Abstract
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Knee stiffness is a widely known and worrying condition in several postoperative knees. Less is known about native stiff knee. The aim of this manuscript is to summarize the available literature on native stiff knee epidemiology, classification and treatment.
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In 1989 stiff knee was defined as a knee with less than 50° of total range of motion. If range of motion is <30°, it is defined as an ankylosed knee. Knee stiffness can be divided into three main types: flexion contractures, extension contractures, and combined contractures. Different risk factors have been associated to native stiff knee and grouped into modifiable or not modifiable. Furthermore, risk factors can be divided into patients’ related no patients’-related.
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Different treatment modalities can be indicated to treat knee stiffness, including manipulation under anesthesia (MUA), arthroscopic and open surgical release. When stiffness is associated with articular disruption TKA represent an option. TKA in native stiff knee can be challenging for the surgeon. Implant’s choice and knee exposure are the first steps. In some cases, additional release and extensive can be considered. A stepwise approach and careful preoperative planning are mandatory to obtain long-term satisfactory outcomes.
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Native stiff knee is a rare but invalidating condition. Different treatment modalities have been proposed as treatment. However, considering that it is frequently associated to sever arthritis, TKA can be an option in painful stiff knees. Nature of knee stiffness necessitates a customized approach to ensure successful management and achieve satisfying outcomes.
Introduction
Knee stiffness is a widely known and worrying condition in several postoperative knees, such as total knee arthroplasty (TKA) or anterior cruciate ligament (ACL) reconstruction (1, 2, 3, 4). However, less is known about native stiff knee. The term ‘arthrofibrosis’ has often been interchangeably employed with the term ‘stiff knee’, even if they are two different conditions. Knee stiffness has been described as a knee range of motion (ROM) of less than 50° (5). Conversely, arthrofibrosis is an excessive accumulation of scar tissue or fibrosis in at least one knee compartment (6, 7, 8), and it can be related to different patient’s predisposing factors (9). Arthrofibrosis is a particular condition related to stiff knees, with structural disruption of the joint's fibrous connective tissue, originating from inflammation triggered by trauma, surgery or infection. Extracellular matrix proliferation, coupled with the development of adhesions, results in joint’s tissue retraction, with consequent pain and restricted knee motion (10, 11). It can be associated to high-energy and multi-ligamentous trauma, as well as to ligament reconstruction. Among literature arthrofibrosis can reach 4% in patient who underwent to ACL reconstruction (12), and it can increase up to 23% in patients who underwent reconstruction of two or more ligaments (13). However, different conditions have been historically linked with articular stiffness and arthrofibrosis such as trauma, infective arthritis, cerebral palsy and hemophilia. The aim of this manuscript is to summarize the available literature on native stiff knee epidemiology, classification and treatment.
Definition and epidemiology
The correct definition of ‘stiff knee’ is still debated. In 1989 it was defined as a knee with less than 50° of total range of motion (14). However, some authors described it as a limitation of flexion between 75 and 90°, while other consider it as a flexion contracture of more than 10°. If knee stiffness is particularly severe, with range of motion <30°, it is defined as an ankylosed knee (15, 16).
Pujol et al. divided knee stiffness into three main types: flexion contractures, extension contractures, and combined contractures (3). Each category is associated with various characteristics contributing to its occurrence, and distinct treatment options are outlined for addressing these specific types of contractures.
Flexion contracture
Flexion contracture has been classified as mild (<5°), moderate (15–30°) and severe (>30°) by Bellemans et al. (17). Different authors confirmed that 125° of flexion is adequate to complete daily life activities, allowing also for squatting activities. Furthermore, flexion less than 90° affects daily quality of life, and even sitting or climbing stairs can be difficult (18). Frequently flexion contracture can be due to three major anatomic conditions: posterior impingement (ostephytes, foreign bodies, tight posterior capsule), retraction of anterior structures or patella baja (19). Patella baja is usually described in conjunction with quadriceps tendon rupture, cerebral palsy and postoperatively after high tibial osteotomy or total knee arthroplasty (20, 21).
Extension contracture
Extension contracture is poorly tolerated due to its impact on daily life. Five degree of extension contracture can cause strain to the quadriceps tendon during weight bearing, increasing muscle activity and subsequent abnormal load on the patellofemoral joint. In case of limited extension, especially after ACL reconstruction, anterior impingement must be always excluded (cyclops lesions, intercondylar eminence deformity, wrong ACL positioning). However, an extension deficit can also be related to a posterior capsule tightness for a gastrocnemius contractures or brevities. Eventually, adherences located behind the patella and in the suprapatellar pouch can also led to quadriceps adhesion to the anterior cortex of the femur causing extension deficiencies (17). Patellar precut and Tarabichi maneuver (removal of suprapatellar pouch adherences) have been described in literature to overcome anterior stiffness. Furthermore, posterior compartment release and thicker cuts are widely used in posterior stiffness. Patella baja management presents some corrective measures with the aim to reestablishing the joint line. Use of distal femoral augments, tibial tubercle osteotomy with proximal displacement, lengthening of the patellar tendon and placement of the patellar implant in a proximal position can be considered (20, 22).
Combined contracture
A coexisting condition of flexion and extension contracture can also be present. If the range of motion is less than 30° it can be considered as a ankylosed knee, which is usually painless (16, 23). Conditions such tibial plateau fractures and arthrofibrosis can usually lead to a combined contracture affecting the range of motion in flexion and extension either (24, 25).
Risk factors
Different risk factors have been associated to native stiff knee and grouped into modifiable or not modifiable (26). Furthermore, risk factors can be divided into patient related and not patient related (Table 1). A brief description of the most important risk factors is listed in the table.
Risk factors for native stiff knee.
| Risk factors | |
|---|---|
| Patient related | |
| Modifiable | >BMI |
| Depression | |
| Not modifiable | Female sex |
| Cerebral palsy | |
| Hemophilia | |
| Diabetes mellitus | |
| Cerebral palsy | |
| Not patient related | Fractures |
| Infections | |
| Previous surgeries | |
| ACL reconstructions |
ACL, anterior cruciate ligament; BMI, body mass index.
Hemophilia (patient related not modifiable)
Continuous joint bleeding in hemophilic patients can cause chronic synovitis and consequent hemophilic arthropathy, which is typically characterized by massive osteophytes and stiffness (27) (Fig. 1). Post et al. described three stages for hemophilic arthropathy development: stage 1 consists of bleeding (acute phase); stage 2 is related to a massive inflammatory response (subacute phase); stage 3 is characterized by the presence of massive degeneration with osteophytes and stiffness (chronic phase) (28). In presence of multiple episodes of hemarthrosis and the consequent development of hemophilic arthropathy, knee flexion contracture (KFC) is not rare in these patients, with 50% of severe hemophiliacs patients suffering for a KFC (29, 30).
Preoperative X-ray of a 55-year-old hemophilic male patient (A, lateral view; B, anteroposterior view).
