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Treatment of arthrofibrosis and stiffness after total knee arthroplasty: an updated review of the literature

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Abstract

Purpose

There is currently no consensus regarding the optimal treatment for stiffness following total knee arthroplasty (TKA). With the increased utilization of value-based models, it is important to determine the most effective treatments that will reduce the need for further intervention and additional expenditure. A systematic review was performed to compare the outcomes of manipulation under anaesthesia (MUA), arthroscopic lysis of adhesions (aLOA), and revision TKA (rTKA) for arthrofibrosis and stiffness following TKA.

Methods

PubMed and MEDLINE databases were reviewed for articles published through October 2020. Studies were included if they reported patient-reported outcome measures (PROMs) following MUA, aLOA, or rTKA. The primary endpoint was PROMs, while secondary outcomes included range of motion and the percentage of patients who pursued further treatment for stiffness.

Results

A total of 40 studies were included: 21 on rTKA, 7 on aLOA, and 14 on MUA. The mean or median post-operative arc ROM was > 90° in 6/20 (30%) rTKA, 5/7 (71%) aLOA, and 7/10 (70%) MUA studies. Post-operative Knee Society (KSS) clinical and functional scores were the greatest in patients who underwent MUA and aLOA. As many as 43% of rTKA patients required further care compared to 25% of aLOA and 17% of MUA patients.

Conclusion

Stiffness following TKA remains a challenging condition to treat. Nonetheless, current evidence suggests that patients who undergo rTKA have poorer clinical outcomes and a greater need for further treatment compared to patients who undergo MUA or aLOA.

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References

  1. Sanders TL, Kremers HM, Bryan AJ, Kremers WK, Stuart MJ, Krych AJ (2017) Procedural intervention for arthrofibrosis after ACL reconstruction: trends over two decades. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-015-3799-x

  2. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS (2007) Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections. A prospective randomized study. J Arthroplasty. https://doi.org/10.1016/j.arth.2007.03.034

  3. Donaldson JR, Tudor F, Gollish J (2016) Revision surgery for the stiff total knee arthroplasty. Bone Joint J. https://doi.org/10.1302/0301-620X.98B5.35969

  4. Vezeridis PS, Goel DP, Shah AA, Sung SY, Warner JJP (2010) Postarthroscopic arthrofibrosis of the shoulder. Sports Med Arthrosc Rev. https://doi.org/10.1097/JSA.0b013e3181ec84a5

  5. Yercan HS, Sugun TS, Bussiere C, Ait Si Selmi T, Davies A, Neyret P (2006) Stiffness after total knee arthroplasty: Prevalence, management and outcomes. Knee. https://doi.org/10.1016/j.knee.2005.10.001

  6. Malahias MA, Birch GA, Zhong H et al (2020) Postoperative serum cytokine levels are associated with early stiffness after total knee arthroplasty: a prospective cohort study. J Arthroplasty. https://doi.org/10.1016/j.arth.2020.02.046

  7. Manrique J, Gomez MM, Parvizi J (2015) Stiffness after total knee arthroplasty. J Knee Surg. https://doi.org/10.1055/s-0034-1396079

  8. Kalson NS, Borthwick LA, Mann DA, Deehan DJ (2016) International consensus on the definition and classification of fibrosis of the knee joint. Bone Joint J. https://doi.org/10.1302/0301-620X.98B10.37957

  9. Desai AS, Karmegam A, Dramis A, Board TN, Raut V (2014) Manipulation for stiffness following total knee arthroplasty: when and how often to do it? Eur J Orthop Surg Traumatol. https://doi.org/10.1007/s00590-013-1387-7

  10. Schairer WW, Vail TP, Bozic KJ (2014) What are the rates and causes of hospital readmission after total knee arthroplasty? Knee. In: Clinical Orthopaedics and Related Research. https://doi.org/10.1007/s11999-013-3030-7

  11. Schroer WC, Berend KR, Lombardi AV et al (2013) Why are total knees failing today? Etiology of total knee revision in 2010 and 2011. J Arthroplasty. https://doi.org/10.1016/j.arth.2013.04.056

  12. Cheuy VA, Foran JRH, Paxton RJ, Bade MJ, Zeni JA, Stevens-Lapsley JE (2017) Arthrofibrosis associated with total knee arthroplasty. J Arthroplasty. https://doi.org/10.1016/j.arth.2017.02.005

  13. Bong MR, Di Cesare PE (2004) Stiffness after total knee arthroplasty. J Am Acad Orthop Surg. https://doi.org/10.5435/00124635-200405000-00004

