Knee Surg Sports Traumatol Arthrosc (2010) 18:346–351
DOI 10.1007/s00167-009-0878-x
KNEE
Arthroscopic arthrolysis for the treatment of stiffness after total
knee replacement gives moderate improvements in range
of motion and functional knee scores
J. E. Arbuthnot Æ R. B. Brink
Received: 22 April 2009 / Accepted: 3 July 2009 / Published online: 1 August 2009

Springer-Verlag 2009
Abstract Twenty-two total knee replacements (TKR’s)
were treated for stiffness with arthroscopy and arthrolysis.
The median follow-up was 38 months. No patients were
lost to follow up. Extensive scarring was found and deb-
rided in all of the knees. The mean Oxford Knee Score
improved from 42.6 (±7.5) to 36.3 (±8.5) (P \ 0.05) with
TKR and from 36.3 (±8.5) to 29.3 (±9.0) (P \ 0.05) with
arthroscopic arthrolysis. The mean arc of motion improved
from 8–69 post-TKR to 3–105 on table, but declined
slightly to 4–93 (P \ 0.05) at most recent review.
Arthroscopic arthrolysis compares well with other methods
of treatment for stiffness with regard to improvements in
range of motion and functional knee scores.
Keywords Arthroscopy
Total knee replacement

Stiffness
Arthrofibrosis
Arthrolysis
Introduction
Knee replacement is a very effective procedure at relieving
pain and improving function in the treatment of osteoar-
thritis. Stiffness complicates a significant proportion of
replacement arthroplasty procedures. Kim et al. [15] esti-
mated the prevalence to be 1.3% in their series of 1000
knees, and defined it as one having a flexion contracture of
15 and/or\75 of flexion. Yercan et al. [31] estimated the
J. E. Arbuthnot
R. B. Brink
Geelong Private Hospital, Victoria, Australia
J. E. Arbuthnot (&)
Warwick Specialist Registrar Training Programme,
21 Dove House Lane, Solihull, West Midlands B91 2HA, UK
e-mail: Jamie@arbuthnot.me.uk
123
prevalence to be higher, finding it to be 5.3% at a mean
follow-up of 31 months in their series of 1188.
The causes of stiffness may be clearly identified as
infection, poor component positioning or sizing, inade-
quate soft tissue balancing, aseptic loosening, inadequate
early pain control or complex regional pain syndrome. Poor
range of motion has been closely related to post-operative
pain and joint-splinting and immobilization [25]. In the
absence of such causes, some replaced knees simply have
increased interstitial fibrosis or excessive intra articular
adhesion formation, either as a primary phenomenon or as
a response to early poor joint movement. Either way, the
result is a stiff knee that is difficult to treat.
The options for the patient and the surgeon in this sit-
uation are either to accept the reduced range of motion or
have it addressed with non-surgical or surgical means. The
surgical options are four fold: manipulation under anaes-
thetic (MUA), arthroscopic arthrolysis, open arthrolysis or
revision of some or all of the components. This study
investigates the change in range of motion and oxford score
after arthroscopic release of a stiff total knee replacement.
Materials and methods
The case series analyzed included all patients from June
1998 to June 2008 undergoing knee replacement operated
upon by the senior author (RBB). This gave 572 knees for
review. For the purposes of this study, we defined stiffness
as, ‘‘a clinical situation where the range of motion achieved
by the patient following total knee replacement restricts
their function and is considered by their surgeon to be
below that which could have been achieved (with reference
to on table post-operative assessment)’’. Of these, 19 knees
had undergone arthroscopy of the replaced knee for the
Knee Surg Sports Traumatol Arthrosc (2010) 18:346–351
treatment of stiffness after mechanical and infective causes
for stiffness had been excluded. The total incidence of
stiffness in this cohort of patients was 4.9% (28/572).
Three additional knees (two patients) were referred to
our department for the treatment of post-operative stiffness
after TKR elsewhere. This gave a total of 22 replaced
knees for study in this series.
