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

Evaluating Knee Recovery Beyond Patient Reports: A Comparative Study of Smart Implantable Device-Derived Gait Metrics Versus Patient-Reported Outcome Measures in Total Knee Arthroplasty

BACKGROUND

Total Knee Arthroplasty (TKA) is frequently performed for advanced osteoarthritis, with patient-reported outcome measures (PROMs) traditionally reporting on efficacy. These subjective evaluations, although useful, may inaccurately reflect post-TKA activity levels. With technological advancements, smart implantable devices (SIDs) offer objective, real-time gait metrics, potentially providing a more accurate postoperative recovery assessment. This study compares these objective metrics with PROMs to evaluate TKA success more effectively.

METHODS

We conducted a retrospective cohort study with 88 participants undergoing TKA using a SID. Eligible patients were aged 18 years or older and had advanced osteoarthritis. We excluded those who had bilateral TKAs, joint infections, or neuromuscular disease. The SID system collected daily gait metrics, including step count, distance traveled, walking speed, stride length, cadence, and functional knee range of motion. The PROMs, including Knee Injury and Osteoarthritis Outcome Score-Joint Replacement, Veterans Rand 12 Physical Component Summary, and Veterans Rand 12 Mental Component Summary, were analyzed against SID gait metrics. Among the 88 patients, 80 provided continuous data over 12 weeks.

RESULTS

All gait metrics, except stride length, significantly increased at the 12-week point (P < .05). The PROMs also significantly improved postoperatively (P < .05). Initial low positive correlations between 12-week PROMs and SID metrics decreased after adjusting for demographic variables, leaving only weak correlations between the Veterans Rand 12 Physical Component Summary and Knee Injury and Osteoarthritis Outcome Score-Joint Replacement with functional knee range of motion (r = 0.389, P = .002; r = 0.311, P = .014, respectively), and Veterans Rand 12 Mental Component Summary with step count (r = 0.406, P = .001) and distance traveled (r = 0.376, P = .003).

CONCLUSIONS

This study indicates that both PROMs and SID gait metrics show significant improvements post-TKA, though they correlate weakly with each other, suggesting a possible discrepancy between perceived recovery and actual functional improvement. The SID gait metrics might provide a valuable addition to traditional PROMs by offering an objective representation of physical capabilities unaffected by patient compliance or subjective perceptions of recovery. Further research is needed to validate these findings in larger populations and to explore whether integrating SID metrics can enhance long-term functional outcomes.

Surgically treated acute knee dislocations with knee stiffness perform equally as well as non-stiff knees when treated with arthroscopic arthrolysis

PURPOSE

Postoperative knee stiffness is a common issue in multiligament knee injuries (MLKIs). This study aims to compare outcomes between MLKI patients who underwent postoperative arthroscopic lysis of arthrofibrosis (LOA) for limited range of motion (ROM) and those who did not.

METHODS

Thirty-one patients (10 IIIM, nine IIIL and 12 IV) were included in this retrospective clinical study with acute type III or IV knee dislocations, while two patients were lost to follow up. Thirteen patients underwent LOA at a mean of 18.7 ± 8.4 weeks (Group A), while 18 did not require this intervention (Group B). Patient-reported outcome measures (IKDC, Lysholm, VAS) and ROM were evaluated.

RESULTS

The average follow up period was 31.0 ± 10.2 months. The mean time to LOA was 19.4 ± 7.6 weeks and a significant increase in ROM was observed after LOA (flexion: before LOA: 83.8° ± 19.2, after LOA: 119.6° ± 9.9; P < 0.0001). There were no significant differences between groups regarding clinical scores (Lysholm: Group A 85.0 ± 13.4, Group B 84.6 ± 14.5; IKDC: Group A 74.3 ± 10.8, Group B 76.7 ± 14.7) and ROM (flexion: Group A 118.6° ± 9.8, Group B 124.3° ± 12.8). There were no complications regarding LOA.

CONCLUSIONS

Patients, whether undergoing LOA or not, performed equally well in terms of ROM and clinical scores at final follow up, while timing of LOA appears less critical. LOA is a simple, durable and safe method of treating ROM deficits in patients treated for acute knee dislocation, with very good results.

