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Management of stiffness following total knee arthroplasty: A systematic review
The Knee 19 (2012) 751–759
Contents lists available at SciVerse ScienceDirect
The Knee
Review
Management of stiffness following total knee arthroplasty: A systematic review H. Ghani a, N. Maffulli b, V. Khanduja a,⁎ a b
Addenbrooke's - Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Barts and The London School of Medicine, London, UK
a r t i c l e
i n f o
a b s t r a c t Aim: The aim of the study was to systematically evaluate the outcome of four main modalities of treatment for arthrofibrosis that develops subsequent to a total knee arthroplasty (TKA), namely manipulation under anesthesia (MUA), arthroscopic debridement, open surgical release and revision TKA. Materials and methods: A computerised search was conducted for relevant studies published from 1975 onwards in all the major databases and various search engines. A total of twenty-five studies were selected, representing a total of 798 patients. Studies that passed the inclusion criteria were then subjected to quality assessment using the Newcastle-Ottawa Scale. On assessment, the 25 studies scored a total of 77 stars out of a possible 125. Two studies were prospective in design, while the remaining case series were retrospective in nature. The primary outcome measures assessed were increase in range of movement (ROM) and the Knee Society Score (KSS) at final follow-up. Results: Our results showed that manipulation under anesthesia (MUA) had a mean increase in ROM of 38.4°, arthroscopic release had a mean increase of 36.2°, open surgical release had a mean increase of 43.4° and revision TKA had a mean increase of 24.7°. No significant differences were found in the KSS of the four treatment modalities. Our analysis suggests that open surgical release would be the most beneficial option for patients who are fit to undergo secondary surgery if their lifestyle requires a higher ROM for activities of daily living. However, there were methodological limitations as majority of the papers were case series, which decreased the quality of the evidence available. © 2012 Elsevier B.V. All rights reserved.
Article history: Received 15 November 2011 Received in revised form 22 February 2012 Accepted 27 February 2012 Keywords: Total knee arthroplasty Stiffness
Contents 1. 2. 3. 4.
Introduction . . . . . . . . . . . . . Materials and methods . . . . . . . . Results . . . . . . . . . . . . . . . Treatment strategies . . . . . . . . . 4.1. Manipulation under anesthesia 4.2. Arthroscopic release . . . . . . 4.3. Open surgical release . . . . . 4.4. Revision total knee arthroplasty 5. Discussion . . . . . . . . . . . . . 6. Conclusion . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . . References . . . . . . . . . . . . . . . .
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1. Introduction
⁎ Corresponding author at: Addenbrooke's - Cambridge University Hospitals NHS Trust, Box 37, Hills Road, Cambridge CB2 0QQ, UK. Tel.: + 44 1223 256 405. E-mail address: [email protected] (V. Khanduja). 0968-0160/$ – see front matter © 2012 Elsevier B.V. All rights reserved. doi:10.1016/j.knee.2012.02.010
Total knee arthroplasty (TKA) is considered to be the most effective and reliable treatment for patients with advanced osteoarthritis of the knee. The definition of stiffness varies widely throughout the available literature, resulting in different reported ranges of prevalence. However,
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two large series performed in recent times by Kim et al. [1] and Yercan et al. [2] report the prevalence to be 1.3% in 1000 knees and 5.3% in 1188 knees respectively. Post-operative stiffness, which is attributed to arthrofibrosis which occurs in the knee joint, can be extremely debilitating for the patient, often making activities of daily living such as climbing stairs or rising from a chair painful and difficult [3,4]. The causes of arthrofibrosis after total knee arthroplasty surgery are multifactorial. Several risk factors for stiffness in the knee post-TKA have been identified. These risk factors can be divided into pre-operative, per-operative and post-operative. The most significant and well-recognised cause of a stiff TKA is decreased pre-operative range of movement [5]. A correlation also has been demonstrated between history of previous surgery and diabetes mellitus and stiffness post-TKA [6]. Per-operative risk factors leading to stiffness include incorrect flexion–extension gap, malpositioning of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope and incomplete resection of posterior osteophytes. Post-operative risk factors leading to decreased range of movement include poor patient motivation, lack of compliance with physiotherapy, deep infection, arthrofibrosis of the knee joint, patellar complications, complex regional pain syndrome and heterotopic ossification [7]. The definition of stiffness in the knee varies within the available literature, Christensen et al. [8] described it as an arc of motion less than 70° whereas Kim et al. [1] describe it as a flexion contracture of >15° and/or b75° of flexion. Another parameter that is used to measure stiffness in the knee is the Knee Society Scoring System, which provides a uniform method to quantify the amount of pain that the patient is experiencing in the knee. It encompasses various aspects of knee movement and function, such as pain, flexion contracture, extension lag, range of movement, alignment and stability [9]. The various treatment options available for arthrofibrosis of the knee are manipulation under anesthesia (MUA), arthroscopic arthrolysis, open arthrolysis and finally revision TKA. MUA is generally regarded as the first step in the treatment of a stiff TKA, especially in the first two months [2]. The technique of performing MUA is uniform, the patient is put under adequate anesthesia to the point of maximum relaxation and the ipsilateral hip is flexed to 90°. The knee is then flexed slowly and gently until the audible and palpable separation of adhesions no longer occurs [10]. Arthroscopic release is another treatment option for the stiff TKA, and is usually performed in moderately painful and stiff knees, preferably within 3 to 6 months after TKA. In arthroscopic debridement, the arthrofibrosis is relieved by resecting large fibrous bands of scar tissue under arthroscopic visualisation [6]. In certain cases, open surgical release is recommended to patients, especially in the case of severe stiffness (b60°). Other cases of severe stiffness, especially those with malpositioned implants, require a revision TKA. Although studies have been performed in the past to examine the effect of these treatment modalities on the stiff knee post-TKA, there is paucity of evidence regarding the comparable effectiveness of these treatments. The aim of this systematic review, therefore, was to pool the studies dealing with different treatment strategies available in order to summarise the outcome of these treatment modalities. In the literature reviewed, different treatments of post-TKA stiffness have been explored to compare the outcomes of improvement in range of movement and improvement in the Knee Society Score (KSS).
replacement arthroplasty” OR (“total” AND “knee” AND “replacement”) OR “total knee replacement” into the various databases used in order to maximise the amount and relevance of articles retrieved. The articles included were those published in English, Italian, French and Spanish from 1975 to date. We used the databases PubMed, Embase, Ovid, CINAHL, The National Research Register, The National Technical Information Service, the UKCRN Portfolio Database and the Cochrane Library. To prevent publication bias we also used the OpenGrey database as well as search engines Yahoo, Google and Google Scholar to find any additional articles that may be unpublished or may have been missed out on during our search. Initially, we identified all abstracts that discussed arthrofibrosis in the knee that developed post-TKA. These articles were then narrowed down further to those in which a specific treatment modality, such as MUA, arthroscopic lysis, open surgical release or revision TKA was carried out. Once these articles were accumulated, they were subjected to scrutiny by the authors. Certain studies were then rejected based on reporting insufficient data, non-standardised scoring systems, lack of precise comparison methods and articles for which translation of the language was unavailable. We then hand searched the reference lists of the articles that had been included to retrieve citations to articles that may have been missed by our search to add to the database, and those articles were then subjected to assessment under the same inclusion criteria. The studies that were included were non-specific for age, gender, operating institution or the type of prosthesis, and non-randomised as well as randomised trials were included. Once the articles had been selected, they were then subjected to quality assessment using the Newcastle-Ottawa Scale (NOS), adjusted for use in studies involving case series. It was originally developed as a tool for quality assessment of non-randomised studies to be used in a systematic review. The NOS uses a ‘star’ rating system to judge the quality of studies based on study design, selection, and assessment of outcome. The maximum number of stars a study may receive in each category is two, one and two respectively, for a total possibility of five stars [11,12]. The outcome measures that were most commonly reported throughout all the studies were measurement of the average range of movement (ROM) after each treatment modality, as well as the Knee Society Pain Score. The minimum average follow-up time at which these outcomes were assessed was at 3 months post-intervention.
2. Materials and methods
A total of 10 studies of the total 25 reviewed reported the results of this technique (Fig. 3). The method by which it was performed was described in all of the articles, and was uniform. In the studies in which the interval between primary TKA and MUA was given, they were all described as being performed within the first 3 months of surgery. The improvement in range of movement (ROM) was clearly given in only 6 out of the 10 studies, the rest choosing to report the
The first step of the research was the data search and selection. Using the medical subject heading terms arthroplasty, replacement and knee along with Boolean operators ‘or’ and ‘and’, we entered the search query “stiffness” AND “(arthroplasty, replacement, knee)” OR (“arthroplasty” AND “replacement” AND “knee”) OR “knee
3. Results Of the 199 papers that were initially gathered during screening, 25 trials were finally selected for data extraction and systematic review (Fig. 1). Of the 25 trials, 23 were retrospective while only two were prospective. The total number of participants was 798. The studies were then subjected to quality assessment using the NewcastleOttawa Scale (NOS). On assessment, the 25 studies scored a total of 77 stars, out of a possible 125. The scores of all individual studies are described in Fig. 2. The two studies that were prospective in design scored the highest, however the remaining case series were retrospective in nature (Fig. 2). The main drawbacks in the studies that affected their quality score were the retrospective nature of the study, the studies being based on a minor group selected by the surgeon, and absence of description for blind assessment.
