Patients Undergoing Manipulation under Anesthesia following Primary Total Knee Arthroplasty: Are Their Patient-Reported Outcome Measures Inferior?

Michael N. Sirignano; Robert S. Rowe; James C. Gainer; Brett W. Royster; Langan S. Smith; Kyle M. Altman; Madhusudhan R. Yakkanti; Arthur L. Malkani

doi:10.1055/a-2509-3109

The Journal of Knee Surgery, Inhaltsverzeichnis

J Knee Surg 2025; 38(08): 407-414
DOI: 10.1055/a-2509-3109

Original Article

Patients Undergoing Manipulation under Anesthesia following Primary Total Knee Arthroplasty: Are Their Patient-Reported Outcome Measures Inferior?

Autoren

Michael N. Sirignano

¹Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
Robert S. Rowe

²University of Louisville School of Medicine, Louisville, Kentucky
James C. Gainer

¹Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
Brett W. Royster

²University of Louisville School of Medicine, Louisville, Kentucky
Langan S. Smith

³ULP Orthopedics, UofL Health, Jewish Hospital, Louisville, Kentucky
Kyle M. Altman

¹Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
Madhusudhan R. Yakkanti

⁴Department of Orthopaedic Surgery, Louisville Orthopaedic Clinic, Louisville, Kentucky
Arthur L. Malkani

¹Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky

Abstract

Stiffness after total knee arthroplasty (TKA) can lead to decreased function and patient dissatisfaction. Manipulation under anesthesia (MUA) is often performed to improve range of motion (ROM); however, there is no consensus on indications or timing. The purpose of this study was to compare clinical results and patient-reported outcome measures (PROMs) between patients who underwent MUA versus those with an uncomplicated postoperative course following primary TKA. This was an institutional review board-approved retrospective review of 116 consecutive patients who underwent MUA from 2013 to 2019 following primary TKA due to stiffness. Indication for MUA was failure to achieve 105 degrees of knee flexion at 6 weeks following surgery. Five patients underwent revision surgery and 15 patients from the MUA group were excluded: 12 lost to follow-up and 3 deaths. The remaining 96 MUA patients were matched to 288 TKAs who did not require MUA or revision, all with a minimum 2-year follow-up. Patients who underwent MUA were younger (60.7 vs. 66.3 years, p < 0.001) and had less preoperative knee flexion (105.4 vs. 110.7 degrees, p < 0.001). There were five (4.9%) revisions in the MUA group: two instability, two chronic pain, and one arthrofibrosis. There were no differences between the groups with respect to postoperative Knee Society Knee Score, Western Ontario and McMaster Universities Osteoarthritis, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Forgotten Joint Score-12, satisfaction, or complications. Satisfaction rates were 88.5% among MUA patients and 89.6% among non-MUA patients (p = 1.0). Patients undergoing MUA following TKA, using the criteria of failure to achieve 105 degrees of flexion by 6 weeks postoperatively, were able to achieve similar PROMs and satisfaction compared with a control group with a low incidence of revision due to persistent arthrofibrosis.

Keywords

total knee arthroplasty - manipulation under anesthesia - range of motion - patient-reported outcome measures - satisfaction

