Early and late manipulation improve flexion after total knee arthroplasty

Predictors and Early Treatment of Knee Arthrofibrosis After Arthroscopic Knee Ligament Reconstruction Surgery in Adolescent Patients

Background

Postoperative knee arthrofibrosis after arthroscopic ligament reconstruction is a serious complication. Among adolescents, risk factors for postoperative arthrofibrosis are not well characterized and the effectiveness of early manipulation under anesthesia (MUA) is not well established.

Purposes

To identify risk factors for arthrofibrosis after arthroscopic knee ligament reconstruction in adolescent patients and to evaluate the safety and effectiveness of early MUA.

Study Design

Case-control study; Level of evidence, 3.

Methods

The charts of all adolescent patients (<19 years of age) who underwent early MUA (<3 months) for knee stiffness after anterior cruciate ligament (ACL) or medial patellofemoral ligament (MPFL) reconstructions between 2008 and 2021 were retrospectively reviewed. Patients were matched 2:1 with patients without MUA from the same study period. The primary outcome was the final range of motion (ROM) after MUA. Logistic regression analysis was performed to identify predictors of MUA.

Results

A total of 25 patients (10 with ACL reconstruction and 15 with MPFL reconstruction) with a mean age of 14.8 ± 2.6 years were included for analysis. Overall, 44% were skeletally immature. Patients underwent MUA at a mean of 63.3 ± 19.5 days after the index surgery. The mean ROM improved significantly from 96.3°± 20.5° to 135°± 9.7° after MUA after a median follow-up of 8.1 months (interquartile range, 5.4-15.0 months). There were no complications associated with MUA, but 2 patients (8.0%) had MUA treatment failure. There were no differences in body mass index, type and frequency of associated procedures, or patellar height on lateral radiographs between the cohorts. The MUA cohort had statistically significant increased operative time, decreased preoperative motion, decreased ROM at 6 weeks postoperatively, and increased pain at 6 weeks postoperatively when compared with the non-MUA cohort. Regression analysis demonstrated that ROM at 6 weeks (OR: 0.83, 95% CI, 0.69-0.98, p = .034) was significantly associated with the need for MUA.

Conclusion

The findings of this study suggest that early (<3 months) MUA is safe and effective in treating knee arthrofibrosis in adolescent patients. MUA is a treatment alternative for patients with restricted ROM at 6 weeks that may help them recover full ROM.

Total knee arthroplasty combined with simultaneous open reduction and internal fixation in the treatment of knee osteoarthritis with patellar fracture: a case report and review of the literature

BACKGROUND

Patients with severe knee osteoarthritis combined with patellar fracture are rare, and it is unclear whether single-stage surgery affects the enhanced recovery after surgery.

CASE PRESENTATION

This case report describes two patients of Han nationality. A 69-year-old male patient was previously diagnosed with severe knee osteoarthritis of the left knee joint and was treated conservatively with long-term oral nonsteroidal antiinflammatory drugs and intraarticular injection of sodium hyaluronate. He was hospitalized for acute left knee injury owing to a fall from a height. He was diagnosed with knee osteoarthritis of the left knee joint and patellar fracture. Another 74-year-old female patient was previously diagnosed with severe knee osteoarthritis, long-term oral nonsteroidal antiinflammatory drugs and topical Chinese medicine to relieve the pain. A month ago, she fell down the stairs and fractured the patella in her left knee, she was diagnosed with severe left knee osteoarthritis combined with an old left patella fracture. Both patients were successfully treated by single-stage primary total knee arthroplasty and fixation of the patellar fracture. They both carried out early functional exercise normally and successfully achieved enhanced recovery.

CONCLUSION

Successful single stage total knee replacement with patella management can not only reduce the number of operations, but also enable patients to achieve rapid postoperative recovery. However, single stage may increase the risk of local surgical complications. Therefore, for most patients, especially those with low risk of anesthesia related complications, standard of treatment remains first fixing the patellar fracture and when the fracture is healed proceed with the total knee arthroplasty.

Outcomes of Early Versus Delayed Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Stiffness following total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA). However, there is debate regarding the timing of MUA, with many recommending against MUA beyond 3 months after TKA. Therefore, the purpose of this systematic review was to evaluate the functional and clinical outcomes of early versus delayed MUA for stiffness following TKA.

METHODS

A search following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was performed in the PubMed, Embase, Scopus, and Cochrane databases in November 2023. Data regarding study characteristics, demographics, knee flexion and extension, patient-reported outcomes, complications, and revisions were collected. A quality assessment was performed using the Methodological Index for Non-randomized Studies. Included were 14 studies analyzing 13,445 knees, 72.1% of which underwent early MUA and 27.8% of which underwent delayed MUA. Of the 14 studies, 10 defined early MUA as being performed within 3 months of the index TKA.

RESULTS

Pre-MUA and post-MUA knee flexion for the early/delayed groups was 71.3°/77.9° and 103.0°/96.1°, respectively. Upon meta-analysis, pre-MUA knee flexion was significantly higher in the delayed group (P = .003), whereas post-MUA flexion was similar in both groups (P = .36). The mean gain in knee flexion for the early and delayed groups was 32.0°/19.2°. The surgical complication and revision TKA rates for the early and delayed groups were 4.9%/10.3% and 5%/9%, respectively. A meta-analysis found the risk of surgical or medical complications and revision TKA to be significantly higher in the delayed MUA group (P < .00001 and = .002, respectively).

CONCLUSIONS

Although post-MUA knee flexion was similar in patients undergoing early and delayed MUA following TKA, the mean gain in flexion for early patients was nearly double that of delayed patients. Delayed patients also had significantly higher risks of surgical or medical complications and revision TKA following MUA.

Late Manipulation under Anesthesia after Total Knee Arthroplasty: Improved Range of Motion and a Low Complication Rate

The purpose of this study was to evaluate outcomes of late manipulation under anesthesia (MUA) for stiffness performed from ≥12 weeks to more than a year after primary total knee arthroplasty (TKA). A total of 152 patients receiving MUA ≥12 weeks after primary TKA from 2014 to 2021 were reviewed. The primary outcome measured was change in range of motion (ROM). We tracked intraoperative complications and the need for repeat MUA or open procedure for continued stiffness after initial MUA. Three subgroups were analyzed: Group 1 included 58 knees between 12 weeks and 6 months after TKA, Group 2 included 44 knees between 6 and 12 months after TKA, and Group 3 included 50 knees ≥12 months after TKA. Analysis included descriptive statistics and univariate analysis, with α <0.05. Groups 1 to 3 all significantly increased their overall ROM by 20.9, 19.2, and 22.0 degrees, respectively. All groups significantly increased their flexion and extension from preoperatively. Group 1 had one intraoperative supracondylar femur fracture (1.7%) requiring open reduction and internal fixation, and five patients required repeat MUA or open procedure (8.6%). Group 2 had no intraoperative fractures, and five patients required repeat MUA or open procedure (11.4%). Group 3 had one intraoperative tibial tubercle avulsion fracture managed conservatively (2.0%) and one repeat MUA (2.0%). Late MUA resulted in significantly improved ROM in all groups. ROM improved more as the time from index TKA increased, although statistically insignificant. Repeat MUA or open procedure rate decreased with MUA ≥12 months from TKA, although statistically insignificant. The overall intraoperative fracture risk was 1.3%.

Nearly 14-Fold Increased Risk of Manipulation Under Anesthesia After Total Knee Arthroplasty When Previous Contralateral Total Knee Arthroplasty Required Manipulation Under Anesthesia

BACKGROUND

Stiffness remains a common complication after primary total knee arthroplasty (TKA). Manipulation under anesthesia (MUA) is the gold standard treatment for early postoperative stiffness; however, there remains a paucity of data on the risk of MUA after primary TKA if a prior contralateral TKA required MUA.

METHODS

We performed a retrospective review of 3,102 patients who had staged primary TKAs between 2016 and 2021. The mean body mass index was 33 (range, 18 to 59) and the mean age was 67 years (range, 24 to 91). The mean preoperative range of motion for the first TKA was 2 to 104°, and for the contralateral TKA was 1 to 107°. The primary outcomes were MUA following first and second primary TKAs. Multivariable Poisson regressions were used to evaluate associations between risk factors and outcomes.

