Manipulation Under Anesthesia After Total Knee Arthroplasty is Associated with An Increased Incidence of Subsequent Revision Surgery

Outcomes of Total Knee Arthroplasty Following a Sham Incision Procedure in Patients with Previous Knee Incisions

BACKGROUND

Tenuous blood supply carries a risk of wound-healing problems and subsequent infection following total knee arthroplasty (TKA). This risk may be increased by the presence of previous incisions. Performing a sham incision procedure allows for detection of wound-healing problems prior to performing TKA. The purpose of this retrospective case series is to describe the indications for and technique of a sham incision procedure in patients with previous knee incisions who underwent TKA following this procedure and to report the clinical outcomes observed in these patients following further surgery.

METHODS

Patients who had prior knee incisions, had undergone a sham incision prior to TKA, and had a minimum follow-up of 2 years were identified, and their cases were retrospectively reviewed. The identified cases typically adhered to the surgeon's standard protocol, which consisted of making a midline incision adventitious to TKA, dissecting down to deep fascia, and closing the wound with suture. Incisions were then observed for at least 4 weeks to determine the viability of the skin flaps before TKA was performed via the same incision.

RESULTS

A total of 47 knees in 47 patients were included in the study cohort. TKA was performed at an average of 21.1 weeks (range, 4 to 163 weeks) following the sham incision. There were no cases of skin necrosis or periprosthetic joint infection at an average follow-up of 4.6 years (range, 2 to 12 years) after sham incision. A total of 11 patients (23.4%) required manipulation under anesthesia for stiffness.

CONCLUSIONS

In our series, no patients developed skin necrosis or periprosthetic joint infection following TKA subsequent to a sham incision procedure, suggesting that healed sham incisions are safe to use for TKA and may be considered prior to TKA in cases in which local previous incisions increase the risk of wound-healing problems.

LEVEL OF EVIDENCE

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

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.

Limited evidence for the usage of renin-angiotensin-aldosterone pathway blockers to prevent arthrofibrosis after total knee arthroplasty. A systematic review of clinical evidence

Purpose

Despite advances in surgical techniques and rehabilitation protocols, arthrofibrosis following total knee arthroplasty (TKA) still has poor outcomes. In the last decade, attention has been focused on the pathogenesis and cascade of events leading to the development of fibrosis. Currently, one of the most promising approaches consists in the indirect antagonisation of transforming growth factor beta 1 (TGF-beta 1) through the downregulation of the renin-angiotensin-aldosterone system (RAAS). This systematic review aims to analyse the available evidence regarding the use of angiotensin receptor blockers (ARBs)/angiotensin-converting-enzyme inhibitors (ACEi) in order to prevent post-operative knee arthrofibrosis following TKA.

Methods

Extensive research on the PubMed, Cochrane, and Google Scholar databases was performed on 8 July 2024, using keywords related to ARBs, ACE inhibitors and arthrofibrosis. Inclusion criteria included: (1) clinical trials of any level of evidence; (2) written in English; (3) studies conducted on humans; and (4) evaluating the antifibrotic effects of ACE inhibitors or ARBs administered for TKA surgeries. Exclusion criteria were articles written in other languages; preclinical studies; expert opinions; reviews and trials evaluating the effects of ACEi/ARBs not related to their antifibrotic effect after TKA.

Results

A total of six studies met the inclusion criteria and were analysed. All studies were retrospective and involved a total of 158,310 patients. Time of administration varied among the studies as well as the dosage, which fell within the range for cardiological use. Four out of six studies focused exclusively on losartan. Three studies reported a clear, significant correlation between the use of ARBs and/or ACEi and a reduced likelihood of developing arthrofibrosis.

Conclusions

The RAAS antagonism could have potential for stiffness prevention after TKA. However, given the side effects and the limited evidence available, the use of ACEi/sartans for the sole purpose of avoiding arthrofibrosis after TKA is not currently recommended.

Level of Evidence

Level III.

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.

Specific Preoperative Factors Increase Manipulations under Anesthesia Following Primary TKA

Arthrofibrosis following primary total knee arthroplasty (TKA) can result in pain and limit postoperative range of motion (ROM), jeopardizing clinical outcomes and patient satisfaction. This study aims to identify preoperative risk factors associated with necessitating a manipulation under anesthesia (MUA) following primary TKA.We retrospectively reviewed 950 cases of consecutive primary TKAs performed at one institution by three arthroplasty surgeons between May 2017 and May 2019. Recorded preoperative variables included smoking status, race, preoperative ROM, presence of effusion or positive anterior drawer, and medical comorbidities. Demographic characteristics were compared with Student's t-tests or chi-square tests as appropriate. For each preoperative factor, we obtained an odds ratio (OR) for MUA risk using multivariate logistic regression.Twenty (2.3%) patients underwent MUA following their index primary TKA surgery. History of ipsilateral knee surgery (OR: 2.727, p = 0.047) and diagnosed hypertension (OR: 4.764, p = 0.016) were identified as risk factors associated with significantly increased risk of MUA. The greater the preoperative ROM, the higher likelihood needed of MUA (OR: 1.031, p = 0.034).Patients who had diagnosed hypertension or a history of prior ipsilateral knee surgery were associated with increased risk of necessitating an MUA following primary TKA. Additionally, a greater total arc of motion preoperatively increased the odds of needing MUA.Level III of evidence was present.

Successful Transition to Same Calendar Day Discharge in Total Joint Arthroplasty at an Academic Center

Background

There has been a shift toward same-day discharge (SDD) in total joint arthroplasty (TJA) in recent years. Our clinical standard had been next-day discharge, but the COVID pandemic led to a hospital bed shortage, causing us to shift to SDD directly from the Post-Anesthesia Care Unit (PACU). The aim of our project was to investigate if the SDD protocol was successful and if it changed complications or 90-day readmission rates. Our secondary aim was to investigate if the protocol created disparities in patient selection.

Methods

A retrospective review compared the first 100 patients intended to discharge from PACU to the 100 patients prior to the SDD protocol undergoing elective primary TJA procedures at our academic institution from September 1, 2020, to March 23, 2021. The SDD protocol started on November 19, 2020.