Volltext

Referenzen

References
1 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 (05) 1598-1605
2 American Joint Replacement Registry (AJRR). 2022 Annual Report. Rosemont, IL: American Academy of Orthopaedic Surgeons (AAOS); 2022
3 Lützner J, Kasten P, Günther KP, Kirschner S. Surgical options for patients with osteoarthritis of the knee. Nat Rev Rheumatol 2009; 5 (06) 309-316
4 Clement ND, Bardgett M, Weir D, Holland J, Deehan DJ. Increased symptoms of stiffness 1 year after total knee arthroplasty are associated with a worse functional outcome and lower rate of patient satisfaction. Knee Surg Sports Traumatol Arthrosc 2019; 27 (04) 1196-1203
5 Scranton Jr PE. Management of knee pain and stiffness after total knee arthroplasty. J Arthroplasty 2001; 16 (04) 428-435
6 Daluga D, Lombardi Jr AV, Mallory TH, Vaughn BK. Knee manipulation following total knee arthroplasty. Analysis of prognostic variables. J Arthroplasty 1991; 6 (02) 119-128
7 Mauerhan DR, Mokris JG, Ly A, Kiebzak GM. Relationship between length of stay and manipulation rate after total knee arthroplasty. J Arthroplasty 1998; 13 (08) 896-900
8 Kim J, Nelson CL, Lotke PA. Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am 2004; 86 (07) 1479-1484
9 Gandhi R, de Beer J, Leone J, Petruccelli D, Winemaker M, Adili A. Predictive risk factors for stiff knees in total knee arthroplasty. J Arthroplasty 2006; 21 (01) 46-52
10 Cheuy VA, Foran JRH, Paxton RJ, Bade MJ, Zeni JA, Stevens-Lapsley JE. Arthrofibrosis associated with total knee arthroplasty. J Arthroplasty 2017; 32 (08) 2604-2611
11 Schairer WW, Vail TP, Bozic KJ. What are the rates and causes of hospital readmission after total knee arthroplasty?. Clin Orthop Relat Res 2014; 472 (01) 181-187
12 Bonutti PM, Marulanda GA, McGrath MS, Mont MA, Zywiel MG. Static progressive stretch improves range of motion in arthrofibrosis following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2010; 18 (02) 194-199
13 Stephenson JJ, Quimbo RA, Gu T. Knee-attributable medical costs and risk of re-surgery among patients utilizing non-surgical treatment options for knee arthrofibrosis in a managed care population. Curr Med Res Opin 2010; 26 (05) 1109-1118
14 Yercan HS, Sugun TS, Bussiere C, Ait Si Selmi T, Davies A, Neyret P. Stiffness after total knee arthroplasty: prevalence, management and outcomes. Knee 2006; 13 (02) 111-117
15 Mamarelis G, Sunil-Kumar KH, Khanduja V. Timing of manipulation under anaesthesia for stiffness after total knee arthroplasty. Ann Transl Med 2015; 3 (20) 316
16 Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery. J Arthroplasty 2015; 30 (9, Suppl): 72-75
17 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (04) 780-785
18 Lee WC, Kwan YH, Chong HC, Yeo SJ. The minimal clinically important difference for Knee Society Clinical Rating System after total knee arthroplasty for primary osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2017; 25 (11) 3354-3359
19 Clement ND, Bardgett M, Weir D, Holland J, Gerrand C, Deehan DJ. What is the minimum clinically important difference for the WOMAC index after TKA?. Clin Orthop Relat Res 2018; 476 (10) 2005-2014
20 Clement ND, Scott CEH, Hamilton DF, MacDonald D, Howie CR. Meaningful values in the Forgotten Joint Score after total knee arthroplasty. Bone Joint J 2021; 103-B (05) 846-854
21 Lyman S, Lee YY, McLawhorn AS, Islam W, MacLean CH. What are the minimal and substantial improvements in the HOOS and KOOS and JR versions after total joint replacement?. Clin Orthop Relat Res 2018; 476 (12) 2432-2441
22 Overview: Reporting of the THA/TKA PRO-PM; 2024. https://qualitynet.cms.gov/inpatient/measures/THA_TKA
23 Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg 2004; 12 (03) 164-171
24 Fisher DA, Dierckman B, Watts MR, Davis K. Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. J Arthroplasty 2007; 22 (6, Suppl 2): 39-42