Citation: EFORT Open Reviews 9, 5; 10.1530/EOR-24-0034
Infections (not patient related)
Septic arthritis is a relatively common condition with a reported annual incidence of 9.2 cases per 100.000 population, highly linked with possible life-threatening consequences (31, 32). Classification of septic arthritis was described by Gacther et al. (33), divided it in four stages according to arthroscopic and radiological finding. In their cohort the efficacy of arthroscopic irrigation plus systemic antibiotic therapy decreased with increasing severity of the initial stage of infection: 96% in stage I, 95% in stage II and 67% in stage III, insufficient results have been showed in stage IV (34). Mortality rates linked with septic arthritis reported among literature are around 10–15% (35, 36, 37), while patient reported poor outcome rates reported are 20–30% (37, 38). Conversion rates to arthroplasty 1 year after septic arthritis have been reported around 1.33% (39). Pre-existing condition such as rheumatoid arthritis, oral corticosteroid consumption, diabetes and recent trauma can be considered as potential risk factors for septic arthritis development (37). During septic arthritis host reactivity causes a massive macrophage-induced inflammation which leads to cartilage and bone erosion (40). Usually stiffness after septic arthritis affects flexion more than extension due to a progressive arthrofibrosis of the suprapatellar pouch and tightness of the posterior capsule (24).
Fractures (not patient related)
Tibial plateau fractures constitute 1% of all fractures (41), and surgical treatment with reduction and fixation is often required. Even with good reduction, the incidence of posttraumatic osteoarthritis has been reported in ranges between 24% and 60%, with possible development of knee stiffness (42, 43).
Particularly, Gaston et al. in a study on 63 patients concluded that 20% of patients presented with a residual knee flexion contracture of >5° at 12 month after surgery (25). Posttraumatic stiffness can be due by intra-articular (inflammation, adhesions, intra-capsular scarring, and bone irregularities after malunion causing impingement) and extra-articular factors (extensor apparatus lesions and fibrosis, and scarring of skin and periarticular soft tissue) (44, 45). Furthermore, prolonged immobilization related to both conservative or surgical treatment, is strictly related to the development of knee stiffness (46). Usually, the sequelae of fractures affect flexion and extension. A trauma causing articular fracture led to arthrofibrosis development with a concomitant quadriceps and hamstring insufficiency with a consequent risk of residual stiffness 1 year after a tibial plateau fracture of 20% (24, 25).
ACL reconstruction (not patient related)
Advanced surgical technique and accelerated rehabilitation protocols have markedly decreased the postoperative stiffness rate after ACL reconstruction from 35% to 4% (47, 48, 49).
The main preoperative risk factors for knee stiffness following ACL reconstruction are preoperative swelling and an limited range of motion (ROM) (8).
However, Magit et al. (18) described different factors which can lead to knee stiffness after ACL reconstruction technique. Lateral placement of tibial tunnel has showed to determine impingement with condyle and extension restriction, while anteromedial tunnel can cause flexion lack. Increased graft tension has been also proposed as a cause of excess constrain of knee joint (50). Timing of surgery still presents controversial results, with several studies reporting worst or similar range of motion for acute reconstruction compared to a delayed one (after 3 weeks) (47, 51, 52). One of the cause of extension deficit after ACL reconstruction is the so-called cyclops syndrome (53). Described by Jackson and Schaefer in 1990 as a nodule of fibrous tissue on the anterior aspect of the ACL graft, the cyclops lesion causes a loss of terminal extension accompanied by symptoms such as pain and stiffness (53). Eventually, ACL reconstruction can lead to extension loss due to misplacement of tibial tunnel, or it can lead to both extension and flexion loss due to arthrofibrosis development. Paulos et al. described the ‘Infrapatellar contracture syndrome as complication’ after ACL reconstruction, which is a combined reduction of more than 10° in extension and 25° in flexion associated with reduced patellar mobility (54).
Diagnosis
A recent international consensus about knee stiffness has been developed and an investigation algorithm has been described (55). Diagnosis should begin with a careful knee clinical examination. Active and passive knee ROM should be evaluated, and knee stiffness should be classified into flexion, extension, or combined restriction. Patellar mobility, quadriceps strength, extensor apparatus, knee deformities and joint stability should be evaluated in each case. Standard X-rays should be performed routinely to evaluate osteophytes, patellar height and other possible reasons for stiffness. There is no evidence for the routine use of MRI, but it can be useful in case of stiffness after ACL reconstruction for scar tissue evaluation (55).
Treatment modalities
Different treatment modalities can be indicated to treat knee stiffness, including manipulation under anesthesia (MUA), arthroscopic and open surgical release (3, 56).
Manipulation under anesthesia
Manipulation under anesthesia (MUA) has been widely used in the past years to treat native stiff knees. Patient is positioned supine under appropriately anesthesia; hip is than flexed to 90°. A progressive load is applied to the proximal tibia to force knee in flexion, audible scar tissue disruption can occur, at the end the passive range of motion is evaluated and compared to the previous one (57). However, recently it has been less performed due to some problems, such as risk for fractures and tendon rupture. A recent study has been published (58) reporting satisfying results for knee stiffness management in hemophiliacs patients treated with MUA. A mean deformity correction of 22° was achieved with single MUA, but the authors suggested that the treatment can be repeated up to three time until less than 10° flexion contracture is achieved. Complications are associated with MUA such as supracondylar femur fractures and not sufficient improve in ROM gain have been reported (49, 59).
Arthroscopic release
Arthroscopic release involves scar tissue debridement in the suprapatellar pouch, in intercondylar fossa and in medial and lateral gutters. Additional accessory portals can be performed in case of severe flexion contracture to release the posterior compartment of the knee (57). This procedure can be considered in case of MUA failure or stiffness developed and structured since at least 3 months. There are different studies on literature on the efficacy of arthroscopic releases in stiff knee, with good outcomes (60, 61, 62). Particularly, a recent study from Eggeling et al. (63) compared mid-term results between very early (<3 months), early (3–6 months) and late (>6 months) arthroscopic release after surgical procedures to treat postoperative knee stiffness. The final ROM after arthrolysis was significantly increased in the group of very early and early arthrolysis while postoperative flexion deficit was higher in the late group. On the other hand, arthroscopic arthrolysis can lead to good results in extension deficit because of the easy access to the suprapatellar pouch enabling the removal of foreign bodies or removing adhesions, while in flexion contracture it can be less effective (12, 64, 65).
Open surgical debridement
Open surgical arthrolysis has been widely used in the past years because it allows also to access the posterior compartment easily compared to arthroscopic releases, even if the indications for these two procedures are similar. A recent study compared open and arthroscopic release in (56), with significant higher success rate for the arthroscopic compared to the open group. The lower success rates related to an open release may be a consequence of the local tissue scare derived from an incision injury. Nowadays arthroscopic approach is the first treatment choice, but open debridement can still be considered for severe stiffness and cases where posterior capsule need to be released. This procedures allow to properly debrief each compartment and can also be useful to perform extra-articular release (57).
TKA in stiff knee
TKA is indicated in patients with advanced knee arthritis to obtain pain relief, knee stability, and correct knee deformities (66) with restoration of good range of motion whenever possible. However, an arthritic stiff knee is a challenging condition and patient should be awarded that postoperative outcomes could be worse compared to other patients, especially regarding ROM. Ritter et al. in a study on 4727 knees demonstrated that preoperative ROM is strictly linked with postoperative ROM. Patients with a preoperative flexion <77° showed a postoperative mean flexion of 93°. This condition appears to be even worst in valgus stiff knee (67).
TKA in stiff knee can be challenging for the surgeon. Implant’s choice and knee exposure are the first steps. In some cases, additional release and extensive approach can be considered. A stepwise approach and careful preoperative planning are mandatory to obtain long-term satisfactory outcomes.
