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Sidhu SP, Howard LC, Levesque G, Greidanus NV, Masri BA, Garbuz DS, Neufeld ME. Risk factors for failure of manipulation under anesthesia after total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3061-3066. [PMID: 38907059 DOI: 10.1007/s00590-024-03974-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/29/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Manipulation under anesthesia (MUA) is a well-established treatment for stiffness after total knee arthroplasty (TKA). Risk factors for failure of MUA remain largely unknown. The primary aim of this study was to identify risk factors for failure of MUA after TKA. METHODS We performed a retrospective cohort study including 470 patients who underwent MUA after primary TKA with minimum 2 year follow-up. Patients were grouped into success (n = 412) or failure (n = 58) cohorts; failure was defined as flexion < 90° at most recent follow-up or revision for stiffness. The increase in flexion post-MUA for the cohort was calculated. Several clinical, patient, and surgical factors were analyzed using univariate, followed by multivariable logistic regression models to identify independent risk factors associated with failure. RESULTS The mean increase in flexion was 42° (range 0-115). BMI 30-35 (p = 0.01, odds ratio (OR) 2.42; 95% CI 1.25-4.68) and poorer pre-MUA flexion (p < 0.01, OR 1.43; 95% CI 1.23-1.67) were risk factors for failure. When considering revision for stiffness only, BMI 30-35 (p = 0.01, OR 3.27; 95% CI 1.41-7.61), lower pre-MUA flexion (p < 0.01, OR 1.43; 95% CI 1.18-1.75), and history of prior knee surgery (p = 0.04, OR 2.31; 95% CI 1.06-5.04) were predictors of failure. Time to MUA (p = 0.48), thromboprophylaxis (p = 0.44), pre-operative opioid use (p = 0.34), depression/anxiety (p = 1.0), and several other factors analyzed were not associated with failure. CONCLUSION In this large cohort, elevated BMI and lower pre-MUA flexion were risk factors for failure of MUA. History of prior knee surgery was an additional predictor of requiring revision for stiffness.
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Affiliation(s)
| | - Lisa C Howard
- University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Gabrielle Levesque
- University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Nelson V Greidanus
- University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Bassam A Masri
- University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Donald S Garbuz
- University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Michael E Neufeld
- University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
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Patel A, Reynolds G, Stitgen A, Ghanem E, Nuelle C. Gravity-Assisted Manipulation (GAM) Technique for the Treatment of Knee Arthrofibrosis. Arthrosc Tech 2023; 12:e2181-e2185. [PMID: 38196856 PMCID: PMC10772969 DOI: 10.1016/j.eats.2023.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/28/2023] [Indexed: 01/11/2024] Open
Abstract
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.
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Affiliation(s)
- Arpan Patel
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Grace Reynolds
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Andrea Stitgen
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Elie Ghanem
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Clayton Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
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Grace TR, Goh GS, Runyon RS, Small I, Gibian JT, Nunley RM, Lonner JH. Manipulation Under Anesthesia is Safe After Cementless Total Knee Arthroplasty: A Multicenter Study. J Arthroplasty 2023; 38:372-375. [PMID: 36038070 DOI: 10.1016/j.arth.2022.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cementless total knee arthroplasty (TKA) is thought to facilitate durable, biological fixation between the bone and implant. However, the 4-12 weeks required for osseointegration coincides with the optimal timeframe to perform a manipulation under anesthesia (MUA) if a patient develops postoperative stiffness. This study aims to determine the impact of early MUA on cementless fixation by comparing functional outcomes and survivorship of cementless and cemented TKAs. METHODS A consecutive series of patients who underwent MUA for postoperative stiffness within 90 days of primary, unilateral TKA at 2 academic institutions between 2014 and 2018 were identified. Cases involving extensive hardware removal were excluded. Cementless TKAs undergoing MUA (n = 100) were propensity matched 1:1 to cemented TKAs undergoing MUA (n = 100) using age, gender, body mass index, and year of surgery. Both groups had comparable baseline Knee Injury and Osteoarthritis Outcome Scores (KOOS), Short Form (SF)-12 Physical, and SF-12 Mental scores. MUA-related complications as well as postoperative KOOS and SF-12 scores were compared. RESULTS MUA-related complications were equivalently low in both groups (P = .324), with only 1 patella component dissociation in the cementless group. No tibial or femoral components acutely loosened in the perioperative period. Postoperative KOOS (P = .101) and SF-12 Mental scores (P = .380) were similar between groups. Six-year survivorship free from any revision after MUA was 98.0% in both groups (P = 1.000). CONCLUSION Early postoperative MUA after cementless TKA was not associated with increased MUA-related complications or worse patient-reported outcomes compared to cemented TKA. Short-term survivorship was also comparable, suggesting high durability of the bone-implant interface.
