JBJS | Poor Outcomes of Isolated Tibial Insert Exchange and Arthrolysis for the Management of Stiffness Following Total Knee Arthroplasty

The Journal of Bone & Joint Surgery, Volume 83, Issue 10

Scientific Article | October 01, 2001

Poor Outcomes of Isolated Tibial Insert Exchange and Arthrolysis for the Management of Stiffness Following Total Knee Arthroplasty

George C. Babis, MD; Robert T. Trousdale, MD; Mark W. Pagnano, MD; Bernard F. Morrey, MD

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Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester, Minnesota

The Journal of Bone & Joint Surgery. 2001; 83:1534-1536

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Abstract

Background: Severe stiffness after total knee arthroplasty is a debilitating problem. In patients with securely fixed and appropriately aligned components, arthrolysis of adhesions and exchange to a thinner tibial polyethylene insert may appear to be a reasonable and logical solution. We reviewed our experience with this procedure to determine its efficacy.

Methods: From 1992 through 1998, seven knees with marked stiffness after total knee arthroplasty were treated at our institution with arthrolysis of adhesions and conversion to a thinner tibial polyethylene insert. Only patients in whom the total knee prosthesis was well aligned, well fixed, and not associated with infection were included. There were five women and two men with a mean age at revision of sixty-one years (range, thirty-eight to seventy-four years). The average time to revision was twelve months, and the mean arc of motion prior to revision was 38.6° (range, 15° to 60°). The duration of follow-up after the insert exchange averaged 4.2 years (range, two to eight years).

Results: Mean Knee Society pain and function scores changed from 44 and 36.4 points preoperatively to 39.6 and 46 points at the time of final follow-up. Two knees were rerevised, one because of infection and the other because of aseptic loosening of the components. The five remaining knees were painful and stiff at the time of final follow-up. Four of these five knees were severely painful, and one knee was moderately and occasionally painful. The mean arc of motion of these five knees was 58° (range, 40° to 70°) at the time of final follow-up.

Conclusion: Isolated tibial insert exchange, arthrolysis, and débridement failed to provide a viable solution to the difficult and poorly understood problem of knee stiffness in a group of carefully selected patients following total knee arthroplasty. We therefore have little enthusiasm for the continued use of this strategy.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Stiffness after total knee arthroplasty is debilitating, and its etiology is often multifactorial. Preoperative, intraoperative, and postoperative mechanical or biological factors may contribute to stiffness^1-4, yet there is no obvious explanation for the symptom in a certain subset of patients. Arthrolysis combined with a thinner polyethylene insert would seem to be a possible solution to this problem that would not require revision of the femoral or tibial component. We report here the results of isolated exchange of the tibial polyethylene insert and arthrolysis for the treatment of marked and persistent stiffness after total knee arthroplasty in seven knees.

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TABLE I: Data on the Seven Patients Managed with Tibial Insert Exchange and Arthrolysis

Case	Range of Motion (deg)		Pain		Knee Society Scores⁵
Pain		Function
Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.
1	?0-40	?0-40	Severe	Severe	33	33	45	45
2	25-85	?0-70	Moderate, continuous	Severe	32	39	?0	50
3	20-70	10-60	Mild	Severe	65	30	30	45
4	15-50	Rerevised	Moderate, occasional	Rerevised	51	Rerevised	45	Rerevised
5	20-35	?0-60	Mild	Moderate, occasional	53	57	45	50
6	10-50	Rerevised	Moderate, continuous	Rerevised	41	Rerevised	55	Rerevised
7	30-60	?0-70	Moderate, continuous	Severe	33	39	35	40

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TABLE I: Data on the Seven Patients Managed with Tibial Insert Exchange and Arthrolysis

Case	Range of Motion (deg)		Pain		Knee Society Scores⁵
Pain		Function
Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.
1	?0-40	?0-40	Severe	Severe	33	33	45	45
2	25-85	?0-70	Moderate, continuous	Severe	32	39	?0	50
3	20-70	10-60	Mild	Severe	65	30	30	45
4	15-50	Rerevised	Moderate, occasional	Rerevised	51	Rerevised	45	Rerevised
5	20-35	?0-60	Mild	Moderate, occasional	53	57	45	50
6	10-50	Rerevised	Moderate, continuous	Rerevised	41	Rerevised	55	Rerevised
7	30-60	?0-70	Moderate, continuous	Severe	33	39	35	40

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From 1992 through 1998, seven patients with severe knee stiffness after total knee arthroplasty were treated at our institution with isolated exchange of the tibial polyethylene insert combined with stiffness of adhesions. Only patients with no other obvious mechanical problem with the knee were included in the study. There were five women and two men with a mean age of sixty-one years (range, thirty-eight to seventy-four years) at the time of the revision operation. The underlying diagnosis leading to the index total knee arthroplasty was osteoarthrosis in six knees and psoriatic arthritis in one.

