Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature.

INTRODUCTION: The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery. METHODS: A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA. RESULTS: Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA. CONCLUSION: Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.

[Temporo-mandibular ankylosis]. / L'ankylose temporo-mandibulaire.

Ankylosis of the temporomandibular joint is defined as a permanent constriction of the jaws with less than 30mm mouth opening measured between the incisors, occurring because of bony, fibrous or fibro-osseous fusion. Resulting complications such as speech, chewing, swallowing impediment and deficient oral hygiene may occur. The overall incidence is decreasing but remains significant in some developing countries. The most frequent etiology in developed countries is the post-traumatic ankylosis occurring after condylar fracture. Other causes may be found: infection (decreasing since the advent of antibiotics), inflammation (rheumatoid arthritis and ankylosing spondylitis mainly) and congenital diseases (very rare). Management relies on surgery: resection of the ankylosis block in combination with bilateral coronoidectomy… The block resection may be offset by the interposition temporal fascia flap, a costochondral graft or a TMJ prosthesis according to the loss of height and to the impact on dental occlusion. Postoperative rehabilitation is essential and has to be started early, to be intense and prolonged. Poor rehabilitation is the main cause of ankylosis recurrence.

What Is the Efficacy of Repeat Manipulations Under Anesthesia to Treat Stiffness Following Primary Total Knee Arthroplasty?

BACKGROUND: Manipulation under anesthesia (MUA) can help post-total knee arthroplasty (TKA) patients who have knee stiffness regain range-of-motion. However, despite undergoing MUA, patients may have persistent knee stiffness. Often, this persistent knee stiffness is treated with a repeat MUA. Therefore, the purpose of this study was to evaluate repeat MUAs by assessing: (1) demographic characteristics, (2) range-of-motion, (3) clinical outcomes, and (4) rate of revision surgery in post-TKA patients with persistent knee stiffness who either underwent a single MUA or repeat MUAs. MATERIALS AND METHODS: One-hundred-and-sixty-seven post-TKA who had undergone an MUA between 2005 and 2011 at two institutions were reviewed. Patients were stratified into those who had a single-MUA (138 knees) and those who had a repeat MUA (29 knees). The mean follow-up period was 63 months (range, 36 to 90 months). The incidence of repeat MUA within this cohort was determined. Demographics and ROM were compared using Student t-test and Chi-square as appropriate. Functional outcomes were assessed using Knee Society scores (KSS) and compared between the two cohorts. RESULTS: Among the 167 patients who underwent a MUA, 29 (17%) required repeat manipulations. The repeat MUA cohort was younger and more likely to have osteonecrosis as the underlying cause of knee disease. For the repeat MUA cohort, 17 patients (59%) had achieved satisfactory mean gains in ROM after their repeat MUAs. These patients had also achieved excellent mean Knee Society objective and functional scores. However, another seven knees (24%) had further persistent knee stiffness requiring arthrolysis of adhesions and five patients (17%) had undergone revision of the polyethylene spacer or patellar component to improve range-of-motion. CONCLUSION: In this study, the majority of patients who had undergone a repeat MUA were able to achieve improvements in flexion range-of-motion and functional outcomes. However, the remaining patients required more invasive procedure to treat persistent knee stiffness. In patients who have persistent knee stiffness after MUAs, a repeat MUA may be helpful to increase range-of-motion and function.

[Transoral coronoidectomy: Technical note]. / Coronoïdectomie intra-orale: note technique.

INTRODUCTION: Among the skeletal causes of limited mouth opening, uni- or bilateral coronoid process hypertrophy, or Langenbeck disease, is the most frequent. It can be associated with an osteochondroma or a coronoid-malar bone conflict and is then called Jacob disease, an unilateral pathology. Treatment rests on coronoidectomy in both cases. This technique is illustrated via two cases, one Langenbeck and one Jacob disease. TECHNICAL NOTE: A transoral approach was performed. After subperiosteal dissection, the coronoid process was cleared. The process was than severed at its base by means of a burr, freed from its temporal muscular fibers and removed. Mouth opening improved peroperatively. The surgical procedure was completed by active long-term physiotherapy beginning immediately after surgery. DISCUSSION: Transoral coronoidectomy is a simple, quick and safe procedure. Extra-oral approaches present a high risk of facial nerve injury. In our first case, mouth opening improved from 24 to 36 mm after bilateral coronoidectomy and to 40 mm after physiotherapy. In our second case, mouth opening improved from 22 to 38 mm after unilateral coronoidectomy and to 43 mm after one year physiotherapy. Long-term post-operative physiotherapy is mandatory to get and maintain good results.

