Manipulation Under Anesthesia Research Articles

Late Manipulation under Anesthesia after Total Knee Arthroplasty: Improved Range of Motion and a Low Complication Rate.

The purpose of this study was to evaluate outcomes of late manipulation under anesthesia (MUA) for stiffness performed from ≥12 weeks to more than a year after primary total knee arthroplasty (TKA). A total of 152 patients receiving MUA ≥12 weeks after primary TKA from 2014 to 2021 were reviewed. The primary outcome measured was change in range of motion (ROM). We tracked intraoperative complications and the need for repeat MUA or open procedure for continued stiffness after initial MUA. Three subgroups were analyzed: Group 1 included 58 knees between 12 weeks and 6 months after TKA, Group 2 included 44 knees between 6 and 12 months after TKA, and Group 3 included 50 knees ≥12 months after TKA. Analysis included descriptive statistics and univariate analysis, with α <0.05. Groups 1 to 3 all significantly increased their overall ROM by 20.9, 19.2, and 22.0 degrees, respectively. All groups significantly increased their flexion and extension from preoperatively. Group 1 had one intraoperative supracondylar femur fracture (1.7%) requiring open reduction and internal fixation, and five patients required repeat MUA or open procedure (8.6%). Group 2 had no intraoperative fractures, and five patients required repeat MUA or open procedure (11.4%). Group 3 had one intraoperative tibial tubercle avulsion fracture managed conservatively (2.0%) and one repeat MUA (2.0%). Late MUA resulted in significantly improved ROM in all groups. ROM improved more as the time from index TKA increased, although statistically insignificant. Repeat MUA or open procedure rate decreased with MUA ≥12 months from TKA, although statistically insignificant. The overall intraoperative fracture risk was 1.3%.

Specific Preoperative Factors Increase Manipulations under Anesthesia Following Primary TKA.

Arthrofibrosis following primary total knee arthroplasty (TKA) can result in pain and limit postoperative range of motion (ROM), jeopardizing clinical outcomes and patient satisfaction. This study aims to identify preoperative risk factors associated with necessitating a manipulation under anesthesia (MUA) following primary TKA.We retrospectively reviewed 950 cases of consecutive primary TKAs performed at one institution by three arthroplasty surgeons between May 2017 and May 2019. Recorded preoperative variables included smoking status, race, preoperative ROM, presence of effusion or positive anterior drawer, and medical comorbidities. Demographic characteristics were compared with Student's t-tests or chi-square tests as appropriate. For each preoperative factor, we obtained an odds ratio (OR) for MUA risk using multivariate logistic regression.Twenty (2.3%) patients underwent MUA following their index primary TKA surgery. History of ipsilateral knee surgery (OR: 2.727, p = 0.047) and diagnosed hypertension (OR: 4.764, p = 0.016) were identified as risk factors associated with significantly increased risk of MUA. The greater the preoperative ROM, the higher likelihood needed of MUA (OR: 1.031, p = 0.034).Patients who had diagnosed hypertension or a history of prior ipsilateral knee surgery were associated with increased risk of necessitating an MUA following primary TKA. Additionally, a greater total arc of motion preoperatively increased the odds of needing MUA.Level III of evidence was present.

Arthroscopic Capsular Release Versus Manipulation under Anesthesia for Refractory Frozen Shoulder: A Systematic Review with Meta-Analysis.

Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS. A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta-analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs). A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, -0.44; 95% CI, -0.71 to -0.18; I2 = 6%; p = 0.001) at over 12-month follow-up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow-up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention. In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short-term follow-up periods. Notably, ACR exhibited statistically superior improvement in the long-term pain relief compared to the MUA group, although it did not reach the MCID.