4. Treatment strategies 4.1. Manipulation under anesthesia
H. Ghani et al. / The Knee 19 (2012) 751–759 # of articles identified through database searching = 176
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# of articles identified throug hot her sources = 23
# of records after duplicates removed=197
# of records screened =197
# of records excluded =154
# of full text articles that were assessed for eligibility = 43
# of full text articles excluded due to not being fit for the inclusion criteria and/or using nonstandardized measures of outcome= 18
# of studies included in the final systematic review = 25
Fig. 1. PRISMA flow diagram.
final increase in flexion instead. The overall mean of the improvement in ROM in degrees for these studies [2,6,10,13–15] was 38.4°. The average increase in flexion was also described in 6 out of the 9 studies [10,13,14,16–18] and was 29.4° respectively. The mean increase in extension was only given in three studies [8,13,14] and was 5.7°. The p-values measured in all of the studies, except for Scranton [6],
Cates [13], Fox [18] and Maloney [15] in which the p-value had not been reported, showed that the improvement in ROM in the reviewed studies was significant. The mean Knee Society Pain Score was only evaluated in two studies, and was shown to be 44 and 46, respectively (Fig. 4). According to Keating et al. [17], the Knee Society Pain Score of 46 at a follow up of
Study ID
Year conducted
Type of study
Sample size (Number of knees)
Male/ Female
Mean follow up time (years + months)
Quality score*
Fox Sprague Campbell Wasilewski Johnson Bae Williams Diduch Esler Scranton Babis Teng Maloney Kim Keeney Yercan Hutchinson Mont Jerosch Keating Mohammed Cates Rubinstein Arbuthnot Ipach
1981 1982 1987 1989 1990 1995 1996 1997 1999 2001 2001 2002 2002 2004 2005 2005 2005 2006 2007 2007 2009 2009 2010 2010 2011
Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective
76 24 8 13 14 13 10 38 59 33 7 11 24 56 25 56 13 18 32 113 21 37 36 22 39
--7/17 3/5 4/9 4/10 0/11 4/5 14/24 18/24 8/25 2/5 6/5 --14/38 --14/49 5/8 11/6 10/22 35/55 10/11 --8/26 7/14 32/7
1+0 0+8 1+0 2+1 0+16 2+6 1+8 1+8 2+0 1+0 4+2 0+3 --3+7 3+0 2+7 7+0 2+6 2+3 4+7 0+3 1+0 3+10 3+8 0+6
3/5 3/5 3/5 3/5 3/5 3/5 3/5 3/5 4/5 3/5 3/5 3/5 3/5 3/5 3/5 3/5 3/5 4/5 3/5 3/5 3/5 3/5 3/5 3/5 3/5
• - Quality assessed according to the Newcastle-Ottawa Scale (NOS), adjusted for case series. --- - Not mentioned in manuscript. Fig. 2. Quality assessment of studies according to Newcastle-Ottawa Scale.
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Study ID
Age range of patients
Sample size of patients
Mean time elapsed between TKA and MUA (months)
Mean ROM before TKA
Mean improvement in ROM in degrees (°)
Mean improvement in flexion
Mean improvement in extension
p-value of mean improvement in ROM
Yercan Esler Scranton Keating Mohammed Cates Rubinstein Fox Maloney Ipach
54-88 46-88 --34-84 56-80 32-80 51-85 ----42-82
46 47 19 90 21 37 37 76 24 39
1 3 1.5-7 2 3 ----.5 1.7 2.6
--102 --102 --115 109 ----104.9
47 --42 --30.2 26 38 --47 ---
--35.4 --35 20.7 22 33 30 --26.5
--------8.1 4 5 -------
p<0.015 p<0.01 --p<0.0001 p<0.001 --p<0.001 -------
--- = not mentioned in manuscript Fig. 3. Manipulation under anesthesia — outcomes.— = not mentioned in manuscript.
one year was significant (p b 0.0001). This was the only study in which the p-value of the Pain Score was provided. The literature pertaining to MUA was very inadequate in terms of reporting improvement in terms of the Knee Society Function and Knee scores, and no other clinical grading system was used in the remaining studies to assess the patients at follow up. The majority of studies pertaining to MUA had low complication rates (Fig. 5). The study by Fox and Poss [18] had the highest complication rate of all the studies, with haemarthrosis occurring in three patients, wound separation in one patient and the death of one patient resulting from pulmonary embolism secondary to deep vein thrombosis in the manipulated leg. One patient in the study by Keating et al. [17] had a supracondylar femoral fracture during or after the MUA. Out of the total patient sample size of 436 that underwent MUA, 29 patients were considered failures, giving us a failure rate of 6.7%. Ten patients underwent a subsequent procedure, either a further MUA, arthroscopic adhesiolysis or femoral revision implantation [6,13,14,19].
and 5 months. The improvement in ROM was examined in all but one study. The average improvement in ROM in degrees for this treatment in these studies was shown to be 36.2°, however we could not ascertain for certain whether or not these improvements were statistically significant because with the exception of three studies (Arbuthnot and Brink [20], Sprague et al. [21] and Johnson et al. [22]) the p-values were not provided in any of the studies reviewed. The mean improvement in flexion was given in 8 of the 12 studies [2,20,22–27] and came to 35.2°. The mean improvement in extension was described in seven out of 12 studies [2,20,22–26] and was 6.4° respectively. The Knee Society Score (KSS) results were not reported in the majority of studies following arthroscopy (Fig. 7). The mean Knee Society Function Score at final follow up was shown in three of the 12 studies reviewed and was 85, 88 and 85 respectively [23,25,28]. The mean Knee Society Knee score was also reported in three out of 12 studies and was 86, 86.4 and 87 respectively [2,23,26]. The mean Knee Society Pain Score at follow up was shown in three of the 12 studies reviewed, and was 38, 41 and 42 respectively [2,21,23]. The complication rate was low in the arthroscopic release patient group. Of the studies reviewed (Fig. 8), complications that occurred were a superficial skin infection in one patient and tenderness in the infrapatellar fat pad in one other patient [19]. One patient had instrument breakage occur during the arthroscopy [20] but this was resolved immediately without any further complications. A superficial wound infection was also reported in one patient in another study [25]. Out of the total sample size of 195 patients, seven were clearly termed as failures (3.6% of total). A total of 15 patients underwent subsequent procedures after arthroscopic adhesiolysis, which consisted of 12 revision TKA's, two repeat arthroscopies and one arthrodesis.
4.2. Arthroscopic release This was the most commonly researched treatment strategy for stiffness post-TKA. A total of 12 studies of the total 25 reported the results of arthroscopic adhesiolysis (Fig. 6). The method by which this technique was performed was also described in each article, and was relatively uniform in their technique, with fibrous bands of scar tissue being inspected in the suprapatellar pouch, medial and lateral gutters and intercondylar notch and subsequently removed with a soft tissue shaver under arthroscopic visualisation. The time interval between the primary TKA and the arthroscopic surgery was described in eight of out the 12 studies and ranged from 8.5 months to 2 years
Study ID
Mean knee society function score at follow-up
Mean knee society knee score at follow-up
Mean knee society pain score at follow-up
Yercan Esler Scranton Keating Mohammed Cates Rubinstein Fox Maloney Ipach
---------------------
---------------------
44 ----46 -------------
--- = not mentioned in manuscript Fig. 4. Manipulation under anesthesia — KSS results.
H. Ghani et al. / The Knee 19 (2012) 751–759
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Study ID
Failures/Complications
Yercan
No complications observed. 3 patients observed persistent pain (7% of MUA group in this particular study). 7 patients’ ROM was not improved by MUA. Patient satisfaction was not asked. No complications as a result of MUA. One patient showed no gain in ROM. 4 of the manual manipulations were failures, requiring arthroscopic treatment, 3 of which were successful. One osteoporotic patient suffered a supracondylar femoral fracture either intraoperatively or postoperatively with under epidural analgesia. 9 patients had continuous pain and no gain in flexion after MUA. No complications observed. One patient showed no improvement in ROM either immediately after MUA or at follow up. No complications observed. 3 patients (8%) did not improve ROM after MUA and 2 patients (5%) underwent further MUA with arthroscopic adhesiolysis. No complications observed. 3 patients had to be re-manipulated due to lack of progress. In 3 patients the manipulation resulted in hemarthrosis and in 1 patient wound separation occurred. 1 patient died within 24 hours of manipulation due to a pulmonary embolism secondary to deep vein thrombosis in the calf of the manipulated leg. --One patient developed a supracondylar fracture during the MUA. A femoral revision implant was then required.
Esler Scranton Keating Mohammed Cates Rubinstein Fox Maloney Ipach
--- = not mentioned/not clearly presented in manuscript. Fig. 5. Manipulation under anesthesia — failures and complications.
The studies pertaining to open surgical release were relatively more regular in terms of reporting the KSS (Fig. 10). The mean Knee Society Function score was evaluated in two out of the total five studies [29,30] and was shown to be 83 and 46 respectively at final follow up. The mean Knee Society Knee score was also evaluated in two out of five studies [29,31] and was shown to be 72 and 77 respectively. The mean Knee Society Pain Score was reported in two out of five studies [2,30], at 44 and 39.6 respectively at final follow up. In the group of patients in which open surgical release was performed, there were no complications reported (Fig. 11). Only one patient was clearly stated in a study [31] to be a treatment failure from the total sample size of 49 (2% of total). Four patients underwent subsequent procedures that consisted of three MUA's and one repeat arthrolysis.
4.3. Open surgical release Out of the 25 studies reviewed, five articles evaluated the treatment of open surgical release (Fig. 9). The technique was described in all the studies, and all scar tissue limiting mobility of the quadriceps mechanism over the femur was removed in these cases by open release. The time interval between TKA and open surgical release was described in three out of the total five studies and ranged from 1 year 2 months to 2 years and 7 months. The overall mean of the improvement in ROM was 38.9°, however the p-value was not reported for the improvement in any of the studies, therefore it cannot be ascertained for sure if these improvements were statistically significant. None of the studies chose to report the improvements in flexion and extension separately as well.
Study ID
Age range of patients
Sample size of patients
Mean ROM before TKA
Mean interval of t ime between TKA and arthroscopy
Mean improvement in ROM in degrees (°)
Mean improvement in flexion in degrees (°)
Mean improvement in extension in degrees (°)
p-value of mean improvement in ROM
Yercan Scranton Jerosch Bae Williams Arbuthnot Sprague Campbell Wasilewski Johnson Teng Diduch
54-88 --56-83 23-72 43-84 45-77 21-52 26-73 46-76 57-81 27-83 57-79
3 7 32 13 10 22 24 8 13 14 11 38
----------115 -----
----8.5 20 29 --12 11.6 30 --13 7.4
60 31 57 42 33 29.2 36 18.5 34 --30.8 26.3
58.4 --34 45 30.5 24.6 ----26 34 29 ---
1.6 --23 3 2.5 4.6 ----8 --1.8 ---
----------p<0.05 p<0.05 ----p<0.05 -----
-------
--- = not mentioned in manuscript
Fig. 6. Arthroscopic release — outcomes.
