Background: Systematic reviews in back pain suggest beneficial effects from spinal manipulation, general exercise, and ‘active management’. These approaches have not been tested rigorously in the UK National Health Service. The UK BEAM trial was designed to evaluate such treatments for back pain in primary care. This paper describes the manipulation package used in the trial and the frequency with which the different elements of the package were delivered by therapists. Methods/Results: At over 150 UK practices, patients consulting GPs with back pain were identified. Eligible and consenting patients were then randomised to receive one of GP active management, manipulation (either in NHS or private premises), exercise classes or both manipulation and exercise. Manipulation was delivered either by a chiropractor, an osteopath, or a physiotherapist. A package of manipulative care, agreed by the three professions, was developed, and practitioners could choose elements from the package within broad constraints. The trial recruited 1334 participants, across 14 centres. Participants who received manipulation alone attended on average 6.5 sessions compared with 5.2 sessions when receiving manipulation combined with exercise. A ‘results embargo’ precludes detailed results prior to the conference, but we shall present findings about the pattern of delivery of the various elements of the manipulation package for these treatments, within NHS or private premises, and whether delivered by a chiropractor, an osteopath, or a physiotherapist. Conclusion: Participants received more treatment sessions when randomised to manipulation alone compared with manipulation and exercise. This may be due to differences in the duration of treatment periods, which affected both clinician and patient availability. Findings will also show if there is variation in the delivery of manipulation depending on the treatment package, setting and profession. We shall use these data in the secondary analysis to determine the extent to which they explain variation in treatment effects

Objective: The UK BEAM trial was designed to evaluate treatments for back pain in primary care. The objective is to briefly describe the different treatments and to present the frequency with which trial participants attended for manipulation, exercise or both. Design: The UK BEAM trial is a national randomised factorial trial in primary care. Participants were randomised to receive one of GP management, exercise classes, manipulation (in either private or NHS premises) or both exercise classes and manipulation. Participants randomised to manipulation alone could receive up to eight sessions delivered by a chiropractor, an osteopath, or a physiotherapist. Those randomised to exercise alone could attend up to nine sessions led by a physiotherapist in a local community facility. Subsequently, those randomised to manipulation followed by exercise could attend up to 17 sessions. Subjects: Participants were recruited from 150 GP practices in 14 centres distributed across the United Kingdom. The target population was patients between 18 and 65 years who present in general practice with non-specific back pain with or without leg pain. Outcome Measures: The frequency that participants attended for manipulation, exercise, or both. Results: The trial recruited 1334 participants. The current analysis shows the mean number of sessions attended by participants for manipulation alone is 6.6. The mean number of sessions attended for exercise alone is 4.4. In contrast, those participants randomised to manipulation followed by exercise attended 5.2 and 3.4 sessions respectively. Conclusions: Those participants who were randomised to manipulation followed by exercise attended fewer sessions on average than those randomised to manipulation or exercise alone

Background: There is evidence that spinal manipulation (SM) has therapeutic benefit in the treatment of back pain. However, there is still poor understanding of the physiological mechanism by which it achieves its therapeutic benefit. In order to explore the mechanism of SM, this study explored it’s immediate anti-nociceptive effect, by measuring the pressure pain threshold (PPT) in spinal muscles pre and post SM, in subjects with low back pain. Methods: A group of low back pain patients (n=60) were randomised into two groups, one received a SM to a dysfunctional segment in the lumbar spine. The second group received a sham procedure, where the patient was placed in a similar ‘wind up’ position, but the thrust applied non-specifically through the low back. Algometry measurements were taken over four spinal muscles (iliocostalis, multifidus, glutei and trapezius), before and after the manipulation or sham procedure. Results: Paired t-tests for within group differences showed statistically significant differences for the SM group iliocostalis (p< 0.001) multifidus (p< 0.001) glutei (p< 0.001) and trapezius (p=0.20) with small to moderate effect size (0.60; 0.58; 0.36 & 0.20 respectively) small between group differences were also noted. There were no significant changes in PPT in any muscle in response to the sham procedure. Conclusion: SM produced a statistically significant change in PPT with a small to medium effect size. No changes were observed in the sham and thus the active component of SM appears to be related to the specific manipulative thrust technique rather than to the general handling and positioning of the patient

