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 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 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 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, 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.

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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. participants included in the present study provided written At the time of indication for MUA, fexion in these patients informed consent prior to the beginning of the study. averaged 71.7 ± 12.6°. Immediately after MUA, a signif- cant increase to 107.7 ± 8.9° (p < 0.001) was observed. Until Statistical analyses the day of discharge, the value dropped signifcantly to 100.5 ± 11.1° (p = 0.002). Patients in the control group were IBM SPSS Statistics software (Armonk, New York, USA) able to bend the knee joint at 93.2 ± 5.6° at the end of their was used for all statistical analyses. For descriptive statistics, inpatient period. This corresponds to a relevant loss of 19° either the mean or median was used. The standard deviations (p < 0.001) compared to value at admission and before TKA. (SD) or percentiles were selected as measures of dispersion. Comparison of both groups at the time of discharge also If a normal distribution was approximately detectable, the t showed a clear, signifcant diference (p < 0.001). Maximum test for associated samples was used to compare the matched fexion of the knee joint 3–6 months postoperatively within MUA and control groups. If no normal distribution could be the MUA group (n = 32) averaged 98.1 ± 11.3°, while it aver- assumed or if the data were ordinally scaled, the Wilcoxon aged 108.3 ± 13.0° within the control group (n = 43); this test was used. Nominal scaled data were tested for signif- corresponded to a signifcant diference of 10° (p = 0.002). cance using the Chi-squared test. To evaluate the SF-12, a Until the second outpatient visit 12 months postoperatively, prefabricated syntax was executed using IBM SPSS Statis- the degree of fexion of the MUA patients (n = 32) increased tics [39]. A p value < 0.05 was set as the two-sided level of to 104.2 ± 13.7°. The control group (n = 38) showed only signifcance. a 1° improvement, increasing to 112.2 ± 12.0°. A signif- cant diference between the two groups in terms of bend- ing ability could no longer be demonstrated at this time Results (p = 0.114). The average fexion at the time of the fnal fol- low-up examination was 107.4 ± 15.3° in the MUA group In each group, 35 female and 16 male patients were inves- and 112.4 ± 10.7° in the control group (p = 0.077, Table 2). tigated. The average age of the MUA collective group Regarding the experience of pain, more pain was signif- was 66.4 ± 9.1 years, while that of the control group was cantly reported in the MUA group after the seventh post- 66.0 ± 8.9 years (p = 0.678). The BMIs were 30.3 ± 5.9 kg/ operative day (p = 0.018). In total, both groups showed a m2 and 30.0 ± 5.5 kg/m2 (p = 0.634), respectively. The length decrease in the pain level from 6, of a 10-point NRS, to 2 at of stay for the MUA cohort was 16.7 ± 3.6 days, while it was the time of discharge. At the time of the fnal follow-up only 10.4 ± 1.8 days for the control group (p < 0.001). The follow- 28.1% patients from the MUA group reported a complete up period averaged 3.0 ± 0.4 years for the MUA group and lack of pain, while 75.7% of the control group did not feel 3.6 ± 0.6 years for the control group (p < 0.001). For the any pain at this time (p = 0.001). The need for pain killers radiological fndings, no statistical diferences were found was also higher in the MUA group than in the control group, before or after surgery in both groups (Table 1). 78.1% vs 16.2% (p < 0.001). At the time of the fnal follow- While no signifcant diferences were found regarding up, the median KSS was 80 points in the MUA group and knee extension in both groups, the knee fexion showed 92 points in the control group (p = 0.006). The comparison

Table 1 Radiographical MUA group (n = 51) Control group (n = 51) p values fndings after TKA in both groups n Mean SD n Mean SD

Femoral articular angle (°) 51 97.06 2.28 51 97.68 2.229 0.091 Tibial articular angle (°) 51 89.95 2.06 51 89.67 2.88 0.537 Femoral fexion angle (°) 51 13.56 4.25 51 12.72 3.3 0.251 Tibial slope (°) 51 4.72 3.03 51 4.84 3.58 0.849 Insall–Salvati index 51 1.12 0.3 51 1.05 0.23 0.072 Blackburne–Peel index 51 0.43 0.21 51 0.38 0.17 0.181

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Table 2 Flexion in degree (°) MUA group (n = 51) Control group (n = 51) p values over the investigation period n Mean SD n Mean SD

