physical therapist-led clinical decision-making program reduced the risk of adverse events after total knee arthroplasty. The risk of not reaching ROM goals by discharge was also substantially reduced.

Mid-term outcomes of posterior capsular release for fixed flexed deformity after total knee arthroplasty

Fixed flexion deformity also called flexion contracture is relatively rare, but a very demanding functional limitation that both surgeons and patients may have to deal with. The purpose of the present study was to evaluate the functional outcomes after posteromedial capsular release in case of fixed flexed deformity > 15 o . Between June 2011 and November 2018, 15 patients (6 males and 9 females) were treated with open posterior capsular release through medial approach for fixed flexion deformity of the knee > 15 o and prospectively followed with a minimum follow-up of 2 years. Primary outcome was knee extension measured with a manual goniometer and secondary outcome treatment related complications. All patients reported inability to walk and clinical semiology of pain and swelling. The mean age of the study population at surgery was 61.7 years with a mean BMI of 30.9 kg/m2. Complete data were recorded for all patients. Statistically significant improvement was found in clinical and functional assessment tools analyzed from baseline to the latest follow-up (p<0.05). More precisely, the mean postoperative fixed flexion deformity was decreased from 23.57 o to 2.86 o . No adverse effect or major complications were recorded during follow-up. Posterior open release via posteromedial was shown to be an efficient and safe salvage procedure to deal with persistent fixed flexion deformity of more than 15 o following TKA at two years follow-up. However, future studies with a higher number of participants and longer follow-up should be conducted to validate our data.

The Impact of Dupuytren Disease on Recovery of Motion at the Knee after Total Knee Arthroplasty

Background: Arthrofibrosis is a complication of total knee arthroplasty (TKA) that can lead to poor outcome. Idiopathic arthrofibrosis and Dupuytren disease (DD) have similar histological appearance. The aim of this study is to determine the influence of DD on the recovery of motion after TKAy. Methods: Patients older than 50 who underwent a TKA for primary osteoarthritis were examined 1 year later for the presence of DD. They were divided into two groups based on the presence or absence of DD. The groups were compared to each other with regard to arc of motion (AOM) of the operated knee at 6 weeks and 1 year; the need for additional measures to improve the AOM, and the effect of obesity [body mass index (BMI) > 30]. Results: The study included 61 patients of which 25 (41%) had DD. There was no difference in AOM at 6 weeks or 1 year between the two groups. Patients in the DD group required a greater number of additional measures to improve AOM. Also, non-obese patients (BMI < 30) in the DD group had lower AOM at 1 year. Conclusions: Patients in the DD group needed additional physiotherapy or manipulation under anaesthesia (MUA) to achieve the same AOM. This might indicate a possible connection between DD and post-operative stiffness of the knee. Identifying patients with DD in the pre-operative period may help recognise patients who may have difficulty in regaining AOM after TKA. Level of Evidence: Level III (Therapeutic).

Multimodal conservative management of arthrofibrosis after total knee arthroplasty compared to manipulation under anesthesia: a feasibility study with retrospective cohort comparison

Background

The ideal treatment of early-stage arthrofibrosis after total knee arthroplasty is unclear. The purpose of this study was to determine the treatment effect, including variability, and feasibility of a multimodal physical therapy program as compared to manipulation under anesthesia.

Methods

This was a prospective feasibility study with a retrospective cohort comparison. Ten consecutive patients (aged 64 ± 9 years, 7 females) with early-stage arthrofibrosis were enrolled 6 weeks after primary total knee arthroplasty and participated in the multimodal physical therapy program. The multimodal physical therapy program consisted of manual therapy, therapeutic exercise, and static progressive splinting delivered over 4 weeks. The outcomes included knee range of motion (ROM), adherence, patient satisfaction, and safety. Data were compared to a retrospective cohort of 31 patients with arthrofibrosis (aged 65 ± 9 years, 20 females) who underwent manipulation under anesthesia followed by physical therapy.

Results

Overall, knee ROM outcomes were similar between multimodal physical therapy (110° ± 14) and manipulation under anesthesia (109° ± 11). Seven out of ten patients achieved functional ROM (≥ 110°) and avoided manipulation under anesthesia with the multimodal physical therapy program. Three out of 10 multimodal physical therapy patients required manipulation under anesthesia secondary to failure to demonstrate progress within 4 weeks of the multimodal physical therapy program. Adherence to the multimodal physical therapy program was 87 ± 9%. The median patient satisfaction with the multimodal physical therapy program was “very satisfied.” Safety concerns were minimal.

Conclusion

The use of the multimodal physical therapy program is feasible for treating early-stage arthrofibrosis after total knee arthroplasty, with 70% of patients avoiding manipulation under anesthesia. Randomized controlled trials are needed to determine the efficacy of the multimodal physical therapy program and to determine the optimal patient selection for the multimodal physical therapy program versus manipulation under anesthesia.

Trial registration

ClinicalTrials.gov, NCT04837872.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01026-y.

Intra-articular celecoxib improves knee extension regardless of surgical release in a rabbit model of arthrofibrosis

Aims

Outcomes of current operative treatments for arthrofibrosis after total knee arthroplasty (TKA) are not consistently positive or predictable. Pharmacological in vivo studies have focused mostly on prevention of arthrofibrosis. This study used a rabbit model to evaluate intra-articular (IA) effects of celecoxib in treating contracted knees alone, or in combination with capsular release.