Implant choice
Careful preoperative planning is mandatory in TKA, especially in cases of a stiff knee. Particularly, it is important to address possible intra-operative difficulties, including the need for an increased constraint. In native stiff knee, posterior cruciate ligament is usually sacrificed, and a posterior stabilized insert can be enough to achieve good stability. However, in case of moderate to severe stiffness, if major releases must be performed to achieve good exposure and gaps, higher constraint implants (condylar constrained) can be needed due to residual instabilities. Posterior stabilized implants showed at satisfactory results in term of ROM improvement and functional score in Boettner cohort (68). No specific studies exist in varus–valgus constrained (VVC) TKA for stiff knees. However, when used in primary TKA for fixed valgus deformities reported, excellent results at long term follow-up have been reported, but with low survivorship compared to primary especially in young patients (69, 70).
Skin incision
Skin incision can be an issue in native stiff knee, especially if previous surgeries have been performed. In presence of different skin incisions, do not forget the safety criteria such as: using the most lateral incision, keep a minimum distance of 7 cm between two incision and at least 60° between the incision and scars to avoid lesions to tissue blood supply (71). Due to knee stiffness, exposure of the knee joint can be challenging with standard parapatellar approach. For these reasons, especially in those patients with preoperative ROM less than 90° and severe stiffness, some extensile approaches can be considered.
Preliminary intraoperative maneuver to improve range of motion
Quadriceps pie-crusting and Tarabichi maneuver have been described in literature to overcome anterior stiffness when approaching a stiff knee. These procedures can be performed as preliminary options to properly expose the knee avoiding the use of extensile approaches (22, 72, 73).
Quadriceps pie-crusting has been reported in only few studies (72, 73). Burge (72) described a blade-based technique reporting a 45° improvement at final follow-up. Zhang et al. (73) with a 18 gauge needle pie crusting reported a mean knee flexion improvement of 35° at 1 year in 16 TKA. Knee Society score (KSS) reported significant improvement at 1 year. This technique is performed with the knee at maximum flexion. First puncture is located in the distal and lateral part of the vastus intermedius tendon about 5 cm from the superior pole of the patella and a series of puncture (10-20 per level) are performed from lateral to medial and from distal to proximal (at 1 cm intervals). Same authors also described a percutaneous technique in stiff TKA providing satisfactory clinical results (74).
Tarabichi maneuver is usually performed to improve exposure during a standard subvastus approach. The underlying supra-patellar pouch is identified, and any adhering bands or fibrotic tissue are removed by hand. This provides direct access to the deep interface between the quadriceps muscle and the anterior surface of the femur, allowing the release to be carried in a stepwise fashion where the knee is flexed. The release is progressed further proximally until a ROM of over 130° is obtained. Their results showed 88% of patients achieving excellent ROM (flexion more than 125 degrees) 3-month after surgery (22).
Extensile approaches
First extensile approach described by Insall (75) is the quadricep snip, which involves an enlarged medial parapatellar approach. Typically, the tendon incision extends from the medial–distal to the lateral–proximal direction with a 45° angle. This technique does not require a restricted postoperative regimen. However, it allows for an improved knee exposure, but it is often not enough to obtain good exposure in severe stiff knees. A recent study evaluated quadriceps snip in 29 knees at 3 years of follow-up. Mean ROM improved from 20° preoperatively to 91° postoperatively. Mean KSS clinical score increased from 48 to 83 postoperatively. Extensor lag was a rare but possible complication occurring in 3 out of 29 cases (76). This procedure cannot be enough for an optimal exposure; in these cases a conversion to V-Y quadricepsplasty can be considered.
The V-Y quadricepsplasty was first described by Coonse and Adams (77) as the V-Y quadriceps turndown and subsequently modified by Insall (75). It consists of a 45° tenotomy of quadriceps tendon from the medial-proximal to lateral-distal creating an inverted V triangular flap, which includes the patella. The patella is then turned down to expose the knee. After the procedure the quadriceps is repaired with possibility to performed some lengthening of the quadriceps converting the V into a and inverted Y repair if needed (78). Postoperative protocols must be modified to permit extensor apparatus healing, using a brace locked in extension for the first six weeks. The maximum ROM allowed should be driven by the maximum passive flexion angle obtained intraoperatively. The brace is then locked in extension for ambulation (79), weight bearing is allowed only in full extension. However, different complications such as residual extension lag and patella baja have been shown after this extensile approach (80). Scott et al. reported a modified V-Y quadricepsplasty in seven ankylosed knees. The ROM improved from a mean preoperative of 26–75° postoperatively with a mean extensor lag of 8° (81). Trousdale reported a significant weakness of 42% at speed tests when compared with normal matched population of a V-Y turndown was performed (78).
Tibial tubercle osteotomy (TTO) is probably the most widely performed extensive approach. The osteotomy is typically 7–10 cm in length and 1 cm thick to avoid fragment fracture and to allow better healing. The osteotomy should be performed from medial to lateral maintaining a lateral hinge while elevating the tibial tubercle. The TTO allows for a perfect visualization, and position of the tibial tubercle can also be slightly modified at the end of the procedure to correct a patella alta or baja. Once TKA is implanted, the osteotomy is fixed with screws or cerclages. Postoperative protocol is slightly different compared to a standard TKA, with ROM limitation up to 90° of flexion for 4–6 weeks, and patients have weightbearing as tolerated with a knee brace locked in extension for 4 weeks (82). A recent systematic review reported a complication rate of 3.8–20% performing TTO during TKA (83). Other studies reported an average nonunion rate of 10% (84, 85, 86). Recently an analysis on 135 knees with a minimum follow-up of 2 years reported a complication rate of 15% with 5% of nonunion but a very low rate of extensor deficit (2%) and satisfactory subjective and objective outcomes (87).
Pro and cons of each technique are reported in Table 2.
Extensile approaches: pro and cons.
| Pros | Cons | |
|---|---|---|
| Quadriceps snip | No different postoperative protocol | Not optimal exposure |
| Extensible to VY | ||
| V-Y quadricepsplasty | Optimal exposure | Different postoperative protocol |
| Extensor lag | ||
| Tibial tubercle osteotomy | Optimal exposure | Different postoperative protocol |
| Realignment extensor mechanism | Nonunion | |
| Knee pain in kneeling |
Stepwise approach to flexion contracture
Different authors proposed a stepwise algorithmic approaches to address flexion contracture during TKA (88, 89, 90, 91). Bellemans et al. in 2006 (17) evaluated 2898 primary TKA with a preoperative flexion contracture of minimum 5°. Patients were grouped into mild (<5°), moderate (5–15°) and severe (>15°) flexion contracture. The first step described by the authors included standard bone resection, osteophyte removal, and eventually an additional 2 mm distal femur resection to enlarge extension space if needed. The second step was performed in moderate contractures (15-30°) and it included a transverse posterior capsule release lateral and/or medial plus a subperiosteal release of the medial and/or lateral head of the gastrocnemius from the femur. The third and fourth steps were usually performed in severe flexion contracture, and they included, respectively, an increased distal femoral cut by 4 mm and a biceps tenotomy to obtain more motion in flexion. In the study the authors concluded that the first two steps were enough to obtain full extension in 100% of mild cases, 87% of moderate and 48% in severe. Adding the third step leads to a deformity correction rate of 76% in case of severe flexion contracture. There were two cases of peroneal nerve palsy, and both of them occurred in patient with a biceps femoral release. Berend et al. (91) also provided a stepwise approach to flexion contracture. Their study includes 52 knees with a fixed flexion contracture >20°. First, osteophyte removal and soft tissue release was performed. If it was not enough, 2 mm increased distal femoral resection was performed. If correction is not obtained PCL can be released as step 3. In step 4, an additional 2 mm distal femoral cut can be performed, while step 5 described in this technique includes additional soft tissue release such as hamstring tenotomy. Two previous articles studied the effect of distal femoral bone resection on fixed flexion deformity with controversial results. Bengs et al. showed a mean 9° flexion correction per 2 mm of additional distal femoral resection. Conversely, Smith described only 1.8° of correction for each mm of distal cut if bone resection alone is used to correct fixed flexion. Furthermore, different authors suggested that increasing distal femoral bone resection up to 8 mm changes the joint line, leading to a reduction in knee function score, range of motion and increased anterior pain rates (92, 93, 94, 95).