Total knee arthroplasty after osseous ankylosis of the knee joint.

OBJECTIVE: A knee fusion is associated with considerable restrictions, including the inability to sit properly, use public transportation, and climb stairs. The purpose of this study is to report and discuss our cases of spontaneous ankylosed knees which were taken down and underwent total knee arthroplasty (TKA). METHODS: Six patients who experienced spontaneous ankylosis of the knee undergoing conversion to TKA between 2003-2012 were enrolled retrospectively in this study. The etiology was childhood pyogenic arthritis in 2 patients, intraarticular fractures in 2, gunshot in 1, and juvenile rheumatoid arthritis in 1. The clinical data were recorded with the use of the Hospital for Special Surgery (HSS) knee rating system, Western Ontario and McMaster Questionnaire (WOMAC), and Visual Analog Scale (VAS), preoperatively and postoperatively at final follow-up. RESULTS: The average follow-up time was 86 months (range: 22-126 months). At the final follow-up, the average range of active flexion was 85° (range: 75-95°). Postoperative average HSS knee rating system was improved from 19.5 (range: 18-22) to 57.49 (range: 46-80), WOMAC was improved from 39.75 (range: 36.4-43) to 62.41 (range: 50.8-74.5). VAS was improved from 9.5 (range: 7-9) to 2.8 (range: 2-4). A pyogenic infection developed in 2 patients; 1 was managed by debridement, and 1 was managed by arthrodesis 2 years later. CONCLUSION: The ability to walk and sit in a normal fashion is of great importance for patients. With good preoperative planning and careful handling, gratifying results are possible with TKA.

A serious complication in the temporomandibular region due to insufficient follow-up.

The aim of this case report is to point out follow-up insufficiency as a contributing factor of ankylotic development after condylar fractures as well as the significance of clinicians' familiarity with this complication and its prevention. Condylar fractures require close follow-up due to the potential emergence of delayed and distressing complications, such as ankylosis, regardless of their proper initial treatment. Regular follow-up for a minimum of 18 months is of crucial importance for the prevention of ankylosis. The clinician's contribution in alerting his patients could be considerable, given he or she is aware of the development of this complication. The case of a 17-year-old patient with bilateral condylar fractures and a mental fracture is presented. He was successfully treated with mental osteosynthesis and intermaxillary fixation. Strict instructions for kinesiotherapy were given and constant re-examinations were made, but the patient's compliance was poor. This resulted in his readmission 2 years later with a great limitation of mouth opening (0.5 cm), demanding more serious surgical procedures. Follow-up insufficiency could be identified as a contributing factor to traumatic temporomandibular joint ankylosis. Intense surveillance and harmonious collaboration is dictated from both the clinician and patient to prevent any untoward development.

Using bone cement for surgical treatment of bilateral osseous temporomandibular joint ankylosis.

Temporomandibular joint (TMJ) ankylosis with complete immobility of lower jaw represents a maximal functional impairment and causes malocclusion and impaired function of mastication. Main goal of surgical treatment of patients with TMJ ankylosis is regaining of organ function and good cosmetic results. Authors modified the implant of articular head by bone cement for surgical treatment of TMJ ankylosis (five cases). Mandibular arch osteotomy on both sides was performed under nasotracheal anesthesia. 1.5-2 cm bone conglomerate was removed and articular fossa was formed in remaining part. Titan mini plate was formed so that it was possible to hang it on osteotomized surface of the arch. Free surface of plate was faced towards the artificial articular fossa, on which the articular head was formed using bone cement. The plate on the other side was fixed on mandibular arch with screws. All cases were followed by good cosmetic and functional effect (period of observation 5 month-4 years). The method, despite of small material size is advantageous due to its good outcome, low cost and relatively simple surgical technique.

A new 3-phase therapy protocol in temporomandibular joint ankylosis: our experience.