Methods

A total of 24 rabbits underwent contracture-forming surgery with knee immobilization followed by remobilization surgery at eight weeks. At remobilization, one cohort underwent capsular release (n = 12), while the other cohort did not (n = 12). Both groups were divided into two subcohorts (n = 6 each) – one receiving IA injections of celecoxib, and the other receiving injections of vehicle solution (injections every day for two weeks after remobilization). Passive extension angle (PEA) was assessed in live rabbits at 10, 16, and 24 weeks, and disarticulated limbs were analyzed for capsular stiffness at 24 weeks.

Results

IA celecoxib resulted in greater mean PEA at ten weeks (69.6° (SD 4.6) vs 45.2° (SD 9.6), p = 0.004), 16 weeks (109.8° (SD 24.2) vs 60.9° (SD10.9), p = 0.004), and 24 weeks (101.0° (SD 8.0) vs 66.3° (SD 5.8), p = 0.004). Capsular stiffness was significantly reduced with IA celecoxib (2.72 Newton per cm (N·cm)/° (SD 1.04), p = 0.008), capsular release (2.41 N·cm/° (SD 0.80), p = 0.008), and capsular release combined with IA celecoxib (3.56 N·cm/° (SD 0.99), p = 0.018) relative to IA vehicle (6.09 N·cm/° (SD 1.64)).

Conclusion

IA injections of a celecoxib led to significant improvements in passive extension angles, with reduced capsular stiffness, when administered to rabbit knees with established experimental contracture. Celecoxib was superior to surgical release, and the combination of celecoxib and a surgical release did not provide any additional value.

Cite this article: Bone Joint Res 2022;11(1):32–39.

Stiffness After Total Knee Arthroplasty: Prevalence and Treatment Outcome

Introduction

Stiffness following total knee arthroplasty (TKA) is an incapacitating complication. The prevalence and causes leading to stiffness are not clearly determined. The aim of the study was to ascertain the prevalence, determine the influencing factors, and evaluate the efficacy of manipulation under anaesthesia (MUA) as a treatment option.

Method

Retrospective review of consecutive series of 1350 primary TKA over a 28-month period. For the purpose of the study, stiffness was defined as flexion contracture of >15 degrees and/or flexion of <75 degrees. Demographic data included co-morbidities, previous knee surgery, pre-operative and post-operative range of movement, anaesthetic techniques and use of nerve blocks, type of prosthesis, ligament balancing including release, mobility post-surgery, patient motivation, physiotherapy, complications, and final range of motion post-MUA.

Results

Of the 1350 patients evaluated, 33 (2.44%) had stiffness defined by the above-outlined criteria and required intervention. Thirty-one patients (2.29%) underwent MUA as a first-line treatment. No complications arose following MUA. One patient (0.07%) required arthroscopic arthrolysis while another patient (0.07%) required revision arthroplasty due to patellar mal-tracking. Following manipulation, mean flexion contracture decreased from 8 degrees to 3.6 degrees, and mean flexion improved from 51.8 degrees to 93.2 degrees. Arc of motion improved in 100% of patients but it is important to note that multiple manipulations were performed in seven patients.

Conclusion

Stiffness after TKA can be difficult to treat and can result in prolonged morbidity and dissatisfaction. This retrospective study highlights the effectiveness of manipulation under anaesthesia as a first-line treatment option leading to improved outcomes especially if done early.

Efficacy of Arthroscopic Arthrolysis in the Treatment of Arthrofibrosis: A Systematic Review

Stiffness after total knee arthroplasty (TKA) remains a clinical challenge for health care professionals. Historically, arthroscopic arthrolysis is a treatment modality that has been reserved for patients that have failed other conservative modalities, including manipulation under anesthesia. However, a systematic review of the literature evaluating the clinical efficacy and complications of arthroscopic arthrolysis for stiffness after TKA has not been performed. A systematic review of medical databases (PubMed, EMBASE, Cochrane Library) was undertaken for articles published from January 1980 to October 2018. A descriptive and critical analysis of the results was performed. From 1,326 studies, 7 studies met the inclusion criteria for this study. A total of 160 patients who underwent arthroscopic arthrolysis for arthrofibrosis following TKA were included for analysis. The quality of the evidence for the included studies ranged between moderate and high. Overall, patients had significant increased range of motion and flexion by 32.5 and 26.7 degrees, respectively following arthroscopic arthrolysis. Functional outcome scores also significantly improved for patients who underwent arthroscopic arthrolysis after TKA. Arthroscopic arthrolysis is an efficacious modality for treatment of stiffness following TKA. The greatest benefit is seen among patients that present with significant loss of flexion. Arthroscopic arthrolysis should be reserved for patients that have previously failed more conservative modalities.

Acquired Idiopathic Stiffness After Contemporary Total Knee Arthroplasty: Incidence, Risk Factors, and Results Over 25 Years

BACKGROUND

Acquired idiopathic stiffness (AIS) remains a common failure mode of contemporary total knee arthroplasties (TKAs). The present study investigated the incidence of AIS and manipulation under anesthesia (MUA) at a single institution over time, determined outcomes of MUAs, and identified risk factors associated with AIS and MUA.

METHODS

We identified 9771 patients (12,735 knees) who underwent primary TKAs with cemented, modular metal-backed, posterior-stabilized implants from 2000 to 2016 using our institutional total joint registry. Mean age was 68 years, 57% were female, and mean body mass index was 33 kg/m². Demographic, surgical, and comorbidity data were investigated via univariate Cox proportional hazard models and fit to an adjusted multivariate model to access risk for AIS and MUA. Mean follow-up was 7 years.

