MANAGEMENT FACTORIALS IN TKA The stiff total knee … · VOL. 94-B, No. 11, NOVEMBER 2012 103...

VOL. 94-B, No. 11, NOVEMBER 2012 103

MANAGEMENT FACTORIALS IN TKA

The stiff total knee arthroplastyCAUSES AND CURES

K. G. Vince

From Whangarei Hospital, Kamo, New Zealand

K. G. Vince, MD, FRCS(C), Consultant Orthopedic SurgeonWhangarei Hospital , Northland District Health Board, 118 Crane Rd. RD 1, Kamo, 0185, New Zealand

Correspondence should be sent to K. G. Vince e-mail: [email protected]

©2012 British Editorial Society of Bone and Joint Surgerydoi:10.1302/0301-620X.94B11. 30793 $2.00

J Bone Joint Surg Br 2012;94-B, Supple A:103–11.

Seven stiff total knee arthroplasties are presented to illustrate the roles of: 1) manipulation under general anesthesia; 2) multiple concurrent diagnoses in addition to stiffness; 3) extra-articular pathology; 4) pain as part of the stiffness triad (pain and limits to flexion or extension); 5) component internal rotation; 6) multifactorial etiology; and 7) surgical exposure in this challenging clinical problem.

Technical skill is mastery of complexity, but creativity is mastery of simplicityThe Cambridge mathematician and topologistChristopher Zeeman, known for the term‘arthrofibrosis’ and his contributions to ‘catas-trophe theory’ said ‘technical skill is mastery ofcomplexity while creativity is mastery of sim-plicity.’ Successful revision of the stiff total kneearthoplasty (TKA) will require the greatest tech-nical skill and the ability to reduce complex fail-ure (catastrophe) to a complete roster of simpleproblems: technical skill and creativity.

These are seven concise case presentations,each one illustrating a facet of the complexproblems that come under the heading of thestiff TKA. Knee motion combined with stabil-ity epitomises the successful arthroplasty sur-gery. Satisfactory surgery requires a stable jointthat extends fully with strength, and bendscomfortably to a degree that permits normalactivities. Ultimately, the limit of flexion in anyTKA will be how far the quadriceps muscle canstretch. Accordingly, pre-op flexion is themajor, but not the only, determinant of post-operative flexion.1

When surgeons describe an arthroplasty asstiff they mean that either extension or flexionfails to reach a certain expected point; usuallyfull extension and some arbitrary amount offlexion, usually in excess of 90°. By contrast,patients often use the word stiff to describe thefeeling of moving the joint. For example twodoors may open and close fully. The one withrusted hinges requires greater force to reachthe same point. Accordingly, a patient with fullextension and flexion to 110°, may yetdescribe their TKA as stiff if motion is difficult.

Every complex mechanism requires all sub-systems to function, for overall success. It is

dangerous to accept stiffness in a TKA withoutanalysis. This implies that the stiff TKA is oneentity and implying further that everyoneunderstands exactly what it is. Worse still is theuse of arthrofibrosis, sounding as it does eruditeand insightful, as a synonym for stiffness.Arthrofibrosis implies that stiffness results fromthe patient’s tendency to form scar tissue, andnot in the arthroplasty. Obviously, if a surgeonbelieves that arthrofibrosis is the cause of stiff-ness, (as it may be in a minority of cases) thenrevision surgery should not be contemplated.Won’t that same unnatural tendency to formscar tissue simply make the revision stiff as well?

Case one: manipulation under general anaestheticA 68-year-old female presented for right TKA.She was pleased with her left TKA but hadrequired a manipulation under general anaes-thesia (MUGA) to achieve functional flexion.(Fig. 1a) The indications for both arthroplast-ies were painful osteoarthritis, in knees withreasonable flexion prior to surgery. The rightTKA was performed uneventfully (Figs. 1b, 1cand 1d). The patellae tracked centrally, indi-cating correct rotational position of all compo-nents. She progressed slowly after surgery anda MUGA was performed eventually resultingin 115° of flexion. This case was straightfor-ward: a patient, unwilling or unable to partic-ipate in effective physical therapy followingTKA who benefited from MUGA. Having per-formed the surgery, I was confident that theTKA was mechanically capable of superiormotion and proceeded with MUGA. Nascentscars stretched easily while the patientwas anaesthetised, and recovery returned toschedule.

