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Manipulation Under Anesthesia

A Safe and Effective Treatment for Posttraumatic Arthrofibrosis of the Knee

Sassoon, Adam A. MD*; Adigweme, Obinna O. MD; Langford, Joshua MD; Koval, Kenneth J. MD; Haidukewych, George J. MD

doi: 10.1097/BOT.0000000000000395
Original Article

Objectives: This study investigates the results of closed manipulations performed under anesthesia (MUA) to evaluate whether it is an effective means to treat posttraumatic knee arthrofibrosis.

Design: Retrospective review.

Setting: Level I trauma center.

Patients/Participants: Twenty-two patients with a mean age of 40 underwent closed MUA for posttraumatic knee arthrofibrosis. Injuries included fractures of the femur, tibia, and patella as well as ligamentous injuries and traumatic arthrotomies. The mean time from treatment to manipulation was 90 days. Mean follow-up after manipulation was 7 months.

Intervention: Closed knee MUA.

Outcome Measurements: Improvement of knee range of motion (ROM) arc was the primary outcome. Patient demographics were correlated with manipulation success using a 2-sample t test. A delay in manipulation of 90 days or greater was also evaluated in this fashion with regard to its role in predicting the benefit of MUA.

Results: The mean premanipulation ROM arc was 59 ± 25 degrees. The mean intraoperative arc of motion, achieved at the time of the manipulation was 123 ± 14 degrees. No complications occurred during the MUA procedure. At the most recent follow-up, the mean ROM arc was 110 ± 19 degrees. Tobacco use, associated injuries, elevated body mass index, open fracture, and advanced age did not impact manipulation efficacy. Additionally, manipulations performed 90 days or more after surgical treatment provided a benefit equaling those performed more acutely (P = 0.12).

Discussion: MUA is a safe and effective method to increase knee ROM in the setting of posttraumatic arthrofibrosis. Improvement in ROM was noted in all patients. A 90-day window between fracture fixation and manipulation did not impact ROM at final follow-up and may prevent fracture displacement during the MUA.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

*Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA; and

Department of Orthopaedic Surgery, Orlando Regional Medical Center, Orlando, FL.

Reprints: George J. Haidukewych, MD, Orlando Regional Medical Center, Orthopedics MP43, 89 W. Copeland, Orlando, FL 32809 (e-mail:

J. Langford: Related to submitted work: consulting fee or honorarium from Stryker; not related to submitted work: received payment for lectures including service on speakers bureaus from Smith and Nephew and has received money for stock/stock options from the Institute for Better Bone Health, LLC and Core Orthopaedicsk. K. J. Koval: Not related to submitted work: received money for consultancy from Biomet and Stryker and payment for lectures including service on speaker bureaus from Biomet and Stryker. G. J. Haidukewych: Related to submitted work: the institution has received money for grants from Synthes Fellowship support; has received money for consulting fee or honorarium from Synthes; has received royalties from Biomet and DePuy. Not related to submitted work: received money for consultancy from Synthes, Biomet, and DePuy; has received royalties from Biomet and DePuy; and has received money for stock/stock options from Institute for Better Bone Health and Orthopaediatrics. The remaining authors report no conflict of interest.

Accepted July 09, 2015

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