Background. Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS. Methods. Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. The technique used 10ml of 1% lignocaine injected anteromedially into the tibiotalar joint. Pain scores (VAS), time from first x-ray to reduction, and acceptability of reduction were recorded. A comparison was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six month period March – August 2020. Results. During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087). In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p < 0.05; ‘pre’ to ‘post’ p < 0.01). In the IAHB group, 23 (92%) had a satisfactory reduction without need of PS or general anaesthetic. In the PS group 23 (82%) had a satisfactory reduction. There was no significant difference in the number of unsatisfactory first attempt reductions between the groups. There were no cases of deep infection post operatively in either group. Conclusion. Intra-articular haematoma block of the ankle appears to be an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures. Advantages of this method include avoiding the risks of procedural sedation, removing the requirement of designated clinical space and need for qualified clinicians to give sedation, and the ability to re-manipulate under the same block

Introduction. Total knee arthroplasty is very successful although the clinical assessment and rated outcome does not always match the patients reported satisfaction. One reason for patient dissatisfaction is less than desired range of motion. Poor postoperative motion inhibits many functional activities and may create a perception of dysfunction. Early in the postoperative period when patients are having trouble regaining motion (usually 6–8 weeks), manipulation under anesthesia can be used to advance range of motion by manually lysing adhesions. Comorbidities have been used as predictors for outcome in total knee arthroplasty in population health studies. Likewise, predicting which patients are most susceptible to early postoperative stiffness/manipulation would be valuable for patient education and to predict outcome. Methods. Prospectively collected data was retrieved from the hospital's MARCQI database (Michigan Arthroplasty Collaborative Quality Initiative) for the years 2014–2018. There were 3098 primary total knees performed during the study period and 139 manipulations (4.44%). The registry specifically abstracts patients’ preoperative comorbidities, operative data, and 90-day postoperative complications. Results. There were 2118 Cruciate Retaining/Cruciate Stabilized knees (105 MUA), 801 Posterior Stabilized (33), and 41 Total Stabilized/Hinge (1), 2160 knees were cemented (91) and 799 uncemented (48). No differences were found between the manipulation and non-manipulation groups for gender, race, alcohol consumption, bleeding disorders, history of DVT or PE, Diabetes, or use of pre-op narcotics or anti-coagulents. Patients undergoing manipulation were younger (67.2 vs. 63.8, p= 0.00001), had a lower BMI (32.6 vs. 30.9 p= 0.0007), and were more likely to be non or former (quit) smokers. There were no differences noted for the constraint of the component (cr/ps), or whether the implants were cemented or uncemented (35% vs. 27%, p= 0.064). Conclusions. Understanding the risk for postoperative stiffness and the potential for manipulation is helpful in the preoperative period for patient education and outcome prediction. Assessing comorbidities and patient characteristics may help avoid the need for manipulations postoperatively. This patient cohort may be biased since the manipulations were not based on predetermined criteria. The cohort represents patients whose range of motion was poor enough to cause the surgeon to perform the procedure. The findings do however highlight a patient pool that was surprisingly at risk: younger, thinner, nonsmokers regardless the implant design or use of cement

Purpose. This study evaluated the acceptability of performing manipulations with intranasal diamorphine and inhaled Entonox to parents of children presenting to our Emergency Department. Method. 65 fractures were manipulated in the Emergency Department in a 4-month timespan. Parents were invited to complete a questionnaire to indicate their experience with the procedure. Fracture position post-reduction was calculated as well as conversion rate to surgery. 32 patients who were admitted and had their forearm fractures managed in theatre were also asked to complete the questionnaire as a comparison group. Results. Overall response rate was 82% . 100% of parents of children who had a manipulation in the emergency department would recommend the treatment to parents of children with similar injuries. Relative risk of perceived distress to parents was 2.42 (0.8–7.2) with manipulation in the emergency department compared to theatre management. Relative risk of distress to the child was 1.45 (0.7–3.3) with manipulation in the emergency department compared to theatre management. This was not statistically significant. Mean (S.D.) fracture displacement was 29.2 (13.0)° pre reduction and 5.8 (5.9)° post reduction. Mean (S.D.) length of stay was 5.5 (3.2) hours from time of injury to discharge for patients receiving manipulation in the Emergency Department and 27.9 (14.3) hours for patients receiving procedures in theatre (p< 0.001). Overall, parents and children were satisfied about manipulations in the Emergency Department. Operative re-intervention rate was 2% when protocol violations were excluded. Reduction was as effective as previous reports and within acceptable treatment limits. Conclusion. Manipulation of paediatric forearm fracture is an effective and acceptable technique when performed with a diamorphine and Entonox protocol