Results

During this SDD period, 98% (98/100) of patients were successfully discharged from the PACU. The 90-day readmission rate changed from 0% to 2% (P = .4975), and the overall complication rate changed from 2% to 5% (P = .4448). Most complications were manipulation under anesthesia to improve range of motion. Manipulations under anesthesia changed from 1% to 4% (P = .3687).

Conclusions

The transition to same SDD in TJA at our academic institution was successfully implemented without markedly increasing complications, readmissions, or changing patient selection. The COVID-19 pandemic likely influenced the recovery of patients before and after the protocol. Future studies are needed to validate this data during the post-COVID era.

Range-of-Motion Predictors for Repeat Manipulation Under Anesthesia and Revision Surgery for Stiffness After Total Knee Arthroplasty

Introduction

Manipulation under anesthesia (MUA) is a first-line treatment for stiffness after total knee arthroplasty (TKA), but predicting outcomes after MUA can be difficult.

Purpose

We sought to determine the association between pre-MUA range-of-motion (ROM) and the risk of repeat MUA and revision in patients who underwent primary TKA.

Methods

We conducted a retrospective review of 543 MUAs for stiffness at a single institution. Mean age was 62.5 years, and 64% were female. Second MUA or revision TKA were considered failures of treatment. Penalized logistic regression models were used to assess risk factors for failures. The Kaplan-Meier survivorship was used to examine survivorship free from second MUA or revision.

Results

Before and after MUA, there was significant improvement in knee flexion (78.0° vs 112.8°, respectively) and extension (4.1° vs 0.8°, respectively); 6.4% of patients required repeat MUA and 5.3% required revision TKA. Survivorship free of second MUA was 90.9%, revision for stiffness was 92.4%, and all-cause revision was 88.2% at 2 years post-MUA. Patients with pre-MUA flexion contracture of ≥5° were more likely to undergo second MUA revision for stiffness and any revision. There were significant improvements in patient-reported outcomes postoperatively.

Conclusions

This retrospective chart review suggests that MUA is an effective treatment for post-TKA stiffness, with good early survivorship, and that worse pre-MUA ROM is associated with MUA failure and need for repeat MUA or revision. This information may have implications for patient counseling and management.

Shoulder Adhesive Capsulitis Prior to Total Knee Arthroplasty is Associated With Increased Rates of Postoperative Stiffness Requiring Manipulation Under Anesthesia and Arthroscopic Lysis of Adhesions

BACKGROUND

Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions.

METHODS

This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years).

RESULTS

Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P > .05).

CONCLUSIONS

Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA.

LEVEL OF EVIDENCE

This is a level III prognostic study.

Use of Botulinum Toxin A to Manage Hamstring-Induced Flexion Contracture Following Total Knee Arthroplasty: A Case Series

Introduction Flexion contractures following total knee arthroplasty (TKA) greatly affect patient function and satisfaction. Botulinum toxin A (BTX) has been described in the literature as a means of addressing post-operative flexion contractures due to hamstring muscle rigidity. Methods We retrospectively report a case series of eight patients with range of motion (ROM) who developed a flexion contracture status post-TKA and were managed with the use of physical therapy, diagnostic hamstring lidocaine injections, and therapeutic hamstring BTX injections. Results All patients had an improvement in extension ROM following diagnostic lidocaine hamstring injections and were therefore considered candidates for therapeutic hamstring BTX injections. Prior to therapeutic hamstring BTX injections, patients had an average flexion contracture of 19° (range: 15°-22°). All patients had an improvement in extension ROM two to four weeks following the therapeutic hamstring BTX injection, with an average improvement in ROM of 7° (range: 2°-19°). At the final follow-up, all patients continued to sustain an improvement in extension ROM with an average deficit of 9° (range: 0°-17°). Conclusion Our case series highlights the use of diagnostic hamstring lidocaine injections to confirm hamstring rigidity as an etiology for flexion contracture following TKA. In addition, we showed a persistent improvement in flexion contracture for all patients after hamstring BTX injections. Therefore, when the appropriate patient is selected, BTX may provide an additional treatment option for a flexion contracture following 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.

Polyethylene exchange versus full component revision for arthrofibrosis following total knee arthroplasty: A retrospective cohort analysis

Introduction

Arthrofibrosis occurs in up to 10% of patients who undergo total knee arthroplasty (TKA). For cases that are not amenable to manipulation under anesthesia (MUA), there is little consensus on how many components should be revised. We compared outcomes of polyethylene exchanges, when doing lysis of adhesions (LOA) versus full component revision. Specifically, we assessed: (1) re-operation rates at one and two years; (2) rates of surgical complications at one year; and (3) associated risk factors for requiring a LOA.

Methods

A database queried all patients who underwent revision TKA for arthrofibrosis. A total of 2410 patients were identified, 1120 (46.5%) of which underwent all-component knee revision, while the remaining 1290 (53.5%) underwent polyethylene spacer revision. Multivariate logistic regressions assessed re-operation rates and risk factors for requiring LOA.

Results

The incidence and odds of re-operation within one year following polyethylene exchange was not significantly different than full component revision (10.9 versus 12.9%, odds ratio (OR) 0.83, 95% confidence interval (CI) [0.64-1.06], p = 0.145). However, the adjusted models for re-operation within one- and two-years following LOA in the form of polyethylene exchange revision was significantly higher than the full component revision cohort (OR 1.52 CI [1.07-2.17], p = 0.022 and OR 1.44 CI [1.06-1.97] p = 0.022). Risk factors associated with the need for lysis of adhesions included age less than 60 years, depression, fibromyalgia, and anxiety.

Conclusions

Full component revision TKA for arthrofibrosis was associated with lower two-year re-operation rate than polyethylene exchange. Risk factors for LOA include younger age and fibromyalgia.

Patient reported outcomes do not correlate to functional knee recovery and range of motion in total knee arthroplasty

Background

Many total knee arthroplasty (TKA) patients exhibit continued pain and limited function following surgery. Determining TKA outcomes is typically reliant on post-operative evaluations and completing patient-reported outcomes (PROMs). Due to low compliance rates, it is essential to identify new strategies for monitoring patients. The purpose of this analysis was to assess the correlations between gait kinematics, PROMs, and knee range of motion (ROM).

Methods

130 patients (75 female) received Persona IQ TKA (Zimmer Biomet, Warsaw, IN, USA) which includes a stem extension with embedded accelerometer and gyroscope. PROM scores were compared at baseline and 6 weeks post-TKA using a paired t-test. Gait kinematics were recorded daily via the Persona IQ stem extension. Pearson's correlation coefficients were derived between PROMs and average gait kinematics.

