Manipulation after total knee arthroplasty.

BACKGROUND: Following total knee arthroplasty, some patients who fail to achieve >90 degrees of flexion in the early perioperative period may be considered candidates for manipulation of the knee under anesthesia. The purpose of this study was to assess the outcomes of manipulation following total knee arthroplasty. METHODS: One hundred and thirteen knees in ninety patients underwent manipulation for postoperative flexion of < or =90 degrees at a mean of ten weeks after surgery. Flexion was measured with a goniometer prior to total knee arthroplasty, at the conclusion of the operative procedure, before manipulation, immediately after manipulation, at six months, and at one, three, and five years postoperatively. RESULTS: Eighty-one (90%) of the ninety patients achieved improvement of ultimate knee flexion following manipulation. The average flexion was 102 degrees prior to total knee arthroplasty, 111 degrees following skin closure, and 70 degrees before manipulation. The average improvement in flexion from the measurement made before manipulation to that recorded at the five-year follow-up was 35 degrees (p < 0.0001, paired t test). There was no significant difference in the mean improvement in flexion when patients who had manipulation within twelve weeks postoperatively were compared with those who had manipulation more than twelve weeks postoperatively. Patients who eventually underwent manipulation had significantly lower preoperative Knee Society pain scores (more pain) than those who had not had manipulation (p = 0.0027). CONCLUSIONS: Manipulation generally increases ultimate flexion following total knee arthroplasty. Patients with severe preoperative pain are more likely to require manipulation.

Patella fracture after post total knee replacements.

A retrospective study was done to determine the incidence, clinical function, and complications of treatment in a large series of patella fractures after total knee replacement (TKR). Between 1983 and 1996, 4583 primary AGC TKRs done at our institution. One hundred seventy-seven fractures were identified in 135 patients for a fracture incidence of 3.8%. Twenty-two fractures were vertical and had a stable implant and intact extension mechanism (Type 1). Twenty-one fractures had disruption of the extensor mechanism of less than 1 cm (Type 2A). Seventeen fractures had disruption of the extensor mechanism of 1 cm or more (Type 2B). One hundred fourteen fractures had a loose component and an intact extension mechanism (Type 3). Patients treated nonoperatively generally had no extensor lag and had adequate pain and function scores. Patients treated operatively had a high complication rate. Four of nine patients treated with excision of an extruded patella button developed a deep infection. Both patients treated with open reduction internal fixation (ORIF)had a nonunion develop. Surgery on patients with patella fractures has a high complication rate and should be avoided if possible.