I had total knee replacement. I do not have full range of motion. Had
my knee rebent three times in the last 18 months and I still do not
have full range. They think I have a lot of scar tissur. What can I do
now to get full range?

Hello smokie,

I was hoping to find some cutting edge treatment or new therapy for
increasing range of motion in .  What I found instead repeated from
many sources was that complete range of motion is a goal but not
necessarily an outcome of total knee replacement surgery.  I've quoted
a typical paragraph below, and the source just under that.

Article Title: Rehabilitation Following Total Knee Arthroplasty by By
Tim Kauffman, PhD, PT
"The biggest predictor of postoperative ROM is preoperative ROM. The
average postoperative ROM is 105°-110° for most patients. At least 90°
of ROM is desirable for a good functional outcome."

He goes on to say:
"The end stage of TKA postoperative rehabilitation, from 3 to 12
months, is frequently ignored because the patient has had good to
excellent pain relief and is walking within 12 weeks. Nevertheless,
full physiological and functional recovery usually requires longer
than 3 months and may never be attained. Walsh and colleagues7
compared patients who were 1 year post-TKA with age- and
gender-matched controls without knee pathology. Isokinetic peak torque
measurements were deficit more than 25% in the TKA females and 35% in
the males at 90° per second when compared with controls. The speeds of
walking and stair climbing also were statistically significantly
slower in the TKA females and males. "

http://www.aboutjoints.com/physicianinfo/topics/kneerehab.htm

I found information on the "knee bending" procedure you had 3 times
over 18 months, which was as I understand it done in the hospital with
anesthesia. I found this suggested as the standard treatment to
restore movement.  The only other treatment appears to be physical
therapy.  Within the physical therapy recommendations the debate
centers around the use of continuous passive motion machines (CPM),
whether or not to use them.  Some studies show that although passive
motion machines increase range of motion (ROM) short term, they have
no effect on long term ROM. Many sites mentioned long term
rehabilitation as well as the post operative rehabilitation.  You did
not specify whether you have had ongoing physical therapy, but it sure
appears to be a crucial factor in restoring maximum ROM.

Here is a web site entitled "Physical Therapy after TKR" that outlines
the physical therapy recommendations that were pretty standard among
many sites.  It has links to research studies, with the researchers'
names and affiliate institutions noted.  This gives you some expert
names to contact in case someone is working on a not-yet-published
cutting edge treatment.

http://www.medmedia.com/o12/59.htm

The site indicated below provides a comprehensive description, with
illustrations, of knee replacement.  Of particular interest is the
section entitled "As You Progress"  "Outpatient Progression".  Sports,
Orthopedic and Rehabilitation Associates:

http://www.soarmedical.com/medical-library/knee/replacement/

About Joints presents this web site, with the page titled "Knee
Rehabilitation After Surgery":

http://www.aboutjoints.com/physicianinfo/topics/kneerehab.htm

Medical Multimedia Group presents this comprehensive web page about
knee replacemnt, with a section on stiffness under the "complications"
section.

http://www.medicalmultimediagroup.com/pated/joints/knee/knee_replacement.html#complications

Deaconess Hospital gives us another site.  If you scroll to the bottom
you will see the section titled "How to Live With Your Total Knee",
which again emphasizes that there are some definite long term
limitations after a knee replacement.

Though from all the sources there is no magic bullet, I hope I have
given you enough rehabilitation discussions and sources to help your
knee problem within the bounds of what modern medicine can with knee
replacements today.

If you would like any clarifications, just let me know.  

Search terms used:

total knee replacement
total knee arthroplasty
ROM complications
rehabilitation 

I used these search terms in various combinations individually and in
phrases.

Regards,

Historybuff

---

Request for Answer Clarification by smokie-ga on 29 Jul 2002 12:39 PDT

You gave me a lot of information, Thank you.    But I have done
everything that was listed. I need to know what the next step would
be. Someone said something about cutting the scar tissur. My ROM is
about 85.

