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

A stiff spine leads to increased demand on the hip, creating an increased risk of total hip arthroplasty (THA) dislocation. Several authors propose that a change in sacral slope of ≤10° between the standing and relaxed-seated positions (ΔSSstanding→relaxed-seated) identifies a patient with a stiff lumbar spine and have suggested use of dual-mobility bearings for such patients. However, such assessment may not adequately test the lumbar spine to draw such conclusions. The aim of this study was to assess how accurately ΔSSstanding→relaxed-seated can identify patients with a stiff spine. This is a prospective, multi-centre, consecutive cohort series. Two-hundred and twenty-four patients, pre-THA, had standing, relaxed-seated and flexed-seated lateral radiographs. Sacral slope and lumbar lordosis were measured on each functional X-ray. ΔSSstanding→relaxed-seated seated was determined by the change in sacral slope between the standing and relaxed-seated positions. Lumbar flexion (LF) was defined as the difference in lumbar lordotic angle between standing and flexed-seated. LF≤20° was considered a stiff spine. The predictive value of ΔSSstanding→relaxed-seated for characterising a stiff spine was assessed. A weak correlation between ΔSSstanding→relaxed-seated and LF was identified (r2= 0.15). Fifty-four patients (24%) had ΔSSstanding→relaxed-seated ≤10° and 16 patients (7%) had a stiff spine. Of the 54 patients with ΔSSstanding→relaxed-seated ≤10°, 9 had a stiff spine. The positive predictive value of ΔSSstanding→relaxed-seated ≤10° for identifying a stiff spine was 17%. ΔSSstanding→relaxed-seated ≤10° was not correlated with a stiff spine in this cohort. Utilising this simplified approach could lead to a six-fold overprediction of patients with a stiff lumbar spine. This, in turn, could lead to an overprediction of patients with abnormal spinopelvic mobility, unnecessary use of dual mobility bearings and incorrect targets for component alignment. Referring to patients ΔSSstanding→relaxed-seated ≤10° as being stiff can be misleading; we thus recommend use of the flexed-seated position to effectively assess pre-operative spinopelvic mobility

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. Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties. Methods. Well-functioning primary TKAs (n = 11), failed non-fibrotic TKAs (n = 5), and patients with a clinical diagnosis of fibrosis. 1. (n = 8) underwent an MRI scan with advanced metal suppression (Slice Encoding for Metal Artefact Correction, SEMAC) with gadolinium contrast. Fibrotic tissue (low intensity on T1 and T2, low-moderate post-contrast enhancement) was quantified (presence and tissue thickness) in six compartments: supra/infrapatella, medial/lateral gutters, and posterior medial/lateral. Results. Fibrotic tissue was identified in all patients studied. However, tissue was significantly thicker in fibrotic patients (4.4 mm ± 0.2 mm) versus non-fibrotic (2.5 mm ± 0.4 mm) and normal TKAs (1.9 mm ± 0.2 mm, p = < 0.05). Significant (> 4 mm thick) tissue was seen in 26/48 (54%) of compartments examined in the fibrotic group, compared with 17/30 (57%) non-fibrotic, and 10/66 (15%) normal TKAs. Although revision surgery did improve range of movement (ROM) in all fibrotic patients, clinically significant restriction remained post-surgery. Conclusion. Stiff TKAs contain intra-articular fibrotic tissue that is identifiable by MRI. Studies should evaluate whether MRI is useful for surgical planning of debridement, and as a non-invasive measurement tool following interventions for stiffness caused by fibrosis. Revision for stiffness can improve ROM, but outcomes are sub-optimal and new treatments are required. Cite this article: Bone Joint J 2020;102-B(10):1331–1340