The optimal timing of when to perform manipulation under anesthesia (MUA) for stiffness following total knee arthroplasty (TKA) is unclear. This study aimed to identify the risk factors for MUA following primary TKA and whether performing an “early” MUA within 3 months results in a greater improvement in range of motion. Primary TKAs performed between January 2013 and December 2018 at three tertiary New Zealand hospitals were reviewed. International Classification of Diseases discharge coding was used to identify patients who underwent an MUA. Multivariate Cox regression was performed to identify patient and surgical risk factors for MUA. Pre- and post-MUA knee flexion angles were identified through manual review of operation notes. Multivariate linear regression was performed to compare the mean flexion angles pre- and post-MUA, as well as the mean gain in flexion, between patients undergoing “early” (<3 months) versus “late” MUA (>3 months). 7386 primary TKAs were analyzed in which 131 underwent subsequent MUA (1.8%). Patients aged <65 years were two times more likely to undergo MUA compared to patients aged ≥65 years (2.5% versus 1.3%, adjusted hazard ratio = 2.1, p<0.001). Gender, body mass index, patient comorbidities or a history of cancer were not associated with the risk of MUA. There was no difference in the final post-MUA flexion angle between patients who underwent early versus late MUA (104.7 versus 104.1 degrees, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3 versus 79.6 degrees, p = 0.012), and subsequently had a greater overall gain in flexion compared to patients who underwent late MUA (mean gain 33.1 versus 24.3 degrees, p<0.001). Younger age was the only patient risk factor for MUA. A greater overall gain in flexion was achieved in patients who underwent early MUA within 3 months

Background. Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the two to see which is better. Aim. To compare the outcome in patients with primary frozen shoulder, who are treated by either MUA or MUA plus ACR. Methods. 56 patients with primary frozen shoulder were treated by either MUA or MUA plus ACR. Each patient had their American Shoulder and Elbow Score (ASES), and their Oxford Shoulder Score (OSS) measured pre- and post-operatively. Results. The patients who had MUA plus ACR had a mean ASES of 19.6 pre-operatively, 78.3 at 6 months, and a mean of 80.1 at 12 months. The mean OSS was 32.5 pre-operatively, 53.6 at 6 months and 53.8 at 12 months. The patients who had a MUA had a mean ASES of 28.7 pre-operatively, 57.9 at 6 months and 58 at 12 months. The mean OSS was 33 pre-operatively, 42.5 at 6 months and 48 at 12 months. Conclusions. Both treatments give good results; MUA plus ACR give significantly superior results at 6 to 12 months post-operatively. However, there is no significant difference beyond 12 months

Background – Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the 2 to see which is better. Aim – To compare the outcome in patients with primary frozen shoulder, who are treated by either MUA or MUA plus ACR. Method – 61 patients with primary frozen shoulder were treated by either MUA or MUA plus ACR. Each patient had their American Shoulder and Elbow Score (ASES), and their Oxford Shoulder Score (OSS) measured pre and post-operatively. Results – The patients who had MUA plus ACR had a mean ASES of 24.8 preoperatively, 64 at 4 months, and a mean of 75.4 at 12 months. The mean OSS was 32.5 pre-operatively, 48.5 at 4 months and 53.4 at 12months. The patients who had a MUA had a mean ASES of 28.7 pre-operatively, 60.9 at 4months and 69.6 at 12months. The mean OSS was 33 preoperatively, 46.5 at 4 months and 50.9 at 12 months. Conclusions – Both treatments give good results. MUA plus ACR give superior numerical results at 6 to 12 months post-operatively, however, these figures did not reach statistical significance