  14. Cohen JS, Gu A, Lopez NS, Park MS, Fehring KA, Sculco PK (2018) Efficacy of revision surgery for the treatment of stiffness after total knee arthroplasty: a systematic review. J Arthroplasty. https://doi.org/10.1016/j.arth.2018.04.036

  15. Moya-Angeler J, Bas MA, Cooper HJ, Hepinstall MS, Rodriguez JA, Scuderi GR (2017) Revision arthroplasty for the management of stiffness after primary TKA. J Arthroplasty. https://doi.org/10.1016/j.arth.2017.01.010

  16. Kim J, Nelson CL, Lotke PA (2004) Stiffness after total knee arthroplasty: prevalence of the complication and outcomes of revision. J Bone Jt Surg - Ser A. https://doi.org/10.2106/00004623-200407000-00017

  17. Farid YR, Thakral R, Finn HA (2013) Low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty. J Arthroplasty 28(8):1314–1320. https://doi.org/10.1016/j.arth.2012.11.009

  18. Harvey LA, Brosseau L, Herbert RD (2014) Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database Syst Rev 2014(2). https://doi.org/10.1002/14651858.CD004260.pub3

  19. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (Minors): development and validation of a new instrument. ANZ J Surg. https://doi.org/10.1046/j.1445-2197.2003.02748.x

  20. Xiong L, Klemt C, Yin J, Tirumala V, Kwon YM (2021) Outcome of revision surgery for the idiopathic stiff total knee arthroplasty. J Arthroplasty. https://doi.org/10.1016/j.arth.2020.09.005

  21. Randsborg PH, Tajet J, Negård H, Røtterud JH (2020) Manipulation under anesthesia for stiffness of the knee joint after total knee replacement. Arthroplast Today. https://doi.org/10.1016/j.artd.2020.05.019

  22. Boo HC, Yeo SJ, Chong HC (2020) Manipulation under anaesthesia for patient reported stiffness after total knee arthroplasty in an Asian population. Malays Orthop J. https://doi.org/10.5704/MOJ.2003.009

  23. Yao D, Bruns F, Ettinger et al (2020) Manipulation under anesthesia as a therapy option for postoperative knee stiffness: a retrospective matched-pair analysis. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03381-y

  24. van Rensch PJH, Hannink G, Heesterbeek PJC, Wymenga AB, van Hellemondt GG (2020) Long-term outcome following revision total knee arthroplasty is associated with indication for revision. J Arthroplasty. https://doi.org/10.1016/j.arth.2020.01.053

  25. Crawford DA, Adams JB, Morris MJ, Berend KR, Lombardi AV (2021) Manipulation under anesthesia after knee arthroplasty is associated with worse long-term clinical outcomes and survivorship. J Knee Surg. https://doi.org/10.1055/s-0039-1700569

  26. Bingham JS, Bukowski BR, Wyles CC, Pareek A, Berry DJ, Abdel MP (2019) Rotating-hinge revision total knee arthroplasty for treatment of severe arthrofibrosis. J Arthroplasty. https://doi.org/10.1016/j.arth.2019.01.072

  27. Hermans K, Vandenneucker H, Truijen J, Oosterbosch J, Bellemans J (2019) Hinged versus CCK revision arthroplasty for the stiff total knee. Knee. https://doi.org/10.1016/j.knee.2018.10.012

  28. van Rensch PJH, Heesterbeek PJC, Hannink G, van Hellemondt GG, Wymenga AB (2019) Improved clinical outcomes after revision arthroplasty with a hinged implant for severely stiff total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-018-5235-5

  29. Cartwright-Terry M, Cohen DR, Polydoros F, Davidson JS, Santini AJA (2018) Manipulation under anaesthetic following total knee arthroplasty: Predicting stiffness and outcome. J Orthop Surg. https://doi.org/10.1177/2309499018802971

  30. Hug KT, Amanatullah DF, Huddleston JI, Maloney WJ, Goodman SB (2018) Protocol-driven revision for stiffness after total knee arthroplasty improves motion and clinical outcomes. J Arthroplasty. https://doi.org/10.1016/j.arth.2018.05.013

  31. Rutherford RW, Jennings JM, Levy DL, Parisi TJ, Martin JR, Dennis DA (2018) Revision total knee arthroplasty for arthrofibrosis. J Arthroplasty. https://doi.org/10.1016/j.arth.2018.03.037