Aims. To compare patients undergoing total knee arthroplasty (TKA) with ≤ 80° range of movement (ROM) operated with a 2 mm increase in the flexion gap with matched non-stiff patients with at least 100° of preoperative ROM and balanced flexion and extension gaps. Methods. In a retrospective cohort study, 98 TKAs (91 patients) with a preoperative ROM of ≤ 80° were examined. Mean follow-up time was 53 months (24 to 112). All TKAs in stiff knees were performed with a 2 mm increased flexion gap. Data were compared to a matched control group of 98 TKAs (86 patients) with a mean follow-up of 43 months (24 to 89). Knees in the control group had a preoperative ROM of at least 100° and balanced flexion and extension gaps. In all stiff and non-stiff knees posterior stabilized (PS) TKAs with patellar resurfacing in combination with adequate soft tissue balancing were used. Results. Overall mean ROM in stiff knees increased preoperatively from 67° (0° to 80°) to 114° postoperatively (65° to 135°) (p < 0.001). Mean knee flexion improved from 82° (0° to 110°) to 115° (65° to 135°) and mean flexion contracture decreased from 14° (0° to 50°) to 1° (0° to 10°) (p < 0.001). The mean Knee Society Score (KSS) improved from 34 (0 to 71) to 88 (38 to 100) (p < 0.001) and the KSS Functional Score from 43 (0 to 70) to 86 (0 to 100). Seven knees (7%) required manipulations under anaesthesia (MUA) and none of the knees had flexion instability. The mean overall ROM in the control group improved from 117° (100° to 140°) to 123° (100° to 130°) (p < 0.001). Mean knee flexion improved from 119° (100° to 140°) to 123° (100° to 130°) (p < 0.001) and mean flexion contracture decreased from 2° (0° to 15°) to 0° (0° to 5°) (p < 0.001). None of the knees in the control group had flexion instability or required MUA. The mean KSS Knee Score improved from 48 (0 to 80) to 94 (79 to 100) (p < 0.001) and the KSS Functional Score from 52 (5 to 100) to 95 (60 to 100) (p < 0.001). Mean improvement in ROM (p < 0.001) and KSS Knee Score (p = 0.017) were greater in knees with preoperative stiffness compared with the control group, but the KSS Functional Score improvement was comparable (p = 0.885). Conclusion. TKA with a 2 mm increased flexion gap provided a significant improvement of ROM in knees with preoperative stiffness. While the improvement in ROM was greater, the absolute postoperative ROM was less than in matched non-stiff knees. PS TKA with patellar resurfacing and a 2 mm increased flexion gap, in combination with adequate soft tissue balancing, provides excellent ROM and knee function when stiffness of the knee had been present preoperatively. Cite this article: Bone Joint J 2020;102-B(4):426–433

Modifiable factors contributing to stiffness include alignment, implant size, implant position and rotation, and soft tissue tightness or laxity. Less modifiable factors include genetics as in predisposition to inflammation and fibrosis, aberrations in perception and experience of emotional pain, and preoperative range of motion. We reviewed 559 knees undergoing revision between 2007 and 2014, selecting out patients with a diagnosis of stiffness and greater than one-year follow-up. Stiffness was defined as greater than 15 degrees of flexion contracture or less than 75 degrees of flexion or less than 90 degrees of active motion and a chief complaint of limited motion and pain. Radiographic analysis used a set of matched controls with greater than 90 degrees and full extension prior to surgery and were further matched by age, gender, BMI. Flexion contracture changed from an average of 9.7 to an average of 2.3 degrees, flexion changed from an average of 81 to an average of 94 degrees, active motion changed from an average of 72 to an average of 92 degrees, pain scores improved from 44 to 72 points, and Knee Society function scores improved from an average of 49 to an average of 70 points. There were four failures for stiffness, two knees underwent additional manipulation, gaining an average of 10 degrees; and two knees were revised. Radiographic analysis demonstrated stiffness to be strongly correlated to anterior condylar offset ratio and to patellar displacement by multivariant regression analysis, suggesting that overstuffing the patellofemoral joint by anteriorization of the femoral component is associated with stiffness. Using modern revision techniques, revision for stiffness creates reliable improvements in pain, Knee Society clinical and functional scores, and motion

