Manipulation Following Total Knee Replacement Surgery
Knee replacement surgery is generally very safe and effective, but it is a major operation. For unknown reasons, scar tissue formation within the knee joint may be excessive in some patients (a condition known as athrofibrosis). This can result in joint pain and stiffness and reduced range of motion (ROM).
This stiffness is sometimes addressed by a forcible, closed manipulation of the knee joint by an orthopedic surgeon. In a recent study in the journal Orthopedics, the authors looked at the effectiveness of manipulation and sought to determine if any patient factors could be used to predict range of motion improvements following this procedure.
In this study the authors describe how manipulation following knee replacement is performed. Patients are given either epidural or general anesthesia. An assistant holds the heel while the surgeon gently extends or straightens the leg.
While straitening the leg, the surgeon applies pressure to the anterior (front) of the knee joint. The knee is then flexed or bent with the assistant holding the thigh while the surgeon applies pressure with his chest on the anterior of the tibial (shin) area to, as they say “allow slow, steady stretching and tearing of the intra-articular scar tissue” (“intra-articular” means within the joint).
This process is repeated until full Range of motion is achieved or until the surgeon “no longer feels creptiation” (crepitation is the dry, crackling sound or sensation resulting from rubbing bones or irregular cartilage surfaces together as in arthritis).
Some interesting findings and observations from this study:
- The surgeons looked at a consecutive series of 767 patients. Forty-six required manipulation. So this condition was observed in 6% of patients.
- On average, patient’s ROM increased significantly after manipulation. Patients were able to bend or flex their knee 22 degrees further, and extend or straighten their knee 4 degrees more.
- The flexion achieved after manipulation was similar to that which the patient had before having knee replacement. (Pre-operative ROM is often a predictor of post-op ROM).
- Several patient factors were not associated with the effectiveness of manipulation. These included patient sex, BMI and alignment of the knee joint before surgery (i.e. the amount of knock-kneed (valgus) or bow-legged (varus) deformity).
- The authors used several different types of implants. Implant design or type did not influence the effectiveness of manipulation.
- Patients manipulated less that 8 weeks after surgery gained more flexion than those manipulated after 8 weeks following their knee replacement.
- The patients were followed for 1 year, and those whom had full extension before manipulation wound up with more flexion at 1 year post-op.
- To avoid the need for manipulation (and presumably the formation of excessive, debilitating scar tissue), the authors suggest aggressive pain management for the first few days after surgery followed by ambulation and some exercise.
This study can be found in the June 2009 issue of Orthopedics.
References
1.Cates HE, Schmidt, JM. Closed Manipulation after Total Knee Arthroplasty: Outcome and Affecting Variables. Orthopedics. 2009; 32:398.
2.Arthritis of the Knee Joint. Complications of Knee Replacement Surgery. http://www.hipsandknees.com/knee/kneesurgerycomplications.htm#scar. 28-Feb-10
Beer….Tastes Great, Less Filling and can Treat Osteoporosis?
A commonly occurring element, silicon, is present in relatively high quantities in beer. It is also a necessary ingredient for proper bone density. Researchers at the Department of Food Science & Technology at the University of California, Davis have proposed that drinking beer is an excellent source of dietary silicon. So next time your grab that cold one, think of it as a refreshing bone builder….
Osteoporosis Cure on the Way?
Most osteoporosis treatments are aimed at slowing down bone loss, but a new investigational study in mice looked at a drug which could actually increase bone mass.
Serotonin is most often associated with the brain. However, it is also synthesized in the gut. Previous studies revealed that serotonin in the gut, worked to limit bone formation. Researches theorized that reducing serotonin in the gut could increase the body’s ability to form bone thereby combating osteoporosis. An existing compound, LP533401, had already been developed for another indication and was effective in reducing serotonin in the gut. When the compound was tested in mice, it was found to increase bone formation.
More on this very exciting study can be found here.