RESULTS

During the study period, 456 knees (3.6%) developed AIS and 336 knees (2.6%) underwent MUA. Range of motion (ROM) increased a mean of 34° after the MUA; however, ROM for patients treated with MUA was inferior to patients without AIS at final follow-up (102° vs 116°, P < .0001). Significant risk factors included younger age (HR 2.3, P < .001), increased tourniquet time (HR 1.01, P < .001), general anesthesia (HR 1.3, P = .007), and diabetes (HR 1.5, P = .001).

CONCLUSION

Acquired idiopathic stiffness has continued to have an important adverse impact on the outcomes of a subset of patients undergoing primary TKAs. When utilized, MUA improved mean ROM by 34°, but patients treated with MUA still had decreased ROM compared to patients without AIS. Importantly, we identified several significant risk factors associated with AIS and subsequent MUA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Sustained Delivery of SB-431542, a Type I Transforming Growth Factor Beta-1 Receptor Inhibitor, to Prevent Arthrofibrosis

Fibrosis of the knee is a common disorder resulting from an aberrant wound healing response and is characterized by extracellular matrix deposition, joint contraction, and scar tissue formation. The principal regulator of the fibrotic cascade is transforming growth factor beta-1 (TGF-β1), a factor that induces rapid proliferation and differentiation of resident fibroblasts. In this study, we demonstrate successful inhibition of TGF-β1-driven myofibroblastic differentiation in human fibroblast-like synoviocytes using a small molecule TGF-β1 receptor inhibitor, SB-431542. We also demonstrate successful encapsulation of SB-431542 in poly(D,L-lactide-co-glycolide) (PLGA) as a potential prophylactic treatment for arthrofibrosis and characterize drug release and bioactivity in a three-dimensional collagen gel contraction assay. We assessed the effects of TGF-β1 and SB-431542 on cell proliferation and viability in monolayer cultures. Opposing dose-dependent trends were observed in cell proliferation, which increased in TGF-β1-treated cultures and decreased in SB-431542-treated cultures relative to control (p < 0.05). SB-431542 was not cytotoxic at the concentrations studied (0-50 μM) and inhibited TGF-β1-induced collagen gel contraction in a dose-dependent manner. Specifically, TGF-β1-treated gels contracted to 18% ± 1% of their initial surface area, while gels treated with TGF-β1 and ≥10 μM SB-431542 showed no evidence of contraction (p < 0.0001). Upon removal of the compound, all gels contracted to control levels after 44 h in culture, necessitating sustained delivery for prolonged inhibition. To this end, SB-431542 was encapsulated in PLGA microspheres (SBMS) that had an average diameter of 87.5 ± 24 μm and a loading capacity of 4.3 μg SB-431542 per milligram of SBMS. Functional assessment of SBMS revealed sustained inhibition of TGF-β1-induced gel contraction as well as hallmark features of myofibroblastic differentiation, including α-smooth muscle actin expression and connective tissue growth factor production. These results suggest that SB-431542 may be used to counter TGF-β1-driven events in the fibrotic cascade in the knee cartilage.

The Impact of Room-Sharing on Length of Stay After Total Hip or Knee Arthroplasty: A Retrospective Study

Background

Prolonged length of stay (LOS) after elective total hip (THA) and knee (TKA) arthroplasty is often associated with worse patient outcomes. Social support through room-sharing has been identified as a factor that may reduce LOS in a hospital setting, but has not yet been examined in an orthopedic population. The aim of this study was to evaluate the effect of single- vs shared-room accommodation after elective TKA or THA on hospital LOS.

Method

A retrospective study was conducted using data from hospital medical records at our institution. Patients receiving unilateral, elective THA or TKA over a 2-year period were eligible. Patients were allocated to either a single room or four-bed shared room. The primary outcome was LOS; secondary outcomes included complications, discharge destination, and return to operating theater.

Results

One hundred eighty-five patients (70 THA, 115 TKA; mean age 65.74 ± 10.38, 59% female) were included, of whom 82 were allocated to a single room and 103 to a shared room. There was no statistically significant difference in LOS between the 2 groups (5.18 ± 2.21 days [single] vs 4.88 ± 2.12 days [shared]; mean difference −0.29 [95% CI −0.92-0.33], P = .36). Analysis modeling for multiple confounders found no association among room allocation, LOS, and discharge destination. However, more patients in single rooms required discharge to rehabilitation (27% vs 9%) and return to theater (7% vs 1%).

Conclusions

Room allocation did not correlate with a difference in LOS in patients undergoing elective THA or TKA.

Flexion contracture is a risk factor for knee osteoarthritis incidence, progression and earlier arthroplasty: Data from the Osteoarthritis Initiative

BACKGROUND

Knee joint osteoarthritis (OA) is often accompanied by flexion contracture (FC), but the impact of FC on important outcomes across the spectrum of OA, such as the incidence, progression and need for total knee arthroplasty (TKA), is not well established.

OBJECTIVE

We evaluated whether the presence and/or severity of knee FC were risk factors for worse OA clinical outcomes, radiographic incidence and progression as well as time to TKA.

METHODS

We evaluated longitudinal 9-year data from the Osteoarthritis Initiative (OAI) database for 3 sub-cohorts: at-risk of knee OA (n=3284), radiographically established knee OA (n=1390), and low-risk controls (n=122). We classified knee FC as none, mild, moderate or severe based on knee extension at enrolment. Knee OA outcomes were extracted from the database.