Prior TKA 51 106.2 12.2 51 112.1 14.5 0.042 3 days after TKA 51 52.1 11.7 51 55.3 12.3 0.187 7 days after TKA 51 71.4 10.4 51 79.1 10.6 < 0.001 Prior MUA 51 71.7 12.6 – – – – After MUA 51 107.7 8.9 – – – – 2 days after MUA 51 101.0 12.1 – – – – Discharge day 51 100.5 11.1 51 93.2 5.6 < 0.001 Rehabilitation (admission) 40 84.1 10.9 48 88.5 10.0 0.107 Rehabilitation (discharge) 40 93.9 10.0 48 99.2 9.0 0.056 Follow-up 3 months 32 98.1 11.3 43 108.3 13.0 0.002 Follow-up 12 months 32 104.2 13.7 38 112.2 12.0 0.114 Final follow-up 51 107.4 15.3 51 112.4 10.7 0.057 of the subitems that are added to the knee score shows that sum scale were not signifcantly diferent with 51 ± 11 points the median pain level of the MUA collective was fve points (MUA) and 53 ± 9 points (control) (p = 0.559). lower than that of the control collective (p = 0.004). The sub- The radiological fndings showed no statistical difer- categories “walking” and “climbing stairs” also had lower ences. Distal femoral joint angle was 97.06 ± 2.28° for scores in the MUA group. As a result, the functional score the MUA group and 97.68 ± 2.29° for the control group of the MUA patients reached a median score of 70. In con- (p = 0.091), while the proximal tibial joint angle was trast, 90 points were calculated for patients in the control determined to be 89.95 ± 2.06° for the MUA group and group. The addition of the knee score and the functional 89.67 ± 2.88° for the control group, p = 0.537. The tibial score resulted in 154 (MUA) and 184 (control) total points, slope was 4.72 ± 3.03° for the MUA group and 4.84 ± 3.58° p = 0.003 (Table 3). for the control group (p = 0.849). Regarding the patella posi- Regarding the WOMAC index, a total score of 430 points tion the Insall–Salvati index showed no statistical signif- was recorded for the MUA group, while 93 points were cance, p = 0.072. recorded for the control group (p = 0.005). There were also signifcant diferences in the subitems “pain”, “stifness” and “functionality” (p = 0.007, p = 0.001 and p = 0.001, respec- Discussion tively). According to the SF-12, patients of the MUA collec- tive achieved an average of 36 ± 13 points within the physi- The contradictory statements in the literature concern- cal sum scale. The control group had a signifcantly higher ing the medium and long-term course of mobility as well score of 44 ± 10 (p = 0.001). The results regarding the mental as the minimally described development of functionality

Table 3 Knee Society Score for MUA group (n = 51) Control group (n = 51) p value MUA and control group at the fnal follow-up Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75

Pain 45 20 50 50 45 50 0.004 Leg axis 0 0 0 0 0 0 0.467 Mobility 23 20 24 23 21 24 0.438 ML-stability 15 15 15 15 15 15 0.868 AP-stability 10 10 10 10 10 10 1.000 Knee-score 80 57 95 92 82 97 0.006 Walking 40 30 50 50 40 50 0.015 Climbing stairs 40 30 50 50 30 50 0.097 Walking aid 0 0 0 0 0 0 0.292 Function-score 70 60 100 90 80 100 0.010 Total-score 154 119 195 184 155 194 0.003