More “Joint-Soothing” Exercise
If your sore joints are getting you down and limiting your ability to exercise or even perform simple activities of daily living, then some “low-key” martial arts may be your answer. A recently published study in Arthritis Care & Research found that Tai Chi was effective in reducing 
knee osteoarthritis in a group of elderly participants. Compared to a control group, the study group, who participated in one-hour classes two times a week for three months, reported a significant decrease in knee pain at the end of the study period. So delay that knee replacement surgery and go Tai Chi!
Follow this link for more on this story…
Wait…So Running Isn’t Bad for My Knees?
In another “counterintuitive conclusion” researchers from some recently published studies are not finding a clear correlation between running and bad knees. In fact, runners may actually be at lower risk for developing 
osteoarthritis compared to non-runners. Go figure. Then go running….
Read more About This Story Here
Weight Gain After Knee Replacement?
A recent study out of the University at Delaware found that patients actually gained weight following knee replacement surgery. Conventional wisdom was that after suffering years of debilitating pain, formerly sedentary arthritis sufferers would resume activity and exercise following their knee replacement. However, researchers found that patients actually gained an average of 14 pounds after a two year follow up period…
Follow this link for more information on this topic
Patellar Clunk Syndrome: Complication Following Knee Replacement Surgery
In general, 
Total knee replacement (TKR) is a highly successful procedure. However, complications, although relatively rare, can sometimes occur. One such complication is known as 
Patellar Clunk Syndrome.
To understand this condition, it helps to first understand a little bit about knee anatomy and function (Figure 1). During knee flexion and extension, the patella (knee-cap) rides within a groove in the femur (thigh bone).
Figure 1: Basic Knee Anatomy
In knee replacement the worn ends of the bones are “resurfaced” with metal and plastic implants. The patellar groove is part of the metal femoral component that is implanted onto the prepared femur during the total knee replacement procedure. At the end of this groove there is a transition between the metallic implant and the native bony surface.
Following knee replacement, scar tissue can sometimes form at the top or “superior pole” of the patella. During particularly deep flexion, this scar tissue may move below the end of the groove in the femoral component and then “catch” on the end of the groove as the patella moves back with knee extension. It is this catching and then forceful release with extension that results in the “clunk” and pain characteristic of this condition.
This condition is more prevalent in a type of knee replacement known as Posterior Stabilized, or “PS” knee replacement, although it has also been reported in Cruciate Retaining (CR) knee designs as well. 1 In PS knee designs, where the posterior cruciate ligament is removed, the patellar groove tends to be shorter to avoid contact (in extension) between the end of the groove and a plastic post on the tibial component found in these types of designs. Consequently, the patella can come off the end of the groove during lesser degrees of flexion.
The publication cited at the end of this article provides more detailed information and a review of some of the literature on patellar clunk.
1 Niikura T, Tsumura N, Tsujimoto K, Yoshiya S, Jurosaka M, Shiba R. Patellar Clunk Syndrome After TKA with Cruciate Retaining Design: A Report of Two Cases. Orthopedics. 2008: 31:90
Joint Stiffness: Complications Following Knee Replacement Surgery
In a relatively recent article 1 published in the Musculoskeletal Journal of Hospital for Special Surgery, Dr. Alejandro Gonzalez Della Valle et al reviewed the origins of and treatments for early onset stiffness, a common complication following knee replacement surgery. We’ll present a brief summary of the article here.
How Prevalent is Stiffness after Knee Replacement?
In a review of the literature, the authors state that stiffness occurs in roughly 6% of cases, making it the most common knee replacement surgery complication.
How is Stiffness Defined?
The researchers reveal that what is perceived as “stiffness” following knee replacement has evolved over time. Several years ago, a knee was considered stiff if the patient could not extend their knee beyond 25 degrees of flexion (that is, a flexion contracture of 25 degrees) or if the full arc of motion was less than 45 degrees. More recently, as surgical technique and implant design have improved and as younger, more active patients receive implants, expectations have changed. Today, stiffness has been defined as a 
flexion contracture equal to or greater than only 10 degrees or an arc of motion less than 95 degrees. The authors note that this degree of motion is what is required for common activities of daily living (walking, sitting, stair climbing). Practically speaking, a joint can be considered “stiff” when it limits the patient’s ability to perform such activities.
