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

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

Introduction. Stiffness after total knee arthroplasty is a common occurrence. Despite its prevalence, little is known as to which patients are at risk for poor range of motion after total knee arthroplasty. The purpose of this study was to determine the risk factors for manipulation under anesthesia (MUA) after total knee arthroplasty (TKA). Methods. Using a single institution registry, 160 patients who underwent a manipulation under anesthesia after total knee arthroplasty between 2007 and 2013 were retrospectively evaluated. Each patient was 1:1 matched by age, gender and laterality to a control group of 160 patients who did not require MUA after TKA. Risk factors for MUA were assessed, and included medical co-morbidities, BMI, prior operations, and preoperative range of motion. Results. There were 160 patients in each group, 48 males and 112 females. Patients who required a MUA after TKA had a significantly higher percentage of overweight patients with a BMI >25 (88% vs 76%, p=0.01, Odds ratio=2.18), and previous surgery including arthroscopy (60% vs 33%, P < 0.0001, Odds ratio=3.12). Patients that underwent an MUA had a higher but not significant prevalence of depression and anxiety (22% vs. 16%, p=0.20, Odds Ratio=1.44) and diabetes (15% vs. 8%, p=0.058, Odds Ratio=2.0). Average ROM was 3–110° (Range −10–130°) and 6–102° (Range 0–140°) in the MUA and control groups respectively. In the MUA group, 29% of patients had pre-operative flexion less than 90 degrees pre-operatively compared to 3% in the control group (p=0.02, Odds Ratio=6.6). While the average preoperative range of motion did not differ between the groups, there were a larger percentage of patients with severe limitations in range of motion who ended up needing a MUA after TKA compared to controls. Conclusion. Patients with increased BMI, preoperative range of motion less than 90°, and a history of prior operations should be counseled on the increased risk of requiring a MUA after TKA

Introduction. Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) helps restore range of motion. This study identifies MUA risk factors to support early interventions to improve functionality. Methods. Data was retrospectively reviewed in 2,925 primary TKAs from October 2013 through December 2015 from 13 orthopedic surgeons using hospital and private practice electronic medical records (EMR). Statistical analysis evaluated MUA and non-MUA groups, comparing demographic, operative, hospital-visit, and clinical factors. T-test, chi-square test, ANOVA and regression analysis were performed. Significance was set at p<0.05. Results. Of 2,925 TKAs, 208 MUAs were performed (7.1%) with no significant differences between groups in sex, BMI, or diabetes status. Mean age of the MUA group was 61.98 years old, and 66.89 years old in the non-MUA group (p<0.005). The ratio of MUA patients with high cholesterol was 3.37% (7/208), and 1.10% (30/2717) in the non-MUA group (p=0.014). The ratio of African-American patients in the MUA group was 6.73% (14/208), and 2.94% (80/2717) in the non- MUA group (p=0.003). Of cases with device data recorded in the EMR (n=1890), MUA incidence in patients receiving a cruciate-retaining (CR) device was 14.58% (50/343), and 9.57% (148/1547) in patients receiving a posterior-stabilized (PS) device (p=0.006). A CR-device patient was 52.35% more likely to undergo MUA than a PS-device patient (95% CI, 1.13–2.05). MUA rate by surgeon training was 6.7% for joint fellowship, 6.8% for general fellowship, and 12.0% for sports medicine fellowship (p=0.015). Further analysis showed that rate of CR-device use was 13.3% for joint-fellowship trained surgeons, 10.2% for general fellowship, and 74.7% for sports medicine fellowship (p<0.001). With the numbers available for this investigation, there were no significant differences found between groups in relation to surgeon, high-volume (>150 TKAs annually) or low-volume surgeons, length of stay, discharge disposition, or smoking status. Conclusion. MUA risk factors include a lower mean age, high cholesterol, African-American, surgeon fellowship training, and receiving a cruciate-retaining device