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CCJR SUPPLEMENT TO THE JOURNAL OF BONE AND JOINT SURGERY

Daluga2 and colleagues remind us that the recommenda-tion for MUGA is not always straightforward. They com-pared 60 TKAs that required MUGA with 41 that achievedmotion routinely. They found that an AP (antero-posterior)dimension of femoral prosthesis more than 12% greaterthan the patient’s femur was a critically independent varia-ble that predisposed to manipulation, i.e. to stiffness. Anoversized femoral component usually makes the TKAtighter in flexion and therefore stiff. Of all the TKA’s thatundergo MUGA, some will be perfectly balanced and ben-efit, while others may have some mechanical impediment tomotion that MUGA cannot overcome.

The first lesson to learn from this case is that a TKA haseither been performed adequately in all respects and so canpermit motion up to the limit imposed by quadriceps flexi-bility or there is some inherent feature that mechanicallylimits motion. The second lesson to learn is that arthrofi-brosis may be one cause of stiffness, but the two terms are

not synonymous. If a TKA is stiff there will be scar. Itdoesn’t mean that the scar caused the stiffness.

Case two: systematic and comprehensive diagnosisStiffness may result from more serious problems, in whichcase manipulation alone will fail. In this case a 74-year-oldmale presented with a stiff TKA. Radiographs indicated aprior tibial tubercle transfer, as treatment for a dislocatingpatella (Fig 2). Our approach to every problem TKA is 1)systematic and 2) comprehensive.3,4 Systematic means thatthe same disciplined evaluation should be followed for eachcase. We use a worksheet that lists the eight indications forrevision on the left, and on the right (Fig 2d), the necessarydata that must be collected to confirm the diagnosis andplan corrective surgery. Infection tops the list, as it must beconsidered in every case. Simple diagnoses follow, some ofwhich can be identified even over the telephone. The most

Fig. 1

Figure 1a – antero-posterior (AP) standing radiographs of the arthritic right knee (viewed on our left) and the successful left TKA. Motion on the leftwas satisfactory only after a MUGA (manipulation under general anesthesia). Figure 1b – AP standing radiograph of right TKA. Figure 1c – merchantpatellofemoral radiograph showing central tracking of the patella and indicating that rotational position of the tibial and femoral components is sat-isfactory. Figure 1d – lateral radiograph of the right TKA with the limb slightly rotated, so that the posterior condyles are seen separately and thefixation lugs do not lineup correctly. This may give the illusion of a larger than ideal femoral component. Tibial slope is satisfactory. Knee motionwas 0° to 75° before and 0° to 115° after manipulation under general anesthesia. Figure 1e – diagram showing that if the increase in the AP dimensionof the femoral condyles by more than 12% was a critically independent variable leading to the need for MUGA. Reprinted from Daluga D, LombardiAV Jr, Mallory TH, Vaughn BK. Knee manipulation following total knee arthroplasty: analysis of prognostic variables. J Arthroplasty 1991;6:119-1282,with permission from Elsevier.

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commonly made diagnosis ‘loosening’ is held in reserveto force us to consider all others first, and not jump toconclusions.

‘Comprehensive means’ that we consider every possi-ble diagnosis, even having identified one compellingproblem in a TKA. This patient presented with stiffness.It would be foolhardy to leave the assessment at thatpoint. A systematic approach required that infection beconsidered first and indeed ESR and CRP were elevated,indicating the importance of an aspiration of synovialfluid.5 White cell count, differential and culture all con-firmed the diagnosis of sepsis. Our comprehensiveapproach forced us to consider patellar tracking prob-lems and their ineluctable association with internal

rotation of tibia and or femoral components.6 The finalassessment was an infected TKA, with a failed tibialtubercle transfer for patellar dislocation because thebasic problem was internal rotation of tibial and femoralcomponents. Incidentally, because of pain, scarring andpatellar dislocation, the TKA was stiff.