RESULTS

The rate of MUA after the first TKA was 2.6% (n = 83 of 3,102) and 1.3% (n = 40 of 3,102) after the contralateral TKA. After adjustment, there was a nearly 14-fold higher rate of MUA after the second TKA if the patient had an MUA after the first TKA (relative risk, 13.80; 95% CI [confidence interval], 7.14 to 26.66). For the first TKA, increasing age (adjusted risk ratio [ARR], 0.65; 95% CI, 0.50 to 0.83) and increasing body mass index (ARR, 0.65; 95% CI, 0.47 to 0.90) were associated with lower risk for MUA. For the second TKA, increasing age was associated with a lower risk of MUA (ARR, 0.60; 95% CI, 0.45 to 0.80).

CONCLUSIONS

For patients undergoing staged bilateral TKA, patients who undergo MUA following the first primary TKA are nearly 14-fold more likely to undergo an MUA following the contralateral primary TKA than those who did not have an MUA after their first TKA.

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.

Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review

» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.

The Risk of Acute Infection Following Intra-Articular Corticosteroid Injection During Total Knee Manipulation Under Anesthesia

BACKGROUND

Manipulation under anesthesia (MUA) is an established option for improving motion in patients presenting with early stiffness following total knee arthroplasty (TKA). Intra-articular corticosteroid injections (IACI) are sometimes administered adjunctively, yet literature examining their efficacy and safety remains limited.

STUDY DESIGN

Retrospective, Level IV METHODS: A total of 209 patients (TKA = 230) were retrospectively examined to determine the incidence of prosthetic joint infections (PJI) within 3 months following manipulation with IACI. Approximately 4.9% of initial patients had inadequate follow-up where the presence of infection could not be determined. Range of motion (ROM) was assessed in patients who had follow-up at or beyond 1 year (n=158) and was recorded over multiple time points.

RESULTS

No infections (0 of 230) were identified within 90 days of receiving IACI during TKA MUA. Before receiving TKA (pre-index) patients averaged 111⁰ of total arc of motion (TAM) and 113⁰ of flexion. Following index procedures, just prior to manipulation (pre-MUA), patient's averaged 83⁰ and 86⁰ of total arc and flexion motion respectively. At final follow-up, patients averaged 110⁰ of TAM and 111⁰ of flexion. At 6 weeks following manipulation, patients had gained a mean of 25⁰ and 24⁰ of their total arc and flexion motion found at 1 year. This motion was preserved through a 12 month follow-up period.

CONCLUSION

Administering IACI during TKA MUA does not harbor an elevated risk for acute PJI. Additionally, its use is associated with substantial increases in short-term ROM at 6 weeks following manipulation, which remains preserved through long-term follow-up.

High Complication Rate Associated With Arthroscopic Lysis of Adhesions Versus Manipulation Under Anesthesia for Arthrofibrosis After Total Knee Arthroplasty

BACKGROUND

Arthrofibrosis after total knee arthroplasty (TKA) is often treated by arthroscopic lysis of adhesions (ALAs) or manipulation under anesthesia (MUA). This study compared the 2-year complication rates of ALA and MUA and range-of-motion (ROM) outcomes for ALA, early MUA (<3 months after TKA), and delayed MUA (>3 months after TKA).

METHODS

This retrospective cohort study included 425 patients undergoing ALA or MUA after primary TKA from 2001 to 2018. Demographics, clinical variables, and complication rates were collected from clinical records and compared using Student t -tests and Kaplan-Meier log-rank tests. Multivariable logistic regressions were used for adjusted analysis. ROM data were analyzed using fixed and mixed-effects models.

RESULTS

ALA patients were younger (55.2 versus 58.9 years, P < 0.001) and underwent surgery later from the index TKA (12 versus 1.9 months, P < 0.001). The Charlson Comorbidity Index was higher in the MUA group. Preoperative ROM was significantly worse in the MUA cohort, but did not differ between groups after the procedure (117°, P = 0.27) or at 2 years. Demographics and ROM outcomes were equivalent between early MUA and delayed MUA ( P = 0.75). The incidence of repeat arthrofibrosis (7.1%) and revision arthroplasty (2.4%) was similar between ALA and MUA cohorts while ALA patients had significantly more surgical site infections (3.8%) compared with MUA patients (0.47%, P = 0.017).

DISCUSSION

Equivalent ROM outcomes were seen between ALA, early MUA, and delayed MUA for the treatment of arthrofibrosis after TKA. However, this study demonstrated a markedly higher complication rate, particularly surgical site infection, after ALA, suggesting that MUA may be the preferred option for treating arthrofibrosis at both early and late time points.

Early manipulation under anaesthesia for stiffness following total knee arthroplasty is associated with a greater gain in knee flexion

PURPOSE

This study aimed to identify the risk factors for manipulation under anaesthesia (MUA) following total knee arthroplasty (TKA) and whether performing an 'early' MUA within 3 months leads to a greater improvement in range of motion.

METHODS

Primary TKAs performed between 2013 and 2018 at three tertiary New Zealand hospitals were reviewed with a minimum follow-up of 1 year. Clinical details of patients who underwent MUA were reviewed to identify the knee flexion angle prior to and following MUA. Multivariate analysis identified the risk factors for undergoing MUA and compared flexion angles between 'early' (< 3 months) and 'late' MUA (> 3 months).

RESULTS

A total of 7386 primary TKAs were analysed in which 131 underwent an MUA (1.8%). Patients aged < 65 years were two times more likely to undergo MUA compared to patients aged ≥ 65 years (2.5 versus 1.3%, p < 0.001; adjusted HR = 2.1, p < 0.001). There was no difference in the final flexion angle post-MUA between early and late MUA (104.7° versus 104.1°, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3° versus 79.6°, p = 0.012), and subsequently had a greater overall gain in flexion compared to those who underwent late MUA (mean gain 33.1° versus 24.3°, p < 0.001).

CONCLUSION

Younger age was the only patient risk factor for MUA. Patients who underwent early MUA had similar post-MUA flexion, but had poorer pre-MUA flexion compared to those who underwent late MUA. Subsequently, a greater overall gain in flexion was achieved in those who underwent early MUA.

LEVEL OF EVIDENCE

III.

The Effect of Early versus Late Manipulation Under Anesthesia on Opioid Use, Surgical Complications, and Revision Following Total Knee Arthroplasty

Previous studies of early versus late manipulation under anesthesia (MUA) do not report on postoperative opioid utilization or revisions and focused on small single-institution retrospective cohorts. The PearlDiver Research Program (www.pearldiverinc.com), which uses an all-inclusive insurance database, was used to identify patients undergoing primary total knee arthroplasty (TKA) who received (1) late MUA (>12 weeks), (2) early MUA (≤12 weeks), or (3) TKA only. To develop the control group cohort of TKA-only patients, 3:1 matching was conducted using 11 risk factor variables deemed significant by chi-squared analysis. Complications and opioid utilization were compared through multivariate regression analysis, controlling for age, gender, and Charlson Comorbidity Index. The risk of TKA revision was assessed through Cox-proportional hazards modeling and Kaplan-Meier survival analysis with log-rank test. Between 2011 and 2017, 2,062 TKA patients with early MUA, 1,112 TKA patients with late MUA, and a control cohort of 8,327 TKA-only patients were identified in the database. The percent of patients registering opioid use decreased from 54.6% 1 month pre-MUA to 4.6% (p < 0.0001) 1 month post-MUA following early MUA, whereas only from 32.6 to 10.4% (p < 0.0001) following late MUA. Late MUA was associated with higher risk of repeat MUA at 6 months (adjusted odds ratio [aOR] = 2.74, p < 0.0001), 1 year (aOR = 2.66, p < 0.0001), and 2 years (aOR = 2.63, p < 0.0001) following index MUA. Hazards modeling and survival analysis showed increased risk of TKA revision following late MUA (adjusted hazard ratio [aHR] = 3.50, 95% confidence interval [CI]: 2.77-4.43, p < 0.0001) compared to early MUA (aHR = 2.15, 95% CI: 1.72-2.70, p < 0.0001), with significant differences in survival to revision curves (p < 0.0001). When compared to early MUA at 1 year, late MUA was associated with a significantly increased risk of prosthesis explantation (aOR = 2.89, p = 0.0026 vs. aOR = 0.93, p = 0.8563). MUA within 12 weeks after index TKA had improved pain resolution and significant curtailing of opioid use. Furthermore, late MUA was associated with prolonged opioid use, increased risks of revision, as well as prosthesis explantation, supporting screening and early intervention in cases of slow progression and stiffness. The level of evidence of this study is III.