Release of PCL has controversial evidence among literature. Some authors suggest that PCL release can cause a larger flexion space in comparison to the extension space of about 2 mm. Consequently, this exacerbates the discrepancy between the flexion and extension gaps present in cases of flexion contracture with an increased lateral flexion gap compared to the medial causing a coronal instability at 90° of flexion (96, 97).
Author’s preferred technique
Skin incision is performed following the safety criteria if previous scar are presents. A medial parapatellar approach is often performed. If joint exposure is not possible because of extensor apparatus stiffness, anterior osteophytes removal to separate patella from femur is performed. Patellar tendon in then careful released without damaging it to dislocate the patella. To properly release the anterior compartment, suprapatellar pouch soft tissue debridement is performed as described by Tarabichi (Fig. 2). If stiffness persists and patella dislocation is not possible, a thin patellar precut is performed (Fig. 3) to gain more space, measuring patellar thickness and avoiding over-resection. If proper exposure is not obtained, the author’s preferred extensile approach is tibial tubercle osteotomy. Tibial tubercle osteotomy is performed 7–10 cm in length and 1 cm in thickness from medial to lateral preserving the lateral hinge (Fig. 4).
After obtaining at least 90° of flexion a stepwise approach is then performed to manage stiffness. First, all the femoral and tibial osteophytes are removed to identified bony landmarks. Mechanical alignment is usually the preferred alignment technique in stiff knees. The distal femoral and proximal tibial cut are performed according to mechanical alignment principles, and alignment and extension gap are evaluated. Femoral sizing and rotation are then decided; in this phase flexion gap is assessed using a Minus spacer. At this point, if the extension gap is thigh compared to the flexion one, a 2 mm distal femoral recut is performed. If both the flexion and extension gap are tight, a 2 mm proximal tibial cut can be performed to obtain symmetric gaps. If proper flexion and extension gaps are obtained, femoral cuts are then completed carefully to avoid notching and protecting collateral ligaments with retractors.
Using laminar spreaders, lateral or medial posterior osteophytes are removed with an osteotome (Fig. 5). After cuts are completed, flexion and extension gap are evaluated again. In moderate posterior contracture is still present, posterior capsule release, PCL release and posterior condyle subperiosteal release are performed. In case of severe posterior stiffness, posterior transverse capsule sectioning and hamstring release can be also included in release strategy. Once gaps and ROM have been accomplished a posterior stabilized implant is usually preferred. In case of unstable condition after release a VVC implant must be available for implant. After implantation is completed, patellar malpositioning is evaluated and TTO is fixed into the desired place, considering tracking and patella height, with two screws or metallic cerclage (Fig. 6).
Postoperative X-rays with a posterior-stabilized implant and a tibial tubercle osteotomy stabilized with screws (A, antero-posterior view; B, lateral view).
Citation: EFORT Open Reviews 9, 5; 10.1530/EOR-24-0034
Evidence about TKA in native stiff knee
There is consensus on the role of preoperative ROM on the postoperative ROM which can be achieved after a TKA in stiff knees (98, 99, 100). However, different studies reported an average of 40° of ROM improvement. McAuley et al. reported in 27 knees at 6 years of follow-up mean ROM improvement of 44° with 86% of patients declaring improved in quality of life, function, and pain (101). Kim et al. showed a mean 60° ROM improvement postoperatively, with significant KSS and WOMAC improvements (102). Boettner et al. retrospectively evaluated 98 stiff knees undergoing a PS TKA with a 2 mm increased flexion gap. At a mean follow-up of 53 months mean ROM improved from 119° to 123°, mean KSS functional score improved from 52 to 95 (68). Despite fair clinical and patient reported outcomes, complication rates tend to be high in stiff knees undergoing TKA. Ranges reported in literature varied from 7% (68) up to 41% (101). Also revision rate can be high, as reported by McAuley et al. in their case series with 18.5% revision rate (Table 3).
Main results of recent literature on TKA in native stiff Knee.
| Reference | Patients and FUP | Mean FUP | Results | Complications |
|---|---|---|---|---|
| Boettner et al. (68) | 98 TKA with a preoperative ROM <80° | 53 months | Mean ROM increased preoperatively from 67° to 114° postoperatively. Mean flexion contracture decreased from 14° to 1°. The mean KSS improved from 34 to 88 and the KSS Functional Score from 43 to 86. | Seven knees (7%) required MUA and none of the knees had flexion instability. |
| Purudappa et al. (103) | 30 TKA with a preoperative ROM between 15° and 90° | 2 years | Mean ROM improved from 75° preoperatively to 108° postoperatively. KSS functional from 58.5 to 93.83 postoperatively. WOMAC from 76.73 to 7.63 postoperatively | 1 superficial wound infection |
| Debette et al. (104) | 304 TKA with preoperative flexion <90° or a flexion contracture >20° | 5 years | ROM improved of 39° in the flexion contraction group and 32° in the flexion deficit group. KSS in the flexion contraction group improved from 65 to 87 and the functional score from 51 to 77. In the flexion deficit group, the knee score improved from 33 to 86 and the functional score from 48 to 72. |
Intraoperative complications rate was relatively higher in the flexion deficit group with 11 cases or 4.6%. In flexion contracture group intraoperative complication were 2. Postoperative complications were 40 in the flexion deficit group and 4 for the flexion contracture group. |
| Kim et al. (102) | 86 TKA with a mean preoperative ROM of 40° | Minimum 5 years | Preoperative ROM improved to a mean 102°. The mean HSS gain from 42 to 84 postoperatively. The mean KSS arise from 11 to 90 postoperatively, while the Knee functional score get from 42 to 84 points, respectively. WOMAC scores moved from 73 to 34 postoperatively. | 12 knees (14%) experienced complications: 5 skin necrosis; 3 PJI ; 2 periprosthetic fractures; 2 quadriceps tendon rupture. |
| Berend et al. (91) | 52 TKA with a preoperative fixed flexion contracture >20° | 3 years | The average preoperative ROM of 90° improved to 112° postoperatively. The average preoperative KSS of 32 points improved to 90 postoperatively. 94% of knees achieved less than 10° contracture | Five of the 52 knees (10%) underwent subsequent procedures: 3 MUA for unacceptable postoperative motion; 1 PJI; 1 constrain change for instability |
| Rajgopal et al. (105) | 84 TKA with a preoperative native knee ROM < 20° | Minimum 4 years | Mean postoperative ROM was 75°, with a mean gain of 61°. Mean postoperative knee score was 75.2 with a gain of 14.6. The mean functional score was 84.7, with a gain of 26.8 | 3 skin necrosis; 2 wound infections; 3 peroneal nerve palsy; 1 Heterotopic ossifications |
| McAuley et al. (101) | 27 TKA in 21 patients with a preoperative mean ROM of 30° | 6 years | Mean postoperative ROM was 74° with a mean gain of 44°. 18 of the 21 patients (86%) reported improved in quality of life, function, and pain | An overall complication rate of 41% (11 of 27) was seen with a revision rate of 5 of 27 (18.5%) |
FUP, follow-up; HSS, Hospital for Special Surgery knee score; KSS, Knee Society score; MUA, manipulation under anesthesia; ROM, range of motion; TKA, total knee arthroplasty; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
Conclusion
Native stiff knee is a rare but invalidating condition. To properly approach these cases it is mandatory to distinguish between stiff knee (less than 50° ROM) and ankylotic knee (less than 30° of ROM). Stiff knee can be clinically classified into three conditions: flexion contracture, extension contracture and combined. Different risk factors have been described and grouped into patient’s related (such as hemophilia, diabetes, female sex, high BMI and depression) and patient’s unrelated (such as infections, trauma and previous surgery). Different treatment modalities have been proposed for native stiff knee. However, considering that it is frequently associated to sever arthritis, TKA can be a valid option in painful stiff knees. TKA in stiff knee is a demanding procedure. Extensive approaches, such as quadriceps snip, VY quadricepsplasty and TTO, may be needed to obtain adequate visualization. A stepwise approach is then useful to obtain adequate tissue release avoiding knee instabilities. Improvement in ROM and clinical outcome in stiff knees are lower than standard TKA with higher complication rate.