RESULTS

FC was present in 32.4% of knees. Participants with FC had increased knee OA incidence with joint space narrowing in the definition (corrected odds ratio 1.31 [95% confidence interval (CI) 1.04-1.64]). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for pain, stiffness and function were worse with than without FC at nearly all times (p<0.001). Effect estimates were significant for all 3 WOMAC sub-scales comparing FC to no FC (pain: 0.15 [95% CI 0.02-0.28], stiffness: 0.11 [0.05-0.18], function: 0.49 [0.05-0.93]). Individuals with knee FC had higher Kellgren and Lawrence grade (effect size 0.31 [95% CI 0.25-0.37]) and were more likely to undergo TKA (corrected odds ratio 1.37 [95% CI 1.10-1.71]) than those without FC. All outcomes were worse with increasing FC severity.

CONCLUSION

The presence of knee FC at enrolment was a risk factor for radiographic OA incidence including joint space narrowing, worse clinical outcomes, radiographic progression and the need for early TKA. Treatment of knee FC may represent an option across the OA spectrum. Further research is needed to evaluate the pathophysiology, joint structure alterations and longitudinal impact of treating FC in individuals with knee OA.

Patients with Dupuytren's Contracture, Ledderhose Disease, and Peyronie's Disease are at higher risk of arthrofibrosis following total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a successful treatment for patients with late stage osteoarthritis, yet arthrofibrosis remains a consistent cause of TKA failure. Dupuytren's, Ledderhose and Peyronie's Diseases are related conditions of increased fibroblast proliferation. The aim of this study was to identify whether an association exists between these conditions and arthrofibrosis following TKA.

METHODS

Patient records were queried from 2010 to 2016 using an administrative claims database to compare the rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with independent chart diagnoses of Dupuytren's Contracture, Ledderhose, or Peyronie's Diseases versus those without. Complications were queried and compared using multivariate logistic regression.

RESULTS

Patients with Dupuytren's (n = 5,232) and Ledderhose (n = 50,716) had a significantly higher rate of ankylosis following TKA: 30-days (OR, 1.54; OR, 1.23), 90-days (OR, 1.20; OR, 1.24), 6-months (OR, 1.23; OR, 1.23), and 1-year (OR, 1.28; OR, 1.23), while patients with Peyronie's (n = 1,186) had a higher rate of diagnosis at 6-months (OR, 1.37) and 1-year (OR, 1.35). Patients with diagnoses of any of the fibroproliferative diseases had a statistically higher risk of MUA at 90-days, 6-month, and 1-year following primary TKA. These cohorts did not have a significantly higher rate of revision TKA.

CONCLUSION

There is an increased odds risk of arthrofibrosis and MUA in patients who have undergone TKA and have a diagnosis of Dupuytren's Contracture, Ledderhose, or Peyronie's Diseases. Improvements to frequency and application of post-operative treatment should be considered in these cohorts to improve outcomes.

Medical stretching devices are effective in the treatment of knee arthrofibrosis: A systematic review

AIMS

This systematic review examines the available evidence on the use of medical stretching devices to treat knee arthrofibrosis, it suggests a focus for future studies addressing limitations in current research and identifies gaps in the published literature to facilitate future works.

MATERIALS AND METHODS

Articles were identified using the Cochrane Library, MEDLINE, PubMed and SCOPUS databases. Articles from peer reviewed journals investigating the effectiveness of medical stretching devices to increase range of movement when treating arthrofibrosis of the knee were included.

RESULTS

A total of 13 studies (558 participants) met the inclusion criteria with the devices falling into the following categories; CPM, load control or displacement control stretching devices. A statistically significant increase in range of movement was demonstrated in CPM, load-control and displacement-control studies (p ​< ​0.001). The results show that the stretch doses applied using the CPM, load-control devices were performed over a considerably longer treatment time and involved significantly more additional physiotherapy compared to the displacement-control and patient actuated serial stretching devices.

CONCLUSION

The systematic review indicates that load-control and displacement-control devices are effective in increasing range of movement in the treatment of knee arthrofibrosis. Displacement-control devices involving patient actuated serial stretching techniques, may be more effective in increasing knee flexion than those utilising static progressive stretch.The paucity of research in this field indicates that more randomised controlled trials are required to investigate the superiority of the different types of displacement-control stretching devices and which of these would be most effective for use in clinical practice and to compare these with standard physiotherapy treatment.

Arthrofibrosis after total knee arthroplasty: patients with keloids at risk

BACKGROUND

Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without.

METHODS

Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant.

RESULTS

Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9).

CONCLUSION

Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT

BACKGROUND

Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes.

OBJECTIVES

To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty.

DESIGN

An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study.

SETTING

The trial took place in 14 NHS physiotherapy departments.

PARTICIPANTS

People identified as being at high risk of a poor outcome after knee arthroplasty.

INTERVENTIONS

A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries.

RESULTS

In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold.

LIMITATIONS

The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded.

CONCLUSIONS

This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13517704.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

The role of knee arthroscopy in managing common soft tissue complications after total knee arthroplasty: a retrospective case series study

BACKGROUND

To investigate the feasibility, safety and therapeutic efficacy of arthroscopy in managing the 3 most common soft tissue complications, peripatellar impingement (PI), arthrofibrosis (AF) and generalized synovitis (GS), after total knee arthroplasty (TKA).

