Acquired Idiopathic Stiffness After Total Knee Arthroplasty

Abstract

Background: Stiffness is a common reason for suboptimal clinical outcomes after primary total knee arthroplasty (pTKA).There is a lack of consensus regarding its definition, which is often conflated with its histopathologic subcategory-i.e., arthrofibrosis. There is value in refining the definition of acquired idiopathic stiffness in an effort to select for patients with arthrofibrosis. We conducted a systematic review and meta-analysis to establish a consensus definition of acquired idiopathic stiffness, determine its prevalence after pTKA, and identify potential risk factors for its development.Methods: MEDLINE, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Scopus databases were searched from 2002 to 2017. Studies that included patients with stiffness after pTKA were screened with strict inclusion and exclusion criteria to isolate the subset of patients with acquired idiopathic stiffness unrelated to known extrinsic or surgical causes. Three authors independently assessed study eligibility and risk of bias and collected data. Outcomes of interest were then analyzed according to age, sex, and body mass index (BMI).Results: In the 35 included studies (48,873 pTKAs), the mean patient age was 66 years. In 63% of the studies, stiffness was defined as a range of motion of <90°or a flexion contracture of >5°at 6 to 12 weeks postoperatively. The prevalence of acquired idiopathic stiffness after pTKA was 4%, and this did not differ according to age (4%, I 2 = 95%, among patients <65 years old and 5%, I 2 = 96%, among those ‡65 years old; p = 0.238). The prevalence of acquired idiopathic stiffness was significantly lower in males (1%, I 2 = 85%) than females (3%, I 2 = 95%) (p < 0.0001) as well as in patients with a BMI of <30 kg/m 2 (2%, I 2 = 94%) compared with those with a BMI of ‡30 kg/m 2 (5%, I 2 = 97%) (p = 0.027).Conclusions: Contemporary literature supports the following definition for acquired idiopathic stiffness: a range of motion of <90°persisting for >12 weeks after pTKA in patients in the absence of complicating factors including preexisting stiffness. The mean prevalence of acquired idiopathic stiffness after pTKA was 4%; females and obese patients were at increased risk.Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. Stiffness is a common reason for failure of primary total knee arthroplasty (pTKA), contributing to up to 58% of reoperations or repeat interventions (such as manipulation under anesthesia) and >25% of 90-day hospital readmissions in some series [1][2][3] . Patients who develop this complication have poor functional outcomes and increased rates of knee pain, and their symptoms often are refractory to nonoperative and even oper-ative management 4,5 . The incidence of TKA increased from 31.2 per 100,000 person-years from 1971 to 1976 to 220.9 per 100,000 person-years from 2005 to 2008 6 . This trend, compounded by an increasing prevalence of obesity and a decreasing mean age of patients undergoing pTKA, wil...

Anti-fibrotic effects of the antihistamine ketotifen in a rabbit model of arthrofibrosis

“…Joint contracture secondary to arthrofibrosis, also recently referred to as acquired idiopathic stiffness of the joint, 1 is a relatively common complication after injuries and surgical procedures, affecting up to 10% of all arthroplasty procedures. 2 Arthrofibrosis is characterized histopathologically by diffuse proliferation of scar tissue in periarticular soft tissues, and causes substantial pain and restricted movement for patients.…”

Reduction of arthrofibrosis utilizing a collagen membrane drug‐eluting scaffold with celecoxib and subcutaneous injections with ketotifen

“…Acquired idiopathic stiffness is a complication that can result from a multitude of etiologies, including injury or surgery to a joint. 1 With a prevalence of 4% to 30% after primary total knee arthroplasty (TKA), acquired idiopathic stiffness affects thousands of people every year in the United States alone. 1 A subset of these patients exhibits true arthrofibrosis, which is characterized histopathologically by extensive scar tissue which painfully restricts motion, develops most commonly in the elbow or knee, and cannot be attributed to component malposition, infection or other reasons.…”

“…1 With a prevalence of 4% to 30% after primary total knee arthroplasty (TKA), acquired idiopathic stiffness affects thousands of people every year in the United States alone. 1 A subset of these patients exhibits true arthrofibrosis, which is characterized histopathologically by extensive scar tissue which painfully restricts motion, develops most commonly in the elbow or knee, and cannot be attributed to component malposition, infection or other reasons. 1,2 Current treatment modalities are limited to physical therapy, manipulation under anesthesia, or revision surgery.…”

Does contralateral knee range of motion predict postoperative knee range of motion after total knee arthroplasty?

“…The literature on preoperative risk factors and predictors for post-TKA flexion contracture and need for MUA mirrors that of predictors for post-TKA ROM, with the strongest and most reliable predictor being the presence of a preoperative flexion contracture in the operative knee, not readily varied by other factors [1,2,9,16,19,21,28,29]. Harato et al [25,26] have conducted gait and weight bearing studies in patients with flexion contractures and have delineated the abnormal forces placed on the contralateral knee in TK A [26] and non-TKA settings [25].…”

“…To date, the factor that has consistently been shown in the literature and is well established to predict postoperative ROM is preoperative ROM in the same knee [4,8,9,[19][20][21]. Preoperative flexion has consistently been shown to be the strongest predictor of postoperative flexion [1,2,4,10,12,22].…”