In summary, the intricate nature of knee stiffness necessitates a customized approach to ensure successful management and achieve satisfying outcomes.
ICMJE Conflict of Interest Statement
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this instructional lecture.
Funding Statement
This instructional lecture did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
References
- 1↑
Böhm H, Hösl M, Schwameder H, & Döderlein L. Stiff-knee gait in cerebral palsy: how do patients adapt to uneven ground? Gait and Posture 2014 39 1028–1033. (https://doi.org/10.1016/j.gaitpost.2014.01.001)
- 2↑
Rodríguez-Merchán EC. The stiff total knee arthroplasty: causes, treatment modalities and results. EFORT Open Reviews 2019 4 602–610. (https://doi.org/10.1302/2058-5241.4.180105)
- 3↑
Pujol N, Boisrenoult P, & Beaufils P. Post-traumatic knee stiffness: surgical techniques. Orthopaedics and Traumatology, Surgery and Research 2015 101(1) S179–S186. (https://doi.org/10.1016/j.otsr.2014.06.026)
- 4↑
Bae D, & Yoon K. Total knee arthroplasty in stiff knees after previous infection. Journal of Bone and Joint Surgery. British Volume 2005 87 333–336.
- 5↑
Vanlauwe J, Vandenneucker H, & Bellemans J. TK A in the Stiff Knee. In: The Knee Joint. Springer, Paris. 2012. (https://doi.org/10.1007/978-2-287-99353-4_84)
- 6↑
Dandy DJ, & Edwards DJ. Problems in regaining full extension of the knee after anterior cruciate ligament reconstruction: does arthrofibrosis exist? Knee Surgery, Sports Traumatology, Arthroscopy 1994 2 76–79. (https://doi.org/10.1007/BF01476476)
- 7↑
Klein W, Shah N, & Gassen A. Arthroscopic management of postoperative arthrofibrosis of the knee joint: indication, technique, and results. Arthroscopy 1994 10 591–597. (https://doi.org/10.1016/s0749-8063(0580053-2)
- 8↑
Mayr HO, Weig TG, & Plitz W. Arthrofibrosis following ACL reconstruction—reasons and outcome. Archives of Orthopaedic and Trauma Surgery 2004 124 518–522. (https://doi.org/10.1007/s00402-004-0718-x)
- 9↑
Massin P, Lautridou C, Cappelli M, Petit A, Odri G, Ducellier F, Sabatier C, Hulet C, Canciani JP, Letenneur J, et al.Total knee arthroplasty with limitations of flexion. Orthopedics and Traumatology, Surgery and Research 2009 95(4) 1–6.
- 10↑
Zeichen J, Van Griensven M, Albers I, Lobenhoffer P, & Bosch U. Immunohistochemical localization of collagen VI in arthrofibrosis. Archives of Orthopaedic and Trauma Surgery 1999 119 315–318. (https://doi.org/10.1007/s004020050417)
- 11↑
Walocha A, Rutowicz B, Przybycień W, Zarzecki M, Kłosiński M, Depukat P, Solewski B, Mizia E, Gil A, & Walocha E. Arthrofibrosis—a myth or true joint disorder? Folia Medica Cracoviensia 2022 62 55–70. (https://doi.org/10.24425/fmc.2022.141691)
- 12↑
Tjoumakaris FP, Tucker BC, Post Z, Pepe MD, Rozco F, & Ong AC. Arthroscopic lysis of adhesions for the stiff total knee: results after failed manipulation. Orthopedics 2014 37 e482–e487. (https://doi.org/10.3928/01477447-20140430-60)
- 13↑
Noyes FR, Berrios-Torres S, Barber-Westin SD, & Heckmann TP. Prevention of permanent arthrofibrosis after anterior cruciate ligament reconstruction alone or combined with associated procedures: a prospective study in 443 knees. Knee Surgery, Sports Traumatology, Arthroscopy 2000 8 196–206. (https://doi.org/10.1007/s001670000126)
- 14↑
Aglietti P, Windsor RE, Buzzi R, & Insall JN. Arthroplasty for the stiff or ankylosed knee. Journal of Arthroplasty 1989 4 1–5. (https://doi.org/10.1016/s0883-5403(8980046-4)
- 15↑
Schiavone Panni A, Cerciello S, Vasso M, & Tartarone M. Stiffness in total knee arthroplasty. Journal of Orthopaedics and Traumatology 2009 10 111–118. (https://doi.org/10.1007/s10195-009-0054-6)
- 16↑
Nelson CL, Kim J, & Lotke PA. Stiffness after total knee arthroplasty. Journal of Bone and Joint Surgery 2005 87(2) 264–270. (https://doi.org/10.2106/JBJS.E-00345)
- 17↑
Bellemans J, Vandenneucker H, Victor J, & Vanlauwe J. Flexion contracture in total knee arthroplasty. Clinical Orthopaedics and Related Research 2006 452 78–82. (https://doi.org/10.1097/01.blo.0000238791.36725.c5)
- 18↑
Magit D, Wolff A, Sutton K, & Medvecky MJ. Arthrofibrosis of the knee. Journal of the American Academy of Orthopaedic Surgeons 2007 15 682–694.
- 19↑
Ritter MA, Lutgring JD, Davis KE, Berend ME, Pierson JL, & Meneghini RM. The role of flexion contracture on outcomes in primary total knee arthroplasty. Journal of Arthroplasty 2007 22 1092–1096. (https://doi.org/10.1016/j.arth.2006.11.009)
- 20↑
Chonko DJ, Lombardi AV Jr, & Berend KR. Patella baja and total knee arthroplasty (TKA): etiology, diagnosis, and management. Surgical Technology International 2004 12 231–238.
