The 67-Year-Old Stiff Knee: More Than 20 Years of Experience I Can - - PowerPoint PPT Presentation

The 67-Year-Old Stiff Knee: More Than 20 Years of Experience – I Can Solve It!

John J. Callaghan, M.D. The Lawrence & Marilyn Dorr Chair University of Iowa Iowa City, IA

Orthopaedic Summit December 2017

• Consultant and Royalties (DePuy) for

intellectual property transfer for hip & knee implant designs.

• Royalties (Wolters Kluwer) for books edited.
• Board Membership

– Journal of Arthroplasty – International Hip Society – OREF (Orthopaedic Research and Education Foundation) – Knee Society

Disclosures

67 Year Old Man with Stiff Knee status post TKA (3 years ago)

Severe pain active ROM 30-80 degrees

Prevention Better Than Treatment

Pre-Operative Considerations:

• Proper indications:

– Not just “arthroscopic arthritis” – Poor preoperative motion – Realistic expectations

Prevention Better Than Treatment

Intra-Operative Considerations:

• Appropriate soft tissue releases and
• steophyte resection
• Avoidances:

– Over stuffing the patella femoral joint – Over stuffing the flexion or extension gap, or both

Post-Operative Considerations:

• Aggressive pain reduction protocols

– Oxycontin – Anti-inflammatory Pre-op – Tylenol

• Injections intra op
• Post op blocks

– Splints for extension – Anti-depressants

• Manipulate if necessary

Prevention Better Than Treatment

Treatment for Stiff TKA

• Manipulation:

– 2-4 months post op

• Arthroscopic debridement:

– limited indications in the first year or 2 post op

• Revision of components

• Recommend performing by 3 months post op
• Rates vary from 1.8% to 6%

– Probably related to indications for manipulation

• Improvement in motion ranges from 22-40

degrees

• Young age and females higher rates
• Obesity protective

Treatment for Stiff TKA: Manipulation (2-4 months)

• PCL release (Windsor et al, CORR 1996)

– Pre op motion: 4-70 degrees – Post op motion: 1.3-112 degrees – Most successful if patient comes to full extension pre-operatively

• Global debridement (Windsor et al, JOA 1996)

– Results: 42% good, 19% fair, 40% poor

Treatment for Stiff TKA: Arthroscopic Debridement

Patient work up history, looking for supratentorial issues

• Multiple arthroscopies prior to TKR
• Pre-operative radiographs with minimal if any arthritis
• Workman’s compensation
• Psychological issues

– (“How high a squirrel count”) – Dorr (JOA 1990). Poor results

• Patella baja
• Keloid formation
• More than 4 surgeries
• PS TKA

Treatment for Stiff TKA: Revision of Components

Exclude or Identify Extrinsic Sources of Knee Stiffness

• Causes

– Severe OA of ipsilateral hip – Muscle rigidity (from neurologic injury) – Tight quadriceps/hamstrings from injury – Heterotopic Ossification

• Revision TKA unlikely to have favorable
• utcome without correction of Extrinsic

Problem

Intrinsic Causes of Knee Stiffness Following TKA

• Overstuffing of the patellofemoral

articulation

• Excessively tight flexion and/or

extension gap

• Tight posterior cruciate ligament
• Femoral and/or tibial malrotation
• Arthrofibrosis
• Infection

Overstuffing of the Patellofemoral Articulation

• Anterior displacement of anterior flange of

the femoral component

– Due to oversizing of the femoral component – From anterior translation of an appropriately sized femoral component

• After patellar resurfacing if patellar

component composite thickness is increased

Excessively Tight Flexion and/or Extension Gap

• Decreased Flexion (tight flexion gap)

– Amount of posterior femoral condylar bone resected is less than thickness of the posterior condyles of the femoral component (increasing offset) – Femoral component oversized or placed posteriorly – Tibial component placed in neutral or anterior slope

• Decreased Extension (tight extension gap)

– Distal femoral resection is too distal – Tibial insert is too thick – Inadequate tibial resection (tightens flexion and extension gap)

Malrotation

• Femoral and/or Tibial Malalignment
• r Malrotation may lead to

pathologic tightness of soft tissue structures

• Malalignment

– Asymmetry of the extension gap

• Malrotation

– Asymmetry of the flexion gap – Patellar tracking problems

Arthrofibrosis

• Excessive pathologic postoperative

scarring inhibiting flexion and/or extension

• One of most unresponsive causes of

stiffness

Evaluation

• Is patella too thick?
• Was adequate bone removed?
• Is femoral component too large?
• Was tibial insert too thick?
• Are components well aligned?

– Appropriate femoral components sizing, offset restored? – Rotation correct? – Tibial and femoral resection appropriate? – Is tibial component slope correct?

30-80 degrees flexion preop

• CR knee
• No posterior

tibial slope

• Stuffed

patellofemoral joint

• Limited distal

femoral resection

Patella

• Prefer patellar

subluxation over eversion

– Less risk of patellar avulsion

• If patella cannot be

mobilized laterally

– Lateral retinacular release – Quadriceps snip

Surgery

• Thin patella
• Undersize femoral component
• Elevate joint line if necessary
• Use TC3 if loose flexion gap
• Substitute PCL

5-110 degrees flexion post op

30-70 degrees flexion

0-120 degrees flexion

Post Op

• Aggressive pain reduction protocols

– Oxycontin – Anti-inflammatory Pre-op – Tylenol

• Injections intra op
• Post op blocks

– Splints for extension – Anti-depressants

• Manipulate if necessary

Haidukewych et al Dorr et al Christensen et al Lotke et al

• 1.3% of TKRs
• KSS

38 86

• KSS function

40 58 pts

• KSS pain

15 47 pts

• Mean motion

54 82°

• Flexion

66 85°

• Extension

11 3°

• 42 knees
• 47 month avg f/u
• Flexion contracture 9.7 2.3
• Flexion 81 94
• ROM 72 92
• KS Functional Score 48 70
• Pain improved 73%

Stiff TKR: Discussion

• Avoidance better than treatment
• Realistic expectations (motivated patients do

best)

• Revise only if you see something you can fix

Thank You