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Affiliation(s)
- Trevor R Grace
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - R Scott Runyon
- Department of Orthopedic Surgery, Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ilan Small
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph T Gibian
- Department of Orthopedic Surgery, Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis, Missouri
| | - Jess H Lonner
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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DeFrance MJ, Cheesman QT, Hameed D, DiCiurcio WT, Harrer MF. Manipulation Under Anesthesia Is Associated With an Increased Rate of Early Total Knee Arthroplasty Revision. Orthopedics 2022; 45:270-275. [PMID: 35700432 DOI: 10.3928/01477447-20220608-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.].
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Kyriakidis T, Tasios N, Vandekerckhove B, Verdonk P, Cromheecke M, Verdonk R. Mid-term outcomes of posterior capsular release for fixed flexed deformity after total knee arthroplasty. Acta Orthop Belg 2022; 88:329-334. [DOI: 10.52628/88.2.10276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fixed flexion deformity also called flexion contracture is relatively rare, but a very demanding functional limitation that both surgeons and patients may have to deal with. The purpose of the present study was to evaluate the functional outcomes after posteromedial capsular release in case of fixed flexed deformity > 15 o . Between June 2011 and November 2018, 15 patients (6 males and 9 females) were treated with open posterior capsular release through medial approach for fixed flexion deformity of the knee > 15 o and prospectively followed with a minimum follow-up of 2 years. Primary outcome was knee extension measured with a manual goniometer and secondary outcome treatment related complications. All patients reported inability to walk and clinical semiology of pain and swelling. The mean age of the study population at surgery was 61.7 years with a mean BMI of 30.9 kg/m2. Complete data were recorded for all patients. Statistically significant improvement was found in clinical and functional assessment tools analyzed from baseline to the latest follow-up (p<0.05). More precisely, the mean postoperative fixed flexion deformity was decreased from 23.57 o to 2.86 o . No adverse effect or major complications were recorded during follow-up.
Posterior open release via posteromedial was shown to be an efficient and safe salvage procedure to deal with persistent fixed flexion deformity of more than 15 o following TKA at two years follow-up. However, future studies with a higher number of participants and longer follow-up should be conducted to validate our data.
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RANTASALO MT, PALANNE RA, SAINI S, VAKKURI AP, MADANAT R, NOORA SK. Postoperative pain as a risk factor for stiff knee following total knee arthroplasty and excellent patientreported outcomes after manipulation under anesthesia. Acta Orthop 2022; 93:432-437. [PMID: 35419610 PMCID: PMC9008578 DOI: 10.2340/17453674.2022.2272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Indexed: 01/31/2023] Open
Abstract
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.
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Affiliation(s)
- Mikko T RANTASALO
- Department of Orthopedics and Traumatology, Arthroplasty Center, University of Helsinki and Helsinki University Hospital
| | - Riku A PALANNE
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital
| | - Sukhdev SAINI
- Department of Medical Imaging, HUS Diagnostic Centre, University of Helsinki and Helsinki University Hospital
| | - Anne P VAKKURI
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital
| | - Rami MADANAT
- Department of Orthopedics and Traumatology, Arthroplasty Center, University of Helsinki and Helsinki University Hospital,Terveystalo Kamppi, Helsinki, Finland
| | - Skants K NOORA
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital
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Rauzi MR, Foran JRH, Bade MJ. Multimodal conservative management of arthrofibrosis after total knee arthroplasty compared to manipulation under anesthesia: a feasibility study with retrospective cohort comparison. Pilot Feasibility Stud 2022; 8:71. [PMID: 35337388 PMCID: PMC8953056 DOI: 10.1186/s40814-022-01026-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 03/07/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Michelle R Rauzi
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, 13121 E 17th Ave, Aurora, CO, 80045, USA
| | - Jared R H Foran
- Panorama Orthopedics & Spine Center, 660 Golden Ridge Rd. #250, Golden, CO, 80401, USA
| | - Michael J Bade
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, 13121 E 17th Ave, Aurora, CO, 80045, USA. .,Veterans Affairs Geriatric Research, Education and Clinical Center, VA Eastern Colorado Healthcare System, 13611 East Colfax, Aurora, CO, 80045, USA.