Aims. Urinary catheter use in the peri-operative and post-operative phase following arthroplasty may be associated with increased risk of urinary tract infection (UTI) and deep prosthetic joint infection (PJI). These can be catastrophic complications in joint arthroplasty. We performed a systematic review of the evidence on routine use of antibiotics for urinary catheter insertion and removal following arthroplasty. Methods. Electronic databases were searched using the HDAS interface. Grey literature was also searched. From 219 citations, six studies were deemed eligible for review. Due to study heterogeneity a narrative approach was adopted. Methodological quality of each study was assessed using the CASP appraisal tool. Included studies were found to have moderate to good methodological quality. Results. A total of 4696 hip and knee arthroplasties were performed on 4578 participants across all studies. Of these 1475 (31%) were undertaken on men and 3189 (68%) on women. The mean age of the study participants was 69 years. 3489 cases (74.3%) related to hip arthroplasty and 629 of cases (13.4%) to knee arthroplasty. 578 cases (12.3%) specified either hip or knee arthroplasty. In total, 45 PJIs were reported across all studies (0.96%). Two of the studies found either no PJI or no statistical difference in the rate of PJI when antibiotic prophylaxis was not used for catheter manipulation. Where studies report potential haematogenous spread from UTIs, this association can only be assumed. Rates of bacteriuria varied greatly between studies and depend on timing of sample and gender. Increased duration of urinary catheterisation is positively associated with UTI. Conclusion. It remains difficult to justify the routine use of prophylactic antibiotics for catheter manipulation in well patients undergoing arthroplasty. Their use is not recommended for this indication

Use of shoulder manipulation in the treatment of frozen shoulder (FS) remains controversial. One of the purported risks associated with the procedure is the development of a rotator cuff tear. However the incidence of iatrogenic rotator cuff tears has not been reported. The purpose of the study was to assess the effect of manipulation of the shoulder on the integrity of the rotator cuff. In a prospective study 20 consecutive patients (21 shoulders) with FS underwent manipulation of the shoulder under anaesthesia (MUA). The average duration of symptoms was 7.3 months (4–18 months). Patients were assessed pre and post manipulation using the Constant score. An ultrasound scan of the rotator cuff was performed before and at 3 weeks after manipulation. In all patients, pre and post manipulation ultrasound scans showed the rotator cuff to be intact. At 12 weeks after manipulation all patients indicated that they had none or only occasional pain. The mean improvement in motion was 83 degrees (range, 20 – 100°) for flexion, 95 degrees (range, 20 – 120°) for abduction, 58 degrees (range, 0 – 80°) for external rotation and 3 levels of internal rotation (range 3–5 levels). These gains in motion were all significant (p < 0.01). No fractures, dislocations or nerve palsies were observed. In conclusion manipulation under anaesthesia for treatment of frozen shoulder resulted in significant improvements in shoulder function and pain relief as early as 3 weeks after surgery and was not associated with rotator cuff tears. When performed carefully this procedure is safe and leads to early improvements in pain relief, range of movement and shoulder function

Adequate range of knee motion is critical for successful total knee arthroplasty. While aggressive physical therapy is an important component, manipulation may be a necessary supplement. There seems to be a lack of consensus with variable practices existing in managing stiff postoperative knees following arthroplasty. Hence we did a postal questionnaire survey to determine the current practice and trend among knee surgeons throughout the United Kingdom. A postal questionnaire was sent out to 100 knee surgeons registered with British Association of Knee Surgeons ensuring that the whole of United Kingdom was well represented. The questions among others included whether the surgeon used Manipulation Under Anaesthaesia (MUA) as an option for stiff postoperative knees; timing of MUA; use of Continuous Passive Motion (CPM) post-manipulation. We received 82 responses. 46.3% of the respondents performed MUA routinely, 42.6% sometimes, and 10.9% never. Majority (71.2%) performed MUA within 3 months of the index procedure. 67.5% routinely used CPM post-manipulation while 7.3% of the respondents applied splints or serial cast post MUA. 41.5% of the surgeons routinely used Patient Controlled Analgaesia +/− Regional blocks. Majority (54.8%) never performed open/arthroscopic debridement of fibrous tissue for adhesiolysis. Knee manipulation requires an additional anaesthetic and may result in complications such as: supracondylar femur fractures, wound dehiscence, patellar tendon avulsions, haemarthrosis, and heterotopic ossification. Moreover studies have shown that manipulation while being an important therapeutic adjunct does not increase the ultimate flexion that can be achieved which is determined by more dominant factors such as preoperative flexion and diagnosis. Manipulation should be reserved for the patient who has difficult and painful flexion in the early postoperative period