The patient was treated with a two-stage re-implantationprotocol for infection7-10 (Figs 2e & 2f). The re-implanta-tion was performed with careful attention to rotationalposition of the tibial and femoral components, yielding acentrally tracking patellar with increased comfort and flex-ion (Figs 2g to 2j).

This case teaches us that poor motion may be the result ofanother more fundamental problem with the arthroplasty

Fig. 2

Figure 2a – radiographs of a 74 year old male patient who presented with a stiff primary TKA, where two screws are evidence of a tibial tubercletransfer to treat a patellar dislocation not long after the TKA had been performed. Figure 2b – lateral radiograph of a stiff TKA demonstrating anoblique image of the patella, normal patellar height, good tibial component slope and an appropriate size of femoral component. The tubercle oste-otomy is apparent. This is maximum flexion, approximately 35°. Figure 2c – merchant patella-femoral radiograph demonstrating oblique position ofa re-surfaced patella, suggesting that it wants to dislocate, but has been strapped into the trochlear groove by the tubercle osteotomy. Figure 2d –problem TKA worksheet listing the reasonable indications for revision TKA on the left column (1 to 8) and # 9: no diagnosis, where further evaluationis mandatory and surgery should be avoided. Figure 2e – lateral radiograph of a non-articulating, antibiotic impregnated, methyl-methacrylate spaceras part of a two-stage re-implantation protocol for infection. Figure 2f – AP radiograph of non-articulating spacer, with removal of all foreign material,including screws. Figure 2g – AP radiograph of reimplanted TKA: the second stage after control of infection. Cement fixation has been employed withfixation augmented by diaphyseal engaging press-fit stems; straight on the femur and with an offset on the tibia. Figure 2h – lateral radiograph ofre-implanted TKA. Figure 2i – partial full length radiograph showing press fit stems engaged in the diaphysess of tibia and femur with restoration ofneutral mechanical axis. Figure 2j – centrally tracking patella in an arthroplasty without infection, significant pain relief and flexion improved to 90°.

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and that no matter what else is wrong with the arthroplastyit may also be infected. Each TKA must be evaluated with adisciplined system and completely.

Case three: extra-articular problemsThis 56 year old female patient was referred to our unitwith a painful, stiff TKA. Her body mass index placed herin the super obese category.11 Several MUGA’s had beenperformed elsewhere. The last one resulted in a tibial frac-ture and loose component (Figs 3a & 3b). A systematic andcomprehensive evaluation yielded a normal ESR and CRP,with low white cell count and differential in aspiratedsynovial fluid. Cultures of the fluid were negative, effec-tively eliminating infection as a cause of the failure.12 Radi-ographs of the pelvis, which we perform routinely prior torevision of the stiff TKA revealed extensive hip arthropathy(Fig.3c).

That knee symptoms may arise from hip pathology hasbeen understood for many years, and not just by orthopedicsurgeons.13,14 Nonetheless, the diagnosis can be missed,perhaps because the patient is difficult to assess. The sur-geons in this case were presumably so focused on stiffness,which they may have attributed to the obvious obesity thatthey neglected to fully evaluate the patient. While there aremany demands on a clinician’s time, this diagnosis cannotbe missed. This stiff TKA was interpreted as a nothing morecomplicated than a condition requiring manipulation. Noaetiology was considered, and causes outside the knee jointwere overlooked.

This case reminds us that stiffness can result from painand that pain may originate outside of the knee joint.

Case four: painA 42-year-old woman presented with pain and stiffness in aTKA that had been performed for premature osteoarthritis

in association with previous athletic injuries. She hadwanted to remain reasonably active, but the results of sur-gery were disappointing (Fig 4). The TKA had a fixed flex-ion deformity of 15° and further flexion to 95°, whichmany surgeons might not consider stiff. She had difficultybending the knee and it was painful. There was no evidenceof infection12 and neither radiographs of the pelvis andlumbo-sacral spine, or a technetium bone scan, could locatea cause outside the knee. No findings other than pain indi-cated chronic regional pain syndrome.