What Causes Stiffness after Knee Replacement?
The authors place the causes of stiffness into three broad categories:
Preoperative – These include things like post-traumatic osteoarthritis, patients with prior high tibial osteotomy and patient whose preoperative range of motion (ROM) is limited.
Intraoperative – Included here are what the authors termed “technical errors” during the procedure. Things like, improperly sized implants and poor “balancing” of the joint through improper bone preparation fall into this category. The researchers explain these as well as other technical errors in detail.
Postoperative - Following surgery, stiffness can be caused by additional factors. Some examples are by patient behavior (“poor patient motivation”) deep infection and inadequate pain management.
How is Stiffness Treated
The authors then outline the various ways in which stiffness can be treated following knee replacement. Manipulation of the knee by the surgeon under anesthesia is generally successful when used within the first three months after surgery. After this period, more aggressive surgical options should be considered since manipulation can result in fracture or soft-tissue damage. Some surgical treatments described are arthroscopy, tibial insert (or spacer) exchange and revision surgery (i.e. exchange of the femoral component typically to correct imbalance in the spacing between the thigh and shin bone created at the time of surgery). The authors also stress the importance of proper rehabilitation following knee replacement.
The original article is available online through PubMed Central.
1. Gonzalez Della Valle A, Leali A, Hass S: Etiology and Surgical Interventions for Stiff Total Knee Replacements. HSSJ 2007, 3: 182-189
What do Cherries and Seaweed Have in Common? They Both May Help Your Osteoarthritis
Osteoarthritis (OA) is joint inflammation caused by the breakdown and eventual loss of articular cartilage. It is characterized by pain, stiffness, and swelling. Recent reports suggest that two natural substances could help reduce pain and improve function in patients suffering from this often debilitating disease.
Researchers at the Baylor Research Institute 1 conducted a pilot study where patients took pills made from tart cherries. This particular group of patients suffered from osteoarthritis of the knees. The scientists found that more than half of the patients had significant improvement in pain and function after taking the pills for eight weeks. These encouraging preliminary results have prompted the researchers to embark on a broader study. It will be interesting to see if the favorable results continue.
In a separate study 2, the use of a supplement made from seaweed was examined. In this study, patients were given a pill derived from a seaweed rich in calcium, magnesium and other minerals. The authors noted that earlier studies have shown that mineral supplements may improve OA symptoms. In this particular study, patients who received the pill were able to walk farther in a controlled test and experienced a small improvement in range of motion when compared to a group receiving a placebo. The study is available online through PubMed Central.
1 “Can Cherries Relieve the Pain of Osteoarthritis.” www.baylorhealth.com 31 Mar. 2009. http://www.baylorhealth.com/About/NewsRoom/BaylorNews/Pages/03182009Cherries.aspx
2 Frestedt JL, Kuskowski MA, Zenk JL. “A Natural Seaweed Derived Mineral Supplement (Aquamin F) for Knee Osteoarthritis: A Randomised, Placebo Controlled Pilot Study” Nutrition Journal, 8:7, 2009
Is Knee Replacement in Your Future?
Most knee replacements are performed for the treatment of osteoarthritis where the smooth cartilage in the knee joint breaks down resulting in pain, stiffness and swelling. The x-ray below is of a knee where osteoarthritis is present. Note the close proximity of the upper (femur) and lower (tibia) bones. In this knee the cartilage, which is not visible on an x-ray has worn away. If this had been a healthy knee, there would be a distinct gap between the two bones.
Osteoarthritis is usually progressive. It often begins mildly, but over time, wear in the cartilage starts to result in an uneven distribution of weight across the knee joint; often with more damage observed on one side versus the other. This in turn causes even more force to pass through the affected side, resulting in even faster degeneration of the joint.
This localized damage is most commonly found on the inside or “medial” part of the knee (
medial compartment), but it can also occur on the “lateral” or outside part of the knee (lateral compartment). When it occurs on the medial side, the patient may have a varus or “bow-legged” deformity. When lateral osteoarthritis is present, a distinct “knock-kneed” or valgus deformity is observed.