Aim: To examine the efficacy and ease of use of the scapular manipulation method in the reduction of anterior shoulder dislocations and the need for sedation/analgesia that usually requires prolonged observation of the patient after reduction. Method: This was a prospective series over six months. All patients presenting to the Waikato Hospital Emergency Department with uncomplicated anterior shoulder dislocations were included in the study. Reduction was firstly attempted with the Scapular Manipulation Method without analgesia or sedation. Where this was unsuccessful, analgesia and/or sedation was given and their shoulders reduced by one of various methods. The patients who received sedation were then observed as required. Results: Thirty-five patients with anterior shoulder dislocations were seen. In 30 cases the scapular manipulation method of reduction was used with a success rate of more than 80%. The need for sedation/analgesia that would usually lead to a period of observation was greatly reduced. Conclusion: The scapular manipulation method of reduction of anterior shoulder dislocation is an easy and safe technique with a success rate, and it obviates the need for prolonged patient observation

Aim: This prospective study was carried out to assess the outcome of manipulation of the shoulder as a treatment for adhesive capsulitis of the shoulder. Method: 31 patients were followed prospectively for twelve months after shoulder manipulation for adhesive capsulitis. All patients underwent manipulation under general anaesthetic and scalene block followed by intra-artificial gleno-humeral injection of steroid and local anaesthetic. Postoperative physiotherapy was started on the day of surgery. Shoulder function was assessed with range of movement, Constant and Murley score and DASH score (Disability of the Arm, Shoulder and Hand by specialist upper limb physiotherapists, pre-operatively, and post – operatively at 6 weeks, 3, 6, and 12 months. Results: The DASH score improved from a mean of 60.1 (range 27–98) pre-operatively to a mean of 24.1 (range 5–83) at final follow up. Constant scores improved from a mean of 34.4 (range 16–51) pre-operatively to 65.8 (range 35–88). The mean improvement in Constant scores was 31.5 points. Pre-operative range of movement (expressed as a percentage of the total ROM of the unaffected side) was 51.5 % (range 23.8–67.2). The mean postoperative ROM was 85.4% (range 56.2 – 99.3). External rotation improved from 41.7% (range 23.5 – 81.5) of the unaffected side preoperatively to 77.7% (range 44.1 – 105.3) at final review. Abduction improved from 47.4 % (range 23.3 – 70.6) to 85.4% (range 49.7 – 100) and forward flexion improved from 59.1% (range 33.5 – 73.9) to 90o (range 64.3 – 100.6). No patients required further manipulation. Conclusion: All outcome measure improved following treatment. These improvements were sustained at 12-month follow up. In particular, external rotation which was the most restricted movement pre-operatively was seen to improve and this improvement was maintained throughout follow-up. We conclude that manipulation of the shoulder under inter-scalene block and general anaesthetic for adhesive capsulitis results in a sustained improvement in function and movement

Purpose of the study: The rate of recurrence after conventional manipulation procedures and arthroscopic debridement for idiopathic adhesive capsulitis of the shoulder is rather high. Arthroscopic release using a radiofrequency method might improve results. The purpose of this prospective study was to compare results of two athroscopic methods: manipulation and debridement versus radiofrequency release. Material and methods: Thirty patients underwent arthroscopic treatment for shoulder pain six months after a conventional treatment for idiopathic adhesive capsulitis. In group A (n=15 patients), manipulation under anesthesia was followed by arthroscopic joint debridement. In group B (n=15 patients) arthroscopic section of the contracted structures was followed by radiofrequency section of the rotator interval and the anterior and posterior capsule. The coracohumeral ligament was sectioned in all cases. Subacromial decompression was achieved arthroscopically in four of the cases in group A and in two in group B. Age, gender and preoperative joint motion were similar in the two groups. Results: Follow-up data at six weeks and at 3, 6, and 12 months were assessed in 27 patients (12 group A and 14 group B). Pain, joint stiffness, and function (UCLA and Constant) were assessed. Recurrence required revision in two patients in group A. There was no significant difference for pain (VAS) but there was an improvement in joint motion at three and six months for patients in group B. The outcome was satisfactory in all patients except one. Discussion and conclusion: Radiofrequency release appears to yield better results than manipulation and arthroscopic debridement. The radiofrequency technique enables section of the rotator interval, the coracohumeral ligament and the capsule to prevent early adhesions and allow more rapid recovery of function

