Aims. The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow. Methods. We developed the Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) based on a dataset of 551 patients who underwent open arthrolysis of the elbow in four institutions. Demographic and clinical characteristics were collected from medical records. The least absolute shrinkage and selection operator regression model was used to optimize the selection of relevant features. Multivariable logistic regression analysis was used to build the SPESSO. Its prediction performance was evaluated using the concordance index (C-index) and a calibration graph. Internal validation was conducted using bootstrapping validation. Results. BMI, the duration of stiffness, the preoperative ROM, the preoperative intensity of pain, and grade of post-traumatic osteoarthritis of the elbow were identified as predictors of outcome and incorporated to construct the nomogram. SPESSO displayed good discrimination with a C-index of 0.73 (95% confidence interval 0.64 to 0.81). A high C-index value of 0.70 could still be reached in the interval validation. The calibration graph showed good agreement between the nomogram prediction and the outcome. Conclusion. The newly developed SPESSO is a valid and convenient model which can be used to predict the outcome of open arthrolysis of the elbow. It could assist clinicians in counselling patients regarding the choice and expectations of treatment. Cite this article: Bone Joint J 2022;104-B(4):486–494

We present a retrospective study of 25 patients treated by open arthrolysis of the elbow for post-traumatic stiffness. The mean follow-up was for 7.8 years (5 to 10.8). The range of movement of the elbow, pain scores and functional outcomes were recorded pre- and postoperatively. An improvement in the mean range of movement from 55° (0° to 95°) to 105° (55° to 135°) was obtained in our patients at one year. This improvement was maintained over the mean follow-up period of 7.8 years (5 to 10.8). Improvement in pain, function and patient satisfaction was recorded in 23 of the 25 patients at final follow-up. On the basis of this study, we believe that the results of open arthrolysis for post-traumatic stiffness of the elbow are durable over the medium term

Stiffness is an uncommon but potentially debilitating complication following total knee replacement (TKR). The treatment of this condition remains difficult and controversial. We present the results of 13 patients who underwent open arthrolysis for stiffness. The mean time between TKR and arthrolysis was 14 months. The mean follow-up was 7.2 years (2 to 10). The mean range of movement prior to arthrolysis was 55°. This increased to 91°, six months after arthrolysis (p < 0.005). The improved range of movement was maintained during the follow-up period. No patient has required revision of their components. We have found arthrolysis to be a useful and successful approach to post-TKR stiffness

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation

Arthrolysis and dynamic splinting have been used in the treatment of elbow contractures, but there is no standardised protocol for treatment of severe contractures with an arc of flexion < 30°. We present our results of radical arthrolysis with twin incisions with the use of a monolateral hinged fixator to treat very severe extra-articular contracture of the elbow. This retrospective study included 26 patients (15 males and 11 females) with a mean age of 30 years (12 to 60). The mean duration of stiffness was 9.1 months (5.4 to 18) with mean follow-up of 5.2 years (3.5 to 9.4). The mean pre-operative arc of movement was 15.6° (0° to 30°), with mean pre-operative flexion of 64.1° (30° to 120°) and mean pre-operative extension of 52.1° (10° to 90°). Post-operatively the mean arc improved to 102.4° (60° to 135°), the mean flexion improved to 119.1° (90° to 140°) and mean extension improved to 16.8° (0° to 30°) (p < 0.001). The Mayo elbow score improved from a mean of 45 (30 to 65) to 89 (75 to 100) points, and 13 had excellent, nine had good, three had fair and one had a poor result. We had one case of severe instability and one wound dehiscence which responded well to treatment. One case had deep infection with poor results which responded well to treatment.

Our findings indicate that this method is very effective in the treatment of severe elbow contracture; however, a randomised controlled study is necessary for further evaluation.

