title: Management of stiffness following total knee arthroplasty: a systematic review.
abstract: OBJECTIVE
  The aim of the study was to systematically evaluate the outcome of four main modalities of treatment for arthrofibrosis that develops subsequent to a total knee arthroplasty (TKA), namely manipulation under anesthesia (MUA), arthroscopic debridement, open surgical release and revision TKA.
  
  
  METHODS
  A computerised search was conducted for relevant studies published from 1975 onwards in all the major databases and various search engines. A total of twenty-five studies were selected, representing a total of 798 patients. Studies that passed the inclusion criteria were then subjected to quality assessment using the Newcastle-Ottawa Scale. On assessment, the 25 studies scored a total of 77 stars out of a possible 125. Two studies were prospective in design, while the remaining case series were retrospective in nature. The primary outcome measures assessed were increase in range of movement (ROM) and the Knee Society Score (KSS) at final follow-up.
  
  
  RESULTS
  Our results showed that manipulation under anesthesia (MUA) had a mean increase in ROM of 38.4°, arthroscopic release had a mean increase of 36.2°, open surgical release had a mean increase of 43.4° and revision TKA had a mean increase of 24.7°. No significant differences were found in the KSS of the four treatment modalities. Our analysis suggests that open surgical release would be the most beneficial option for patients who are fit to undergo secondary surgery if their lifestyle requires a higher ROM for activities of daily living. However, there were methodological limitations as majority of the papers were case series, which decreased the quality of the evidence available.
authors.affiliation: Addenbrooke's - Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
authors.forename: H
authors.initials: H
authors.lastname: Ghani
authors.forename: N
authors.initials: N
authors.lastname: Maffulli
authors.forename: V
authors.initials: V
authors.lastname: Khanduja
mesh_terms: D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D005355:Fibrosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D020370:Osteoarthritis, Knee / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D016059:Range of Motion, Articular / Q000502:physiology*; D012086:Reoperation; D016896:Treatment Outcome