OBJECTIVE. Post TKR manipulation under anesthesia is required when post operatively patients don't achieve desired range of motion. The rates quoted in various western literature ranges from 1 to 2 %. A knee is considered to be stiff when the patient fails to achieve 60 degrees of flexion. The objective of the study was to find out the differentiating factor responsible for low rate of MUA in Indian post TKR patients as compared to Anglo-Saxon population. MATERIAL & METHODS. We studied 100 consecutive patients operated from January 2016. The following parameters of these 100 patients were recorded. Pre-op ROM. Age and Sex of the TKR patient. Duration of home physiotherapy. Post opROM. All patients received post operative physiotherapy at home every day for first 2 weeks, 3 times a week for next 2 weeks and then once a week for next two weeks. The implant used was Maxx Freedom knee (PS design). RESULTS. Of the 300 TKR patients 270 were females and 30 were males. The age range for male patients was 65 to 87 years with a mean of 73 years. The age range of female patients was 65 to 83 years with a mean of 71 years. The mean range of motion achieved was 121 degrees. Only one of our patient required manipulation under anesthesia.(0.333%). CONCLUSION. Our rate of MUA is totally different from that of reported from Western world. According to us home physiotherapy is the main differentiating factor responsible for this low rate. Hence we strongly advocate personalized home physiotherapy post TKR with constant feedback mechanism between the operating doctor and the treating physiotherapist

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

Introduction. Arthrofibrosis following total knee arthroplasty (TKA) is a complex and multifactorial complication that may require manipulation under anesthesia (MUA). However, patient and surgical factors that potentially influence the development of knee stiffness following TKA are not fully understood. The purpose of this study was to identify patient and surgical factors that may influence arthrofibrosis following TKA by assessing a cohort of patient that underwent MUA and comparing them to a matched cohort of patients without arthrofibrosis. Methods. The joints registry of a university hospital was searched for patient that underwent MUA following primary TKA between 2004 and 2013. Demographic and surgical information was obtained from the electronic medical record including range of motion (ROM), comorbidities and timing of MUA. Patients who underwent MUA were then double-matched by baseline (prior to primary TKA) knee ROM to patients who underwent primary TKA without postoperative arthrofibrosis during the same time period. Results. Fifty-two patients (56 TKAs, 71% female, mean BMI 32.2kg/m2) underwent MUA after TKA during the study period. MUA was performed a mean of 13.6 weeks after primary TKA. Study patient were then double-matched by baseline flexion (mean 107º±2º) to 111 patients (112 TKAs) with a similar mean baseline flexion (104º±2º, p=0.138). Patient requiring MUA were younger (mean age 56 vs. 64 years, p<0.001), had more comorbidities (5 vs. 3, p<0.001), and a higher number of previous knee surgery (56% vs. 21%, p<0.001) compared with controls. The risk for requiring MUA following primary TKA was significantly higher (2.4, p<0.001) in patient with previous knee surgery (arthroscopy for meniscal pathology, ACL reconstruction, osteotomies). Tourniquet time, length of stay, number of physical therapy sessions, blood loss >50 mL and any complication during the hospital stay were not found to be associated with increased risk of requiring MUA. Discussion. Younger patients with more comorbidities and a history of previous knee surgery were found to have significantly higher risk for developing arthrofibrosis and requiring MUA after primary TKA in the current study. Patients with this risk profile need to counseled regarding the risk for arthrofibrosis possibly requiring MUA after primary TKA

A reduced range of movement post total knee replacement (TKR) surgery is a well recognised problem. Manipulation under anaesthesia (MUA) is a commonly performed procedure in the stiff post operative TKR. Long term results have been variable in the literature. We prospectively followed up 48 patients since 1996 from one centre, over an average of 7.5 years, (range 1 to 10 years) and report on the long term results. The mean time to MUA post TKR was 12.3 weeks (range 3 to 48). Pre MUA, the mean flexion was 53°. The mean immediate passive flexion post MUA was 97°, an improvement of 44° (Range 10° to 90°, CI < 0.05). By one year, the mean flexion was 87°, improvement of 34°, (range −15° to 70°, CI< 0.05). At ten years the mean flexion was 86°. We found no difference between those knees manipulated before or after 12 weeks. In addition there was no difference found in those knees which had a pre TKR flexion of greater or less than 90°. There were no complications as a result of MUA. However, one patient was eventually revised at two years secondary to low grade infection. Our findings show that MUA is safe and effective method at improving the range of motion in a stiff post operative TKR. The improvement is maintained in the long term irrespective of time to MUA and range of motion pre TKR

