Manipulation Under Anesthesia As a Therapy Option for Postoperative Knee Stifness: a Retrospective Matched‑Pair Analysis

Archives of Orthopaedic and Trauma Surgery (2020) 140:785–791 https://doi.org/10.1007/s00402-020-03381-y KNEE ARTHROPLASTY Manipulation under anesthesia as a therapy option for postoperative knee stifness: a retrospective matched‑pair analysis Daiwei Yao1 · Frederik Bruns2 · Sarah Ettinger1 · Kiriakos Daniilidis3 · Christian Plaass1 · Christina Stukenborg‑Colsman1 · Leif Claassen1 Received: 1 April 2019 / Published online: 25 February 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020 Abstract Introduction Due to demographic changes, total knee arthroplasty (TKA) is one of the most frequently performed orthopedic surgeries. Therapies for associated postoperative complications, such as postoperative knee stifness (PKS), are becoming increasingly important. The aim of this retrospective matched-pair analysis was to evaluate mid-term-results following manipulation under anesthesia (MUA). Materials and methods Fifty-one patients with PKS were evaluated and 51 matched-pair patients without PKS after primary TKA were chosen for the control group. In addition to the range of motion, the functionality was recorded by Knee Society Score (KSS), Western Ontario and Mc Masters Universities Osteoarthritis Index (WOMAC), and Short-Form-12 Question- naire (SF-12). Experience of pain was mapped using a 10-point Numeric Rating Scale (NRS), and the analgesic requirement was mapped using the WHO step scheme. A fnal follow-up examination was conducted approximately three years after TKA. To evaluate potential risk factors for the development of PKS, TKA alignment was measured via postoperative X-ray images. Results Improvement of the average knee fexion of 35.7° and total fexion of 107.4° was detected in PKS patients after MUA. The fexion of the control group was 112.4°; no signifcant between-group diference was present regarding prosthesis type, sex, age and BMI. Regarding KSS, WOMAC, and SF-12, the MUA cohort achieved statistically-relevant lower overall scores than the control group, p = 0.006, p = 0.005, p = 0.001, respectively. Signifcantly higher experiences of pain and a higher need for analgesics in MUA patients were reported (p = 0.001 and p < 0.001, respectively). Radiological evaluation of the prosthesis alignment did not show any diferences between the two groups. Conclusions MUA can improve mobility after PKS, whereby MUA seemed to be a functional therapy option for PKS. Compared to the control group, the MUA group showed lower functional values and an increased experience of pain. A correlation between prosthesis malalignment and MUA could not be detected radiologically. Further studies are necessary to investigate the reasons for PKS. Keywords Total knee arthroplasty · Postoperative knee stifness · Manipulation under anesthesia · Osteoarthritis · Knee fexion · Mobility Introduction Total knee arthroplasty (TKA) is an efective and long-term proven therapy option for high-grade gonarthrosis [1–3], * Daiwei Yao [email protected] which signifcantly improves the quality of life in patients for years after surgery [2, 4–9]. The primary criterion of 1 Department of Orthopaedic Surgery in Diakovere Annastift, postoperative knee stifness (PKS) is restricted fexion. In Hannover Medical School (MHH), Anna-von-Borries-Straße the literature, most studies defne PKS as a restriction in 1-7, 30625 Hannover, Germany movement and < 90° fexion, which can be attributed to 2 Clinic for Internal Medicine, Diakovere Henriettenstift, arthrofbrosis [10–13]. The incidence of PKS after TKA Marienstraße 72-90, 30171 Hannover, Germany varies in previous studies, but ranges between 1.3 and 5.3% 3 OTC, Orthopaedic Traumatology Centre Regensburg, [12–18]. An evaluation of 1449 K-TEP revisions showed Paracelsusstraße 2, 93053 Regensburg, Germany Vol.:(0123456789)1 3 786 Archives of Orthopaedic and Trauma Surgery (2020) 140:785–791 that PKS was one of the four most frequent surgical indica- three-year postoperative period after TKA was investi- tions [19]. The exact causes of PKS and arthrofbrosis of gated and is of interest in this study. The collective MUA the knee joint are still not known. They are likely caused by was compared to a matched-pair control group, which many factors, rather than a single trigger. Many risk factors, contained individually-matched partners with regard to which can be jointly responsible for the pain and restricted prosthesis type, sex, age and BMI. From 2009 to 2011, a movement, have been identifed in previous studies [12, 18, total of 105 patients who received an MUA were identi- 20–24]. A low preoperative bending ability is presumably fed in our clinic. Due to exclusion criteria (revision sur- one of the most important factors that infuences a bad post- gery, TKA change, malposition of components), a total operative course [12, 13, 25, 26]. Other preoperative fac- of 76 patients were enrolled in this study; 51 of these tors, such as psychiatric diseases, systematic illnesses (i.e., patients were willing to participate. In most cases, MUA diabetes mellitus and rheumatoid