Results

Knee Injury and Osteoarthritis Outcome Score (KOOS Jr.) and Veterans RAND 12 (VR-12) physical scores improved following surgery (p ≤ 0.001, p = 0.003, respectively). Weak statistically significant correlations were found between PROMS and gait kinematics.

Conclusion

Weak correlations between PROMs and gait kinematics indicate patient perception of improvement and objectively measured functional status may not be interchangeable. Further, compliance with Persona IQ data reached 95.4-97.7% (depending on the parameter) at 6 weeks following surgery, a 20% higher compliance rate over PROMs. Daily functional measurements provide insight into the patient's progression and may be useful in detecting poor outcomes.

The Cost of Stiffness After Total Knee Arthroplasty

BACKGROUND

Stiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact.

METHODS

An observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options.

RESULTS

The prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA.

CONCLUSION

Patients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.

Manipulation Following Primary Total Knee Arthroplasty is Associated With Increased Rates of Infection and Revision

BACKGROUND

Stiffness following total knee arthroplasty (TKA) is a disabling complication and manipulation under anesthesia (MUA) is often performed as an early intervention. Few studies have focused on the revision risk, infection risk, demographics, and clinical outcomes in Medicare patients undergoing MUA following primary TKA.

METHODS

We reviewed 142,440 patients who had primary TKA from a national database and identified 3,652 patients (2.6%) who underwent MUA. Patient demographics and comorbid conditions were evaluated to identify risk factors. Incidence of revision and periprosthetic joint infection (PJI) at 1-, 2-, and 5-year time points in a cohort of MUA patients was compared to patients who did not undergo MUA. Multivariate Cox regressions were used for statistical analyses.

RESULTS

The incidence of MUA was higher in Black versus White individuals (4.1 versus 2.5%, P < .001). Revision risk was significantly greater in the MUA group at 1-, 2-, and 5-year time points with a hazard ratio (HR) of, 3.81, 3.90, and 3.22 respectively, P < .001. One- and 2-year revision risk was significantly greater when MUA occurred at 6 to 12 months post-TKA when compared to <3 months, P < .05. Risk of PJI was significantly greater in the MUA group with a HR of 2.2, 2.2, and 2.1 at 1, 2, and 5 years, respectively P < .001.

CONCLUSION

The incidence of MUA was 2.6%. There was an increased incidence of revision surgery and PJI in patients undergoing MUA. Patients at increased risk for stiffness following TKA should be closely monitored and treated with early intervention to minimize risk of poor outcomes.

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.

Understanding rates, risk factors, and complications associated with manipulation under anesthesia after total knee arthroplasty (TKA): An analysis of 100,613 TKAs

BACKGROUND

Considering the growing adoption of technology-assisted total knee arthroplasties (TKA), previous database studies evaluating post-operative stiffness may be outdated. The present study aimed to: (1) evaluate the incidence of manipulation under anesthesia (MUA) after primary TKA; (2) determine independent risk factors for MUA; and (3) assess complications after MUA.

METHODS

Primary TKAs, with at least 6-month follow-up, were identified from the Florida State Inpatient Database (January 2016-June 2018) and linked to outpatient records from the Florida State Ambulatory Surgery and Services Database. Multivariable regression analyses were performed to compare patient factors and complications (e.g., mechanical, non-mechanical, infectious) associated with MUA, while adjusting for baseline demographics, comorbidities, use of robotic- and computer-technologies, time to MUA (0-3, 3-12, or >12 months), and need for repeat MUA (one-time vs >1).

RESULTS

The MUA rate was 2.8% (2821 of 100,613). Being younger, a woman, Black or Hispanic; having private or self-pay insurance; and conventional TKA were associated with significantly higher odds of undergoing MUA. Higher rates of mechanical complications and acute posthemorrhagic anemia were observed in the MUA cohort. Time to MUA, repeat MUA, and baseline demographics were not associated with complication rates among the MUA cohort.

CONCLUSION

Overall, 1 in 36 patients underwent MUA after primary TKA. Several non-modifiable patient characteristics, such as Black or Hispanic race, female sex, and younger age were associated with an increased risk of MUA. However, technology-assisted TKA might help to decrease the risk of MUA.

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.].

Perioperative Use of Antifibrotic Medications Associated With Lower Rate of Manipulation After Primary TKA: An Analysis of 101,366 Patients

BACKGROUND

Several commonly prescribed medications have known antifibrotic properties and have been shown to reduce postoperative scar formation in other clinical areas, but it is unknown whether the use of such medications perioperatively in patients undergoing TKA may improve rates of postoperative stiffness.

METHODS

A large US employer-sponsored healthcare database (Truven Marketscan) was queried for patients who underwent elective primary TKA for primary osteoarthritis between 2015-2019. Demographic information and comorbidities were recorded, along with whether patients were prescribed one of several medications with known antifibrotic properties during the three months before or after surgery.

RESULTS

Complete data were available for 101,366 patients undergoing TKA, of which 4,536 underwent MUA (4.5%). Perioperative use of any antifibrotic medication was associated with a lower likelihood of undergoing MUA (P < .001). When controlling for age, sex, comorbidities, opioid use, length of stay, among other variables, perioperative use of specific ACE inhibitors (OR 0.91, CI 0.84-1, P = .042), COX-2 inhibitors (OR 0.88, CI 0.81-0.96, P = .002), and angiotensin II receptor blockers, specifically losartan (OR 0.80, CI 0.70-0.91, P = .007) all remained significantly associated with lower rates of MUA.

CONCLUSION

This study, spanning over a hundred thousand primary TKA procedures over a recent five-year period, demonstrates an association between perioperative use of specific medications with antifibrotic properties and a decreased rate of MUA. These data will help inform future studies aimed to prospectively evaluate the potential of antifibrotic medications in preventing postoperative stiffness in high-risk patients undergoing knee arthroplasty.

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.

Aspirin Administered for Venous Thromboembolism Prophylaxis May Protect Against Stiffness Following Total Knee Arthroplasty

BACKGROUND

Aspirin has become the main agent for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA). This study assessed whether aspirin is associated with less knee stiffness compared to warfarin and other chemoprophylaxis agents.