- 21↑
Roosth HP. Flexion deformity of the hip and knee in spatic cerebral palsy: treatment by early release of spastic hip-flexor muscles. Journal of Bone and Joint Surgery 1971 53 1489–1510. (https://doi.org/10.2106/00004623-197153080-00003)
- 22↑
Tarabichi S, El-Naggar A, & Adi M. Operative procedure for primary TKR: how to increasing ROM. Soft Tissue Balancing in Total Knee Arthroplasty 2017 1 3 9–1 49. (https://doi.org/10.1007/978-3-662-54082-4_12)
- 23↑
Bhan S, Malhotra R, & Kiran EK. Comparison of total knee arthroplasty in stiff and ankylosed knees. Clinical Orthopaedics and Related Research 2006 451 87–95. (https://doi.org/10.1097/01.blo.0000229313.20760.13)
- 24↑
Baldini A, Castellani L, Traverso F, Balatri A, Balato G, & Franceschini V. The difficult primary total knee arthroplasty: a review. Bone and Joint Journal 2015 97–B(10_Supple_A) 30–39. (https://doi.org/10.1302/0301-620X.97B10.36920)
- 25↑
Gaston P, Will EM, & Keating JF. Recovery of knee function following fracture of the tibial plateau. Journal of Bone and Joint Surgery 2005 87 1233–1236. (https://doi.org/10.1302/0301-620X.87B9.16276)
- 26↑
Fisher DA, Dierckman B, & Watts M. Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. Journal of Arthroplasty 2007 22(2) 306.
- 27↑
Silva M, Luck JV Jr, & Llinás A. Chronic hemophilic synovitis: the role of radiosynovectomy. Treatment of Hemophilia World Fed Hemophilia 2004 33 1–10.
- 28↑
Post M, Watts G, & Telfer M. Synovectomy in hemophilic arthropathy: a retrospective review of 17 cases. Clinical Orthopaedics and RELATED RESEARCH® 1986 202 139–146.
- 29↑
Daffunchio C, Caviglia H, Nassif J, Morettil N, & Galatro G. Knee flexion contracture treated with botulinum toxin type A in patients with haemophilia (PWH). Haemophilia 2016 22 134–141. (https://doi.org/10.1111/hae.12745)
- 30↑
Balci HI, Kocaoglu M, Eralp L, & Bilen FE. Knee flexion contracture in haemophilia: treatment with circular external fixator. Haemophilia 2014 20 879–883. (https://doi.org/10.1111/hae.12478)
- 31↑
Morgan DS, Fisher D, Merianos A, & Currie BJ. An 18 year clinical review of septic arthritis from tropical Australia. Epidemiology and Infection 1996 117 423–428. (https://doi.org/10.1017/s0950268800059070)
- 32↑
Mathews CJ, Weston VC, Jones A, Field M, & Coakley G. Bacterial septic arthritis in adults. Lancet 2010 375 846–855. (https://doi.org/10.1016/S0140-6736(0961595-6)
- 33↑
Stutz G, & Gächter A. Diagnostik und stadiengerechte Therapie von Gelenkinfekten. Unfallchirurg 2001 104 682–686. (https://doi.org/10.1007/s001130170068)
- 34↑
Stutz G, Kuster MS, Kleinstück F, & Gächter A. Arthroscopic management of septic arthritis: stages of infection and results. Knee Surgery, Sports Traumatology, Arthroscopy 2000 8 270–274. (https://doi.org/10.1007/s001670000129)
- 35↑
Riveros A, Mateo L, Martínez-Morillo M, Tejera B, Rodríguez S, Sanint J, Holgado S, Canellas J, Tena X, Olivè A, et al.THU0434 pyogenic arthritis: clinical and epidemiological features of 101 cases at a University Hospital. Annals of the Rheumatic Diseases 2013 72(Supplement 3) A311.2–A3A311. (https://doi.org/10.1136/annrheumdis-2013-eular.962)
- 36↑
Kaandorp CJ, Krijnen P, Moens HJB, Habbema JDF, & van Schaardenburg D. The outcome of bacterial arthritis: a prospective community-based study. Arthritis and Rheumatism 1997 40 884–892. (https://doi.org/10.1002/art.1780400516)
- 37↑
Weston VC, Jones AC, Bradbury N, Fawthrop F, & Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982–1991. Annals of the Rheumatic Diseases 1999 58 214–219. (https://doi.org/10.1136/ard.58.4.214)
- 38↑
Leroy R, Segaud N, Migaud H, Senneville E, Cortet B, & Flipo R-M. SAT0499 septic arthritis in rheumatology: management and evolution over the past 50 years. About 374 cases. Annals of the Rheumatic Diseases 2016 75(Suppl 2) 851. (https://doi.org/10.1136/annrheumdis-2016-eular.3432).
- 39↑
Abram SGF, Alvand A, Judge A, Beard DJ, & Price AJ. Mortality and adverse joint outcomes following septic arthritis of the native knee: a longitudinal cohort study of patients receiving arthroscopic washout. Lancet. Infectious Diseases 2020 20 341–349. (https://doi.org/10.1016/S1473-3099(1930419-0)
- 40↑
Colavite PM, & Sartori A. Septic arthritis: immunopathogenesis, experimental models and therapy. Journal of Venomous Animals and Toxins Including Tropical Diseases 2014 20 19. (https://doi.org/10.1186/1678-9199-20-19)
- 41↑
Reátiga Aguilar J, Rios X, González Edery E, De La Rosa A, & Arzuza Ortega L. Epidemiological characterization of tibial plateau fractures. Journal of Orthopaedic Surgery and Research 2022 17 106. (https://doi.org/10.1186/s13018-022-02988-8)
- 42↑
Vega-Caicedo R, Piñeros-Ramírez DF, Galván-Villamarín F, & Medina-Castiblanco C. Descripción epidemiológica y evaluación de los desenlaces de interés de las fracturas de platillos tibiales. Revista de la Facultad de Medicina 2013 61 25–33.
- 43↑
Jagdev SS, Pathak S, Kanani H, & Salunke A. Functional outcome and incidence of osteoarthritis in operated tibial plateau fractures. Archives of Bone and Joint Surgery 2018 6 508–516.
- 44↑
Kugelman DN, Qatu AM, Strauss EJ, Konda SR, & Egol KA. Knee stiffness after tibial plateau fractures: predictors and outcomes (OTA-41). Journal of Orthopaedic Trauma 2018 32 e421–e427. (https://doi.org/10.1097/BOT.0000000000001304)
- 45↑
Reahl GB, Marinos D, O'Hara NN, Howe A, Degani Y, Wise B, Maceroli M, & O'Toole RV. Risk factors for knee stiffness surgery after tibial plateau fracture fixation. Journal of Orthopaedic Trauma 2018 32 e339–e343. (https://doi.org/10.1097/BOT.0000000000001237)
- 46↑
Gálvez-Sirvent E, Ibarzábal-Gil A, & Rodríguez-Merchán EC. Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management. EFORT Open Reviews 2022 7 554–568. (https://doi.org/10.1530/EOR-22-0004)
- 47↑
Harner CD, Irrgang JJ, Paul J, Dearwater S, & Fu FH. Loss of motion after anterior cruciate ligament reconstruction. American Journal of Sports Medicine 1992 20 499–506. (https://doi.org/10.1177/036354659202000503)
- 48↑
Shelbourne KD, & Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. American Journal of Sports Medicine 1990 18 292–299. (https://doi.org/10.1177/036354659001800313)
- 49↑
Dodds JA, Keene JS, Graf BK, & Lange RH. Results of knee manipulations after anterior cruciate ligament reconstructions. American Journal of Sports Medicine 1991 19 283–287. (https://doi.org/10.1177/036354659101900313)
- 50↑
Bach BR, Jones GT, Sweet FA, & Hager CA. Arthroscopy-assisted anterior cruciate ligament reconstruction using patellar tendon substitution: two-to four-year follow-up results. The American Journal of Sports Medicine 1994 22 758–767.