Efficacy of non-operative treatment of patients with knee arthrofibrosis using high-intensity home mechanical therapy: a retrospective review of 11,000+ patients

Background

Recovery from knee surgery or injury can be hindered by knee arthrofibrosis, which can lead to motion limitations, pain and delayed recovery. Surgery or prolonged physical therapy are often treatment options for arthrofibrosis, but they can result in increased costs and decreased quality of life. A treatment option that can regain lost motion without surgery would help minimize risks and costs for the patient. The purpose of this study was to determine treatment efficacy of high-intensity home mechanical stretch therapy in patients with knee arthrofibrosis.

Methods

Records were reviewed for 11,000+ patients who were prescribed a high-intensity stretch device to regain knee flexion. Initial and last recorded knee flexion and days between measurements were available for 9842 patients (Dataset 1). Dataset 2 was a subset of 966 patients from Dataset 1. These 966 patients had separate more rigorous measurements available from physical therapy notes (Dataset 3) in addition to data from the internal database (Dataset 2). Within and between dataset statistics were calculated using t tests for comparison of means and Cohen’s d for determination of effect size.

Results

All dataset showed significant gains in flexion (p < 0.01). Mean initial flexion, last recorded flexion and flexion gain were 79.5°, 108.4°, and 29.9°, respectively in Dataset 1. Differences between Datasets 2 and 3 had small effect sizes (Cohen’s d < 0.17). The were no significant differences when comparing workers’ compensation and non-workers’ compensation patients. The average last recorded flexion for all datasets was above the level required to perform activities of daily living. Motion gains were recorded in under 60 days from device delivery.

Conclusions

High-intensity home mechanical stretch therapy was effective in restoring knee flexion, generally in 2 months or less, and in avoiding additional surgery in severe motion loss patients regardless of sex, age, or workers’ compensation status. We believe high-intensity stretching should be considered in any patient who is at risk for a secondary motion loss surgery, because in over 90% of these patients, the complications and costs associated with surgery can be avoided.

Mid-term outcomes of posterior capsular release for fixed flexed deformity after total knee arthroplasty

Fixed flexion deformity also called flexion contracture is relatively rare, but a very demanding functional limitation that both surgeons and patients may have to deal with. The purpose of the present study was to evaluate the functional outcomes after posteromedial capsular release in case of fixed flexed deformity > 15 o . Between June 2011 and November 2018, 15 patients (6 males and 9 females) were treated with open posterior capsular release through medial approach for fixed flexion deformity of the knee > 15 o and prospectively followed with a minimum follow-up of 2 years. Primary outcome was knee extension measured with a manual goniometer and secondary outcome treatment related complications. All patients reported inability to walk and clinical semiology of pain and swelling. The mean age of the study population at surgery was 61.7 years with a mean BMI of 30.9 kg/m2. Complete data were recorded for all patients. Statistically significant improvement was found in clinical and functional assessment tools analyzed from baseline to the latest follow-up (p<0.05). More precisely, the mean postoperative fixed flexion deformity was decreased from 23.57 o to 2.86 o . No adverse effect or major complications were recorded during follow-up. Posterior open release via posteromedial was shown to be an efficient and safe salvage procedure to deal with persistent fixed flexion deformity of more than 15 o following TKA at two years follow-up. However, future studies with a higher number of participants and longer follow-up should be conducted to validate our data.

Postoperative pain as a risk factor for stiff knee following total knee arthroplasty and excellent patientreported outcomes after manipulation under anesthesia

BACKGROUND AND PURPOSE

Manipulation under anesthesia (MUA) is the first-choice treatment for stiffness following total knee arthroplasty (TKA) unresponsive to pain management and physiotherapy. Some of the predisposing factors and patient-reported outcome measures (PROMs) following MUA remain poorly studied. We retrospectively investigated the etiological risk factors and the outcomes of MUA.

PATIENTS AND METHODS

391 TKA patients from a randomized trial comparing the use of a tourniquet and anesthesia (spinal or general) were analyzed, and patients needing MUA were identified (MUA group). We evaluated in-hospital opioid consumption, Oxford Knee Score (OKS), range of motion (ROM), and pain assessed by the Brief Pain Inventory-short form with a 1-year follow-up.

RESULTS

39 (10%) MUA patients were identified. The MUA patients were younger (60 years vs. 64 years, difference -4, 95% CI -6 to -1) and had higher postoperative oxycodone consumption (66 mg vs. 51 mg, median difference 11, CI 1-22) than the no-MUA patients. The proportion of MUA patients who contacted the emergency department within 3 months because of pain was larger than that of non-MUA patients (41% vs. 12%, OR 5, CI 3-10). At the 1-year follow-up, the ROM was improved by 39° following MUA, but the total ROM was worse in the MUA group (115° vs. 124°, p < 0.001). No difference was found in the OKS between the MUA and no-MUA patients.

INTERPRETATION

Higher postoperative pain seems to predict MUA risk. MUA performed 3 months postoperatively offers substantial ROM improvement and comparable PROMs to no-MUA patients 1 year after TKA.

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.

Effect of Manipulation under Anesthesia of the First Knee in Staged Bilateral Total Knee Arthroplasty on Clinical Outcome and Satisfaction

This study aimed to evaluate whether manipulation under anesthesia (MUA) affect clinical outcome including range of motion (ROM) and patient satisfaction after total knee arthroplasty (TKA). It is hypothesized that MUA improves clinical outcomes and patient satisfaction after primary TKA. This retrospective study analyzed 97 patients who underwent staged bilateral primary TKA. MUA of knee flexion more than 120 degrees was performed a week after index surgery just before operation of the opposite site. The first knees with MUA were classified as the MUA group and the second knees without MUA as the control group. ROM, Knee Society Knee Score, Knee Society Functional Score, Western Ontario and McMaster Universities (WOMAC) score, and patient satisfaction were assessed. Postoperative flexion was significantly greater in the MUA group during 6 months follow-up (6 weeks: 111.6 vs. 99.8 degrees, p < 0.001; 3 months: 115.9 vs. 110.2 degrees, p = 0.001; 6 months: 120.2 vs. 117.0 degrees, p = 0.019). Clinical outcomes also showed similar results with knee flexion during 2 years follow-up. Patient satisfaction was significantly high in the MUA group during 12 months (3 months: 80.2 vs. 71.5, p < 0.001; 6 months: 85.8 vs. 79.8, p < 0.001; 12 months: 86.1 vs. 83.9, p < 0.001; 24 months: 86.6 vs. 85.5, p = 0.013). MUA yielded improvement of clinical outcomes including ROM, and patient satisfaction, especially in the early period after TKA. MUA in the first knee could be taken into account to obtain early recovery and to improve patient satisfaction in staged bilateral TKA.

Manipulation under Anesthesia after Knee Arthroplasty Is Associated with Worse Long-Term Clinical Outcomes and Survivorship

The literature is mixed on the long-term fate of knees that undergo manipulation under anesthesia (MUA). The purpose of this study is to evaluate the long-term outcomes and survivorship of patients who required a MUA after primary total knee arthroplasty (TKA) compared with a cohort of patients who did not undergo a MUA. Between 2003 and 2007, 2,193 patients (2,783 knees) underwent primary TKA with 2-year minimum follow-up; 182 knees (6.5%) had a MUA. Patients who had a manipulation were younger (p < 0.001) and had worse preoperative range of motion (ROM) (p < 0.001). Postoperative ROM, Knee Society clinical (KSC), functional, and pain (KSP) scores, revisions, and survivorship were compared between MUA and no MUA. Mean follow-up was 9.7 years. MUA patients had lower postoperative ROM (p < 0.001), change in ROM (p < 0.001), KSC (p < 0.001), KSP (p < 0.001), and change in KSP scores (0.013). Revisions occurred in 18 knees (9.9%) in the MUA group compared with 77 knees (3%) without a MUA (p < 0.001). Most common reason for revision after MUA was continued stiffness (50%). Relative risk for revision after one MUA was 2.01 (95% confidence interval [CI], 1.1-3.8, p < 0.001) and after three or more MUAs were 27.02 (95% CI, 16.5-44.1, p < 0.001). Ten-year survival after MUA was 89.4% (95% CI, 87.1-91.7%) compared with 97.2% (95% CI, 96.9-97.5%) without a MUA (p < 0.001). Patients who undergo a MUA after primary TKA may have a knee at risk with higher revision rates, worse long-term clinical scores, ROM and survivorship.

