Manipulation of total knee replacements. Is the flexion gained retained?

Glenfield Hospital, Leicester, England, UK.
The Bone & Joint Journal (Impact Factor: 3.31). 01/1999; 81(1):27-9.
Source: PubMed


As part of a prospective study of 476 total knee replacements (TKR), we evaluated the use of manipulation under anaesthesia in 47 knees. Manipulation was considered when intensive physiotherapy failed to increase flexion to more than 80 degrees. The mean time from arthroplasty to manipulation was 11.3 weeks (median 9, range 2 to 41). The mean active flexion before manipulation was 62 degrees (35 to 80). One year later the mean gain was 33 degrees (Wilcoxon signed-rank test, range -5 to 70, 95% CI 28.5 to 38.5). Definite sustained gains in flexion were achieved even when manipulation was performed four or more months after arthroplasty (paired t-test, p < 0.01, CI 8.4 to 31.4). A further 21 patients who met our criteria for manipulation declined the procedure. Despite continued physiotherapy, there was no significant increase in flexion in their knees. Six weeks to one year after TKR, the mean change was 3.1 degrees (paired t-test, p = 0.23, CI -8.1 to +2).

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Available from: Paul J Gregg, Aug 11, 2015
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    • "The formation of intraarticular adhesion is a common complication after total knee arthroplasty or anterior cruciate ligament (ACL) reconstruction123. Intraarticular adhesion of knee can extremely debilitate for the patients, which often causes the activities of daily living painful and difficult, such as climbing stairs, rising from a chair and tying a shoelace45. "
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    ABSTRACT: 10-Hydroxycamptothecin could reduce intraarticular adhesion by inhibiting fibroblasts proliferation after knee surgery. However, the ideal concentration of hydroxycamptothecin have not been defined. This study was tried to verify the optimal concentration of 10-hydroxycamptothecin in preventing knee intraarticular adhesion. Sixty rabbits were randomly divided into five groups. Approximately 10 mm × 10 mm of the cortical bone was removed from both sides of the femoral condyle and the underneath cancellous bone was exposed. Various concentrations of hydroxycamptothecin (0.1 mg/ml, 0.5 mg/ml, 1.0 mg/ml, 2.0 mg/ml) or saline were applied to the decorticated areas for 10 minutes. After four weeks, the degree of inraarticular adhesion was assessed by macroscopic evaluation, biochemical analysis of hydroxyproline content and histological evaluation. The results demonstrated that the extent of knee inraarticular adhesion in 1.0 mg/ml group and 2.0 mg/ml hydroxycamptothecin group were significantly lower than those of 0.5 mg/ml group, 0.1 mg/ml hydroxycamptothecin group and control group. Moreover, there was no significant difference between 1.0 mg/ml group and 2.0 mg/ml hydroxycamptothecin group. In conclusion, topical application of 1.0 mg/ml hydroxycamptothecin may be the optimal concentration in reducing intraarticular adhesion after knee surgery in rabbits.
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    • "Our results indicate that MUA results in significant improvement in flexion, which is consistent with other studies [11,12]. Six weeks after MUA a statistically significant decrease in flexion was measured at the follow-up examinations. "
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    ABSTRACT: Stiffness with decreased range of motion (ROM) has been described as a frustrating complication after TKA. If all methods of physiotherapeutic treatment have been exhausted trying to develop ROM, manipulation under anaesthesia (MUA) can be discussed. The aim of the present study was to show the effect of MUA and to determine the influence of BMI, number of previous surgical procedures, pre-MUA ROM and timing of MUA for the results after MUA in regard to absolute flexion and gain in flexion. 858 patients underwent TKA at our institution between 2004 and 2009. 39 of these patients underwent MUA because of postoperative knee stiffness. The data were retrospective analysed for the influence of BMI, pre-MUA flexion (</≥ 70°), timing of MUA (>/≤ 30 days after TKA) and number of previous surgery on the results after MUA (absolute Flexion/gain in flexion). The prevalence for stiffness after TKA was 4.54%. There was a statistically significant improvement in flexion not only directly after MUA but also 6 weeks after MUA. Patients with two or more previous operations before TKA showed statistically significant worse results six weeks after MUA in absolute flexion and gain in flexion(p = 0.039) than patients with one or two previous operations. No statistical significance in absolute flexion (p = 0.655) and gain in flexion (p = 0.328) after MUA between "early" and "late" was detected. The stiffer knees with a flexion below 70° showed significantly worse results (p = 0.044) in absolute flexion six weeks after MUA, but they also had statistical statistically better results with regard to gain in flexion (p ≤ 0.001). MUA is a good instrument for improving ROM after TKA. The time between TKA and MUA seems less important, so different types of physiotherapeutic treatment could be tried before the procedure is started. MUA in patients with many previous operations and a flexion of less than 70° before MUA is not as effective as in other patients, but they also benefit from MUA.
    Full-text · Article · Aug 2011 · BMC Musculoskeletal Disorders
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    ABSTRACT: Postoperative stiffness is a debilitating complication of total knee arthroplasty. Preoperative risk factors include limited range of motion, underlying diagnosis, and history of prior surgery. Intraoperative factors include improper flexion-extension gap balancing, oversizing or malpositioning of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope, and inadequate resection of posterior osteophytes. Postoperative factors include poor patient motivation, arthrofibrosis, infection, complex regional pain syndrome, and heterotopic ossification. The first steps in treating stiffness are mobilizing the patient and instituting physical therapy. If these interventions fail, options include manipulation, lysis of adhesions, and revision arthroplasty. Closed manipulation is most successful within the first 3 months after total knee arthroplasty. Arthroscopic or modified open lysis of adhesions can be considered after 3 months. Revision arthroplasty is preferred for stiffness from malpositioned or oversized components. Patients who initially achieve adequate range of motion (>90 degrees of flexion) but subsequently develop stiffness more than 3 months after surgery should be assessed for intrinsic as well as extrinsic causes.
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