Range-of-Motion Predictors for Repeat Manipulation Under Anesthesia and Revision Surgery for Stiffness After Total Knee Arthroplasty

Introduction: Manipulation under anesthesia (MUA) is a first-line treatment for stiffness after total knee arthroplasty (TKA), but predicting outcomes after MUA can be difficult. Purpose: We sought to determine the association between pre-MUA range-of-motion (ROM) and the risk of repeat MUA and revision in patients who underwent primary TKA. Methods: We conducted a retrospective review of 543 MUAs for stiffness at a single institution. Mean age was 62.5 years, and 64% were female. Second MUA or revision TKA were considered failures of treatment. Penalized logistic regression models were used to assess risk factors for failures. The Kaplan-Meier survivorship was used to examine survivorship free from second MUA or revision. Results: Before and after MUA, there was significant improvement in knee flexion (78.0° vs 112.8°, respectively) and extension (4.1° vs 0.8°, respectively); 6.4% of patients required repeat MUA and 5.3% required revision TKA. Survivorship free of second MUA was 90.9%, revision for stiffness was 92.4%, and all-cause revision was 88.2% at 2 years post-MUA. Patients with pre-MUA flexion contracture of ≥5° were more likely to undergo second MUA revision for stiffness and any revision. There were significant improvements in patient-reported outcomes postoperatively. Conclusions: This retrospective chart review suggests that MUA is an effective treatment for post-TKA stiffness, with good early survivorship, and that worse pre-MUA ROM is associated with MUA failure and need for repeat MUA or revision. This information may have implications for patient counseling and management.

Outcomes of Early Versus Delayed Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review and Meta-analysis

BackgroundStiffness following total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA). However, there is debate regarding the timing of MUA, with many recommending against MUA beyond three months after TKA. Therefore, the purpose of this systematic review was to evaluate the functional and clinical outcomes of early versus delayed manipulation under anesthesia (MUA) for stiffness following total knee arthroplasty (TKA). MethodsA search following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was performed in the PubMed, Embase, Scopus, and Cochrane databases in November 2023. Data regarding study characteristics, demographics, knee flexion and extension, patient-reported outcomes (PROs), complications, and revisions. A quality assessment was performed using the Methodological Index for Non-randomized Studies. Included were fourteen studies analyzing 13,445 knees, 72.1% of which underwent early MUA and 27.8% of which underwent delayed MUA. Of the 14 studies, ten defined early MUA as being performed within three months of the index TKA. ResultsPre- and post-MUA knee flexion for the early/delayed groups was 71.3°/77.9° and 103.0°/96.1°, respectively. Upon meta-analysis, pre-MUA knee flexion was significantly higher in the delayed group (P = 0.003), whereas post-MUA flexion was similar in both groups (P = 0.36). The mean gain in knee flexion for the early and delayed groups was 32.0°/19.2°. The surgical complication and revision TKA rates for the early and delayed groups were 4.9%/10.3% and 5%/9%, respectively. A meta-analysis found the risk of surgical or medical complications and revision TKA to be significantly higher in the delayed MUA group (P < 0.00001 and = 0.002, respectively). ConclusionsThough post-MUA knee flexion was similar in patients undergoing early and delayed MUA following TKA, the mean gain in flexion for early patients was nearly double that of delayed patients. Delayed patients also had significantly higher risks of surgical or medical complications and revision TKA following MUA.

How to manage a native stiff knee.

Knee stiffness is a widely known and worrying condition in several postoperative knees. Less is known about native stiff knee. The aim of this manuscript is to summarize the available literature on native stiff knee epidemiology, classification and treatment. In 1989 stiff knee was defined as a knee with less than 50° of total range of motion. If range of motion is <30°, it is defined as an ankylosed knee. Knee stiffness can be divided into three main types: flexion contractures, extension contractures, and combined contractures. Different risk factors have been associated to native stiff knee and grouped into modifiable or not modifiable. Furthermore, risk factors can be divided into patients' related no patients'-related. Different treatment modalities can be indicated to treat knee stiffness, including manipulation under anesthesia (MUA), arthroscopic and open surgical release. When stiffness is associated with articular disruption TKA represent an option. TKA in native stiff knee can be challenging for the surgeon. Implant's choice and knee exposure are the first steps. In some cases, additional release and extensive can be considered. A stepwise approach and careful preoperative planning are mandatory to obtain long-term satisfactory outcomes. Native stiff knee is a rare but invalidating condition. Different treatment modalities have been proposed as treatment. However, considering that it is frequently associated to sever arthritis, TKA can be an option in painful stiff knees. Nature of knee stiffness necessitates a customized approach to ensure successful management and achieve satisfying outcomes.

