A retrospective study was performed in 100 children aged between two and 16 years, with a dorsally angulated stable fracture of the distal radius or forearm, who were treated with manipulation in the emergency department (ED) using intranasal diamorphine and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs, the final radiographs and the clinical notes were reviewed. A successful reduction was achieved in 90 fractures (90%) and only three children (3%) required remanipulation and Kirschner wire fixation or internal fixation.

The use of Entonox and intranasal diamorphine is safe and effective for the closed reduction of a stable paediatric fracture of the distal radius and forearm in the ED.

By facilitating discharge on the same day, there is a substantial cost benefit to families and the NHS and we recommend this method.

Take home message: Simple easily reducible fractures of the distal radius and forearm in children can be successfully and safely treated in the ED using this approach, thus avoiding theatre admission and costly hospital stay.

Cite this article: Bone Joint J 2016;97-B:131–6.

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

Aims. The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining. Methods. A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires. Results. Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections. Conclusion. Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J 2021;103-B(5):902–907

Aims. Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m. 2. (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups. Results. Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication. Conclusion. IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126–130

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

The purpose of this study was to compare clinical outcomes of total knee arthroplasty (TKA) after manipulation under anaesthesia (MUA) for post-operative stiffness with a matched cohort of TKA patients who did not requre MUA. . In total 72 patients (mean age 59.8 years, 42 to 83) who underwent MUA following TKA were identified from our prospective database and compared with a matched cohort of patients who had undergone TKA without subsequent MUA. Patients were evaluated for range of movement (ROM) and clinical outcome scores (Western Ontario and McMaster Universities Arthritis Index, Short-Form Health Survey, and Knee Society Clinical Rating System) at a mean follow-up of 36.4 months (12 to 120). MUA took place at a mean of nine weeks (5 to 18) after TKA. In patients who required MUA, mean flexion deformity improved from 10° (0° to 25°) to 4.4° (0° to 15°) (p < 0.001), and mean range of flexion improved from 79.8° (65° to 95°) to 116° (80° to 130°) (p < 0.001). There were no statistically significant differences in ROM or functional outcome scores at three months, one year, or two years between those who required MUA and those who did not. There were no complications associated with manipulation. At most recent follow-up, patients requiring MUA achieved equivalent ROM and clinical outcome scores when compared with a matched control group. While other studies have focused on ROM after manipulation, the current study adds to current literature by supplementing this with functional outcome scores. Cite this article: Bone Joint J 2015;97-B:1640–4

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

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

As part of a prospective study of 476 total knee replacements (TKR), we evaluated the use of manipulation under anaesthesia in 47 knees. Manipulation was considered when intensive physiotherapy failed to increase flexion to more than 80°. The mean time from arthroplasty to manipulation was 11.3 weeks (median 9, range 2 to 41). The mean active flexion before manipulation was 62° (35 to 80). One year later the mean gain was 33° (Wilcoxon signed-rank test, range −5 to 70, 95% CI 28.5 to 38.5). Definite sustained gains in flexion were achieved even when manipulation was performed four or more months after arthroplasty (paired t-test, p < 0.01, CI 8.4 to 31.4). A further 21 patients who met our criteria for manipulation declined the procedure. Despite continued physiotherapy, there was no significant increase in flexion in their knees. Six weeks to one year after TKR, the mean change was 3.1° (paired t-test, p = 0.23, CI −8.1 to +2)