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.

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.

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.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Complications of Bicruciate-Retaining Total Knee Arthroplasty: The Importance of Alignment and Balance

Bicruciate-retaining total knee arthroplasty (BCR TKA) results in kinematics closer to the native knee and in greater patient satisfaction but information concerning its outcome and complications is lacking.The goal of this study is to report the clinical and radiological outcomes of BCR prosthesis implanted using a spacer-based gap balancing technique and to assess if some preoperative factors are associated with a worse prognosis.A cohort of 207 knees in 194 patients who underwent BCR TKA, with a minimum 1-year follow-up, was retrospectively analyzed.Patients were followed at 6 weeks, 6 months, 1 year, and then every following year postoperatively, and filled questionnaires (Knee Society and Knee injury and Osteoarthritis Outcome Score) at every visit. Clinical and radiological assessments included range of motion, knee alignment, pain, and complications as defined by the Knee Society's Standardized list and definition of Complication of Total Knee Arthroplasty.Forty-three knees (20.8%) suffered major complications. Twenty-one knees (10.1%) underwent revision at an average of 32.1 months after the index procedure. Revision-free survival at 100 months was 85.7%. Revision was performed for aseptic tibial loosening in eight knees (3.9%) and stiffness in five knees (2.4%). There were 29 reoperations other than revision (14.0%), the most frequent procedure being manipulation under anesthesia in 14 knees (6.8%). Minor complications included tendonitis (20.8%), persistent synovitis (6.8%), and superficial wound infections (6.3%).All outcomes scores were greatly improved at the 1-year follow-up compared with preoperatively (p < 0.001). However, maximum flexion at the last follow-up was significantly reduced compared with preoperatively (mean maximum flexion ± standard deviation: 119.9 ± 15.6 vs. 129.9 ± 14.4, p < 0.001). Aseptic tibial loosening was associated with a hypercorrection in varus of preoperative valgus knees (p = 0.012).BCR TKA can give functional results similar to other types of prostheses but involves a substantial risk of complications. Important factors that can explain failed BCR TKA and guide its use were identified, more particularly knee alignment and its role in aseptic tibial loosening.

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.

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.

Intervention of Refractory Arthrofibrosis After Anterior Cruciate Ligament Reconstruction: A Case Report

OBJECTIVES

Although nonsurgical and surgical management of knee arthrofibrosis has been reported in the literature, there is little information on the effect of procedural treatment modalities of refractory arthrofibrosis on clinical outcomes. The purpose of this case report is to describe the intervention of refractory knee arthrofibrosis after anterior cruciate ligament reconstruction and investigate long-term clinical outcomes after procedural intervention.

METHODS

A 27-year-old male presented with decreased range of motion (ROM), patellar mobility, strength, and knee joint function following anterior cruciate ligament reconstruction of his left knee. After failed conservative management, the patient underwent manipulation under anesthesia (MUA) to release scar tissue. Following MUA, the emphasis of comprehensive physiotherapy was on decreasing inflammation, relieving pain, and maintaining patellar mobility while increasing knee joint ROM and strength. Knee ROM, patellofemoral motion, gait, and quadriceps recruitment were measured 3, 6, 12, and 24 months after MUA.

RESULTS

At 2-year follow-up after MUA, the patient continued to present with decreased ROM and quadriceps strength compared to the contralateral knee, but had returned to a running program and reported knee joint dysfunction no longer interfered with his daily activities.

CONCLUSIONS

This case report demonstrates signs and symptoms that could indicate knee arthrofibrosis and introduces procedural intervention for refractory arthrofibrosis after anterior cruciate ligament reconstruction.

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.

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.

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.

Multimodal conservative management of arthrofibrosis after total knee arthroplasty compared to manipulation under anesthesia: a feasibility study with retrospective cohort comparison

Background

The ideal treatment of early-stage arthrofibrosis after total knee arthroplasty is unclear. The purpose of this study was to determine the treatment effect, including variability, and feasibility of a multimodal physical therapy program as compared to manipulation under anesthesia.