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576–584

Aims. Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome. Methods. Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively. Results. A total of 138 patients underwent ADROM; 111 patients were available for long-term follow-up at a mean of 10.9 years (range 1 to 20). Mean age was 50.8 years (18 to 75);79 (57.2%) were female. Mean time from primary ORPF to ADROM was 11.9 months (6 to 19). Five patients developed superficial wound infection; ten developed symptomatic osteonecrosis/post-traumatic arthrosis (ON/PTA); four underwent revision arthrolysis. Median OSS improved from 17 (interquartile range (IQR) 12.0 to 22.0) preoperatively to 40.0 (IQR 31.5 to 48.0) postoperatively, and 39.0 (IQR 31.5 to 46.5) at long-term follow-up (p < 0.001). Median EQ-5D-3L improved from 0.079 (IQR -0.057 to 0.215) to 0.691 (IQR 0.441 to 0.941) postoperatively, and 0.701 (IQR 0.570 to 0.832) at long-term follow-up (p < 0.001). We found that aROM improved in all planes (p < 0.001). Among the variables assessed on multivariable analysis, a manual occupation, worsening Charlson Comorbidity Index and increasing socioeconomic deprivation were most consistently predictive of worse patient-reported outcome scores. Patients who subsequently developed ON/PTA reported significantly worse one-year and late OSS. Conclusion. ADROM in patients with persistent symptomatic stiffness following ORPF can achieve excellent short- and long-term outcomes. More deprived patients, those in a manual occupation, and those with worsening comorbidities have worse outcomes following ADROM. Cite this article: Bone Joint J 2022;104-B(1):157–167

Aims. This study aimed to determine the minimal detectable change (MDC), minimal clinically important difference (MCID), and substantial clinical benefit (SCB) under distribution- and anchor-based methods for the Mayo Elbow Performance Index (MEPI) and range of movement (ROM) after open elbow arthrolysis (OEA). We also assessed the proportion of patients who achieved MCID and SCB; and identified the factors associated with achieving MCID. Methods. A cohort of 265 patients treated by OEA were included. The MEPI and ROM were evaluated at baseline and at two-year follow-up. Distribution-based MDC was calculated with confidence intervals (CIs) reflecting 80% (MDC 80), 90% (MDC 90), and 95% (MDC 95) certainty, and MCID with changes from baseline to follow-up. Anchor-based MCID (anchored to somewhat satisfied) and SCB (very satisfied) were calculated using a five-level Likert satisfaction scale. Multivariate logistic regression of factors affecting MCID achievement was performed. Results. The MDC increased substantially based on selected CIs (MDC 80, MDC 90, and MDC 95), ranging from 5.0 to 7.6 points for the MEPI, and from 8.2° to 12.5° for ROM. The MCID of the MEPI were 8.3 points under distribution-based and 12.2 points under anchor-based methods; distribution- and anchor-based MCID of ROM were 14.1° and 25.0°. The SCB of the MEPI and ROM were 17.3 points and 43.4°, respectively. The proportion of the patients who attained anchor-based MCID for the MEPI and ROM were 74.0% and 94.7%, respectively; furthermore, 64.2% and 86.8% attained SCB. Non-dominant arm (p = 0.022), higher preoperative MEPI rating (p < 0.001), and postoperative visual analogue scale pain score (p < 0.001) were independent predictors of not achieving MCID for the MEPI, while atraumatic causes (p = 0.040) and higher preoperative ROM (p = 0.005) were independent risk factors for ROM. Conclusion. In patients undergoing OEA, the MCID for the increased MEPI is 12.2 points and 25° increased ROM. The SCB is 17.3 points and 43.3°, respectively. Future studies using the MEPI and ROM to assess OEA outcomes should report not only statistical significance but also clinical importance. Cite this article: Bone Joint J 2021;103-B(2):366–372