ACE Inhibitor Use Does Not Significantly Affect Occurrence of Manipulation Under Anesthesia Following Total Knee Arthroplasty

Introduction Common medications may attenuate fibroblast proliferation and scar tissue formation. This study aims to evaluate the association between angiotensin converting enzyme inhibitor (ACEI) use and post-operative stiffness assessed by rate of manipulation under anesthesia (MUA) and change in range of motion (ROM) following total knee arthroplasty (TKA). Methods Patients undergoing primary TKA January 2014 - September 2019 were identified. Demographic information, use of ACEI medications, occurrence of MUA in the 6 months following surgery, and ROM was determined by chart review. MUA was indicated upon failure to achieve 90° ROM at 1-month follow-up. Demographics were analyzed using Student’s t-test and Chi-Squared tests. SPSS (version 24, IBM) multivariate regression calculated odds ratios for MUA controlling for age, BMI, American Society of Anesthesiologist’s class, and gender. Results 1590 primary TKA’s were identified. 274 patients (17.3%) were taking ACEI medications. 46 patients required MUA (2.9%). Five patients (1.8%) taking an ACEI required MUA, versus 41 of the 1316 control patients (3.1%). No significant difference in MUA rates between the ACEI and control cohorts (odds ratio 0.670, 95% CI: 0.259 – 1.735, p=0.410) was identified. Change in ROM was not significantly different between cohorts at 1 and 3 month intervals. At 1-year, improvement in ROM was significantly less in patients taking ACEIs (+6.54° vs. +9.90°, p=0.035) and significantly fewer ACEI cohort patients achieved 118° flexion (56.9% vs. 68.4%, p=0.013). Conclusions This study supplies evidence that ACEIs do not reduce post-operative stiffness following TKA. Additionally, patients taking ACEI medications have significantly less improvement in ROM 1 year post-operatively.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees

BackgroundPatients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies. MethodsAll patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee’s results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years). ResultsThere were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (−10.6 at 2 weeks, −27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, −8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (−5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs. ConclusionsThe second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

A Comparison Between Polyethylene Exchange and Full Revision for Arthrofibrosis Following Total Knee Arthroplasty

BackgroundArthrofibrosis is a debilitating postoperative complication and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) range of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis. MethodsPatients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > .05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = .85), and flexion (81 versus 82 degrees, P = .80) versus extension (11 versus 11 degrees, P = .87) ROM. ResultsThe full component revision had higher KOOS, JR (65 versus 55, P = .04), and flexion (102 versus 92 degrees, P = .02), but similar extension (3 versus 3 degrees, P = .80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. The MUA (18.2 versus 18.8%, P = .96) and LOA (2.0 versus 0.0%, P = .32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision. ConclusionsThe full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, and preoperative indications, as well as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange.