Study ID
Mean knee society function score at follow-up
Mean knee society knee score at follow-up
Mean knee society pain score at follow-up
Yercan Scranton Jerosch Bae Williams Arbuthnot Sprague Campbell Wasilewski Johnson Teng Diduch
----85 --88 ------------85
----86 --86.4 ------------87
38 --41 --42 ---------------
--- = not mentioned in manuscript Fig. 7. Arthroscopic release — KSS results.
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Study ID
Complications/Failures
Yercan Scranton Jerosch Bae Williams Arbuthnot Sprague
No complications observed. One patient reported very satisfied, the other two reported satisfied. --No major complications or revisions observed. 3 patients were termed failures. 8 patients (88%) reported satisfaction and 2 patients (22%) required revision TKA. No complications observed. One knee deteriorated (5% of total). Superficial skin infection developed in 1 patient. In 1 other patient tenderness developed in the region of the infrapatellar fat pad. 3 patients (12.5% of total) were considered treatment failures. None were worsened. 1 patient had significant increase in pain and underwent revision TKA. Subsequent revision TKR was performed on 5 patients (38% of total). Instrument breakage occurred in 1 patient perioperatively, was retrieved arthroscopically without sequalae. 2 patients underwent subsequent procedures, revision TKR and arthrodesis respectively. 1 patient had a superficial wound infection that was treated with antibiotics. No further surgeries needed. No complications observed. 2 patients underwent repeat arthroscopy and 3 patients underwent revision TKA.
Campbell Wasilewski Johnson Teng Diduch
Fig. 8. Arthroscopic release — failures and complications.
4.4. Revision total knee arthroplasty Out of the 25 studies reviewed, two articles evaluated the outcome of a revision total knee arthroplasty (Fig. 12). The technique was described in all studies, and all scar tissue limiting mobility of the quadriceps mechanism over the femur was removed in these cases by open release. The time interval between TKA and revision TKA was described in both studies and ranged from 1 year 6 months to 2 years. The overall mean of the improvement in ROM was 24.7°, and the p-value was reported for the study by Kim et al. [1] to be significant, however the study by Keeney et al. [32] did not find its results to be significant. The studies pertaining to revision TKR were regular in terms of reporting the KSS (Fig. 13). The mean Knee Society Function score was evaluated in both studies and was shown to be 58.4 and 62.5 respectively at final follow up. The mean Knee Society Knee score was also evaluated in both studies and was shown to be 46.9 and 74.7 respectively. The mean Knee Society Pain Score was only reported in Kim et al. [1] respectively at final follow up. In the group of patients in which revision TKR was performed, the authors chose not to mention anything about complications (Fig. 14). Four patients underwent subsequent MUA and two knees required repeat revision TKR out of a total sample size of 79. The improvement in ROM in a group of patients with stiffness post-TKA in whom no intervention was implemented was only examined in one study by Esler et al. [16]. The mean improvement in the ROM was only 5.4° at a follow up of one year (p = 0.37, CI 7.2–2.7) Study ID
Age range of patients
Sample size of patients
Mean ROM before TKA in degrees ( ).
Yercan Scranton Hutchinson Babis Mont
54-88 --50-78 38-74 35-74
7 4 13 7 18
----122 -----
Mean time interval between TKA and open surgical release (in months) ----14 12 31
in a total of 21 patients. However, this cannot be considered a true control group, as the patients were not selected at random. The mean KSS at final follow up for a group of arthrofibrosis patients with no treatment was only assessed in one study by Keating et al. [17], which was 46. 5. Discussion The goal of this systematic review was to bring together a number of separately conducted studies, critically appraise them and synthesise their results to find out whether the scientific findings are consistent. Ideally, we would have preferred large, randomised controlled trials for a systematic review, as that is the highest quality in research and would have enhanced the quality assessment scores in our study. However, we realise that conducting randomised controlled trials presents obstacles in an orthopaedic surgery setting, because of difficulties such as blinding, surgeon preference and inability to include adequate groups [33]. Therefore, case series were the form of studies most commonly reported in our review, and the NOS quality assessment scale adjusted for use in case series studies [11] was used. Another impediment regarding the quality of the studies was that most of the trials eligible for this study did not report data such as standard deviation and range. A related concern in comparing trials is the use of different scoring systems. Uniform reporting with at least one common scoring system would facilitate comparing results of different studies, and would make further statistical analyses such as a meta-analysis possible in the future regarding this subject.
Mean improvement in ROM in degrees ( )
Mean improvement in flexion in degrees ( )
Mean improvement p-value of mean in extension in improvement degrees ( ) in ROM
41 62 41 19.4 31
-----------
-----------
--- = not mentioned in manuscript Fig. 9. Open surgical release — outcomes.
Study ID
Mean knee society function score at follow-up
Yercan --Scranton --Hutchinson 83 Babis 46 Mont ----- = not mentioned in manuscript
Mean knee society knee score at follow-up
Mean knee society pain score at follow-up
----72 --77
44 ----39.6 ---
Fig. 10. Open release — KSS results.
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Study ID
Failures/Complications
Yercan Scranton Hutchinson Babis Mont
No complications reported. Two patients reported very satisfied, others reported satisfied. --1 patient underwent subsequent arthrolysis. No complications reported. 3 patients (43% of total) required subsequent MUA. One patient considered treatment failure, showed no improvement in ROM.
--- = Not mentioned/not clearly presented in manuscript Fig. 11. Open release — failures and complications.
not be assessed thoroughly because in majority of the studies as a control group was not available for comparison. In the one study that it was examined, however, the improvement in ROM with no intervention was shown to be minimal. The increases in flexion and extension were not as regularly reported across the three treatment modalities therefore cannot be truly compared. Another outcome that was evaluated in the course of our review was the mean Knee Society Score at final follow up of the patient. The mean Knee Society Function and Knee scores were only reported in the arthroscopic surgery, open surgical release and revision TKA groups. Of these three groups, the scores were slightly higher in the arthroscopy group. However since it was inconsistently reported in both groups, a true comparison cannot be drawn. The Knee Society Pain Score was higher in the patients in whom MUA was performed, and lowest in the arthroscopic release patients. However since this outcome was also not consistently reported in the four treatment modalities, it is difficult to draw a definitive conclusion from these findings. This was further hampered by the use of alternative function measures such as the Brigham and Women's Hospital Knee Scale used in Wasilewski and Frankl [26], which could not be included in the review. To improve the reporting of functional recovery in future studies, it would be beneficial to adopt one universal method of measuring knee pain and/or function across the board. Most authors recommend MUA as an early treatment of stiffness post-TKA, as early as 6–12 weeks following the initial surgery [2]. This was closely adhered to by the studies included in our review, and the time intervals reported were all less than 3 months of TKA. MUA has proven over time to be an effective first line of treatment for stiffness post-TKA [10]. Although by and large a safe procedure, it could cause tearing of the intra-articular tissue, rupture the patellar tendon or initiate complex regional pain syndrome [35]. The studies regarding MUA in this review also presented the complications of haemarthrosis, wound separation, pulmonary embolism secondary to deep vein thrombosis and supracondylar femoral fracture. Arthroscopic adhesiolysis is a gentle and selective way of separating the adhesions inside the knee [36]. It also avoids haematoma formation by
In a systematic review conducted by Fitzsimmons et al. [34], the change in degrees in ROM post-treatment was examined in regard to timing of procedure and post-operative complications. According to Fitzsimmons et al., MUA and arthroscopy result in similar gains in ROM in patients with arthrofibrosis after TKA. Open arthrolysis to treat arthrofibrosis after TKA was reported to have inferior results when compared with MUA or arthroscopy. Our review concluded similar results in terms of MUA and arthroscopy having similar gains in ROM, however the result regarding open surgical release was vastly different to what was deduced from our study. This was most probably because Fitzsimmons et al. had only included the results of three studies in this category whereas ours was more quantitative and contained those three studies as well as two more which evaluated the results of open arthrolysis. There were also many differences between the study design of this review and the review we have conducted. In our systematic review we also examined the change in the Knee Society Pain Score post-operatively for each procedure as to determine the improvement in terms of pain as well as ROM. The quality of the studies in Fitzsimmons et al. was assessed using a quality appraisal form, not a quantitative score like we used with the Newcastle-Ottawa Scale. However both this review and ours maintained that the lack of randomised controlled trials in this particular field of study limits the quality of the evidence that can be included and such trials should be done in the future to confirm the results found in both studies. In this systematic review of 25 trials comparing the clinical outcomes of MUA, arthroscopy, surgical release and revision TKA in arthrofibrosis of the knee post-TKA, we tried to interpret the significance of divergent results reported by trials that had already been performed. The results suggest that of the four treatment modalities examined, revision TKA had the least mean improvement in TKA at 24.7°, arthroscopy had a mean improvement in ROM at 36.2°, MUA had the second highest value of improvement at 38.4° and open surgical release showed the highest improvement in ROM at 43.4°. However, since the ROM was only available for 6 out of the total 10 studies regarding MUA, the average increase in ROM of only those six studies is counted. Nevertheless, the significance of the improvements could
Study ID
Age range of patients
Sample size of patients
Mean ROM before TKA in degrees ( ).
Kim Keeney
36-89 45-80
56 23
99.62 ---
Mean time interval between TKA and open surgical release (in months) 18 24
Mean Improvement in ROM in degrees ( )
Mean Improvement in flexion in degrees ( )
Mean Improvement in extension in degrees ( )
p-value of Mean Improvement in ROM
27.6 21.8
19.6 12
8.1 10.5
p< 0.001 p=0.28
Fig. 12. Revision TKR — outcomes.
Study ID
Mean knee society function score at follow-up
Mean knee society knee score at follow-up
Mean knee society pain score at follow-up
Kim Keeney
58.4 62.5
46.9 74.7
46.9 ---
Fig. 13. Revision TKR — KSS results.