Osteoporosis is an international health and financial burden of ever increasing proportions. Current treatments limit the rate of bone resorption and reduce fracture risk, however they are often associated with significant and debilitating side effects. The most commonly used therapies also do not stimulate osteoblast activity . 1,2,3. Much current research focus is aimed at the metabolic and epigenetic pathways involved in osteoporosis. MicroRNAs have been shown to play an important role in bone homeostasis and pathophysiological conditions of the musculoskeletal system. Up-regulation of specific microRNAs has been identified in-vivo in osteoporotic patients . 4,5. It is hypothesized that modulation of specific microRNA expression may have a key role in future targeted therapies of musculoskeletal diseases. The assessment and analysis of their potential therapeutic use in Osteoporosis is of great importance, due to the burden of the disease. We have developed a 3D osteoporotic model from human bone marrow, without the use of scaffold. Magnetic nanoparticles are utilised to form spheroids, which provides a closer representation of the in-vivo environment than monolayer culture. This model will provide the basis for analysing future microRNA experiments to assess the potential up-regulation of osteoblastogenesis without cessation of osteoclast activity. The results of initial monolayer and spheroid experiments will be presented. Optimisation of the osteoporotic bone marrow culture conditions, involving response to differentiation medias, analysis of adipose and bone markers and cell migration in spheroid culture will be displayed. Quantitative and qualitative results, including fluorescence microscopy and in cell western, assessing the monolayer and spheroid cultures will be presented. The development of a pseudo osteoporosis model from healthy bone marrow will also be discussed. This model will form a basis of future work on microRNA targeting. The development of improved therapies for osteoporosis is of great significance due to the predicted rise in incidence of the disease and associated fragility fractures. Targeted therapies, such as the manipulation of microRNA expression, offer the opportunity to increase osteoblastogenesis and decrease osteoclastogenesis, potentially without the associated side effects of older, systemic therapies. We believe our 3D human bone marrow derived osteoporotic model offers the closest relation to the in-vivo environment for assessment and manipulation of microRNA expression

Introduction: Several theories have been proposed to explain the therapeutic benefit of spinal manipulation (SM), one of which is the reflexogenic response, whereby there is thought to be a reflex reduction in pain, muscle hypertonicity and functional improvement. Methods: 60 patients were randomised to receive a single high velocity low amplitude thrust or a sham manipulation, where a similar thrust was given to the subject, but applied non-specifically. After testing for reliability, physiological effects in a number of muscle groups was explored through assessment of pressure pain threshold (PPT) and muscle activity using algometry and surface electromyography (sEMG) respectively. The sEMG reflex response was recorded during the manipulation and a record of whether cavitation was achieved was recorded. PPT measurements were taken pre and post intervention over three experimental visits (each visit being a week apart). Results: There were no statistically significant differences in the magnitude of the sEMG reflex response to a single SM compared to the sham. However at the third application a significantly larger sEMG reflex response was seen in the SM group compared to the sham manipulation, for multifidus (F=9.57, p=0.01) and gluteus maximus muscles (F=6.41, p=0.02). There were no associations between the size of the reflex response and any of the subject’s baseline characteristics or changes in pain at any time point. Conclusion: It is unlikely SM influences pain and function via a muscular reflexogenic effect. It may be that the longitudinal change in the reflex response indicates a biomechanical change in one group

Introduction: Stiffness is a disabling problem following TKR surgery. The overall incidence is 1–3%. Though multiple factors have been implicated in development of stiffness, it still remains an incompletely understood condition. Furthermore, opinion is divided about the efficacy, timing and the number of MUA’s post TKR surgery, as there are no definitive guidelines. Aims & Objectives: The aim of this study was to assess the predisposing factors for stiffness following TKR surgery, to determine the efficacy of single and multiple manipulations and to investigate the most appropriate timing for manipulation. Material & Methods: We retrospectively reviewed 86 patients who underwent manipulation for stiffness post-primary TKR surgery with at least one-year follow up. The number of manipulations, predisposing factors, the flexion gain at different intervals, final gain in flexion and range of movement was noted till the end of 1 year. Results: Results were assessed by timing and number of MUA’s performed. Sixty five patients underwent single MUA and 21 had multiple MUA. At the end of one year the single MUA group showed 310 of sustained gain in flexion and in the multiple MUA group only 90 flexion gain was noted (p=0.003). MUA within 20 weeks of primary surgery showed 300 of flexion gain, whereas only 70 of flexion gain was seen when MUA was undertaken after 20 weeks (p=0.004). Patients on warfarin (9.5%) and with previous major surgeries to the knee prior to TKR (11.5%) had increase incidence of stiffness and poor flexion gain. Conclusion: The timing of the 1st MUA is crucial, with better results achieved in MUA performed less than 20 weeks (particularly between 12–14 weeks) from primary surgery. Age, sex and type of disease do not influence the severity of stiffness in this study. There appears to be no added benefit in re-manipulation