Excellent 2-Year Outcomes of a Midlevel Constrained Liner Used in Stemless Primary TKA

Introduction: Instability after total knee arthroplasty (TKA) remains a leading cause of revision TKA and can lead to patient dissatisfaction. While many companies have developed midlevel constrained (MLC) polyethylene inserts in primary TKAs, there is little data on their outcomes. Purpose: We sought to analyze short-term outcomes including survivorship, rates of manipulation under anesthesia (MUA), and improvements in patient-reported outcome measures (PROMs) preoperatively to postoperatively in one design of MLC TKA. Methods: We prospectively followed consecutive primary TKA patients who received constrained inserts (Journey II or Legion Genesis II, Smith and Nephew) from 5 surgeons, 2019 to 2020, at a single academic institution. We analyzed revision-free survivorship, MUA rates, and PROMs, preoperatively to postoperatively. Results: A total of 356 patients were included with a mean age of 64 years; 49% were male and the mean body mass index (BMI) was 31 kg/m2. Sixteen patients (4.5%) underwent MUA and 3 patients (0.8%) underwent revision. Two patients underwent polyethylene exchange and patellar resection for patellar loosening. One patient underwent liner exchange for instability. The 2-year revision-free survivorship was 98.5% (95% confidence interval [CI]: 96.6%–100%). Survivorship free from revision for tibial or femoral aseptic loosening was 100% at 2 years. The 2-year survivorship free from MUA was 92.3% (95% CI: 88.6%–96.1%). The mean Knee Osteoarthritis and Injury Outcomes Score Joint Replacement (KOOS JR) was 81 at 2 years follow-up, while the Lower Extremity Activity Score (LEAS) score was 10.5. Conclusion: At a mean of 3 years follow-up, 2 types of MLCs used in primary TKA were associated with a low rate of early revision, low rate of MUA, and reliable improvement in functional outcomes. These MLCs were not associated with early loosening or unique failure modes.

The association between losartan potassium prescription and postoperative outcomes following total knee arthroplasty: A TriNetX analysis

BackgroundTotal knee arthroplasty (TKA) is a common surgical procedure performed to alleviate pain and improve functional outcomes in patients with knee osteoarthritis and rheumatoid arthritis who have failed conservative treatments. Arthrofibrosis has been extensively studied due to its negative impact on TKA outcomes. Losartan, an angiotensin receptor blocker (ARB), has the potential to improve TKA outcomes by inhibiting TGF-β and decreasing fibrosis. This study aims to analyze a large-scale, real-world healthcare database to investigate the association between losartan potassium prescription and postoperative outcomes such as readmissions, ED visits, and the need for MUA or revision TKA. HypothesisBased on previous literature and the nature of ARBs, it is expected that the addition of losartan will aid in better outcomes for patients following a primary TKA. Patients and methodsIn this retrospective observational study, the TriNetX Research Network (TriNetX) database was queried as of June 21, 2023. All patients who underwent a primary total knee arthroplasty (TKA) prior to June 21, 2022 were included. Patients were then divided into two cohorts by whether they had an active losartan potassium prescription within the year prior to their surgery to within 90days postoperatively. Patients were then propensity-matched to eliminate differences in demographics and comorbidities. ResultsLosartan TKA patients were 1.18 [OR: 0.85 (95% CI: 0.79–0.90), p<0.001] times less likely to be readmitted within 90days and were 1.15 (OR: 0.87 (95% CI: 0.79–0.96); p=0.009) times less likely to undergo a manipulation under anesthesia (MUA) within the 1-year postoperative period. There were no statistically significant differences in rates of emergency department (ED) visits at 90days postoperatively or revision TKAs at 1year postoperatively. DiscussionIn conclusion, patients with an active losartan prescription prior to TKA had a significantly lower likelihood of readmission within 90days and a lower likelihood of undergoing MUA within the 1-year postoperative period compared to patients not taking losartan. This presents an opportunity for further clinical investigation to explore the value of losartan in TKA. Level of evidenceIII; an observational cohort study.