---

Clarification of Answer by historybuff-ga on 29 Jul 2002 18:51 PDT

Hi Smokie,

Initially, I put my clarification in "comments" by mistake, so I've
pasted it here as the clarification you requested.
 
I found extensive information on scar removal and debridement but only
as it relates to other knee surgery, not total knee replacement.  I
found a discussion forum dedicated to knee problems.  You may want to
go there and type in "scar removal" in their search box, being sure to
check the button that says "search within knee guru only".  The
discussions I checked mentioned breaking up scar tissue through
manipulation and having it removed surgically.  The caution was that
removing scar tissue surgically can just cause more new scar tissue to
form.  In any case, it may be worth joining the forum and posting your
question there.
 
http://www.kneeguru.co.uk 
 
I'm sorry I could not provide you with the information you had hoped
to find.  Please feel free to reject by answer.  At this point, I feel
I've exhausted all the online possibilities.  Perhaps talking to one
of the researchers mentioned in my answer above may lead you to
finding new treatments.

---

Clarification of Answer by historybuff-ga on 30 Jul 2002 09:45 PDT

Smokie,

Your predicament bothered me, so I kept looking.  I found several
articles on post knee replacement surgery to clear scar tissue.  It's
called "arthroscopic arthrolysis".
An article, 'Technical aspects of arthroscopic arthrolysis after total
knee replacement' written by Court C, Gauliard C, Nordin JY, in the
publication Rev Chir Orthop Reparatrice Appar Mot 1999 Jul;85.  The
abstract can be found in English, though the article itself is French.
 There were a few other articles on the topic that you can link to
from the same page, but this one seemed to be the most on target.

Here is the beginning text of the article:

Arthroscopic arthrolysis is a reliable technique for the treatment of
knee stiffness due to arthrofibrosis following ligament replacement or
following the treatment of knee fracture. However, its use is uncommon
for this indication in total knee arthroplasty (TKA). In this study,
we questioned whether or not arthroscopy is a reliable technique for
treatment of knee stiffness following TKA, due to arthrofibrosis.

Another article, 'Arthroscopic treatment of symptomatic total knee
arthroplasty', by Bocell JR, Thorpe CD, Tullos HS, published in Clin
Orthop 1991 Oct;(271):125-34 states:

"Of the seven patients with arthrofibrosis, two patients had knee
fusions, two are awaiting that procedure, and three patients
maintained increased motion, although one remains symptomatic with
pain." and then concludes "In the authors' experience, operative
arthroscopy of the prosthetic knee was reliable, safe, and effective."

Here is how you find those and a couple of other similar articles. 
The Medline systems works by indexing abstracts, then providing links
to either online information or providing locations of hard copy
publications in libraries.  In other words, you can find the complete
text of the first article at two libraries, though not online.  The
abstracts do a pretty good job explaining the medical results, and
they do give you the expert(s) who did the study.

Start by going to the Medline site:

http://www.ncbi.nlm.nih.gov/

You will see two search boxes, the first a drop-down menu, the second
free-form text.  In the drop-down menu, select PubMed.  In the text
box copy and paste the following:

arthrofibrosis knee arthroplasty

You will see a list of articles.  The first one I mentioned comes up
as number six.  The second article is number four.

I hope this starts you on your way to better knee ROM.

Regards,

historybuff

Hi Smokie,

I found extensive information on scar removal and debridement but only
as it relates to other knee surgery, not total knee replacement.  I
found a discussion forum dedicated to knee problems.  You may want to
go there and type in "scar removal" in their search box, being sure to
check the button that says "search within knee guru only".  The
discussions I checked mentioned breaking up scar tissue through
manipulation and having it removed surgically.  The caution was that
removing scar tissue surgically can just cause more new scar tissue to
form.  In any case, it may be worth joining the forum and posting your
question there.

http://www.kneeguru.co.uk

I'm sorry I could not provide you with the information you had hoped
to find.  Please feel free to reject by answer.  At this point, I feel
I've exhausted all the online possibilities.  Perhaps talking to one
of the researchers mentioned in my answer above may lead you to
finding new treatments.