Critical evaluation of the radiographs revealed that thefemoral component was of an appropriate size, but hadbeen implanted posteriorly, making the flexion gap smallerand tighter. Effectively, this component functions like oneof a larger size, replicating the effect noted above andreported by Daluga.2 CT scanning revealed internal rota-tion positioning of the tibial component.

The patient described pain and stiffness, but had 95° offlexion. Revision arthroplasty with careful component sizingaccording to soft-tissue tension, balancing of flexion andextension gaps15 and rotational positioning of componentswas successful. The flexion contracture was eliminated butflexion increased only modestly from 95° to 110°. Thepatient, however, was pleased with decreased pain.

The stiff knee is usually a triad of flexion contracture,poor flexion and pain. We learned in 2001 from Barrack’selegant case-control study16 comparing satisfied TKApatients with those suffering anterior knee pain, patientswith otherwise unexplained anterior knee pain, had moreinternal rotation of femoral and in particular, tibial compo-nent position. If we identify the underlying problems in theTKA that presents primarily with stiffness and correctthem, we stand a good chance of improving pain which isusually a very important part of the procedure. In otherwords, success may have more to do with reducing a feeling

Fig. 3b

Figure 3a – AP radiograph of failed, loose, stiff TKA in a super obese patient. Serial MUGA’s eventually lead to aseptic loosening with a peri-prostheticfracture, seen here. Figure 3b – lateral radiograph showing proximal tibial fracture, that one can visualise resulting from forced flexion during aMUGA. The femoral component has been implanted in an undesirably flexed position that encroaches on the flexion gap, making the correct sizedimplant function like one that is too large. Figure 3c – AP radiograph of the pelvis demonstrating a severely arthritic hip (arrow) ipsilateral to thepainful stiff TKA.

Fig. 3a Fig. 3c



of painful tightness in a stiff TKA than with dramaticincreases in the motion. Component rotational positioningis very important in understanding these arthroplasties.

This case illustrates the triad of the stiff TKA: 1) flexioncontracture; 2) poor flexion; and 3) pain. There are usuallyseveral mechanical features that predispose to stiffness andpain. While the total amount of flexion provided by revisionmay be modest, function improves with elimination of flexioncontractures and patients are grateful if the knee is more com-fortable and moves more freely, even within a limited arc.

Case five: internal rotationA 41-year-old athletic male, developed arthritis after ananterior cruciate ligament reconstruction and underwent aTKA complicated by pain and very poor motion. The kneelacked 10° of extension and flexed to only 45°. The painwas disabling. Good quality radiographs were impossible.When the prosthesis was imaged symmetrically, the limb isexternally rotated (Figs 5a & 5b). When the limb wasrotated correctly, the prosthesis could not be viewed well.The tibia was implanted in internal rotation and facilitated

Figure 4a – Lateral radiograph of 42-year-old athletic mother of two boys who was profoundly disappointed with pain and stiffness after a TKA forarthritis following sports injuries and ligamentous reconstructions. The arrow indicates a notch in the anterior femur and posterior positioning of anappropriately sized femoral component, translating it into the flexion gap and functioning like an oversized component. Figure 4b – AP radiographshowing subtle evidence of an internally rotated femoral component. A reasonably symmetric image of the tibia component appears only when thelimb has been externally rotated by the radiology technician. This posture of the limb moves the proximal fibula (dotted outline) behind the tibia.Figure 4c – the patella has been resurfaced, but cut asymmetrically sand seems to be tethered in the trochlear groove. Figure 4d – the stiff TKA maymanifest with one or all of the three constituents: 1) fixed flexion contracture, 2) poor flexion and 3) pain. Figure 4e -– AP radiograph of the revisionwith one size smaller femoral component to accommodate a tighter, scarred soft tissue envelope. The tibial component appears symmetrically andthe proximal fibula is not overlapped as much by the tibia indicating better rotational position of the component. Figure 4f -– lateral radiograph show-ing the one size smaller femoral component and an anterior augment which brings the femoral component back into the desired position relative tothe anterior femoral cortex. Figure 4g –- long AP radiograph depicting diaphyseal press fit stems, using offset to manage anatomic asymmetry, fix-ation and alignment. Figure 4h – the patella was not revised given the compromised residual bone stock. It is tracking centrally. The flexion contrac-ture was eliminated, modest gains were made in flexion, but the patient was most grateful for pain reduction.