METHODS

A retrospective review of patients undertaking arthroscopy for PI, AF and GS was conducted. Outcome measures included complications, postoperative range of motion (ROM), Knee Society Score (KSS) and rates of symptom recurrence, prosthesis revision. Intraoperative findings and surgical procedures were also recorded. Paired t test, Fisher's exact test, Kruskal-Wallis test and post hoc analysis with Bonferroni correction were used for statistical evaluation.

RESULTS

A total of 74 patients, including 35 patients with peripatellar impingement, 25 patients with arthrofibrosis and 14 patients with generalized synovitis, with a mean age of 66.1 ± 7.9 years, were analysed. The mean follow-up (FU) duration was 81.3 ± 40.6 months. All patients underwent arthroscopic surgery safely without intraoperative complications. However, there were 4 postoperative complications, including 1 acute myocardial infarction and 3 periprosthetic joint infections. Overall, patients acquired improvements in ROM from 81.7 ± 23.1° to 96.8 ± 20.5° (p < 0.05), in KSS knee score from 64.2 ± 9.6 to 78.7 ± 12.1 (p < 0.05) and in KSS function score from 61.1 ± 7.4 to 77.3 ± 12.2 (p < 0.05) postoperatively. Patients in all 3 groups had improvements in ROM (p < 0.05), KSS knee score (p < 0.05) and KSS function score (p < 0.05). The overall recurrence rate was 22.9% (95% confidence interval (CI) 15.1-34.9%), and the overall revision rate was 14.9% (95% CI 8.6-25.6%). There were significant differences in both the symptom recurrence and prosthesis revision rates among the groups (p < 0.05). The PI group had a significantly lower symptom recurrence rate (11.4%, 95% CI 4.5-28.7%) and revision rate (8.6%, 95% CI 2.9-25.3%) (p < 0.017), while the GS group had a significantly higher recurrence rate (42.9%, 95% CI 23.4-78.5%) and revision rate (35.7%, 95% CI 17.6-72.1%) (p < 0.017).

CONCLUSIONS

In the setting of symptomatic TKA, although carrying certain risks for PJI and other complications, arthroscopic intervention could be feasible and provide clinical improvement in most cases at an average of 81.3 months follow-up. Patients with PI had the best outcomes, while patients with GS had the worst outcomes.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Lysis of Adhesions With Manipulation for Management of Late-Presenting Stiffness After Total Knee Arthroplasty

Background

Arthrofibrosis is a known complication of total knee arthroplasty (TKA). Closed manipulation is the treatment of choice for arthrofibrosis within 90 days of TKA. Treatment for arthrofibrosis that has failed prior interventions remains controversial, and the role for arthroscopic lysis of adhesions has not been examined for late-presenting arthrofibrosis.

Methods

A retrospective analysis of patients who underwent arthroscopic lysis of adhesions (LOAs) with manipulation for post-TKA arthrofibrosis was performed. Chart review included patient characteristics, time from TKA, prior interventions, and range of motion (ROM) data. Knee extension, flexion, and total ROM were recorded preoperatively, intraoperatively, and throughout follow-up. Knee ROM was compared at the different time intervals using Wilcoxon signed-rank tests.

Results

A total of 13 patients (6 male and 7 female) with a mean age of 66.3 years were included. Average time since index TKA was 57.2 months (3.7-209.5). Ten of 13 patients had undergone prior interventions for arthrofibrosis, which included closed manipulation under anesthesia, open LOA, and revision arthroplasty. The mean preoperative knee flexion and extension values for the cohort were 76.5 ± 17.4 and −4.6 ± 6.1 degrees, respectively. Postoperative improvements in knee ROM were significant at all time points, with mean improvements of 17.2 ± 16.3 degrees at 1 week (P = .022), 17.2 ± 13.2 degrees at 4 weeks (P = .001), 19.2 ± 16.0 degrees at 8 weeks (P = .004), and 25.2 ± 13.1 degrees at 12 weeks (P = .005). No complications were recorded.

Conclusions

Arthroscopic LOAs with manipulation achieves significant improvements in knee ROM for late-presenting arthrofibrosis after TKA.

Manipulation under Anesthesia for Stiffness of the Knee Joint after Total Knee Replacement

Background

Stiffness of the knee joint is a feared complication after total knee replacement (TKR). An initial noninvasive treatment option is the manipulation of the knee under anesthesia (MUA). The purpose of this study is to evaluate the midterm result of the MUA for joint stiffness after primary TKR.

Methods

Patients treated with the MUA for knee stiffness after primary TKR surgery performed at Akershus University Hospital during 2014-2018 were invited to a follow-up clinic. The range of motion (ROM) of the knee joint was measured using a goniometer, and the patients reported the Lysholm score, Knee injury and Osteoarthritis Outcome Score, and Tegner score. In addition, any complications or reoperation after the MUA was noted.

Results

A total of 24 patients were identified in the journal system at the hospital. Twenty-three of these (17 women and 6 men) attended the designated follow-up on average 26 months (range [r], 16-35) after the MUA. The total ROM was 97° (r, 84°-116°) at the time of follow-up, compared with 70° (r, 50°-80°) before the MUA (P < .001, the Mann-Whitney U-test). A regression analysis indicated that the ROM at follow-up was predicted by the time from the index TKR surgery to the MUA, with the early MUA improving results (P = .02). The median Lysholm score was 57.1 (r, 17.9-92.9).

Conclusions

There is a clinically and statistically significant increase of the total ROM of the knee joint after the MUA for knee stiffness after TKR. The earlier MUA yields a better total ROM. Despite improvement in the ROM, the patients did not achieve normal function of the knee joint.