METHODS

This is a retrospective review of all primary and revision TKAs performed between January 2009 and October 2020 at a high volume institution. Demographics, comorbidity data, and operative variables were extracted from medical records. VTE prophylaxis administered during this time period included aspirin, warfarin, and "others" (factor Xa, unfractionated heparin, low-molecular-weight heparin, fondaparinux, adenosine diphosphate receptor inhibitor, and direct thrombin inhibitor). The primary outcome assessed was manipulation under anesthesia (MUA) performed within 6 months of index surgery. Secondary outcome included major bleeding events. Univariate followed by multivariate regression analyses were performed.

RESULTS

A total of 15,903 cases were included in the study, of which 531 (3.3%) patients developed stiffness that required MUA. The rates of MUA were 2.7% (251/9223) for patients receiving aspirin, 4.2% (238/5709) for patients receiving warfarin, and 4.3% (42/971) for all others (P's < .001). Multivariate regression analysis confirmed that aspirin is associated with lower rates of VTE compared to warfarin (adjusted odds ratio 1.423, 95% confidence interval 1.158-1.747, P < .001) and compared to other anticoagulation medications (adjusted odds ratio 1.742, 95% confidence interval 1.122-2.704, P = .013). Major bleeding events were also significantly lower in patients who received aspirin compared to the other 2 groups (P's = .001).

CONCLUSION

Aspirin prophylaxis is associated with lower rates of MUA following TKA compared to warfarin and other VTE chemoprophylactic agents when grouped together.

Arthrofibrosis Nightmares: Prevention and Management Strategies

Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathologic periarticular fibrosis and symptomatic joint stiffness. The knee, elbow, and shoulder are particularly susceptible to AF, often in the setting of trauma, surgery, or adhesive capsulitis. Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss. Reliable nonoperative modalities exist and outcomes are improved when etiology, joint involved, and level of dysfunction are considered in the clinical decision making process. Surgical procedures should be reserved for cases recalcitrant to nonoperative measures. The purpose of this review is to provide an overview of the current understanding of AF pathophysiology, identify common risk factors, describe prevention strategies, and outline both nonoperative and surgical treatment options. This manuscript will focus specifically on sterile AF of the knee, elbow, and shoulder.

Angiotensin Receptor Blockers Were Not Associated With Decreased Arthrofibrosis After Total Knee Arthroplasty

Stiffness after total knee arthroplasty (TKA) remains a challenging problem. Angiotensin receptor blockers (ARBs) have been associated with decreased muscle fibrosis. The aim of this study was to evaluate whether perioperative use of ARBs was associated with a reduction in arthrofibrosis and manipulation under anesthesia (MUA) in patients undergoing primary TKA at 90 days and 1 year postoperative. In this retrospective study, the authors used a national database to evaluate patients undergoing TKA for primary osteoarthritis from 2007 to 2017. They evaluated patients with filled prescriptions for ARBs within the study time frame and the specific type of ARB and its association with arthrofibrosis and MUA. After adjusting for age, sex, a comorbidity index, and obesity, any ARB or specific ARBs were not associated with a reduction in the rate of arthrofibrosis or MUA after TKA (P≥.05). Male sex, age 55 years or older, and obesity were associated with a reduction in the rate of arthrofibrosis and MUA after TKA (P≤.05). Studies should be performed to evaluate ARBs to see whether there is a more specific role in preventing joint stiffness in certain patient subpopulations following TKA. [Orthopedics. 2021;44(2):e274-e280.].

Accuracy of Measuring Knee Flexion after TKA through Wearable IMU Sensors

Wearable sensors have the potential to facilitate remote monitoring for patients recovering from knee replacement surgery. Using IMU sensors attached to the patients' leg, knee flexion can be monitored while the patients are recovering in their home environment. Ideally, these flexion angle measurements will have an accuracy and repeatability at least on par with current clinical standards. To validate the clinical accuracy of a two-sensor IMU system, knee flexion angles were measured in eight subjects post-TKA and compared with other in-clinic angle measurement techniques. These sensors are aligned to the patients' anatomy by taking a pose resting their operated leg on a box; an initial goniometer measurement defines the patients' knee flexion while taking that pose. The repeatability and accuracy of the system was subsequently evaluated by comparing knee flexion angles against goniometer readings and markerless optical motion capture data. The alignment pose was repeatable with a mean absolute error of 1.6 degrees. The sensor accuracy through the range of motion had a mean absolute error of 2.6 degrees. In conclusion, the presented sensor system facilitates a repeatable and accurate measurement of the knee flexion, holding the potential for effective remote monitoring of patients recovering from knee replacement surgery.

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.

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.

Effects of electromyography biofeedback for patients after knee surgery: A systematic review and meta-analysis

There has been no systematic review evaluating the efficacy of electromyography (EMG) biofeedback after knee surgery recently. This meta-analysis aimed to determine whether EMG-biofeedback is effective for improving the range of motion (ROM), physical function, and pain relief in patients after knee. Randomized controlled trials (RCTs) assessing the effect of EMG-biofeedback after any knee surgery were retrieved from EMBASE, PubMed, Cochrane Library, Physiotherapy Evidence Database, ClinicalTrials.gov, ProQuest. This review identified 773 unique studies, and six RCTs were in the final meta-analysis. EMG-Biofeedback treatment has a significant difference compared to other rehabilitation therapy in knee ROM improving (SMD = -0.48, 95% CI = -0.82 to -0.14, p = 0.006, I² = 37%). Moreover, there was no significant difference in pain (SMD = -0.33, 95% CI = -0.67 to0.02, p = 0.07, I² = 41%) and physical function scores (MD = 1.83, 95% CI = -3.48 to7.14, p = 0.50, I² = 0%). The results illustrate that EMG-biofeedback can improve knee ROM in patients after knee surgery. However, it is not superior to other rehabilitation methods for pain relief and physical function improvement.

Home physiotherapy with vs. without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty

Abstract

The aim of this retrospective cohort study was to compare home physiotherapy with or without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty.

Methods

A total of 900 patients (including 810 females and 90 males) who had undergone total knee arthroplasty were divided into group A (n = 300) and group B (n = 600). Patients in group A had home physiotherapy on their own after discharge from hospital. The physiotherapist did not visit them at home. Patients in group B received home physiotherapy under supervision of physiotherapist for 6 weeks after discharge from hospital. Patients’ age, range of motion of the knee, and forgotten joint score-12 were assessed. A p < 0.05 was considered statistically significant.

