The Cost of Stiffness After Total Knee Arthroplasty

Published:October 29, 2022DOI:



      Stiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact.


      An observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options.


      The prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA.


      Patients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.


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        • Kim J.
        • Nelson C.L.
        • Lotke P.A.
        Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision.
        J Bone Joint Surg Am. 2004; 86: 1479-1484
        • Moya-Angeler J.
        • Bas M.A.
        • Cooper H.J.
        • Hepinstall M.S.
        • Rodriguez J.A.
        • Scuderi G.R.
        Revision arthroplasty for the management of stiffness after primary TKA.
        J Arthroplasty. 2017; 32: 1935-1939
        • Xiong L.
        • Klemt C.
        • Yin J.
        • Tirumala V.
        • Kwon Y.M.
        Outcome of revision surgery for the idiopathic stiff total knee arthroplasty.
        J Arthroplasty. 2021; 36: 1067-1073
        • Owen A.R.
        • Tibbo M.E.
        • van Wijnen A.J.
        • Pagnano M.W.
        • Berry D.J.
        • Abdel M.P.
        Acquired idiopathic stiffness after contemporary total knee arthroplasty: incidence, risk factors, and results over 25 years.
        J Arthroplasty. 2021; 36: 2980-2985
        • Rodríguez-Merchán E.C.
        The stiff total knee arthroplasty: causes, treatment modalities and results.
        EFORT Open Rev. 2019; 4: 602-610
        • Mont M.A.
        • Seyler T.M.
        • Marulanda G.A.
        • Delanois R.E.
        • Bhave A.
        Surgical treatment and customized rehabilitation for stiff knee arthroplasties.
        Clin Orthop Relat Res. 2006; 446: 193-200
        • Bhave A.
        • Mont M.
        • Tennis S.
        • Nickey M.
        • Starr R.
        • Etienne G.
        Functional problems and treatment solutions after total hip and knee joint arthroplasty.
        J Bone Joint Surg Am. 2005; 87 Suppl 2: 9-21
        • Bong M.R.
        • Di Cesare P.E.
        Stiffness after total knee arthroplasty.
        J Am Acad Orthop Surg. 2004; 12: 164-171
        • Werner B.C.
        • Carr J.B.
        • Wiggins J.C.
        • Gwathmey F.W.
        • Browne J.A.
        Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery.
        J Arthroplasty. 2015; 30: 72-75
        • Abram S.
        • Yusuf B.
        • Alvand A.
        • Sabah S.
        • Beard D.
        • Price A.
        Manipulation under anaesthetic following primary knee arthroplasty is associated with a higher rate of subsequent revision surgery.
        J Arthroplasty. 2020; 35: 2640-2645.e2
        • Cregar W.M.
        • Khazi Z.M.
        • Lu Y.
        • Forsythe B.
        • Gerlinger T.L.
        Lysis of adhesion for arthrofibrosis after total knee arthroplasty is associated with increased risk of subsequent revision total knee arthroplasty.
        J Arthroplasty. 2021; 36: 339-344
        • Wang W.L.
        • Rondon A.J.
        • Tan T.L.
        • Wilsman J.
        • Purtill J.J.
        Self-directed home exercises vs outpatient physical therapy after total knee arthroplasty: value and outcomes following a protocol change.
        J Arthroplasty. 2019; 34: 2388-2391
        • Zachwieja E.
        • Theosmy E.G.
        • Yacovelli S.J.
        • Beatty E.W.
        • McGrath M.E.
        • Lonner J.H.
        Web-based self-directed exercise program is cost-effective compared to formal physical therapy after primary total knee arthroplasty.
        J Arthroplasty. 2020; 35: 2335-2341
        • Delanois R.E.
        • Mistry J.B.
        • Gwam C.U.
        • Mohamed N.S.
        • Choksi U.S.
        • Mont M.A.
        Current epidemiology of revision total knee arthroplasty in the United States.
        J Arthroplasty. 2017; 32: 2663-2668
        • Bhandari M.
        • Smith J.
        • Miller L.E.
        • Block J.E.
        Clinical and economic burden of revision knee arthroplasty.
        Clin Med Insights Arthritis Musculoskelet Disord. 2012; 5: 89-94
        • Brigati D.P.
        • Huddleston J.
        • Lewallen D.
        • Illgen R.
        • Jaffri H.
        • Ziegenhorn D.
        • et al.
        Manipulation under anesthesia after total knee: who still requires a revision arthroplasty?.
        J Arthroplasty. 2020; 35: S348
        • Kurtz S.M.
        • Lau E.
        • Ong K.
        • Zhao K.
        • Kelly M.
        • Bozic K.J.
        Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030.
        Clin Orthop Relat Res. 2009; 467: 2606-2612
        • Losina E.
        • Katz J.N.
        Total knee arthroplasty on the rise in younger patients: are we sure that past performance will guarantee future success?.
        Arthritis Rheum. 2012; 64: 339-341
        • Zmistowski B.
        • Restrepo C.
        • Kahl L.K.
        • Parvizi J.
        • Sharkey P.F.
        Incidence and reasons for nonrevision reoperation after total knee arthroplasty.
        Clin Orthop Relat Res. 2011; 469: 138-145
        • Tjoumakaris F.P.
        • Tucker B.C.
        • Post Z.
        • Pepe M.D.
        • Orozco F.
        • Ong A.C.
        Arthroscopic lysis of adhesions for the stiff total knee: results after failed manipulation.
        Orthopedics. 2014; 37: e482-e487
        • Bodendorfer B.M.
        • Kotler J.A.
        • Zelenty W.D.
        • Termanini K.
        • Sanchez R.
        • Argintar E.H.
        Outcomes and predictors of success for arthroscopic lysis of adhesions for the stiff total knee arthroplasty.
        Orthopedics. 2017; 40: e1062
        • Middleton A.M.
        • Ziegele M.J.
        • Vetter C.S.
        • Edelstein A.I.
        Arthroscopic lysis of adhesions with manipulation for management of late-presenting stiffness after total knee arthroplasty.
        Arthroplast Today. 2020; 6: 761-765
        • Lovro L.R.
        • Kang H.P.
        • Bolia I.K.
        • Homere A.
        • Weber A.E.
        • Heckmann N.
        Knee arthroscopy after total knee arthroplasty: not a benign procedure.
        J Arthroplasty. 2020; 35: 3575-3580
        • Steele J.R.
        • Ryan S.P.
        • Jiranek W.A.
        • Wellman S.S.
        • Bolognesi M.P.
        • Seyler T.M.
        Cost of aseptic revision total knee arthroplasty at a tertiary medical center.
        J Arthroplasty. 2021; 36: 1729-1733
        • Ong K.L.
        • Lotke P.A.
        • Lau E.
        • Manley M.T.
        • Kurtz S.M.
        Prevalence and costs of rehabilitation and physical therapy after primary TJA.
        J Arthroplasty. 2015; 30: 1121-1126
        • Okafor C.
        • Hodgkinson B.
        • Nghiem S.
        • Vertullo C.
        • Byrnes J.
        Cost of septic and aseptic revision total knee arthroplasty: a systematic review.
        BMC Musculoskelet Disord. 2021; 22: 706