Understanding rates, risk factors, and complications associated with manipulation under anesthesia after total knee arthroplasty (TKA): An analysis of 100,613 TKAs

Published:September 01, 2022DOI:


      • 1 in 36 patients undergo manipulation after primary total knee arthroplasty.
      • Manipulation is most commonly performed within 3 months (70%).
      • Risk factors for manipulation are younger age, female sex, Black or Hispanic race.
      • Robotic and computer-assisted TKA are associated with less risk of manipulation.
      • Though infrequent, manipulation may be associated with mechanical complications.



      Considering the growing adoption of technology-assisted total knee arthroplasties (TKA), previous database studies evaluating post-operative stiffness may be outdated. The present study aimed to: (1) evaluate the incidence of manipulation under anesthesia (MUA) after primary TKA; (2) determine independent risk factors for MUA; and (3) assess complications after MUA.


      Primary TKAs, with at least 6-month follow-up, were identified from the Florida State Inpatient Database (January 2016–June 2018) and linked to outpatient records from the Florida State Ambulatory Surgery and Services Database. Multivariable regression analyses were performed to compare patient factors and complications (e.g., mechanical, non-mechanical, infectious) associated with MUA, while adjusting for baseline demographics, comorbidities, use of robotic- and computer-technologies, time to MUA (0–3, 3–12, or >12 months), and need for repeat MUA (one-time vs >1).


      The MUA rate was 2.8% (2821 of 100,613). Being younger, a woman, Black or Hispanic; having private or self-pay insurance; and conventional TKA were associated with significantly higher odds of undergoing MUA. Higher rates of mechanical complications and acute posthemorrhagic anemia were observed in the MUA cohort. Time to MUA, repeat MUA, and baseline demographics were not associated with complication rates among the MUA cohort.


      Overall, 1 in 36 patients underwent MUA after primary TKA. Several non-modifiable patient characteristics, such as Black or Hispanic race, female sex, and younger age were associated with an increased risk of MUA. However, technology-assisted TKA might help to decrease the risk of MUA.


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