Methods

This was a prospective feasibility study with a retrospective cohort comparison. Ten consecutive patients (aged 64 ± 9 years, 7 females) with early-stage arthrofibrosis were enrolled 6 weeks after primary total knee arthroplasty and participated in the multimodal physical therapy program. The multimodal physical therapy program consisted of manual therapy, therapeutic exercise, and static progressive splinting delivered over 4 weeks. The outcomes included knee range of motion (ROM), adherence, patient satisfaction, and safety. Data were compared to a retrospective cohort of 31 patients with arthrofibrosis (aged 65 ± 9 years, 20 females) who underwent manipulation under anesthesia followed by physical therapy.

Results

Overall, knee ROM outcomes were similar between multimodal physical therapy (110° ± 14) and manipulation under anesthesia (109° ± 11). Seven out of ten patients achieved functional ROM (≥ 110°) and avoided manipulation under anesthesia with the multimodal physical therapy program. Three out of 10 multimodal physical therapy patients required manipulation under anesthesia secondary to failure to demonstrate progress within 4 weeks of the multimodal physical therapy program. Adherence to the multimodal physical therapy program was 87 ± 9%. The median patient satisfaction with the multimodal physical therapy program was “very satisfied.” Safety concerns were minimal.

Conclusion

The use of the multimodal physical therapy program is feasible for treating early-stage arthrofibrosis after total knee arthroplasty, with 70% of patients avoiding manipulation under anesthesia. Randomized controlled trials are needed to determine the efficacy of the multimodal physical therapy program and to determine the optimal patient selection for the multimodal physical therapy program versus manipulation under anesthesia.

Trial registration

ClinicalTrials.gov, NCT04837872.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01026-y.

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.

Efficacy of Arthroscopic Arthrolysis in the Treatment of Arthrofibrosis: A Systematic Review

Stiffness after total knee arthroplasty (TKA) remains a clinical challenge for health care professionals. Historically, arthroscopic arthrolysis is a treatment modality that has been reserved for patients that have failed other conservative modalities, including manipulation under anesthesia. However, a systematic review of the literature evaluating the clinical efficacy and complications of arthroscopic arthrolysis for stiffness after TKA has not been performed. A systematic review of medical databases (PubMed, EMBASE, Cochrane Library) was undertaken for articles published from January 1980 to October 2018. A descriptive and critical analysis of the results was performed. From 1,326 studies, 7 studies met the inclusion criteria for this study. A total of 160 patients who underwent arthroscopic arthrolysis for arthrofibrosis following TKA were included for analysis. The quality of the evidence for the included studies ranged between moderate and high. Overall, patients had significant increased range of motion and flexion by 32.5 and 26.7 degrees, respectively following arthroscopic arthrolysis. Functional outcome scores also significantly improved for patients who underwent arthroscopic arthrolysis after TKA. Arthroscopic arthrolysis is an efficacious modality for treatment of stiffness following TKA. The greatest benefit is seen among patients that present with significant loss of flexion. Arthroscopic arthrolysis should be reserved for patients that have previously failed more conservative modalities.

Manipulation under anaesthesia after primary total knee arthroplasty : minimal differences in intravenous sedation alone versus neuraxial anaesthesia

AIMS

Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia.

METHODS

We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m² (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups.

RESULTS

Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication.

CONCLUSION

IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126-130.

Clinical Trial Registry Use in Orthopaedic Surgery Systematic Reviews

BACKGROUND

Results from systematic reviews and meta-analyses, which have the highest level of evidence (Level I), often drive clinical decision-making and health policy. Often, unpublished trial data are omitted from systematic reviews, raising concerns about the extent of the reliability and validity of results that have been drawn from systematic reviews. We aimed to determine the extent to which systematic review authors include searches of clinical trial registries for unpublished data when conducting systematic reviews in orthopaedic surgery.