Aims. Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE. Methods. This was a retrospective review of a single institution’s prospectively collected shoulder arthroplasty database for TSAs undertaken between 2007 and 2020. A total of 344 aTSAs and 163 rTSAs, which were performed in patients with OA and an intact rotator cuff with a minimum follow-up of two years, were included. Using the definition of preoperative stiffness as passive FE ≤ 105°, three cohorts were matched 1:1 by age, sex, and follow-up: stiff aTSAs (85) to non-stiff aTSAs (85); stiff rTSAs (74) to non-stiff rTSAs (74); and stiff rTSAs (64) to stiff aTSAs (64). We the compared ROMs, outcome scores, and complication and revision rates. Results. Compared with non-stiff aTSAs, stiff aTSAs had poorer passive FE and active external rotation (ER), whereas there were no significant postoperative differences between stiff rTSAs and non-stiff rTSAs. There were no significant differences in preoperative function when comparing stiff aTSAs with stiff rTSAs. However, stiff rTSAs had significantly greater postoperative active and passive FE (p = 0.001 and 0.004, respectively), and active abduction (p = 0.001) compared with stiff aTSAs. The outcome scores were significantly more favourable in stiff rTSAs for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, and the Constant score, compared with stiff aTSAs. When comparing the proportion of stiff aTSAs versus stiff rTSAs that exceeded the minimal clinically important difference and substantial clinical benefit, stiff rTSAs achieved both at greater rates for all measurements except active ER. The complication rate did not significantly differ between stiff aTSAs and stiff rTSAs, but there was a significantly higher rate of revision surgery in stiff aTSAs (p = 0.007). Conclusion. Postoperative overhead ROM, outcome scores, and rates of revision surgery favour the use of a rTSA rather than aTSA in patients with glenohumeral OA, an intact rotator cuff and limited FE, with similar rotational ROM in these two groups. Cite this article: Bone Joint J 2023;105-B(12):1303–1313

Objectives. Microindentation has the potential to measure the stiffness of an individual patient’s bone. Bone stiffness plays a crucial role in the press-fit stability of orthopaedic implants. Arming surgeons with accurate bone stiffness information may reduce surgical complications including periprosthetic fractures. The question addressed with this systematic review is whether microindentation can accurately measure cortical bone stiffness. Methods. A systematic review of all English language articles using a keyword search was undertaken using Medline, Embase, PubMed, Scopus and Cochrane databases. Studies that only used nanoindentation, cancellous bone or animal tissue were excluded. Results. A total of 1094 abstracts were retrieved and 32 papers were included in the analysis, 20 of which used reference point indentation, and 12 of which used traditional depth-sensing indentation. There are several factors that must be considered when using microindentation, such as tip size, depth and method of analysis. Only two studies validated microindentation against traditional mechanical testing techniques. Both studies used reference point indentation (RPI), with one showing that RPI parameters correlate well with mechanical testing, but the other suggested that they do not. Conclusion. Microindentation has been used in various studies to assess bone stiffness, but only two studies with conflicting results compared microindentation with traditional mechanical testing techniques. Further research, including more studies comparing microindentation with other mechanical testing methods, is needed before microindentation can be used reliably to calculate cortical bone stiffness. Cite this article: M. Arnold, S. Zhao, S. Ma, F. Giuliani, U. Hansen, J. P. Cobb, R. L. Abel, O. Boughton. Microindentation – a tool for measuring cortical bone stiffness? A systematic review. Bone Joint Res 2017;6:542–549. DOI: 10.1302/2046-3758.69.BJR-2016-0317.R2

Aims. The aim of this study was to examine the results of revision total knee arthroplasty (TKA) undertaken for stiffness in the absence of sepsis or loosening. Patients and Methods. We present the results of revision surgery for stiff TKA in 48 cases (35 (72.9%) women and 13 (27.1%) men). The mean age at revision surgery was 65.5 years (42 to 83). All surgeries were performed by a single surgeon. Stiffness was defined as an arc of flexion of < 70° or a flexion contracture of > 15°. The changes in the range of movement (ROM) and the Western Ontario and McMasters Osteoarthritis index scores (WOMAC) were recorded. Results. At a mean follow up of 59.9 months (12 to 272) there was a mean improvement in arc of movement of 45.0°. Mean flexion improved from 54.4° (5° to 100°) to 90° (10° to 125°) (p <  0.05) and the mean flexion contracture decreased from 12.0° (0° to 45°) to 3.5° (0° to 25°) (p < 0.05). The mean WOMAC scores improved for pain, stiffness and function. In patients with extreme stiffness we describe a novel technique, which we have called the ‘sloppy’ revision. This entails downsizing the polyethylene insert by 4 mm and using a more constrained liner to retain stability. Conclusion. To our knowledge, this is the largest series of revision surgeries for stiffness reported in the literature where infection and loosening have been excluded. . Take home message: Whilst revision surgery is technically demanding, improvements in ROM and outcome can be achieved, particularly when the revision is within two years of the primary surgery. Cite this article: Bone Joint J 2016;98-B:622–7