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Study ID
Failures/Complications
Kim Keeney
4 knees underwent a subsequent MUA and 2 knees were re-revised, 2 patients were considered to worsen. 16 patients (69.6% of total) were declared to have substantial clinical and functional improvement. Fig. 14. Revision — failures and complications.
allowing for haemostasis by thorough wash out and drain insertion, which can help to prevent further stiffness in the future. This was also reflected in the lack of hematoma formation in the complications experienced in the arthroscopy group in our review. However, arthroscopy also introduces the potential risks of an invasive procedure, which is shown in this group to cause complications such as skin and wound infections and instrument breakage during arthroscopy. Authors recommend that arthroscopy should be performed in moderately painful and stiff knees, preferably within 3 to 6 months after TKA. The studies in this review adhered to this principle and all took place well after 3 months from the primary TKA. Open surgical release is recommended when there is significant limitation of motion (60°), when instrumentation by an arthroscope is difficult due to severe arthrofibrotic reaction and malposition of implants [6]. It is also reserved for those patients who do not respond to the previous two treatment modalities. It is contraindicated however; in patients who might have an extrinsic cause of knee stiffness not related to arthrofibrosis, such as decreased range of motion of the hip secondary to arthrodesis or neurological impairment [23]. The complication rates reported in these studies was very low, but this may be due to the smaller sample size and/or failure to report complications that occurred by the authors. Revision TKA is considered optimal for those patients with severe restriction of motion and an identifiable implant or technical concern [32]. However, the gains by this surgery prove to be minimal in terms of increase in ROM. Also as the authors chose not to comment on any complications that might have occurred post-surgery, we are unable to compare the complication rates of this modality with others. An acceptable range of knee motion depends on the patient, but in general 70° of flexion has been reported as necessary for the swing phase of gait, 90° to descend stairs, and 105° to get up from a low chair [37]. The natural history of stiffness in the knee post-TKA has been evaluated in available literature in regard to fixed flexion contracture following TKA. In the case of stiffness caused by isolated fixed flexion contracture, a recent prospective review of 136 patients by Quah et al. [38]demonstrated that patients with stiffness due to fixed flexion contracture gradually improve over time with complete resolution occurring in 94.1% of patients at 10.8 months of follow-up. Previous studies by Tanzer and Miller [39] and Aderinto et al. [40] found similar results in patients with fixed flexion contracture, showing that gradual improvement in knee extension can be expected with rehabilitation and physiotherapy. To our knowledge, the natural history of other causes of stiffness in the knee has not been suitably researched and further prospective studies are needed to examine the course of conservative treatment for other causes of restricted motion of the knee post-TKA. In light of the results obtained from our systematic review, it appears that in terms of outcome in ROM, the most significant improvement was shown in the patients receiving open surgical release of their arthrofibrosis. However, this treatment has its limitations in terms of risk to patients with co-morbidities and the anxiety of patients in regard to multiple surgeries. Therefore it is reasonable to conclude that in younger, physically fit patients requiring an increased ROM to accommodate more active lifestyles, open surgical release is the best option, as this will provide them with an adequate improvement in ROM. However, in older patients with comorbidities for whom limited movement is sufficient to fulfil their
activities of daily living and lifestyle, MUA can provide a beneficial option early after TKA or with arthroscopic release within 3 to 6 months after TKA. 6. Conclusion In summary our analysis represents the recent available evidence regarding the efficacy of the four main treatment modalities of stiffness post total knee replacement surgery. Our review suggests that open surgical release provides the highest increase in ROM at final follow up, however the Knee Society Score remained relatively consistent for all four treatments. We did however face methodological limitations as the majority of papers in this systematic review were case series, which decreased the quality of the evidence available. Well-designed trials with blinded measurement of outcomes would help generate a higher quality of evidence, which would help in reaching more robust conclusions regarding these treatment modalities and would enable us to statistically analyse the outcomes as well. Conflict of interest The authors declare there is no conflict of interest. References [1] Kim J, Nelson CL, Lotke PA. Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am 2004;86-A(7): 1479–84. [2] Yercan H, Sugun T, Bussiere C, Selmi T, Davies A, Neyret P. Stiffness after total knee arthroplasty: prevalence, management and outcomes. Knee 2006;13:2. [3] Lee DC, Kim DH, Scott RD, Suthers K. Intraoperative flexion against gravity as an indication of ultimate range of motion in individual cases after total knee arthroplasty. J Arthroplasty 1998;13:500–3. [4] Schurman DJ, Parker JN, Ornstein D. Total condylar knee replacement. A study of factors influencing range of motion as late as two years after arthroplasty. J Bone Joint Surg Am 1985;67:1006–14. [5] Schiavone Panni A, Cerciello S, Vasso M, Tartarone M. Stiffness in total knee arthroplasty. J Orthop Traumatol Sep. 2009;10(3):111–8. [6] Scranton P. Management of knee pain and stiffness after total knee arthroplasty. J Arthroplasty 2001;16:4. [7] Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg May–Jun 2004;12(3):164–71. [8] Christensen CP, Crawford JJ, Olin MD, Vail TP. Revision of the stiff total knee arthroplasty. J Arthroplasty Jun. 2002;17(4):409–15. [9] Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res Nov 1989;248:13–4. [10] Mohammed R, Syed S, Ahmed N. Manipulation under anaesthesia for stiffness following knee arthroplasty. Ann R Coll Surg Engl 2009;91(3). [11] Zengerink M, Strujis PA, Tol JL, van Dijk CN. Treatment of osteochondral lesions of the talus; a systematic review. Knee Surg Sports Traumatol Arthrosc Feb. 2009;18(2):238–46. [12] Wells GA, Shea B, O'Connell D. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Proceedings from the 3rd Symposium on Systematic Reviews. Beyond the Basics: improving quality and impact. Oxford, UK; 2000. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford. htm. [13] Cates HE, Schmidt JM. Closed manipulation after total knee arthroplasty: outcome and affecting variables. Orthopedics 2009;32(6):398. [14] Rubinstein Jr RA, DeHaan A. The incidence and results of manipulation after primary total knee arthroplasty. Knee 2010;17(1):29–32. [15] Maloney WJ. The stiff total knee arthroplasty: evaluation and management. J Arthroplasty Jun 2002;17(4 Suppl. 1):71–3. [16] Esler C, Lock K, Harper W, Gregg P. Manipulation of total knee replacements. J Bone Joint Surg 1999;81-B. [17] Keating EM, Ritter MA, Harty LD, Haas G, Meding JB, Faris PM, et al. Manipulation after total knee arthroplasty. J Bone Joint Surg Am 2007;89:2. [18] Fox JL, Poss R. The role of manipulation following total knee replacement. J Bone Joint Surg Am 1981;63(3):357–62.
H. Ghani et al. / The Knee 19 (2012) 751–759 [19] Ipach I, Mittag F, Lahrmann J, Kunze B, Kluba T. Arthrofibrosis after TKA — influence factors on the absolute flexion and gain in flexion after manipulation under anaesthesia. BMC Musculoskelet Disord Aug 2011;12:184. [20] Arbuthnot JE, Brink RB. 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 2010;18(3):346–51. [21] Sprague III NF, O'Connor RL, Fox JM. Arthroscopic treatment of postoperative knee fibroarthrosis. Clin Orthop Relat Res Jun 1982;166:165–72. [22] Johnson DR, Friedman RJ, McGinty JB, Mason JL, St Mary EW. The role of arthroscopy in the problem total knee replacement. Arthroscopy 1990;6(1):30–2. [23] Nelson CL, Kim J, Lotke PA. Stiffness after total knee arthroplasty. J Bone Joint Surg Am 2005;87:264–70. [24] Bae DK, Hong KL, Cho JH. Arthroscopy of symptomatic total knee replacements. Arthroscopy 1995;11(6):664–71. [25] Williams III RJ, Westrich GH, Siegel J, Windsor RE. Arthroscopic release of the posterior cruciate ligament for stiff total knee arthroplasty. Clin Orthop Relat Res 1996(331):185–91. [26] Wasilewski SA, Frankl U. Arthroscopy of the painful dysfunctional total knee replacement. Arthroscopy 1989;5(4):294–7. [27] Teng HP, Lu YC, Hsu CJ, Wong CY. Arthroscopy following total knee arthroplasty. Orthopedics Apr 2002;25(4):422–4. [28] Diduch DR, Scuderi GR, Scott WN, Insall JN, Kelly MA. The efficacy of arthroscopy following total knee replacement. Arthroscopy Apr 1997;13(2):166–71. [29] Hutchinson JR, Parish EN, Cross MJ. Results of open arthrolysis for the treatment of stiffness after total knee replacement. J Bone Joint Surg Br 2005;87(10): 1357–60. [30] Babis GC, Trousdale RT, Pagnano MW, Morrey BF. Poor outcomes of isolated tibial insert exchange and arthrolysis for the management of stiffness following total knee arthroplasty. J Bone Joint Surg Am 2001;83-A(10):1534–6.
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[31] Mont MA, Seyler TM, Marulanda GA, Delanois RE, Bhave A. Surgical treatment and customized rehabilitation for stiff knee arthroplasties. Clin Orthop Relat Res 2006 May;446:193–200. [32] Keeney JA, Clohisy JC, Curry M, Maloney WJ. Revision total knee arthroplasty for restricted motion. Clin Orthop Relat Res 2005;440:135–40. [33] Boutron I, Ravaud P, Nizard R. The design and assessment of prospective randomized, controlled trials in orthopaedic surgery. J Bone Joint Surg Br 2007;89: 369–72. [34] Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat the stiff total knee arthroplasty?: a systematic review. Clin Orthop Relat Res Apr 2010;468(4):1096–106. [35] Jerosch J, Aldawoudy AM. Arthroscopic treatment of patients with moderate arthrofibrosis after total knee replacement. Knee Surg Sports Traumatol Arthrosc 2007(15):71–7. [36] Campbell Jr ED. Arthroscopy in total knee replacements. Arthroscopy 1987;3(1):31–5. [37] Laubenthal KN, Smidt GL, Kettelkamp DB. A quantitative analysis of knee motion during activities of daily living. Phys Ther 1972;52:34. [38] Quah C, Swamy G, Lewis J, Kendrew J, Badhe N. Fixed flexion deformity following total knee arthroplasty. A prospective study of the natural history (Published online ahead of print October 13 2011) Knee Oct 2011, doi: 10.1016/j.knee.2011.09.003. [39] Tanzer M, Miller J. The natural history of flexion contracture in total knee arthroplasty. A prospective study. Clin Orthop Relat Res Nov 1989;248: 129–34. [40] Aderinto J, Brenkel IJ, Chan P. Natural history of fixed flexion deformity following total knee replacement: a prospective five-year study. J Bone Joint Surg Br Jul 2005;87(7):934–6.
