Epidemiology and Risk Factors for Arthrofibrosis Following Total Knee Arthroplasty: Toward Effective Prevention

Amir Human Hoveidaei; Chase W. Smitterberg; Yasaman Tavakoli; Seyed Arman Moein; Reza Katanbaf; Monica Misch; James Nace; Ronald E. Delanois; Michael A. Mont

doi:10.1055/a-2756-0644

The Journal of Knee Surgery, Table of Contents

J Knee Surg
DOI: 10.1055/a-2756-0644

Special Focus Section

Epidemiology and Risk Factors for Arthrofibrosis Following Total Knee Arthroplasty: Toward Effective Prevention

Authors

Amir Human Hoveidaei

¹The Rubin Institute for Advanced Orthopedics, Lifebridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
Chase W. Smitterberg

¹The Rubin Institute for Advanced Orthopedics, Lifebridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
Yasaman Tavakoli

²Department of Medicine, Student Research Committee, Mazandaran University of Medical Science, Mazandaran, Sari, Iran
Seyed Arman Moein

³Orthopedic & Rehabilitation Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Reza Katanbaf

¹The Rubin Institute for Advanced Orthopedics, Lifebridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
Monica Misch

¹The Rubin Institute for Advanced Orthopedics, Lifebridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
James Nace

¹The Rubin Institute for Advanced Orthopedics, Lifebridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
Ronald E. Delanois

¹The Rubin Institute for Advanced Orthopedics, Lifebridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
Michael A. Mont

¹The Rubin Institute for Advanced Orthopedics, Lifebridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland, United States

Abstract

Arthrofibrosis is a debilitating complication following total knee arthroplasty (TKA), resulting in limited knee range of motion (ROM) and functional impairment. This review explores the (1) epidemiology, (2) risk factors, and (3) prevention strategies associated with arthrofibrosis. The incidence of arthrofibrosis ranges from 3 to 10% in primary TKA cases, with up to 13% in some series, and it contributes to up to 10% of revision surgeries within 5 years. Genetic and molecular factors may play a role in predisposition. Other risk factors include younger age, preoperative limited ROM, and surgical factors like prosthetic malpositioning. Prevention strategies focus on patient education, rehabilitation, and pharmacological interventions, with emerging evidence supporting the use of celecoxib, dexamethasone, COX-2 inhibitors, and losartan in reducing the risk of arthrofibrosis. Despite progress, gaps remain, particularly regarding standardized definitions and high-quality randomized controlled trials to assess the optimal treatment methods.