The inserts were exchanged at a mean of twelve months (range, four months to 2.5 years) after the previous total knee replacement. Four patients had undergone prior surgical attempts to treat the stiffness. All patients had a condylar-type total knee prosthesis, cemented in six knees and fixed without cement in one. Three of the knee components were posterior-stabilized, and four were posterior-cruciate-ligament-retaining. All patients had a thorough preoperative radiographic evaluation, which showed that the components were well fixed and well aligned. On the basis of aspiration and laboratory data, all knees were determined to be free of infection. The average arc of motion prior to revision was 38.6° (range, 15° to 60°). Lack of full extension averaged 17° (range, 0° to 30°), while flexion averaged 56° (range, 35° to 85°). One patient experienced severe pain; three patients had moderate, continuous pain; one had moderate, occasional pain; and two had mild pain (Table I).

At the time of insert revision, all components were found to be well fixed and well aligned. Intraoperative pathological specimens and cultures showed no evidence of infection in any of the seven knees. Complete synovectomy, removal of scar tissue, and lateral retinacular release was performed in all cases. One patient required a quadriceps snip for exposure, but none had a tibial tubercle osteotomy. In six knees, a thinner insert was used for the revision. These revision inserts averaged 9.5 mm (range, 8 to 11 mm) compared with 12 mm (range, 10 to 15 mm) for the primary inserts. In one knee, trial reduction with an insert that was 2 mm thinner resulted in intraoperative instability, and an insert of the same thickness as the primary insert was used instead. Range of motion of the knees was checked intraoperatively. Full extension and a mean of 100° of flexion (range, 90° to 120°) was achieved in all patients. All patients had an epidural catheter for forty-eight hours to control postoperative pain. Rehabilitation with continuous passive motion was begun on the first postoperative day and was followed by supervised physiotherapy for all patients. Three knees were treated with manipulation under anesthesia within two months after the procedure.

Results

Introduction | Materials and Methods | Results | Discussion | References

Follow-up after the insert exchange averaged 4.2 years (range, two to eight years). Two knees were rerevised, one because of deep infection at two and one-half years after the insert exchange and the other because of aseptic loosening of both the tibial and the femoral component at two years after the insert exchange. Of the remaining knees, four had severe pain and a fifth had moderate pain at final follow-up. The mean Knee Society pain and function scores⁵ changed from 44 and 36.4 points preoperatively to 39.6 and 46 points at the time of final follow-up (Table I).

The mean arc of motion was 38.6° (range, 15° to 60°) preoperatively and improved to 58° (range, 40° to 70°) at the time of final follow-up. Flexion contracture decreased in all cases, including those in which the prosthesis had failed and was rerevised. Four of the five patients who had retained the prosthesis could fully extend the knee. The fifth patient had a 10° flexion contracture compared with one of 20° preoperatively. The maximum flexion decreased in two of the five knees that had not been rerevised.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Severe knee stiffness, a well-recognized complication of total knee arthroplasty, is a debilitating problem. Walking on level ground requires 65° of knee flexion; rising from a chair or going up stairs, >70° of flexion; and going down stairs, 90° of flexion^6,7. The complication has been linked to several possible factors: a limited preoperative range of motion, an increased tendency for arthrofibrosis, poor patient motivation, an extended duration of immobilization, technical issues, a low pain threshold, and reflex sympathetic dystrophy^2,4,8-10. Technical issues include poor implant design, axial or rotational malalignment of components, overstuffing of the patellofemoral joint, mismatch of flexion and extension gaps, a tight posterior cruciate ligament in knees in which a posterior cruciate-retaining prosthesis is used, and poor ligament-balancing^2,4,6,9-13.

There is little information regarding knee stiffness that has no known cause, and the treatment options are unclear. Nicholls and Dorr³ reported the results of thirteen revision total knee arthroplasties that were performed because of symptomatic stiffness. Eleven patients reported improved satisfaction primarily because of a decrease in pain. However, a specific cause of the stiffness was identified in only ten of the thirteen knees. Fibrosis of the knee joint was present in only three patients, and all three had a poor outcome with a markedly limited range of motion at final follow-up. Williams et al.¹³ reported the results of arthroscopic posterior cruciate ligament release in ten knees that were stiff following posterior cruciate-sparing total knee replacement. Eight patients were satisfied with the result of that procedure, and the average increase in flexion was 30.5° (range, 10° to 50°).

Modular implants were developed partly to allow the surgeon to perform a tibial insert exchange to treat a malfunctioning total knee prosthesis. Isolated insert exchange can be justified only in the presence of a well-fixed and well-aligned prosthesis. In spite of the logic of the approach, the change to a thinner tibial polyethylene liner was not beneficial in our experience. Extension was improved in all cases, but flexion was not. Importantly, all patients continued to report pain.

