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1. Early Flexion Contracture
Total Knee Arthroplasty
Wg. Cdr. Chawalit Nakprasert

2. When do you get worried?

3. Stiffness After TKA
Common problem 5% and 30%
Limited range of motion (ROM) that affects
activities of daily living
International Consensus on definition of stiffness
of the knee
• Flexion deficit : mild, moderate or severe
(90–100, 70–89, <70)
• Extension deficit (5–10, 11–20, >20)
P.K. Sculco. THE STIFF KNEE: CAUSES AND CURES; Orthopaedic ProceedingsVol. 99-B, No. SUPP_15. Published Online:21 Feb 2018

4. Risk Factors
Male gender
Higher age
Preoperative flexion contracture > 5 degree
BMI no role in persistence of flexion deformity
after surgical correction

5. Cause of Stiffness
P.K. Sculco. THE STIFF KNEE: CAUSES AND CURES; Orthopaedic ProceedingsVol. 99-B, No. SUPP_15. Published Online:21 Feb 2018
Osseous
• Heterotopic bone
• Retained posterior
osteophytes
Soft tissue
• Fibrotic tissue
• Hamstring shortening
• Ligament contracture
Prosthetic
• Oversized
• Malrotation
Miscelleneus
• Infection ---gradually
loses motion
• CRPS
• Kinesiophobia

6. Cause of Stiffness
Heterotopic bone Posterior osteophytes

7. Component & Surgical Technique Errors
Excessive flexion or extension of the femoral
component --- limitation of motion
Excessive posterior slope --- lack of full extension
and instability in flexion
Anterior slope --- recurvatum deformity and lack
of full flexion
Thigh in extension gap
Oversizing of the femoral component tightening
of the collateral ligaments in flexion
Van P. Stamos and James V. Bono; Management of the Stiff Total Knee Arthroplasty. CHAPTER 23 Revision Total Knee Arthroplasty

8. Component & Surgical Technique Errors
Undersizing of the tibial tray and excessive anterior
placement mechanical block in flexion
Oversizing of the tibial component and liner results
limiting both flexion and extension
Maltracking or tilting or too thickness of the patella
limit full flexion
Loose bodies or cements
Van P. Stamos and James V. Bono; Management of the Stiff Total Knee Arthroplasty. CHAPTER 23 Revision Total Knee Arthroplasty

9. What do you do?

10. Treatment of The Stiff TKA
Early physical therapy and manipulation under
anesthesia (MUA) within 3 months is the greatest
to increase ROM
After 6 months, arthroscopic or open surgery is
recommended Arthroscopic lysis of adhesions can
improve ROM greater than 1 year after index TKA
Average improvement of ROM for both MUA and
arthroscopic lysis of adhesions 30 degrees
P.K. Sculco. THE STIFF KNEE: CAUSES AND CURES; Orthopaedic ProceedingsVol. 99-B, No. SUPP_15. Published Online:21 Feb 2018

11. Treatment of The Stiff TKA
Open lysis of adhesions are reportedly poor but
current adjuvant therapies may improve these
clinical outcomes
Component revision performed for component
malposition and stiffness has variable outcomes
P.K. Sculco. THE STIFF KNEE: CAUSES AND CURES; Orthopaedic ProceedingsVol. 99-B, No. SUPP_15. Published Online:21 Feb 2018

12. Manipulation Under Anesthesia (MUA)
Increased risk of femur fracture, patellar fracture,
or rupture of the extensor mechanism
Adhesions are torn feel a sensation of crepitus
and flexion of the knee will gradually increase
CPM should be immediately and set to the maximum
extension and flexion achieved with manipulation
Van P. Stamos and James V. Bono; Management of the Stiff Total Knee Arthroplasty. CHAPTER 23 Revision Total Knee Arthroplasty

13. Indication: motion of the knee is less than initial
at surgery, rehabilitation is slow to progress, etiology
is arthrofibrosis, tightness of the PCL
after the 6-week postoperative time
lysis of adhesions
fibrous bands of secondary scar
release of the posterior cruciate ligament
removal of a foreign body
Van P. Stamos and James V. Bono; Management of the Stiff Total Knee Arthroplasty. CHAPTER 23 Revision Total Knee Arthroplasty
Arthroscopy

14. Technical imperfections
Potential complications
Van P. Stamos and James V. Bono; Management of the Stiff Total Knee Arthroplasty. CHAPTER 23 Revision Total Knee Arthroplasty
Revision Surgery

15. Grade I Flexion Contracture
KavinKhatri,etal.:ManagementofFlexionContractureinTotalKneeArthroplasty.Openaccesspeer-reviewedchapter.Published:April22nd2020DOI:10.5772/intechopen.90417

16. Grade II Flexion Contracture
KavinKhatri,etal.:ManagementofFlexionContractureinTotalKneeArthroplasty.Openaccesspeer-reviewedchapter.Published:April22nd2020DOI:10.5772/intechopen.90417

17. Grade III Flexion Contracture
KavinKhatri,etal.:ManagementofFlexionContractureinTotalKneeArthroplasty.Openaccesspeer-reviewedchapter.Published:April22nd2020DOI:10.5772/intechopen.90417

18. Removal of posterior osteophytes
Posterior capsular release
Fixed flexion deformity of 10° or greater resect
an additional 2 mm of distal femoral bone
Release of the posterior cruciate ligament
Decrease in the posterior slope of the tibial cut
Flexion contractures of >30°, the collateral ligaments
require release
Avoids flexion of the femoral component
Surgical technique
E. P. Su; Fixed flexion deformity and total knee Arthroplasty. J Bone Joint Surg Br 2012;94-B, Supple A:112–15.

19. Flexion contractures (>30°)
the author uses occasional
plaster splints, and keeps them
fully extended for 48 hours
CPM incorporates a static stretch
splint into its frame
Post-operative management
E. P. Su; Fixed flexion deformity and total knee Arthroplasty. J Bone Joint Surg Br 2012;94-B, Supple A:112–15.
Placement of a shoe-lift on the contralateral side; by lengthening
the contralateral

20. THANK YOU