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Treatment of arthrofibrosis and stiffness after total knee arthroplasty: an updated review of the literature. INTERNATIONAL ORTHOPAEDICS 2022; 46:1253-1279. [PMID: 35301559 DOI: 10.1007/s00264-022-05344-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/08/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE There is currently no consensus regarding the optimal treatment for stiffness following total knee arthroplasty (TKA). With the increased utilization of value-based models, it is important to determine the most effective treatments that will reduce the need for further intervention and additional expenditure. A systematic review was performed to compare the outcomes of manipulation under anaesthesia (MUA), arthroscopic lysis of adhesions (aLOA), and revision TKA (rTKA) for arthrofibrosis and stiffness following TKA. METHODS PubMed and MEDLINE databases were reviewed for articles published through October 2020. Studies were included if they reported patient-reported outcome measures (PROMs) following MUA, aLOA, or rTKA. The primary endpoint was PROMs, while secondary outcomes included range of motion and the percentage of patients who pursued further treatment for stiffness. RESULTS A total of 40 studies were included: 21 on rTKA, 7 on aLOA, and 14 on MUA. The mean or median post-operative arc ROM was > 90° in 6/20 (30%) rTKA, 5/7 (71%) aLOA, and 7/10 (70%) MUA studies. Post-operative Knee Society (KSS) clinical and functional scores were the greatest in patients who underwent MUA and aLOA. As many as 43% of rTKA patients required further care compared to 25% of aLOA and 17% of MUA patients. CONCLUSION Stiffness following TKA remains a challenging condition to treat. Nonetheless, current evidence suggests that patients who undergo rTKA have poorer clinical outcomes and a greater need for further treatment compared to patients who undergo MUA or aLOA.
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Sayah SM, Karunaratne S, Beckenkamp PR, Horsley M, Hancock MJ, Hunter DJ, Herbert RD, de Campos TF, Steffens D. Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression. J Arthroplasty 2021; 36:3993-4002.e37. [PMID: 34275710 DOI: 10.1016/j.arth.2021.06.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/17/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA. METHODS The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression. RESULTS In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively. CONCLUSION Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.
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Affiliation(s)
- Said Mohamad Sayah
- Surgical Outcomes Resource Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Resource Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Paula R Beckenkamp
- Discipline of Physiotherapy, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark Horsley
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia
| | - Mark J Hancock
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
| | - David J Hunter
- Institute of Bone and Joint Research, The University of Sydney, Sydney, New South Wales, Australia; Rheumatology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Robert D Herbert
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
| | - Tarcisio F de Campos
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Resource Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Lim JW, Park YB, Lee DH, Lee HJ. Effect of Manipulation under Anesthesia of the First Knee in Staged Bilateral Total Knee Arthroplasty on Clinical Outcome and Satisfaction. J Knee Surg 2021; 34:1429-1435. [PMID: 32330972 DOI: 10.1055/s-0040-1709675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Jung-Won Lim
- Department of Orthopedic Surgery, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Dongjak-gu, Seoul, South Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Dongjak-gu, Seoul, South Korea
| | - Dong-Hoon Lee
- Department of Orthopedic Surgery, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Dongjak-gu, Seoul, South Korea
| | - Han-Jun Lee
- Department of Orthopedic Surgery, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Dongjak-gu, Seoul, South Korea
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Chalmers BP, Goytizolo E, Mishu MD, Westrich GH. Manipulation under anaesthesia after primary total knee arthroplasty : minimal differences in intravenous sedation alone versus neuraxial anaesthesia. Bone Joint J 2021; 103-B:126-130. [PMID: 34053290 DOI: 10.1302/0301-620x.103b6.bjj-2020-1950.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Brian P Chalmers
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Mithun D Mishu
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
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Crawford DA, Adams JB, Morris MJ, Berend KR, Lombardi AV. Manipulation under Anesthesia after Knee Arthroplasty Is Associated with Worse Long-Term Clinical Outcomes and Survivorship. J Knee Surg 2021; 34:739-744. [PMID: 31645072 DOI: 10.1055/s-0039-1700569] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
| | | | - Michael J Morris
- Joint Implant Surgeons, Inc., New Albany, Ohio.,Mount Carmel Health System, New Albany, Ohio
| | - Keith R Berend
- Joint Implant Surgeons, Inc., New Albany, Ohio.,Mount Carmel Health System, New Albany, Ohio
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc., New Albany, Ohio.,Mount Carmel Health System, New Albany, Ohio.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Manipulation under Anesthesia for Stiffness of the Knee Joint after Total Knee Replacement. Arthroplast Today 2020; 6:470-474. [PMID: 32637518 PMCID: PMC7329891 DOI: 10.1016/j.artd.2020.05.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/07/2020] [Accepted: 05/25/2020] [Indexed: 11/20/2022] Open
Abstract
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.
