Putman Sophie, André Paul-Antoine, Pasquier Gilles, Dartus Julien
Metrics, Université Lille-Nord de France, 59000 Lille, France; Service d'Orthopédie 2, CHU Lille, France.
Service d'Orthopédie 2, CHU Lille, France.
Orthop Traumatol Surg Res. 2025 Feb;111(1S):104060. doi: 10.1016/j.otsr.2024.104060. Epub 2024 Nov 22.
Stiffness following total knee replacement is defined as >15° flexion contracture and/or flexion <75° or, for other authors, arc of motion <70° or 45° or 50°. Alternatively, it could be defined as a range of motion less than the patient needs in order to be able to do what they wish. The first step in management is to determine the causes: preoperative (history of stiffness, patient-related risk factors, etc.), intraoperative (technical error: malpositioning, oversizing, overhanging, etc.), and postoperative (defective pain management and/or rehabilitation, etc.). Treatment depends on the interval since replacement and on the type of stiffness (flexion or extension), and should be multidisciplinary (surgery, rehabilitation, pain management). For intervals less than 3 months, manipulation under anesthesia gives good results for flexion. If this fails, surgery should be considered. If there was no significant technical error, arthrolysis may be indicated, and is usually arthroscopic. It is technically difficult, but has a low rate of complications. Open arthrolysis allows greater posterior release and replacement of the insert by a thinner model. In case of malpositioning or oversizing or of failure of other procedures, implant revision is the only option, although the risk of complications is high. After exposure, which is often difficult, the aim is to correct the technical errors and to restore joint-line height and two symmetrical, well-balanced spaces in extension and flexion. A semi-constrained or even hinged implant may be needed, although with uncertain lifetime for young patients in the latter case. In all cases, the patient needs to accept that treatment is going to be long, with more than the intervention itself (i.e., specific pain management and rehabilitation), and that expectations have to be reasonable as results are often imperfect. LEVEL OF EVIDENCE: expert opinion.
屈曲挛缩大于15°和/或屈曲小于75°；或者，其他作者认为，活动弧度小于70°或45°或50°。或者，也可定义为活动范围小于患者为能够做自己想做的事情所需要的范围。处理的第一步是确定病因：术前（僵硬病史、患者相关危险因素等）、术中（技术失误：位置不当、尺寸过大、悬垂等）和术后（疼痛管理和/或康复存在缺陷等）。治疗取决于置换后的时间间隔以及僵硬的类型（屈曲或伸直），且应采用多学科方法（手术、康复、疼痛管理）。对于置换后时间小于3个月的情况，麻醉下手法操作对屈曲僵硬效果良好。如果失败，则应考虑手术。如果没有明显的技术失误，可考虑行关节松解术，通常采用关节镜手术。该手术技术难度大，但并发症发生率低。开放性关节松解术可实现更大程度的后方松解，并可更换为更薄型号的衬垫。如果存在位置不当、尺寸过大或其他手术失败的情况，植入物翻修是唯一选择，尽管并发症风险很高。暴露手术往往很困难，其目的是纠正技术失误，恢复关节线高度以及伸直和屈曲时两个对称、平衡良好的间隙。可能需要使用半限制性甚至铰链式植入物，不过对于年轻患者而言，后者的使用寿命不确定。在所有情况下，患者都需要接受治疗将是漫长的，不仅包括干预本身（即特定的疼痛管理和康复），而且期望必须合理，因为结果往往并不完美。证据水平：专家意见。