Intraoperative manipulation for flexion contracture during total knee arthroplasty

BACKGROUND

Joint gap unbalancing during total knee arthroplasty (TKA) induces flexion contracture. Flexion contracture is one of the most serious complications of TKA. When flexion contracture is found during surgery, intraoperative manipulation is often empirically performed. We evaluated the effects of intraoperative manipulation on joint gap and postoperative flexion contracture.

MATERIALS AND METHODS

TKA was performed for 136 knees. Intraoperative manipulation was performed for flexion contracture in 61 knees. Joint gap changes before and after manipulation were measured at six positions from extension to 120° of flexion. Manipulation was not performed for 75 knees. The extension angle was measured radiographically immediately after surgery, at 3 months, and 6 months postoperatively. Extension angles with manipulation and without manipulation were compared.

RESULTS

Joint gap changes (mm) before and after manipulation were 0.1, 0.0, -0.2, -0.3, -0.1, and -0.3 at 0°, 30°, 45°, 60°, 90°, and 120° of flexion, respectively, indicating that manipulation could not change joint gaps significantly. Extension angles (°) with and without manipulation were -4.0 ± 4.6 and -3.8 ± 3.9 immediately after surgery, -5.3 ± 6.7 and -5.5 ± 6.2 at 3 months postoperatively, and -2.7 ± 6.0 and -3.8 ± 5.8 at 6 months postoperatively. No statistically significant difference existed between the values with or without manipulation during all periods.

CONCLUSION

Intraoperative manipulation does not enlarge the gap or resolve postoperative flexion contracture. Developing the new surgical technique is required to achieve perfect balance at TKA.

Static progressive stretch orthosis-consensus modality to treat knee stiffness-rationale and literature review

The current literature supports static progressive stretch (SPS) orthoses as the consensus modality to treat joint stiffness as an adjunct to manual therapy. Over 50 published studies prove the efficacy and safety of this modality as an adjunct to therapy to improve range of motion (ROM) as well as decrease stiffness and pain. Data from a large prospective study on SPS effectiveness identified a 90% improvement in ROM, 84% reduction in stiffness and swelling, 70% reduction in pain, and no reports of complications or injury. Another 13 studies evaluating patients with knee stiffness have shown excellent results with SPS, and a reduced need for manipulation under anesthesia or additional surgeries. The bidirectional SPS device allows for ROM therapy in both flexion and extension, uses short, 5-minute incremental stretches for up to a 30-minute session applied 1 to 3 times per day for 8 weeks, though treatment might be needed for longer durations (8 to 12 weeks) in cases with chronic stiffness/contracture, to improve motion and significantly reduces need for manipulation or surgery for treatment of knee fibrosis. Earlier application of SPS therapy, even immediately postoperative following corrective surgery for motion loss, can greatly improve the results for patients who have limitations in knee motion.

Efficacy of manipulation under anesthesia beyond three months following total knee arthroplasty

Background

Stiffness after total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA) to improve range of motion (ROM). However, many authors recommend against MUA beyond 3 months after TKA. This study investigates the timing of MUA for stiffness after TKA, focusing on MUA performed at >12 weeks.

Methods

In total, 142 MUAs were retrospectively reviewed. “Early” MUAs were at <12 weeks after TKA; “Late” MUAs were >12 weeks. MUAs were further subdivided into 4 groups: 83 “Group I” cases at <12 weeks, 34 “Group II” between 12 and 26 weeks, 12 “Group III” between 26 and 52 weeks, and 13 “Group IV” at >52 weeks. Gains in ROM were compared between groups.

Results

Gains in flexion and overall ROM were statistically equivalent in Early vs Late MUA when controlling for pre-MUA ROM. ROM gains between the early Group I and the later Groups II-IV were also statistically comparable. Overall ROM gain in Group I was 24.1°, 17.9° in Group II, 20.8° in Group III, and 11.1° in Group IV. There were no significant complications.

Conclusions

Early and late MUA resulted in statistically equivalent gains in ROM, regardless of timing after TKA. All groups showed an average improvement in ROM of ≥11°. MUA performed beyond 3 months, and even beyond 1 year, appears to be safe and may improve ROM and allow select patients to avoid revision surgery.

The stiff total knee arthroplasty: causes, treatment modalities and results

It is clear that the stiff total knee arthroplasty (TKA) is a multifactorial entity associated with preoperative, intraoperative and postoperative factors.

Management of the stiff TKA is best achieved by preventing its occurrence using strategies to control preoperative factors, avoid intraoperative technical errors and perform aggressive, painless postoperative physical medicine and rehabilitation; adequate pain control is paramount in non-invasive management.

Careful attention to surgical exposure, restoring gap balance, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, pain control and adequate physical medicine and rehabilitation (physiotherapy, Astym therapy) all serve to reduce its incidence.

For established stiff TKA, there are multiple treatment options available including mobilization under anaesthesia (MUA), arthroscopic arthrolysis, revision TKA, and combined procedures.

Cite this article: EFORT Open Rev 2019;4:602-610. DOI: 10.1302/2058-5241.4.180105

Younger age is associated with increased odds of manipulation under anesthesia for joint stiffness after total knee arthroplasty

INTRODUCTION

Limited range of motion (ROM) after total knee replacement (TKR) is associated with low function and might require manipulation under anaesthesia (MUA). In order to identify factors associated with a limited ROM we investigated predictors for MUA. We hypothesized that older age was associated with higher MUA due to limited ROM post TKR.