BACKGROUND. The need for post-operative manipulation under anesthesia (MUA) for stiffness after primary total knee arthroplasty is a frustrating complication that can lead to suboptimal outcomes if range-of-motion to a functional level is not regained. Implant morphology and kinematics, PCL imbalance, and soft-tissue balancing can all contribute to post-operative stiffness. Utilization of total knee arthroplasty components that replicate the native knee's medial ball and socket kinematics may lead to easier maintenance of flexion post-operatively compared to conventional components. PURPOSE. To determine if a medial pivot total knee arthroplasty design can reduce the need for post-operative MUA after primary total knee arthroplasty. METHODS. A retrospective chart review of primary total knee arthroplasties performed between 2013 and 2016 by a single fellowship-trained joint replacement surgeon was performed. Cases that met criteria for inclusion were: primary total knee arthroplasty, identifiable implant based on operative report and/or post-operative radiographs, immediate post-operative passive flexion against gravity of at least 110 degrees, and availability of post-operative follow-up notes documenting range-of-motion that was either satisfactory or necessitating need for MUA. The need for a MUA was deemed necessary if post-operative flexion was not beyond 90 degrees within six weeks of surgery. The percentage of patients requiring MUA for a group implanted with the EVOLUTION Medial Pivot System was compared to a group implanted with all other designs (Stryker Triathlon CR, PS, TS). RESULTS. One hundred fifty-six cases met criteria for inclusion and were reviewed. The Triathlon system was used predominantly in the first half of the study period and accounted for 65 (42%) of the cases performed. Six patients in this group underwent MUA and two patients required repeated MUA. An additional patient in the Triathlon group met the criteria for MUA but had other conditions which prevented the investigators from performing it. The percentage of patients who met the indication for MUA in the Triathlon group was 10.8%. The EVOLUTION system was used predominantly in the second half of the study period and accounted for 91 (58%) of the cases performed. There were two patients (2.2%) who met criteria for MUA and both patients subsequently underwent MUA. There was a statistically significant reduction in the number of patients meeting criteria for MUA in the EVOLUTION group compared with the Triathlon group (p=0.024). CONCLUSION. Utilization of a medial ball and socket design for primary total knee arthroplasty allows the polyethylene implant to control the position of the femur on the tibia. This design possibly allows for improved early maintenance of post-operative flexion, which may minimize the need for post-operative MUA. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Multiligament knee injuries (MLKI) are rare and life-altering injuries that remain difficult to treat clinically due to a paucity of evidence guiding surgical management and timing. The purpose of this study was to compare injury specific functional outcomes following early versus delayed surgical reconstruction in MLKI patients to help inform timing decisions in clinical practice. A retrospective analysis of prospectively collected data from patients with MLKIs at a single academic level 1-trauma center was conducted. Patients were eligible for inclusion if they had an MLKI, underwent reconstructive surgery either prior to 6wks from injury or between 12weeks and 2 years from injury, and had at least 12months of post-surgical follow-up. Patients with a vascular injury, open injuries or associated fractures were excluded. Study participants were stratified into early (12 weeks - 2 years from injury). The primary outcome was patient reported, injury specific, quality of life in the form of the Multiligament Quality of Life questionnaire (MLQOL) and its four domains (Physical Impairment, Emotional Impairment, Activity Limitations and Societal Involvement). We secondarily analyzed differences in the need for manipulation under anesthesia, and reoperation rates, as well as radiographic Kellgren Lawrence (KL) arthritis grades, knee laxity grading and range of motion at the most recent follow-up. A total of 131 patients met our inclusion criteria, all having had surgery between 2006 and 2019. There were 75 patients in the early group and 56 in the delayed group. The mean time to surgery was 17.6 ± 8.0 days in the early group versus 279 ± 146.5 days in the delayed. Mean postoperative follow-up was 58 months. There were no significant differences between early and delayed groups with respect to age (34 vs. 32.8 years), sex (77% vs 63% male), BMI (28.3 vs 29.7 kg/m2), or injury mechanism (p>0.05). The early surgery group was found to include more patients with lateral sided injuries (n=49 [65%] vs. n=23 [41%]; p=0.012), a higher severity of Schenck Classification (p=0.024) as well as nerve injuries at initial presentation (n=35 [49%] vs n=8 [18%]; p0.05), when controlling for age, sex, Schenck classification, medial versus lateral injury, and nerve injury status. In terms of our secondary outcomes, we found that the early group underwent significantly more manipulations under anesthesia compare with the delayed group (n=24, [32%] vs n=8 [14%], p=0.024). We did not identify a significant difference in physical examination laxity grades, range of motion, KL grade or reoperation rates between groups (p>0.05). We found no difference in patient reported outcomes between those who underwent early versus delayed surgery following MLKI reconstruction. In our secondary outcomes, we found significantly more patients in the early surgery group required a manipulation under anesthesia following surgery, which may indicate a propensity for arthrofibrosis after early MLKI reconstruction