The underlying pathology necessitating replacement
arthroplasty was osteoarthritis for 17 patients and post-
traumatic secondary arthritis for 5. There were 14 women
and seven men. The left knee was involved for 13 and the
right for 9. The mean age was 62 (range: 45–77) and the
mean body mass index was 30.9 (range 23–40). Ten knees
had a pre-replacement varus alignment (mean 5, range 3–
11) and six knees had a pre-operative valgus alignment
(mean 5.5, range 3–10).
The 19 TKR procedures carried out by the senior author
were with identical surgical technique. The patella was
only resurfaced in knees where it was felt that the patel-
lofemoral cartilage was markedly degenerate or where the
native patella had poor congruency with the prosthetic
trochlear groove. Resurfacing was carried out for seven
knees. Soft tissue releases were necessary in 15 of the 19
knees replaced at this centre: four had a lateral release; four
had a medial release; five had a posterior release and, of the
14 CR knees, the PCL was recessed in four. Ten knees had
a lateral patella retinaculum release to ensure satisfactory
‘‘no-thumbs’’ patella tracking.
All patients routinely received a high volume regional
anaesthetic infiltration as described by Kerr and Kohan
[14]. Our modification of this protocol is to replace the
delayed intra articular bolus with a 48 h steady infusion of
1000 mg Ropivacaine in 100 ml mixed with adrenaline
(0.5 ml of 1/1000) starting 12 h after wound closure [28].
Post-operative thrombo-embolic prophylaxis was with
enoxoparin (40 mg) given once daily at night until dis-
charge at which time aspirin 150 mg was taken once daily
until 6 weeks post-op. No patients received warfarin post-
operatively either as prophylaxis or as a treatment for
thrombo-embolic disease.
Mechanical alignment post-operatively was measured
on long leg standing films (as pre-operatively) and found to
be within 3 of neutral for all except two knees (4 valgus
and 5 varus).
The patients had been evaluated before TKR, just prior
to arthroscopy and they were evaluated at regular intervals
post-arthroscopy. Outcome measures assessed were range
of motion assessment with long goniometer and the Oxford
knee functional outcome score [5]. Statistical analysis was
carried out with commercially available software by use of
the paired t-test for significance of difference.
The mean follow-up was 40 months (range 5 months–
10.5 years). No patients were lost to follow up.
347
Six of the knees that subsequently went on to have an
arthroscopy had first undergone an MUA at a median of
2.5 months (range 1–9 months) post-TKR. Arthroscopic
arthrolysis was carried out at a median of 8.5 months post-
TKR (range 2–24 months). The implants used were: 11
Profix knees (Smith and Nephew, Memphis, TN, USA);
five Journey knees (Smith and Nephew, Memphis, TN,
USA); three Genesis II knees (Smith and Nephew, Mem-
phis, TN, USA); two PFC knees (DePuy, Leeds, UK) and
one Natural knee (Zimmer, Warsaw IND). Sixteen knees
were cruciate-retaining, and six were posterior stabilized.
Arthroscopy was performed with normal saline inflow
through a pressure and flow controlled pump (Intelliget
Smith and Nephew, Andover, MA) using an average of 3.5
portals per case. Viewing through the first anterolateral
portal, the anteromedial portal is created under direct
vision. The motorized shaver and linear manual arthro-
scopic punches are used alternately to clear the notch and
gradually expand the field of view towards the inferior pole
of the patella, the edges of the femoral component supe-
riorly (all typically quite heavily scarred) and the prosthetic
joint lines inferiorly. The knee is then held in full extension
and the contracted neo-suprapatellar pouch is broken down
with a linear punch, typically revealing an intra articular
space proximal to it containing relatively flimsy scar tissue.
The apex of the false pouch is progressively resected until
the dimensions of the original pouch are re-established
when fibres of the articularis genu muscle are seen. An
extensive lateral retinacular release is then carried out. A
superolateral portal is then established through which a 70
arthroscope is introduced to inspect patella position and
tracking. If medial tilt or maltracking of the patella is
evident, a medial retinacular release is performed although
this is infrequently necessary.
The portals were carefully sutured with 3/0 nylon and
additionally covered with steri-strips taking deliberately
more deep subcutaneous tissue than skin. The soft tissues
about the knee are typically less elastic and there is an
increased tendency to develop synovial fistulae in com-
parison to arthroscopic surgery on virgin knees. Physical
therapy is commenced immediately post-op in conjunction
with continuous passive motion for 48 h as an in-patient.
