Revision Knee Replacement:
Revision knee replacement (revision knee arthroplasty) is the last resort in treating arthrofibrosis. Revision is considered in patients with long standing, severe arthrofibrosis (chronic severe arthrofibrosis) and in patients who failed to improve with other treatment approaches like prolonged aggressive physical therapy, manipulation under anesthesia, arthroscopic or open removal of scar tissue (resistant arthrofibrosis).
Revision knee replacement is usually performed 1 year after the initial knee replacement. Revision knee replacement could be considered after 6 months and better outcomes are reported if it is done within 2 years.
Before making a diagnosis of arthrofibrosis, the knee has to be thoroughly evaluated by an arthrofibrosis specialist experienced in “arthrofibrosis following knee replacement” to find out the exact cause of stiffness following knee replacement. As the first step, low-grade infection as well as painful knee conditions causing muscle spasm should be excluded. Following this, all other possible causes of knee stiffness have to be excluded. Other than arthrofibrosis, there are multiple other causes for stiffness following knee replacement. After excluding other possible causes of stiffness following total knee replacement, the diagnosis of arthrofibrosis is considered. Arthrofibrosis may also coexist with other causes of stiffness. Once a specific diagnosis is made, the treatment is planned.
1. Knee stiffness following knee replacement due to an “identifiable cause for stiffness alone without arthrofibrosis”:
If a specific cause for the stiffness is found, the cause is treated. Various treatment approaches including different revision procedures have been descried in the literature depending on the cause of stiffness in each patient.
2. Knee stiffness following knee replacement due to “arthrofibrosis alone without an identifiable cause for stiffness”:
They are treated with revision knee replacement.
We use low dose radiation to the knee immediately before revision surgery to prevent further scarring (arthrofibrosis) and formation of bone in soft tissues (heterotopic ossification).
Revision knee replacement for arthrofibrosis is complex and is technically demanding. The goals of revision surgery in arthrofibrosis are to improve flexion contracture, range of flexion, arc of motion, pain, functional outcome and patient satisfaction. This is achieved by various combinations of different surgical steps depending on the specific circumstance in each patient. These surgical steps could be categorized into the following categories.
(A). Soft tissue releases / lengthening to improve flexion and extension
(B). Additional bone resection to improve extension
(C). Revision of prosthesis. A prosthesis with higher level of constraint may be necessary to maintain knee stability of the knee.
(D). Removal of scar tissue and the newly formed bone (heterotopic ossification) if necessary. The scar tissue and heterotopic ossification that obstruct restoration of knee motion is removed.
Postoperatively we prescribe aggressive physical therapy as well as home flexionator / extensionator therapy for 3 months.
We have good results with this approach.
3. Knee stiffness following knee replacement due to “both arthrofibrosis as well as an identifiable cause for stiffness”:
In such cases, the arthrofibrosis is more significant in causing stiffness than an identifiable cause for stiffness. We treat these patients as arthrofibrosis alone since treating arthrofibrosis with revision knee replacement will also address the identifiable cause for stiffness.