Management of Stiffness following Total Knee Arthroplasty: International Survey on Surgeon Preferences

Introduction: Stiffness following total knee arthroplasty (TKA) is a challenging complication and can result in a poor functional outcome. There is considerable debate concerning the definition, work-up, and optimal management of this complication. The aim of this study was to record the definition of stiffness, management practices, and expectations of outcome among surgeons from an international community using a peer-reviewed questionnaire. Methods: A 23-item peer-reviewed online questionnaire was sent to all members of SICOT to gauge and record the management practices and expectations of outcome in the management of patients with stiffness following TKA. Results: A total of 315 surgeons completed this peer-reviewed questionnaire. Manipulation under anaesthesia (MUA) was the preferred treatment option for stiffness post-TKA, with a majority of the surgeons opting to carry out this procedure between 6 and 12 weeks following the index TKA. Physiotherapy and a continuous passive motion device were also used by the majority of surgeons following MUA, as additional treatment measures. Discussion: MUA is perceived to be a safe and effective primary treatment option for stiffness following TKA. It is best performed between weeks 6 and 12 with expected gains in range of motion from 10 to 20 degrees in 75% of patients.

Patients undergoing manipulation after total knee arthroplasty are at higher risk of revision within 2 years

BACKGROUND

Total knee arthroplasty (TKA) is a very common orthopedic procedure and stiffness is a common complication following TKA. There is extensive data regarding timing and success of Manipulation under anesthesia (MUA) for stiffness following TKA. However, Studies reporting outcome following MUA have often focused on the improvement in ROM and improvement in functional score with very few studies reporting on the revision risk.

METHODS AND MATERIALS

In this study we retrospectively reviewed PearlDiver insurance database and analyzed the characteristics of the patient undergoing MUA after TKA. We also analyzed the risk of revision at 2 years in a cohort of MUA patients who were matched to patients without MUA.

RESULT

Our study identified 9156 patients who underwent MUA within one year following TKA. MUA was slightly more common in females and risk of manipulation decreases with increasing age. Comparative analysis showed that at two years, patients in the matched MUA cohort (538 patients, 5.99%) were 2.9 times more likely to undergo revision TKA compared to the matched non MUA group (194, 2.16%)OR 2.88 (95% CI-2.44 to 3.41), P < 0.05 CONCLUSION: Retrospective database review showed that the risk of revision is higher in patients undergoing MUA after TKA and hence patient should be counselled about the possibility of revision in the future.

Arthroscopic Lysis of Adhesions With Manipulation for Management of Late-Presenting Stiffness After Total Knee Arthroplasty

Background

Arthrofibrosis is a known complication of total knee arthroplasty (TKA). Closed manipulation is the treatment of choice for arthrofibrosis within 90 days of TKA. Treatment for arthrofibrosis that has failed prior interventions remains controversial, and the role for arthroscopic lysis of adhesions has not been examined for late-presenting arthrofibrosis.

Methods

A retrospective analysis of patients who underwent arthroscopic lysis of adhesions (LOAs) with manipulation for post-TKA arthrofibrosis was performed. Chart review included patient characteristics, time from TKA, prior interventions, and range of motion (ROM) data. Knee extension, flexion, and total ROM were recorded preoperatively, intraoperatively, and throughout follow-up. Knee ROM was compared at the different time intervals using Wilcoxon signed-rank tests.

Results

A total of 13 patients (6 male and 7 female) with a mean age of 66.3 years were included. Average time since index TKA was 57.2 months (3.7-209.5). Ten of 13 patients had undergone prior interventions for arthrofibrosis, which included closed manipulation under anesthesia, open LOA, and revision arthroplasty. The mean preoperative knee flexion and extension values for the cohort were 76.5 ± 17.4 and −4.6 ± 6.1 degrees, respectively. Postoperative improvements in knee ROM were significant at all time points, with mean improvements of 17.2 ± 16.3 degrees at 1 week (P = .022), 17.2 ± 13.2 degrees at 4 weeks (P = .001), 19.2 ± 16.0 degrees at 8 weeks (P = .004), and 25.2 ± 13.1 degrees at 12 weeks (P = .005). No complications were recorded.

Conclusions

Arthroscopic LOAs with manipulation achieves significant improvements in knee ROM for late-presenting arthrofibrosis after TKA.

Manipulation Under Anesthetic After Primary Knee Arthroplasty Is Associated With a Higher Rate of Subsequent Revision Surgery

AIM

To determine the association between manipulation under anesthetic (MUA) after primary knee arthroplasty and subsequent revision surgery.

METHODS

Patients undergoing primary knee arthroplasty from April 2011 to April 2016 with minimum 1-year follow-up to April 2017 were identified from the national hospital episode statistics for England. The first arthroplasty per patient, per side, was included; cases with a record of subsequent infection or periprosthetic fracture were excluded. Patients undergoing MUA within 1 year to the same knee were identified, defining the populations for the MUA and non-MUA cohorts. Mortality-adjusted Kaplan-Meier survival analysis (revision arthroplasty) was performed to a maximum of 6 years. A Cox proportional hazards model was used to determine the hazard for revision, adjusting for type of primary arthroplasty, gender, age group, year, comorbidity index, obesity, regional deprivation, rurality, and ethnicity.

RESULTS

A total of 309,650 primary arthroplasty cases (309,650 patients) were included. MUA within 1 year was recorded in 6882 patients (2.22%; 95% confidence interval [95% CI], 2.17-2.28) defining the MUA cohort; all others were included in the parallel non-MUA cohort. At 6 years, the mortality-adjusted estimated implant survival rate in the MUA cohort was 91.2% (95% CI, 90.0-92.2) in comparison to 98.1% (95% CI, 98.0-98.2) in the non-MUA cohort. In the fully adjusted model, this corresponded to an adjusted hazard for revision of 5.03 (hazard ratio; 95% CI, 4.55-5.57).

CONCLUSION

Patients who underwent MUA within 1 year of primary arthroplasty were at a 5-fold increased risk of subsequent revision even after excluding cases of infection or fracture. Further investigation of the etiology of stiffness after primary knee arthroplasty and the optimal treatment options to improve outcomes is justified.

Treatment with posterior capsular release, botulinum toxin injection, hamstring tenotomy, and peroneal nerve decompression improves flexion contracture after total knee arthroplasty: minimum 2-year follow-up

PURPOSE

No definite treatment option with reasonable outcome has been presented for old and refractory flexion contracture after total knee arthroplasty (TKA). We describe a surgical technique for 21 refractory cases of knee flexion contracture, including 12 patients with history of failed manipulation under anesthesia (MUA).

METHODS

Retrospective review was conducted for procedures performed by a single surgeon between 2005 and 2016. Twenty-one knees (19 patients) with knee flexion contracture after primary TKA were treated with all the following procedures: posterior capsular release, hamstring tenotomy, prophylactic peroneal nerve decompression, and botulinum toxin type A injections. Twelve of the 21 knees had at least 1 prior unsuccessful MUA before this soft-tissue release procedure. Mean age at intervention was 60 years (range 46-78 years). Mean preoperative knee range of motion (ROM) was - 27° extension (range - 20° to - 40°) to 100° flexion (range 90°-115°). All radiographs were evaluated for proper component sizing and signs of loosening.

RESULTS

Full extension was achieved immediately after surgery in all patients. Only one knee required repeat botulinum toxin type A injection. All patients had full extension at mean follow-up of 31 months (range 24-49 months). No significant change was observed in knee flexion after the procedure (n.s.). Significant improvement was noted in the postoperative Knee Society Score (KSS) (mean 80, range 70-90) when compared with preoperative KSS (mean 45, range 25-65) (p = 0.008).

CONCLUSION

The proposed surgical technique is efficacious in treating patients with refractory knee flexion contracture following TKA to gain and maintain full extension at minimum 2-year follow-up.

LEVEL OF EVIDENCE

IV, retrospective case series.

Manipulation under Anesthesia for Stiffness of the Knee Joint after Total Knee Replacement

Background

Stiffness of the knee joint is a feared complication after total knee replacement (TKR). An initial noninvasive treatment option is the manipulation of the knee under anesthesia (MUA). The purpose of this study is to evaluate the midterm result of the MUA for joint stiffness after primary TKR.

Methods

Patients treated with the MUA for knee stiffness after primary TKR surgery performed at Akershus University Hospital during 2014-2018 were invited to a follow-up clinic. The range of motion (ROM) of the knee joint was measured using a goniometer, and the patients reported the Lysholm score, Knee injury and Osteoarthritis Outcome Score, and Tegner score. In addition, any complications or reoperation after the MUA was noted.