Contents lists available at SciVerse ScienceDirect
The Knee
Review
Management of stiffness following total knee arthroplasty: A systematic review H. Ghani a, N. Maffulli b, V. Khanduja a,⁎ a b
Addenbrooke's - Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Barts and The London School of Medicine, London, UK
a r t i c l e
i n f o
a b s t r a c t Aim: The aim of the study was to systematically evaluate the outcome of four main modalities of treatment for arthrofibrosis that develops subsequent to a total knee arthroplasty (TKA), namely manipulation under anesthesia (MUA), arthroscopic debridement, open surgical release and revision TKA. Materials and methods: A computerised search was conducted for relevant studies published from 1975 onwards in all the major databases and various search engines. A total of twenty-five studies were selected, representing a total of 798 patients. Studies that passed the inclusion criteria were then subjected to quality assessment using the Newcastle-Ottawa Scale. On assessment, the 25 studies scored a total of 77 stars out of a possible 125. Two studies were prospective in design, while the remaining case series were retrospective in nature. The primary outcome measures assessed were increase in range of movement (ROM) and the Knee Society Score (KSS) at final follow-up. Results: Our results showed that manipulation under anesthesia (MUA) had a mean increase in ROM of 38.4°, arthroscopic release had a mean increase of 36.2°, open surgical release had a mean increase of 43.4° and revision TKA had a mean increase of 24.7°. No significant differences were found in the KSS of the four treatment modalities. Our analysis suggests that open surgical release would be the most beneficial option for patients who are fit to undergo secondary surgery if their lifestyle requires a higher ROM for activities of daily living. However, there were methodological limitations as majority of the papers were case series, which decreased the quality of the evidence available. © 2012 Elsevier B.V. All rights reserved.
Article history: Received 15 November 2011 Received in revised form 22 February 2012 Accepted 27 February 2012 Keywords: Total knee arthroplasty Stiffness
Contents 1. 2. 3. 4.
Introduction . . . . . . . . . . . . . Materials and methods . . . . . . . . Results . . . . . . . . . . . . . . . Treatment strategies . . . . . . . . . 4.1. Manipulation under anesthesia 4.2. Arthroscopic release . . . . . . 4.3. Open surgical release . . . . . 4.4. Revision total knee arthroplasty 5. Discussion . . . . . . . . . . . . . 6. Conclusion . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . . References . . . . . . . . . . . . . . . .
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1. Introduction
⁎ Corresponding author at: Addenbrooke's - Cambridge University Hospitals NHS Trust, Box 37, Hills Road, Cambridge CB2 0QQ, UK. Tel.: + 44 1223 256 405. E-mail address: [email protected] (V. Khanduja). 0968-0160/$ – see front matter © 2012 Elsevier B.V. All rights reserved. doi:10.1016/j.knee.2012.02.010
Total knee arthroplasty (TKA) is considered to be the most effective and reliable treatment for patients with advanced osteoarthritis of the knee. The definition of stiffness varies widely throughout the available literature, resulting in different reported ranges of prevalence. However,
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two large series performed in recent times by Kim et al. [1] and Yercan et al. [2] report the prevalence to be 1.3% in 1000 knees and 5.3% in 1188 knees respectively. Post-operative stiffness, which is attributed to arthrofibrosis which occurs in the knee joint, can be extremely debilitating for the patient, often making activities of daily living such as climbing stairs or rising from a chair painful and difficult [3,4]. The causes of arthrofibrosis after total knee arthroplasty surgery are multifactorial. Several risk factors for stiffness in the knee post-TKA have been identified. These risk factors can be divided into pre-operative, per-operative and post-operative. The most significant and well-recognised cause of a stiff TKA is decreased pre-operative range of movement [5]. A correlation also has been demonstrated between history of previous surgery and diabetes mellitus and stiffness post-TKA [6]. Per-operative risk factors leading to stiffness include incorrect flexion–extension gap, malpositioning of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope and incomplete resection of posterior osteophytes. Post-operative risk factors leading to decreased range of movement include poor patient motivation, lack of compliance with physiotherapy, deep infection, arthrofibrosis of the knee joint, patellar complications, complex regional pain syndrome and heterotopic ossification [7]. The definition of stiffness in the knee varies within the available literature, Christensen et al. [8] described it as an arc of motion less than 70° whereas Kim et al. [1] describe it as a flexion contracture of >15° and/or b75° of flexion. Another parameter that is used to measure stiffness in the knee is the Knee Society Scoring System, which provides a uniform method to quantify the amount of pain that the patient is experiencing in the knee. It encompasses various aspects of knee movement and function, such as pain, flexion contracture, extension lag, range of movement, alignment and stability [9]. The various treatment options available for arthrofibrosis of the knee are manipulation under anesthesia (MUA), arthroscopic arthrolysis, open arthrolysis and finally revision TKA. MUA is generally regarded as the first step in the treatment of a stiff TKA, especially in the first two months [2]. The technique of performing MUA is uniform, the patient is put under adequate anesthesia to the point of maximum relaxation and the ipsilateral hip is flexed to 90°. The knee is then flexed slowly and gently until the audible and palpable separation of adhesions no longer occurs [10]. Arthroscopic release is another treatment option for the stiff TKA, and is usually performed in moderately painful and stiff knees, preferably within 3 to 6 months after TKA. In arthroscopic debridement, the arthrofibrosis is relieved by resecting large fibrous bands of scar tissue under arthroscopic visualisation [6]. In certain cases, open surgical release is recommended to patients, especially in the case of severe stiffness (b60°). Other cases of severe stiffness, especially those with malpositioned implants, require a revision TKA. Although studies have been performed in the past to examine the effect of these treatment modalities on the stiff knee post-TKA, there is paucity of evidence regarding the comparable effectiveness of these treatments. The aim of this systematic review, therefore, was to pool the studies dealing with different treatment strategies available in order to summarise the outcome of these treatment modalities. In the literature reviewed, different treatments of post-TKA stiffness have been explored to compare the outcomes of improvement in range of movement and improvement in the Knee Society Score (KSS).
replacement arthroplasty” OR (“total” AND “knee” AND “replacement”) OR “total knee replacement” into the various databases used in order to maximise the amount and relevance of articles retrieved. The articles included were those published in English, Italian, French and Spanish from 1975 to date. We used the databases PubMed, Embase, Ovid, CINAHL, The National Research Register, The National Technical Information Service, the UKCRN Portfolio Database and the Cochrane Library. To prevent publication bias we also used the OpenGrey database as well as search engines Yahoo, Google and Google Scholar to find any additional articles that may be unpublished or may have been missed out on during our search. Initially, we identified all abstracts that discussed arthrofibrosis in the knee that developed post-TKA. These articles were then narrowed down further to those in which a specific treatment modality, such as MUA, arthroscopic lysis, open surgical release or revision TKA was carried out. Once these articles were accumulated, they were subjected to scrutiny by the authors. Certain studies were then rejected based on reporting insufficient data, non-standardised scoring systems, lack of precise comparison methods and articles for which translation of the language was unavailable. We then hand searched the reference lists of the articles that had been included to retrieve citations to articles that may have been missed by our search to add to the database, and those articles were then subjected to assessment under the same inclusion criteria. The studies that were included were non-specific for age, gender, operating institution or the type of prosthesis, and non-randomised as well as randomised trials were included. Once the articles had been selected, they were then subjected to quality assessment using the Newcastle-Ottawa Scale (NOS), adjusted for use in studies involving case series. It was originally developed as a tool for quality assessment of non-randomised studies to be used in a systematic review. The NOS uses a ‘star’ rating system to judge the quality of studies based on study design, selection, and assessment of outcome. The maximum number of stars a study may receive in each category is two, one and two respectively, for a total possibility of five stars [11,12]. The outcome measures that were most commonly reported throughout all the studies were measurement of the average range of movement (ROM) after each treatment modality, as well as the Knee Society Pain Score. The minimum average follow-up time at which these outcomes were assessed was at 3 months post-intervention.
2. Materials and methods
A total of 10 studies of the total 25 reviewed reported the results of this technique (Fig. 3). The method by which it was performed was described in all of the articles, and was uniform. In the studies in which the interval between primary TKA and MUA was given, they were all described as being performed within the first 3 months of surgery. The improvement in range of movement (ROM) was clearly given in only 6 out of the 10 studies, the rest choosing to report the
The first step of the research was the data search and selection. Using the medical subject heading terms arthroplasty, replacement and knee along with Boolean operators ‘or’ and ‘and’, we entered the search query “stiffness” AND “(arthroplasty, replacement, knee)” OR (“arthroplasty” AND “replacement” AND “knee”) OR “knee
3. Results Of the 199 papers that were initially gathered during screening, 25 trials were finally selected for data extraction and systematic review (Fig. 1). Of the 25 trials, 23 were retrospective while only two were prospective. The total number of participants was 798. The studies were then subjected to quality assessment using the NewcastleOttawa Scale (NOS). On assessment, the 25 studies scored a total of 77 stars, out of a possible 125. The scores of all individual studies are described in Fig. 2. The two studies that were prospective in design scored the highest, however the remaining case series were retrospective in nature (Fig. 2). The main drawbacks in the studies that affected their quality score were the retrospective nature of the study, the studies being based on a minor group selected by the surgeon, and absence of description for blind assessment.