Results
Every knee displayed extensive scarring of the soft tissues,
the distribution of which was fairly uniform: in all cases the
supra-patella pouch was nearly or completely obliterated
and dense scar tissue filled the anteromedial and antero-
lateral aspects of the knee. All of the knees had a release of
the suprapatellar pouch and antero medial and anterolat-
eral scar tissue. Fifteen lateral releases were carried out.
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Oxford Score
Mean 28 months post-
arthrolysis
Prior to arthrolysis
Prior to TKR
0 10 20 30 40
Fig. 1 Changes in mean oxford knee score
Arc Flexion
Mean 28 months post-
arthrolysis
On table post-arthrolysis
Prior to arthrolysis
Prior to TKR
0 50 100
Fig. 2 Changes in mean arc of motion and maximum flexion
A medial retinacular release was carried out for seven
knees and four had the PCL released from the femur.
The changes in Oxford Knee Score are shown in Fig. 1.
TKR improves the mean score from 42.6 (±7.5) to 36.3
(±8.5) (P \ 0.05). Arthroscopic arthrolysis effects a sub-
sequent change to 29.3 (±9.0) at most recent follow-up
(mean 28 months post-arthrolysis, P \ 0.05).
Change in the range of motion is shown in Fig. 2. The
mean range of motion prior to TKR was from 8 (±3.6)
of fixed flexion deformity (FFD) to 107 (±16.6). This
changed to 8–64 (Standard deviations 7.2 and 23.5,
respectively) following TKR. Immediately after arthro-
scopic arthrolysis the mean on-table extension was 3
(±5.3) and flexion was 105 (±11.7). At most recent
review (mean 34 months, range 2–124 post-arthroscopic
arthrolysis), mean extension was still 4 (±4.6) and mean
maximum flexion was to 93 (±21.0). The mean
improvement of range of motion at most recent review
compared to pre-arthroscopic arthrolysis of 4.6 extension
and 24.6 flexion was statistically significant (P \ 0.05) as
was the deterioration in maximum flexion immediately
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Knee Surg Sports Traumatol Arthrosc (2010) 18:346–351
post-arthroscopy to that at most recent follow (105–93,
P \ 0.05). In comparing arc of motion from pre-arthrolysis
EUA with the most recent arc, one knee deteriorated. This
knee was a patient seeking workers’ compensation fol-
lowing an injury. The remainder (21 out of 22, 95%) had an
improvement (mean 29.9, range 3–84) in the arc of
motion: five knees gained 0–10; four knees gained 10–
20; two knees gained 20–30; three knees gained 30–40
and seven knees gained over 40 (Table 1).
Discussion
50
The most important finding of this paper was that
arthroscopy has a role in the diagnosis and management of
problems after knee replacement [6, 19, 31] and that
arthroscopic arthrolysis can produce modest improvements
in total range of motion when used to treat stiff total knee
replacements. We offer this treatment as a first line inter-
vention in this situation as it provides moderate improve-
ments in range of motion and functional knee scores
without the morbidity of open arthrolysis or revision sur-
gery. There is a widespread view that arthroscopic release
is not reliable for severely stiff knees [31] or that arthros-
copy does not allow adequate release of mature scar tissue,
particularly when having to treat a tight posterior capsule
[12]. However, we would advocate its use in all appropriate
cases where underlying infective and mechanical causes of
150 stiffness and complex regional pain syndromes have been
excluded.
The results in this series are almost as good as some
similar reports in the literature. In the largest case series the
Knee Society Knee Score improved for 25 of the 32 knees
(78%) studied, with the mean Knee Score improving from
70 to 86 and the function score from 68 to 85 [13]. Similar
results to this were achieved by Dijan et al. [7] and Court
et al. [3] in smaller studies of six and four knees, respec-
tively, with increased flexion from 70 to 100 and from
65 to 93.
The use of arthroscopic release of anterior interval scar
tissue has been described in the native knee. It is thought
that the significant improvements in anterior knee pain
achieved by arthroscopic intervention are mediated by
relieving the tension on the fat pad, synovium, transverse
ligament and periosteum [8, 27].