Results

A total of 24 patients were identified in the journal system at the hospital. Twenty-three of these (17 women and 6 men) attended the designated follow-up on average 26 months (range [r], 16-35) after the MUA. The total ROM was 97° (r, 84°-116°) at the time of follow-up, compared with 70° (r, 50°-80°) before the MUA (P < .001, the Mann-Whitney U-test). A regression analysis indicated that the ROM at follow-up was predicted by the time from the index TKR surgery to the MUA, with the early MUA improving results (P = .02). The median Lysholm score was 57.1 (r, 17.9-92.9).

Conclusions

There is a clinically and statistically significant increase of the total ROM of the knee joint after the MUA for knee stiffness after TKR. The earlier MUA yields a better total ROM. Despite improvement in the ROM, the patients did not achieve normal function of the knee joint.

Manipulation under anesthesia as a therapy option for postoperative knee stiffness: a retrospective matched-pair analysis

INTRODUCTION

Due to demographic changes, total knee arthroplasty (TKA) is one of the most frequently performed orthopedic surgeries. Therapies for associated postoperative complications, such as postoperative knee stiffness (PKS), are becoming increasingly important. The aim of this retrospective matched-pair analysis was to evaluate mid-term-results following manipulation under anesthesia (MUA).

MATERIALS AND METHODS

Fifty-one patients with PKS were evaluated and 51 matched-pair patients without PKS after primary TKA were chosen for the control group. In addition to the range of motion, the functionality was recorded by Knee Society Score (KSS), Western Ontario and Mc Masters Universities Osteoarthritis Index (WOMAC), and Short-Form-12 Questionnaire (SF-12). Experience of pain was mapped using a 10-point Numeric Rating Scale (NRS), and the analgesic requirement was mapped using the WHO step scheme. A final follow-up examination was conducted approximately three years after TKA. To evaluate potential risk factors for the development of PKS, TKA alignment was measured via postoperative X-ray images.

RESULTS

Improvement of the average knee flexion of 35.7° and total flexion of 107.4° was detected in PKS patients after MUA. The flexion of the control group was 112.4°; no significant between-group difference was present regarding prosthesis type, sex, age and BMI. Regarding KSS, WOMAC, and SF-12, the MUA cohort achieved statistically-relevant lower overall scores than the control group, p = 0.006, p = 0.005, p = 0.001, respectively. Significantly higher experiences of pain and a higher need for analgesics in MUA patients were reported (p = 0.001 and p < 0.001, respectively). Radiological evaluation of the prosthesis alignment did not show any differences between the two groups.

CONCLUSIONS

MUA can improve mobility after PKS, whereby MUA seemed to be a functional therapy option for PKS. Compared to the control group, the MUA group showed lower functional values and an increased experience of pain. A correlation between prosthesis malalignment and MUA could not be detected radiologically. Further studies are necessary to investigate the reasons for PKS.

Intraoperative manipulation for flexion contracture during total knee arthroplasty

BACKGROUND

Joint gap unbalancing during total knee arthroplasty (TKA) induces flexion contracture. Flexion contracture is one of the most serious complications of TKA. When flexion contracture is found during surgery, intraoperative manipulation is often empirically performed. We evaluated the effects of intraoperative manipulation on joint gap and postoperative flexion contracture.

MATERIALS AND METHODS

TKA was performed for 136 knees. Intraoperative manipulation was performed for flexion contracture in 61 knees. Joint gap changes before and after manipulation were measured at six positions from extension to 120° of flexion. Manipulation was not performed for 75 knees. The extension angle was measured radiographically immediately after surgery, at 3 months, and 6 months postoperatively. Extension angles with manipulation and without manipulation were compared.

RESULTS

Joint gap changes (mm) before and after manipulation were 0.1, 0.0, -0.2, -0.3, -0.1, and -0.3 at 0°, 30°, 45°, 60°, 90°, and 120° of flexion, respectively, indicating that manipulation could not change joint gaps significantly. Extension angles (°) with and without manipulation were -4.0 ± 4.6 and -3.8 ± 3.9 immediately after surgery, -5.3 ± 6.7 and -5.5 ± 6.2 at 3 months postoperatively, and -2.7 ± 6.0 and -3.8 ± 5.8 at 6 months postoperatively. No statistically significant difference existed between the values with or without manipulation during all periods.

CONCLUSION

Intraoperative manipulation does not enlarge the gap or resolve postoperative flexion contracture. Developing the new surgical technique is required to achieve perfect balance at TKA.

Same-Day Surgery Does Not Increase the Manipulation Under Anesthesia and Reoperation Rates for Stiffness Following Bilateral Total Knee Arthroplasty

BACKGROUND

There is a paucity of data on the incidence of stiffness and need for subsequent manipulation under anesthesia (MUA) and reoperation following same-day bilateral total knee arthroplasty (BTKA). We compared the rates of at least 1 MUA, bilateral knee involvement, single and multiple MUA rates, and stiffness-related reoperation rates between patients undergoing same-day, same-admission staged, and staged within 1 year BTKA in a tertiary institution.

METHODS

We analyzed institutional data for 3175 same-day (group A), 153 same-admission staged (group B), and 1226 staged within 1 year BTKA patients (group C) from 1998 to 2009. Several variables, including patient demographics, comorbidity profile, Charlson-Deyo index, and range of motion at different time points, were tabulated. Follow-up was minimum 1 year after first MUA. Univariate analyses were performed using the Wilcoxon rank-sum or Kruskal-Wallis test, and Fisher exact or the chi-square test for continuous and categorical variables, respectively. The Cochran-Armitage trend test was used to check the bilateral knee involvement rate across groups.

RESULTS

Overall, 2.2% (98/4554) of BTKA patients required MUA. The rate of at least 1 MUA was similar across groups but the percentage of bilateral knee involvement was higher in group A. The single MUA rate was comparable among groups. Both no revision and revision reoperation rates were similar among the manipulated groups.

CONCLUSION

Same-day BTKA was not associated with increased incidence of single or multiple MUA and stiffness-related reoperation rates. These findings may facilitate preoperative counseling in patients with symptomatic bilateral knee disease, eligible for same-day BTKA.

Efficacy of manipulation under anesthesia beyond three months following total knee arthroplasty

Background

Stiffness after total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA) to improve range of motion (ROM). However, many authors recommend against MUA beyond 3 months after TKA. This study investigates the timing of MUA for stiffness after TKA, focusing on MUA performed at >12 weeks.

Methods

In total, 142 MUAs were retrospectively reviewed. “Early” MUAs were at <12 weeks after TKA; “Late” MUAs were >12 weeks. MUAs were further subdivided into 4 groups: 83 “Group I” cases at <12 weeks, 34 “Group II” between 12 and 26 weeks, 12 “Group III” between 26 and 52 weeks, and 13 “Group IV” at >52 weeks. Gains in ROM were compared between groups.

Results

Gains in flexion and overall ROM were statistically equivalent in Early vs Late MUA when controlling for pre-MUA ROM. ROM gains between the early Group I and the later Groups II-IV were also statistically comparable. Overall ROM gain in Group I was 24.1°, 17.9° in Group II, 20.8° in Group III, and 11.1° in Group IV. There were no significant complications.

Conclusions

Early and late MUA resulted in statistically equivalent gains in ROM, regardless of timing after TKA. All groups showed an average improvement in ROM of ≥11°. MUA performed beyond 3 months, and even beyond 1 year, appears to be safe and may improve ROM and allow select patients to avoid revision surgery.

Manipulation under anesthesia after primary knee arthroplasty in Sweden: incidence, patient characteristics and risk of revision

Background and purpose - The incidence of manipulation under anesthesia (MUA) after knee arthroplasty surgery has been reported to vary between 0.5% and 10%. We evaluated the incidence of MUA after primary knee arthroplasty in Sweden, the demographics of the patients and the risk of revision. Patients and methods - Between 2009 and 2013, 64,840 primary total and unicompartmental knee arthroplasties (TKA and UKA) were registered in the Swedish Knee Arthroplasty Register (SKAR). MUAs performed between 2009 and 2014 were identified through the in- and outpatient registers of the Swedish National Board of Health and Welfare. Pertinent data were verified through medical records and patient demographics and revisions were obtained from the SKAR. Results - 1,258 MUAs were identified. Of these, 1,078 were 1st-time MUAs, performed within 1 year after the primary knee arthroplasty. The incidence of MUA was 1.7% and the incidence varied between hospitals from 0% to 5%. The majority were performed after TKA (98%), in younger patients (65% < 65 years), women (64%), and relatively healthy persons (88% had ASA ≤ 2). The cumulative risk of revision at 10 years was 10% (95% CI 8.6-12), similar for men and women. Interpretation - In Sweden, MUA is a rather uncommon measure after knee arthroplasty, especially after UKA. The CRR at 10 years was doubled compared to the general knee arthroplasty population. The frequency of the procedure varies between hospitals but in general it is performed more frequently in healthier and younger patients.