4. Treatment strategies 4.1. Manipulation under anesthesia
H. Ghani et al. / The Knee 19 (2012) 751–759 # of articles identified through database searching = 176
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# of articles identified throug hot her sources = 23
# of records after duplicates removed=197
# of records screened =197
# of records excluded =154
# of full text articles that were assessed for eligibility = 43
# of full text articles excluded due to not being fit for the inclusion criteria and/or using nonstandardized measures of outcome= 18
# of studies included in the final systematic review = 25
Fig. 1. PRISMA flow diagram.
final increase in flexion instead. The overall mean of the improvement in ROM in degrees for these studies [2,6,10,13–15] was 38.4°. The average increase in flexion was also described in 6 out of the 9 studies [10,13,14,16–18] and was 29.4° respectively. The mean increase in extension was only given in three studies [8,13,14] and was 5.7°. The p-values measured in all of the studies, except for Scranton [6],
Cates [13], Fox [18] and Maloney [15] in which the p-value had not been reported, showed that the improvement in ROM in the reviewed studies was significant. The mean Knee Society Pain Score was only evaluated in two studies, and was shown to be 44 and 46, respectively (Fig. 4). According to Keating et al. [17], the Knee Society Pain Score of 46 at a follow up of
Study ID
Year conducted
Type of study
Sample size (Number of knees)
Male/ Female
Mean follow up time (years + months)
Quality score*
Fox Sprague Campbell Wasilewski Johnson Bae Williams Diduch Esler Scranton Babis Teng Maloney Kim Keeney Yercan Hutchinson Mont Jerosch Keating Mohammed Cates Rubinstein Arbuthnot Ipach
1981 1982 1987 1989 1990 1995 1996 1997 1999 2001 2001 2002 2002 2004 2005 2005 2005 2006 2007 2007 2009 2009 2010 2010 2011
Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective
76 24 8 13 14 13 10 38 59 33 7 11 24 56 25 56 13 18 32 113 21 37 36 22 39
--7/17 3/5 4/9 4/10 0/11 4/5 14/24 18/24 8/25 2/5 6/5 --14/38 --14/49 5/8 11/6 10/22 35/55 10/11 --8/26 7/14 32/7
1+0 0+8 1+0 2+1 0+16 2+6 1+8 1+8 2+0 1+0 4+2 0+3 --3+7 3+0 2+7 7+0 2+6 2+3 4+7 0+3 1+0 3+10 3+8 0+6
3/5 3/5 3/5 3/5 3/5 3/5 3/5 3/5 4/5 3/5 3/5 3/5 3/5 3/5 3/5 3/5 3/5 4/5 3/5 3/5 3/5 3/5 3/5 3/5 3/5
• - Quality assessed according to the Newcastle-Ottawa Scale (NOS), adjusted for case series. --- - Not mentioned in manuscript. Fig. 2. Quality assessment of studies according to Newcastle-Ottawa Scale.
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Study ID
Age range of patients
Sample size of patients
Mean time elapsed between TKA and MUA (months)
Mean ROM before TKA
Mean improvement in ROM in degrees (°)
Mean improvement in flexion
Mean improvement in extension
p-value of mean improvement in ROM
Yercan Esler Scranton Keating Mohammed Cates Rubinstein Fox Maloney Ipach
54-88 46-88 --34-84 56-80 32-80 51-85 ----42-82
46 47 19 90 21 37 37 76 24 39
1 3 1.5-7 2 3 ----.5 1.7 2.6
--102 --102 --115 109 ----104.9
47 --42 --30.2 26 38 --47 ---
--35.4 --35 20.7 22 33 30 --26.5
--------8.1 4 5 -------
p<0.015 p<0.01 --p<0.0001 p<0.001 --p<0.001 -------
--- = not mentioned in manuscript Fig. 3. Manipulation under anesthesia — outcomes.— = not mentioned in manuscript.
one year was significant (p b 0.0001). This was the only study in which the p-value of the Pain Score was provided. The literature pertaining to MUA was very inadequate in terms of reporting improvement in terms of the Knee Society Function and Knee scores, and no other clinical grading system was used in the remaining studies to assess the patients at follow up. The majority of studies pertaining to MUA had low complication rates (Fig. 5). The study by Fox and Poss [18] had the highest complication rate of all the studies, with haemarthrosis occurring in three patients, wound separation in one patient and the death of one patient resulting from pulmonary embolism secondary to deep vein thrombosis in the manipulated leg. One patient in the study by Keating et al. [17] had a supracondylar femoral fracture during or after the MUA. Out of the total patient sample size of 436 that underwent MUA, 29 patients were considered failures, giving us a failure rate of 6.7%. Ten patients underwent a subsequent procedure, either a further MUA, arthroscopic adhesiolysis or femoral revision implantation [6,13,14,19].
and 5 months. The improvement in ROM was examined in all but one study. The average improvement in ROM in degrees for this treatment in these studies was shown to be 36.2°, however we could not ascertain for certain whether or not these improvements were statistically significant because with the exception of three studies (Arbuthnot and Brink [20], Sprague et al. [21] and Johnson et al. [22]) the p-values were not provided in any of the studies reviewed. The mean improvement in flexion was given in 8 of the 12 studies [2,20,22–27] and came to 35.2°. The mean improvement in extension was described in seven out of 12 studies [2,20,22–26] and was 6.4° respectively. The Knee Society Score (KSS) results were not reported in the majority of studies following arthroscopy (Fig. 7). The mean Knee Society Function Score at final follow up was shown in three of the 12 studies reviewed and was 85, 88 and 85 respectively [23,25,28]. The mean Knee Society Knee score was also reported in three out of 12 studies and was 86, 86.4 and 87 respectively [2,23,26]. The mean Knee Society Pain Score at follow up was shown in three of the 12 studies reviewed, and was 38, 41 and 42 respectively [2,21,23]. The complication rate was low in the arthroscopic release patient group. Of the studies reviewed (Fig. 8), complications that occurred were a superficial skin infection in one patient and tenderness in the infrapatellar fat pad in one other patient [19]. One patient had instrument breakage occur during the arthroscopy [20] but this was resolved immediately without any further complications. A superficial wound infection was also reported in one patient in another study [25]. Out of the total sample size of 195 patients, seven were clearly termed as failures (3.6% of total). A total of 15 patients underwent subsequent procedures after arthroscopic adhesiolysis, which consisted of 12 revision TKA's, two repeat arthroscopies and one arthrodesis.
4.2. Arthroscopic release This was the most commonly researched treatment strategy for stiffness post-TKA. A total of 12 studies of the total 25 reported the results of arthroscopic adhesiolysis (Fig. 6). The method by which this technique was performed was also described in each article, and was relatively uniform in their technique, with fibrous bands of scar tissue being inspected in the suprapatellar pouch, medial and lateral gutters and intercondylar notch and subsequently removed with a soft tissue shaver under arthroscopic visualisation. The time interval between the primary TKA and the arthroscopic surgery was described in eight of out the 12 studies and ranged from 8.5 months to 2 years
Study ID
Mean knee society function score at follow-up
Mean knee society knee score at follow-up
Mean knee society pain score at follow-up
Yercan Esler Scranton Keating Mohammed Cates Rubinstein Fox Maloney Ipach
---------------------
---------------------
44 ----46 -------------
--- = not mentioned in manuscript Fig. 4. Manipulation under anesthesia — KSS results.
H. Ghani et al. / The Knee 19 (2012) 751–759
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Study ID
Failures/Complications
Yercan
No complications observed. 3 patients observed persistent pain (7% of MUA group in this particular study). 7 patients’ ROM was not improved by MUA. Patient satisfaction was not asked. No complications as a result of MUA. One patient showed no gain in ROM. 4 of the manual manipulations were failures, requiring arthroscopic treatment, 3 of which were successful. One osteoporotic patient suffered a supracondylar femoral fracture either intraoperatively or postoperatively with under epidural analgesia. 9 patients had continuous pain and no gain in flexion after MUA. No complications observed. One patient showed no improvement in ROM either immediately after MUA or at follow up. No complications observed. 3 patients (8%) did not improve ROM after MUA and 2 patients (5%) underwent further MUA with arthroscopic adhesiolysis. No complications observed. 3 patients had to be re-manipulated due to lack of progress. In 3 patients the manipulation resulted in hemarthrosis and in 1 patient wound separation occurred. 1 patient died within 24 hours of manipulation due to a pulmonary embolism secondary to deep vein thrombosis in the calf of the manipulated leg. --One patient developed a supracondylar fracture during the MUA. A femoral revision implant was then required.
Esler Scranton Keating Mohammed Cates Rubinstein Fox Maloney Ipach
--- = not mentioned/not clearly presented in manuscript. Fig. 5. Manipulation under anesthesia — failures and complications.
The studies pertaining to open surgical release were relatively more regular in terms of reporting the KSS (Fig. 10). The mean Knee Society Function score was evaluated in two out of the total five studies [29,30] and was shown to be 83 and 46 respectively at final follow up. The mean Knee Society Knee score was also evaluated in two out of five studies [29,31] and was shown to be 72 and 77 respectively. The mean Knee Society Pain Score was reported in two out of five studies [2,30], at 44 and 39.6 respectively at final follow up. In the group of patients in which open surgical release was performed, there were no complications reported (Fig. 11). Only one patient was clearly stated in a study [31] to be a treatment failure from the total sample size of 49 (2% of total). Four patients underwent subsequent procedures that consisted of three MUA's and one repeat arthrolysis.
4.3. Open surgical release Out of the 25 studies reviewed, five articles evaluated the treatment of open surgical release (Fig. 9). The technique was described in all the studies, and all scar tissue limiting mobility of the quadriceps mechanism over the femur was removed in these cases by open release. The time interval between TKA and open surgical release was described in three out of the total five studies and ranged from 1 year 2 months to 2 years and 7 months. The overall mean of the improvement in ROM was 38.9°, however the p-value was not reported for the improvement in any of the studies, therefore it cannot be ascertained for sure if these improvements were statistically significant. None of the studies chose to report the improvements in flexion and extension separately as well.
Study ID
Age range of patients
Sample size of patients
Mean ROM before TKA
Mean interval of t ime between TKA and arthroscopy
Mean improvement in ROM in degrees (°)
Mean improvement in flexion in degrees (°)
Mean improvement in extension in degrees (°)
p-value of mean improvement in ROM
Yercan Scranton Jerosch Bae Williams Arbuthnot Sprague Campbell Wasilewski Johnson Teng Diduch
54-88 --56-83 23-72 43-84 45-77 21-52 26-73 46-76 57-81 27-83 57-79
3 7 32 13 10 22 24 8 13 14 11 38
----------115 -----
----8.5 20 29 --12 11.6 30 --13 7.4
60 31 57 42 33 29.2 36 18.5 34 --30.8 26.3
58.4 --34 45 30.5 24.6 ----26 34 29 ---
1.6 --23 3 2.5 4.6 ----8 --1.8 ---
----------p<0.05 p<0.05 ----p<0.05 -----
-------
--- = not mentioned in manuscript
Fig. 6. Arthroscopic release — outcomes.
