I had a total knee replacement six months ago and still can't bend that knee enough to tie my own shoes. I went back to the surgeon and she gave me some options: manipulation, clean the joint out using a scope, and possibly even take the implant out and start over. Which one of these choices is the best one for me?

When a patient ends up with a stiff and sticky joint, the surgeon can do something about it. As you have been told, there are three basic choices: 1) manipulation under anesthesia (MUA), 2) arthroscopic exam and debridement, and 3) open incision with revision.

During manipulation under anesthesia, the patient is asleep while the surgeon moves the joint through its full range-of-motion. This forced movement breaks through areas of fibrosis and scar tissue.

Debridement refers to gently scraping away any adhesions or fibrotic tissue that is keeping the joint "stuck" or unable to move beyond a certain point in the range of motion.

Arthroscopy allows the surgeon to see inside the joint and find out what's holding it back from moving normally. Using a long, thin needle with a tiny TV camera on the end (the arthroscope, the surgeon can then correct the problem. If necessary, an improperly positioned implant can be removed and replaced using an open incision.

But which one of these approaches should be used? And how successful are the procedures? Surgeons from the Department of Orthopedics at the Mount Sinai Hospital in New York City conducted a systematic review in an attempt to answer these questions. They reviewed all of the articles on the three surgical techniques just described published between 1966 and 2008.

They only found a small number of high quality studies on each one. There wasn't a large number to help guide surgeons in developing a standard of care. Each article was reviewed for information on age of patients, sex (male versus female), timing of the procedure after total knee arthroplasty, technique used, and type of anesthesia used.

Results of each treatment approach were measured using change in knee motion and total motion. Any complications that affected the patients recovery or outcomes were also analyzed. The first question addressed was how soon to do something about a stiff knee after knee replacement. The answers ranged from two weeks to three months after the initial replacement surgery.

Many surgeons send these patients to a physical therapist first before considering manipulation or a revision surgery. After exploring when to do the surgery, they turned their attention to the "How" question. How should the surgery be done? Which technique (manipulation, debridement, revision) should be done to get the best results?

Manipulation under anesthesia (MUA) and arthroscopy work better than open surgery to remove adhesions. MUA alone (without arthroscopy) may gain the most motion. Most of the studies combined MUA with arthroscopy so comparing MUA alone against arthroscopy alone was not possible.

Using an open incision to gain access to the joint had the worst results overall. The exact timing for best results with MUA is unknown. The earlier the MUA, the better the results, but late MUA is still effective. The force required to break adhesions and move the joint may be greater as time goes by and more adhesions develop. With greater force can come more complications (e.g., fractures).

Timing does not seem to be an issue when using arthroscopy. The surgeon simply finds the adhesions and snips them no matter how many there are present. The authors of that review concluded there weren't enough high-quality studies comparing these three surgical approaches to form a clear plan for everyone with a stiff knee after total knee replacement.

Each patient must be examined by the surgeon who can make recommendations based on what these studies show and your particular situation. Sometimes the final treatment decision isn't made until during the procedure when the surgeon gets a clearer view of what's going on inside the joint.

Reference: 

Sean E.Fitzsimmons, MD, et al. How To Treat the Stiff Total Knee Arthroplasty? A Systematic Review. In Clinical Orthopaedics and Related Research. April 2010.Vol. 468. Pp.1096-1106.

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