title: How to treat the stiff total knee arthroplasty?: a systematic review.
abstract: BACKGROUND
  Multiple modalities have been used to treat the stiff TKA, including manipulation under anesthesia (MUA), arthroscopy, and open arthrolysis.
  
  
  OBJECTIVE
  We reviewed the literature to address three questions: (1) How many degrees of ROM will a stiff TKA gain after MUA, arthroscopy, and open arthrolysis? (2) Does the timing of each procedure influence this gain in ROM? (3) What is the number of clinically important complications for each procedure?
  
  
  METHODS
  We performed a PubMed search of English language articles from 1966 to 2008 and identified 20 articles, mostly Level IV studies.
  
  
  RESULTS
  For patients who have arthrofibrosis after TKA, the gains in ROM after MUA and arthroscopy (with or without MUA) are similar. Open arthrolysis seems to have inferior gains in ROM. MUA is more successful in increasing ROM when performed early but still may be effective when performed late. Arthroscopy combined with MUA still is useful 1 year after the index TKA. The numbers of clinically important complications after MUA and arthroscopy (with or without MUA) are similar.
  
  
  CONCLUSIONS
  Stiffness after TKA is a common problem that can be improved with MUA and/or arthroscopic lysis of adhesions with few complications. The low quality of available literature makes it difficult to develop treatment protocols.
  
  
  METHODS
  Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedics, The Mount Sinai Hospital, New York, NY, 10029, USA.
authors.forename: Sean E
authors.initials: SE
authors.lastname: Fitzsimmons
authors.forename: Edward A
authors.initials: EA
authors.lastname: Vazquez
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bronson
mesh_terms: D000758:Anesthesia; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects / Q000534:rehabilitation; D001182:Arthroscopy / Q000379:methods; D005355:Fibrosis / Q000209:etiology / Q000534:rehabilitation / Q000601:surgery; D006801:Humans; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery*; D009068:Movement / Q000502:physiology; D009126:Muscle Relaxation / Q000502:physiology; D009135:Muscular Diseases / Q000534:rehabilitation*; D026201:Musculoskeletal Manipulations / Q000379:methods*; D020370:Osteoarthritis, Knee / Q000503:physiopathology / Q000534:rehabilitation / Q000601:surgery; D011183:Postoperative Complications / Q000503:physiopathology / Q000534:rehabilitation*; D016059:Range of Motion, Articular