Background: Following total knee arthroplasty, some patients who
fail to achieve >90° 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 =90° 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° prior to total knee arthroplasty, 111° following skin
closure, and 70° before manipulation. The average improvement in flexion
from the measurement made before manipulation to that recorded at the
five-year follow-up was 35° (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 =
Conclusions: Manipulation generally increases ultimate flexion
following total knee arthroplasty. Patients with severe preoperative pain are
more likely to require manipulation.
Level of Evidence: Therapeutic Level III. See
Instructions to Authors for a complete description of levels of evidence.