Keywords

arthrofibrosis - TKA - epidemiology

Full Text

References

References
1 Tibbo ME, Limberg AK, Salib CG. et al. Acquired idiopathic stiffness after total knee arthroplasty: a systematic review and meta-analysis. J Bone Joint Surg Am 2019; 101 (14) 1320-1330
2 Kalson NS, Borthwick LA, Mann DA. et al. International consensus on the definition and classification of fibrosis of the knee joint. Bone Joint J 2016; 98-B (11) 1479-1488
3 Limberg AK, Salib CG, Tibbo ME. et al. Immune cell populations differ in patients undergoing revision total knee arthroplasty for arthrofibrosis. Sci Rep 2022; 12 (01) 22627
4 Abdul N, Dixon D, Walker A. et al. Fibrosis is a common outcome following total knee arthroplasty. Sci Rep 2015; 5: 16469
5 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
6 Butnaru M, Senioris A, Pagenstert G. et al. Arthroscopic management of unexplained pain following total knee arthroplasty. Arch Orthop Trauma Surg 2022; 142 (06) 1109-1115
7 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
8 Van de Ven MPF, Bongers J, Spekenbrink-Spooren A, Koëter S. Factors associated with arthrofibrosis-related revision following 14,325 total or unicompartmental knee arthro-plasties: an analysis from the Dutch Arthroplasty Registry. Acta Orthop 2024; 95: 607-611
9 Walker EA, Fox MG, Blankenbaker DG. et al; Expert Panel on Musculoskeletal Imaging. ACR appropriateness criteria imaging after total knee arthroplasty: 2023 update. J Am Coll Radiol 2023; 20 (11S): S433-S454
10 Singh J, Rassir R, Sierevelt IN. et al. Total knee arthroplasty in the post-traumatic knee: revision risks and functional outcomes compared to osteoarthritic knees. a report of primary procedures from the Dutch Arthroplasty Register. J Arthroplasty 2024; 39 (02) 363-367
11 Walsh JM, Sullivan TC, Varghese B, Incavo SJ, Brown TS, Park KJ. Manipulation under anesthesia after primary total knee arthroplasty. J Arthroplasty 2025; 40 (9S1): S535-S544
12 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-S14 , 14.e1
13 Owen AR, Tibbo ME, van Wijnen AJ, Pagnano MW, Berry DJ, Abdel MP. Acquired idiopathic stiffness after contemporary total knee arthroplasty: incidence, risk factors, and results over 25 years. J Arthroplasty 2021; 36 (08) 2980-2985
14 Patel S, Tran S, Overbey J. et al. Risk factors for the need for manipulation under anesthesia following total knee arthroplasty: a systematic review and meta-analysis. J Arthroplasty 2025; 40 (10) 2498-2509.e3
15 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
16 Cregar WM, Khazi ZM, Lu Y, Forsythe B, Gerlinger TL. Lysis of adhesion for arthrofibrosis after total knee arthroplasty is associated with increased risk of subsequent revision total knee arthroplasty. J Arthroplasty 2021; 36 (01) 339-344.e1
17 Wang CX, Flick TR, Patel AH, Sanchez F, Sherman WF. Patients with Dupuytren's contracture, Ledderhose disease, and Peyronie's disease are at higher risk of arthrofibrosis following total knee arthroplasty. Knee 2021; 29: 190-200
18 Dagneaux L, Owen AR, Bettencourt JW. et al. Human fibrosis: is there evidence for a genetic predisposition in musculoskeletal tissues?. J Arthroplasty 2020; 35 (11) 3343-3352
19 Ly T-D, Sambale M, Klösener L. et al. Understanding of arthrofibrosis: new explorative insights into extracellular matrix remodeling of synovial fibroblasts. PLoS One 2023; 18 (05) e0286334
20 Faust I, Traut P, Nolting F. et al. Human xylosyltransferases–mediators of arthrofibrosis? New pathomechanistic insights into arthrofibrotic remodeling after knee replacement therapy. Sci Rep 2015; 5: 12537
21 Gandhi R, de Beer J, Leone J, Petruccelli D, Winemaker M, Adili A. Predictive risk factors for stiff knees in total knee arthroplasty. J Arthroplasty 2006; 21 (01) 46-52
22 Lee SA, Kang SB, Chang CB. et al. Does the severity or cause of preoperative stiffness affect the clinical results and range of motion after total knee arthroplasty?. PLoS One 2018; 13 (10) e0205168
23 Li Y, Ajia A, Wu Z. et al. Previous knee surgery increases risks of revision, infection, pain and stiffness after knee replacement arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord 2025; 26 (01) 869
24 Liu Y, Zhao XD, Zou C. Lingering risk: a meta-analysis of outcomes following primary total knee arthroplasty for patients with post-traumatic arthritis. Int J Surg 2020; 77: 163-172
25 Pitta M, Esposito CI, Li Z, Lee YY, Wright TM, Padgett DE. Failure after modern total knee arthroplasty: a prospective study of 18,065 knees. J Arthroplasty 2018; 33 (02) 407-414
26 Nakamura S, Kuriyama S, Nishitani K, Morita Y, Matsuda S. Medial laxity leads to inferior postoperative clinical outcomes and function in total knee arthroplasty. J Arthroplasty 2025; 40 (7S1): S220-S228
27 Boldt JG, Stiehl JB, Hodler J, Zanetti M, Munzinger U. Femoral component rotation and arthrofibrosis following mobile-bearing total knee arthroplasty. Int Orthop 2006; 30 (05) 420-425
28 Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg 2004; 12 (03) 164-171
29 Lara-Taranchenko Y, Moreira T, Sandiford NA, Guerra-Farfán E, Gehrke T, Citak M. Unexpected positive cultures in patients with arthrofibrosis following total hip and total knee arthroplasty. Int Orthop 2024; 48 (02) 345-350
30 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
31 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
32 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
33 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;
34 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-S1015 , 1015.e1
35 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
36 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
37 Konnyu KJ, Thoma LM, Cao W. et al. Rehabilitation for total knee arthroplasty: a systematic review. Am J Phys Med Rehabil 2023; 102 (01) 19-33
38 Bravi M, Longo UG, Laurito A. et al. Supervised versus unsupervised rehabilitation following total knee arthroplasty: a systematic review and meta-analysis. Knee 2023; 40: 71-89
39 Zhang H, Wang J, Jiang Z, Deng T, Li K, Nie Y. Home-based tele-rehabilitation versus hospital-based outpatient rehabilitation for pain and function after initial total knee arthroplasty: a systematic review and meta-analysis. Medicine (Baltimore) 2023; 102 (51) e36764
40 Florez-García M, García-Pérez F, Curbelo R. et al. Efficacy and safety of home-based exercises versus individualized supervised outpatient physical therapy programs after total knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2017; 25 (11) 3340-3353
41 Buhagiar MA, Naylor JM, Harris IA. et al. Effect of inpatient rehabilitation vs a monitored home-based program on mobility in patients with total knee arthroplasty: the HIHO randomized clinical trial. JAMA 2017; 317 (10) 1037-1046
42 Jette DU, Hunter SJ, Burkett L. et al; American Physical Therapy Association. Physical therapist management of total knee arthroplasty. Phys Ther 2020; 100 (09) 1603-1631
43 Sattler LN, Walker AT, Kan AJ, Hing WA, Vertullo CJ. Stratification of outpatient physical therapy following total knee arthroplasty: knee arthroplasty physical therapy pathways (KAPPA) nonrandomized controlled trial. J Arthroplasty 2024; 39 (07) 1685-1691
44 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
45 Longo UG, De Salvatore S, Valente F, Villa Corta M, Violante B, Samuelsson K. Artificial intelligence in total and unicompartmental knee arthroplasty. BMC Musculoskelet Disord 2024; 25 (01) 571
46 Oettl FC, Zsidai B, Oeding JF. et al; ESSKA Artificial Intelligence Working Group. Beyond traditional orthopaedic data analysis: AI, multimodal models and continuous monitoring. Knee Surg Sports Traumatol Arthrosc 2025; 33 (06) 2269-2275