Younger age is associated with increased odds of manipulation under anesthesia for joint stiffness after total knee arthroplasty

INTRODUCTION

Limited range of motion (ROM) after total knee replacement (TKR) is associated with low function and might require manipulation under anaesthesia (MUA). In order to identify factors associated with a limited ROM we investigated predictors for MUA. We hypothesized that older age was associated with higher MUA due to limited ROM post TKR.

METHODS

In a case control study we investigated all patients undergoing primary TKR at a University Hospital in Sweden between 2007-2012. We registered background factors and compared those between the group who underwent MUA and those who did not. Odds ratios (OR) were calculated in a univariate analysis and an adjusted regression analysis.

RESULTS

Of the total of 669 TKRs performed, 31 patients who had undergone MUA were identified. The prevalence of MUA was 4.6%. The mean increase in ROM after MUA was 27 degrees at final minimum one-year follow-up. After controlling for confounders, patients with good health and young age had increased OR for MUA. OR decreased 0.93 (CI 0.93-0.97) per increased age year in the multiple regression analysis. Diabetes mellitus, BMI and sex did not have a significant effect on the odds ratio for MUA.

DISCUSSION

Young patients undergoing TKR has earlier been identified as a group with a higher grade of dissatisfaction and complications. We found an association between young age and MUA after TKR indicating an additional, rather unknown complication for this group of patients. The background and reasons for this has to be further investigated.

LEVEL OF EVIDENCE

II, cohort study/case control study (case control is level III).

Alternative technique for knee manipulation under anesthesia

Total knee arthroplasty is a successful surgery for the majority of patients with osteoarthrosis of the knee. Approximately 5% of patients undergoing total knee arthroplasty experience loss of motion or arthrofibrosis. Manipulation under anesthesia (MUA) is generally indicated for patients who do not achieve >90° of flexion by 6-12 weeks postoperatively. Complications from MUA are rare but can be devastating. We describe a novel technique for MUA with no reported major complications in our review of 78 patients. The average flexion improved from 80.0 (±3.8) before manipulation to 115.4 (±2.1) after manipulation. There were no major complications including fracture or extensor mechanism injury.

Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature

INTRODUCTION

The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery.

METHODS

A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA.

RESULTS

Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA.

CONCLUSION

Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.

Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness

OBJECTIVES

Evaluate the safety and efficacy of manipulation under anesthesia (MUA) for posttraumatic elbow stiffness.

DESIGN

Retrospective, case series.

SETTING

Single institution; level 1 trauma center.

PATIENTS/PARTICIPANTS

Chart review of 45 patients over a 10-year period treated with MUA for posttraumatic elbow stiffness after elbow injuries treated both operatively and nonoperatively.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Change in total flexion arc pre- to postmanipulation; time to manipulation; complications.

RESULTS

Average time from most recent surgical procedure or date of injury to MUA was 115 days. Average premanipulation flexion arc was 57.9 degrees; average flexion arc at the final follow-up was 83.7 degrees. The improvement in elbow flexion arc of motion was statistically significant (P < 0.001). Post hoc analysis of the data revealed 2 distinct groups: 28 patients who underwent MUA within 3 months of their most recent surgical procedure (early manipulation), and 17 patients who underwent MUA after 3 months (late manipulation). Average improvement in elbow flexion arc in the early MUA group was 38.3 degrees (P < 0.001); improvement in the late MUA group was 3.1 degree. Comparison of improvement between the early and late MUA groups found a significant difference (P < 0.001) in mean flexion arc improvement from premanipulation to postmanipulation, favoring the early group. One patient had a complication directly attributable to MUA. Nineteen patients required additional procedures on the injured extremity after MUA.

CONCLUSIONS

MUA is a safe and effective adjunct to improving motion in posttraumatic elbow stiffness when used within 3 months from the original injury or time of surgical fixation. After 3 months, MUA does not reliably increase elbow motion.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Knee stiffness following primary total knee arthroplasty can lead to unsatisfactory patient outcomes secondary to persistent pain and loss of function. Manipulation under anesthesia (MUA) remains a viable option for treatment of post-operative stiffness. However, the optimal timing and clinical efficacy of manipulation of anesthesia remains unknown.

METHODS

A systematic review of the literature was performed to identify studies that reported clinical outcomes for patients who underwent MUA for post-operative stiffness treatment. Repeat MUA procedures were included in the study but were analyzed separately.

RESULTS

Twenty-two studies (1488 patients) reported on range of motion (ROM) after MUA, and 4 studies (81 patients) reported ROM after repeat MUA. All studies reported pre-MUA motion of less than 90°, while mean ROM at last follow-up exceeded 90° in all studies except 2. For studies reporting ROM improvement following repeat MUA, the mean pre-manipulation ROM was 80° and the mean post-manipulation ROM was 100.6°.

CONCLUSION

MUA remains an efficacious, minimally invasive treatment option for post-operative stiffness following TKA. MUA provides clinically significant improvement in ROM for most patients, with the best outcomes occurring in patients treated within 12 weeks post-operatively.

PROSPERO REGISTRATION NUMBER

CRD42016052215.

Knee manipulation for reduced flexion after Total Knee Arthroplasty. Is timing critical?

BACKGROUND

Reduced flexion following knee arthroplasty (TKA) may compromise patient's function and outcome. The timing of manipulation under anaesthesia (MUA) has been controversial. We present our experience in a high volume practice and analyse the impact of timing.

METHODS

All TKA patients requiring MUA from February 1996 to June 2015 under the care of a single surgeon were analysed. MUA was offered to patients who had ≤ 75° of flexion post-op, providing that they had 30° more flexion preoperatively. To address the impact of timing from primary surgery to MUA on flexion gain we looked at 3 groups: Group I ≤ 90 days, Group II 91-180 days and Group III > 180 days.

RESULTS

Sixty two out of 7,423 (0.84%) underwent MUA. The MUA patients were significantly younger than the overall TKA cohort 61.2 vs 70.5 years (p = < 0.01). The median duration between arthroplasty and MUA was 3.9 months (IQR 3.4, Range 1.6-72.5 months). Overall flexion gained at 6-12 Weeks and 1 year post MUA showed significant improvements of 20.9° (p = <0.01) and 25° respectively (p = < 0.01). The flexion gain in group I (≤ 90 days) was significantly better than group III ( > 180 days) both at 6 weeks and 1 year following MUA but not better than group II (90-180 days).

CONCLUSIONS

MUA is an effective treatment for reduced flexion following TKA and should be the first line of management after failed physiotherapy. It can still have benefit beyond 6 months but the gains become less effective with time.

Risk Factors, Outcomes, and Timing of Manipulation Under Anesthesia After Total Knee Arthroplasty

BACKGROUND

Knee stiffness requiring manipulation under anesthesia (MUA) is an undesirable outcome following total knee arthroplasty (TKA), but risk factors for, and optimal timing of, MUA remain unclear.

METHODS

Primary TKAs performed at a single center were retrospectively reviewed. Clinical variables were compared between patients who underwent MUA and those who did not; variables that differed were utilized to identify an appropriately matched control group of non-MUA patients. The MUA group was divided into early (MUA ≤6 weeks from index) and late (>6 weeks) subgroups. Flexion values at multiple time points were compared.

RESULTS

In total, 1729 TKA patients were reviewed; MUA was performed in 62 patients. Patients undergoing MUA were younger (55.2 vs 65.3 years, P < .001) and had higher rates of current smoking (21.0% vs 7.3%, P < .001) and prior procedure (59.7% vs 40.4%, P = .002), most commonly arthroscopy; a control group of patients not requiring MUA, matched on the basis of these variables, was identified. While no difference in pre-TKA flexion existed across groups, final flexion in the early MUA group (106.7°) was equivalent to that of controls (115.6°), while final flexion in the late MUA group was not (101.3°, P = .001).

