Stiffness is a relatively uncommon complication after total knee arthroplasty. It has been defined as a painful limitation in the range of movement (ROM). Its pathogenesis is still unclear even if some risk factors have been identified. Patient-related conditions may be difficult to treat. Preoperative ROM is the most important risk factor, but an association with diabetes, reflex sympathetic dystrophy, and general pathologies such as juvenile rheumatoid arthritis and ankylosing spondylitis has been demonstrated. Moreover, previous surgery may be an additional cause of an ROM limitation. Postoperative factors include infections, arthrofibrosis, heterotrophic ossifications, and incorrect rehabilitation protocol. Infections represent a challenging problem for the orthopaedic surgeon, and treatment may require long periods of antibiotics administration. However, it is widely accepted that an aggressive rehabilitation protocol is mandatory for a proper ROM recovery and to avoid the onset of arthrofibrosis and heterotrophic ossifications. Finally, surgeryrelated factors represent the most common cause of stiffness; they include errors in soft-tissue balancing, component malpositioning, and incorrect component sizing. Although closed manipulation, arthroscopic and open arthrolysis have been proposed, they may lead to unpredictable results and incomplete ROM recovery. Revision surgery must be proposed in the case of welldocumented surgical errors. These operations are technically demanding and may be associated with high risk of complications; therefore they should be accurately planned and properly performed.

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This study compared the clinical outcome of anterior cruciate ligament (ACL) reconstruction between the inside-out and the outside-in techniques and assessed radiographically whether surgical technique affects the position and direction of the bone tunnels. A patellar tendon ACL reconstruction was performed in 141 patients with inside-out (group I, n = 78) and outside-in technique (group II, n = 63). Clinical results were evaluated using the International Knee Documentation Committee (IKDC) form; radiographic study was performed in anteroposterior, lateral, and notch views. Overall results in group I were normal in 23% of cases, nearly normal in 55%, and abnormal in 22%; in group II there were normal results in 19% of cases, nearly normal in 57%, abnormal in 19%, and severely abnormal in 5%. Radiographic examination identified important differences between the two groups. The main differences between the two surgical techniques were related to the positioning of the femoral tunnel. With the inside-out technique the femoral tunnel was significantly more vertical, both in the frontal and the sagittal planes. Moreover, the femoral tunnel was higher when drilled from the inside, but the difference between the two techniques was not statistically significant. The differences found between the two techniques regarding the tibial tunnel were not significant, although in the inside-out group the tibial tunnel seemed slightly more lateral, vertical, and posterior. Moreover, we observed a greater risk of bone-screw divergence on the femur in the inside-out group. This divergence was greatest in the sagittal plane. However, we observed no effect of this bone-screw divergence on the stability of the knee at follow-up.

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