Results

In group A, the mean age was 69.1 ± 14.3 years (range: 58 to 82 years); in group B, the mean age was 66.5 ± 15.7 years (range: 56 to 83 years) (p > 0.05). Preoperatively, the mean range of motion of the knee in group A and B was 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p > 0.05). The mean forgotten joint score-12 of group A and B were 11.90 ± 11.3 and 11.72 ± 12.1 (p > 0.05), respectively. Six weeks after total knee arthroplasty, the mean ROM of the knee in group A and B was 109.7° ± 22.3° and 121° ± 21.5°, respectively (p < 0.05). The mean postoperative forgotten joint score-12 of the group A and B was 24.5 ± 16.4 and 25.6 ± 17.4, respectively (p > 0.05). The rate of manipulation under anaesthesia was 3% in group A and 0.2% in group B (p < 0.05).

Conclusion

After total knee arthroplasty, frequent physiotherapist’s instruction helps the patients improve knee exercises and therefore decrease the risk of revision surgery. The home physiotherapy under supervision of physiotherapist lowers the rate of manipulation under anaesthesia.

Level of evidence

Therapeutic study, Level IIa.

Lysis of Adhesion for Arthrofibrosis After Total Knee Arthroplasty Is Associated With Increased Risk of Subsequent Revision Total Knee Arthroplasty

BACKGROUND

The aim of this study is to determine incidence of lysis of adhesion (LOA) for postoperative arthrofibrosis following primary total knee arthroplasty (TKA), patient factors associated with LOA, and impact of LOA on revision TKA.

METHODS

Patients who underwent primary TKA were identified in the Humana and Medicare databases. Patients who underwent LOA within 1 year after TKA were defined as the "LOA" cohort. Multiple binomial logistic regression analyses were performed to identify patient factors associated with undergoing LOA within 1 year after index TKA, and identify risk factors including LOA on risk for revision TKA within 2 years of index TKA.

RESULTS

In total, 58,538 and 48,336 patients underwent primary TKA in the Medicare and Humana databases, respectively. Incidence of LOA within 1 year after TKA was 0.56% in both databases. Age <75 years was a significant predictor of LOA in both databases (P < .05 for both). Incidence of revision TKA was significantly higher for the "LOA" cohort when compared to the "TKA Only" cohort in both databases (P < .0001 for both). LOA was the strongest predictor of revision TKA within 2 years after index TKA in both databases (P < .0001 for both). Additionally, age <65 years, male gender, obesity, fibromyalgia, smoking, alcohol abuse, and history of anxiety or depression were independently associated with increased odds of revision TKA within 2 years after index TKA (P < .05 for all).

CONCLUSION

Incidence of LOA after primary TKA is low, with younger age being the strongest predictor for requiring LOA. Patients who undergo LOA for arthrofibrosis within 1 year after primary TKA have a substantially high risk for subsequent early revision TKA.

LEVEL OF EVIDENCE

III, Retrospective Cohort Study.

Range of Motion at Discharge Predicts Need for Manipulation following Total Knee Arthroplasty

Stiffness following total knee arthroplasty (TKA) is a common complication that can result in unsatisfactory outcomes. Manipulation under anesthesia (MUA) has been widely employed to treat this problem. It is uncertain whether an association exists between range of motion (ROM) at discharge and need for MUA following primary TKA.A retrospective review of an institutional joint registry identified cases of primary TKA performed by three surgeons at a single institution over a 22-month period. A logistic regression model was used to examine the association between ROM at discharge and subsequent MUA controlling for confounding variables related to patient demographics and perioperative details. Of the 1,546 cases identified, 113 (7.3%) cases underwent subsequent MUA. As discharge ROM increased, manipulation rates decreased. Patients with discharge flexion <65 degrees were more likely to undergo MUA than those with flexion >90 degrees (odds ratio [OR] = 17.57, 95% confidence interval [CI] [7.97, 38.73], p < 0.0001). The largest differential in odds of MUA was observed between the <65 degrees at discharge group (OR = 17.57) and the 65 ≤ 75 degrees at discharge group (OR = 7.89). At discharge ROM of 80 ≤ 90 degrees of flexion, patients had more than a twofold increase in odds of MUA relative to those in the >90 degrees group (OR = 2.22, 95% CI [1.20, 4.10], p = 0.011). The results of this study suggest that there is an association between lower ROM at discharge and greater risk of MUA post primary TKA. Counseling patients in regard to discharge ROM and associated risk of MUA may optimize gains in ROM during recovery.

Prior Manipulation under Anesthesia is a Predictor of Contralateral Manipulation in Staged Bilateral Total Knee Arthroplasty

BACKGROUND

There are many risk factors for arthrofibrosis and manipulation under anesthesia (MUA) following total knee arthroplasty (TKA). However, no study has elucidated whether a history of MUA increases the risk of contralateral MUA in patients undergoing staged bilateral TKA.

METHODS

A retrospective review of an institutional database of TKAs was performed. All patients aged ≥18 years who underwent primary staged bilateral TKAs were screened for inclusion. Staged bilateral TKAs were viewed as 2 distinct events based on the temporal order in which they occurred: TKA#1 (occurred first) and TKA#2 (occurred second). Following TKA#1, patients were split into 2 groups: those who underwent MUA (Group MANIP) and those who did not (Group NO MANIP). The subsequent risk of undergoing MUA following TKA#2 was then assessed and compared between the 2 groups. Chi-squared tests were used for comparison.

RESULTS

A total of 5,330 patients who underwent primary uncomplicated staged bilateral TKAs (10,660 knees) during the study period were identified. Overall, 2.1% of patients underwent MUA following TKA#1 and 1.9% of patients underwent MUA following TKA#2. In the MANIP group, 21.4% of patients underwent MUA following TKA#2, while only 1.5% underwent MUA in the NO MANIP group. This 14.3-fold increase in the risk of MUA in the MANIP group following TKA#2 was statistically significant (21.4% vs 1.5%, absolute risk reduction = 19.9%, relative risk reduction = 93.0%, P < .0001).

