title: What Is the Efficacy of Repeat Manipulations Under Anesthesia to Treat Stiffness Following Primary Total Knee Arthroplasty?
abstract: BACKGROUND
  Manipulation under anesthesia (MUA) can help post-total knee arthroplasty (TKA) patients who have knee stiffness regain range-of-motion. However, despite undergoing MUA, patients may have persistent knee stiffness. Often, this persistent knee stiffness is treated with a repeat MUA. Therefore, the purpose of this study was to evaluate repeat MUAs by assessing: (1) demographic characteristics, (2) range-of-motion, (3) clinical outcomes, and (4) rate of revision surgery in post-TKA patients with persistent knee stiffness who either underwent a single MUA or repeat MUAs.
  
  
  METHODS
  One-hundred-and-sixty-seven post-TKA who had undergone an MUA between 2005 and 2011 at two institutions were reviewed. Patients were stratified into those who had a single-MUA (138 knees) and those who had a repeat MUA (29 knees). The mean follow-up period was 63 months (range, 36 to 90 months). The incidence of repeat MUA within this cohort was determined. Demographics and ROM were compared using Student t-test and Chi-square as appropriate. Functional outcomes were assessed using Knee Society scores (KSS) and compared between the two cohorts.
  
  
  RESULTS
  Among the 167 patients who underwent a MUA, 29 (17%) required repeat manipulations. The repeat MUA cohort was younger and more likely to have osteonecrosis as the underlying cause of knee disease. For the repeat MUA cohort, 17 patients (59%) had achieved satisfactory mean gains in ROM after their repeat MUAs. These patients had also achieved excellent mean Knee Society objective and functional scores. However, another seven knees (24%) had further persistent knee stiffness requiring arthrolysis of adhesions and five patients (17%) had undergone revision of the polyethylene spacer or patellar component to improve range-of-motion.
  
  
  CONCLUSIONS
  In this study, the majority of patients who had undergone a repeat MUA were able to achieve improvements in flexion range-of-motion and functional outcomes. However, the remaining patients required more invasive procedure to treat persistent knee stiffness. In patients who have persistent knee stiffness after MUAs, a repeat MUA may be helpful to increase range-of-motion and function.
authors.affiliation: Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey.
authors.forename: Kimona
authors.initials: K
authors.lastname: Issa
authors.affiliation: Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey.
authors.forename: Todd P
authors.initials: TP
authors.lastname: Pierce
authors.affiliation: Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey.
authors.forename: Alexander
authors.initials: A
authors.lastname: Brothers
authors.affiliation: Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey.
authors.forename: Vincent K
authors.initials: VK
authors.lastname: McInerney
authors.affiliation: Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland.
authors.forename: Morad
authors.initials: M
authors.lastname: Chughtai
authors.affiliation: Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland.
authors.forename: Jaydev B
authors.initials: JB
authors.lastname: Mistry
authors.affiliation: Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland.
authors.forename: Wayne W
authors.initials: WW
authors.lastname: Bryant
authors.affiliation: Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland.
authors.forename: Ronald E
authors.initials: RE
authors.lastname: Delanois
authors.affiliation: Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New York.
authors.forename: Steven F
authors.initials: SF
authors.lastname: Harwin
authors.affiliation: Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Mont
mesh_terms: D000768:Anesthesia, General / Q000706:statistics & numerical data; D000844:Ankylosis / Q000175:diagnosis* / Q000534:rehabilitation*; D019645:Arthroplasty, Replacement, Knee / Q000534:rehabilitation* / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D026201:Musculoskeletal Manipulations / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology / Q000534:rehabilitation; D016059:Range of Motion, Articular; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology