Management of Arthrofibrosis After Total Knee Arthroplasty: Insights and Future Directions

Abstract

Arthrofibrosis is a debilitating complication following total knee arthroplasty (TKA), affecting 3 to 13% of primary TKA patients and leading to 10% of revision surgeries. This review evaluates the current management strategies for arthrofibrosis, answering key questions on treatment modalities: (1) nonsurgical interventions, (2) arthroscopic and open surgical approaches, (3) revision procedures, and (4) adjunct and emerging therapies. Nonsurgical treatments, including aggressive physical therapy and continuous passive motion devices, show some improvements in range of motion (ROM), but long-term efficacy remains uncertain. Arthroscopic lysis of adhesions improves knee flexion by 26.7 to 51.2 degrees, with a mean final flexion of 100 to 103 degrees, but carries higher infection and revision risks. Open arthrolysis provides ROM improvements up to 43.4 degrees, with higher morbidity and complications. Revision TKA yields better functional outcomes, with mean flexion improvements of 15 to 25 degrees, but 43% of patients require further care. Emerging therapies, such as low-dose irradiation and pharmacologic agents like celecoxib and dexamethasone, show promise but require further validation. Despite advancements, gaps in high-quality data and standardized protocols persist, underscoring the need for more prospective trials.

Keywords

arthrofibrosis - total knee arthroplasty - management

Publikationsverlauf

Eingereicht: 14. Oktober 2025

Angenommen: 06. November 2025

Accepted Manuscript online:
12. November 2025

Artikel online veröffentlicht:
24. November 2025

• References

• 1 Cheuy VA, Foran JRH, Paxton RJ, Bade MJ, Zeni JA, Stevens-Lapsley JE. Arthrofibrosis associated with total knee arthroplasty. J Arthroplasty 2017; 32 (08) 2604-2611
• 2 Yayac MF, Albana MF, Braithwaite HC. et al. A decade of experience with arthroscopic lysis of adhesions for arthrofibrosis after total knee arthroplasty. J Arthroplasty 2025; 40 (10) 2525-2530
• 3 Thompson R, Novikov D, Cizmic Z. et al. Arthrofibrosis after total knee arthroplasty: pathophysiology, diagnosis, and management. Orthop Clin North Am 2019; 50 (03) 269-279
• 4 Fatoye F, Yeowell G, Wright JM, Gebrye T. Clinical and cost-effectiveness of physiotherapy interventions following total knee replacement: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2021; 141 (10) 1761-1778
• 5 Hall MC, Smith B, Sheehan KJ. et al. Non-surgical interventions for arthrofibrosis following knee joint replacement: a systematic review. Clin Rehabil 2025; 39 (05) 580-599
• 6 Abdel MP, Salmons HI, Larson DR. et al. The Chitranjan S. Ranawat Award: manipulation under anesthesia to treat postoperative stiffness after total knee arthroplasty: a multicenter randomized clinical trial. J Arthroplasty 2024; 39 (8S1): S9 , 14.e1
• 7 Rantasalo MT, Palanne RA, Saini S, Vakkuri AP, Madanat R, Noora SK. Postoperative pain as a risk factor for stiff knee following total knee arthroplasty and excellent patient reported outcomes after manipulation under anesthesia. Acta Orthop 2022; 93: 432-437
• 8 Gu A, Michalak AJ, Cohen JS, Almeida ND, McLawhorn AS, Sculco PK. Efficacy of manipulation under anesthesia for stiffness following total knee arthroplasty: a systematic review. J Arthroplasty 2018; 33 (05) 1598-1605
• 9 Roullet CA, Descamps S, Monadjemi S. et al; French Society of Orthopedic and Traumatologic Surgery (SOFCOT). Manipulation under anesthesia for stiffness after total knee arthroplasty: a French multicenter study with 5 years' follow-up including 344 cases. Orthop Traumatol Surg Res 2025; 104432: 104432
• 10 Akhtar M, Razick D, Seibel A, Asad S, Shekhar A, Shelton T. Outcomes of early versus delayed manipulation under anesthesia for stiffness following total knee arthroplasty: a systematic review and meta-analysis. J Arthroplasty 2024; 39 (11) 2872-2879
• 11 Sirignano MN, Rowe RS, Gainer JC. et al. Patients undergoing manipulation under anesthesia following primary total knee arthroplasty: are their patient-reported outcome measures inferior?. J Knee Surg 2025; 38 (08) 407-414
• 12 Haffar A, Goh GS, Fillingham YA, Torchia MT, Lonner JH. Treatment of arthrofibrosis and stiffness after total knee arthroplasty: an updated review of the literature. Int Orthop 2022; 46 (06) 1253-1279
• 13 Zhunussov Y, Danenov Y, Alimbek G. Arthroscopic arthrolysis of the knee joint following total knee arthroplasty. J Clin Med 2025; 14 (14) 4917
• 14 Volchenko E, Schwarzman G, Robinson M, Chmell SJ, Gonzalez MH. Arthroscopic lysis of adhesions with manipulation under anesthesia versus manipulation alone in the treatment of arthrofibrosis after TKA: a matched cohort study. Orthopedics 2019; 42 (03) 163-167
• 15 Cohen JS, Gu A, Kapani N. et al. Efficacy of arthroscopic arthrolysis in the treatment of arthrofibrosis: a systematic review. J Knee Surg 2021; 34 (12) 1349-1354
• 16 Thomas NP, Liu C, Varady N, Iban YC, Schwab PE, Chen AF. High complication rate associated with arthroscopic lysis of adhesions versus manipulation under anesthesia for arthrofibrosis after total knee arthroplasty. J Am Acad Orthop Surg 2023; 31 (04) e216-e225
• 17 Niknam K, Lezak BA, Mercer NP. et al. Rates of periprosthetic joint infection and revision increase after arthroscopic lysis of adhesions subsequent to primary TKA. JBJS 2021; 10: 2106
• 18 Ghani H, Maffulli N, Khanduja V. Management of stiffness following total knee arthroplasty: a systematic review. Knee 2012; 19 (06) 751-759
• 19 Hutchinson J, Parish E, Cross M. Results of open arthrolysis for the treatment of arthrofibrosis following uncemented total knee replacement. In, Orthopaedic Proceedings: Bone & Joint; 2006: 255-255
• 20 Rockov ZA, Byrne CT, Rezzadeh KT. et al. Revision total knee arthroplasty for arthrofibrosis improves range of motion. Knee Surg Sports Traumatol Arthrosc 2023; 31 (05) 1859-1864
• 21 Dubin JA, Hameed D, Bains SS. et al. A comparison between polyethylene exchange and full revision for arthrofibrosis following total knee arthroplasty. J Arthroplasty 2024; 39 (09) 2363-2367
• 22 Xiong L, Klemt C, Yin J, Tirumala V, Kwon YM. Outcome of revision surgery for the idiopathic stiff total knee arthroplasty. J Arthroplasty 2021; 36 (03) 1067-1073
• 23 Rutherford RW, Jennings JM, Levy DL, Parisi TJ, Martin JR, Dennis DA. Revision total knee arthroplasty for arthrofibrosis. J Arthroplasty 2018; 33 (7S): S177-S181
• 24 Hug KT, Amanatullah DF, Huddleston III JI, Maloney WJ, Goodman SB. Protocol-driven revision for stiffness after total knee arthroplasty improves motion and clinical outcomes. J Arthroplasty 2018; 33 (09) 2952-2955
• 25 Lex JR, Entezari B, Backstein DJ, Wolfstadt JI. Reliable outcomes provided by a rotating hinge knee arthroplasty for patients who have moderate-to-severe arthrofibrosis. J Arthroplasty 2025;
• 26 Liow MHL, Flevas DA, Braun S, Nocon A, Lee GC, Sculco PK. TKAF Consortium. Rotating hinge revision total knee arthroplasty provides greater arc of motion gains for patients who have severe arthrofibrosis. J Arthroplasty 2025; 40 (01) 198-202
• 27 Schneider AM, Rice SJ, Lancaster N, McGraw M, Farid Y, Finn HA. Low-dose irradiation and rotating-hinge revision for the treatment of severe idiopathic arthrofibrosis following total knee arthroplasty: a review of 60 patients with a mean 6-year follow-up. J Arthroplasty 2024; 39 (04) 1075-1082
• 28 Bingham JS, Bukowski BR, Wyles CC, Pareek A, Berry DJ, Abdel MP. Rotating-hinge revision total knee arthroplasty for treatment of severe arthrofibrosis. J Arthroplasty 2019; 34 (7S): S271-S276
• 29 Smith EB, Franco M, Foltz C, DiNome J, Chen AF. Can adjunctive perioperative radiation improve range of motion after total knee revision for arthrofibrosis?. Knee 2020; 27 (05) 1426-1432
• 30 Farid YR, Thakral R, Finn HA. Low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty. J Arthroplasty 2013; 28 (08) 1314-1320
• 31 Hall RP, Verhey JT, Deckey DG. et al. Which medications are effective in reducing the risk of arthrofibrosis after total knee arthroplasty?. J Arthroplasty 2025;
• 32 Albright JA, Testa EJ, Ibrahim Z. et al. Postoperative angiotensin receptor blocker use is associated with decreased rates of manipulation under anesthesia, arthroscopic lysis of adhesions, and prosthesis-related complications in patients undergoing total knee arthroplasty. J Arthroplasty 2024; 39 (04) 954-959.e1
• 33 Premkumar A, Anatone A, Illescas A. et al. Perioperative use of antifibrotic medications associated with lower rate of manipulation after primary TKA: an analysis of 101,366 patients. J Arthroplasty 2022; 37 (8S): S1010 , 1015.e1
• 34 Limberg AK, Tibbo ME, Salib CG. et al. Reduction of arthrofibrosis utilizing a collagen membrane drug-eluting scaffold with celecoxib and subcutaneous injections with ketotifen. J Orthop Res 2020; 38 (11) 2474-2483
• 35 Kirsch JR, Williamson AK, Yeritsyan D. et al. Minimally invasive, sustained-release relaxin-2 microparticles reverse arthrofibrosis. Sci Transl Med 2022; 14 (666) eabo3357
• 36 Lee AJ, Mahoney CM, Cai CC. et al. Sustained delivery of SB-431542, a type I transforming growth factor beta-1 receptor inhibitor, to prevent arthrofibrosis. Tissue Eng Part A 2021; 27 (21–22): 1411-1421
• 37 Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat the stiff total knee arthroplasty?: a systematic review. Clin Orthop Relat Res 2010; 468 (04) 1096-1106
• 38 Salmons HI, Payne AN, Taunton MJ. et al. Nonsteroidal anti-inflammatory drugs and oral corticosteroids mitigated the risk of arthrofibrosis after total knee arthroplasty. J Arthroplasty 2023; 38 (6S): S350-S354