The surgical alternatives to arthroscopy are MUA, open
arthrolysis or component revision. The results of MUA are
difficult to compare to more invasive treatments as an
MUA is often carried out earlier, for less resistant cases or,
as for six patients in this series, as a prequel to subsequent
more invasive surgery. MUA alone has been reported to
have good results [4, 9, 18, 20, 31], even when carried out
at 6 months post-op [21], with the range of motion
Knee Surg Sports Traumatol Arthrosc (2010) 18:346–351 349

Table 1 Table of individual patient range of motion, follow-up and pain

Patient Pre-TKR EUA pre-arthroscopic Painful stiffness Pain after Recent Time of follow-up Interval from TKR
ROM () arthrolysis ROM () pre-scope? arthrolysis? ROM () since TKR (months) to scope (months)

1–R 7–115 0–40 No Still none 0–124 24 8

1–L 5–110 2–90 Yes Yes 5–100 6 3
2 5–115 10–85 No Still none 0–118 126 6
3 3–125 0–70 No Still none 0–130 7 2
4 5–106 15–69 Yes Yes 7–80 45 9
5 9–110 0–80 No Still none 0–83 68 8
6 12–100 10–70 Yes Yes 0–78 51 13
7 5–120 30–65 Yes No 5–90 36 3
8 9–130 10–85 Yes Yes 0–102 36 14
9 7–118 10–65 Yes No 3–80 13 7
10 8–83 0–10 No Still none 0–55 78 15
11 5–125 5–91 Yes Yes 13–80 82 40
12 12–120 10–90 Yes No 6–96 53 17
13 5–115 5–30 Yes No 5–111 50 2
14 n/a 5–100 Yes No 0–109 24 21
15 n/a 10–75 Yes No 0–96 5 2
16 10–72 7–50 No Still none 0–55 33 5
17 15–83 8–82 No Still none 10–90 14 6
18–R 5–80 5–50 No Still none 5–84 39 20
18–L 5–90 10–40 No Still none 5–72 39 24
19 15–120 19–93 Yes No 0–122 40 15
20 13–113 18–90 Yes No 15–95 17 14

achieved often sustained at final follow-up [31]. We would
recommend MUA as an alternative to arthroscopic release
only if the patient declined the more invasive procedure as
we believe that the arthroscopic approach offers a more
controlled solution with a low complication rate in pub-
lished series.
Hutchinson et al. [12] studied their results on the out-
come of open arthrolysis for stiffness after TKR which was
carried out for 13 of the 1522 patients in their series. The
mean interval from TKR was 14 months. Five patients
(38%) had secondary patella resurfacing during the open
arthrolysis as damage to the articular surface was noticed
(only one of the un-resurfaced patellae in our study was
found to be slightly worn with a small area of partial
thickness cartilage loss only) and three patients (23%) had
down-sizing of the tibial insert to the thinnest available. No
complications were encountered: one patient developed an
infection, but this was attributed to an episode of septi-
caemia following a spider bite. Eleven of the 13 patients
had an improvement in Knee Society Knee Scores and
seven had an improvement in Knee Society Function
Scores. The maximum flexion was increased at last follow-
up for all 13 patients with a mean range of motion from 0
to 96. Another study of seven knees [1], where open
arthrolysis and tibial insert exchange were carried out,
suggested that their results of Knee Society knee scores
changing from 44 to 39.6 and function scores from 36 to 46
and arc of motion from 39 to 58 ‘‘failed to provide a viable
solution to the difficult and poorly understood problem of
knee stiffness…’’
The results of revision of components for stiffness after
knee replacement have had variable outcomes. Haiduke-
wych et al. [11] state that they obtained only modest
improvements in pain, function and arc of motion with the
16 knees in their study (Knee Society knee score improved
from 28 to 65 and function score from 45 to 58; the arc of
motion from 40 to 73 but four out of the 16 required further
surgery for stiffness). Ries and Badalamente [23] had a
much smaller series with only slightly better results
reported: the six knees in their study improved their arc of
motion from 36 to 86. Kim et al. [15] reported the largest
series of revisions for stiffness: 56 knees had a mean
improvement in the Knee Society knee score from 38.5 to
86.7 and a function score from 40 to 58.4. The mean
flexion changed from 55 to 82. They concluded that their
results suggested that the benefits were modest.
