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Manipulation


CASE STUDY

An active 59-year-old male patient with osteoarthritis of the right knee underwent total knee arthroplasty with a posterior-stabilized prosthesis. Preoperative range of motion (ROM) was 5 degrees of flexion contracture to 120 degrees of flexion. Surgery was uncomplicated, but at a 6-week postoperative visit, ROM was limited to 5 to 90 degrees. Component position and alignment were considered acceptable ( Fig. 14.1 ). The patient was advised to undergo manipulation under anesthesia (MUA) and consented. After induction of general anesthesia, the ROM was found to be 5 to 95 degrees with gravity alone ( Fig. 14.2 ). After 5 minutes of gentle, passive stretch, ROM was improved to 5 to 122 degrees with gravity alone. Video and photographs of this case are presented in this chapter.

FIGURE 14.1, A, Hip-to-ankle radiograph demonstrates acceptable limb alignment (arrow) . B, Lateral radiograph shows appropriately positioned and sized components. C, Patellar view demonstrates a mild tilt but shows no evidence of overstuffing or malpositioning.

FIGURE 14.2, A, The knee flexion that is obtained after induction of anesthesia with gravity alone is recorded. B, A gentle, sustained flexion force is applied to the lower leg by the surgeon’s hand placed over the proximal tibia. Five to 15 minutes of progressive stretch may be needed to reach a firm end point. C, The surgeon’s contralateral hand is placed over the knee and is used to palpate the stretch and crepitus as the intraarticular fibrotic bands release. D, The knee flexion obtained at the conclusion of the procedure is documented, and a photograph is provided to the patient for motivation during physical therapy.

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Chapter Synopsis

Limited range of motion occurs in about 5% of patients after total knee arthroplasty. Manipulation under anesthesia (MUA) should be considered for patients who fail to achieve about 90 degrees of flexion by 6 to 12 weeks after surgery.

Important Points

  • Exclude gross component malpositioning or sizing errors.

  • Document intact extensor mechanism before manipulation.

  • Avoid manipulation for improvement of significant flexion contracture alone.

  • Manage pain aggressively after manipulation.

  • Set up postprocedure physical therapy and a continuous passive motion (CPM) machine for outpatients before manipulation.

Clinical/Surgical Pearls

  • General anesthesia with muscle relaxation or regional anesthesia may be used.

  • Apply gentle, progressive pressure over the proximal one third of the tibia to achieve flexion.

Clinical/Surgical Pitfalls

  • Avoid manipulation for flexion contractures.

  • Avoid applying flexion force to the lower leg over the distal tibia, because this may increase the risk of fracture or tendon injury, particularly in patients with osteopenic bone.

  • To better understand these pitfalls, see the video of MUA ( ).

Introduction

Limited postoperative range of motion (ROM) after total knee arthroplasty (TKA) occurs in approximately 1% to 10% of patients. This problem, although associated with pain in many patients, is defined by restricted flexion on physical examination. It should be distinguished from the subjective complaint of stiffness, which may be associated with a normal ROM in some cases. Although the objective measurements that define limited postoperative ROM have not been rigidly defined, published criteria usually specify failure to achieve 75 to 95 degrees of flexion within 6 to 12 weeks after surgery.

Limited postoperative motion may have multiple causes, including arthrofibrosis; an abnormal periarticular fibroblastic response to injury ; technical errors such as component malrotation, overstuffing of the patellofemoral joint, or failure to balance the posterior cruciate ligament in a cruciate-retaining (CR) prosthesis; and inadequate postoperative rehabilitation. Patient risk factors that may contribute to limited postoperative ROM include limited preoperative ROM, obesity; younger age; female gender; and poor postoperative pain control.

Nonsurgical treatment options include physical therapy; continuous passive motion (CPM) machines; active splints; and optimization of pain management; but reported gains in the ROM with these interventions have been inconsistent. Surgical options include MUA, arthroscopic lysis of adhesions and manipulation; open arthrolysis with or without polyethylene exchange; and component revision. Factors that should be considered when selecting optimal treatment include the magnitude of the restriction in motion; time from surgery; technical errors in prosthesis positioning and sizing; type of prosthesis (e.g., CR versus posterior stabilized); and patient factors that cannot be modified, including significant preoperative restrictions in ROM and morbid obesity.

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