Limitations in oral opening may be due either to intra-articular or extra-articular ankylosis (pseudoankylosis). The principal means of therapy usually consist of 2 steps: surgical removal of the ankylotic block and immediate functional rehabilitation. In the postoperative period, however, immediate and adequate functional rehabilitation is not always possible because of pain and swelling of the temporomandibular joint, resulting in a very high risk of relapse. To prevent this, the authors introduce a third phase between the 2 already mentioned (surgery and functional therapy) in which the oral opening obtained with surgery is held in place while clinical conditions (pain and swelling) are allowed to stabilize before initiating intensive physiotherapy. Through the discussion of 18 clinical cases (8 of which were treated in the traditional way), the authors report on the intermediate treatment phase introduced by them between the surgical stage and the rehabilitation. Immediately after the operation, a handmade wedge, that is, a bite block of suitable size, is placed between the dental arches for a period of about 3 weeks, while appropriate pharmacological therapy was administered. The results showed an improvement of the mandibular movements both in opening and laterally, on the right and left sides, in patients treated with the new protocol. The proposed protocol holds the opening obtained with surgery until the clinical conditions make it possible to initiate intensive physiotherapy. In this way, the authors obtained better results in both recovery and in mandibular movements.

Total knee replacement for patients with ankylosed knees.

The purpose of this study was to determine objectively the outcome of total knee replacement in patients with ankylosed knees. There were 82 patients (99 knees) with ankylosed knees who underwent total knee replacement with a condylar constrained or a posterior stabilised prosthesis. Their mean age was 41.9 years (23 to 60) and the mean follow-up was for 8.9 years (6.6 to 14). Pre- and post-operative data included the Hospital for Special Surgery (HSS), the Knee Society (KS) and the Western Ontario and McMaster University Osteoarthritis index (WOMAC) scores. The mean HSS, KS and WOMAC scores improved from 60, 53, and 79 pre-operatively to 81, 85, and 37 at follow-up. These improvements were statistically significant (p = 0.018, 0.001 and 0.014 respectively). The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = 0.023 and p < 0.001 respectively). The mean satisfaction score was 8.5 (SD 1.5). Total knee replacement gives good mid-term results in patients with ankylosed knees.

[Underfoot pressure distribution of a patient with unilateral ankylosis of talonavicular joint during rheumatoid arthritis--case report]. / Rozklad nacisków na podeszwowej stronie stóp u chorej z jednostronnym skostnieniem stawu skokowo-lódkowego w przebiegu reumatoidalnego zapalenia stawów--opis przypadku.

The aim of our study was to estimate underfoot pressure distribution of a patient with unilateral ankylosis of talonavicular joint during rheumatoid arthritis. The pedobarographic examination during bipedal standing revealed localisation of maximal pressure at the H region on the side opposite of ankylosis and increased underfoot pressure on the T region and decreased on GT, MT1-MT3 and H foot regions on the pathology side. After the end of orthopaedic treatment underfoot, pressure distribution changes persist in spite of pain regression.

Static progressive stretch for the treatment of knee stiffness.

Persistent knee stiffness is common after knee arthroplasties, cruciate ligament repairs, and trauma. Static progressive stretch protocols have shown success in treating contractures of the elbow, ankle, and knee in case reports and small case series. This study evaluated static progressive stretch as a treatment method for patients who had refractory knee stiffness, and compared the outcomes to published results of other therapeutic modalities. Forty-one patients who had knee stiffness and who had not improved with conventional physical therapy modalities were treated with a patient-directed orthosis that utilized the principles of static progressive stretch. After a mean of 9 weeks of use (range, 3 to 27 weeks), the total arc of motion increased by a mean of 33 degrees (range, 0 to 85 degrees ). Forty of 41 patients had increased motion at a mean final follow-up time of 1 year (range, 6 months to 2 years), and 93% were satisfied with the results. The outcomes were comparable to other nonoperative treatments reported in the literature, but the results in the present study occurred in a shorter mean treatment time. An orthosis that utilizes the principles of static progressive stretch may be a successful treatment for improving the range of motion and satisfaction of patients who have knee contractures.

Sacroiliac joint fusion and the implications for manual therapy diagnosis and treatment.

The present paper examines gender differences and changes in prevalence of ankylosed sacroiliac joint (SIJ) with age. SIJs of 287 patients (159 males and 128 females), aged 22-93 years, were examined for fusion, using 3-D CT images. Presence, side and location of the fusion along the joint borders were recorded. Fusion of the SIJ was found to be gender and age dependent; present in 27.7% of all males in contrast to only 3.0% in females (p<0.001). The phenomenon increased with age in the male population from 5.8% in the 20-39 age cohorts to 46.7% in the 80+ cohort. As mobilization and/or manipulation of a dysfunctional SIJ are common procedures used by manual therapists, the effect that aging has on SIJ mobility requires therapists to alter or change their method with advancing age.

