CLINICIAN’S CORNER

Doc Talk Recap: Dr. Daniel Witmer on Total Knee/ Arthro brosis and Associated Rehab Perspectives

By: Natalie Peterson, PT, DPT Physical Therapist at PTSMC Plainville

On March 29th, PTSMC Plainville was honored to host Dr. Dan Witmer, Board Certi ed Orthopedic Surgeon out of Hartford Hospital’s Bone and Joint Institute, who educated clinicians on arthro brosis of a total knee arthroplasty. Dr. Witmer, a Pennsylvania native, received his medical degree from Je erson Medical College in Philadelphia. He then came to Connecticut to complete a residency in orthopedic surgery at the University of Connecticut, in which he was presented with the Cavazos Award for Most Outstanding Resident during his graduating year. He then completed a one-year fellowship in Adult Reconstruction and Joint Replacement at Indiana University. During his fellowship, he was trained in complex hip and knee replacement and revision surgery, computer assisted surgery, cementless and partial knee replacement, and rapid recovery techniques enabling outpatient joint replacement for optimized patient recovery. Dr. Witmer’s discussion with PTSMC clinicians focused on the most current research along with his vast personal experience regarding patient’s experiencing arthro brosis of a total knee arthroplasty (TKA).

Arthro brosis, or the “advanced sti ening” of a joint, occurs in 1-5% of patients following a TKA procedure. In regard to the knee joint, arthro brosis is de ned as >10 degrees of loss of extension, and only 80-110 degrees of exion. Dr. Witmer identi ed the most prevalent risk factors for TKA arthro brosis, speci c to the patient, as being poor preoperative range of motion, diabetes, females aged 50 and older, previous history of knee surgery, pain catastrophizing or anxiety. Technical risk factors include internal rotation of the femoral or tibial components, lack of tibial slope, raising of the joint line, over-tensioning of MCL/PCL, or basic malalignment. In situations where arthro brosis is not responding appropriately to conservative treatments, revision or manipulation may be implemented. In more recent studies, Dr. Witmer conveyed that the most common reasons for TKA revisions include, in order, infection, loosening of replacement parts, exion instability, sti ness, and lastly malalignment/malrotation. Though necessary in certain patient cases, Dr. Witmer highlights that manipulations are not always benign procedures. Rare but still considerable risks of TKA manipulations include patellar tendon rupture and supracondylar femur fracture due to the lost of a patient’s protective mechanisms against the manipulative intervention while under anesthesia. He highlights that patients who have undergone a manipulation should receive skilled physical therapy immediately (same day) to initiate mobility as soon as possible and most successfully prevent further arthro brosis. Most positive results with manipulations are those performed within 6-8 weeks of surgery. Following manipulation, the average