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Tibbo ME, Limberg AK, Salib CG, Ahmed AT, van Wijnen AJ, Berry DJ, Abdel MP. Acquired Idiopathic Stiffness After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2019; 101:1320-1330. [PMID: 31318813 PMCID: PMC6641113 DOI: 10.2106/jbjs.18.01217] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stiffness is a common reason for suboptimal clinical outcomes after primary total knee arthroplasty (pTKA). There is a lack of consensus regarding its definition, which is often conflated with its histopathologic subcategory-i.e., arthrofibrosis. There is value in refining the definition of acquired idiopathic stiffness in an effort to select for patients with arthrofibrosis. We conducted a systematic review and meta-analysis to establish a consensus definition of acquired idiopathic stiffness, determine its prevalence after pTKA, and identify potential risk factors for its development. METHODS MEDLINE, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Scopus databases were searched from 2002 to 2017. Studies that included patients with stiffness after pTKA were screened with strict inclusion and exclusion criteria to isolate the subset of patients with acquired idiopathic stiffness unrelated to known extrinsic or surgical causes. Three authors independently assessed study eligibility and risk of bias and collected data. Outcomes of interest were then analyzed according to age, sex, and body mass index (BMI). RESULTS In the 35 included studies (48,873 pTKAs), the mean patient age was 66 years. In 63% of the studies, stiffness was defined as a range of motion of <90° or a flexion contracture of >5° at 6 to 12 weeks postoperatively. The prevalence of acquired idiopathic stiffness after pTKA was 4%, and this did not differ according to age (4%, I = 95%, among patients <65 years old and 5%, I = 96%, among those ≥65 years old; p = 0.238). The prevalence of acquired idiopathic stiffness was significantly lower in males (1%, I = 85%) than females (3%, I = 95%) (p < 0.0001) as well as in patients with a BMI of <30 kg/m (2%, I = 94%) compared with those with a BMI of ≥30 kg/m (5%, I = 97%) (p = 0.027). CONCLUSIONS Contemporary literature supports the following definition for acquired idiopathic stiffness: a range of motion of <90° persisting for >12 weeks after pTKA in patients in the absence of complicating factors including preexisting stiffness. The mean prevalence of acquired idiopathic stiffness after pTKA was 4%; females and obese patients were at increased risk. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Meagan E. Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Afton K. Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Ahmed T. Ahmed
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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15
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Volchenko E, Schwarzman G, Robinson M, Chmell SJ, Gonzalez MH. Arthroscopic Lysis of Adhesions With Manipulation Under Anesthesia Versus Manipulation Alone in the Treatment of Arthrofibrosis After TKA: A Matched Cohort Study. Orthopedics 2019; 42:163-167. [PMID: 31099882 DOI: 10.3928/01477447-20190424-08] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/21/2019] [Indexed: 02/03/2023]
Abstract
Arthrofibrosis following total knee arthroplasty (TKA) is a debilitating complication. Treatment options include physical therapy, manipulation under anesthesia (MUA), and arthroscopic lysis of adhesions (ALOA) with or without MUA. The authors studied 70 patients with arthrofibrosis after TKA treated with MUA or ALOA plus MUA. In this matched cohort study, 35 patients were treated with MUA and 35 patients were treated with ALOA plus MUA. Total knee arthroplasty followed by MUA was performed by 2 surgeons and TKA followed by MUA plus ALOA was performed by 1 surgeon at 1 institution. Electronic records were used to collect information and match cohorts based on age, sex, body mass index, diabetes mellitus, perioperative range of motion (ROM), and timing of the procedure for arthrofibrosis. The combination of MUA and ALOA yielded changes in ROM: a 72.7% increase 4 to 12 weeks after index TKA (P=.032), a 50.0% increase 12+ weeks after TKA (P=.032), and a 99.8% increase in patients with a pre-manipulation ROM of 0° to 60° (P=.001). Manipulation under anesthesia yielded a 49.2% increase 4 to 12 weeks after TKA (P=.161), a 27.0% increase 12+ weeks after TKA (P=.161), and a 68.8% increase in patients with pre-manipulation ROM of 0° to 60° (P=.084). Patients treated with ALOA plus MUA had greater increases in ROM (P=.026) and final knee flexion (P=.028) compared with those treated with MUA alone. Arthrofibrosis following TKA is a complication that often requires additional procedures. Traditionally, ALOA is added 3+ months from index TKA, when abundant scar formation has occurred. This study found a benefit to ALOA plus MUA compared with MUA alone, with the largest benefit in patients whose pre-manipulation ROM was 0° to 60°. [Orthopedics. 2019; 42(3):163-167.].
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16
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Baum KS, Luo TD, Comadoll S, Marois A, Langfitt M, Shields J. Alternative technique for knee manipulation under anesthesia. Arthroplast Today 2018; 4:452-453. [PMID: 30569008 PMCID: PMC6287960 DOI: 10.1016/j.artd.2017.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/14/2017] [Accepted: 07/19/2017] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Kelli S Baum
- Wake Forest Baptist Hospital, Winston-Salem, NC, USA
| | - Tianyi D Luo
- Wake Forest Baptist Hospital, Winston-Salem, NC, USA
| | - Shea Comadoll
- Wake Forest Baptist Hospital, Winston-Salem, NC, USA
| | | | | | - John Shields
- Wake Forest Baptist Hospital, Winston-Salem, NC, USA
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17
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Kornuijt A, Das D, Sijbesma T, de Vries L, van der Weegen W. Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature. Musculoskelet Surg 2018; 102:223-230. [PMID: 29546693 DOI: 10.1007/s12306-018-0537-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 03/08/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery. METHODS A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA. RESULTS Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA. CONCLUSION Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.
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Affiliation(s)
- A Kornuijt
- Department of Physiotherapy, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - D Das
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - T Sijbesma
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands
| | - L de Vries
- Department of Orthopedic Surgery, Westfriesgasthuis Hospital, Maelsonstraat 3, 1624 NP, Hoorn, The Netherlands
| | - W van der Weegen
- Department of Orthopedic Surgery, St. Anna Hospital, Bogardeind 2, 5664 EH, Geldrop, The Netherlands.
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Hug KT, Amanatullah DF, Huddleston JI, Maloney WJ, Goodman SB. Protocol-Driven Revision for Stiffness After Total Knee Arthroplasty Improves Motion and Clinical Outcomes. J Arthroplasty 2018; 33:2952-2955. [PMID: 29859726 DOI: 10.1016/j.arth.2018.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/14/2018] [Accepted: 05/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Stiffness after revision total knee arthroplasty (TKA) is a difficult problem without a well-defined treatment algorithm. The purpose of this study was to evaluate the results of revision TKA for stiffness within the context of differential component replacement. METHODS Consecutive patients who underwent revision TKA were retrospectively identified and included those who received debridement and polyethylene liner exchange alone, revision of only one of the femoral or tibial fixed components, or revision of all components. Preoperative and postoperative range of motion and Knee Society score (KSS) were collected. RESULTS Sixty-nine knees were included in the study group with a mean follow-up of 43 months (range, 12-205 months). The mean prerevision flexion contracture of 17° improved to 5° after surgical intervention (P < .001). Similarly, mean flexion and motion arc improved from 70° to 92° and from 53° to 87°, respectively (P < .001). Mean KSS knee scores improved from 42 to 70 and KSS function scores improved from 41 to 68 (P < .001). Mean arc of motion improved by 45° in patients who underwent complete component revision, 32° with component retention, and 29° with single component revision (P = .046). KSS knee scores improved by 34, 25, and 28 points in these respective groups (P = .049). KSS function scores improved by 33, 27, and 25 points (P = .077). CONCLUSION Revision surgery with or without component revision can improve motion and function in patients with stiffness after TKA. Complete component revision may offer the largest improvements in these outcome measures in properly selected patients.