  32. Filho PGT de S, Chisté YL, e Albuquerque RSP, Cobra HA de AB, Barretto JM, Cavanellas NT (2017) Late evaluation of patients undergoing manipulation of the knee after total arthroplasty. Acta Ortop Bras. https://doi.org/10.1590/1413-785220172506165770

  33. Pierce TP, Issa K, Festa A, Scillia AJ, McInerney VK, Mont MA (2017) Does manipulation under anesthesia increase the risk of revision total knee arthroplasty? A matched case control study. J Knee Surg. https://doi.org/10.1055/s-0037-1598040

  34. Yoo JH, Oh JC, Oh HC, Park SH (2015) Manipulation under anesthesia for stiffness after total knee arthroplasty. Knee Surg Relat Res. https://doi.org/10.5792/ksrr.2015.27.4.233

  35. Dzaja I, Vasarhelyi EM, Lanting BA et al (2015) Knee manipulation under anaesthetic following total knee arthroplasty: a matched cohort design. Bone Jt J. https://doi.org/10.1302/0301-620X.97B12.35767

  36. Heesterbeek PJC, Goosen JHM, Schimmel JJP, Defoort KC, van Hellemondt GG, Wymenga AB (2016) Moderate clinical improvement after revision arthroplasty of the severely stiff knee. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-015-3712-7

  37. Issa K, Kapadia BH, Kester M, Khanuja HS, Delanois RE, Mont MA (2014) Clinical, objective, and functional outcomes of manipulation under anesthesia to treat knee stiffness following total knee arthroplasty. J Arthroplasty. https://doi.org/10.1016/j.arth.2013.07.046

  38. Hegazy AM, Elsoufy MA (2011) Outcome of arthroscopic arthrolysis of arthrofibrosis after total knee replacement. Univ Pa Orthop J

  39. Kim GK, Mortazavi SMJ, Parvizi J, Purtill JJ (2012) Revision for stiffness following TKA: a predictable procedure? Knee. https://doi.org/10.1016/j.knee.2011.06.016

  40. Hartman CW, Ting NT, Moric M, Berger RA, Rosenberg AG, Della Valle CJ (2010) Revision total knee arthroplasty for stiffness. J Arthroplasty. https://doi.org/10.1016/j.arth.2010.04.013

  41. Patil N, Lee K, Huddleston JI, Harris AHS, Goodman SB (2010) Aseptic versus septic revision total knee arthroplasty: patient satisfaction, outcome and quality of life improvement. Knee. https://doi.org/10.1016/j.knee.2009.09.001

  42. Arbuthnot JE, Brink RB (2010) Arthroscopic arthrolysis for the treatment of stiffness after total knee replacement gives moderate improvements in range of motion and functional knee scores. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-009-0878-x

  43. Sharma V, Maheshwari A, Tsailas P, Ranawat A, Ranawat C (2008) The results of knee manipulation for stiffness after total knee arthroplasty with or without an intra-articular steroid injection. Indian J Orthop. https://doi.org/10.4103/0019-5413.41855

  44. Keating EM, Ritter MA, Harty LD et al (2007) Manipulation after total knee arthroplasty. J Bone Jt Surg - Ser A. https://doi.org/10.2106/JBJS.E.00205

  45. Jerosch J, Aldawoudy AM (2007) Arthroscopic treatment of patients with moderate arthrofibrosis after total knee replacement. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-006-0099-5

  46. Mont MA, Seyler TM, Marulanda GA, Delanois RE, Bhave A (2006) Surgical treatment and customized rehabilitation for stiff knee arthroplasties. Clin Orthop Relat Res. https://doi.org/10.1097/01.blo.0000214419.36959.8c

  47. Keeney JA, Clohisy JC, Curry M, Maloney WJ (2005) Revision total knee arthroplasty for restricted motion. Clin Orthop Relat Res. https://doi.org/10.1097/01.blo.0000185312.43955.c8

  48. Haidukewych GJ, Jacofsky DJ, Pagnano MW, Trousdale RT (2005) Functional results after revision of well-fixed components for stiffness after primary total knee arthroplasty. J Arthroplasty. https://doi.org/10.1016/j.arth.2004.09.057

  49. Christensen CP, Crawford JJ, Olin MD, Vail TP (2002) Revision of the stiff total knee arthroplasty. J Arthroplasty. https://doi.org/10.1054/arth.2002.32105