Objectives. The ability to determine human bone stiffness is of clinical relevance in many fields, including bone quality assessment and orthopaedic prosthesis design. Stiffness can be measured using compression testing, an experimental technique commonly used to test bone specimens in vitro. This systematic review aims to determine how best to perform compression testing of human bone. Methods. A keyword search of all English language articles up until December 2017 of compression testing of bone was undertaken in Medline, Embase, PubMed, and Scopus databases. Studies using bulk tissue, animal tissue, whole bone, or testing techniques other than compression testing were excluded. Results. A total of 4712 abstracts were retrieved, with 177 papers included in the analysis; 20 studies directly analyzed the compression testing technique to improve the accuracy of testing. Several influencing factors should be considered when testing bone samples in compression. These include the method of data analysis, specimen storage, specimen preparation, testing configuration, and loading protocol. Conclusion. Compression testing is a widely used technique for measuring the stiffness of bone but there is a great deal of inter-study variation in experimental techniques across the literature. Based on best evidence from the literature, suggestions for bone compression testing are made in this review, although further studies are needed to establish standardized bone testing techniques in order to increase the comparability and reliability of bone stiffness studies. Cite this article: S. Zhao, M. Arnold, S. Ma, R. L. Abel, J. P. Cobb, U. Hansen, O. Boughton. Standardizing compression testing for measuring the stiffness of human bone. Bone Joint Res 2018;7:524–538. DOI: 10.1302/2046-3758.78.BJR-2018-0025.R1

Seven stiff total knee arthroplasties are presented to illustrate the roles of: 1) manipulation under general anesthesia; 2) multiple concurrent diagnoses in addition to stiffness; 3) extra-articular pathology; 4) pain as part of the stiffness triad (pain and limits to flexion or extension); 5) component internal rotation; 6) multifactorial etiology; and 7) surgical exposure in this challenging clinical problem

Stiffness after total knee arthroplasty (TKA) is a common problem occurring between 5% and 30% of patients. Stiffness is defined as limited range of motion (ROM) that affects activities of daily living. A recent International Consensus on definition of stiffness of the knee graded stiffness as mild, moderate or severe (90–100, 70–89, <70, respectively) or an extension deficit (5–10, 11–20, >20). Stiffness can be secondary to an osseous, soft tissue, or prosthetic block to motion. Heterotopic bone or retained posterior osteophytes, abundant fibrotic tissue, oversized components with tight flexion or extension gaps or component malrotation can all limit knee motion. Infection should always be considered in the knee that gradually loses motion. Alternative causes include complex regional pain syndrome and Kinesiophobia that can limit motion without an underlying mechanical cause. The evaluation of knee stiffness radiographs of the knee and cross-section imaging should be performed if component malrotation is considered. A metal suppression MRI assists in quantifying the extent of fibrosis and its location in the anterior or posterior compartment of the knee. Inflammatory markers and joint aspiration as indicated to rule out infection. Arthrofibrosis, or post-surgical fibrosis, is related to abnormal scar formation after surgery that leads to loss of motion. The cause of arthrofibrosis is multifactorial and likely related to genetic host factors. Current research is focusing on molecular signatures that may better identify patients at risk. In addition, therapeutic interventions are being studied that best prevent fibrosis and its recurrence and include the use of anti-inflammatories, corticosteroids, Colchicine, biologic medications (IL-1 inhibitors) and low-dose radiation. Early treatment of the stiff TKA includes physical therapy and manipulation under anesthesia (MUA). MUA performed within 3 months may have the greatest increase in ROM but notable improvement can occur up to 6 months after TKA. After six months, arthroscopic or open surgery is recommended for persistent stiffness. Arthroscopic lysis of adhesions can improve ROM greater than 1 year after index TKA. Average improvement of ROM for both MUA and arthroscopic lysis of adhesions (usually in conjunction with MUA) is approximately 30 degrees. The outcome after open lysis of adhesions are reportedly poor but current adjuvant therapies may improve these clinical outcomes as this addresses the biologic, in addition to the mechanical, basis of fibrosis. Component revision performed for component malposition and stiffness has variable outcomes but a recent study reports a mean increase in ROM of 20 degrees and a modest improvement in overall knee function. The cause of post-operative stiffness after TKA is a complex interplay of the patient, surgeon, and post-operative factors. Correct diagnosis of the underlying cause of the stiff total knee is essential to optimizing treatment outcomes. More research in needed in how to best prevent and treat the biologic risk factors and pathways that contribute to post-surgical fibrosis

