Alternative technique for knee manipulation under anesthesia

The Influence of Preimplant Balancing on Manipulation under Anesthesia Rates following Imageless Robotic-Assisted Total Knee Arthroplasty

Acquired idiopathic stiffness (AIS) following total knee arthroplasty (TKA) often requires manipulation under anesthesia (MUA). Robotic-assisted TKA (RA-TKA) systems provide gap balance templates for objective correlation with the rate of AIS. The purpose of this study was to assess intraoperative balancing parameters that were associated with MUA utilizing an "anatomical" implant design.We performed a retrospective chart review of 265 imageless RA-TKA procedures performed by R.M. and K.D. between 2018 and 2020. The primary outcome for AIS or clinically significant "arthrofibrosis" was MUA. Patient intraoperative gap planning data were examined for association.The rate of MUA was 8.7% (23/265), which was performed at a mean follow-up time of 75.9 ± 32.2 days. The lateral to medial gap difference in extension was significantly less in patients requiring MUA (odds ratio [OR] = 0.86, 95% confidence interval [CI], 0.75-0.99) (p = 0.034). Significantly less preoperative varus mechanical axis was associated with knees requiring MUA (1.83° vs. 4.04°, OR = 1.09, 95% CI, 1.00-1.19). Decreased templated mechanical axis correction was associated with MUA (2.09° vs. 4.75°, p < 0.0001).A tighter lateral-to-medial gap in extension, less preoperative varus, and smaller templated mechanical axis corrections were associated with increased rates of MUA.

Gravity-Assisted Manipulation (GAM) Technique for the Treatment of Knee Arthrofibrosis

Arthrofibrosis is a known complication after knee surgery, resulting in stiffness and decreased range of motion for patients. Manipulation under anesthesia is a commonly used technique to address postoperative arthrofibrosis after knee surgery. Often, direct pressure is applied to the knee during the manipulation. This can be difficult and can place undue stress above and below the joint. This Technical Note presents the technique for manipulation under anesthesia using gravity and the native knee motion alone to improve knee range of motion.

Manipulation under Anesthesia Following TKA with Persona IQ: A Case Series

Introduction

Although surgical devices and techniques continue to improve, regular post-operative monitoring of patients is required to ensure the best outcomes. New technological advances have allowed physicians to monitor the daily recovery of total knee arthroplasty (TKA) patients. This report is the first to describe the utilization of an implantable gait monitoring device and its capacity to detect poor early post-operative outcomes.

Case Report

Two patients, a 78-year-old male and a 34-year-old female, were assessed post-TKA utilizing remote gait kinematics and clinical evaluations and determined to need manipulation under anesthesia due to severely limited range of motion. One patient, a 51-year-old female, with good clinical outcomes, was used for comparison.

Conclusion

Remote monitoring may provide an earlier indication than clinical evaluations in identification of TKA patients at risk of poor outcomes and may who need intervention. The use of remote kinematic gait data in earlier identification of patients at risk has the potential to help improve outcomes for the broader population of TKA patients.

Manipulation Under Anesthesia Is Associated With an Increased Rate of Early Total Knee Arthroplasty Revision

Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) frequently has been used as a first-line treatment to restore functional range of motion after unsuccessful physical therapy. Although there are studies reporting that MUA assisted in restoring range of motion, there is a paucity of literature on the influence of MUA on the risk of revision TKA. The goal of our study was to determine whether MUA was associated with an increase in the rate of revision TKA within 2 years of MUA. A total of 49,310 patients within a single institution who underwent primary TKA were identified from 1999 to 2019. Data were matched at a 1:3 ratio (TKA with and without MUA, respectively) based on age, sex, and body mass index. A matched comparison cohort was conducted, with the MUA cohort having 575 patients and the no MUA cohort having 1725 patients. A statistically significant increase in the rate of noninfectious etiology revision TKA was found in the MUA cohort (7.3%) compared with the no MUA cohort (4.9%; P=.034). The most common reason for revision TKA after MUA was persistent stiffness, including arthrofibrosis and ankylosis; however, aseptic loosening, ligamentous instability, and periprosthetic fracture were found to be responsible for 21.4% of revision TKA procedures. Although MUA is a commonly performed procedure for treating stiffness after primary TKA, the orthopedic surgeon should counsel patients on the association of increased rate of revision TKA after MUA, most commonly, persistent stiffness. [Orthopedics. 2022;45(5):270-275.].