  50. Babis GC, Trousdale RT, Pagnano MW, Morrey BF (2001) Poor outcomes of isolated tibial insert exchange and arthrolysis for the management of stiffness following total knee arthroplasty. J Bone Jt Surg - Ser A. https://doi.org/10.2106/00004623-200110000-00012

  51. Ries MD, Badalamente M (2000) Arthrofibrosis after total knee arthroplasty. Clin Orthop. https://doi.org/10.1097/00003086-200011000-00024

  52. Williams RJ, Westrich GH, Siegel J, Windsor RE (1996) Arthroscopic release of the posterior cruciate ligament for stiff total knee arthroplasty. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-199610000-00026

  53. Daluga D, Lombardi AV, Mallory TH, Vaughn BK (1991) Knee manipulation following total knee arthroplasty: Analysis of prognostic variables. J Arthroplasty. https://doi.org/10.1016/S0883-5403(11)80006-9

  54. Nicholls DW, Dorr LD (1990) Revision surgery for stiff total knee arthroplasty. J Arthroplasty. https://doi.org/10.1016/S0883-5403(08)80029-0

  55. Campbell ED (1987) Arthroscopy in total knee replacements. Arthroscopy. https://doi.org/10.1016/S0749-8063(87)80007-5

  56. Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the knee society clinical rating system. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-198911000-00004

  57. Rosso F, Cottino U, Dettoni F, Bruzzone M, Bonasia DE, Rossi R (2019) Revision total knee arthroplasty (TKA): mid-term outcomes and bone loss/quality evaluation and treatment. J Orthop Surg Res. https://doi.org/10.1186/s13018-019-1328-1

  58. Sanz-Ruiz P, Villanueva-Martínez M, Matas-Diez JA, Vaquero-Martín J (2015) Revision TKA with a condylar constrained prosthesis using metaphyseal and surface cementation: a minimum 6-year follow-up analysis. BMC Musculoskelet Disord. https://doi.org/10.1186/s12891-015-0485-6

  59. Greidanus NV, Peterson RC, Masri BA, Garbuz DS (2011) Quality of life outcomes in revision versus primary total knee arthroplasty. J Arthroplasty. https://doi.org/10.1016/j.arth.2010.04.026

  60. Stirling P, Middleton SD, Brenkel PJW IJ (2020) Revision total knee arthroplasty versus primary total knee arthroplasty a matched cohort study. Bone Jt Open. https://doi.org/10.1302/2633-1462.13.BJO-2019-0001.R1 

  61. Hardeman F, Londers J, Favril A, Witvrouw E, Bellemans J, Victor J (2012) Predisposing factors which are relevant for the clinical outcome after revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-011-1624-8

  62. Kannan A, O’Connell RS, Kalore N, Curtin BM, Hull JR, Jiranek WA (2015) Revision TKA for flexion instability improves patient reported outcomes. J Arthroplasty. https://doi.org/10.1016/j.arth.2014.12.010

  63. Scott CEH, Turnbull GS, Powell-Bowns MFR, MacDonald DJ, Breusch SJ (2018) Activity levels and return to work after revision total hip and knee arthroplasty in patients under 65 years of age. Bone Jt J. https://doi.org/10.1302/0301-620X.100B8.BJJ-2017-1557.R2

  64. Issa K, Banerjee S, Kester MA, Khanuja HS, Delanois RE, Mont MA (2014) The effect of timing of manipulation under anesthesia to improve range of motion and functional outcomes following total knee arthroplasty. J Bone Jt Surg - Am Vol 96(16):1349–1357. https://doi.org/10.2106/JBJS.M.00899

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  1. Rothman Orthopaedic Institute, 125 S 9th Street, Suite 1000, Philadelphia, PA, 19107, USA

    Amer Haffar, Graham S. Goh, Yale A. Fillingham & Jess H. Lonner

  2. Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA

    Michael T. Torchia

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  1. Amer Haffar
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Contributions

AH: data collection, analysis, manuscript writing. GSG: data collection, analysis, manuscript writing. YAF: data collection, analysis, manuscript review and editing. MTT: data collection, analysis, manuscript review and editing. JHL: data collection, analysis, manuscript review and editing.

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Correspondence to Jess H. Lonner.

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This work was performed at Rothman Orthopaedic Institute in Philadelphia, PA.

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Haffar, A., Goh, G.S., Fillingham, Y.A. et al. Treatment of arthrofibrosis and stiffness after total knee arthroplasty: an updated review of the literature. International Orthopaedics (SICOT) 46, 1253–1279 (2022). https://doi.org/10.1007/s00264-022-05344-x

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