[Algorithm of comprehensive treatment of adult patients with TMJ ankylosis and concomitant deformations of face skeleton].

There was offered an algorithm of optimal tactics of treatment and rehabilitation of adult patients with TMJ ankylosis and concomitant deformations of face skeleton.

Treatment of severe bilateral temporomandibular joint ankylosis in adults: our protocol.

AIM: In order to evaluate the reliability of interpositional gap arthroplasty with temporalis myofascial flap the authors retrospectively analysed the data of 5 patients suffering from bilateral temporomandibular ankylosis operated on with this technique. METHODS: The preoperative assessment included evaluation of pain during function, interference with eating and the maximal interincisal distance. All patients received bony ankylosis removal, interposition of a finger-shaped temporalis myofascial flap in the articular gap and coverage with temporoparietal fascial flap as a new capsule. In the postoperative period an aggressive physiotherapy was carried on for at least 6 months. RESULTS: All cases experimented release of pain (evaluated by a Visual Analogue Scale method), a return to a normal diet and a stable improvement in mouth opening during the follow-up period. CONCLUSIONS: This technique should be considered a reliable method to avoid relapse of ankylosis and to stabilize postoperative results.

Modified temporalis anchorage in craniomandibular reankylosis.

This study evaluates the long-term outcomes and clinical results of costochondral graft and temporalis muscle flap interpositioning with submandibular anchorage in the management of TMJ re-ankylosis. Thirty-one patients, 9 children and 22 adults, with recurrence of ankylosis after gap arthroplasty, with a mouth opening less than 5 mm were evaluated. The management protocol consisted of resection of the ankylotic mass through an Al-Kayat and Bramley incision; contralateral coronoidectomy in unilateral cases; replacement of the condyle in children by means of a costochondral graft through Risdon's approach and interpositional temporalis muscle flap and submandibular anchorage of the temporalis flap in children and adults. Regular clinical and radiological follow up was done for 6 years during which the average mouth opening of 38 mm was maintained, with good occlusion and proper function. The temporalis muscle flap was seen to be an ideal interpositional material due to its close proximity to the site, good vascular supply, ease of access to the condyle area and minimal risk of nerve damage. Submandibular anchorage of the broad temporalis muscle flap prevents reankylosis by inhibiting flap contraction, and decreases need for rigorous physiotherapy.

[Treatment of elbow joint ankylosis by repair of articular surface with periosteal autograft].

OBJECTIVE: To evaluate the clinical effect of periosteal autograft in repair of ankylosis of elbow joint. METHODS: From May 1985 to November 1999, 18 cases of elbow joints ankylosis (6 cases of osteo-ankylosis, 12 cases of fibroankylosis) were treated by repairing articular surface with periosteal autografting. Out of 18 cases, 13 were caused by old dislocation and fracture of elbow joints, 3 by late rheumatoid arthritis, and 2 by old total joint tuberculosis. In this surgical approach, periosteum from upper end of tibia was transplanted into articular surface after correction of the elbow joint from ankylosis deformity, and continuous passive or active movement of the operated joint was adopted with skeletal traction through olecranon of ulna for 4 weeks after operation. All of the cases were followed up for 1-9 years, 5.2 years on average, before clinical evaluation. RESULTS: The elbow joints in 11 cases were restored to normal, the joints in 4 cases obtained active movement in the range of 100 degrees-0 degree, and the joints in the other 3 cases could only have limited movement because of severe muscular atrophy. CONCLUSION: The articular surface in arthroplasty of elbow joint ankylosis could be effectively repaired by periosteal autograft, and the function of the joints could be obviously improved by continuous movement of the joints after operation with skeletal traction.

Full-thickness skin graft interposition after temporomandibular joint ankylosis surgery. A study of 31 cases.

Recurrence is a major problem after release of temporomandibular joint ankylosis. Early physiotherapy and choice of interpositional material are important in preventing recurrence. Currently, the most used technique is gap arthroplasty associated with coronoidectomy, temporalis muscle flap interposition and reconstruction of the condylar unit with a costochondral graft. Full-thickness skin graft interposition, using the technique described by Popescu & Vasiliu, can also be used. This retrospective review of 31 patients confirms the reliability of full-thickness skin graft interposition. Results were successful in 90% of the 20 patients with follow-up longer than one year.