Etiopathology and Management of Stiff Knees: A Current Concept Review

Increased symptoms of stiffness after opening-wedge high tibial osteotomy are associated with worse postoperative knee function outcomes and lower patient satisfaction rate

BACKGROUND

Symptoms of knee stiffness after open wedge high tibial osteotomy (OW-HTO) can significantly affect surgical effectiveness, but no studies have reported risk factors for knee stiffness after OW-HTO.

METHODS

Patients treated with OW-HTO for the first time between 2018 and 2021 were included. Data were collected on patient demographics, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form (SF) 12 scores, hip-knee-ankle angle (HKA) and patient satisfaction before and after surgery. Patients with worse WOMAC stiffness scores at 1 year were defined as the 'increased stiffness' group and the other cohort as the 'non-stiffness' group. The primary outcome of the study was to compare postoperative knee function scores (WOMAC and SF-12), HKA and patient satisfaction rate between the two groups. The secondary outcome was the use of logistic regression to analyze independent predictors of increased postoperative stiffness symptoms.

RESULTS

At 1 year postoperatively, 95 (11.3%) patients had a significant increase in stiffness. Patients had significantly (p < .001) less improvement in pain, function, and total WOMAC scores, and SF-12 score than those in the non-stiffness group (n = 745). However, the differences in WOMAC and SF-12 scores in increased stiffness group at 1 year post-operatively were statistically significant (p < .001) compared to the non-stiffness group. There was no statistically significant difference in HKA in the increased stiffness group (172.9° ± 2.3°) compared to non-stiffness group (173.4° ± 2.6°) at 1 year postoperatively (p = .068). Patient satisfaction was significantly lower in the increased stiffness group (p < .001). Logistic regression analysis showed that diabetes (odds ratio (OR) 1.809, p = .034) and preoperative WOMAC stiffness score of 44 or less (OR 4.255 p < .001) were predictors of increased stiffness.

CONCLUSIONS

Patients with increased stiffness after OW-HTO had worse functional outcomes and lower patient satisfaction rates and patients at risk of being in this group should be informed pre-operatively.

Patellar Base Support Technique During Manipulation Under Anesthesia for Knee Arthrofibrosis Limits the Risk of Iatrogenic Complications

Knee extension contracture is a common postinjury and postsurgical complication, which decreases knee joint flexion. Many techniques have been described in the literature to restore knee flexion, with the most common one being an arthroscopic lysis of adhesions. However, in severe cases, additional intra- and extra-articular procedures are needed to restore full knee flexion. Manipulation under anesthesia (MUA) is one of them. Unfortunately, it may lead to devastating complications, such as iatrogenic rupture of the patellar tendon or fractures of the patella or tibial tuberosity. Therefore, the purpose of this report is to present a safer modification of MUA for knee extension contracture in cases in which excessive force is demanded to achieve flexion. The key aim of the "patellar base support" technique (PBS technique) is to stretch the contracted quadriceps muscle with controlled and decreased tension on the patella, patellar tendon, and tibial tuberosity.

Mid-resection Workflow for Robotic-assisted Total Knee Arthroplasty in a Stiff Knee

Introduction

With the growing prevalence of robotic-assisted total knee arthroplasty (RATKA), the significance of effectively addressing complex deformities using this approach is gaining widespread recognition. This article underscores the importance of a novel mid-resection workflow specifically tailored for RATKA in cases with complex deformities.

Case Report

A 58-year-old female patient diagnosed with severe osteoarthritis in both knees and a stiff left knee underwent RATKA utilizing a mid-resection workflow. The surgery resulted in favorable intraoperative stability and achieved a satisfactory range of motion. Follow-up at the 1-year post-operative mark demonstrated a range of movement of 110° and a positive functional outcome for the patient.

Conclusion

Severe knee arthritis with flexion deformity represents a common condition encountered in surgical practice. The advent of RATKA has provided us with an opportunity to assess and establish the effectiveness of mid-resection workflow in managing such cases.

Study of Clinical Results and Functional Outcome of Patients With Distal Femur Fracture Treated With Dual Plating

Introduction Distal femur fracture has been routinely fixed with a single lateral locking plate. This method of fixation in intra-articular distal femur fractures has proved to give a higher outcome of varus collapse as well as higher rates of mal-union due to inadequate fixation of the medial aspect of the distal femur. To address this drawback of single lateral plating, the use of medial assisted plating (MAP) has been introduced recently, which was proposed to give better stability to the medial fragments. This Is a prospective case series of 50 patients with distal femur fractures treated with dual plating. Materials and methods Fifty cases of patients with distal femur fractures were treated with dual plating between August 2020 and September 2022. Patients were followed up postoperatively till the third month, when patients were assessed clinically and radiologically. Range of motion of the knee, postoperative fracture displacement, limb shortening, and signs of union and infection were checked. Neer's scoring and Kolmet's scoring were used to grade the outcome for the patients.  Results The mean age of the patients was 39. Only 12% of the cases were open fractures. Eighty-four percent of the cases did not have fixed flexion deformity (FFD) and only 4% had FFD of 15 degrees; 72% of the cases achieved flexion of the knee beyond 120 degrees. Eighty-four percent of patients had normal walking ability by the 12th week postoperatively; 16% of the cases had a postoperative displacement of more than 1.6 cm, with the maximum being 2.5 cm.  Conclusion From the study, we have concluded that outcomes were better for fractures of distal femur when treated with dual fixation, probably due to superior fixation and earlier postoperative mobilization.

Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.

Effect of Remote Control Augmented Reality Multimedia Technology for Postoperative Rehabilitation of Knee Joint Injury

This study was aimed at exploring the application value of augmented reality (AR) in postoperative rehabilitation training for patients with knee joint injury. 40 patients who underwent knee joint injury surgery were selected as the research objects, and the patients were randomly divided into two groups: an experimental group (20 cases) and a control group (20 cases). Patients in the experimental group were treated with AR-based rehabilitation methods, while those in the control group were treated with traditional rehabilitation methods. Afterwards, the two groups of patients were compared with various indicators such as pain value, swelling, structural and functional recovery, time to complete weight bearing, time to return to work, and X-ray examination results. The main evaluation tools used were Hospital for Special Surgery (HSS) score and Visual Analogue Scale (VAS) score. The results showed that after six weeks, the HSS score of the control group was 82.88 ± 3.07, and the HSS score of the experimental group was 85.46 ± 3.21. The difference between the two groups was statistically significant (P < 0.05). After three months, the HSS score of the control group was 89.96 ± 3.76, and that of the experimental group was 93.21 ± 4.33. The difference between the two groups was statistically significant (P < 0.05). There was a significant difference in pain scores between the two groups at 7 days (3.81 ± 0.48 vs. 5.06 ± 0.66) and 14 days (2.03 ± 0.45 vs. 3.61 ± 0.63) after surgery, with statistical significances (P < 0.05). There were statistically significant differences between the two groups in terms of time to complete weight bearing (7 ± 0.87 weeks vs. 8.82 ± 0.88 weeks) and time to return to work (8.69 ± 0.94 vs. 9.93 ± 0.88 weeks) (P < 0.05). One month after surgery, the X-ray examination results of both groups showed recovery. The AR-based rehabilitation training system showed a good application effect and prospect in the postoperative structural and functional recovery of patients with knee joint injury.