The etiology of this type of complication is poorly understood. Since an adequate range of motion was achieved intraoperatively in all patients, recurrent stiffness may be attributed to a predisposition to scar formation. Our poor results are consistent with those of others¹⁴. While no reliable treatment for knee stiffness after total knee arthroplasty has yet been reported, our data clearly reveal that débridement and polyethylene insert exchange was not effective, in our hands, for the type of patients defined by our selection criteria. This technique still may be considered, however, in uncommon instances in which an excessively thick insert is clearly identified as the cause of the loss of range of motion and there is no evidence of a tendency toward excessive scarring.

Note: Nothing in this publication implies that the Mayo Foundation endorses the products or companies mentioned in this manuscript.

References

Introduction | Materials and Methods | Results | Discussion | References

Jordan LR, Olivo JL. Stiffness and limitation of motion: prevention and management. In: Lotke PA, Garino JP, editors. Revision total knee arthroplasty. Philadelphia: Lippincott-Raven; 1999. p 461-7

Lonner JH,Lotke PA. Aseptic complications after total knee arthroplasty. J Am Acad Orthop Surg,1999;7: 311-24. 7311 1999 [PubMed]

Nicholls DW,Dorr LD. Revision surgery for stiff total knee arthroplasty. J Arthroplasty,1990;5 Suppl: 73-7. 5 Suppl73 1990

Papagelopoulos PJ,Lewallen DG. Knee ankylosis or stiffness after a total knee arthroplasty: treatment and long term outcome. Knee,1994;1: 105-10. 1105 1994

Insall JN, Dorr LD, Scott RD,Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop,1989;248: 13-4.. 24813 1989 [PubMed]

Moreland JR. Mechanisms of failure in total knee arthroplasty. Clin Orthop,1988;226: 49-64. 22649 1988 [PubMed]

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. 671006 1985 [PubMed]

Aglietti P, Windsor RE, Buzzi R,Insall JN. Arthroplasty for the stiff or ankylosed knee. J Arthroplasty,1989;4: 1-5. 41 1989 [PubMed]

Insall JN, Haas SB. Complications of total knee arthroplasty. In: Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P, editors. Surgery of the knee. 2nd ed, vol 2. New York: Churchill Livingstone; 1993. p 914-5.

Ritter MA,Stringer EA. Predictive range of motion after total knee replacement. Clin Orthop,1979;143: 115-9. 143115 1979 [PubMed]

Bertin KC. Evaluation of the unsuccessful total knee arthroplasty. In: Engh GA, Rorabeck CH, editors. Revision total knee arthroplasty. Baltimore: Williams and Wilkins; 1997. p 28-45

Maloney WJ,Schurman DJ. The effects of implant design on range of motion after total knee arthroplasty. Total condylar versus posterior stabilized total condylar designs. Clin Orthop,1992;278: 147-52. 278147 1992 [PubMed]

Williams RJ 3rd, Westrich GH, Siegel J,Windsor RE. Arthroscopic release of the posterior cruciate ligament for stiff total knee arthroplasty. Clin Orthop, 1996;331: 185-91. 331185 1996 [PubMed]

Engh GA, Koralewicz LM,Pereles TR. Clinical results of modular polyethylene insert exchange with retention of total knee arthroplasty components. J Bone Joint Surg Am,2000;82: 516-23. 82516 2000 [PubMed]

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TABLE I: Data on the Seven Patients Managed with Tibial Insert Exchange and Arthrolysis

Case	Range of Motion (deg)		Pain		Knee Society Scores⁵
Pain		Function
Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.
1	?0-40	?0-40	Severe	Severe	33	33	45	45
2	25-85	?0-70	Moderate, continuous	Severe	32	39	?0	50
3	20-70	10-60	Mild	Severe	65	30	30	45
4	15-50	Rerevised	Moderate, occasional	Rerevised	51	Rerevised	45	Rerevised
5	20-35	?0-60	Mild	Moderate, occasional	53	57	45	50
6	10-50	Rerevised	Moderate, continuous	Rerevised	41	Rerevised	55	Rerevised
7	30-60	?0-70	Moderate, continuous	Severe	33	39	35	40

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TABLE I: Data on the Seven Patients Managed with Tibial Insert Exchange and Arthrolysis

Case	Range of Motion (deg)		Pain		Knee Society Scores⁵
Pain		Function
Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.
1	?0-40	?0-40	Severe	Severe	33	33	45	45
2	25-85	?0-70	Moderate, continuous	Severe	32	39	?0	50
3	20-70	10-60	Mild	Severe	65	30	30	45
4	15-50	Rerevised	Moderate, occasional	Rerevised	51	Rerevised	45	Rerevised
5	20-35	?0-60	Mild	Moderate, occasional	53	57	45	50
6	10-50	Rerevised	Moderate, continuous	Rerevised	41	Rerevised	55	Rerevised
7	30-60	?0-70	Moderate, continuous	Severe	33	39	35	40