It is interesting to see that some authors [3] advocate
using a minimum number of portals to reduce the risk of
damage to the components and possibly also to minimise
the infection risk. It is our view that the careful creation of

123
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as many portals as is necessary is the best way to carry out
an adequate procedure and still minimise any compromise
of the articular surface.
Following the arthroscopy and lysis of adhesions, a
gentle manipulation was carried out using pressure on the
tibial tubercle [6, 7] just as when carrying out a manipu-
lation alone. The force required to carry out the manipu-
lation is less after arthroscopic arthrolysis than with MUA
alone which reduces the risk of intra-operative fracture.
Most reported series follow the arthroscopic arthrolysis
with a period of continuous passive motion, a regional
anaesthesia protocol and a course of perioperative, intra-
venous antibiotics [6] as was done here. There were no
arthroscopy-related complications or infections in ours or
most of the other series reviewed [3, 6, 7, 13] although
post-operative infection has been described [16, 17].
With regard to the timing of the various possible inter-
ventions after the index arthroplasty procedure, the general
consensus is that that arthroscopic arthrolysis should not be
employed until 3 months post-op [2, 3, 31]. However,
Tirveilliot et al. had a significantly inferior result when
arthroscopic arthrolysis was carried out more than
6 months after TKR [29]. We believe that earlier inter-
vention has a more favourable outcome and would not
advocate unnecessary delay.
Pre-operative ROM is one of the most important factors
in predicting post-TKR ROM [22, 24] although in this
study the mean pre-operative maximum flexion was 106.1
(±18.88, range 72–130). This is a finding repeated in
another study investigating arthrofibrosis post-TKR [30]:
the disease process does not appear to simply represent
poor movement post-op, but a distinct clinical picture. An
association with post-operative stiffness, the use of thera-
peutic warfarin and also with female sex has been descri-
bed [24]. Other factors associated with poor ROM are
posterior capsule release without posterior osteophyte
removal, extreme varus alignment and sagitally over-sized
implants.
Gollwitzer et al. [10] define arthrofibrosis after knee
replacement as stiffness with scarring and soft tissue pro-
liferation and suggest an overall incidence of approxi-
mately 10%. The aetiology of arthrofibrosis after knee
replacement is unclear, but it may have a genetic pre-
disposition [26]. The histopathology typically shows
subsynovial fibrosis with synovial hyperplasia, chronic
inflammatory infiltration and excessive and unregulated
proliferation of collagen (I, III and VI) and fibroblasts [32].
Kim et al. [15] noted no significant differences in age,
gender, implant design, diagnosis or the need for lateral
release between the patients with and without stiffness. We
note with interest that the mean age of the patients in this
study is 62. The mean age of patients undergoing TKR at this
unit is 70.3. This could be a reflection of the expectations of
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Knee Surg Sports Traumatol Arthrosc (2010) 18:346–351
the younger age group and the unwillingness to cope with a
sub-optimal result. Also, the underlying pathology necessi-
tating replacement arthroplasty is unusual. The arthroplasty
population from which this series is derived has a 3% (17/
572) post-traumatic arthritis incidence: five out of 22
patients (23%) in this study had an underlying diagnosis of
post-traumatic arthritis, but the study population is too small
to derive anything significant from this regarding the aeti-
ology of the arthrofibrosis process.
The shortcomings of this study are that, with only 22
knees studied the numbers are small. Measurements of
range of motion were made with a long-arm goniometer
which provides limited accuracy. The inclusion criteria for
this study were not rigidly defined by a discrete value of
limited extension or flexion as we felt that our criteria for
‘‘knee stiffness’’ were more personalized to the patient and
thus more clinically relevant. Some of the patients in this
study underwent MUA prior to arthroscopy which adds a
degree of heterogeneity to the study group. The advantages
of this study are that it is a single surgeon series with 100%
follow-up of cases and an adequate duration.
Conclusion
Treating stiffness after TKR is challenging with any
recognised intervention but the results of arthroscopic
arthrolysis are generally good with a low incidence of
short-term complications.
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