Etiopathology and Management of Stiff Knees: A Current Concept Review

1. Journal club
Etiopathology and Management of Stiff Knees: A Current Concept
Review
Dr.Anandu Mathews Anto
Orthopedic Resident
Government Medical College Kottaym

2. Reference
• Article DOI: https://doi.org/10.1007/s43465-020-00287-0

3. INTRODUCTION
➢A potential devastating complication after any intra
or extra articular injury
➢Complex nature makes treatment often difficult

4. ANATOMY
➢Largest & complex joint in body
➢Intra articular structures
➢Uniplanar movement
➢Collateral ligaments
❖ Synovial membrane
❖ Hoffa’s pad of fat
❖ Muscle move on bony surface
❖ Patella adherence

5. Normal functioning
• Patellar tendon
• Hoffa’s pad of fat
• Synovium
• Patella
• Free gliding Quadriceps
❑Damage to any one structure alter the biomechanics
, is a sophisticated system of gliding, rolling and
spinning movements

6. FUNCTIONAL ROM
❖ 65⁰ walking
❖ 90⁰ squatting
❖ 110⁰ stand from sitting
❖ 85⁰ stair climbing
❖ 70⁰ lifting objects
Inability, impedes your flexibility, strength and stability throughout the entire leg

8. • Reported incicdence of intraarticular fibrosis of the knee varies from 4
to 35%.
• Traumatic injuries and external fixation contributes to almost 14.5 %
of knee stiffness cause.

9. Causes of knee stiffness
• (A) Post-traumatic (fractures in and around the knee joint)
• (B) Post-inflammatory and infective joint disease
• (C) After cast immobilization
• (D) Scarred skin (post-burn contractures, post-traumatic)
• (D) After excessive massage (e.g., by quacks)
• (E) Postoperative:
• Open reduction and internal fixation (ORIF)
• Arthroscopic procedures
• Arthrotomy
• Total knee arthroplasty

10. McNamara et al. [8], in a meta-analysis, identified
several risk factors for motion loss after the knee injuries.
1. fracture severity,
2. external fixation,
3. malreduction,
4. soft-tissue injury,
5. surgical timing, and
6. Postoperative immobilization.
On the contrary, a well-performed surgery
with achieving anatomic fracture reduction and stable internal
fixation, and early range of motion(ROM) is crucial in
decreasing the risk of arthrofibrosis.

11. Pathology of stiff knee
• Within the knee vs proximal to knee
Leads to stiff knee with either
1. loss of extension or
2. loss of flexion
3. Combined

12. Extraarticular
a) Fibrosis and/or shortening of the quadriceps muscles eg rectus
femoris and vastus intermedius
b) Adhesion of the vastus lateralis to femoral condyle
c) Adhesion of skin in the deeper layers
d) Scarred skin-post urns post traumatic

14. A case done at Government Medical College
Kottayam

16. Intraarticular
• Adhesions in tibio femoral joint
• Adhesion in intercondylar notch extension loss
• Adhesions in suprapatellar pouch
• Intraarticular adhesions in the patella femoral flexion loss
and medial and lateral gutters
• Cyclops lesion-fibroproliferative scar formation in the intercondylar
notch-combined flexion and extension loss- described by Jackson and
Schaefer

19. Arthroscopic release and MUA were found to be the most effective

20. Author prefers :Arthroscopic debridement
• Pre procedure
• Procedure
• Post procedure

21. Pre-procedure assessment
• Documentation of the active and passive ROM of the knee before the
anesthesia and after anesthesia.
• If there is no significant difference in these two findings, it would
suggest a
resistant and severe type of knee contracture.
The muscle wasting around the knee, presence of scar or contractures,
patellar mobility must be noted.

22. The main investigations
• plain radiographs, and
• Magnetic Resonance Imaging (MRI).
• Why- to assess
• injuries and fractures around the knee,
• The state of the articular cartilage and any other coincidental
• finding.
• Computed Tomography (CT) is needed if there is a need to assess any bony
defect or deformity

23. • A supine position
• general or spinal/epidural anesthesia are preferred.
• For the postoperative pain relief, an epidural catheter may be left, or
patient-controlled analgesia (PCA) and regional nerve blocks can be
used.
• pneumatic tourniquet may or may not be used, depending
on the patients’ condition and the choice of a surgeon.