METHODS

In a case control study we investigated all patients undergoing primary TKR at a University Hospital in Sweden between 2007-2012. We registered background factors and compared those between the group who underwent MUA and those who did not. Odds ratios (OR) were calculated in a univariate analysis and an adjusted regression analysis.

RESULTS

Of the total of 669 TKRs performed, 31 patients who had undergone MUA were identified. The prevalence of MUA was 4.6%. The mean increase in ROM after MUA was 27 degrees at final minimum one-year follow-up. After controlling for confounders, patients with good health and young age had increased OR for MUA. OR decreased 0.93 (CI 0.93-0.97) per increased age year in the multiple regression analysis. Diabetes mellitus, BMI and sex did not have a significant effect on the odds ratio for MUA.

DISCUSSION

Young patients undergoing TKR has earlier been identified as a group with a higher grade of dissatisfaction and complications. We found an association between young age and MUA after TKR indicating an additional, rather unknown complication for this group of patients. The background and reasons for this has to be further investigated.

LEVEL OF EVIDENCE

II, cohort study/case control study (case control is level III).

Manipulation under anaesthetic following total knee arthroplasty: Predicting stiffness and outcome

PURPOSE

A stiff total knee replacement can severely limit a patient's post-operative function, but there remain few prospective trials identifying those patients at risk, nor the efficacy of manipulation. We analysed our prospectively collected database to assess predictors of stiffness and outcomes following manipulation.

METHODS

Using prospectively collected knee arthroplasty data, including preoperative and post-operative range of knee movement, SF-12 (physical and mental) and The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, patients requiring manipulation were compared to a matched group of patients not requiring manipulation, with a detailed statistical analysis undertaken to assess potential risk factors and the post-manipulation outcome.

RESULTS

Of the 1313 arthroplasty patients, 69 required manipulation. Patients with less than 80° of flexion at discharge, diabetes or on warfarin were more likely to require manipulation, but flexion at discharge was the overwhelming predictive factor for stiffness. Forty per cent of the range of movement gained during manipulation was maintained at 1 year, with earlier manipulation deriving greater improvements. While the WOMAC scores improved post-manipulation, there was no significant difference in either of the SF12 scores.

CONCLUSION

Flexion at discharge is the overwhelming predictive factor for the requirement for manipulation.

Manipulation Under Anesthesia With Lysis of Adhesions Is Effective in Arthrofibrosis After Sulcus-Deepening Trochleoplasty: A Prospective Study

Background

Sulcus-deepening trochleoplasty has been established as an effective treatment for patellar instability due to trochlear dysplasia. However, arthrofibrosis is a known complication following trochleoplasty, which may require manipulation under anesthesia (MUA) with or without lysis of adhesions (LOA) to increase the knee range of motion (ROM), especially flexion.

Purpose

To prospectively follow patients for ROM improvements and subsequent complications after undergoing MUA with or without LOA in the setting of sulcus-deepening trochleoplasty.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 76 knees with severe trochlear dysplasia were prospectively enrolled and underwent sulcus-deepening trochleoplasty, with a mean (±SD) follow-up of 32.5 ± 19.3 months. Concomitant procedures included medial patellofemoral ligament reconstruction, lateral retinacular release, and tibial tubercle osteotomy. Physical examination including ROM and findings of recurrent patellar instability were collected for all patients. Arthrofibrosis was defined as active and passive flexion less than 90° within 3 months of surgery combined with a plateau in progress with physical therapy. Paired-samples and independent-samples t tests were used. A P value less than .05 was considered significant.

Results

A total of 62 knees met inclusion and exclusion criteria and were included in the study. Of these patients, 11 experienced arthrofibrosis as a complication and underwent MUA within 3 months of their index procedure. Of these 11 patients, 9 subsequently underwent arthroscopic LOA following MUA because acceptable ROM could not be achieved with manipulation alone. Patients with arthrofibrosis had a premanipulation mean ROM that was significantly different from those without arthrofibrosis (77.3° ±18.6° vs 133.3° ± 12.7°, respectively; P < .001). In the arthrofibrotic group, postoperative ROM increased significantly after MUA and/or LOA compared with the preoperative ROM (127.3° ± 12.5° vs 77.3° ± 18.6°, respectively; P < .001). ROM in the arthrofibrotic group after MUA/LOA was not significantly different from that in the nonarthrofibrotic group (flexion, 127.3° ± 12.5° vs 133.3° ± 12.7°, respectively; P = .156). No complications from the MUA or LOA were reported at subsequent follow-up visits.

Conclusion

When indicated in the setting of severe trochlear dysplasia, sulcus-deepening trochleoplasty is a treatment for disabling recurrent patellar instability with a known complication of arthrofibrosis. Initiation of postoperative physical therapy within 3 days of surgery may reduce the incidence of arthrofibrosis. If arthrofibrosis is encountered after a sulcus-deepening trochleoplasty, MUA without LOA is not as effective as when following other procedures of the knee, whereas MUA with LOA is an effective procedure likely to result in ROM and patient outcome scores similar to those of a nonarthrofibrotic knee after the same procedure. Both MUA and LOA appear to be safe based on the limited number of patients in this study without complication.

Rotating-Hinge Revision Total Knee Arthroplasty for Treatment of Severe Arthrofibrosis

BACKGROUND

Revision total knee arthroplasty (TKA) for arthrofibrosis is fraught with challenges. Because rotating-hinge (RH) prostheses do not rely on ligaments for stability, a more aggressive soft-tissue release is possible. The goal of this study was to report arc of motion, Knee Society scores, and implant survivorship in patients with arthrofibrosis revised with an RH.

