Joint Stiffness: Complications Following Knee Replacement Surgery

In a relatively recent article 1 published in the Musculoskeletal Journal of Hospital for Special Surgery, Dr. Alejandro Gonzalez Della Valle et al reviewed the origins of and treatments for early onset stiffness,  a common complication following knee replacement surgery. We’ll present a brief summary of the article here.

How Prevalent is Stiffness after Knee Replacement?

In a review of the literature, the authors state that stiffness occurs in roughly 6% of cases, making it the most common knee replacement surgery complication.

How is Stiffness Defined?

The researchers reveal that what is perceived as “stiffness” following knee replacement has evolved over time. Several years ago, a knee was considered stiff if the patient could not extend their knee beyond 25 degrees of flexion (that is, a flexion contracture of 25 degrees) or if the full arc of motion was less than 45 degrees. More recently, as surgical technique and implant design have improved and as younger, more active patients receive implants, expectations have changed. Today, stiffness has been defined as a equal to or greater than only 10 degrees or an arc of motion less than 95 degrees. The authors note that this degree of motion is what is required for common activities of daily living (walking, sitting, stair climbing). Practically speaking, a joint can be considered “stiff” when it limits the patient’s ability to perform such activities.

What Causes Stiffness after Knee Replacement?

The authors place the causes of stiffness into three broad categories:

Preoperative – These include things like post-traumatic osteoarthritis, patients with prior high tibial osteotomy and patient whose preoperative range of motion (ROM) is limited.

Intraoperative – Included here are what the authors termed “technical errors” during the procedure. Things like, improperly sized implants and poor “balancing” of the joint through improper bone preparation fall into this category. The researchers explain these as well as other technical errors in detail.

Postoperative - Following surgery, stiffness can be caused by additional factors. Some examples are by patient behavior (“poor patient motivation”) deep infection and inadequate pain management.

How is Stiffness Treated

The authors then outline the various ways in which stiffness can be treated following knee replacement. Manipulation of the knee by the surgeon under anesthesia is generally successful when used within the first three months after surgery. After this period, more aggressive surgical options should be considered since manipulation can result in fracture or soft-tissue damage. Some surgical treatments described are arthroscopy, tibial insert (or spacer) exchange and revision surgery (i.e. exchange of the femoral component typically to correct imbalance in the spacing between the thigh and shin bone created at the time of surgery). The authors also stress the importance of proper rehabilitation following knee replacement.

The original article is available online through PubMed Central.

1. Gonzalez Della Valle A, Leali A, Hass S: Etiology and Surgical Interventions for Stiff Total Knee Replacements. HSSJ 2007, 3: 182-189

Comments

3 Responses to “Joint Stiffness: Complications Following Knee Replacement Surgery”

  1. Carole Weigel on April 21st, 2009 3:33 pm

    Had TKR on rt knee in ‘06; followed by an arthoscopy 3 months later to remove large amount of scar tissue which affected my gait to no avail. Had partial revision (replacement of patellar component & removal of still more scar tissue) in ‘07; despite physical therapy, acupuncture, massage, water theraphy and much effort, both times, additional scarring and stiffness which never has let up. I cannot see going in for another arthoscopy only to have this scar tissue reappear. I have no idea why I am plagued by this condition. I regret ever having this operation.

  2. Mark on October 2nd, 2009 7:57 am

    I was facing the same problem and had a severe pain in my knee but somehow managed to get rid of this problem with my physician’s help.

  3. Antonio on August 15th, 2010 10:27 pm

    On June 1st 2010 I injured my knee and went to the ER the next day, where they gave me a diagnosis of a torn MCL and Meniscus tear, they immediately put me on a brace to restrict movement and also crutches. On June 14th i had an MRI done which showed a partial MCL tear and a medial meniscus tear. On June 19th i saw an orthopedic surgeon, i explained my symptoms as follows: My main issue was the inability to fully extend and flex my leg which was a symptom that developed immediately after the injury, and also the normal pain on the area where the MCL is located when twisting or basically any movement of my leg. The doctor’s response was that my MCL tear was partial and it would heal by itself on a period of three months and instructed me to keep wearing the knee brace adjusted to bend only at 90 degrees and he basically ignored my meniscus tear saying that it would not cause any difficulties, he said the reason for the loss of range of motion was the swelling and instructed me to come back in 6 weeks.

    So i followed instructions and finally on August 12 i went back to the clinic and saw a different doctor to which i explained my condition all over again, at this point my inability to fully extend or flex my leg is still present, pain has dramatically reduced and it think the source of the pain is the torn meniscus as the area of the pain is different and lower intensity. This pain keeps me from trying to bend my knee past 90 degrees, when trying to extend the pain is more tolerable but still my joint is so stiff that i have had no success trying to improve my range of motion. As i explained this to the doctor he was leaning to surgery as an option to repair the torn meniscus which he believed to be the cause, but he had to talk to his chief surgeon before any decisions were made. The chief surgeon examined my knee and looked at the MRI and discarded my injury from being the cause of the problem and explained that my leg was so stiff and have to get it moving or I will never regain full range of motion, surgery at this point was not an option because it will make me even more stiff, he only prescribed physical therapy for the next six weeks to regain full range of motion.

    At this point i am stressed out and scared that my leg will stay like this forever, I am doubtful as to if the instructions given by the surgeon are the most appropriate.

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