24. A preoperative ROM is recorded with the patient prior
to and after the anesthesia .
A video recording and photographs of the ROM prior and after the
procedure are useful for hospital documentation and patient
awareness

25. Arthroscopic Procedure
(a) Position of portals:
An anterolateral (AL), anteromedial (AM), superomedial
(SM), and superolateral (SL) portals are used
for both working portals and outflow cannula.
posteromedial (PM) and posterolateral (PL) portals
-a posterior capsular release is required for severe flexion deformities.

29. Supra-patellar release: It is best done from the SL portal as the viewing
portal and the SM portal as the working portal.
It is not always possible to begin the arthroscopy traditionally from the
AL portal, as in most cases, the knee cannot be flexed more than 90°.

30. First, debridement of the patella-femoral and suprapatellar region is
done, using conventional 30° arthroscope
It is important to realize that the extent of the suprapatellar
pouch is about a hand width or three inches proximal
to the patella.
After the debridement and release, the patella
should be felt mobile.

31. Clearance of gutters
The medial and lateral gutter is then freed from any adhesions.

32. Medial and lateral capsular release
Lateral retinacular release is helpful in further releasing of the tethered
patella. If still tight, medial release can also be done.

33. Anterior interval release
Kukreja et al. have elaborately described the release of the anterior
interval of the knee between the anterior tibial plateau
and the patellar tendon.
First, the hypertrophic and scarred infrapatellar (Hoffa) fat pad and
adhesions in the pre-tibial recess is released.

35. Intercondylar notch debridement
All the scar tissue and hypertrophic synovium are excised, taking care
of not damaging the cruciate ligaments. A notchplasty
may also be done if required

36. Clearance of tibio-femoral compartment
Any obstructing pathology in this compartment like a
loose chondral flap, meniscal tear, or a loose body
should be removed.

37. Manipulation under anesthesia (MUA)
After complete lysis of adhesions in all three compartments
and both gutters, capsular release, and anterior interval
release, gentle manipulation of the knee helps to
break any hidden adhesions and improve the ROM.

38. Infiltration of local anesthetic agents (e.g., Ropivacaine or Bupivacaine)
with or without steroids (e.g., Triamcinolone) may be used, especially
there was severe inflammation present in the knee

39. Finally, if the flexion ROM is still restricted due to tight and shortened,
then pie-crusting or multiple surgical niches into the involved
quadriceps muscle is a useful technique to increase the flexion
arc of the knee, and act as ‘closed quadricepsplasty.’
In cases of tethered quadriceps muscles to the femoral
shaft, the use of a periosteal elevator through
the supra-patellar arthroscopic portals is an
effective technique.

40. Technical difficulties
Due to fibrosis and inadequate visualization initially, restricted
movement of the arthroscope and instruments inside the knee joint
and hence the triangulation is difficult.

41. • The main case selection criteria for arthroscopic arthrolysis
• include:
• (a) No gain in motion by the conservative treatment
• (b) Presence of scarring pathology in and around the knee
• joint ± restricted patellar mobility
• (c) No active joint infection
• (d) Intact articular surfaces
• (e) Healed Intra and peri-articular fractures (if any)

42. The most suitable cases for arthroscopic release include:
1. post-surgical and post-immobilization stiffness,
2. fractures
3. around the knee joint (patella, intra-articular tibial and femoral,and
distal femoral),
4. post-TKA, and
5. stiffness associated with scarred skin

43. Post-procedure Management
(a) Analgesia:
intra-articular local anesthesia, oral NSAIDs, and Opiates, the use of
epidural
infusion of local anesthetics or PCA and nerve blocks (femoral and
obturator).

44. (b) Physical therapy:
In cases of stiffness in extension, the knee should be kept in a flexed
position, using pillow etc the immediate post-operative period.
Cryotherapy and the use of CPM for the first couple of weeks are
crucial
in relieving pain and regaining the ROM.
The ROM and stretching exercises should be started as soon as possible
and gradually increased.

45. discussion
The aims of treatment are
(a) to control pain,
(b) to resolve inflammation,
(c) to regain an early functional arc of motion

46. The management of knee stiffness is guided by several
factors like the
1. type of initial injury,
2. amount of loss of ROM,
3. time since injury,
4. and the status of articular cartilage

47. Arthroscopic
lysis
If more than
3 months
Stiff knee
conservative
supervised
physiotherapy
continuous
passive
motion (CPM
dynamic
splinting,
If less than 3
months
MUA

48. Mua - BEWARE
Forceful manipulation can lead to the development of extreme and
excessive contact forces in the already jeopardized joint structures,
leading to complications like peri-articular fractures, chondral damage,
tear of ligaments and muscles

49. Current concept
Nowadays, open surgical procedures, like excision of infrapatellar and
prepatellar adhesions and quadricepsplasty, are not done commonly as
these are associated with additional surgical morbidity and may be less
favorable for management of flexion contracture.