Introduction. Lumbar spine fusion in patients undergoing THA (total hip arthroplasty) is a known risk factor for hip dislocation with some studies showing a 400% increased incidence compared to the overall THA population. Reduced spine flexibility can effectively narrow the cup anteversion safe zone while alterations in pelvic tilt can alter the center of the anteversion safe zone. The use of precision cup alignment technology combined with patient-specific cup alignment goals based on preoperative assessment has been suggested as a method of addressing this problem. The current study assess the dislocation rate of THA patients with stiff or fused lumbar spines treated using surgical navigation with patient-specific cup orientation goals. Methods. Seventy-five THA were performed in 54 patients with a diagnosis of lumbar fusion, lumbar disc replacement, and scoliosis with Cobb angles greater than 40 degrees were treated by the senior author (SM) as part of a prospective, non-randomized study of surgical navigation in total hip arthroplasty. All patients were treated using a smart mechanical navigation tool for cup alignment (HipXpert System, Surgical Planning Associates, Inc., Boston, MA). Cup orientation goals were set on a patient-specific basis using supine pelvic tilt as measured using CT. Patients with increased pelvic tilt had a goal for increased cup anteversion and patients with decreased pelvic tilt had a goal for decreased cup anteversion (relative to the anterior pelvic plane coordinate system). Each patient's more recent outpatient records were assessed for history of dislocation, instability, mechanical symptoms, decreased range of motion or progressive pain. Additionally, last clinic radiographs were reviewed to confirm lumbar pathology in the form of spinal surgical hardware. Results. Seventy-five total hip arthroplasties with stiff lumbar spine were reviewed with and average follow up of 6.04 years. The average number of levels of lumbar fusion was 2.3 levels. Since the most recent follow up on all patients in this cohort no hip dislocations had occurred. Discussion and Conclusion. Fusion or stiffness of the lumbar spine is a known risk factor for instability following elective THA. The current study demonstrates that patient-specific planning of cup placement taking abnormal pelvic tilt into consideration combined with the use of accurate intra-operative cup alignment technology can be used to address this problem

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

Stiffness after total knee replacement remains a significant factor in a suboptimal result after total knee arthroplasty. Interference with function including stair climbing, arising from a seated position, driving and return to activities of daily living and recreational sports are all compromised when stiffness results after knee replacement. The key indicator for resultant range of motion after knee replacement remains knee motion prior to surgery. A knee with limited motion prior to surgery will rarely achieve the same motion as a fully mobile knee and the patient should be counseled to this ultimate result. Patients with prior knee surgery, post-traumatic knee arthritis also tend to be stiffer after knee replacement. If a knee is stiff after replacement it is key to determine if there is a mechanical impediment to motion (e.g. implant sizing problem, overstuffing of the patellofemoral joint) and revision knee replacement to address this problem will be necessary and is best done when recognised. When referring to a stiff knee after replacement flexion less than 90 degrees is generally accepted. Management of the knee with limited motion after knee replacement should first be treated with manipulation of the knee under anesthesia. Timing of manipulation is key to its success and if a patient is not progressing after 4–6 weeks manipulation is generally indicated. Manipulation can be performed up to 6–12 months after replacement but ultimate motion is negatively impacted by delay as scar tissue becomes more indurated and fixed. Arthroscopic lysis of adhesions can be performed in the recalcitrant knee but in my experience will generally improve motion in the 10- to 15-degree range, if at all. In patients with persistent and disabling stiffness, open resection with radical scar excision can be performed and if there is not an implant sizing issue this may improve motion. It is important to rapidly mobilise these patients after surgery with early flexion to beyond 90 degrees with use of optimal analgesia to allow vigorous early motion. At time of open lysis of adhesions revision of components should be performed if there is any question of need to do this to improve range of motion