Aims. Since redesign of the Oxford phase III mobile-bearing unicompartmental knee arthroplasty (UKA) femoral component to a twin-peg design, there has not been a direct comparison to total knee arthroplasty (TKA). Thus, we explored differences between the two cohorts. Patients and Methods . A total of 168 patients (201 knees) underwent medial UKA with the Oxford Partial Knee Twin-Peg. These patients were compared with a randomly selected group of 177 patients (189 knees) with primary Vanguard TKA. Patient demographics, Knee Society (KS) scores and range of movement (ROM) were compared between the two cohorts. Additionally, revision, re-operation and manipulation under anaesthesia rates were analysed. Results. The mean follow-up for UKA and TKA groups was 5.4 and 5.5 years, respectively. Six TKA (3.2%) versus three UKAs (1.5%) were revised which was not significant (p = 0.269). Manipulation was more frequent after TKA (16; 8.5%) versus none in the UKA group (p <  0.001). UKA patients had higher post-operative KS function scores versus TKA patients (78 versus 66, p < 0.001) with a trend toward greater improvement, but there was no difference in ROM and KS clinical improvement (p = 0.382 and 0.420, respectively). Conclusion. We found fewer manipulations, and higher functional outcomes for patients treated with medial mobile-bearing UKA compared with TKA. TKA had twice the revision rate as UKA although this did not reach statistical significance with the numbers available. . Cite this article: Bone Joint J 2016;98-B(10 Suppl B):28–33

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. The study was undertaken to compare the efficacy of Woodcast splints and plaster-of-Paris casts in maintaining correction following sequential manipulation of idiopathic clubfeet. Methods. In this randomized prospective trial, 23 idiopathic clubfeet were immobilized with plaster-of-Paris casts and 23 clubfeet were immobilized with a splint made of Woodcast that encircled only two-thirds the circumference of the limb. The number of casts or splints needed to obtain full correction, the frequency of cast or splint-related complications, and the time taken for application and removal of the casts and splints were compared. Results. The mean number of casts required to obtain full correction of the deformity (Pirani Score 0) was 4.35 (95% confidence interval (CI) 3.74 to 4.95) when plaster-of-Paris was used and 4.87 (95% CI 4.33 to 5.41) when the Woodcast splint was used (p = 0.190). The time required for application and removal of the Woodcast splint were significantly less than that required for application and removal of plaster-of-Paris casts (p < 0.001). Woodcast splint-related complications were not more frequent than plaster-of-Paris cast related complications. Conclusion. Though Woodcast splints covering two-thirds of the circumference of the lower limbs of infants were effective in maintaining the correction of clubfoot deformity during serial manipulation and casting treatment, the superiority of Woodcasts over plaster-of-Paris could not be established. Cite this article: Bone Joint J 2020;102-B(10):1399–1404

Aims. Postoperative range of movement (ROM) is an important measure of successful and satisfying total knee arthroplasty (TKA). Reduced postoperative ROM may be evident in up to 20% of all TKAs and negatively affects satisfaction. To improve ROM, manipulation under anaesthesia (MUA) may be performed. Historically, a limited ROM preoperatively was used as the key harbinger of the postoperative ROM. However, comorbidities may also be useful in predicting postoperative stiffness. The goal was to assess preoperative comorbidities in patients undergoing TKA relative to incidence of postoperative MUA. The hope is to forecast those who may be at increased risk and determine if MUA is an effective form of treatment. Methods. Prospectively collected data of TKAs performed at our institution’s two hospitals from August 2014 to August 2018 were evaluated for incidence of MUA. Comorbid conditions, risk factors, implant component design and fixation method (cemented vs cementless), and discharge disposition were analyzed. Overall, 3,556 TKAs met the inclusion criteria. Of those, 164 underwent MUA. Results. Patients with increased age and body mass index (BMI) had decreased likelihood of MUA. For every one-year increase in age, the likelihood of MUA decreased by 4%. Similarly, for every one-unit increase in BMI the likelihood of MUA decreased by 6%. There were no differences in incidence of MUA between component type/design or fixation method. Current or former smokers were more likely to have no MUA. Surprisingly, patients discharged to home health service or skilled nursing facility were approximately 40% and 70% less likely than those discharged home with outpatient therapy to be in the MUA group. MUA was effective, with a mean increased ROM of 32.81° (SD 19.85°; -15° to 90°). Conclusion. Younger, thinner patients had highest incidence of MUA. Effect of discharge disposition on rate of MUA was an important finding and may influence surgeons’ decisions. Interestingly, use of cement and component design (constraint) did not impact incidence of MUA. Level of Evidence II: Prospective cohort study. Cite this article: Bone Joint J 2020;102-B(6 Supple A):66–72

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

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

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