CONCLUSION

Patients who undergo MUA during the first TKA of a staged bilateral TKA are 14.3 times more likely to undergo a subsequent MUA than those who did not undergo MUA following their first 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.

Web-Based Self-Directed Exercise Program Is Cost-Effective Compared to Formal Physical Therapy After Primary Total Knee Arthroplasty

BACKGROUND

Web-based physical therapy (WBPT) is a potential means to reduce costs following total knee arthroplasty (TKA). Although outcomes data support the use of self-directed therapy after TKA, there is a paucity of literature evaluating its cost-effectiveness. This study aimed to determine utilization trends of either outpatient physical therapy (OPPT) or WBPT after TKA, assess the outcomes of patients based on their use of WBPT, OPPT, or both, and evaluate OPPT costs based on the amount of WBPT used.

METHODS

A retrospective review of 701 patients (731 TKAs) was performed. Patients were given a prescription for OPPT and access to a self-directed WBPT program. Functional scores were obtained preoperatively and 6 months postoperatively, and the rate of manipulation under anesthesia (MUA), range of motion, and PT costs were recorded.

RESULTS

About 49.8% of patients utilized WBPT, 34.7% of patients utilized WBPT and OPPT, and 23% of patients utilized neither source of therapy. Patients that utilized both WBPT and OPPT demonstrated the lowest rates of MUA. There were no differences in postoperative outcomes based on the number of WBPT logins. Overall, PT cost was 3.4× higher for those that underwent MUA. Subgroup analysis of patients that utilized WBPT revealed that the cost and number of PT visits decreased as the number of logins increased. Patients younger than 65 utilized more WBPT and OPPT while demonstrating worse outcomes (lower Knee Injury and Osteoarthritis Outcome Score for Joint Replacement postoperative scores and more MUAs).

CONCLUSION

WBPT can be an effective option to offset costs associated with OPPT, without compromising outcomes.

Molecular pathology of human knee arthrofibrosis defined by RNA sequencing

Arthrofibrosis is an abnormal histopathologic response, is debilitating for patients, and poses a substantial unsolved clinical challenge. This study characterizes molecular biomarkers and regulatory pathways associated with arthrofibrosis by comparing fibrotic and non-fibrotic human knee tissue. The fibrotic group encompasses 4 patients undergoing a revision total knee arthroplasty (TKA) for arthrofibrosis (RTKA-A) while the non-fibrotic group includes 4 patients undergoing primary TKA for osteoarthritis (PTKA) and 4 patients undergoing revision TKA for non-arthrofibrotic and non-infectious etiologies (RTKA-NA). RNA-sequencing of posterior capsule specimens revealed differences in gene expression between each patient group by hierarchical clustering, principal component analysis, and correlation analyses. Multiple differentially expressed genes (DEGs) were defined in RTKA-A versus PTKA patients (i.e., 2059 up-regulated and 1795 down-regulated genes) and RTKA-A versus RTKA-NA patients (i.e., 3255 up-regulated and 3683 down-regulated genes). Our findings define molecular and pathological markers of arthrofibrosis, as well as novel potential targets for risk profiling, early diagnosis and pharmacological treatment of patients.

Manipulation Under Anesthesia After Total Knee: Who Still Requires a Revision Arthroplasty?

BACKGROUND

Stiffness after total knee arthroplasty (TKA) is a multifactorial complication involving patient, implant, surgical technique, and rehabilitation, occasionally necessitating manipulation under anesthesia (MUA) or revision. Few modern databases contain sufficient longitudinal information of all factors. We characterized MUA after primary TKA and identified independent risk factors for revision TKA after MUA from the American Joint Replacement Registry.

METHODS

We retrospectively reviewed primary TKAs for American Joint Replacement Registry patients ≥65 years from January 1, 2012 to 31 March, 2019. We linked these to the Centers for Medicare and Medicaid Services database to identify MUA and revision TKA procedure codes. We compared groups with chi-squared testing, identifying independent risk factors for subsequent revision with binary logistic regression presented as odds ratios with 95% confidence intervals.

RESULTS

Of 664,604 primary TKAs, 3918 (0.6%) underwent MUA after a median of 2.0 ± 1.0 months. Revision surgery occurred in 131 (3.4%) MUA patients after a median of 9.0 months. Timing of MUA was not different between revision and no revision patients (P = .09). Patients undergoing MUA compared to no MUA were older (age 71.5 vs 70.7, P < .01), predominantly female (63.9% vs 61.2%, P < .01), current/former tobacco users (24.2% vs 13.3%, P < .01), with osteoarthritis diagnoses (98.0% vs 84.3%, P < .01). Independent risk factors for revision after MUA were male gender (1.56, 1.09-2.22).

CONCLUSION

The incidence of MUA after primary TKA is low (0.6%) in Medicare patients ≥65 years of age; 3.4% progress to revision after a median of 9 months. Being male was significantly associated with revision TKA after MUA.

Risk factors for manipulation under anaesthesia after total knee arthroplasty

Aims

Postoperative range of movement (ROM) is an important measure of successful and satisfying total knee arthroplasty (TKA). Reduced postoperative ROM may be evident in up to 20% of all TKAs and negatively affects satisfaction. To improve ROM, manipulation under anaesthesia (MUA) may be performed. Historically, a limited ROM preoperatively was used as the key harbinger of the postoperative ROM. However, comorbidities may also be useful in predicting postoperative stiffness. The goal was to assess preoperative comorbidities in patients undergoing TKA relative to incidence of postoperative MUA. The hope is to forecast those who may be at increased risk and determine if MUA is an effective form of treatment.

Methods

Prospectively collected data of TKAs performed at our institution’s two hospitals from August 2014 to August 2018 were evaluated for incidence of MUA. Comorbid conditions, risk factors, implant component design and fixation method (cemented vs cementless), and discharge disposition were analyzed. Overall, 3,556 TKAs met the inclusion criteria. Of those, 164 underwent MUA.

Results

Patients with increased age and body mass index (BMI) had decreased likelihood of MUA. For every one-year increase in age, the likelihood of MUA decreased by 4%. Similarly, for every one-unit increase in BMI the likelihood of MUA decreased by 6%. There were no differences in incidence of MUA between component type/design or fixation method. Current or former smokers were more likely to have no MUA. Surprisingly, patients discharged to home health service or skilled nursing facility were approximately 40% and 70% less likely than those discharged home with outpatient therapy to be in the MUA group. MUA was effective, with a mean increased ROM of 32.81° (SD 19.85°; -15° to 90°).

