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Causes of stiffness after total knee arthroplasty: a systematic review

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Abstract

Background

Knee stiffness after total knee arthroplasty (TKA) often leads to pain and discomfort, failing to meet patients’ expectations on the surgical procedure. Despite the growing debate on the topic, a comprehensive literature analysis of stiffness causes has never been conducted. Thus, the purpose of the present study was to systematically review the literature regarding the main causes of stiffness after TKA.

Methods

Pubmed Central, Scopus, and EMBASE databases were systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines for studies on stiffness and pain or discomfort after TKA through November 2020. Overall, 25 articles matched the selection criteria and were included in the study. Clinical relevance and strength of evidence of the included studies were graded using the risk of bias and the methodological index for non-randomized studies quality assessment tools.

Results

The main causes of pain and discomfort due to stiffness were surgery-related issues, i.e., component malpositioning and over-voluming, implant loosening, psychological distress, and obesity, which could be considered “modifiable” factors, and expression of profibrotic markers, high material hypersensitivity-related cytokines level, male gender, previous contralateral TKA, and high pre-operative pain, which could be considered “non-modifiable” factors.

Conclusion

The use of alternative technologies such as surgical robots, anatomy-based devices, and more inert and less stiff component materials could help in reducing stiffness caused by both modifiable and even some non-modifiable factors. Furthermore, early diagnostic detection of stiffness onset could consistently support surgeons in patient-specific decision-making.

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Data availability

Not applicable.

Abbreviations

MRI:

Magnetic resonance images

KSS:

Knee Society Score

PCS:

Pain Catastrophizing Scale Score

OKS:

Oxford Knee Score

FP:

Infrapatellar fat pad

SM:

Synovial membrane

WOMAC:

Western Ontario and McMaster Universities Osteoarthritis Index

QWB-7:

Quality of Well-Being scale

SF:

Short Form 12 scores

KOOS:

The Knee injury and Osteoarthritis Outcome Score

ER:

External rotation

IR:

Internal rotation

NR:

Normal rotation

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Funding

This research was supported by Invibio Knees Limited: Resolution n.194 of June 12th 2020.

Author information

Authors and Affiliations

  1. 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy

    Stefano Zaffagnini, Domenico Alesi & Nicola Pizza

  2. University of Bologna, Via Zamboni, 33, 40126, Bologna, Italy

    Stefano Zaffagnini, Stefano Di Paolo, Raffaele Zinno, Giuseppe Barone & Laura Bragonzoni

  3. Central Institute of Orthopaedics, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, 110029, India

    Amit Meena

Authors
  1. Stefano Zaffagnini
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  2. Stefano Di Paolo
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  3. Amit Meena
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  4. Domenico Alesi
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  5. Raffaele Zinno
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Contributions

S.Z and L.B conceived of the presented idea and were in charge of overall direction and planning; S.DP, A.M, D.A, and N.P wrote the manuscript with input from all authors; R.Z and G.B did the bibliographical research and drew up tables and figure.

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Correspondence to Domenico Alesi.

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Appendix

Appendix

Table 3 Methodological quality assessment. Individual MINORS criteria [37]
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Zaffagnini, S., Di Paolo, S., Meena, A. et al. Causes of stiffness after total knee arthroplasty: a systematic review. International Orthopaedics (SICOT) 45, 1983–1999 (2021). https://doi.org/10.1007/s00264-021-05023-3

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