Aim: To assess the functional and occupational outcome of open elbow arthrolysis for post-traumatic contractures. Materials and Methods: Prospective evaluation of 60 consecutive cases (86% male,14%female) of post-traumatic extrinsic elbow stiffness. Average age was 37 years (24–48). Moderate to high physical demand at work in 96% of cases. 56% of cases involved the right side. Open arthrolysis (column procedure) trough a lateral (72%) or posterior (28%) approach followed a minimum rehabilitation period of 6 months post original injury. In 8 cases, an anterior transposition of the ulnar nerve was required. Patients received postoperative analgesia with Bupivacaine 0,0125% trough an indwelling catheter. No chemical or radiotherapy ectopic calcification prophylaxis was used. Postoperative complications, range of motion, X-ray evaluation, time to return to work, activity level and workers’ compensation were evaluated at the end of follow-up (24 months, range 12–36). Results: Complications occurred in 14% of cases. Two patients required revision surgery for ectopic calcifications restricting prono-supination. The flexo-extension (FE) arc of motion improved from 49 ° to 115 ° and that of prono-supination (PS) from 100 ° to 158 ° The results were found to be statistically significant for FE (p= 0.054) and PS (p> 0,00001). In 20% of cases, patients returned to their previous job with some restrictions (33% disability) and 12% changed to a less physically demanding occupation. Conclusions: Open arthrolysis is an effective surgical procedure to improve mobility in post-traumatic stiff elbows. It is indicated when the joint interline is preserved. Good functional and occupational outcome in a high percentage of case in the working population was observed

Introduction: Stiffness following Total Knee Arthroplasty is a serious and debilitating complication. There are many different patient and surgical factors implicated in it cause. Previous studies have suggested that it will occur in approximately 1% of TKR patients. Arthrofibrosis is an uncommon but potentially debilitating cause in an otherwise well positioned implant. The cause of this abnormal scar formation is as yet unknown. The treatment of this condition remains difficult and controversial. Revision of the TKR has been suggested as the gold standard treatment as other operative strategies have had limited success. Our approach to this problem has been to conserve the prosthesis and try to release the scar tissue. Aim: The aim of this study is to assess the results of open arthrolysis in the treatment of established arthrofibrosis. Method: 1522 patients undergoing primary uncemented TKR have been prospectively followed up (2022 TKR’s) using the International Knee Society Scores. 13 patients underwent open Arthrolysis for stiffness post-op (Incidence 0.64%). The average age was 65 (range 50–78). 6 cases were simultaneous bilateral procedures (Incidence 1.2% of simultaneous bilateral procedures). The average time between TKR and arthrolysis was 14 months. Our average follow-op was 7.2 years (range 2 – 10 years). Results: The average ROM just prior to Arthrolysis was 58°. The average ROM six months after surgery had improved to 91° (p< 0.05). The average ROM at last follow-up was 95° (p< 0.05) with an average Knee Society score of 155 (pain 83, function 72). No patients have required revision of their components. Conclusions: We have found open arthrolysis a successful approach to post-op arthrofibrosis. Although a large procedure it has been well tolerated by our patients. They have had an improvement in range of movement by six months which has been maintained up to 10 years

Aim. Over the last 15 years there has been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management. Many advocate the use of passive stretching techniques in the early post-operative period if range of motion fails to improve satisfactorily. The purpose of this study was to assess our results of open elbow arthrolysis in patients who did not receive any passive stretching after discharge from hospital. Methods. Prospectively collected data of 55 patients with a minimum follow-up of 1 year after arthrolysis were analysed. All procedures were performed by the same surgeon (LR), achieving as much improvement in elbow motion as possible at operation. All patients had continuous brachial plexus blocks and continual passive motion for 2-3 days post-operatively but none received any passive stretching after discharge. At review, a senior physiotherapist (BD) formally assessed all the patients. Results. All patients' arc of movement improved from 68 degrees to 104 degrees (flexion 18 degrees/extension 23 degrees). Upper limb function (Disabilities of the Arm, Shoulder and Hand score) improved by 50%. Pain decreased from 20 to 9, measured with a Visual Analogue Score. The greatest improvement in motion was obtained in the stiffest elbows - 7 patients with an arc of 30 degrees or less pre-operatively achieved an arc of 100 degrees by the time of the last review. Conclusions. Good results of open arthrolysis for post-traumatic elbow stiffness can be achieved with continuous brachial plexus blocks and continual passive motion for 2-3 days post-operatively. There appears to be little evidence to support treatment with passive stretching techniques after discharge from hospital, as our results are similar to other reported series

