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Home > Knee Joint Manipulation or Manipulation Under Anesthesia (MUA) – Part II

Knee Joint Manipulation or Manipulation Under Anesthesia (MUA) – Part II

Boyd W. Haynes, III, M.D.Boyd W. Haynes III, MD

In Part I of this series, Dr. Carlson gave you all the reasons why a patient may need a MUA after knee replacement surgery.  In review, they may:

  1. Have lots of scar tissue (genetics, prolonged swelling)
  2. Be unmotivated (many reasons)
  3. Be afraid of pain/are Protective Muscle Guarding (PMG)

In Part II of this series, I’m going to talk about the actual procedure itself, how the patient prepares for having it done, and what happens during the procedure in the OR.

When we’ve exhausted your tolerance for the intensive knee manipulation program in physical therapy and you are still experiencing a great deal of pain and stiffness, I may recommend a Manipulation Under Anesthesia (MUA) procedure.

There are certain patients for whom MUA may not be recommended.  Those who have the following should have the procedure with caution:

  • Osteoporosis
  • Cancer
  • Cardiovascular Disease
  • Flaring Inflammatory Arthritis
  • Bone Fracture(s)
  • Staph or Strep infection
  • Uncontrolled Diabetes
  • Uncontrolled Hypertension

As with any other procedure that involves anesthesia, I will ask that you not eat or drink anything after midnight before your procedure the next day.  Your MUA will be done to allow you to be discharged to go home immediately thereafter. As the knee manipulation doesn’t require making an incision, you won’t have to wash with antiseptic scrub before the procedure, nor will you have to take prophylactic antibiotics.

The good news is the anesthesia we use for this procedure is called MAC (monitored anesthesia care) also known as twilight sedation. You are only given the level of sedation needed to keep you pain free, you won’t need to have a breathing tube and can follow instructions if needed.  This type of sedation consists of short-acting medications, so when you wake up, you won’t remember what happened, but you won’t be groggy for days afterward. I will also inject local anesthetic into your knee so that you won’t be so sore after the procedure.

Once you are comfortably sedated, I will begin to gently bend and straighten your knee repeatedly, using just a little more force each time.  I must take care not to exert too much pressure, too quickly on the scar tissue, ligaments or tendons, but allow them to stretch over the course of about ten minutes.  Because you don’t feel pain and aren’t muscle guarding, I won’t have to fight the normal resistance you may exhibit while awake.  I will attempt to get your leg as straight as I can while extended and as close to 120º of flexion (bend) as possible.  Then it will be time to send you to recovery to fully awaken.

While risks and complications for this procedure are rare, they do exist.  There is a danger of going in too fast and too hard which could result in a broken bone, torn ligament or tendon avulsion, and nobody wants that to happen!  Slow and steady stretching of scar tissue wins the race in my book! Extremely rare are pulmonary embolism, re-opening of the surgical wound, bleeding in the knee joint and bone growth in soft tissue, aka hypertrophic ossification.

Once you are awake, drinking some ginger ale and walking, you will be sent home to recover.  Your knee will be sore and feel exhausted.  You’ve had quite a work-out, even if you don’t remember it!  You will be given pain medication and will be advised to elevate and ice your knee intermittently for the first 24 hours after surgery.    It will be very important to bend and move your knee soon after your procedure, even if it is painful.

Physical Therapy will start 1-2 days after your procedure, so you do not lose the movement and range of motion gained. Your PT will address any residual soreness and swelling with modalities designed to reduce inflammation while ensuring you maximize your range of motion.

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