CONCLUSION

TKA patients undergoing MUAs were younger, more likely to be current smokers, and more likely to have undergone prior knee surgery. Even in patients with severe initial postoperative limitations in range of motion, MUA within 6 weeks may allow for final outcomes that are equivalent to those experienced by similar patients not requiring manipulation.

Predictors of outcome after manipulation under anaesthesia in patients with a stiff total knee arthroplasty

PURPOSE

Flexion in a stiff total knee arthroplasty (TKA) can be improved by manipulation under anaesthesia (MUA). Although this intervention usually results in an improvement in range of motion, the expected result is not always achieved. The purpose of this study is to determine which factors affect range of motion after manipulation in patients with a stiff total knee.

METHODS

After exclusion (n = 22), the data of 158 patients (138 knees) with a stiff knee after TKA who received a manipulation under anaesthesia between 2004 and 2014 were retrospectively analysed. Pre-, peri- and post-operative variables were identified and examined for their influence on flexion after the manipulation using Kruskal-Wallis and Mann-Whitney U tests and Spearman correlations.

RESULTS

After MUA, a mean improvement in flexion of 30.3° was observed at the final follow-up. Preoperative TKA flexion, design of TKA and interval between TKA procedure and MUA were positive associated with an increase in flexion after MUA. MUA performed 12 weeks or more after TKA procedure deteriorated the outcome.

CONCLUSIONS

Three factors, pre-TKA flexion type of prosthesis and interval between TKA procedure and manipulation under anaesthesia, were found to have impact on flexion after TKA and MUA were identified. Results are expected to be inferior in patients with low flexion before TKA procedure or with a long interval (>12 weeks) between the TKA procedure and the manipulation under anaesthesia.

LEVEL OF EVIDENCE

IV.

LATE EVALUATION OF PATIENTS UNDERGOING MANIPULATION OF THE KNEE AFTER TOTAL ARTHROPLASTY

Objective:

We compared gains in range of motion in patients who underwent manipulation within 12 weeks of total knee arthroplasty (TKA) and after this period. We also evaluated maintenance of the arc obtained from knee manipulation in late follow-up, along with factors associated with poorer outcomes.

Method:

The study was divided into two groups according to the time after TKA; the surgeries took place between January 2008 and December 2014.

Results:

When comparing the range of motion between early and late manipulations, the group that underwent manipulation within 12 weeks of the TKA exhibited better outcomes, but these were not statistically significant. We observed that 14.3% of cases retained the same range attained at the time of manipulation. In late evaluation after manipulation, 47.7% of the sample had a range of less than 90 degrees. The significant risk factors for recurrence of knee stiffness in the long term are poor range of motion before TKA and before manipulation, female sex, and secondary arthritis.

Conclusion:

Women previously diagnosed with secondary osteoarthritis and poor range of motion before TKA or manipulation are at higher risk for late stiffness. Level of Evidence III, Retrospective Comparative Study.

Arthrofibrosis Associated With Total Knee Arthroplasty

BACKGROUND

Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions.

METHODS

In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined.

RESULTS

Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes.

CONCLUSION

Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Revision surgery for the stiff total knee arthroplasty

AIMS

The aim of this study was to examine the results of revision total knee arthroplasty (TKA) undertaken for stiffness in the absence of sepsis or loosening.

PATIENTS AND METHODS

We present the results of revision surgery for stiff TKA in 48 cases (35 (72.9%) women and 13 (27.1%) men). The mean age at revision surgery was 65.5 years (42 to 83). All surgeries were performed by a single surgeon. Stiffness was defined as an arc of flexion of < 70° or a flexion contracture of > 15°. The changes in the range of movement (ROM) and the Western Ontario and McMasters Osteoarthritis index scores (WOMAC) were recorded.

RESULTS

At a mean follow up of 59.9 months (12 to 272) there was a mean improvement in arc of movement of 45.0°. Mean flexion improved from 54.4° (5° to 100°) to 90° (10° to 125°) (p < 0.05) and the mean flexion contracture decreased from 12.0° (0° to 45°) to 3.5° (0° to 25°) (p < 0.05). The mean WOMAC scores improved for pain, stiffness and function. In patients with extreme stiffness we describe a novel technique, which we have called the 'sloppy' revision. This entails downsizing the polyethylene insert by 4 mm and using a more constrained liner to retain stability.

CONCLUSION

To our knowledge, this is the largest series of revision surgeries for stiffness reported in the literature where infection and loosening have been excluded.

TAKE HOME MESSAGE

Whilst revision surgery is technically demanding, improvements in ROM and outcome can be achieved, particularly when the revision is within two years of the primary surgery. Cite this article: Bone Joint J 2016;98-B:622-7.

Intraoperative Manipulation for Flexion Contracture During Total Knee Arthroplasty

Joint gap balancing during total knee arthroplasty (TKA) is important for ensuring postoperative joint stability and range of motion. Although the joint gap should be balanced to ensure joint stability, it is not easy to achieve perfect balancing during TKA. In particular, relative extension gap shortening can induce flexion contracture. Intraoperative manipulation is often empirically performed. This study evaluated the tension required for this manipulation and investigated the influence of intraoperative manipulation on the joint gap in cadaveric knees. Total knee arthroplasty was performed in 6 cadaveric knees from whole body cadavers. Flexion contracture was induced using an insert that was 4 mm thicker than the extension gap, and intraoperative manipulation was performed. Study measurements included the changes in the joint gap after manipulation at 6 positions, with the knee bending from extension to 120° flexion, and the manipulation tension that was required to create a 4-mm increase in the gap. The manipulation tension needed to create a 4-mm increase in the extension gap was 303±17 N. The changes in the joint gap after manipulation were 0.4 mm, 0.6 mm, 0.2 mm, -0.2 mm, -0.4 mm, and -0.6 mm at 0°, 30°, 45°, 60°, 90°, and 120° flexion, respectively. Therefore, the joint gap was not significantly changed by the manipulation. Intraoperative manipulation does not resolve flexion contracture. Therefore, if flexion contracture occurs during TKA, treatment with additional bone cutting and soft tissue release is likely more appropriate than manipulation. [Orthopedics. 2016; 39(6):e1070-e1074.].

Manipulation under anesthesia for post traumatic stiff knee-pearls, pitfalls and risk factors for failure

BACKGROUND

Stiffness is common following fractures around knee. Manipulation under anesthesia (MUA) is the initial noninvasive procedure usually performed for such patients. Though MUA has been extensively evaluated for knee arthroplasty, there is paucity of literature regarding its benefits in trauma cases. The purpose of this study was to define the role of manipulation in post traumatic stiff knees.

METHODS

Hospital inpatient and outpatient records from January 2010 to June 2014 were retrospectively reviewed to identify patients undergoing MUA at our institution. Patients with more than one year follow up and adequate data were included. Clinical and radiographic parameters were analyzed to assess outcomes, complications, effect of timing on flexion gain as well as identify risk factors associated with failure.

RESULTS

Out of 45 patients undergoing manipulation, 41 patients with 48 knees (34 unilateral and 7 bilateral) met inclusion criteria. Thirty six manipulations were successful while 3 were abandoned due to tight tissues and 9 developed complications.Successful MUA resulted in immediate gain of 62.36° of flexion which decreased to 49.86° at 1year. There was statistically significant loss of flexion of 12.5° over a year (p value 0.0013). Arc of motion improved from 48.5° to 106.1° at 1year (p value <0.0001). Significant improvement was also seen in extension and fixed flexion deformity (p value <0.0001). No significant difference could be detected between early (<3 months) and late (>3 months) groups with respect to outcomes (p value 0.883)or complications (p value 0.3193). Failed group had significantly lower pre MUA flexion and pre MUA range of motion (p value 0.003). Univariate analysis showed that extensor mechanism ruptures during injury (p value <0.0001) and knees with Flexion <40° (p value 0.0022) or ROM<30° (p value 0.0002) were significantly associated with failures.

CONCLUSION

MUA is a suitable non invasive treatment option for post traumatic stiffness. There is no effect of timing on outcome and late manipulation also results in good outcome. Extensor mechanism rupture and pre manipulation ROM<30° or flexion <40° are associated with failure and such cases should be considered for alternative options for better outcome.

