Manipulation Following Primary Total Knee Arthroplasty is Associated With Increased Rates of Infection and Revision

Published:September 30, 2022DOI:



      Stiffness following total knee arthroplasty (TKA) is a disabling complication and manipulation under anesthesia (MUA) is often performed as an early intervention. Few studies have focused on the revision risk, infection risk, demographics, and clinical outcomes in Medicare patients undergoing MUA following primary TKA.


      We reviewed 142,440 patients who had primary TKA from a national database and identified 3,652 patients (2.6%) who underwent MUA. Patient demographics and comorbid conditions were evaluated to identify risk factors. Incidence of revision and periprosthetic joint infection (PJI) at 1-, 2-, and 5-year time points in a cohort of MUA patients was compared to patients who did not undergo MUA. Multivariate Cox regressions were used for statistical analyses.


      The incidence of MUA was higher in Black versus White individuals (4.1 versus 2.5%, P < .001). Revision risk was significantly greater in the MUA group at 1-, 2-, and 5-year time points with a hazard ratio (HR) of, 3.81, 3.90, and 3.22 respectively, P < .001. One- and 2-year revision risk was significantly greater when MUA occurred at 6 to 12 months post-TKA when compared to <3 months, P < .05. Risk of PJI was significantly greater in the MUA group with a HR of 2.2, 2.2, and 2.1 at 1, 2, and 5 years, respectively P < .001.


      The incidence of MUA was 2.6%. There was an increased incidence of revision surgery and PJI in patients undergoing MUA. Patients at increased risk for stiffness following TKA should be closely monitored and treated with early intervention to minimize risk of poor outcomes.