ADJUNCT CPM THERAPY DOES NOT APPEAR TO IMPROVE THE ROM ACHIEVED AFTER MUA FOR STIFFNESS IN TOTAL KNEE ARTHROPLASTY

Stiffness is reported in up to 16% of patients after total knee replacement (TKR)1. Treatment of stiffness after TKR remains a challenge. Manipulation under anaesthesia (MUA) accounts for between 6%-36% of readmissions following TKR2,3. The outcomes of MUA remain variable/unpredictable. Post-operative CPM is used as an adjuvant to MUA, potentially offering improved ROM, however, remains the subject of debate. We report a retrospective study comparing MUA with and without post-operative CPM.In our institution patients undergoing MUA to receive CPM post-operatively. Owing to the COVID-19 pandemic hospital admissions were limited. During this period MUA procedures were undertaken without CPM. Two cohorts were included: 1) MUA + post-operative CPM 2) Daycase MUA. Patients’ demographics, pre-manipulation ROM, post-MUA ROM, and ROM at final follow-up were recorded.Between 2017-2022 126 patients underwent MUA and were admitted for CPM and 42 had daycase MUA. The median Age was 66.5 and 64% were female. 57% had extension deficit (&gt;5o), 70% had flexion deficit (&lt; 90o), and 37% had both. The mean Pre-operative ROM was 72.3o(SD:18.3o) vs. 68.5o(19.0o), ROM at MUA was 95.5o(SD:20.7o) vs 108.3o(SD:14.1o) [p&lt; 0.01], and at final follow-up 87.4o(SD:21.9o) vs. 92.1o(SD:18.2o) for daycase and CPM groups respectively. At final follow-up for the daycase and CPM groups respectively 10% vs. 7% improved, 29% vs. 13% maintained, and 57% vs. 79% regressed from the ROM achieved at MUA. The mean percentage of ROM gained at MUA maintained at final follow-up was 92%(SD:17) and 85%(SD:14)[p=0.03] for daycase and CPM groups respectively.There was no significant difference in ROM achieved at final follow-up despite the significantly greater improvement in ROM achieved at MUA for the CPM group. The CPM group lost a greater ROM after MUA (15% vs. 8%). We conclude that post-operative CPM does not improve ROM achieved after MUA.

Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial

BackgroundFrozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with recovery of shoulder function at long term. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy program (PT) compared to a PT program alone in patients with stage two FS. MethodsA prospective, single center randomized controlled trial was performed. Patients between 18 and 70 years old with a stage two FS were deemed eligible if an initial course of conservative treatment, consisting of physiotherapy and an intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block and an intensive physiotherapy treatment protocol was started within 4 hours after MUA. In the PT group patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the SPADI score. Secondary outcomes were pain, range of motion, OSS, quality of life and ability to work. ResultsIn total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, OSS, pain, range of motion and quality of life in both groups at 1 year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significant bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations or brachial plexus injuries occurred in this trial. ConclusionMUA in stage 2 FS can be considered safe and results in a faster recovery of range of motion and improved functional outcome, measured with SPADI scores, compared to PT alone at short term. After 1 year, except for slightly better range of motion scores for MUA, the result of MUA is equal to PT.

Arthroscopic findings after manipulation under anesthesia in idiopathic capsulitis of the shoulder: A prospective study.

Manipulation under anesthesia (MUA) of the shoulder joint is a commonly used method for the treatment of adhesive capsulitis. Though it has been known to be associated with a variety of complications, there is a paucity of studies describing the arthroscopic findings after MUA. To describe the arthroscopic findings in patients with idiopathic adhesive capsulitis of the shoulder after MUA. We recruited 28 patients with idiopathic adhesive capsulitis who underwent arthroscopic capsular release. Manipulation of the shoulder was performed under anesthesia in all of these patients before capsular release. Intra-articular findings were recorded during arthroscopic capsular release in these patients. All patients showed the presence of synovitis. Twenty-seven patients showed tears in the capsule on the anterior aspect. One patient had an avulsion of the anterior rim of the glenoid and labrum following the manipulation. Four patients had partial rotator cuff tears, and one patient showed a superior labrum anterior posterior lesion, which was not diagnosed preoperatively on magnetic resonance imaging. MUA leads to rupture of the capsule, which is the desired outcome. However, the site of rupture of the capsule is dependent on the maneuvers of MUA. In addition, partial tears of the rotator cuff and osteochondral fractures of the glenoid can also occur.