METHODS

Systematic reviews and/or meta-analyses were gathered from the top 5 orthopaedic surgery journals based on the h5-index from Google Scholar Metrics. Systematic reviews that had been published in the Cochrane Database of Systematic Reviews, which requires the inclusion of a clinical trial registry search, served as controls. For the primary outcome, each systematic review from the top 5 orthopaedic journals was screened to determine whether the authors of each study searched for unpublished data in clinical trial registries. We then compared the rate of registry searches with those in the control group. For the secondary analysis, a search of ClinicalTrials.gov was performed for unpublished trial data for 100 randomized systematic reviews.

RESULTS

All 38 of the Cochrane systematic reviews (100%) included clinical trial registry searches, while the top 5 orthopaedic journals had only 31 of 480 studies (6.5%) that looked at clinical trial registries. The secondary analysis yielded 59 of 100 systematic review articles (59.0%) that could have included unpublished clinical trial data from ≥1 studies to their sample.

CONCLUSIONS

Systematic reviews that have been published in the top orthopaedic surgery journals seldom included a search for unpublished clinical trial data.

CLINICAL RELEVANCE

The exclusion of clinical trial registry searches potentially contributes to publication bias within the orthopaedic literature. Moving forward, systematic review authors should include clinical trial registry searches for unpublished clinical trial data to provide the most accurate representation of the available evidence for systematic reviews and meta-analyses.

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.

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline

BACKGROUND

Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making.

AIM

To provide guidelines for surgeons and units delivering revision KR services.

METHODS

A formal consensus process was followed by BASK's Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data.

RESULTS

There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model.

CONCLUSIONS

Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.

Medical stretching devices are effective in the treatment of knee arthrofibrosis: A systematic review

AIMS

This systematic review examines the available evidence on the use of medical stretching devices to treat knee arthrofibrosis, it suggests a focus for future studies addressing limitations in current research and identifies gaps in the published literature to facilitate future works.

MATERIALS AND METHODS

Articles were identified using the Cochrane Library, MEDLINE, PubMed and SCOPUS databases. Articles from peer reviewed journals investigating the effectiveness of medical stretching devices to increase range of movement when treating arthrofibrosis of the knee were included.

RESULTS

A total of 13 studies (558 participants) met the inclusion criteria with the devices falling into the following categories; CPM, load control or displacement control stretching devices. A statistically significant increase in range of movement was demonstrated in CPM, load-control and displacement-control studies (p ​< ​0.001). The results show that the stretch doses applied using the CPM, load-control devices were performed over a considerably longer treatment time and involved significantly more additional physiotherapy compared to the displacement-control and patient actuated serial stretching devices.

CONCLUSION

The systematic review indicates that load-control and displacement-control devices are effective in increasing range of movement in the treatment of knee arthrofibrosis. Displacement-control devices involving patient actuated serial stretching techniques, may be more effective in increasing knee flexion than those utilising static progressive stretch.The paucity of research in this field indicates that more randomised controlled trials are required to investigate the superiority of the different types of displacement-control stretching devices and which of these would be most effective for use in clinical practice and to compare these with standard physiotherapy treatment.

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.

Higher incidence of manipulation under anesthesia following TKA associated with the periarticular infiltration of a liposomal bupivacaine cocktail compared to a modified Ranawat cocktail

BACKGROUND

The purpose of this study was to compare the frequency of postoperative stiffness requiring manipulation under anesthesia (MUA) before and after switching from the intraoperative use of liposomal bupivacaine (LB).

METHODS

This was an institutional review board (IRB)-exempt retrospective cohort study (IRB#71733) on all patients who underwent primary total knee arthroplasty (TKA) by a single surgeon between April 2016 and December 2017. We compared 169 knees that received LB group to 167 knees that received a modified Ranawat cocktail (MR group). Perioperative care pathways remained consistent during the study period, as were requirements for MUA which included flexion range of motion below approximately 90 at 6-12 weeks. To compare the incidence of MUA between the groups, a population-averaged Poisson regression analysis was used.