- 51↑
Shelbourne KD, Wilckens JH, Mollabashy A, & DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction: the effect of timing of reconstruction and rehabilitation. American Journal of Sports Medicine 1991 19 332–336. (https://doi.org/10.1177/036354659101900402)
- 52↑
Sterett WI, Hutton KS, Briggs KK, & Steadman JR. Decreased range of motion following acute versus chronic anterior cruciate ligament reconstruction. Orthopedics 2003 26 151–154. (https://doi.org/10.3928/0147-7447-20030201-16)
- 53↑
Jackson DW, & Schaefer RK. Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction. Arthroscopy 1990 6 171–178. (https://doi.org/10.1016/0749-8063(9090072-l)
- 54↑
Paulos LE, Wnorowski DC, & Greenwald AE. Infrapatellar contracture syndrome: diagnosis, treatment, and long-term followup. American Journal of Sports Medicine 1994 22 440–449. (https://doi.org/10.1177/036354659402200402)
- 55↑
Kalson NS, Borthwick LA, Mann DA, Deehan DJ, Lewis P, Mann C, Mont MA, Mogran-Jones R, Oussedik S, Williams FMK, et al.International consensus on the definition and classification of fibrosis of the knee joint. Bone and Joint Journal 2016 98–B 1479–1488. (https://doi.org/10.1302/0301-620X.98B10.37957)
- 56↑
Johns BP, Loewenthal MR, & Dewar DC. Open compared with arthroscopic treatment of acute septic arthritis of the native knee. Journal of Bone and Joint Surgery 2017 99 499–505. (https://doi.org/10.2106/JBJS.16.00110)
- 57↑
Scuderi GR. Techniques in Revision Hip and Knee Arthroplasty. Elsevier Health Sciences, Philadelphia, PA, USA. 2014.
- 58↑
Thakkar P, John JA, Thomas R, Tilak M, Kandagaddala M, Poonnoose P, Fouzia Abubacker NA, Abrahm A, & Srivastava A. Mobilization under anaesthesia for correction of knee flexion deformity in haemophilia. Haemophilia 2023 29 1597–1603. (https://doi.org/10.1111/hae.14870)
- 59↑
Smith EL, Banerjee SB, & Bono JV. Supracondylar femur fracture after knee manipulation: a report of 3 cases. Orthopedics 2009 32 18. (https://doi.org/10.3928/01477447-20090101-22)
- 60↑
Sprague NF, O'Connor RL, & Fox JM. Arthroscopic treatment of postoperative knee fibroarthrosis. Clinical Orthopaedics and Related Research 1982 166 165–172. (https://doi.org/10.1097/00003086-198206000-00029)
- 61↑
Kim DH, Gill TJ, & Millett PJ. Arthroscopic treatment of the arthrofibrotic knee. Arthroscopy 2004 20(Supplement 2) 187–194. (https://doi.org/10.1016/j.arthro.2004.04.036)
- 62↑
Gittings D, Hesketh P, Dattilo J, Zgonis M, Kelly J, & Mehta S. Arthroscopic lysis of adhesions improves knee range of motion after fixation of intra-articular fractures about the knee. Archives of Orthopaedic and Trauma Surgery 2016 136 1631–1635. (https://doi.org/10.1007/s00402-016-2561-2)
- 63↑
Eggeling L, Klepsch L, Akoto R, & Frosch K-H. Clinical results after very early, early and late arthroscopic arthrolysis of the knee. International Orthopaedics 2022 46 265–271. (https://doi.org/10.1007/s00264-021-05193-0)
- 64↑
Schwarzkopf R, William A, Deering RM, & Fitz W. Arthroscopic lysis of adhesions for stiff total knee arthroplasty. Orthopedics 2013 36 e1544–e1548. (https://doi.org/10.3928/01477447-20131120-20)
- 65↑
Bodendorfer BM, Kotler JA, Zelenty WD, Termanini K, Sanchez R, & Argintar EH. Outcomes and predictors of success for arthroscopic lysis of adhesions for the stiff total knee arthroplasty. Orthopedics 2017 40 e1062–e1068. (https://doi.org/10.3928/01477447-20171012-06)
- 66↑
Rankin EA, Alarcòn GS, Chang RW, & Cooney LM Jr. NIH Consensus Statement on total knee replacement December 8–10, 2003. Journal of Bone and Joint Surgery 2004 86 1328–1335. (https://doi.org/10.2106/00004623-200406000-00030)
- 67↑
Ritter MA, Harty LD, Davis KE, Meding JB, & Berend ME. Predicting range of motion after total knee arthroplasty: clustering, log-linear regression, and regression tree analysis. Journal of Bone and Joint Surgery 2003 85 1278–1285. (https://doi.org/10.2106/00004623-200307000-00014)
- 68↑
Boettner F, Sculco P, Faschingbauer M, Rueckl K, Windhager R, & Kasparek MF. Clinical outcome of posterior-stabilized total knee arthroplasty using an increased flexion gap in patients with preoperative stiffness. Bone and Joint Journal 2020 102–B 426–433. (https://doi.org/10.1302/0301-620X.102B4.BJJ-2018-1404.R3)
- 69↑
Easley ME, Insall JN, Scuderi GR, & Bullek DD. Primary constrained condylar knee arthroplasty for the arthritic valgus knee. Clinical Orthopaedics and Related Research® 2000 380 58–64.
- 70↑
Anderson JA, Baldini A, MacDonald JH, Pellicci PM, & Sculco TP. Primary constrained condylar knee arthroplasty without stem extensions for the valgus knee. Clinical Orthopaedics and Related Research® 2006 442 199–203.
- 71↑
Garbedian S, Sternheim A, & Backstein D. Wound healing problems in total knee arthroplasty. Orthopedics 2011 34 e516–e518. (https://doi.org/10.3928/01477447-20110714-42)
- 72↑
Burge JR, Sanchez HB, & Wagner RA. Quadriceps and patellar tendon pie-crusting as a treatment for limited flexion in total knee arthroplasty. American Journal of Orthopedics 2014 43 E83–E88.
- 73↑
Zhang Y, Ye LY, Liu HX, & Wen H. Quadriceps tendon pie-crusting release of stiff knees in total knee arthroplasty. Journal of Orthopaedic Science 2015 20 669–674. (https://doi.org/10.1007/s00776-015-0731-7)
- 74↑
Shang P, Liu HX, Zhang Y, Xue EX, & Pan XY. A mini-invasive technique for severe arthrofibrosis of the knee: a technical note. Injury 2016 47 1867–1870. (https://doi.org/10.1016/j.injury.2016.06.015)
- 75↑
Jn I, Insall JN, Windsor RE, Scott WN, Kelly MA, & Alietti P, eds. Osteotomy Surgery of the Knee, pp. 635–676. New York, NY: Churchill Livingstone 1993.
- 76↑
Tang X, Kong X, Cao Z, Chen Q, & Chai W. Application of quadriceps snip in complex total knee arthroplasty. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi= Zhongguo Xiufu Chongjian Waike Zazhi= Chinese Journal of Reparative and Reconstructive Surgery 2020 34 1096–1100. (https://doi.org/10.7507/1002-1892.202001075)
- 77↑
Coonse K. A new operative approach to the knee joint. Surgery, Gynecology and Obstetrics 1943 77 344–347.
- 78↑
Trousdale RT, Hanssen AD, Rand JA, & Cahalan TD. VY quadricepsplasty in total knee arthroplasty. Clinical Orthopaedics and Related Research 1993 286 48–55.