Fig. 4d

Fig. 4

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by patella alta, the patella was subluxing and would prob-ably dislocate if the knee was flexed further (Figs 5c & 5d).

CT scanning is very useful in evaluating the stiff TKAand essential in this case. A validated protocol quantifiesthe rotational position of tibial and femoral components,with four cuts: one through the femoral epicondyles andthree through the proximal tibia.17 Tibial CT cuts imagethe component, the geometric center of the proximaltibia and the tibial tubercle. Given the asymmetry of theproximal tibia, upto 18° of internal rotation of the tibialcomponent is permissible.6 This patient had a tibialcomponent oriented at 42° of internal rotation. (Figs5e to 5g).

By the time of revision arthroplasty, the knee had been sostiff over a prolonged period of time that the quadricepshad difficulty stretching. Gains in flexion were modest, cor-rection of flexion contracture complete and the improve-ment in pain gratifying. Our experience with revision TKAdemonstrated that one of the most consistent findings in thestiff TKA is internal rotation of the tibial component,18

usually the result of limited exposure and a desire to max-imise coverage of the asymmetric tibia. It is difficult to dis-cuss the stiff TKA now without quantitative CT scan dataon rotational positioning of the components.

The lesson to learn from this case is that internal rotationpredisposes to stiffness through maltracking. As the patient

Figure 5a – radiograph of a painful stiff TKA cannot depict the limb and both components in a true AP rendering simultaneously, because of problemswith the rotational position of the components. In this image the limb is reasonably well positioned, but the tibial (more prominent later tibial fixationflange) and femoral (more prominent lateral femoral condyle) components are internally rotated. Figure 5b – the difficulty continues with the lateralradiograph which shows non-overlapping posterior femoral condyles as well as patella alta. Figure 5c – lateral radiograph showing maximum flexion,with a femoral component that is probably slightly larger AP than the native bone. Figure 5d - patella is almost dislocated and certainly tracking poorlyrelated to rotational positioning of tibial and femoral components.19 Figure 5e – CT scan of TKA according to a validated protocol to quantify rotationalposition of components,6,17 showing the most proximal of three cuts on the tibia, establishing the tibial component angle, and illustrated by the lineat 90° to the line passing through the posterior tibial condyles and projected to the upper left (arrow head). Its relation to the proximal tibia is estab-lished by two additional, more distal cuts. Figure 5f – the most distal CT scan cut (third of three) through the level of the tibial tubercle. TCA is repro-duced from figure 5e and the “geometric center” (see label and arrow at the right of the image) was established on a CT cut just below the component.A line has been drawn from the geometric center through the center of the tibial tubercle. Figure 5g – figures 5e and 5f have been overlaid. It is clearthe tibial component has been positioned internally, 42° to where it might have been aligned with the tubercle. Figure 5h -– a patella has been addedto figure 5g, showing how internal rotation of the tibial component delivers the patella, not to the central trochlear groove, but to the condyle withresultant maltracking and perhaps dislocation.