RESULTS

The two groups were similar, with mean age of 63 (range 31-91) in the LB group and 64 (range 42-84) in the MR group, a preponderance of females in both groups (p = 0.866), similar preoperative knee flexion between groups (p = 0.162), and similar Patient-Reported Outcomes Measurement Information System scores. The frequency of MUA, however, was significantly lower in the MR group (LB: 7.7% [95% CI 3.7-12%] vs. MR: 2.4% [95% CI <1-4.7%] [IRR 3.2, 95% CI 1.08-9.76, p . 0.037]).

CONCLUSIONS

In summary, this is a novel report of a potentially previously unrecognized increased incidence of MUA associated with the use of LB compared with a MR cocktail. Given no other notable changes to the perioperative care or MUA thresholds following TKA, the reasons for these findings are unclear but deserve additional investigation.

Top ten research priorities for problematic knee arthroplasty

AIMS

The James Lind Alliance aims to bring patients, carers, and clinicians together to identify uncertainties regarding care. A Priority Setting Partnership was established by the British Association for Surgery of the Knee in conjunction with the James Lind Alliance to identify research priorities related to the assessment, management, and rehabilitation of patients with persistent symptoms after knee arthroplasty.

METHODS

The project was conducted using the James Lind Alliance protocol. A steering group was convened including patients, surgeons, anaesthetists, nurses, physiotherapists, and researchers. Partner organizations were recruited. A survey was conducted on a national scale through which patients, carers, and healthcare professionals submitted key unanswered questions relating to problematic knee arthroplasties. These were analyzed, aggregated, and synthesized into summary questions and the relevant evidence was checked. After confirming that these were not answered in the current literature, 32 questions were taken forward to an interim prioritization survey. Data from this survey informed a shortlist taken to a final consensus meeting.

RESULTS

A total of 769 questions were received during the initial survey with national reach across the UK. These were refined into 32 unique questions by an independent information specialist. The interim prioritization survey was completed by 201 respondents and 25 questions were taken to a final consensus group meeting between patients, carers, and healthcare professionals. Consensus was reached for ranking the top ten questions for publication and dissemination.

CONCLUSIONS

The top ten research priorities focused on pain, infection, stiffness, health service configuration, surgical and non-surgical management strategies, and outcome measures. This list will guide funders and help focus research efforts within the knee arthroplasty community. Cite this article: Bone Joint J 2020;102-B(9):1176-1182.

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.

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.

Recovery of knee range of motion after total knee arthroplasty in the first postoperative weeks: poor recovery can be detected early

PURPOSE

The aim of this study was to analyze in detail how knee flexion and extension progress in the first 8 weeks after primary total knee arthroplasty (TKA). The secondary goal was to compare knee range of motion (ROM) recovery patterns between patients with normal and delayed ROM recovery 8 weeks after TKA.

METHODS

This prospective clinical trial included all patients who underwent a primary unilateral TKA between February and December 2016 with weekly ROM data documented by the treating outpatient physical therapists (n = 137). Goniometry was used to measure knee ROM preoperatively, postoperatively on day 1 and weekly until follow-up at the orthopedic clinic 8 weeks after surgery. ROM recovery patterns were compared between patients with sufficient (≥ 90°) or insufficient (< 90°) knee flexion 8 weeks after TKA.

RESULTS

Knee flexion recovered from a median of 80° in the first postoperative week to 110° 8 weeks after surgery and knee extension from a mean of - 10.7° to - 3.2°. Recovery was nonlinear, with greatest improvements in the first 4 weeks for knee flexion. In contrast to patients with sufficient knee flexion 8 weeks postoperatively, the insufficient group (n = 8, 5.8%) had poor knee flexion on the first postoperative day and from week 4 to week 8 almost no improvement or even worsening of knee flexion.

CONCLUSIONS

Both knee flexion and extension recover in a nonlinear manner after TKA surgery. Poor postoperative knee function can be detected early, using ROM data from the first postoperative day up to the fourth week.

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 With Lysis of Adhesions Is Effective in Arthrofibrosis After Sulcus-Deepening Trochleoplasty: A Prospective Study

Background

Sulcus-deepening trochleoplasty has been established as an effective treatment for patellar instability due to trochlear dysplasia. However, arthrofibrosis is a known complication following trochleoplasty, which may require manipulation under anesthesia (MUA) with or without lysis of adhesions (LOA) to increase the knee range of motion (ROM), especially flexion.