METHODS

Thirty-four patients revised with an RH for arthrofibrosis were matched to 68 patients revised without an RH. The mean age was 63 years, 62% were female, mean body mass index was 31 kg/m², and mean follow-up was 6 years (range, 2-15 years).

RESULTS

The mean arc of motion increased 20° (74°-94°) in the RH group versus 12° (87°-99°) in the non-RH group (P = .048). Two manipulations under anesthesia were performed in the RH group compared to 9 in the non-RH group (P = .2). Knee Society scores increased significantly in both groups (P = .01 and P < .001, respectively). Survivorship free of revision for aseptic loosening at 10 years was 83% in the RH group versus 96% in the non-RH group (P = .44). Survivorship free of any revision at 10 years was 54% in the RH group and 90% in the non-RH group (P = .03). Forty percent of the revisions in the RH group were related to insert and bushing exchanges.

CONCLUSION

In this series, patients with arthrofibrosis revised to an RH TKA had a 20° improvement in arc of motion and manipulations under anesthesia were half as common. However, there was a higher risk of re-revision in the RH group.

LEVEL OF EVIDENCE

III.

Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management

Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.

Development of a functional rehabilitation intervention for post knee arthroplasty patients: COmmunity based Rehabilitation post Knee Arthroplasty (CORKA) trial

Knee osteoarthritis is a common cause of disability in older people and knee arthroplasty surgery in the UK is increasing. The CORKA trial is a randomised controlled trial of rehabilitation targeted at patients identified as being at risk of a poor outcome after knee arthroplasty. This paper describes the development and delivery of the CORKA intervention. It was informed by current evidence, relevant guidelines, expert and patient opinion, practical considerations and a pilot study. The intervention is a multicomponent rehabilitation programme with the main component being an exercise programme delivered to participants in their own home. It includes functional task practice, strategies to improve adherence and where appropriate the provision of appropriate aids and equipment.

Arthroscopic Lysis of Adhesions With Manipulation Under Anesthesia Versus Manipulation Alone in the Treatment of Arthrofibrosis After TKA: A Matched Cohort Study

Arthrofibrosis following total knee arthroplasty (TKA) is a debilitating complication. Treatment options include physical therapy, manipulation under anesthesia (MUA), and arthroscopic lysis of adhesions (ALOA) with or without MUA. The authors studied 70 patients with arthrofibrosis after TKA treated with MUA or ALOA plus MUA. In this matched cohort study, 35 patients were treated with MUA and 35 patients were treated with ALOA plus MUA. Total knee arthroplasty followed by MUA was performed by 2 surgeons and TKA followed by MUA plus ALOA was performed by 1 surgeon at 1 institution. Electronic records were used to collect information and match cohorts based on age, sex, body mass index, diabetes mellitus, perioperative range of motion (ROM), and timing of the procedure for arthrofibrosis. The combination of MUA and ALOA yielded changes in ROM: a 72.7% increase 4 to 12 weeks after index TKA (P=.032), a 50.0% increase 12+ weeks after TKA (P=.032), and a 99.8% increase in patients with a pre-manipulation ROM of 0° to 60° (P=.001). Manipulation under anesthesia yielded a 49.2% increase 4 to 12 weeks after TKA (P=.161), a 27.0% increase 12+ weeks after TKA (P=.161), and a 68.8% increase in patients with pre-manipulation ROM of 0° to 60° (P=.084). Patients treated with ALOA plus MUA had greater increases in ROM (P=.026) and final knee flexion (P=.028) compared with those treated with MUA alone. Arthrofibrosis following TKA is a complication that often requires additional procedures. Traditionally, ALOA is added 3+ months from index TKA, when abundant scar formation has occurred. This study found a benefit to ALOA plus MUA compared with MUA alone, with the largest benefit in patients whose pre-manipulation ROM was 0° to 60°. [Orthopedics. 2019; 42(3):163-167.].

Pathological mechanisms and therapeutic outlooks for arthrofibrosis

Arthrofibrosis is a fibrotic joint disorder that begins with an inflammatory reaction to insults such as injury, surgery and infection. Excessive extracellular matrix and adhesions contract pouches, bursae and tendons, cause pain and prevent a normal range of joint motion, with devastating consequences for patient quality of life. Arthrofibrosis affects people of all ages, with published rates varying. The risk factors and best management strategies are largely unknown due to a poor understanding of the pathology and lack of diagnostic biomarkers. However, current research into the pathogenesis of fibrosis in organs now informs the understanding of arthrofibrosis. The process begins when stress signals stimulate immune cells. The resulting cascade of cytokines and mediators drives fibroblasts to differentiate into myofibroblasts, which secrete fibrillar collagens and transforming growth factor-β (TGF-β). Positive feedback networks then dysregulate processes that normally terminate healing processes. We propose two subtypes of arthrofibrosis occur: active arthrofibrosis and residual arthrofibrosis. In the latter the fibrogenic processes have resolved but the joint remains stiff. The best therapeutic approach for each subtype may differ significantly. Treatment typically involves surgery, however, a pharmacological approach to correct dysregulated cell signalling could be more effective. Recent research shows that myofibroblasts are capable of reversing differentiation, and understanding the mechanisms of pathogenesis and resolution will be essential for the development of cell-based treatments. Therapies with significant promise are currently available, with more in development, including those that inhibit TGF-β signalling and epigenetic modifications. This review focuses on pathogenesis of sterile arthrofibrosis and therapeutic treatments.