Introduction. Arthrofibrosis remains a persistent complication following total knee arthroplasty (TKA). Although manipulation under anesthesia (MUA) is an effective early treatment, the risks and value of this procedure beyond 3 months after TKA remain controversial. The purpose of this study was to examine the safety and efficacy of late MUAs for arthrofibrosis. Methods. From our institutional total joint registry, 82 TKAs (77 patients) who underwent MUA >3 months after primary (83%) or revision (17%) TKA were identified. Mean time to MUA was 7 months: 66% performed between 4–6 months, 18% between 7–12 months, 16% beyond 12 months. MUAs were coupled with arthroscopic assistance in 26% (12% limited lysis of adhesions, 13% formal arthroscopic debridement). Mean age was 61 years, 59% females, and mean BMI was 33kg/m. 2. Mean follow-up was 5 years. Results. No fractures, extensor mechanism disruptions, or other complications related to late MUA occurred. The mean ROM gained after MUA was 18° (76° to 94°, p<0.001). Substantial ROM gains (≥20°) occurred in 50%, while 21% made no gains or lost ROM after MUA. ROM gains ≥20° occurred in 54% of primary TKAs and 28% of revision TKAs. While ROM gains were higher when performed between 3–6 months (21°) compared to 6–12 months (13°) and >12 months (11°), these differences did not reach statistical significance (p=0.26). No differences in mean ROM gains were observed in MUAs performed with or without arthroscopic assistance (19° versus 15°, p=0.54). Kaplan Meier survivorship free of repeat MUA and revision TKA were 85% and 80% at 20 years, respectively. Conclusion. Late MUA, coupled with arthroscopic assistance in selected patients, was safe in a broad range of stiff primary and revision TKAs with no fractures or extensor disruptions occurring. While mean ROM improvements were modest, a substantial subset of patients achieved clinically important ROM gains ≥20°. Summary. Late MUA substantially improved ROM in a subset of patients with stiff TKAs and was done safely. In selected patients, arthroscopic lysis of adhesions or formal debridement aided the perceived safety and efficacy

Purpose. To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure. Methods. Prospective analysis of patients who required MUA post TKA performed by two surgeons using the same prosthesis from 2003 to 2008. Compared to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. Risk factors were identified including warfarin and statin use, diabetes and body mass index. Results. Seventy-two patients required an MUA out of 1313 TKAs (5.5%) compared to a control group of 50 patients. The mean arc of motion preoperatively was 89.0° (MUA group) vs 92.2° (control) (p=0.47), at discharge 71.0° vs 76.8° (p< 0.05) and 6 weeks follow-up 64.0° vs 97.3° (p< 0.0001). Post manipulation the mean arc of motion was 108° on table, 83.1° at 3 months follow-up and 81.9° at 12 months. Patients whose manipulation was within 3 months of TKA (23 patients) improved their mean arc of motion from 53.6° to 78.0° (p< 0.0025), those 3–12 months (42 patients) from 67° to 83.0° (p< 0.0001) and those >12 months (7 patients) 81° to 89° (p=0.32). Mean increase of extension was 3.7° on table and 3.6° at 12 months. Mean flexion increase was 40.5° on table and 15.7° at 12 months. The relative risk factor for requiring an MUA was 6.97 warfarin (p< 0.05), 1.58 statins, 2.85 diabetes and 1.17 obesity. Conclusions. MUA following primary TKA improves their range of motion if done within 12 months, however only 50% improvement is maintained. Patients with less than 75° flexion at discharge or those on warfarin therapy are likely to require a manipulation to improve their range of movement