Aims: To establish the results of elbow arthrolysis for the post-traumatic stiff elbow. Methods: A retrospective review of 20 patients undergoing open arthrolysis of the elbow under brachial plexus block followed by continuous passive motion between 1994 and 2002. Results: Eighteen patients were reviewed independently at an average follow up of 35 months (6–84 months). The range of motion improved in all patients from a mean preoperative arc of ßexion of 59.7û (5û–85û) to a mean postoperative arc of ßexion of 99.3û (55û–120û). However, the range of motion achieved intra-operatively was rarely maintained at review. The greatest improvement was seen in those with the most severe restriction in movement preoperatively. A functional range of movement (30û–130û) was achieved in 14 patients (77.7%). According to the Mayo Elbow Performance Score, measuring functional outcome, 17 patients (94%) had a good or excellent result. Arthrolysis had the added beneþt of relieving chronic post-traumatic elbow pain in 10 patients (56%). We recorded no signiþcant complications and no evidence of contracture recurrence. Conclusions: The results of conservative treatment for elbow stiffness are often disappointing. Although open elbow arthrolysis can be technically challenging a functional range of motion is readily achievable. It has been shown to be a safe procedure with a high level of patient satisfaction

The purpose of this study was to demonstrate the beneficial effects of elbow arthrolysis. This was a prospective study on 88 patients with post-traumatic elbow stiffness with a mean follow-up of 51 months (1 year - 11 years), who had failed to improve their range of movement at a mimimum period of 6 months after their injury. All patients had an open arthrolysis. Post-operatively patients received continuous passive movement (CPM) for 48 to 72 hours. This was facilitated by good analgesia afforded by a continuous brachial plexus block. All patients received no physiotherapy thereafter and were advised to actively mobilise their elbow. ROM was assessed using a goniometer and function assessed using the Mayo elbow performance index. The ROM improved from a mean of 56 degrees pre-operatively to 106 degrees post-operatively. This improvement in ROM was reflected in the improvement of pre-operative flexion from 107 to 138 degrees and improvement of extension from 60 to 31 degrees. Function improved from a mean of 65 to 85 on the Mayo elbow performance score. 95% of the patients were satisfied with the outcome. Complications included ulnar nerve paraesthesia in 3 patients, 1 triceps avulsion and 1 superficial infection. 3 patients required a manipulation of the elbow in the postoperative period. This was performed within 2 weeks of the operation. There were no cases of elbow instability or heterotopic ossification in this series. Conclusion: Open elbow arthrolysis combined with continuous brachial plexus block and CPM in the postoperative period is a safe, reliable and durable procedure for improving ROM and function in patients with post-traumatic elbow stiffness

Over the last 15 years there have been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management. Aim. To assess the results of open elbow arthrolysis in patients who did not receive any physiotherapy after discharge from hospital, although this is routinely prescribed by many surgeons. Patients and Methods. Prospectively collected data of 34 patients with a minimum follow-up of 1 year after arthrolysis was analysed. All the procedures were performed by the same surgeon, achieving as much improvement in elbow motion as possible at operation. All the patients had continuous brachial plexus blocks and continual passive motion for 2–3 days postoperatively but none received any physiotherapy after discharge. At review, a senior physiotherapist formally assessed all the patients, including measuring elbow motion with a goniometer. Results. All patients’ arc of movement improved from, with mean elbow flexion increasing by 16 degrees and extension 20 degress at the last follow-up. Upper limb function, assessed with a Disabilities of the Arm, Shoulder and Hand score (DASH), had improved 30%. Pain had decreased from 4.8 to 3.1 using the Visual Analogue Score. The greatest improvement in motion was obtained in the stiffest elbows – 5 patients with an arc of 30 degrees or less pre-operatively achieved an arc of 96 degrees by the time of the last review. Only early complications occurred – ulnar neuritis and significant pain – but these symptoms had largely settled by the time of the last review. Conclusions. Good results of open arthrolysis for post-traumatic elbow stiffness can be achieved with continuous brachial plexus blocks and continual passive motion for 2–3 days post-operatively. There appears to be little evidence to support formal treatment with physiotherapy after discharge from hospital, as our results are similar to other reported series