Study ID
Mean knee society function score at follow-up
Mean knee society knee score at follow-up
Mean knee society pain score at follow-up
Yercan Scranton Jerosch Bae Williams Arbuthnot Sprague Campbell Wasilewski Johnson Teng Diduch
----85 --88 ------------85
----86 --86.4 ------------87
38 --41 --42 ---------------
--- = not mentioned in manuscript Fig. 7. Arthroscopic release — KSS results.
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Study ID
Complications/Failures
Yercan Scranton Jerosch Bae Williams Arbuthnot Sprague
No complications observed. One patient reported very satisfied, the other two reported satisfied. --No major complications or revisions observed. 3 patients were termed failures. 8 patients (88%) reported satisfaction and 2 patients (22%) required revision TKA. No complications observed. One knee deteriorated (5% of total). Superficial skin infection developed in 1 patient. In 1 other patient tenderness developed in the region of the infrapatellar fat pad. 3 patients (12.5% of total) were considered treatment failures. None were worsened. 1 patient had significant increase in pain and underwent revision TKA. Subsequent revision TKR was performed on 5 patients (38% of total). Instrument breakage occurred in 1 patient perioperatively, was retrieved arthroscopically without sequalae. 2 patients underwent subsequent procedures, revision TKR and arthrodesis respectively. 1 patient had a superficial wound infection that was treated with antibiotics. No further surgeries needed. No complications observed. 2 patients underwent repeat arthroscopy and 3 patients underwent revision TKA.
Campbell Wasilewski Johnson Teng Diduch
Fig. 8. Arthroscopic release — failures and complications.
4.4. Revision total knee arthroplasty Out of the 25 studies reviewed, two articles evaluated the outcome of a revision total knee arthroplasty (Fig. 12). The technique was described in all studies, and all scar tissue limiting mobility of the quadriceps mechanism over the femur was removed in these cases by open release. The time interval between TKA and revision TKA was described in both studies and ranged from 1 year 6 months to 2 years. The overall mean of the improvement in ROM was 24.7°, and the p-value was reported for the study by Kim et al. [1] to be significant, however the study by Keeney et al. [32] did not find its results to be significant. The studies pertaining to revision TKR were regular in terms of reporting the KSS (Fig. 13). The mean Knee Society Function score was evaluated in both studies and was shown to be 58.4 and 62.5 respectively at final follow up. The mean Knee Society Knee score was also evaluated in both studies and was shown to be 46.9 and 74.7 respectively. The mean Knee Society Pain Score was only reported in Kim et al. [1] respectively at final follow up. In the group of patients in which revision TKR was performed, the authors chose not to mention anything about complications (Fig. 14). Four patients underwent subsequent MUA and two knees required repeat revision TKR out of a total sample size of 79. The improvement in ROM in a group of patients with stiffness post-TKA in whom no intervention was implemented was only examined in one study by Esler et al. [16]. The mean improvement in the ROM was only 5.4° at a follow up of one year (p = 0.37, CI 7.2–2.7) Study ID
Age range of patients
Sample size of patients
Mean ROM before TKA in degrees ( ).
Yercan Scranton Hutchinson Babis Mont
54-88 --50-78 38-74 35-74
7 4 13 7 18
----122 -----
Mean time interval between TKA and open surgical release (in months) ----14 12 31
in a total of 21 patients. However, this cannot be considered a true control group, as the patients were not selected at random. The mean KSS at final follow up for a group of arthrofibrosis patients with no treatment was only assessed in one study by Keating et al. [17], which was 46. 5. Discussion The goal of this systematic review was to bring together a number of separately conducted studies, critically appraise them and synthesise their results to find out whether the scientific findings are consistent. Ideally, we would have preferred large, randomised controlled trials for a systematic review, as that is the highest quality in research and would have enhanced the quality assessment scores in our study. However, we realise that conducting randomised controlled trials presents obstacles in an orthopaedic surgery setting, because of difficulties such as blinding, surgeon preference and inability to include adequate groups [33]. Therefore, case series were the form of studies most commonly reported in our review, and the NOS quality assessment scale adjusted for use in case series studies [11] was used. Another impediment regarding the quality of the studies was that most of the trials eligible for this study did not report data such as standard deviation and range. A related concern in comparing trials is the use of different scoring systems. Uniform reporting with at least one common scoring system would facilitate comparing results of different studies, and would make further statistical analyses such as a meta-analysis possible in the future regarding this subject.
Mean improvement in ROM in degrees ( )
Mean improvement in flexion in degrees ( )
Mean improvement p-value of mean in extension in improvement degrees ( ) in ROM
41 62 41 19.4 31
-----------
-----------
--- = not mentioned in manuscript Fig. 9. Open surgical release — outcomes.
Study ID
Mean knee society function score at follow-up
Yercan --Scranton --Hutchinson 83 Babis 46 Mont ----- = not mentioned in manuscript
Mean knee society knee score at follow-up
Mean knee society pain score at follow-up
----72 --77
44 ----39.6 ---
Fig. 10. Open release — KSS results.
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757
Study ID
Failures/Complications
Yercan Scranton Hutchinson Babis Mont
No complications reported. Two patients reported very satisfied, others reported satisfied. --1 patient underwent subsequent arthrolysis. No complications reported. 3 patients (43% of total) required subsequent MUA. One patient considered treatment failure, showed no improvement in ROM.
--- = Not mentioned/not clearly presented in manuscript Fig. 11. Open release — failures and complications.
not be assessed thoroughly because in majority of the studies as a control group was not available for comparison. In the one study that it was examined, however, the improvement in ROM with no intervention was shown to be minimal. The increases in flexion and extension were not as regularly reported across the three treatment modalities therefore cannot be truly compared. Another outcome that was evaluated in the course of our review was the mean Knee Society Score at final follow up of the patient. The mean Knee Society Function and Knee scores were only reported in the arthroscopic surgery, open surgical release and revision TKA groups. Of these three groups, the scores were slightly higher in the arthroscopy group. However since it was inconsistently reported in both groups, a true comparison cannot be drawn. The Knee Society Pain Score was higher in the patients in whom MUA was performed, and lowest in the arthroscopic release patients. However since this outcome was also not consistently reported in the four treatment modalities, it is difficult to draw a definitive conclusion from these findings. This was further hampered by the use of alternative function measures such as the Brigham and Women's Hospital Knee Scale used in Wasilewski and Frankl [26], which could not be included in the review. To improve the reporting of functional recovery in future studies, it would be beneficial to adopt one universal method of measuring knee pain and/or function across the board. Most authors recommend MUA as an early treatment of stiffness post-TKA, as early as 6–12 weeks following the initial surgery [2]. This was closely adhered to by the studies included in our review, and the time intervals reported were all less than 3 months of TKA. MUA has proven over time to be an effective first line of treatment for stiffness post-TKA [10]. Although by and large a safe procedure, it could cause tearing of the intra-articular tissue, rupture the patellar tendon or initiate complex regional pain syndrome [35]. The studies regarding MUA in this review also presented the complications of haemarthrosis, wound separation, pulmonary embolism secondary to deep vein thrombosis and supracondylar femoral fracture. Arthroscopic adhesiolysis is a gentle and selective way of separating the adhesions inside the knee [36]. It also avoids haematoma formation by
In a systematic review conducted by Fitzsimmons et al. [34], the change in degrees in ROM post-treatment was examined in regard to timing of procedure and post-operative complications. According to Fitzsimmons et al., MUA and arthroscopy result in similar gains in ROM in patients with arthrofibrosis after TKA. Open arthrolysis to treat arthrofibrosis after TKA was reported to have inferior results when compared with MUA or arthroscopy. Our review concluded similar results in terms of MUA and arthroscopy having similar gains in ROM, however the result regarding open surgical release was vastly different to what was deduced from our study. This was most probably because Fitzsimmons et al. had only included the results of three studies in this category whereas ours was more quantitative and contained those three studies as well as two more which evaluated the results of open arthrolysis. There were also many differences between the study design of this review and the review we have conducted. In our systematic review we also examined the change in the Knee Society Pain Score post-operatively for each procedure as to determine the improvement in terms of pain as well as ROM. The quality of the studies in Fitzsimmons et al. was assessed using a quality appraisal form, not a quantitative score like we used with the Newcastle-Ottawa Scale. However both this review and ours maintained that the lack of randomised controlled trials in this particular field of study limits the quality of the evidence that can be included and such trials should be done in the future to confirm the results found in both studies. In this systematic review of 25 trials comparing the clinical outcomes of MUA, arthroscopy, surgical release and revision TKA in arthrofibrosis of the knee post-TKA, we tried to interpret the significance of divergent results reported by trials that had already been performed. The results suggest that of the four treatment modalities examined, revision TKA had the least mean improvement in TKA at 24.7°, arthroscopy had a mean improvement in ROM at 36.2°, MUA had the second highest value of improvement at 38.4° and open surgical release showed the highest improvement in ROM at 43.4°. However, since the ROM was only available for 6 out of the total 10 studies regarding MUA, the average increase in ROM of only those six studies is counted. Nevertheless, the significance of the improvements could
Study ID
Age range of patients
Sample size of patients
Mean ROM before TKA in degrees ( ).
Kim Keeney
36-89 45-80
56 23
99.62 ---
Mean time interval between TKA and open surgical release (in months) 18 24
Mean Improvement in ROM in degrees ( )
Mean Improvement in flexion in degrees ( )
Mean Improvement in extension in degrees ( )
p-value of Mean Improvement in ROM
27.6 21.8
19.6 12
8.1 10.5
p< 0.001 p=0.28
Fig. 12. Revision TKR — outcomes.
Study ID
Mean knee society function score at follow-up
Mean knee society knee score at follow-up
Mean knee society pain score at follow-up
Kim Keeney
58.4 62.5
46.9 74.7
46.9 ---
Fig. 13. Revision TKR — KSS results.