Incidence and effectiveness of manipulation under anaesthesia for stiffness following primary total knee arthroplasty

Background

There are various modalities of cor- rection of stiffness following total knee arthro-plasty. Manipulation under anaesthesia (MUA) is generally indicated for people who fail to achieve their pre operative range of motion at 12 weeks. The purpose of this study was to determine: (1) the effect of MUA on Flexion arc (2) the influence of timing of MUA from index procedure and of diabetes mellitus on final flexion achieved.

Methods

We retrospectively evaluated patients who underwent manipulation following total knee arthroplasty at our institution between January 2016 to December 2018. For the purpose of analysis, we have divided the patients into two groups. Those who underwent manipulation within 12 weeks and later than 12 weeks. We have also compared the effect of MUA between diabetic and non-diabetic patients. All were operated with posterior stabilised (PS) prosthesis by a single senior arthroplasty surgeon. The final flexion achieved during their last clinical follow-up were recorded and compared with the pre MUA flexion.

Results

The incidence of MUA after TKA at our institute during this period is about 1.14 %. There was a significant statistical difference between the pre and post manipulation flexion, with p value <0.01. There was no significant statistical difference between those who were manipulated before 12 weeks and after 12 weeks in improving the Flexion of the operated knees. We have found that both the diabetic and non diabetic group had comparable flexion after the manipulation in our study.

Conclusion

Manipulation after anaesthesia is a safe first intervention to improve post operative stiffness and gain additional range of motion following TKA in patients who develop stiffness. It can be done even after 12 weeks of surgery with reasonably good gain in range of motion.

Acute Femoropopliteal Bypass Graft Occlusion After Knee Manipulation Under Anesthesia: A Case Report and Review of Current Literature

Bilateral tibiofemoral knee dislocations are a relatively rare injury, and there is a scarcity of literature on its appropriate evaluation and treatment. Even less knee dislocations with concomitant popliteal artery injury have been described. Postoperative graft occlusion accounts for approximately half of the overall complication rate, occurring in up to 18% of the patients undergoing femoropopliteal bypass grafting. Furthermore, anticoagulation and antiplatelet therapy after graft placement is a point of contention. Here, we describe a case of a knee dislocation with associated popliteal artery transection treated initially with successful knee-spanning external fixation and arterial grafting, respectively. At 6 weeks after injury, the patient underwent external fixation removal and closed manipulation of the knee for arthrofibrosis. After manipulation, yet still under anesthesia, distal pulses were acutely diminished and subsequent CTA demonstrated femoropopliteal graft thrombosis. This case demonstrates successful recognition, thrombectomy, and restoration of arterial blood flow, which has since been maintained. Written consent by the patient involved in this case report was obtained.

The STAK tool: evaluation of a new device to treat arthrofibrosis and poor range of movement following total knee arthroplasty and major knee surgery

Aims

This study aims to evaluate a new home medical stretching device called the Self Treatment Assisted Knee (STAK) tool to treat knee arthrofibrosis.

Methods

35 patients post-major knee surgery with arthrofibrosis and mean range of movement (ROM) of 68° were recruited. Both the STAK intervention and control group received standard physiotherapy for eight weeks, with the intervention group additionally using the STAK at home. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at all timepoints. An acceptability and home exercise questionnaire capturing adherence was recorded after each of the interventions.

Results

Compared to the control group, the STAK intervention group made significant gains in mean ROM (30° versus 8°, p < 0.0005), WOMAC (19 points versus 3, p < 0.0005), and OKS (8 points versus 3, p < 0.0005). The improvements in the STAK group were maintained at long-term follow-up. No patients suffered any complications relating to the STAK, and 96% of patients found the STAK tool ‘perfectly acceptable’.

Conclusion

The STAK tool is effective in increasing ROM and reducing pain and stiffness. Patients find it acceptable and adherence to treatment was high. This study indicates that the STAK tool would be of benefit in clinical practice and may offer a new, cost-effective treatment for arthrofibrosis.

Cite this article: Bone Joint Open 2020;1-8:465–473.