The Chitranjan S. Ranawat Award: Manipulation Under Anesthesia (MUA) to Treat Postoperative Stiffness after Total Knee Arthroplasty: A Multicenter Randomized Clinical Trial.

INTRODUCTION: Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial (RCT) investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy (PT) on range of motion (ROM) and outcomes.

METHODS: There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and PT, while the treatment group also received one dose of pre-MUA intravenous (IV) dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov.

RESULTS: The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < 0.001). The ROM was similar between the treatment and control groups at six weeks following MUA (101 versus 99°, respectively; P = 0.35) and at one year following MUA (108 versus 108°, respectively; P = 0.98). Clinical outcomes were similar at both end points.

CONCLUSIONS: In this multicenter RCT, the addition of IV dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatories medications remains warranted.