Multiligament knee injuries (MLKI) are rare and life-altering injuries that remain difficult to treat clinically due to a paucity of evidence guiding surgical management and timing. The purpose of this study was to compare injury specific functional outcomes following early versus delayed surgical reconstruction in MLKI patients to help inform timing decisions in clinical practice. A retrospective analysis of prospectively collected data from patients with MLKIs at a single academic level 1-trauma center was conducted. Patients were eligible for inclusion if they had an MLKI, underwent reconstructive surgery either prior to 6wks from injury or between 12weeks and 2 years from injury, and had at least 12months of post-surgical follow-up. Patients with a vascular injury, open injuries or associated fractures were excluded. Study participants were stratified into early (<6wks from injury) and delayed surgical intervention (>12 weeks – 2 years from injury). The primary outcome was patient reported, injury specific, quality of life in the form of the Multiligament Quality of Life questionnaire (MLQOL) and its four domains (Physical Impairment, Emotional Impairment, Activity Limitations and Societal Involvement). We secondarily analyzed differences in the need for manipulation under anesthesia, and reoperation rates, as well as radiographic Kellgren Lawrence (KL) arthritis grades, knee laxity grading and range of motion at the most recent follow-up. A total of 131 patients met our inclusion criteria, all having had surgery between 2006 and 2019. There were 75 patients in the early group and 56 in the delayed group. The mean time to surgery was 17.6 ± 8.0 days in the early group versus 279 ± 146.5 days in the delayed. Mean postoperative follow-up was 58 months. There were no significant differences between early and delayed groups with respect to age (34 vs. 32.8 years), sex (77% vs 63% male), BMI (28.3 vs 29.7 kg/m. 2. ), or injury mechanism (p>0.05). The early surgery group was found to include more patients with lateral sided injuries (n=49 [65%] vs. n=23 [41%]; p=0.012), a higher severity of Schenck Classification (p=0.024) as well as nerve injuries at initial presentation (n=35 [49%] vs n=8 [18%]; p<0.001). Multivariable linear regression analyses of the four domains of the MLQOL did not demonstrate an independent association with early versus delayed surgery status (p>0.05), when controlling for age, sex, Schenck classification, medial versus lateral injury, and nerve injury status. In terms of our secondary outcomes, we found that the early group underwent significantly more manipulations under anesthesia compare with the delayed group (n=24, [32%] vs n=8 [14%], p=0.024). We did not identify a significant difference in physical examination laxity grades, range of motion, KL grade or reoperation rates between groups (p>0.05). We found no difference in patient reported outcomes between those who underwent early versus delayed surgery following MLKI reconstruction. In our secondary outcomes, we found significantly more patients in the early surgery group required a manipulation under anesthesia following surgery, which may indicate a propensity for arthrofibrosis after early MLKI reconstruction