Introduction and Aims: The aim of this study was to assess the results of open elbow arthrolysis for post-traumatic stiffness. Method: This is a prospective study of 89 patients (M: F 53:36) with a mean age of 34 years. All patients had open elbow arthrolysis followed by continuous passive motion (CPM) for 72 hours. CPM was facilitated by analgesia in the form of a continuous brachial plexus block. After CPM patients were advised to actively mobilise their elbow. The minimum follow-up was one year. (Mean follow-up 47 months). Range of movement (ROM) was recorded using a goniometer; function was assessed using the mayo score and pain using the visual analogue score. Results: ROM improved from 60.9 to 104.2 degrees, flexion improved from 119.8 to 136.3 and extension improved from 58.9 to 32.1 degrees. Pain improved from 4.8 to 3.1 and the Mayo score improved from 60 to 85. In the sub-group of 25 patients with severe stiffness (pre-operative arc < 50 degrees), ROM improved from 29.6 to 89 degrees. Flexion improved from 99.2 to 132.2 degrees, extension improved 70 to 43.2 degrees. Pain improved from 5.6 to 4.0 and the Mayo score improved from 40 to 75. In the sub-group of 29 patients with a minimum follow-up of five years, ROM improved from 57.7 to 104.3 degrees at the year one post-operative assessment. ROM was maintained at their last follow-up, measuring 108.6 degrees. The pain score improved from 4.3 to 2.8 and was at 2.7 at their last follow-up. The Mayo score improved from 65 to 85 at year one, which was maintained at their last follow-up. Conclusion: Open elbow arthrolysis for post-traumatic stiffness of the elbow is a durable procedure for improving ROM and function. Moreover the results of elbow arthrolysis are not influenced by the degree of pre-operative stiffness

Stiffness after TKR is a frustrating complication that has many possible causes. Though the definition of stiffness has changed over the years, most would agree that flexion > 75 degrees and a 15-degree lack of extension constitutes stiffness. This presentation will focus upon the potential causes of a stiff TKR, intra-operative tips, the post-operative evaluation and management, and the results of revision for a stiff TKR. The management of this potentially unsatisfying situation begins pre-operatively with guidance of the patient's expectations; it is well-known that pre-operative stiffness is strongly correlated with post-operative lack of motion. At the time of surgery, osteophytes must be removed and the components properly sised and aligned and rotated. Soft-tissue balancing must be attained in both the flexion/extension and varus/valgus planes. One must avoid overstuffing the tibio-femoral and/or patello-femoral compartments with an inadequate bone resection. Despite these surgical measures and adequate pain control and rehabilitation, certain patients will continue to frustrate our best efforts. These patients likely have a biological predisposition for formation of scar tissue. Other potential causes for the stiff TKR include complex regional pain syndrome or joint infection. Close followup of a patient's progress is crucial for the success in return of ROM. Should motion plateau early in the recovery phase, the patient should be evaluated for manipulation under anesthesia. At our institution, most manipulations are performed within 3 months post-operative under an epidural anesthetic; patients will stay overnight for continuous epidural pain relief and immediate aggressive PT. The results of re-operations for a stiff TKR are variable due to the multiple etiologies. A clear cause of stiffness such as component malposition, malrotation or overstuffing of the joint has a greater chance of regaining motion than arthrofibrosis without a clear cause. Although surgical treatment with open arthrolysis, isolated component or complete revision can be used to improve TKR motion, results have been variable and additional procedures are often necessary