Fig. 5a Fig. 5b Fig. 5c

Fig. 5d

Fig. 5f Fig. 5g Fig. 5h

Fig. 5e



flexes the knee and senses that the patella will dislocate,they become unwilling to flex further and never achievesfunctional flexion.19

Case six: multi-factorialA 47-year-old female, four years after TKA presented with astiff, painful TKA since surgery. There was a 5° fixed flex-ion contracture with flexion limited to 65°. Pain wassevere and constant. The modular tibial polyethyleneinsert was thick, probably chosen to balance the extensiongap and eliminate recurvatum in a patient who had a rel-atively small flexion gap. The posterior slope for this pros-thesis is recommended to duplicate normal anatomy, but

here there was virtually no slope, which tends to tightenthe knee in flexion. The lateral view showed a thick patel-lar construct and the merchant view showed that thepatella was trying to dislocate, indicating problems withrotational alignment of the tibial and or femoral compo-nents (Figs 6a, 6b and 6c).

Revision surgery that focuses on only one feature of this TKAwill likely fail. The assessment must be analytical and detailed.Only a complete revision that can modify every variable infavor of greater motion over greater stability can be expected tosucceed. Even with that, the elasticity of an extensor mechanismthat has not been fully stretched in four years will ultimatelylimit motion.

Fig. 6

Figure 6a – AP radiograph of painful stiff TKA which in another era might have been labeled a mystery knee, because of no obvious explanation forpain. A further diagnosis of arthrofibrosis may have been added because of limited motion. Figure 6b – lateral radiograph shows a thick polyethyleneinsert after a reasonable amount of tibial resection, plus neutral tibial slope, a relatively large femoral component and a thick patella construct. Noneof these feature by themselves might compromise motion, but together they add up to trouble. Figure 6c – merchant patella-femoral view showspatellar maltracking, synonomous with internal rotation of tibial and femoral components. Figure 6d – AP radiograph after complete revision arthro-plasty with non-linked, constrained implants. A diaphyseal engaging press fit stem has been used on the femur for alignment and fixation, with afully cemented stubby stem extension fully cement into the tibia because of relatively small stature. The stem extension has been modified intra-operatively to avoid endosteal impingement. Figure 6e – patella is tracking centrally on the Merchant view indicating that rotational position of tibialand femoral components has been corrected. Figure 6f – lateral radiographs shows satisfactory joint line height and patellar position. Figure 6g – fishdiagram illustrating the multifactorial nature of the stiff TKA. In particular, rotational positioning of components is of greater significance than hasbeen appreciated in the past.

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The lesson to learn from this case is that stiffness com-plicating TKA is often a multi-factorial problem.Accordingly, complete revision arthroplasty is appropri-ate and lesser interventions are rarely successful.

Although some of the first cases described above wereused to illustrate specific single points, every one of themwas revised with attention to all of the variables that wehave covered.

Fig. 7o

Figure 7a –- full-length AP radiographs showing well aligned but extremely stiff TKAs. Figure 7b -– AP radiograph

of the first TKA performed with correction of the extra-articular deformity above. Figure 7c –- AP radiograph of

second TKA also complicated by stiffness that patent has requested help with. Figure 7d –- lateral radiograph of

left TKA stiff but not for revision) with severe patella infer/baja. Figure 7e -– attempted Merchant patella-femoral

view impaired by patients inability to flex past 15°. Figure 7f –- lateral of stiff left TKA for revision. Slope and sizing

are reasonable. It cannot be established whether the contracted patellar tendon contributes to or results from the

stiffness. Figure 7g –- in surgery, immediately prior to revision arthroplasty. Flexion limited to less than 40° with

very hard end point. Figure 7h –- extensive synovectomy, decreases thickness of scar and reveal supple tissue in

the supra-patellar pouch. Figure 7i -– scar on either side of the femur is released longitudinally, to re-establish

the normal para-femoral gutters. This improves the excursion of the extensor mechanism. Figure 7j -– thick wad

of scar on the deep surface of the patellar tendon, which when removed, allows the tendon the stretch and twist

more normally. The tendon is less likely to avulse from its insertion. Figure 7k – a lateral patellar retinacular

release is performed for exposure, not patellar tracking. It allows the entire soft tissue envelope to expand. Figure