Postoperative stiffness is a relatively uncommon issue in total knee arthroplasty (TKA). However, it can be a debilitating complication when it occurs. Manipulation under anesthesia (MUA) is commonly used as the primary treatment modality following failed physiotherapy. The ADVANCE® Medial Pivot Knee (Wright Medical Technology) was created in an effort to prevent stiffness postoperatively and increase range of motion. The EVOLUTION® Medial Pivot Knee is a second generation design that builds upon the technology of the ADVANCE® knee. We performed a retrospective review of prospectively collected data on 881 primary medial pivot knees (592 ADVANCE® knees, 289 EVOLUTION® knees). We theorized that the design changes made to the EVOLUTION® knees might contribute toward reducing the need for MUA. We found that the EVOLUTION® knees required significantly fewer manipulations under anesthesia (p = 0.036). The design modifications made to the EVOLUTION® knees may have contributed to the lower rate of MUA

Stiffness after knee arthroplasty is an important complication that the orthopaedic surgeon must be prepared to manage. In some cases, patients have a low-pain threshold or unidentifiable etiologic findings with no clinical indicators of septic or aseptic failure, and no radiographic evidence of mechanical complications. Psychosocial issues are important to consider, such as patient motivation and etiologic findings related to a worker's compensation claim. For patients who fail to achieve satisfactory ROM after TKA with no identifiable cause, treatment options may be categorised as non-surgical and surgical interventions. Non-surgical interventions would be physical therapy and pharmaceutical control for pain management. Surgical interventions include non-invasive options such as manipulation under anesthesia, and invasive options such as arthroscopy and mini-arthrotomy. Manipulation under anesthesia is indicated in the TKA that has less than 90° ROM after six weeks, no progression or regression in ROM. A modified technique has evolved for patients with persistent stiffness after standard-technique manipulation. The modified technique uses epidural anesthesia continued for post-operative analgesia, hospital stay of 1–3 days, CPM for 2–3 days, and daily PT. Continuous epidural infusion with local anesthetic is administered to provide complete analgesia, but allows muscle activation to be maintained during the hospital stay. Although open revision is sometimes required, arthroscopic management may be an effective alternative in certain instances, and also is helpful in diagnosis and treatment of other conditions of the knee that include prosthetic loosening and failure, retained cement, loose bodies, and sub-clinical infections. However, the painful TKA without evidence of significant intra-articular pathologic findings does not always respond well to arthroscopic management. Another option is open arthrotomy, done mainly to excise scar tissue. A synovectomy may be done as well. The polyethylene insert may be removed and an examination of the posterior cruciate ligament (PCL) performed. If the PCL is tight, it can be released and the existing components may be retained. Sometimes the polyethylene liner may be exchanged to a lipped insert to maintain stability. Revision surgery represents another option of treatment that can provide improved results whether manipulation or arthroscopic debridement has been done (14). Revision of one or all components combined with arthrolysis continues to have a role in improvement of ROM and outcomes in the stiff TKA

MPFL reconstruction has demonstrated a very high success rate with improved patella stability, physical function, and patient-reported outcomes. However technical error and a lack of consideration of anatomic risk factors have been shown to contribute to failure after MPFL reconstruction. Previous research has also reported a complication rate of 26% following surgery. The purposes of this study were to determine the re-dislocation rate, type and number of complications, and most common additional surgical procedures following MPFL reconstruction. Patients with symptomatic recurrent patellofemoral instability underwent an MPFL reconstruction (n = 268) and were assessed with a mean follow-up of 31.5 months (minimally 24-months). Concomitant procedures were performed in addition to the MPFL reconstruction in order to address significant anatomic or biomechanical characteristics. Failure of the patellofemoral stabilization procedure was defined as post-operative re-dislocation of the patella. Rates of complications and re-procedures were assessed for all patients. The re-dislocation rate following MPFL reconstruction was 5.6% (15/268). There were no patella fractures. A total of 49/268 patients (18.3%) returned to the operating room for additional procedures following surgery. The most common reason for additonal surgery was removal of symptomatic tibial tubercle osteotomy hardware in 24/268 patients (8.9%). A further 9.3% of patients underwent addtional surgery including revision MPFL reconstruction: with trochleoplasty 8/268 (3.0%), with tibial tubercule osteotomy 4/286 (1.5%) and with femoral derotation osteotomy 3/268 (1.1%); manipulation under anaesthesia for reduced knee range of motion 4/268 (1.5%); knee arthroscopy for pain 8/268 (3.0%); and cartilage restoration procedures 3/268 (1.1%). There was 1 case of wound debridement for surgical incision infection. MPFL reconstruction using an a la carte approach to surgical selection demonstrated a post-operative redislocation rate of 5.6%. The rate of complications following surgical stabilization was low, with the most common reason for additional surgery being removal of hardware