A multi-center, single-blinded, randomized, parallel-group, superiority study to compare the efficacy of manipulation under anesthesia versus intra-articular steroid injection in the treatment of patients with frozen shoulder and a diagnosis of rotator cuff injury or tear by MRI: study protocol for a randomized controlled trial

BackgroundFrozen shoulder (FS) is a common condition that can cause severe pain and limited range of motion in the shoulder joint. While intra-articular steroid injection has been shown to be an effective treatment for FS, manipulation under anesthesia (MUA) is an alternative treatment that has gained popularity in recent years. However, there is a lack of evidence regarding the effectiveness of MUA on FS patients with concomitant rotator cuff injury or tear. Though a few studies have shown that MUA is not associated with rotator cuff tears, and will not exacerbate the injury, more high-quality studies with bigger sample sizes are needed. Therefore, the aim of this multi-center, single-blinded, randomized, parallel-group, superiority study is to compare the efficacy of MUA versus intra-articular steroid injection in the treatment of FS patients with a diagnosis of rotator cuff injury or tear by MRI.MethodsA parallel, single-blinded, multi-center randomized controlled trial of 320 patients will be conducted at three hospitals of China. Eligible patients with frozen shoulder and rotator cuff injury or tear diagnosed by MRI will be randomly assigned to, in equal proportions, the manipulation under anesthesia group and the intra-articular steroid injection group via a central randomization system, undergoing a corresponding operation on day one and a sequent physical exercise for 14 days. The primary outcome is the comprehensive efficacy evaluation (total effective rate) and the change of Constant-Murley Score. Outcome assessors and data analysts will be blinded, and participants will be asked not to reveal their allocation to assessors.DiscussionThis study aims to explore the superiority of manipulation under anesthesia in reducing pain and improving shoulder function in frozen shoulder patients accompanied with rotator cuff injury. To provide a scientific basis for the dissemination and application of manipulation under anesthesia, and a better knowledge for the role of MUA in the treatment of frozen shoulder accompanied with rotator cuff injury.Trial registrationChictr.org.cn ChiCTR2200067122. Registered on 27 December 2022. ChiCTR is a primary registry of the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) network and includes all items from the WHO Trial Registration data set in Trial registration.

Patellar Base Support Technique During Manipulation Under Anesthesia for Knee Arthrofibrosis Limits the Risk of Iatrogenic Complications

Knee extension contracture is a common postinjury and postsurgical complication, which decreases knee joint flexion. Many techniques have been described in the literature to restore knee flexion, with the most common one being an arthroscopic lysis of adhesions. However, in severe cases, additional intra- and extra-articular procedures are needed to restore full knee flexion. Manipulation under anesthesia (MUA) is one of them. Unfortunately, it may lead to devastating complications, such as iatrogenic rupture of the patellar tendon or fractures of the patella or tibial tuberosity. Therefore, the purpose of this report is to present a safer modification of MUA for knee extension contracture in cases in which excessive force is demanded to achieve flexion. The key aim of the “patellar base support” technique (PBS technique) is to stretch the contracted quadriceps muscle with controlled and decreased tension on the patella, patellar tendon, and tibial tuberosity.

Modern robotics platform associated with reduced 90-day complications in hospital setting