Conclusion

Younger, thinner patients had highest incidence of MUA. Effect of discharge disposition on rate of MUA was an important finding and may influence surgeons’ decisions. Interestingly, use of cement and component design (constraint) did not impact incidence of MUA. Level of Evidence II: Prospective cohort study. Cite this article: Bone Joint J 2020;102-B(6 Supple A):66–72.

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.

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.

Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from "The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man"

OBJECTIVE

We aimed to test whether a national Enhanced Recovery After Surgery (ERAS) Programme in total knee replacement (TKR) had an impact on patient outcomes.

DESIGN

Natural-experiment (April 2008-December 2016). Interrupted time-series regression assessed impact on trends before-during-after ERAS implementation.

SETTING

Primary operations from the UK National Joint Registry (NJR) were linked with Hospital Episode Statistics (HES) data which contains inpatient episodes undertaken in National Health Service (NHS) trusts in England, and Patient Reported Outcome Measures (PROMs).

PARTICIPANTS

Patients undergoing primary planned TKR aged ≥18 years.

INTERVENTION

ERAS implementation (April 2009-March 2011).

OUTCOMES

Regression coefficients of monthly means of Length of stay (LOS), bed day costs, change in Oxford knee scores (OKS) 6-months after surgery, complications (at 6 months), and rates of revision surgeries (at 5 years).

RESULTS

486,579 primary TKRs were identified. Overall LOS and bed-day costs decreased from 5.8 days to 3.7 and from £7607 to £5276, from April 2008 to December 2016. Oxford knee score (OKS) change improved from 15.1 points in April 2008 to 17.1 points in December 2016. Complications decreased from 4.1 % in April 2008 to 1.7 % in March 2016. 5-year revision rates remained stable at 4.8 per 1000 implants years in April 2008 and December 2011. After ERAS, declining trends in LOS and bed costs slowed down; OKS improved, complications remained stable, and revisions slightly increased.

CONCLUSIONS

Different secular trends in outcomes for patients having TKR have been observed over the last decade. Although patient outcomes are better than a decade ago ERAS did not improve them at national level.

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.

Tibiofemoral joint mobilizations following total knee arthroplasty and manipulation under anesthesia

STUDY DESIGN

Case report.

BACKGROUND

The purpose of this case report is to describe the use of tibiofemoral joint mobilizations to improve knee flexion in a patient with arthrofibrosis following total knee arthroplasty (TKA) and failed manipulation under anesthesia (MUA).

CASE DESCRIPTION

A 62-year-old female presented to physical therapy 15 days after TKA with full knee extension, 45 deg of active knee flexion, 48 deg of passive knee flexion, pain, and a Lower Extremity Functional Scale (LEFS) score of 28.

INTERVENTIONS/OUTCOMES

A multimodal intervention strategy was used initially with minimal improvement in knee flexion. The patient was diagnosed with fibrosis and MUA was performed. Passive knee flexion was 80 deg before MUA and 75 deg after MUA. Focused grade III and IV tibiofemoral joint mobilizations were used after MUA. At discharge, the patient had 90 deg of active and 116 deg of passive knee flexion, no pain, and an LEFS score of 80.

DISCUSSION

A conventional multimodal intervention approach was ineffective for a patient who developed arthrofibrosis following TKA. A focused intervention approach of grade III and IV tibiofemoral joint mobilizations improved knee flexion, pain, and function following TKA and failed MUA.

The effect of a preoperative education class on the rate of manipulation under anesthesia after total knee arthroplasty in a veterans population

Background

Arthrofibrosis after total knee arthroplasty (TKA) is a common complication, potentially occurring in up to 25% of patients, and may be treated during the early recovery period by manipulation under anesthesia (MUA). The majority of preoperative factors that predispose patients to postoperative stiffness are patient specific and not modifiable. The United States Veteran Affairs is a particularly challenging group given a higher baseline rate of medical comorbidities and opioid dependence than the general population. Patient education about postoperative expectations and complications has been shown to improve outcomes in certain orthopedic procedures. This retrospective study aims to determine if preoperative counseling for veterans undergoing primary TKA reduces the rate of postoperative stiffness, and consequently MUA, in this subset of patients.

Methods

We evaluated the medical records of 244 veterans at a single veteran affairs hospital who underwent 278 TKAs during a 6-year period under one surgeon. Patients were separated into groups based on attendance in the preoperative counseling session. Effects of various factors, including age, sex, body mass index, preoperative knee range of motion, and history of previous knee surgery, were compared between these 2 cohorts.

Results

Attendance in the preoperative course did not have a statistically significant impact on the rate of manipulation (odds ratio [OR], 1.07). Female gender and prior manipulation had an increased OR of knee manipulation, whereas age > 65 years had a decreased OR that did not reach significance.

Conclusions

Our results show that preoperative counseling did not have a benefit in terms of postoperative MUA rates in veterans. Preoperative education may be helpful for setting appropriate expectations of pain, recovery, and function after total joint arthroplasty and may be useful in an online or video format in small practices in which cost may be prohibitive. Further studies are needed to determine whether they provide any benefit in postoperative arthrofibrosis rates.

Postoperative Stiffness Requiring Manipulation Under Anesthesia Is Significantly Reduced After Simultaneous Versus Staged Bilateral Total Knee Arthroplasty

BACKGROUND

For patients with symptomatic bilateral knee arthritis, it is unknown whether the risk of developing stiffness requiring manipulation under anesthesia postoperatively is higher or lower for those undergoing simultaneous bilateral total knee arthroplasty (TKA) compared with those having staged bilateral TKA. Therefore, we undertook this study to evaluate the risk of requiring manipulation under anesthesia in staged versus simultaneous bilateral TKA as well as patients undergoing unilateral TKA.

METHODS

We utilized the California Patient Discharge Database, which is linked with the California Emergency Department, Ambulatory Surgery, and master death file databases. Using a literature-based estimate of the number of patients who failed to undergo the second stage of a staged bilateral TKA, replacement cases were randomly selected from patients who had unilateral TKA and were matched on 8 clinical characteristics of the patients who had staged bilateral TKA. Hierarchical multivariate logistic regression was performed to determine the risk-adjusted odds of manipulation in patients undergoing unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA using yearly hospital TKA volume as a random effect. Adjustment was made to allow fair comparison of the outcome at 90 and 180 days of follow-up after staged compared with simultaneous bilateral TKA.