Treatment of tibial plateau fractures Schatzker type V and VI or with soft tissues injuries is still remains under discussion. The purpose of this study is to evaluate the results of treatment with circular frame and closed reduction in 25 patients (15 males and 10 females) with tibial plateau fractures, with a mean age of 42 years old (20 – 76 years). Five fractures were classified as Schatzker type II and III and 20 as type V and VI. Reduction was obtained in 22 cases under foot traction and in 3 arthroscopically. Bone grafts inserted through a hole (• 1 cm) in the inner cortex of the tibia metaphysis under fluoroscopy. Eight unstable knees needed bridging the joint for 4 weeks. In 2 cases a cannulated interfragmentary screw was used. Full weight bearing was allowed 3 months after injury when the device was removed. Follow up ranged from 1 to 10 years (mean 5 years). All fractures were united and there was no infection. Full range of the knee motion was achieved in 23 patients while 2 needed an open arthrolysis. There were 2 malunions which were treated with one valgus osteotomy and one TKR. Asymptomatic arthritis appeared in 6 patients. According to Knee Society Score (KSS) the results were classified as excellent in 12, good in 8, fair in 3 and poor in 2 patients. Circular frames are a satisfactory alternative method for the treatment of tibial plateau fractures either in severe soft tissues injuries or in very complex cases

Introduction: Chronic stiffness is an uncommon complication of total knee arthroplasty (TKA) with reports in the literature citing an incidence of 1–5%. Surgical options to manage this debilitating condition include manipulation under anaesthesia (MUA) and arthrolysis; there is concern regarding revision surgery given the potential for stiffness recurrence. Methods: Patients undergoing revision TKA for stiffness were prospectively identified. Inclusion criteria required a flexion contracture greater than 10 degrees and/or less than 70 degrees arc of motion. WOMAC and SF-36 self-report questionnaires were completed by all patients’ pre and post revision surgery. Results: Between July 2005 and Dec 2006, 7 consecutive, aseptic, primary TKA’s were revised to address limited range of motion. Five female and 2 male patients (mean age: 57.6 years) underwent revision TKA 17.1 months (range, 7–25 months) after index TKA. All patients had attempted MUA, with additional open arthrolysis unsuccessful in 1 case. A medial parapatellar approach was performed although 3 required additional quadriceps snip for exposure. Five cases were revised with the Scorpio TS system and 2 with posterior stabilised components. Femoral augmentation was required in 2 cases and tibial in 1. Gap imbalance with increased soft tissue tension was noted intra-operatively in 5 cases with arthrofibrosis found in the remainder. At 6 months follow-up, arc of motion increased from a mean of 41.3° preoperatively to 81.4° (p=0.001) while mean flexion contracture decreased from 17.4° to 2.1° (p=0.004). Subjective improvement was also demonstrated: mean WOMAC decreased from 46.5 to 22.5 (p=0.023) and SF-36 scores increased by a mean of 35.8 points (p=0.001). Conclusion: When conservative, implant preserving measures fail, revision surgery can be considered a viable option in addressing restricted movement following primary TKA. Aggressive physiotherapy and good patient compliance is required to minimise the recurrence of stiffness