50. PROS AND CONS OF SCOPY DEBRIDEMENT

51. TAKE AWAY
• TAKE PROPER HISTORY AND DO PHYSICAL EXAMINATION – TO IDENTIFY CAUSE
OF STIFNESS- INTRA VS EXTRA ARTICULAR VS COMBINED
• MOST OF THE CAUSES OF STIFFNESS CAN BE ADDRESSED ARTHROSCOPICALLY
NOW
• IN ADDITION , IF THE ROM IS NOT SATISFACTORY ,IN CASES WITH REMNANT
FLEXION RESTRICTION,PIE CRUSTING OF QUADRICEPS TENDON WILL INCREASE
THE ROM
Shang et al. reported from the experience of five post-traumatic stiff knees that
a mean maximum flexion was increased from 35° preoperatively to 80°, after
arthroscopic adhesiolysis and further increased to 120° after pie-crusting.

52. Bansal et al. technique
Saline-soaked ribbon gauze packing in the patellafemoral
joint to prevent direct friction between chondral surfaces and, thus,
avoiding inevitable complications such as cartilage damage,
subchondral fractures.
They also felt that it breaks the remaining adhesions involving the
quadriceps expansion in the lateral and medial recesses, the
suprapatellar bursa, and the muscle adhesions to the distal femur, thus
achieving further improvement in the range of flexion.

54. When to intervene and what if you dont
The definitive management of knee stiffness should be done as early as
possible
Delay or neglect of knee stiffness may lead to the development of
extra-articular contractures and adhesions, which may not be
amenable to arthroscopic surgery

55. The best time for considering arthroscopic release is between
3 and 6 months after definitive fracture management.
It is, however, debatable as to after which duration and the
severity of stiffness, arthroscopic surgery should not be
done

56. For the flexion contractures of the knee, an open or arthroscopic
posteromedial release of the capsule is required.
Arthroscopic posterior release needs the use of a posteromedial
portal.
LaPrade et al. [20] reported good results in their
first 15 patients in 2008 and concluded that the arthroscopic
posterior release is as effective as an open procedure.

57. Shelbourne et al classification of
arthrofibrosis post Acl reconstruction
• The arthrofibrosis was classified into one of four types based on loss
of motion and patellar tightness and contracture compared with the
opposite, uninjured knee.
• Type 1 arthrofibrosis was < 10° of extension loss and normal flexion.
• Type 2 was >10° of extension loss and normal flexion.
• Type 3 was >10° of extension loss and >25° of flexion loss with
decreased medial and lateral movement of the patella (patellar
tightness) and no patellar infera.
• Type 4 was > 10° of extension loss, 30° or more of flexion loss, and
objective patella infera with marked patellar tightness.

58. They have suggested anterior scar resection up to the proximal tibia, in
types 2, 3, and 4 arthrofibrosis.
Notchplasty was required some time and the medial and lateral
capsular releases, with the knee manipulation in type 3 or 4
arthrofibrosis.

59. Infrapatellar contracture syndrome.

60. Acquired patella baja
Patella baja is an uncommon but devastating complication after knee surgery and may cause loss of
knee extension.
-prolonged immobilization, surgery around the tibial tubercle, and patella tendon surgery.
- causes knee stiffness,pain and functional limitations.
Excision of the scar with arthroscopic surgery is recommended when the conservative treatments
have failed. In resistant cases, an open patellar tendon tenotomy is required
Acquired patella baja is the result of the shortening of patellar tendon secondary to the
scarring of the patellar tendon to the upper tibia or shrinkage of the fibers of the tendon.
Drexler et al. [24] treated patella baja with proximalization of the tibial tuberosity and have
reported satisfactory outcomes.

61. Stiffness after TKA
Causes
• inadequate pain control,
• Reflex sympathetic dystrophy,
• infection,
• abnormal component positioning or sizing,
• insufficient soft-tissue balancing,
• and aseptic loosening

62. Management
NON-OPERATIVE treatment
1. adequate pain relieving measures,
2. intense physiotherapy, and
3. Dynamic knee bracing.
THE OPERATIVE OPTIONS
1. MUA,
2. arthroscopic
3. or open arthrolysis, and
4. revision of the abnormally placed components

63. The most common indications for arthroscopy after TKA could be a
soft tissue impingement,
arthrofibrosis,
peri-prosthetic infection,
and the removal of free bodies or cement fragments

64. conclusion