RESULTS

During the time period from 2005 through 2013, the cumulative incidence of manipulation within 90 days was 2.14% for unilateral TKA (4,398 events per 205,744 patients), 2.11% for staged bilateral TKA (724 events per 34,352 patients), and 1.62% for simultaneous bilateral TKA (195 events per 12,013 patients). At 180 days of complete follow-up, the cumulative incidence of manipulation was 3.07% after unilateral TKA (6,313 events per 205,649 patients), 2.89% after staged bilateral TKAs (957 events per 33,169 patients), and 2.29% after simultaneous bilateral TKA (267 events per 11,653 patients). With multivariate analyses used to adjust for relevant risk factors, the 90-day odds ratio (OR) of undergoing manipulation after simultaneous bilateral TKA was significantly lower than that for unilateral TKA (OR = 0.70; 95% confidence interval [CI], 0.57 to 0.86) and staged bilateral TKA (OR = 0.71; 95% CI, 0.57 to 0.90). Similarly, at 180 days, the odds of undergoing manipulation were significantly lower after simultaneous bilateral TKA than after both unilateral TKA (OR = 0.71; 95% CI, 0.59 to 0.84) and staged bilateral TKA (OR = 0.76; 95% CI, 0.63 to 0.93). The frequency of manipulation was significantly associated with younger age, fewer comorbidities, black race, and the absence of obesity.

CONCLUSIONS

Although the ORs were small (close to 1), simultaneous bilateral TKA had a significantly decreased rate of stiffness requiring manipulation under anesthesia at 90 days and 180 days after knee replacement compared with that after staged bilateral TKA and unilateral TKA.

LEVEL OF EVIDENCE

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

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.

Higher Total Knee Arthroplasty Revision Rates Among United States Blacks Than Whites: A Systematic Literature Review and Meta-Analysis

BACKGROUND

Reportedly 2% to 5.7% of total knee arthroplasties (TKAs) require revision within 5 years. The purpose of this study was to determine whether blacks are at higher risk of TKA revision than whites in the United States.

METHODS

We performed a systematic review of English-language articles published from 2000 to 2015. Study inclusion criteria were (1) performance of the study in the United States, (2) TKA as the primary procedure studied, (3) a follow-up period at least 2 years, (4) reporting of revision rates, and (5) analysis of patient race as an independent predictor of revision. We then performed a random-effects meta-analysis to calculate a pooled hazard ratio for TKA revision in blacks compared with whites.

RESULTS

A total of 4,286 studies were identified and screened by title; 106, by abstract; and 24, by full text. Six studies met the inclusion criteria. Only 4 of the 6 studies could undergo meta-analysis because of overlapping study populations in 3 of them. The meta-analysis represented 451,960 patients who underwent TKA, of whom 28,772 (6.4%) were black. Of the total, 31,568 patients (7.0%) underwent revision surgery. The risk of revision TKA was significantly higher among blacks than whites (pooled hazard ratio, 1.38; 95% confidence interval, 1.20 to 1.58; p < 0.001). Analysis of the 3 studies with overlapping study populations demonstrated discordant results as a result of adjustment compared with non-adjustment for insurance eligibility, a surrogate for socioeconomic status.

CONCLUSIONS

Blacks in the United States are at higher risk of revision TKA than whites. Socioeconomic status contributed to revision risk and is an important confounder in analyses of race.

LEVEL OF EVIDENCE

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

Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair

BACKGROUND

Although the general health consequences of tobacco use have been well defined, the effects of perioperative tobacco use on arthroscopic shoulder procedures remain largely unknown. The purpose of this study is to use a national database to investigate the relationship between tobacco use and rates of superior labrum anterior and posterior (SLAP) repair failure and postoperative infection after primary SLAP repair compared with matched controls.

METHODS

A national private-payer insurance database was queried for patients who underwent arthroscopic primary SLAP from 2005-2012. These patients were divided into tobacco use and non-tobacco use cohorts using International Classification of Diseases, Ninth Revision coding. The non-tobacco use patients were then matched to the patients with coded tobacco use. Both cohorts were assessed for postoperative infection within 90 days and subsequent ipsilateral revision SLAP repair or biceps tenodesis within up to 7 years postoperatively.

RESULTS

The incidences of revision SLAP repair or revision to a biceps tenodesis (P = .023) and postoperative infection (P = .034) were significantly higher in patients who used tobacco versus matched controls.

CONCLUSIONS

SLAP repair in patients who use tobacco is associated with significantly increased rates of postoperative infection and revision SLAP repair or conversion to a biceps tenodesis.

Predominance of synovial sensory nerve fibers in arthrofibrosis following total knee arthroplasty compared to osteoarthritis of the knee

BACKGROUND

So far, there exists no golden standard for the treatment of arthrofibrosis (AF) following total knee arthroplasty (TKA). Although pain is a hallmark of AF, nociceptive nerve fibers have never been investigated in affected joint tissue.

METHODS

A total of 24 patients with osteoarthritis (OA) of the knee (n = 12) and post-TKA AF of the knee (n = 12) were included. Along evaluation of typical clinical signs and symptoms by using the Knee Society Clinical Rating System (KSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC index), the innervation of joint tissue was studied by semiquantitative immunofluorescence of nerve fibers.

RESULTS

Patients with AF compared to OA had a lower KSS and lower KOOS. In all compartments (anterior, medial, and lateral recesses), the density of synovial sympathetic nerve fibers was significantly higher in OA compared to AF, which was also true for the density of sensory nerve fibers in the medial and lateral recesses. In synovial tissue of the anterior recess of patients with AF compared to OA, the density of nociceptive sensory nerve fibers was significantly higher relative to sympathetic nerve fibers. This was similarly observed in the neighboring infrapatellar fat pad of the knee.

CONCLUSIONS

Similar as in many painful musculoskeletal diseases, this study indicates that patients with arthrofibrosis of the knee after TKA demonstrate a preponderance of profibrotic sensory nerve fibers over antifibrotic sympathetic nerve fibers. This could serve as a starting point for AF therapy with specific antifibrotic pain medication or regional anesthetic techniques.