arthritis), age, body mass was performed after TKA during the same inpatient stay index (BMI) and smoking status also impact postoperative 10 ± 3 days postoperatively, as the fexion restriction > 90° mobility [12, 19–21]. Intraoperative risk factors might be manifested itself early. malposition of TKA, which also causes a reduced mobility MUA was performed under general anesthesia. The hip postoperatively [27–30]. Insufcient physiotherapy and pain was fexed in a supine position of 90°, stabilizing the knee management in the postoperative therapy regimen can also joint at the proximal and distal tibia. Under the infuence of lead to PKS [31, 32]. Manipulation under anesthesia (MUA) gravity and careful pressure on the proximal tibia, the knee is one of the many therapy options for PKS. It serves as a joint was fexed until the resistance was noticeably released. medium between conservative therapy options with physi- Thus, intraoperatively, a fexion of at least 90° could be otherapy and pain management and operative therapies like achieved in all patients. After the anesthesia had subsided, arthroscopic or open arthrolysis. MUA is more efective and the neurological and vascular status was checked. In addi- manipulative than physiotherapy; it is also less invasive and tion, an X-ray was taken to exclude iatrogenic fractures. has no postoperative complications like operative therapies. Initially, all patients received the same postoperative Due to its favorable risk-to-beneft ratio, it is generally the treatment after TKA. From the first postoperative day preferred procedure, where it is appropriate [18, 33–35]. onwards, all patients received physiotherapy once a day MUA also has its limits and is not indicated in cases where as well as movement training twice a day using a continu- there is a signifcant prosthesis defect, attenuated patella alta ous passive movement (CPM) machine. Patients within the or patella baja, rheumatoid arthritis, or any other mechanical MUA group received physiotherapy twice a day and CPM obstacle that cannot be infuenced from the outside. Due to therapy as much as possible after MUA intervention. the lack of internationally defned criteria for PKS, the indi- cation for MUA varies in the literature. However, the major- ity of recent studies postulate that MUA is indicated when Assessments a knee fexion < 90° occurs [10–13]. While several studies agree about immediate improvement in mobility after MUA, The nursing and medical documentation during the inpa- there are only a few studies which include inhomogeneous tient stay, the documentation of the rehabilitation facilities, mid-term and long-term results [10, 12, 14, 36–38]. and the outpatient letters were evaluated 3–6 months and Therefore, the aim of our study was to investigate the 12–24 months postoperatively for all participants. Finally, mid-term outcomes from patients with PKS following MUA; the clinical status was assessed approximately 3 years post- in particular, the functionality, experience of pain and qual- operatively and during the follow-up examination. The ity of life outcomes were assessed. The primary hypothesis experience of pain was registered using a 10-point Numeric of this study was that the mobility of the knee joint can be Rating Scale (NRS). Also the mobility of the knee joint improved continuously by MUA in patients with PKS after and the use of analgesics were recorded. In addition, the TKA. The secondary hypothesis was that this therapy option subjective sensation of the patients was determined by the leads to a comparable quality of life compared to patients Western Ontario and Mc Masters Universities Osteoarthri- without PKS after TKA. tis Index (WOMAC) and the Short-Form-12 questionnaire (SF-12); the functionality of the knee was evaluated by the Knee Society Score (KSS) during the follow-up examina- Materials and methods tion. The positioning of the prosthesis was checked in the postoperative radiographs due to the evaluation of possible Participants and study process risk factors contributing to limited mobility after primary TKA. Knee overview images in anteroposterior and lateral This retrospective study evaluates the clinical course projection were made to determine the varus and valgus of patients who received MUA after primary TKA. The deviation, tibial slope and the patella position. 1 3 Archives of Orthopaedic and Trauma Surgery (2020) 140:785–791 787 Ethics notable diferences during the duration of the study. Before TKA, patients in the MUA group were able to bend their The described study project was reviewed and approved knee joint by 106.2 ± 12.2°, while patients in the control by the ethics commission of the Hannover Medical School group achieved a signifcantly higher degree of fexion of (MHH). All patients were informed of the study proce- 112.1 ± 14.5° (p = 0.042) at the same time. After TKA, the dures in personal conversation and in writing prior to their fexion angle was initially low in both groups; 52.1 ± 11.7 participation in the study according to the guidelines. All for the MUA group and 55.3 ± 12.3° for the control group.

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