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Manipulation of total knee replacement: Is the flexion gaine

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2009-02-21 17:22:25

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 deg. 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 deg (35 to 80). One year later the mean gain was 33 deg (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

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Project Management Standard Program 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 deg (paired t-test, p = 0*23, CI -8.1 to +2).

While the primary aims of total knee arthroplasty are relief of pain and restoration of mobility, an adequate range of movement (ROM) is also desirable. Laubenthal, Smidt and Kettelkamp assessed the amount of flexion necessary for everyday activities and found that the mean flexion required to climb stairs, to sit, and to tie a shoelace was 83 deg, 93 deg and 106 deg, respectively. The ROM attained after total knee replacement (TKR) depends not only on such factors as prosthetic design and soft-tissue balance, but also on patient morphology, the preoperative ROM and motivation. Some patients may be satisfied with less flexion as long as they have relief from pain.

The long-term benefits of manipulation under anaesthesia (MUA) after TKR have been questioned.5 The known complications of manipulation, including supracondylar fracture, avulsion of the patellar tendon, myositis ossificans and wound breakdown, may further compromise poor results. These occur, however, in fewer than 3% of patients. Our aim was to evaluate the use of MUA in patients whose maximum flexion was less than 80 deg despite intensive physiotherapy.

Patients and Methods

In 1987, we began a prospective, randomised study comparing 476 cemented and uncemented posterior-cruciateretaining TKRs (PFC; Johnson & Johnson, Bracknell, UK) which had been performed or directly supervised by the senior author (PJG). None of the patellae had been resurfaced but their osteophytes had been excised. The deep and superficial layers had been closed with interrupted sutures. Under the supervision of a physiotherapist, knee flexion began when the wound drains were removed 48 hours after surgery. Continuous passive motion (CPM) was not used except after manipulation. A goniometer was used to measure results.

Manipulation was considered in patients in whom maximum flexion remained less than 80 deg despite intensive physiotherapy. This was performed on 47 (group 1) out of 68 knees. The remaining 21 patients (group 2) declined manipulation but continued with physiotherapy.

Group 1 (manipulation group). There were 18 men and 24 women with a mean age of 67 years (51 to 88). Five patients had bilateral replacements, two of them simultaneously, and required manipulation of both knees. In all but one, who had rheumatoid arthritis (RA), the underlying pathology was osteoarthritis (OA). High tibial osteotomy had been performed on two knees: these were the only previous surgical procedures in this group. There were varus deformities in 38 knees. In 19 cases neither the femoral nor the tibial component had been cemented. Before arthroplasty, the mean active flexion was 102 deg (60 to 135). The mean time from implantation to manipulation was 11.3 weeks (median 9, range 2 to 41). Before manipulation, the mean flexion was 62 deg (median 65, range 35 to 80).

Group 2 (patients who declined manipulation). There were nine men and 12 women with a mean age of 67 years (46 to 81). The primary pathology was OA in 19 patients and RA in two. None had previous knee surgery. Before arthroplasty, there were varus deformities in 20 knees. In five, the implants were uncemented. The mean active flexion before arthroplasty was 84.7 deg (60 to 110). The physiotherapist continued to treat these patients.

Manipulation technique. Before manipulation, the ROM of the knee and its resistance to further flexion were assessed under general anaesthesia. The surgeon supported the lower leg proximally and distally and an assistant supported the thigh. A steady progressive force was applied to the proximal tibia until the adhesions gave way. After this, all the knees could be flexed, under anaesthesia, to at least 90 deg. For 24 hours after MUA a CPM machine was used. Patients were discharged when they had made satisfactory progress.

Statistical analysis. The Wilcoxon signed-rank test was used to determine whether the recorded changes in flexion were significant. We used a paired t-test to compare changes in flexion within each group and a two-sample t-test to compare the groups. The 95% confidence intervals (CI) are given.

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