25 Knapp P, Weishuhn L, Pizzimenti N, Markel DC. Risk factors for manipulation under anaesthesia after total knee arthroplasty. Bone Joint J 2020; 102-B (6_Suppl_A, Suppl A): 66-72
26 Lee SA, Kang SB, Chang CB. et al. Does the severity or cause of preoperative stiffness affect the clinical results and range of motion after total knee arthroplasty?. PLoS One 2018; 13 (10) e0205168
27 Abdelhameed MA, Abdelnasser MK, Zaky BR, Bakr HM, Aziz M, Mahran M. Preoperative stiffness is the most important predictor of postoperative patient's satisfaction after total knee arthroplasty. Eur J Orthop Surg Traumatol 2023; 33 (07) 3019-3024
28 Nelson CL, Kim J, Lotke PA. Stiffness after total knee arthroplasty. J Bone Joint Surg Am 2005; 87 (Pt 2, Suppl 1): 264-270
29 Tibbo ME, Limberg AK, Salib CG. et al. Acquired idiopathic stiffness after total knee arthroplasty: a systematic review and meta-analysis. J Bone Joint Surg Am 2019; 101 (14) 1320-1330
30 Owen AR, Tibbo ME, van Wijnen AJ, Pagnano MW, Berry DJ, Abdel MP. Acquired idiopathic stiffness after contemporary total knee arthroplasty: incidence, risk factors, and results over 25 years. J Arthroplasty 2021; 36 (08) 2980-2985
31 Parkulo TD, Likine EF, Ong KL, Watson HN, Smith LS, Malkani AL. Manipulation following primary total knee arthroplasty is associated with increased rates of infection and revision. J Arthroplasty 2023; 38 (03) 567-572.e1
32 Issa K, Banerjee S, Kester MA, Khanuja HS, Delanois RE, Mont MA. The effect of timing of manipulation under anesthesia to improve range of motion and functional outcomes following total knee arthroplasty. J Bone Joint Surg Am 2014; 96 (16) 1349-1357
33 Cartwright-Terry M, Cohen DR, Polydoros F, Davidson JS, Santini AJ. Manipulation under anaesthetic following total knee arthroplasty: predicting stiffness and outcome. J Orthop Surg (Hong Kong) 2018; 26 (03) 2309499018802971
34 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 patient reported outcomes after manipulation under anesthesia. Acta Orthop 2022; 93: 432-437
35 Yao D, Bruns F, Ettinger S. et al. Manipulation under anesthesia as a therapy option for postoperative knee stiffness: a retrospective matched-pair analysis. Arch Orthop Trauma Surg 2020; 140 (06) 785-791
36 Esler CNA, Lock K, Harper WM, Gregg PJ. Manipulation of total knee replacements. Is the flexion gained retained?. J Bone Joint Surg Br 1999; 81 (01) 27-29
37 Maloney WJ. The stiff total knee arthroplasty: evaluation and management. J Arthroplasty 2002; 17 (4, Suppl 1) 71-73
38 Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009; 467 (10) 2606-2612
39 Rowe PJ, Myles CM, Walker C, Nutton R. Knee joint kinematics in gait and other functional activities measured using flexible electrogoniometry: how much knee motion is sufficient for normal daily life?. Gait Posture 2000; 12 (02) 143-155
40 American Joint Replacement Registry (AJRR). 2021 Annual Report. Rosemont, IL: American Academy of Orthopaedic Surgeons (AAOS); 2021
41 Wallace HA, Basehore BM, Zito PM. Wound Healing Phases. StatPearls Publishing; Treasure Island (FL): 2017
42 Bowden LG, Byrne HM, Maini PK, Moulton DE. A morphoelastic model for dermal wound closure. Biomech Model Mechanobiol 2016; 15 (03) 663-681
43 Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat the stiff total knee arthroplasty? A systematic review. Clin Orthop Relat Res 2010; 468 (04) 1096-1106
44 Brassard MF, Insall JN, Scuderi GR, Faris PM. Complications of total knee arthroplasty. Surgery of the Knee, 3^rd ed., 1814–1816; 2001.
45 Fox JL, Poss R. The role of manipulation following total knee replacement. J Bone Joint Surg Am 1981; 63 (03) 357-362
46 Shoji H, Solomonow M, Yoshino S, D'Ambrosia R, Dabezies E. Factors affecting postoperative flexion in total knee arthroplasty. Orthopedics 1990; 13 (06) 643-649