Video chapter from our Udemy course on Knee Stiffness after injury or surgery

We have re-used some chapters from our paid courses, so that you can have access here, but of course the context of the original may be a bit different.

 

 

Transcript of the video

Certain knee procedures and situations carry an increased risk of leaving a patient with a stiff knee:

  • Injuries and surgical procedures around the patella or kneecap, for example, carry a higher risk of rehabilitation stiffness, particularly fractures involving the patella and tendon ruptures both above and below the patella.

    The procedure of lateral release, where tissues are cut towards the side of the patella to change its alignment or tilt, is also relevant.
  • Cruciate ligament reconstructions performed under inappropriate conditions may lock up the notch in which they sit with scar tissue.
  • There are also many publications of knee replacements and revision knee replacements reporting patients being left with a stiff knee.

 

Certain high risk scenarios like these may trigger an excessive inflammatory response that then progresses to result in knee stiffness. Perhaps as we go through the list you can check off whether any of these high risk triggers apply to your own situation:

Tourniquet Use

One of the factors that is important to consider is whether or not a tourniquet was used during surgery, and whether or not there was great diligence in ensuring that there were no 'bleeders' once the tourniquet was released.

A tourniquet is a band, just like the one used for taking your blood pressure, that is wrapped around the top of the leg before surgery. The blood is drained from the leg by lifting it or by wrapping it with a tight rubber bandage, and then the tourniquet is pumped up to well above the patient's blood pressure. This ensures that there is no bleeding during the operation.

Surgeons will differ in their use of tourniquets. Some put them in place but use them only in an emergency if bleeding gets out of control during the procedure. Others apply them and pump them up beforehand, but then let them down well before the end of the operation and diligently cauterise any bleeders. But some surgeons may be less careful and just rely on firm bandages to keep the joint from blowing up after surgery.

Blood in the joint

When a joint is filled with blood the condition is known as 'haemarthrosis'. A little bit of blood in the joint after injury or surgery may soon be resorbed, but when the knee is tense and painful then this is very different. The blood can be aspirated and the joint washed out via a needle if it is early enough, but once the blood is clotted then only an open procedure to evacuate the clots would resolve it.

The blood itself can cause painful irritation, in addition to the stretching of the joint capsule. The pain and irritation cause inhibition of the quads muscle and rehab becomes a real problem.

Insufficient pain relief

Pain management will be a combination of keeping down the swelling, active movement within tolerable limits, passive movement beyond the limits, pain killer medication, icing the knee where appropriate, and taking care not to trigger undue inflammation.

Pain is not pleasant at the best of times, but knee pain after injury or surgery can sometimes - rarely but still significantly - result in the complication called Complex Regional Pain Syndrome or CRPS.

Prolonged joint immobilisation

The next important trigger is prolonged knee immobilisation. Sometimes a bone break or a particular kind of surgical procedure necessitate immobilising the knee beyond what would normally be recommended. This always creates a rehabilitation challenge.

Excessive inlammation

Excessive inflammation is the next potential trigger. Inflammation is normal after knee injury or surgery, but it should be monitored and not allowed to become excessive due to too frenetic attempts at rehabilitation. Rehab is a fine dance between encouraging movement but not triggering abnormal inflammation. If things flare up, then it is time to step back a level with the rehab, focus on working within a pain-free range, getting help with passive movement, and using icing and anti-inflammatory medication where appropriate.

Joint infection

Joint infection is another major problem. An infected joint is a very bad scenario, and one of the complications, even after the infection might be cleared, is internal scarring and residual stiffness.

Genetic 'aggressive scar formers'

And finally we get to the topic of people who are ‘scar formers’. Some people, and it seems to be genetic, have the propensity to trigger inflammatory responses way out of the normal range, with florid overgrowth of joint lining tissue and adhesions and internal scarring completely out of control. This goes on until the knee is locked up with scar tissue. Surgery to remove it restores movement, but then the process re-triggers. So this group of people need to be identified and tagged on the first occasion and referred to specialist units as early as possible, before the joint is wrecked by repeated non-expert attempts to restore natural joint anatomy.

 

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This video is from one of our external courses


Knee Arthrofibrosis: Everything you need to know to recognize, treat, and prevent loss of knee motion after injury or surgery

If you would like free access to the first chapter of this eBook by Dr Noyes and Sue Barber-Westin - fully illustrated - just click here.

If you are considering purchasing the full book, see the KNEEguru Shop.

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