7l –- long handled scissors are useful to divide scars halfway up the thigh that have stuck the deep extensor to

the femur. Figure 7m –- before any components are removed a gentle manipulation takes advantage of the

releases that have been performed. Figure 7n –- the quadriceps snip is useful and well known.24 An alternate

maneuver that can be performed first is the quadriceps split whereby the arthrotomy is extended up into the muscle fibers. If this is inadequate, the snip should follow. Figure 7o – the patient under consider-

ation, was still difficult to exposure after all of the above steps had been taken. Ultimately, if a conventional medial release is performed, of the proximal medial and postereromedisal sleeve, as in a a classic

release to correct varus deformity, the tibial can be flexed and externally rotated, driving the tubercle laterally to safely dislocate the knee. This may necessitate a constrained implant, but the exposure is superb

and the extensor is protected. Figure 7p – post revision AP with non-linked constrained implant. Aggressive release of scar usually destabilises a knee like this so that constraint is necessary. Figure 7q – later

radiograph after revision showing press fit stem extensions, anterior augmentation to bring the (smaller sized) femoral component out of flexion and thus decreasing the size and tension in the flexion gap.

Motion improved to about 75° of flexion

Fig. 7a Fig. 7b Fig. 7c Fig. 7d

Fig. 7e

Fig. 7f Fig. 7g

Fig. 7h Fig. 7i Fig. 7j Fig. 7k

Fig. 7l Fig. 7m

Fig. 7p

Fig. 7n

Fig. 7q



Case seven: surgical exposureA 67-year-old male presented with bilateral stiff TKAs withrelatively little pain. His main complaint was that with only35° of flexion bilaterally, should he fall to the ground, hewould be unable to get up. He was involved in a road trafficaccident that left him with solidly healed femur fracturesand decreased flexion in knees that eventually developedarthritis. The arthroplasties performed on stiff knees, inturn, became even stiffer.

The argument can be made that his knees would be lim-ited by the quadriceps muscle stiffness even if revision wasperformed. The patient is adamant that he would like toproceed as the current situation is unmanageable. The sur-gical team feels that aggressive lysis of scar and revision tocomponents that permit greater laxity in flexion, (i.e.smaller femoral component) combined with an assiduousphysical therapy protocol may improve the situation. Evenmodest gains would be welcome (Fig. 7).

Many surgeons might recommend a tibial tubercle oste-otomy for exposure. I believe that approach is unnecessaryin this situation, as well as limiting and risky for aggressivephysical therapy. In addition, the tubercle osteotomy doesnot, in itself, liberate the patient and the knee from exten-sive scarring. Surgical access might be excellent, but oncethe procedure is complete and the tubercle fixed back to thetibia, the extensor is stiff. The patellar turn-down isoutdated20, the V-Y plasty misguided21-23 (lengthening theextensor mechanism often leaves the patient with adisabling lag even if it increases flexion) and the quadricepssnip is of limited effectiveness.24-27

The surgical approach must include: synovectomy, re-establishment of the parafemoral gutters, quadricepsliberation from the scarring that adheres to the anteriorfemur, scar removal from around the patellar tendon andsometimes a lateral patellar retinacular release for exposure,not patellar tracking. Ultimately, release of the proximalmedial capsule and deep collateral ligament permits safeexternal rotation of the tibia. This drives the tubercle later-ally, dislocating the knee. Non-linked constrained implantsare useful generally in cases like these and will splint or sup-plant the medial soft-tissue envelope after the exposure. Thishas long been my approach for revision arthroplasty and hasevolved concurrently and been reported by others as the,“Extensor Mechanism Tenolysis”.28

This case brings us full circle to stiffness that is primarilyof soft-tissue origin, a case of arthrofibrosis. It poses specifyand significant challenges in terms of surgical exposure.

No benefits in any form have been received or will be received from a commer-cial party related directly or indirectly to the subject of this article.This paper isbased on a study which was presented at the Winter 2011 Current Concepts inJoint Replacement meeting in Orlando, Florida, 7th – 10th December.

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MANAGEMENT FACTORIALS IN TKA The stiff total knee … · VOL. 94-B, No. 11, NOVEMBER 2012 103...

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