These deformities are usually corrected at the time of knee replacement surgery.
It is interesting to consider what, if anything, may initiate this cycle of uneven wear, worsening load distribution, and further wear. Is it possible that some folks may be predisposed to this condition due to their bony anatomy? A presentation at this years AAOS meeting looked to answer this very question. 1 The researchers examined the anatomy in patients receiving knee replacements whose pre-operative varus and valgus deformities were significant. In those patients, they found that key functional axes in the knee were not aligned normally. Specifically, they found that the alignment of the “mechanical axis” of the lower limb to the 
epicondylar axis in the knee was not normal. To understand these axes and their observed relationship, a review of basic knee anatomy is required.
In the normal lower limb, the mechanical axis is defined as an imaginary line originating at the center of the femoral head (the “ball” on the “ball-and-socket hip joint) passing through the center of the knee and ending at the center of the ankle. When the hip, knee and ankle line up in this way, the lower limb and knee joint alignment are considered “normal”. In a varus or valgus knee, the center of the knee is no longer on this line and is pushed “outward” in varus and “inward” in valgus.
The epicondylar axis is an imaginary line connecting the femoral (thigh-bone) origins of the medial collateral and lateral collateral ligaments (MCL and LCL). One can think of these ligaments as the “ropes” or “chains holding a swing. In this analogy, the epicondylar axis is like the top bar of the swing. The tibia or thigh bone is the swing which rotates about the bar (epicondylar axis) during knee flexion and extension.
In their study, the authors observed that in patients with severe varus or valgus deformities, the epicondylar axis was “misaligned” relative to the mechanical axis in the same direction (albeit smaller in magnitude) as in the knee joint deformity. For example, if a patient had severe osteoarthritis in the medial or inside part of the knee, a significant bow-legged or varus deformity was observed and the epicondylar axis was “tilted” in the same direction. In other words, the inherent bony anatomy appeared to predispose certain patients to uneven loading across the knee joint (a “crooked swing”), which, in turn appears to have made them more susceptible to the resulting osteoarthritic deformity. The results were not statistically significant, but a noticeable trend was observed. So to answer the question “is knee replacement in your future?” one may not have to look much further than one’s own bony anatomy.
1. Beyers-Thering MT, Krackow KA, Mihalko WM. “Relationship of the Femoral Epicondylar Axis to the Mechanical Axis in Deformed Osteoarthritic Knees.” 2009 AAOS Annual Meeting, Poster No. P201
-
Introductory Topics
Introduction - Home Normal Knee Anatomy The Diseased Knee: Osteoarthritis The Knee Replacement Procedure
Surgery Overview > Total Knee Replacement Surgery Video Knee Replacement Complications Minimally Invasive Knee Replacement Unicompartmental Knee Replacement Computer Assisted Knee Replacement Knee Replacement Implants
The Parts of a Total Knee Replacement Mobile Bearing Knee Replacement Knee Implant Wear Knee Implant Manufacturers Related Topics
Knee Arthroscopy Total Hip Replacement Osteoporosis -
Stay up to date on the latest Total Knee Replacement news!
-
- Manipulation Following Total Knee Replacement Surgery 177 comment(s)
- Joint Stiffness: Complications Following Knee Replacement Surgery 157 comment(s)
- Patellar Clunk Syndrome: Complication Following Knee Replacement Surgery 71 comment(s)
- Knee Replacement Allergies - Nothing to Sneeze At? 55 comment(s)
- Knee Replacement “Clicking” 14 comment(s)
- Video Showing a Traditional Total Knee Replacement Surgery 7 comment(s)
- New Total Knee Replacements Specially Designed for Female Anatomy 4 comment(s)
- What’s the “Best” Total Knee Replacement? 2 comment(s)
- Is Knee Replacement in Your Future? 2 comment(s)
- With Knee Replacement Rehabilitation, the Sooner the Better New Study Shows. 2 comment(s)