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        • Kim J.
        • Nelson C.L.
        • Lotke P.A.
        Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision.
        J Bone Joint Surg Am. 2004; 86: 1479-1484
        • Yercan H.S.
        • Sugun T.S.
        • Bussiere C.
        • Ait Si Selmi T.
        • Davies A.
        • Neyret P.
        Stiffness after total knee arthroplasty: prevalence, management and outcomes.
        Knee. 2006; 13: 111-117
        • Nelson C.L.
        • Kim J.
        • Lotke P.A.
        Stiffness after total knee arthroplasty.
        J Bone Joint Surg Am. 2005; 87: 264-270
        • Tibbo M.E.
        • Limberg A.K.
        • Salib C.G.
        • Ahmed A.T.
        • van Wijnen A.J.
        • Berry D.J.
        • et al.
        Acquired Idiopathic Stiffness After Total Knee Arthroplasty.
        J Bone Joint Surg. 2019; 101: 1320-1330
        • Owen A.R.
        • Tibbo M.E.
        • van Wijnen A.J.
        • Pagnano M.W.
        • Berry D.J.
        • Abdel M.P.
        Acquired idiopathic stiffness after contemporary total knee arthroplasty: incidence, risk factors, and results over 25 years.
        J Arthroplasty. 2021; 36: 2980-2985
        • Insall J.N.
        • Dorr L.D.
        • Scott R.D.
        • Scott W.N.
        Rationale of the Knee Society clinical rating system.
        Clin Orthop Relat Res. 1989; 248: 13-14
        • Abram S.G.F.
        • Yusuf B.
        • Alvand A.
        • Sabah S.A.
        • Beard D.J.
        • Price A.J.
        Manipulation under anesthetic after primary knee arthroplasty is associated with a higher rate of subsequent revision surgery.
        J Arthroplasty. 2020; 35: 2640-2645
        • Thorsteinsson H.
        • Hedström M.
        • Robertsson O.
        • Lundin N.
        • W-Dahl A.
        Manipulation under anesthesia after primary knee arthroplasty in Sweden: incidence, patient characteristics and risk of revision.
        Acta Orthop. 2019; 90: 484-488
        • Werner B.C.
        • Carr J.B.
        • Wiggins J.C.
        • Gwathmey F.W.
        • Browne J.A.
        Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery.
        J Arthroplasty. 2015; 30: 72-75
        • Newman E.T.
        • Herschmiller T.A.
        • Attarian D.E.
        • Vail T.P.
        • Bolognesi M.P.
        • Wellman S.S.
        Risk factors, outcomes, and timing of manipulation under anesthesia after total knee arthroplasty.
        J Arthroplasty. 2018; 33: 245-249
        • Issa K.
        • Banerjee S.
        • Kester M.A.
        • Khanuja H.S.
        • Delanois R.E.
        • Mont M.A.
        The effect of timing of manipulation under anesthesia to improve range of motion and functional outcomes following total knee arthroplasty.
        J Bone Joint Surg Am. 2014; 96: 1349-1357
        • Sambandam S.
        • Mounasamy V.
        • Wukich D.
        Patients undergoing manipulation after total knee arthroplasty are at higher risk of revision within 2 years.
        Eur J Orthop Surg Traumatol. 2021; 32: 145-150
        • Abdul N.
        • Dixon D.
        • Walker A.
        • Horabin J.
        • Smith N.
        • Weir D.J.
        • et al.
        Fibrosis is a common outcome following total knee arthroplasty.
        Sci Rep. 2015; 5: 16469
        • Schroer W.C.
        • Berend K.R.
        • Lombardi A.V.
        • Barnes C.L.
        • Bolognesi M.P.
        • Berend M.E.
        • et al.
        Why are total knees failing today? Etiology of total knee revision in 2010 and 2011.
        J Arthroplasty. 2013; 28: 116-119
        • Sloan M.
        • Premkumar A.
        • Sheth N.P.
        Projected volume of primary total joint arthroplasty in the US, 2014 to 2030.
        J Bone Joint Surg Am. 2018; 100: 1455-1460
        • Cartwright-Terry M.
        • Cohen D.R.
        • Polydoros F.
        • Davidson J.S.
        • Santini A.J.
        Manipulation under anesthetic following total knee arthroplasty: predicting stifness and outcome.
        J Orthop Surg (Hong Kong). 2018; 26 (2309499018802971)
        • Issa K.
        • Rifai A.
        • Boylan M.R.
        • Pourtaheri S.
        • McInerney V.K.
        • Mont M.A.
        Do various factors affect the frequency of manipulation under anesthesia after primary total knee arthroplasty?.
        Clin Orthop Relat Res. 2015; 473: 143-147
        • Knapp P.
        • Weishuhn L.
        • Pizzimenti N.
        • Markel D.C.
        Risk factors for manipulation under anesthesia after total knee arthroplasty.
        Bone Joint J. 2020; 102-B: 66-72
        • Brigati D.P.
        • Huddleston J.
        • Lewallen D.
        • Illgen R.
        • Jaffri H.
        • Ziegenhorn D.
        • et al.
        Manipulation under anesthesia after total knee: who still requires a revision arthroplasty?.
        J Arthroplasty. 2020; 35: S348-S351
        • Crawford D.A.
        • Adams J.B.
        • Morris M.J.
        • Berend K.R.
        • Lombardi Jr., A.V.
        Manipulation under anesthesia after knee arthroplasty is associated with worse long-term clinical outcomes and survivorship.
        J Knee Surg. 2009; 34: 739-744
        • Salib C.G.
        • Reina N.
        • van Wijnen A.J.
        • Hanssen A.D.
        • Berry D.J.
        • Abdel M.P.
        Absence of signature inflammatory markers in synovial fluid for total knee arthroplasties revised for arthrofibrosis.
        Orthop Traumatol Surg Res. 2021; 107: 102870
        • Stone A.H.
        • MacDonald J.H.
        • Joshi M.S.
        • King P.J.
        Differences in perioperative outcomes and complications between African American and white patients after total joint arthroplasty.
        J Arthroplasty. 2019; 34: 656-662
        • Pfefferle K.J.
        • Shemory S.T.
        • Dilisio M.F.
        • Fening S.D.
        • Gradisar I.M.
        Risk factors for manipulation after total knee arthroplasty: a pooled electronic health record database study.
        J Arthroplasty. 2014; 29: 2036-2038
        • Suleiman L.I.
        • Manista G.C.
        • Sherman A.E.
        • Adhia A.H.
        • Karas V.
        • Sporer S.M.
        • et al.
        The impact of race and socioeconomic status on total joint arthroplasty care.
        J Arthroplasty. 2021; 36: 2729-2733
        • Barbera J.P.
        • Raymond H.E.
        • Zubizarreta N.
        • Poeran J.
        • Chen D.D.
        • Hayden B.L.
        • et al.
        Racial differences in manipulation under anesthesia rates following total knee arthroplasty.
        J Arthroplasty. 2022; 37: 1865-1869