Introduction. Treatment of non-union in open tibial fractures Gustilo-Anderson(GA)-3A/3B fractures remains a challenging problem. Most of these can be dealt using treatment methods that requires excision of the non-union followed by bone grafting, masquelet technique, or acute shortening. Circular fixators with closed distraction or bone transport also remains a useful option. However, sometimes due to patient specific factors these cannot be used. Recently antibiotic loaded bone substitutes have been increasingly used for repairing infected non-unions. They provide local antibiotic delivery, fill dead space, and act as a bone conductive implant, which is resorted at the end of a few months. We aimed to assess the outcome of percutaneous injection of bone substitute while treating non-union of complex open tibial fractures. Materials & Methods. Three cases of clinical and radiological stiff tibial non-union requiring further intervention were identified from our major trauma open fracture database. Two GA-3B cases, treated with a circular frame developed fracture-related-infection(FRI) manifesting as local cellulitis, loosened infected wires/pins with raised blood-markers, and one case of GA-3A treated with an intramedullary nail. At the time of removal of metalwork/frame, informed consent was obtained and Cerament-G. TM. (bone-substitute with gentamicin) was percutaneously injected through a small cortical window using a bone biopsy(Jamshedi needle). All patients were allowed to weight bear as tolerated in a well-fitting air-cast boot and using crutches. They were followed up at 6 weekly intervals with clinical assessment of their symptoms and radiographs. Fracture union was assessed using serial radiographs with healing defined as filling of fracture gap, bridging callus and clinical assessment including return to full painless weight bearing. Results. Follow-up at 6 months showed all fractures had healed with no defect or gaps with evidence of new trabecular bone and significant resorption of Cerament-G. TM. at final follow-up. There was no evidence of residual infection with restoration of normal limb function. Fractures with no internal fixation showed a mild deformity that had developed during the course of the healing, presumed due to mild collapse in the absence of fixation. These were less than 10 degrees in sagittal and coronal planes and were clinically felt to be insignificant by the patients. Conclusions. Cerament-G's unique combination of high dose antibiotics and hydroxy apatite matrix provided by calcium sulphate might help provide an osteoconductive environment to allow these stiff non-unions to heal. The matrix appears to provide a scaffold-like structure that allows new bone in-growth with local release of antibiotics helping reduce deep-seated infections. The final deformation at fracture site underlines the need for fixation- and it is very unlikely that this technique will work in mobile nonunions. Whilst similar fractures may heal without the use of bone substitute injections, the speed of healing in presence of significant fracture gap suggests the use of these bone substitutes did help in our cases. Further studies with a larger cohort, including RCTs, to evaluate the effectiveness of this technique compared to other methods are needed

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

Stiffness remains one of the most common, and challenging postoperative complications after TKA. Preoperative motion and diagnosis can influence postoperative motion, and careful patient counseling about expectations is important. Postoperative stiffness should be evaluated by ruling out infections, metal allergy, or too aggressive physical therapy. A careful physical and radiographic examination is required. Manipulation under anesthesia (MUA) in selected cases can be helpful. The best timing to perform MUA is between the 6th and 10th week postoperatively. Careful technique is required to minimise the risk of fracture or soft tissue injury. This requires complete paralysis! For more chronic stiffness, revision may be indicated if an etiology can be identified. An excessively thick patellar resurfacing, an overstuffed tibia insert, an oversized femoral component, or gross malrotation should be corrected. During revision, thorough synovectomy, release of contractures, ligamentous balancing and restoration of the joint line is required. Careful attention to component rotation, and sizing is critical. Downsizing components is helpful to place less volume into the joint space. Patients should be counseled that the results of revision for stiffness are mixed and somewhat unpredictable. More frequent postoperative nurturing is helpful to guide rehabilitation progress. Manipulation after revision at 6 weeks is almost expected