BACKGROUND: Early complications in total knee arthroplasty (TKA) associated with modern robotics platforms integrated with digital balancing technology have not been investigated. OBJECTIVE: The objective was to compare 90-day complication rates between a manual technique and a modern robotic-assisted ligament balancing TKA platform. METHODS: 895 primary TKA procedures from a single surgeon were retrospectively reviewed (614 manual TKA, 281 using a modern robotics platform with an integrated digitally controlled ligament balancing device). Post-operative complications within the 90-day episode of care were recorded by the Michigan Arthroplasty Registry Collaborative Quality Initiative. Differences in complication rates between techniques were further divided into inpatient hospital, outpatient hospital, and ambulatory surgery center (ASC) cohorts. RESULTS: In the pooled hospital cohort and inpatient hospital cohort, ‘Return to OR’ was significantly lower for the robotic assisted group (1.3% vs 5.2% and 0% vs 4.9%, respectively, p&lt; 0.0370). Specifically, the need for manipulation under anesthesia (MUA) was reduced for the robotics group (0.0% vs 2.5%, p= 0.0352). No differences in overall complication rate or cause of complication was found between manual and robotics cases for the hospital outpatient and ASC cohorts (p⩾ 0.68). CONCLUSION: Within the hospital setting, robotic assisted ligament balancing technology was associated with reduced 90-day postoperative complications for ‘Return to OR’ and MUA.

Surgical Outcomes of Synthetic Cartilage Implant Hemiarthroplasty for Metatarsophalangeal Arthropathy.

Introduction Metatarsophalangeal joint (MTPJ) arthropathy in the great toe causes considerable pain and debilitation, severely impacting quality of life. Traditional management options included conservative measures, steroid injections, and arthrodesis. New options include Cartiva, a synthetic cartilage hemiarthroplasty for the MTPJ. This prosthesis has evidence of improved pain and function without the sacrifice of joint movement seen with arthrodesis. However, the implant itself has mixed reviews. This study aims to identify the pre-, peri, and short-term post-surgical outcomes of Cartiva surgery and review the literature for existing reported outcomes. Methods We retrospectively reviewed a cohort of 22 consecutive Cartiva procedures between 2016 and 2022 in a single UK institution. Hospital records were analyzed for peri-operative complications, implant survival, additional operative interventions, patient-reported outcomes, and functional improvement. Results Twenty-one patients underwent Cartiva for the first MTPJ pathology and one for the third MTPJ pathology. Prior to surgery, 40.9% of patients had undergone alternative therapies, including MTPJ steroid injections (seven patients), cheilectomy (four patients), and bunionectomy (one patient). Total complication rates, inclusive of medical, surgical, and implant complications were 45.5% (10/22). Total reoperation rates were 18.2% (4/22) including two revisions to arthrodesis and two manipulations under anesthesia (MUA) with local anesthetic injection. At the final follow-up, 55% were still experiencing pain, 15% neurovascular symptoms, 10% swelling, and 50% stiffness or reduced range of movement. However, 85% of patients returned to usual activities of daily living within two years. Conclusion Cartiva surgery for metatarsophalangeal arthropathy has demonstrated outcomes of persistent pain, limited range of movement, and restricted function at short-term follow-up. Rates of reoperation and revision to arthrodesis were comparable with similar studies.

No clinical advantage with customized individually made implants over conventional off-the-shelf implants in total knee arthroplasty: a systematic review and meta-analysis.

Total knee arthroplasty (TKA) can be performed with either conventional off-the-shelf (OTS) or customized individually-made (CIM) implants. The evidence for CIM implants is limited and variable, and the aim of this review was to compare clinical and radiological outcomes between CIM and OTS implants. A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Studies reporting on clinical, radiological, or alignment outcomes for CIM and OTS implants were selected. The studies were appraised using the Methodical index for non-randomized studies tool. Twenty-three studies fulfilled the inclusion criteria. The studies comprised 2856 CIM and 1877 OTS TKAs. Revision rate was higher with CIM (5.9%) compared to OTS (3.7%) implants [OR 1.23(95% CI 0.69-2.18)]. Manipulation under anesthesia (MUA) was higher in CIM (2.2%) compared to OTS (1.1%) group [OR 2.95(95% CI 0.95-9.13)] and complications rate was higher in CIM (5%) vs. OTS (4.5%) [OR 1.45(95% CI 0.53-3.96)] but neither reached statistical significance. Length of stay was significantly shorter in CIM group 2.9days vs. 3.5days [MD -0.51(95% CI -0.82 to -0.20)]. Knee Society Score showed no difference between CIM and OTS groups for Knee 90.5 vs. 90.6 [MD -0.27(95% CI -4.27 to 3.73)] and Function 86.1 vs. 83.1 [MD 1.51(95% CI -3.69 to 6.70)]. CIM implants in TKA have theoretical benefits over OTS prostheses. However, in this present review, CIM implants were associated with higher revisions, MUA, and overall complication rates. There was no difference in outcome score and CIM implants did not improve overall target alignment; however, more CIM TKAs were found to be in the HKA target zone compared to OTS TKAs. The findings of this review do not support the general utilization of CIM over OTS implants in TKA.

