Stiffness in total knee arthroplasty

Stiffness is a relatively uncommon complication after total knee arthroplasty. It has been defined as a painful limitation in the range of movement (ROM). Its pathogenesis is still unclear even if some risk factors have been identified. Patient-related conditions may be difficult to treat. Preoperative ROM is the most important risk factor, but an association with diabetes, reflex sympathetic dystrophy, and general pathologies such as juvenile rheumatoid arthritis and ankylosing spondylitis has been demonstrated. Moreover, previous surgery may be an additional cause of an ROM limitation. Postoperative factors include infections, arthrofibrosis, heterotrophic ossifications, and incorrect rehabilitation protocol. Infections represent a challenging problem for the orthopaedic surgeon, and treatment may require long periods of antibiotics administration. However, it is widely accepted that an aggressive rehabilitation protocol is mandatory for a proper ROM recovery and to avoid the onset of arthrofibrosis and heterotrophic ossifications. Finally, surgery-related factors represent the most common cause of stiffness; they include errors in soft-tissue balancing, component malpositioning, and incorrect component sizing. Although closed manipulation, arthroscopic and open arthrolysis have been proposed, they may lead to unpredictable results and incomplete ROM recovery. Revision surgery must be proposed in the case of well-documented surgical errors. These operations are technically demanding and may be associated with high risk of complications; therefore they should be accurately planned and properly performed.