- 79↑
Della Valle CJ, Berger RA, & Rosenberg AG. Surgical exposures in revision total knee arthroplasty. Clinical Orthopaedics and Related Research 2006 446 59–68. (https://doi.org/10.1097/01.blo.0000214434.64774.d5)
- 80↑
Hsu CH, Lin PC, Chen WS, & Wang JW. Total knee arthroplasty in patients with stiff knees. Journal of Arthroplasty 2012 27 286–292. (https://doi.org/10.1016/j.arth.2011.05.001)
- 81↑
Scott RD, & Siliski JM. The use of a modified VY quadricepsplasty during total knee replacement to gain exposure and improve flexion in the ankylosed knee. Orthopedics 1985 8 45–48. (https://doi.org/10.3928/0147-7447-19850101-07)
- 82↑
Abdel MP, & Della Valle CJ. The surgical approach for revision total knee arthroplasty. Bone and Joint Journal 2016 98–B(1_Supple_A) 113–115. (https://doi.org/10.1302/0301-620X.98B1.36315)
- 83↑
Divano S, Camera A, Biggi S, Tornago S, Formica M, & Felli L. Tibial tubercle osteotomy (TTO) in total knee arthroplasty, is it worth it? A review of the literature. Archives of Orthopaedic and Trauma Surgery 2018 138 387–399. (https://doi.org/10.1007/s00402-018-2888-y)
- 84↑
Punwar SA, Fick DP, & Khan RJK. Tibial tubercle osteotomy in Revision Knee Arthroplasty. Journal of Arthroplasty 2017 32 903–907. (https://doi.org/10.1016/j.arth.2016.08.029)
- 85↑
Choi HR, Kwon YM, Burke DW, Rubash HE, & Malchau H. The outcome of sequential repeated tibial tubercle osteotomy performed in 2-stage revision arthroplasty for infected total knee arthroplasty. Journal of Arthroplasty 2012 27 1487–1491. (https://doi.org/10.1016/j.arth.2012.03.016)
- 86↑
Payne J, Rimmke N, Schmitt LC, Flanigan DC, & Magnussen RA. The incidence of complications of tibial tubercle osteotomy: a systematic review. Arthroscopy 2015 31 1819–1825. (https://doi.org/10.1016/j.arthro.2015.03.028)
- 87↑
Cance N, Batailler C, Shatrov J, Canetti R, Servien E, & Lustig S. Contemporary outcomes of tibial tubercle osteotomy for revision total knee arthroplasty. Bone and Joint Journal 2023 105–B 1078–1085. (https://doi.org/10.1302/0301-620X.105B10.BJJ-2022-1140.R2)
- 88↑
Firestone TP, Krackow KA, Davis JD, Teeny SM, & Hungerford DS. The management of fixed flexion contractures during total knee Arthropfasty. Clinical Orthopaedics and Related Research 1992 284 221–227. (https://doi.org/10.1097/00003086-199211000-00031)
- 89↑
Lombardi A. Dealing with flexion contracture in total knee arthroplasty. Bone resection versus soft tissue release. In Current Concepts in Primary and Revision Total Knee Arthroplasty. Inshall JN, Scott NW, & Scuderi GR, eds. Philadelphia: Lippincortt-Raven 1996.
- 90↑
Mihalko WM, & Whiteside LA. Bone resection and ligament treatment for flexion contracture in knee arthroplasty. Clinical Orthopaedics and Related Research® 2003 406 141–147.
- 91↑
Berend KR, Lombardi AV Jr, & Adams JB. Total knee arthroplasty in patients with greater than 20 degrees flexion contracture. Clinical Orthopaedics and Related Research® 2006 452 83–87.
- 92↑
Smith CK, Chen JA, Howell SM, & Hull ML. An in vivo study of the effect of distal femoral resection on passive knee extension. Journal of Arthroplasty 2010 25 1137–1142. (https://doi.org/10.1016/j.arth.2009.05.030)
- 93↑
Liu DW, Reidy JF, & Beller EM. The effect of distal femoral resection on fixed flexion deformity in total knee arthroplasty. Journal of Arthroplasty 2016 31 98–102. (https://doi.org/10.1016/j.arth.2015.07.033)
- 94↑
Bengs BC, & Scott RD. The effect of distal femoral resection on passive knee extension in posterior cruciate ligament–retaining total knee arthroplasty. Journal of Arthroplasty 2006 21 161–166. (https://doi.org/10.1016/j.arth.2005.06.008)
- 95↑
Figgie HE, Goldberg VM, Heiple KG, Moller HS 3rd, & Gordon NH. The influence of tibial-patellofemoral location on function of the knee in patients with the posterior stabilized condylar knee prosthesis. Journal of Bone and Joint Surgery 1986 68 1035–1040. (https://doi.org/10.2106/00004623-198668070-00009)
- 96↑
Mihalko WM, & Krackow KA. Posterior cruciate ligament effects on the flexion space in total knee arthroplasty. Clinical Orthopaedics and Related Research® 1999 360 243–250.
- 97↑
Kayani B, Konan S, Horriat S, Ibrahim MS, & Haddad FS. Posterior cruciate ligament resection in total knee arthroplasty: the effect on flexion-extension gaps, mediolateral laxity, and fixed flexion deformity. Bone and Joint Journal 2019 101–B 1230–1237. (https://doi.org/10.1302/0301-620X.101B10.BJJ-2018-1428.R2)
- 98↑
Gatha NM, Clarke HD, Fuchs R, Scuderi GR, & Insall JN. Factors affecting postoperative range of motion after total knee arthroplasty. Journal of Knee Surgery 2004 17 196–202. (https://doi.org/10.1055/s-0030-1248221)
- 99↑
Harvey IA, Barry K, Kirby SP, Johnson R, & Elloy MA. Factors affecting the range of movement of total knee arthroplasty. Journal of Bone and Joint Surgery 1993 75 950–955. (https://doi.org/10.1302/0301-620X.75B6.8245090)
- 100↑
Mullen JO. Range of motion following total knee arthroplasty in ankylosed joints. Clinical Orthopaedics and Related Research 1983 179 200–203. (https://doi.org/10.1097/00003086-198310000-00031)
- 101↑
McAuley JP, Harrer MF, Ammeen D, & Engh GA. Outcome of knee arthroplasty in patients with poor preoperative range of motion. Clinical Orthopaedics and Related Research 2002 404 203–207. (https://doi.org/10.1097/00003086-200211000-00033)
- 102↑
Kim YH, & Kim JS. Does TKA improve functional outcome and range of motion in patients with stiff knees? Clinical Orthopaedics and Related Research 2009 467 1348–1354. (https://doi.org/10.1007/s11999-008-0445-7)
- 103↑
Purudappa PP, Sharma OP, Chandrasekharan J, Sudevan PJ, Mounasamy V, & Sambandam SN. Clinical outcome, functional outcome and patient satisfaction after cruciate retaining total knee arthroplasty for stiff arthritic knee - a short term outcome study. Journal of Orthopaedics 2020 20 6–11. (https://doi.org/10.1016/j.jor.2019.12.001)
- 104↑
Debette C, Lustig S, Servien E, Lording T, Villa V, Demey G, & Neyret P. Total knee arthroplasty of the stiff knee: three hundred and four cases. International Orthopaedics 2014 38 285–289. (https://doi.org/10.1007/s00264-013-2252-3)
- 105↑
Rajgopal A, Ahuja N, & Dolai B. Total knee arthroplasty in stiff and ankylosed knees. Journal of Arthroplasty 2005 20 585–590. (https://doi.org/10.1016/j.arth.2005.04.002)