Flexion contracture sometimes occurs after primary total knee arthroplasty (TKA). In most cases, flexion contracture after TKA gradually improves over time. However, some severe cases require manipulation or revision surgery. We searched our clinical database for patients who underwent primary TKA at our institution between 2008 and 2015. By reviewing patient records, we identified three patients (one man and two women) with a severe flexion contracture 30° after primary TKA. Although all three patients gained more than 120° in flexion intraoperatively, they developed flexion contracture after discharge from our institution. We performed manipulation under anaesthesia (MUA) for all three cases several months later. The two female patients had improved range of motion (ROM) right after the manipulation. However, one of them regained flexion contracture 1 year after the MUA. We report the details of the male patient, who had the worst flexion contracture (−60°). An 80-year-old man had right knee osteoarthritis. His history indicated only hypertension. The right knee ROM before the TKA was −20° extension and 135° flexion. His radiographs showed advanced-stage osteoarthritis. We performed cemented TKA (posterior stabiliser design). Three weeks after the operation, his right knee pain improved. The right knee ROM was −10° extension and 100° flexion just before discharge. However, he returned to our institution because of right knee pain and flexion contracture 31 months after the surgery. The flexion contracture gradually worsened without any trauma. When he returned, the right knee ROM was −60° extension and 135° flexion. Manipulation under general anaesthesia was not effective. Therefore, we performed revision TKA immediately. We excised the scar tissue of the posterior knee joint. Then, we shortened the distal femoral end by 1 cm and reduced the size of the femoral component. After the operation, the right knee ROM was improved to −10° flexion and 130° extension. The reported prevalence of stiffness after TKA was from 1.3% to 13%. Although the deleterious effects of persistent flexion contractures > 15° is well understood, whether they resolve with time or need surgical intervention is controversial. MUA is generally the initial option for patients with flexion contractures, with the possibility of some improvement. If severe flexion contracture remains after manipulation, revision TKA, which may be considered as a useful treatment option, should be considered

Introduction. This study sought to evaluate the patient experience and short-term clinical outcomes associated with the hospital stay of patients who underwent robotic arm-assisted total knee arthroplasty (TKA). These results were compared to a cohort of patients who underwent TKA without robotic assistance performed by the same surgeon. Methods. A cohort of consecutive patients undergoing primary TKA for the diagnosis of osteoarthritis by a single fellowship trained orthopaedic surgeon over a 39-month period was identified. Patients who underwent TKA during the year this surgeon transitioned his entire knee arthroplasty practice to robotic assistance were excluded to eliminate selection bias and control for the learning curve. A final population of 538 TKAs was identified. Of these, 314 underwent TKA without robotic assistance and 224 underwent robotic arm-assisted TKA. All patients received the same prosthesis and post-operative pain protocol. Patient demographic characteristics and short-term clinical data were analyzed. Results. Robotic arm-assisted TKA was associated with shorter length of stay (2.3 versus 2.6 days, p< 0.001), a 50% reduction in morphine milligram equivalent utilization (from 213 to 105, p< 0.001), decreased visual analog scale pain score on post-op day 1 and 2 (p< 0.001), and a mean increase in procedure time of 8.2 minutes (p=0.08). There were no post-operative infections in either cohort. Additionally, there were no significant differences in rates of manipulation under anesthesia, emergency department visits, readmissions, or return to the operating room. Conclusions. This analysis corroborates existing literature suggesting that robotic arm-assisted TKA can be correlated with improved short-term clinical outcomes. This study reports on a single surgeon's experience with regard to analgesic requirements, length of stay, pain scores, and procedure time following a complete transition to robotic arm-assisted TKA. These results underscore the importance of continued evaluation of clinical outcomes as robotic arthroplasty technology continues to grow. For any figures or tables, please contact authors directly