ML medial–lateral, AP anterior–posterior

1 3 Archives of Orthopaedic and Trauma Surgery (2020) 140:785–791 789 show the necessity of further research in this feld. In the after 3 years) and Issa et al. (114° after 4 years) [11–13]. It is present study, a mid-term increase in fexion by the MUA also noticeable that the latter described higher initial fexion group compared to the initial value was shown, align- values before the MUA (Rubinstein = 82° and Issa = 81°). ing with the fndings of previous studies [11, 12, 14, 38]. This could suggest a less pronounced PKS with a better Moreover, after approximately 3 years, there was no sta- course [11, 13]. In principle, varying methods of physi- tistically significant difference from the control group. otherapy between clinics cannot be excluded as parameters When the preoperative bending ability of the knee joint is infuencing the course of PKS. Compared to the baseline compared between the MUA group (106.2 ± 12.2°) and the value before the MUA, a highly signifcant improvement control group 112.1 ± 14.5°), a fexion diference of 5.9° is over a period of three years was achieved in this study in obtained. Although this diference is statistically signifcant the mid-term. (p = 0.042), it is not clinically relevant. Meneghini et al. for One week after TKA, a signifcant diference in pain example, described the lack of additional functional benefts intensity between the MUA and control groups was observed of high-grade fexion in their research [40]. As a decisive for the frst time (p = 0.018). This relationship could be minimum, a bending capacity of 90° is presented in many explained by the increasing stifness in the knee joint at studies [6, 12, 13, 15]. Nevertheless, it cannot be excluded this time. Schiavone, for example, defned PKS by arthrof- that the existing diference of 5.9° and a preoperative fexion brosis as a painful restriction of the range of motion [42]. angle of 106.2 ± 12.2° had an infuence on later results. Conversely, the primary occurrence of severe pain could On the seventh day after K-TEP there was a signifi- have caused a reactive reduction of mobility and subsequent cant diference in fexion for the frst time (p = 0.001); this fbrosis due to inactivity. PKS with consecutive arthrof- is interpreted as the frst manifestation of PKS (Table 2). brosis would, therefore, be either a primary or secondary Before the subsequent MUA, the fexion was 71.7 ± 12.6°. problem. After MUA, the pain was reduced and similar to Directly after MUA, an increase of 37° was measured. Other that of the control group. In 2007, Namba and colleagues studies have reported comparable results (range 23°–41° demonstrated similar fndings: after MUA, the pain intensity increase) with an average initial value of 70° fexion [10, was signifcantly reduced to a 10-point NRS [37]. In sum- 12, 24, 36]. A subsequent slight loss of mobility (p = 0.002) mary, a more intense and more frequent experience of pain also corresponds to the fndings of other studies [14, 41]. has been observed at various times in the MUA group. The This can be explained by the fact that, in most cases, the pain may have been caused either by a basic and persisting frst measurement was taken after MUA in the anesthetized pathology in the knee joint or by a greater sensitivity to pain. patient. The pain that reappears after sedation and higher The theoretical approach was considered unlikely that the muscle tone can lead to a renewed reduction in mobility. MUA itself caused severe pain until post-examination. The At the time of inpatient discharge, following MUA, a sig- pain diference noted before the MUA supports this theory. nifcantly higher knee fexion was seen, compared to the Evaluation of the KSS showed signifcant diferences in control group (p < 0.001). After 3–6 months, a signifcantly the knee score (p = 0.006), the functional score (p = 0.010) lower fexion was measured in the MUA group (p = 0.002) and the calculated total score (p = 0.003) between the MUA compared to the control. This diference was equalized after group and the control group at the time of the follow-up 12–24 months (p = 0.45) and the MUA patients achieved examination. Closer evaluation showed that walking on level fexion values of 104.2 ± 13.7°. Compared to the data in the surfaces caused problems for MUA patients. The overall literature, this value is above the average (87°–101°) [12, score diference was largely due to the diferences in the 15, 36]. knee score, which, in turn, was signifcantly infuenced by At the time of the follow-up examination, after an aver- the data on pain perception. However, this result was contra- age of 3 years, no signifcant diference could be measured dictory to fndings from previous studies; for example, Issa between the two collectives (p = 0.057). From this it can be et al. did not fnd any diferences in the postoperative KSS in suggested that MUA successfully restored the knee fexion their study [43]. Although the control group in this study was of patients with PKS after TKA. These fndings contradict considerably larger than in the present study (n = 1671), no the results of Issa et al. who still observed a signifcantly adjustment was made using matched-pair procedures, so the lower fexion in MUA patients after an investigation period MUA patients were signifcantly younger than the patients in of 4 years [11]. This may be due to the high mobility in their the control group. This could be a possible explanation for control group, which, at a fexion of 125°, is much higher the KSS in the MUA collective group. Lavernia et al. also than the average fexion value of the control group of the reported no signifcant diferences in the functional postop- present study (112°). The comparison of the fexion of our erative KSS (p = 0.04) [44]. However, a tendency towards MUA collective to those in the literature showed a lower lower scores within the MUA group was discernible. value in a study by Keating et al. (101° after 3 years) and The analysis of WOMAC showed clear diferences in pain higher values in studies conducted by Rubinstein et al. (115° sensitivity (p = 0.007), stifness (p = 0.001) and functionality

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(p = 0.008). It was noticed that there were distinct diferences support the importance of MUA for the therapy of arthrof- in these data, regarding activities like “climbing stairs” and brosis after primary TKA implantation. Low invasiveness “standing”. The overall score was, therefore, signifcantly and low complication rates are two major advantages of higher in the MUA group, refecting poorer functionality MUA compared to arthroscopic or open arthrolysis, which (p = 0.005). Only one study in the recent literature contains are described in the recent literature [18, 33–35, 45]. Further comparable information on WOMAC. Lavernia et al. were investigations comparing MUA with arthroscopic and open also able to demonstrate a signifcantly worse postopera- arthrolysis using prospective randomized studies are neces- tive WOMAC in MUA patients (p = 0.01) in a comparison sary to classify and validate the various therapy options for between a MUA collective group (n = 53) and a control PKA. Besides, other diagnostic parameters should be taken group (n = 58) [44]. The results of the physical sum scale into consideration for further investigations, as recent studies of SF-12 showed worse statistical relevance in the MUA reveal that histological evaluation and immunohistochemical group (p = 0.001). Most likely, the dimension “disability due assessment of CD68, ASMA, β-catenin and BMP-2 expres- to pain” is responsible for this, as it was already the case in sion may be useful to prove the diagnosis of arthrofbrosis the evaluation of the KSS. The literature does not contain and to analyze arthrofbrosis activity [46]. any information on SF-12 in MUA patients. In summary, despite good mobility, which does not difer from that of the control group, in the mid-term, there is a signifcantly Compliance with ethical standards worse assessment of functionality among the MUA patients. Further conclusions are limited due to the low data available. 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