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Affiliation(s)
- Kevin T Hug
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, California
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19
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Tyagi V, Huez C, Henderson S, Lukasiewicz A, Gardner E, Rubin L, Weis L. The effect of a preoperative education class on the rate of manipulation under anesthesia after total knee arthroplasty in a veterans population. Arthroplast Today 2018; 4:359-362. [PMID: 30186922 PMCID: PMC6123243 DOI: 10.1016/j.artd.2018.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/18/2018] [Accepted: 06/22/2018] [Indexed: 11/02/2022] Open
Abstract
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.
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Affiliation(s)
- Vineet Tyagi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Coridon Huez
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Shasta Henderson
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Adam Lukasiewicz
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Elizabeth Gardner
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Lee Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Lawrence Weis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Gu A, Michalak AJ, Cohen JS, Almeida ND, McLawhorn AS, Sculco PK. Efficacy of Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review. J Arthroplasty 2018; 33:1598-1605. [PMID: 29290334 DOI: 10.1016/j.arth.2017.11.054] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/13/2017] [Accepted: 11/27/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Knee stiffness following primary total knee arthroplasty can lead to unsatisfactory patient outcomes secondary to persistent pain and loss of function. Manipulation under anesthesia (MUA) remains a viable option for treatment of post-operative stiffness. However, the optimal timing and clinical efficacy of manipulation of anesthesia remains unknown. METHODS A systematic review of the literature was performed to identify studies that reported clinical outcomes for patients who underwent MUA for post-operative stiffness treatment. Repeat MUA procedures were included in the study but were analyzed separately. RESULTS Twenty-two studies (1488 patients) reported on range of motion (ROM) after MUA, and 4 studies (81 patients) reported ROM after repeat MUA. All studies reported pre-MUA motion of less than 90°, while mean ROM at last follow-up exceeded 90° in all studies except 2. For studies reporting ROM improvement following repeat MUA, the mean pre-manipulation ROM was 80° and the mean post-manipulation ROM was 100.6°. CONCLUSION MUA remains an efficacious, minimally invasive treatment option for post-operative stiffness following TKA. MUA provides clinically significant improvement in ROM for most patients, with the best outcomes occurring in patients treated within 12 weeks post-operatively. PROSPERO REGISTRATION NUMBER CRD42016052215.
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Affiliation(s)
- Alex Gu
- Department of Medicine, George Washington School of Medicine and Health Sciences, Washington, District of Columbia; Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Adam J Michalak
- Department of Medicine, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jordan S Cohen
- Department of Medicine, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Neil D Almeida
- Department of Medicine, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Donaldson JR, Tudor F, Gollish J. Revision surgery for the stiff total knee arthroplasty. Bone Joint J 2017; 98-B:622-7. [PMID: 27143732 DOI: 10.1302/0301-620x.98b5.35969] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 01/14/2016] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to examine the results of revision total knee arthroplasty (TKA) undertaken for stiffness in the absence of sepsis or loosening. PATIENTS AND METHODS We present the results of revision surgery for stiff TKA in 48 cases (35 (72.9%) women and 13 (27.1%) men). The mean age at revision surgery was 65.5 years (42 to 83). All surgeries were performed by a single surgeon. Stiffness was defined as an arc of flexion of < 70° or a flexion contracture of > 15°. The changes in the range of movement (ROM) and the Western Ontario and McMasters Osteoarthritis index scores (WOMAC) were recorded. RESULTS At a mean follow up of 59.9 months (12 to 272) there was a mean improvement in arc of movement of 45.0°. Mean flexion improved from 54.4° (5° to 100°) to 90° (10° to 125°) (p < 0.05) and the mean flexion contracture decreased from 12.0° (0° to 45°) to 3.5° (0° to 25°) (p < 0.05). The mean WOMAC scores improved for pain, stiffness and function. In patients with extreme stiffness we describe a novel technique, which we have called the 'sloppy' revision. This entails downsizing the polyethylene insert by 4 mm and using a more constrained liner to retain stability. CONCLUSION To our knowledge, this is the largest series of revision surgeries for stiffness reported in the literature where infection and loosening have been excluded. TAKE HOME MESSAGE Whilst revision surgery is technically demanding, improvements in ROM and outcome can be achieved, particularly when the revision is within two years of the primary surgery. Cite this article: Bone Joint J 2016;98-B:622-7.
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Affiliation(s)
| | - F Tudor
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - J Gollish
- Sunnybrook Health Sciences Centre, Toronto, Canada
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