Purpose

To prospectively follow patients for ROM improvements and subsequent complications after undergoing MUA with or without LOA in the setting of sulcus-deepening trochleoplasty.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 76 knees with severe trochlear dysplasia were prospectively enrolled and underwent sulcus-deepening trochleoplasty, with a mean (±SD) follow-up of 32.5 ± 19.3 months. Concomitant procedures included medial patellofemoral ligament reconstruction, lateral retinacular release, and tibial tubercle osteotomy. Physical examination including ROM and findings of recurrent patellar instability were collected for all patients. Arthrofibrosis was defined as active and passive flexion less than 90° within 3 months of surgery combined with a plateau in progress with physical therapy. Paired-samples and independent-samples t tests were used. A P value less than .05 was considered significant.

Results

A total of 62 knees met inclusion and exclusion criteria and were included in the study. Of these patients, 11 experienced arthrofibrosis as a complication and underwent MUA within 3 months of their index procedure. Of these 11 patients, 9 subsequently underwent arthroscopic LOA following MUA because acceptable ROM could not be achieved with manipulation alone. Patients with arthrofibrosis had a premanipulation mean ROM that was significantly different from those without arthrofibrosis (77.3° ±18.6° vs 133.3° ± 12.7°, respectively; P < .001). In the arthrofibrotic group, postoperative ROM increased significantly after MUA and/or LOA compared with the preoperative ROM (127.3° ± 12.5° vs 77.3° ± 18.6°, respectively; P < .001). ROM in the arthrofibrotic group after MUA/LOA was not significantly different from that in the nonarthrofibrotic group (flexion, 127.3° ± 12.5° vs 133.3° ± 12.7°, respectively; P = .156). No complications from the MUA or LOA were reported at subsequent follow-up visits.

Conclusion

When indicated in the setting of severe trochlear dysplasia, sulcus-deepening trochleoplasty is a treatment for disabling recurrent patellar instability with a known complication of arthrofibrosis. Initiation of postoperative physical therapy within 3 days of surgery may reduce the incidence of arthrofibrosis. If arthrofibrosis is encountered after a sulcus-deepening trochleoplasty, MUA without LOA is not as effective as when following other procedures of the knee, whereas MUA with LOA is an effective procedure likely to result in ROM and patient outcome scores similar to those of a nonarthrofibrotic knee after the same procedure. Both MUA and LOA appear to be safe based on the limited number of patients in this study without complication.

The assessment of the stability of the tibial component of a novel knee arthroplasty system using radiostereometric analysis

Aims

The introduction of a novel design of total knee arthroplasty (TKA) must achieve outcomes at least as good as existing designs. A novel design of TKA with a reducing radius of the femoral component and a modified cam-post articulation has been released and requires assessment of the fixation to bone. Radiostereometric analysis (RSA) of the components within the first two postoperative years has been shown to be predictive of medium- to long-term fixation. The aim of this study was to assess the stability of the tibial component of this system during this period of time using RSA.

Patients and Methods

A cohort of 30 patients underwent primary, cemented TKA using the novel posterior stabilized fixed-bearing (ATTUNE) design. There was an even distribution of men and women (15:15). The mean age of the patients was 64 years (sd 8) at the time of surgery; their mean body mass index (BMI) was 35.4 kg/m 2 (sd 7.9). RSA was used to assess the stability of the tibial component at 6, 12, and 24 months compared with a six-week baseline examination. Patient-reported outcome measures were also assessed.

Results

The mean maximum total point motion (MTPM) of the tibial component between 12 and 24 months postoperatively was 0.08 mm (sd 0.08), which is well below the published threshold of 0.2 mm (p < 0.001). Patient-reported outcome measures consistently improved.

Conclusion

The tibial component of this novel design of TKA showed stability between assessment 12 and 24 months postoperatively, suggesting an acceptably low risk of medium- to long-term failure due to aseptic loosening.