Stiffness after a TKA might be said to be present when reasonable functions of daily living cannot be performed or can only be performed with difficulty or pain. This will certainly be true if flexion is less than 75 degrees and/or there is a 15-degree lack of full extension. The purpose of this presentation is to discuss the causes of a stiff TKA, consider the aspects of surgical technique that are associated with the occurrence of stiffness, present post-surgical management that impacts on the development of stiffness and summarise the results of the surgical treatment of a stiff TKA. Pre-operative stiffness is strongly correlated with post-operative limitation of motion. Therefore, pre-surgical measures to optimise motion should be carried out. These include appropriate physical therapy, adequate pain management and a discussion with the patient of the issues likely to affect post-operative range of motion. It is particularly important to discuss with the patient appropriate expectations with regard to the likely range of motion that will be achieved following TKA surgery. There are a number of steps that can be taken during the performance of a TKA that have an impact on range of motion. Osteophytes must be removed. Correctly sized implants must be used to avoid over-stuffing the tibio-femoral and patello-femoral compartments. Mal-positioning implants and the extremity can adversely affect range of motion. Inadequate bone resection will also lead to a reduced range of motion. Improper soft tissue balancing in both flexion and extension may be associated with post-surgical stiffness. Post-operative management must include adequate pain management as well as appropriate rehabilitation. Close post-surgical surveillance will help identify those patients likely to achieve unsatisfactory range of motion. Manipulation of appropriate patients within the first 6 weeks following surgery is usually associated with a satisfactory final range of motion. When persistent stiffness occurs, an attempt must be made to identifying possible causes, including component mal-alignment or mal-rotation, component mis-sizing or mis-positioning and inadequate soft tissue balancing. The surgical treatment of a stiff total knee include: 1) arthroscopic debridement and manipulation; 2) arthrotomy with debridement; and 3) single or complete component revision. Although surgical intervention often results in improved range of motion, the results are variable and somewhat limited

Purpose. The purpose of this study is to evaluate stiff knees which have a preoperative arc of motion (AOM) < 65 degrees and maximum flexion < 90 degrees under anesthesia for primary TKA. Material and Methods. We prospectively evaluated 25 knees, 20 patients, the follow up period was 5±3 years, OA 13, RA 10 and traumatic OA 2 knees. All case were medial para-patella approaches and snip was added in one knee operation, 23 PS-type and 2 constrain-type TKAs. Results. Preoperative and postoperative FTA were 185.3±8.4 and 174.2±2.8 degrees, α95.5±3.0, β88.6±2.1, γ4.1±2.9, σ83.8±3.0, CTA1.4±1.9 degrees. Soft tissue releases were performed in Clayton stage I 9, II 14 and III 2 knees, and additional resection for the posterior capsule 11, vastus intermedius 2 and ITT 4 knees and lateral release 4 knees. Additional bone cuts were performed in 19 knees including femur 14 knees and tibia 12 knees. Component gaps (20/30/40lb) of medial and lateral were 9.8±0.8/10.8±2.9/12.2±1.9 mm and 11.0±2.1/12.6±2.5/13.6±2.8 mm at 0 degrees, they were 11.4±2.8/13.5±3.6/15.8±4.1 mm and 12.5±2.7/15.1±3.8 /18.0±4.2 mm at 90 degrees. (Figure1) MCL avulsion was in 3 knees. AOMs in preoperative, perioperative, 1-year later and final observation were 45.0±16.5, 110.4±15.5, 110.8±18.4 and 113.4±18.2 degrees. (Figure2) Flexions were72.5±17.7, 104.0±14.0, 104.0±14.0 and 106.5±14.4 degrees. Extensions were −28.3±10.5, −6.0±7.5, −6.0±7.0 and −6.9±7.8 degrees. There were no statistical differences between perioperative and final AOM, flexion and extension, and between OA and RA. Discussion. AOM improved and remained after the surgeries. We evaluated soft tissue release and component gaps in 25 stiff knees when preoperative arc of motion (AOM) was < 65 degrees and maximum flexion < 90 degrees under anesthesia for primary TKA. There were no statistical differences between perioperative and final AOM, flexion and extension, and between OA and RA. For any figures or tables, please contact the authors directly