Introduction/Aim. The NAVIO robotic-assisted TKA (RA-TKA) application received FDA clearance in May 2017. This semi-active robotic technique aims to improve the accuracy and precision of total knee arthroplasty. The addition of robotic-assisted technology, however, also introduces another potential source of surgery-related complications. This study evaluates the safety profile of NAVIO RA-TKA. Materials and Methods. Beginning in May 2017, the first 250 patients undergoing NAVIO RA-TKA were included in this study. All intra-operative complications were recorded, including: bleeding; neuro-vascular injury; peri-articular soft tissue injury; extensor mechanism complications; and intra-operative fracture. During the first 90 days following surgery, patients were monitored for any post-operative complications, including: superficial and deep surgical site infection; pin-tract infection; pin site fractures; peri-prosthetic fractures; axial or sagittal joint instability; axial mal-alignment; patello-femoral instability; DVT/PE; re-operation or re-admission due to surgical-related complications. Surgical technique and multi-modality pain management protocol was consistent for all patients in the study. A combined anesthetic technique was employed for all cases, including: low-dose spinal, adductor canal block and general anesthetic. Patients were mobilized per our institution's rapid recovery protocol. Results. No patients were lost to follow-up. During the study period, no intra-operative complications were recorded. Specifically, no complications related to the introduction of the high-speed burr associated with the NAVIO RA-TKA were noted. Within the 90-day follow-up period, there was one case of deep infection. One patient sustained a fall resulting in a peri-prosthetic femoral fracture, that occurred remote from the femoral pin tracts. No cases of axial or sagittal joint instability, axial mal-alignment, patello-femoral instability, pin site infections or fractures; or DVT/PE were identified. Four patients underwent manipulation under anesthesia. No other patients required a re-operation or re-admission due to surgical-related complications. Discussion/Conclusions. The initial experience with the NAVIO robotic assisted total knee arthroplasty has demonstrated excellent safety profile. Relative to known risks associated with total knee arthroplasty, no increased risk of peri-operative complications, re-operation or re-admission for surgical related complications was identified with the introduction of the NAVIO RA-TKA

Stiffness remains one of the most common, and challenging postoperative complications after TKA. Preoperative motion and diagnosis can influence postoperative motion, and careful patient counseling about expectations is important. Postoperative stiffness should be evaluated by ruling out infections, metal allergy, or too aggressive physical therapy. A careful physical and radiographic examination is required. Manipulation under anesthesia (MUA) in selected cases can be helpful. The best timing to perform MUA is between the 6th and 10th week postoperatively. Careful technique is required to minimise the risk of fracture or soft tissue injury. This requires complete paralysis! For more chronic stiffness, revision may be indicated if an etiology can be identified. An excessively thick patellar resurfacing, an overstuffed tibia insert, an oversized femoral component, or gross malrotation should be corrected. During revision, thorough synovectomy, release of contractures, ligamentous balancing and restoration of the joint line is required. Careful attention to component rotation, and sizing is critical. Downsizing components is helpful to place less volume into the joint space. Patients should be counseled that the results of revision for stiffness are mixed and somewhat unpredictable. More frequent postoperative nurturing is helpful to guide rehabilitation progress. Manipulation after revision at 6 weeks is almost expected