POSTOPERATIVE CPM DOES NOT IMPROVE ROM ACHIEVED AFTER MUA FOR STIFFNESS IN TOTAL KNEE ARTHROPLASTY

AbstractObjectivesStiffness is reported in 4%–16% of patients after having undergone total knee replacement (TKR). Limitation to range of motion (ROM) can limit a patient's ability to undertake activities of daily living with a knee flexion of 83o, 93o, and 106o required to walk up stairs, sit on a chair, and tie one's shoelaces respectively. The treatment of stiffness after TKR remains a challenge. Many treatment options are described for treating the stiff TKR. In addition to physiotherapy the most employed of these is manipulation under anaesthesia (MUA). MUA accounts for up to 36% of readmissions following TKR. Though frequently undertaken the outcomes of MUA remain variable and unpredictable. CPM as an adjuvant therapy to MUA remains the subject of debate. Combining the use of CPM after MUA in theory adds the potential benefits of CPM to those of MUA potentially offering greater improvements in ROM. This paper reports a retrospective study comparing patients who underwent MUA with and without post-operative CPM.MethodsStandard practice in our institution is for patients undergoing MUA for stiff TKR to receive CPM for between 12–24hours post-operatively. Owing to the COVID-19 pandemic hospital admissions were limited. During this period several MUA procedures were undertaken without subsequent inpatient CPM. We retrospectively identified two cohorts of patients treated for stiff TKR: group 1) MUA + post-operative CPM 2) Daycase MUA. All patients had undergone initial physiotherapy to try and improve their ROM prior to proceeding to MUA. In addition to patients’ demographics pre-manipulation ROM, post-MUA ROM, and ROM at final follow-up were recorded for each patient.ResultsIn total 168 patients who had undergone MUA between 2017–2022 were identified with a median Age of 66.5 years and 64% female. 57% had extension deficit (&gt;5o), 70% had flexion deficit (&lt; 90o), and 37% had both. 42 had daycase MUA without CPM and the remaining 126 were admitted for post-operative CPM. The mean Pre-operative ROM was 72.3o (SD:18.3o) and 68.5o (19.0o) for the daycase and CPM groups respectively. The mean ROM recorded at MUA was 95.5o (SD:20.7o) and 108.3o (SD:14.1o) [p&lt;0.01] and at final follow-up was 87.4o (SD:21.9o) and 92.1o (SD:18.2o) for daycase and CPM groups respectively. At final follow-up for the daycase and CPM groups respectively 10% vs. 7% improved, 29% vs. 13% maintained, and 57% vs. 79% regressed from the ROM achieved at MUA. The mean percentage of ROM gained at MUA maintained at final follow-up was 92% (SD:17%) and 85% (SD:14%) [p=0.03] for daycase and CPM groups respectively.ConclusionOverall, there was no significant difference in ROM achieved at final follow-up despite the significantly greater improvement in ROM achieved at MUA for the CPM group. Analysis of the percentage ROM gained at MUA maintained at follow up showed that most patients regressed from ROM achieved at MUA in both groups with those in the CPM only maintaining 85% as opposed to 92% in the daycase patients. It is our observation that post-operative CPM does not improve ROM achieved after MUA as compared to MUA alone.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.