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H. Ghani et al. / The Knee 19 (2012) 751–759
Study ID
Failures/Complications
Kim Keeney
4 knees underwent a subsequent MUA and 2 knees were re-revised, 2 patients were considered to worsen. 16 patients (69.6% of total) were declared to have substantial clinical and functional improvement. Fig. 14. Revision — failures and complications.
allowing for haemostasis by thorough wash out and drain insertion, which can help to prevent further stiffness in the future. This was also reflected in the lack of hematoma formation in the complications experienced in the arthroscopy group in our review. However, arthroscopy also introduces the potential risks of an invasive procedure, which is shown in this group to cause complications such as skin and wound infections and instrument breakage during arthroscopy. Authors recommend that arthroscopy should be performed in moderately painful and stiff knees, preferably within 3 to 6 months after TKA. The studies in this review adhered to this principle and all took place well after 3 months from the primary TKA. Open surgical release is recommended when there is significant limitation of motion (60°), when instrumentation by an arthroscope is difficult due to severe arthrofibrotic reaction and malposition of implants [6]. It is also reserved for those patients who do not respond to the previous two treatment modalities. It is contraindicated however; in patients who might have an extrinsic cause of knee stiffness not related to arthrofibrosis, such as decreased range of motion of the hip secondary to arthrodesis or neurological impairment [23]. The complication rates reported in these studies was very low, but this may be due to the smaller sample size and/or failure to report complications that occurred by the authors. Revision TKA is considered optimal for those patients with severe restriction of motion and an identifiable implant or technical concern [32]. However, the gains by this surgery prove to be minimal in terms of increase in ROM. Also as the authors chose not to comment on any complications that might have occurred post-surgery, we are unable to compare the complication rates of this modality with others. An acceptable range of knee motion depends on the patient, but in general 70° of flexion has been reported as necessary for the swing phase of gait, 90° to descend stairs, and 105° to get up from a low chair [37]. The natural history of stiffness in the knee post-TKA has been evaluated in available literature in regard to fixed flexion contracture following TKA. In the case of stiffness caused by isolated fixed flexion contracture, a recent prospective review of 136 patients by Quah et al. [38]demonstrated that patients with stiffness due to fixed flexion contracture gradually improve over time with complete resolution occurring in 94.1% of patients at 10.8 months of follow-up. Previous studies by Tanzer and Miller [39] and Aderinto et al. [40] found similar results in patients with fixed flexion contracture, showing that gradual improvement in knee extension can be expected with rehabilitation and physiotherapy. To our knowledge, the natural history of other causes of stiffness in the knee has not been suitably researched and further prospective studies are needed to examine the course of conservative treatment for other causes of restricted motion of the knee post-TKA. In light of the results obtained from our systematic review, it appears that in terms of outcome in ROM, the most significant improvement was shown in the patients receiving open surgical release of their arthrofibrosis. However, this treatment has its limitations in terms of risk to patients with co-morbidities and the anxiety of patients in regard to multiple surgeries. Therefore it is reasonable to conclude that in younger, physically fit patients requiring an increased ROM to accommodate more active lifestyles, open surgical release is the best option, as this will provide them with an adequate improvement in ROM. However, in older patients with comorbidities for whom limited movement is sufficient to fulfil their
activities of daily living and lifestyle, MUA can provide a beneficial option early after TKA or with arthroscopic release within 3 to 6 months after TKA. 6. Conclusion In summary our analysis represents the recent available evidence regarding the efficacy of the four main treatment modalities of stiffness post total knee replacement surgery. Our review suggests that open surgical release provides the highest increase in ROM at final follow up, however the Knee Society Score remained relatively consistent for all four treatments. We did however face methodological limitations as the majority of papers in this systematic review were case series, which decreased the quality of the evidence available. Well-designed trials with blinded measurement of outcomes would help generate a higher quality of evidence, which would help in reaching more robust conclusions regarding these treatment modalities and would enable us to statistically analyse the outcomes as well. Conflict of interest The authors declare there is no conflict of interest. References [1] Kim J, Nelson CL, Lotke PA. Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am 2004;86-A(7): 1479–84. [2] Yercan H, Sugun T, Bussiere C, Selmi T, Davies A, Neyret P. Stiffness after total knee arthroplasty: prevalence, management and outcomes. Knee 2006;13:2. [3] Lee DC, Kim DH, Scott RD, Suthers K. Intraoperative flexion against gravity as an indication of ultimate range of motion in individual cases after total knee arthroplasty. J Arthroplasty 1998;13:500–3. [4] Schurman DJ, Parker JN, Ornstein D. Total condylar knee replacement. A study of factors influencing range of motion as late as two years after arthroplasty. J Bone Joint Surg Am 1985;67:1006–14. [5] Schiavone Panni A, Cerciello S, Vasso M, Tartarone M. Stiffness in total knee arthroplasty. J Orthop Traumatol Sep. 2009;10(3):111–8. [6] Scranton P. Management of knee pain and stiffness after total knee arthroplasty. J Arthroplasty 2001;16:4. [7] Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg May–Jun 2004;12(3):164–71. [8] Christensen CP, Crawford JJ, Olin MD, Vail TP. Revision of the stiff total knee arthroplasty. J Arthroplasty Jun. 2002;17(4):409–15. [9] Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res Nov 1989;248:13–4. [10] Mohammed R, Syed S, Ahmed N. Manipulation under anaesthesia for stiffness following knee arthroplasty. Ann R Coll Surg Engl 2009;91(3). [11] Zengerink M, Strujis PA, Tol JL, van Dijk CN. Treatment of osteochondral lesions of the talus; a systematic review. Knee Surg Sports Traumatol Arthrosc Feb. 2009;18(2):238–46. [12] Wells GA, Shea B, O'Connell D. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Proceedings from the 3rd Symposium on Systematic Reviews. Beyond the Basics: improving quality and impact. Oxford, UK; 2000. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford. htm. [13] Cates HE, Schmidt JM. Closed manipulation after total knee arthroplasty: outcome and affecting variables. Orthopedics 2009;32(6):398. [14] Rubinstein Jr RA, DeHaan A. The incidence and results of manipulation after primary total knee arthroplasty. Knee 2010;17(1):29–32. [15] Maloney WJ. The stiff total knee arthroplasty: evaluation and management. J Arthroplasty Jun 2002;17(4 Suppl. 1):71–3. [16] Esler C, Lock K, Harper W, Gregg P. Manipulation of total knee replacements. J Bone Joint Surg 1999;81-B. [17] Keating EM, Ritter MA, Harty LD, Haas G, Meding JB, Faris PM, et al. Manipulation after total knee arthroplasty. J Bone Joint Surg Am 2007;89:2. [18] Fox JL, Poss R. The role of manipulation following total knee replacement. J Bone Joint Surg Am 1981;63(3):357–62.
H. Ghani et al. / The Knee 19 (2012) 751–759 [19] Ipach I, Mittag F, Lahrmann J, Kunze B, Kluba T. Arthrofibrosis after TKA — influence factors on the absolute flexion and gain in flexion after manipulation under anaesthesia. BMC Musculoskelet Disord Aug 2011;12:184. [20] Arbuthnot JE, Brink RB. 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 2010;18(3):346–51. [21] Sprague III NF, O'Connor RL, Fox JM. Arthroscopic treatment of postoperative knee fibroarthrosis. Clin Orthop Relat Res Jun 1982;166:165–72. [22] Johnson DR, Friedman RJ, McGinty JB, Mason JL, St Mary EW. The role of arthroscopy in the problem total knee replacement. Arthroscopy 1990;6(1):30–2. [23] Nelson CL, Kim J, Lotke PA. Stiffness after total knee arthroplasty. J Bone Joint Surg Am 2005;87:264–70. [24] Bae DK, Hong KL, Cho JH. Arthroscopy of symptomatic total knee replacements. Arthroscopy 1995;11(6):664–71. [25] Williams III RJ, Westrich GH, Siegel J, Windsor RE. Arthroscopic release of the posterior cruciate ligament for stiff total knee arthroplasty. Clin Orthop Relat Res 1996(331):185–91. [26] Wasilewski SA, Frankl U. Arthroscopy of the painful dysfunctional total knee replacement. Arthroscopy 1989;5(4):294–7. [27] Teng HP, Lu YC, Hsu CJ, Wong CY. Arthroscopy following total knee arthroplasty. Orthopedics Apr 2002;25(4):422–4. [28] Diduch DR, Scuderi GR, Scott WN, Insall JN, Kelly MA. The efficacy of arthroscopy following total knee replacement. Arthroscopy Apr 1997;13(2):166–71. [29] Hutchinson JR, Parish EN, Cross MJ. Results of open arthrolysis for the treatment of stiffness after total knee replacement. J Bone Joint Surg Br 2005;87(10): 1357–60. [30] Babis GC, Trousdale RT, Pagnano MW, Morrey BF. Poor outcomes of isolated tibial insert exchange and arthrolysis for the management of stiffness following total knee arthroplasty. J Bone Joint Surg Am 2001;83-A(10):1534–6.
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[31] Mont MA, Seyler TM, Marulanda GA, Delanois RE, Bhave A. Surgical treatment and customized rehabilitation for stiff knee arthroplasties. Clin Orthop Relat Res 2006 May;446:193–200. [32] Keeney JA, Clohisy JC, Curry M, Maloney WJ. Revision total knee arthroplasty for restricted motion. Clin Orthop Relat Res 2005;440:135–40. [33] Boutron I, Ravaud P, Nizard R. The design and assessment of prospective randomized, controlled trials in orthopaedic surgery. J Bone Joint Surg Br 2007;89: 369–72. [34] Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat the stiff total knee arthroplasty?: a systematic review. Clin Orthop Relat Res Apr 2010;468(4):1096–106. [35] Jerosch J, Aldawoudy AM. Arthroscopic treatment of patients with moderate arthrofibrosis after total knee replacement. Knee Surg Sports Traumatol Arthrosc 2007(15):71–7. [36] Campbell Jr ED. Arthroscopy in total knee replacements. Arthroscopy 1987;3(1):31–5. [37] Laubenthal KN, Smidt GL, Kettelkamp DB. A quantitative analysis of knee motion during activities of daily living. Phys Ther 1972;52:34. [38] Quah C, Swamy G, Lewis J, Kendrew J, Badhe N. Fixed flexion deformity following total knee arthroplasty. A prospective study of the natural history (Published online ahead of print October 13 2011) Knee Oct 2011, doi: 10.1016/j.knee.2011.09.003. [39] Tanzer M, Miller J. The natural history of flexion contracture in total knee arthroplasty. A prospective study. Clin Orthop Relat Res Nov 1989;248: 129–34. [40] Aderinto J, Brenkel IJ, Chan P. Natural history of fixed flexion deformity following total knee replacement: a prospective five-year study. J Bone Joint Surg Br Jul 2005;87(7):934–6.