INTRODUCTION. Over the past 40 years of knee arthroplasty, significant advances have been made in the design of knee implants, resulting in high patient satisfaction. Patellar tracking has been central to improving the patient experience, with modern designs including an optimized Q-angle, deepened trochlear groove, and thin anterior flange.[1–4] Though many of today's femoral components are specific for the left and right sides, Total Joint Orthopedics’ (TJO) Klassic® Knee System features a universal design to achieve operating room efficiencies while providing all the advancements of a modern knee. The Klassic Femur achieves this through a patented double Q-angle to provide excellent patellar tracking whether implanted in the left or the right knee (Figure 1). The present study examines a prospective cohort of 145 consecutive TKA's performed using a modern universal femur and considers patients’ pre- and post-operative Knee Society Clinical Rating System score (KSS). METHODS AND MATERIALS. 145 primary total knee arthroplasties (TKA) were performed during the study using a measured resection technique with a slope-matching tibial cut for all patients. The posterior cruciate ligament (PCL) was sacrificed to accommodate an ultra-congruent polyethylene insert. The distal femur was cut at five degrees (5°) valgus; the tibia was resected neutral (0°) alignment for valgus legs and in two degrees (2°) of varus for varus alignment. The patella was resurfaced for all patients. Patients were followed annually for up to 46 months and were evaluated using the KSS score on a 200-point scale. RESULTS. The final study group comprised 127 primary TKAs. The average age was 68 years (51–90) with 45 males and 68 females. The average weight was 110kg (range: 75–151kg) for men and 88kg (range: 50–129kg) for women. One patient deceased during the follow-up period, four required manipulation under anesthesia, and two required revision for periprosthetic joint infection. There were no failures due to patellar maltracking. No special soft tissue releases were required in any patient. Average pre-operative knee score was 107, improving to 182 at average follow-up of 41 months (36–46 months). Results are summarized in Table 1. DISCUSSION. The improvement in patient clinical experience demonstrates that a universal femoral design can achieve excellent results if it incorporates modern technologies. A double Q-angle design with a deepened trochlear groove and a thin anterior flange appears to provide excellent patellar tracking for all patients in this cohort. This study is limited to the experience of a single institution. Further study would improve the extensibility of these findings. It does show, however, that a femur using a universal design with modern patellar tracking can improve patient satisfaction with their knee following TKA. For any figures or tables, please contact the authors directly

Introduction. Close to 30% of the surgical causes of readmission within 90 days post-total knee arthroplasty (TKA) and nearly half of those occurring in the first 2 years are caused by instability, arthrofibrosis, and malalignment, all of which may be addressed by improving knee balance. Furthermore, the recently launched Comprehensive Care for Joint Replacement (CJR) initiative mandates that any increase in post-acute care costs through 90-days post-discharge will come directly from the bundle payment paid to providers. Post-discharge costs, including the cost of readmissions for complications are one of the largest drivers of the 90-day cost of care. It is hypothesized that balanced knees post-TKA will lower the true provider costs within the 90-day bundle. Methods. Cost, outcomes and resource utilization data were collected from three independent surgeons pre- and post- adoption of intraoperative technology developed to provide real-time, quantitative load data within the knee. In addition, data were collected from Medicare claims, hospital records, electronic medical records (EMR), clinical, and specialty databases. The cohorts consisted of 932 patients in the pre-adoption group and 709 patients in the post-adoption group. These 2 groups were compared to the CMS national average data from 291,201 cases. The groups were controlled for age, sex, state, and BMI with no major differences between cohorts. The cost factors considered were the length of hospital stay, physician visits and physical therapy visits in addition to post-operative complications (e.g., manipulation under anesthesia (MUA) and aseptic revision). Results. After adoption of technology to improve ligament balancing intra-operatively, all three surgeons decreased their patients’ hospital stay (3.0 days to 2.6 days), number of physician visits (2.3 to 2.1), number of outpatient physical therapy visits (14.9 to 10.6) and MUA rate (2.3% to 1.8%). These clinical benefits subsequently lowered the 90-day net cost of TKA an average of $443 per case. When compared to the national average, this cost savings was $725 per case. Conclusions. Appropriately balancing TKA patients intra-operatively might help mitigate costs associated with TKA procedures within the 90-day bundle. In this study, it was found that using new joint balancing technology generated a substantial cost-savings post-discharge, primarily due to patients requiring less outpatient physical therapy