Novel Protocol for Knee Mobilization Under Femoral and Sciatic Nerve Blocks for Postoperative Knee Stiffness

The purpose of this study was to evaluate the effectiveness of intermittent femoral and sciatic nerve blocks combined with an in-house physiotherapy protocol for treating postoperative knee stiffness. Sixty-eight patients with postoperative knee stiffness were evaluated for passive knee flexion and extension at different time points, beginning preoperatively and continuing throughout a median 10-month follow-up after mobilization intervention. Sciatic and femoral nerve catheters were activated 1 hour prior to each physiotherapy session, which was performed twice per day and supported by a continuous passive range of motion machine. Median time from admission to catheter removal was 4 days (range, 1-8 days). Mean hospital length of stay was 7 days (range, 2-19 days). Overall mean flexion increased significantly from pretreatment (74°) to discharge (109°; P<.01). There was no significant difference in mean flexion at 6-week follow-up compared with that at discharge (108°; P=.764), but there was a significant increase in flexion at final follow-up (120°; P=.002). Overall mean knee extension lag decreased significantly from pretreatment (5°) to discharge (0.4°; P=.001). There was no significant increase in mean extension lag from discharge to final follow-up (1°; P=.2). Overall, 11 patients underwent revision surgery for persistent stiffness. This novel protocol for continuous knee mobilization under perineural blocks is a valuable alternative to knee manipulation under anesthesia for this select group of procedures. The 2 techniques produced a similar early range of motion gain, but the reported protocol resulted in less range of motion loss at follow-up and fewer possible complications. [Orthopedics. 2016; 39(4):e708-e714.].

Knee manipulation under anaesthetic following total knee arthroplasty

The purpose of this study was to compare clinical outcomes of total knee arthroplasty (TKA) after manipulation under anaesthesia (MUA) for post-operative stiffness with a matched cohort of TKA patients who did not requre MUA.

In total 72 patients (mean age 59.8 years, 42 to 83) who underwent MUA following TKA were identified from our prospective database and compared with a matched cohort of patients who had undergone TKA without subsequent MUA. Patients were evaluated for range of movement (ROM) and clinical outcome scores (Western Ontario and McMaster Universities Arthritis Index, Short-Form Health Survey, and Knee Society Clinical Rating System) at a mean follow-up of 36.4 months (12 to 120). MUA took place at a mean of nine weeks (5 to 18) after TKA. In patients who required MUA, mean flexion deformity improved from 10° (0° to 25°) to 4.4° (0° to 15°) (p < 0.001), and mean range of flexion improved from 79.8° (65° to 95°) to 116° (80° to 130°) (p < 0.001). There were no statistically significant differences in ROM or functional outcome scores at three months, one year, or two years between those who required MUA and those who did not. There were no complications associated with manipulation.

At most recent follow-up, patients requiring MUA achieved equivalent ROM and clinical outcome scores when compared with a matched control group. While other studies have focused on ROM after manipulation, the current study adds to current literature by supplementing this with functional outcome scores.

Cite this article: Bone Joint J 2015;97-B:1640–4.

Effect of repeated manipulation on range of motion in patients with stiff total knee arthroplasty

Although manipulation under anesthesia (MUA) has been considered effective first-line treatment for stiff total knee arthroplasty (TKA), there is no consensus regarding the usefulness of repeated MUA. The purpose of this study was to investigate the usefulness of repeated MUA performed for patients in whom satisfactory range of motion (ROM) was not achieved by MUA. The authors retrospectively reviewed 15 patients who underwent repeated MUA after failure of initial MUA for stiff TKA. Demographic and ROM data were collected. A final ROM of less than 90° was considered a failed manipulation (failure group) and a final ROM of 90° or more was considered a successful manipulation (success group). Average pre-repeated MUA ROM (72.3°±19.5°) immediately improved to 112.3°±9.7° (P<.001) in the operating room, and final ROM was 89.6°±23.9°, an overall gain of 17.3° (P=.04). However, despite this overall ROM increase, a successful final ROM (90° or more) was achieved in approximately half of patients (7 of 13; 54%). There were no significant differences in demographics between the success and failure groups, except that there was significantly less pre-TKA ROM in the failure group (P=.02). There were no complications related to either the first or the repeated MUA procedures. The findings of this study suggest that repeated MUA can improve overall ROM for stiff TKA. The success rate of repeated MUA was less than that of primary MUA; however, it is a useful treatment modality for stiff TKA. Decreased pre-TKA ROM appeared to be associated with poor outcomes after repeated MUA.

Methodological considerations in observational comparative effectiveness research for implantable medical devices: an epidemiologic perspective

Medical devices play a vital role in diagnosing, treating, and preventing diseases and are an integral part of the health-care system. Many devices, including implantable medical devices, enter the market through a regulatory pathway that was not designed to assure safety and effectiveness. Several recent studies and high-profile device recalls have demonstrated the need for well-designed, valid postmarketing studies of medical devices. Medical device epidemiology is a relatively new field compared with pharmacoepidemiology, which for decades has been developed to assess the safety and effectiveness of medications. Many methodological considerations in pharmacoepidemiology apply to medical device epidemiology. Fundamental differences in mechanisms of action and use and in how exposure data are captured mean that comparative effectiveness studies of medical devices often necessitate additional and different considerations. In this paper, we discuss some of the most salient issues encountered in conducting comparative effectiveness research on implantable devices. We discuss special methodological considerations regarding the use of data sources, exposure and outcome definitions, timing of exposure, and sources of bias.

The effect of timing of manipulation under anesthesia to improve range of motion and functional outcomes following total knee arthroplasty

BACKGROUND

Manipulation under anesthesia has been reported to improve range of motion when other rehabilitative efforts fail to obtain adequate motion after total knee arthroplasty. The purpose of this study was to evaluate the effects of the timing of the manipulation on knee range of motion and clinical outcomes.

METHODS

All 2128 total knee arthroplasties performed at our institution from 2005 to 2011 were reviewed to determine the number of patients who had undergone manipulation under anesthesia. A total of 144 manipulations in eighty-eight women and forty-five men were reviewed. Manipulations under anesthesia that were performed within the first twelve weeks after total knee arthroplasty were considered early and those after that period were considered late. Patients were further substratified according to the timing of the manipulation: Group I included those who had the manipulation within six weeks; Group II, at seven to twelve weeks; Group III, at thirteen to twenty-six weeks; and Group IV, after twenty-six weeks. Outcomes evaluated included gains in flexion and final range of motion, and Knee Society objective and function scores between early and late manipulation, using various adjusted multivariable regression models and at a mean follow-up of fifty-one months (range, twelve to eighty-one months). Mediation analysis was used to investigate whether gains in range of motion from the manipulations under anesthesia alone had mediated the effect between the timing of the manipulation and the clinical outcomes.

RESULTS

Patients who underwent early manipulation had a significantly higher mean gain in flexion (36.5° versus 17°), higher final range of motion (119° versus 95°), and higher Knee Society objective (89 versus 84 points) and function scores (88 versus 83 points) than those who had late manipulation under anesthesia. There were no significant differences in the outcomes of Groups I and II. Manipulations after twenty-six weeks resulted in unsatisfactory clinical outcomes. Multivariable regression analyses confirmed significantly better clinical outcomes with early manipulation. Mediation analysis showed that the timing of manipulation independently had significantly contributed to the outcomes.

CONCLUSIONS

Orthopaedic surgeons should have a low threshold for performing early manipulations with the patient under anesthesia within twelve weeks after an arthroplasty, to achieve higher knee range of motion and improved clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

How often is functional range of motion obtained by manipulation for stiff total knee arthroplasty?

PURPOSE

To evaluate how often manipulation under anesthesia (MUA) can achieve functional flexion ≥ 90 degrees and identify predictor for successful outcome of MUA for stiff total knee arthroplasty (TKA).

METHODS

Demographic data, range of motion, and surgical and anesthetic information of 143 MUAs were retrospectively analyzed from 2000 to 2011.

RESULTS

One-hundred thirty-six out of 143 patients (95 %) improved mean range of motion (ROM) from pre-MUA 62 ± 17° to final ROM 101 ± 21° (p < 0.001). Flexion ≥ 90 degrees was achieved in 74% (106/143) of patients. Regional anesthesia was identified as predictor of successful MUA outcome (p = 0.007, OR: 8.5, 95% CI: 1.2-66.7).

CONCLUSIONS

Although the proportion of patients regaining flexion ≥ 90 degrees following MUA was less than those patients with simple overall ROM increase, the functional flexion ≥ 90 degrees was achieved in the vast majority of patients with stiff TKA following MUA.