To establish the efficacy of a new arthroscopic technique, for the treatment of stiffness after TKR. Introduction: The usual surgical procedure for stiffness after a total knee replacement is an open arthrolysis, though an arthroscopic procedure can be considered within six months of the index surgery. We have evolved a new procedure of capsulectomy and anterior release which can be used at any time after TKR in patients with a reduced range of movement (ROM). Methods: 22 patients (10 women and 12 men) underwent arthroscopic capsulectomy and anterior release for the treatment of loss of movement after TKR. The mean age was 62 (range 47–71 yrs). Mean time between TKR and arthrolysis was 27 months (range 3–54). Indication for the arthroscopic procedure was decreased ROM following TKR. Arthroscopy was performed using anteromedial and anterolateral portals. The dense scar tissue was divided and completely excised arthroscopically. ROM was assessed pre-operatively, immediately post-operatively and at 2, 6, 12 weeks, 6 months and 1 year. The Oxford Knee Score (OKS) and American Knee Society Score (AKSS) were used pre-operatively and at 6 months and 1 year post-operatively. Results: Pre-operatively mean flexion was 50 degrees (Range 20–90°). Post-operatively it was 94.5° (Range 55–125°). At 1 year this was maintained. The mean OKS pre-operatively was 18.4 (range 8–39). At 1 year it was 29.8 (range 9–39). The AKSS (knee and functional components) showed a similar improvement. The mean knee score increased from 47.3 pre-operatively to 71.6 at 1 year. The functional score rose from a mean of 51.3 pre-operatively to 76.9 at 1 year. Conclusions: Our technique of arthroscopic capsulectomy and anterior release for the treatment of stiffness following TKR is both successful and safe. At 1 year post-operatively the patients have maintained an increased ROM and significantly improved Oxford and American Knee Society Scores

Restricted motion in flexion is a frequent TKA complication (0.1–5.3%). The aetiology has to be searched because adhesive knee arthritis is a rare pathology. Neglecting an implant malposition, an infection or a RSDS can lead to early recurrence of stiffness. After 8 weeks, it is very dangerous to try a knee manipulation under anaesthesia. Thus, we have the choose between two difficult arthrolysis: the open and the arthroscopic. We have developed the Less Invasive Arthrolysis (LIA) as a less aggressive technique to treat knee flexion stiffness. This subcutaneous procedure (performed by one or two arthroscopic portals) was already described on a short number of patients or as a part of the arthroscopic arthrolysis. In our institution, we have performed 3738 TKA, 144 knee manipulations (3.8%) and 67LIA after TKA (21% from other surgeons) between 1997 and 2009. We have reviewed retrospectively these 67 cases (Group A) and reviewed clinically 41 of these patients in a study consultation (Group B). Subjective results: from 41 patients (B), 66% have more flexion, 32% feel less pain (VAS: 6), 49% feel better than before LIA. 58% would undergo a new LIA if they had to do it again. Objective ROM (A):preoperative ROM: 88°, in the early postoperative period, we noted a 31° flexion improvement. At the last evaluation (6–120m after LIA), the flexion improvement was 17°(−15/+80) and the final ROM was 105°. The flexion falls of 45% in the first 6 months and became stable at the 7th month (until120m). We have isolated two particular subgroups: the first including the carriers of femoral implants positioned in internal rotation (< 5°) (6% of A), in which the flexion was only improved by 6°; the second including those who underwent a stiffness recurrence (9% of A) after knee manipulation, for which we obtained a stabilization of their flexion at 105° 1 year after LIA. Relative patellar mobility(B): 66% kept a free and painless patella. Mean clinical scores (B): the long term OXF-12 score (best=12) is 33 (−18%), the HSS (best=104) is 74 (+12%). Considering the delay between TKA and LIA (67 patients, mean 28m (2–120)), the best results were obtained when we performed 6 to 24m after TKA (flexion +19° in the 7–12m, +17° in the 13–24m, versus 14° in the > 25m group). No infection occurred (0/67). We never did twice the LIA in the same knee. The published series on open arthrolysis performed 17m after TKA show an improvement of flexion by 25°, 8° for extension. An arthroscopic arthrolysis performed 12m after TKA can lead to 20° of improvement in flexion (17–42) and 3° in extension. The gold operative indication is a flexion reduced to less than 90°, 6 months after TKA, with anterior knee pain. This study presents a reliable less invasive technique studied on a bigger group with a longer follow-up and approachable by the majority of surgeons