Manipulation under anesthesia is independently associated with development of prosthetic joint infection within 1 year of total knee arthroplasty
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Updated: Jun 18, 2026
Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction
Published on: December 3, 2017
Muhammad Umar Jawad1, Haroon M Kisana2, Devin W Morrow1
1Department of Orthopedic Surgery, University of Arizona College of Medicine - Phoenix, Banner University Medical Center - Phoenix, 1320 N 10th St., Phoenix, AZ 85006, United States.
Background:
Prosthetic joint infection (PJI) is a devastating complication after total knee arthroplasty (TKA). Manipulation under anesthesia (MUA) is a treatment used to address post-operative stiffness following TKA. Association between MUA and development of PJI is controversial.
Methods:
A national claims database (PearlDiver®) was used to isolate TKA and MUA within 4 months of TKA cases using the Current Procedural Terminology (CPT) codes from 2010 to 2022. PJI cases within 1 year of TKA and previously validated risk factors were identified using International Classification of Disease, 9th &10th (ICD-9&10) codes. Chi-square and logistic regression were used for univariable and multivariable analyses respectively.
Results:
A total of 1,660,301 TKA cases were isolated. MUA within 16 weeks of TKA was performed in 57,113 cases. PJI within 1 year of TKA was diagnosed in 3302 cases. Rate of PJI among patients undergoing MUA (0.26%; n = 146) was significantly (p = 0.002) higher than rate of PJI among patients not undergoing MUA (0.197%; n = 3156). Multivariable analysis showed MUA within 16 weeks to be independently associated with PJI within 1 year of TKA (OR = 1.34; 95% CI: 1.13-1.58; p < 0.001). Male gender (OR = 2.36; 95%CI: 1.7-3.29; p < 0.001), deficiency anemia (OR = 1.75; 95%CI: 0.98-2.93; p = 0.044), rheumatoid arthritis (OR = 3.23; 95%CI: 1.44-6.26; p = 0.002) and blood transfusion (OR = 7.26; 95%CI: 4.28-11.67; p < 0.001) were identified as independent risk factors for development of PJI in this cohort. The ROC-AUC for the model was 0.7.
Conclusion:
MUA within 16 weeks of TKA is independently associated with development of PJI within 1 year, on multivariable analysis. Further studies will help delineate whether MUA is causative of infection or if stiffness is an early symptom of an already existing, indolent infection.
Insights
Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) is linked to a higher risk of prosthetic joint infection (PJI). This study found MUA within 16 weeks independently associated with PJI within one year.
Area of Science:
- Orthopedic Surgery
- Infectious Disease Epidemiology
Background:
- Prosthetic joint infection (PJI) is a serious complication following total knee arthroplasty (TKA).
- Manipulation under anesthesia (MUA) is used for post-TKA stiffness, but its link to PJI is debated.
Purpose of the Study:
- To investigate the association between MUA and the development of PJI after TKA.
- To identify risk factors for PJI in TKA patients.
Main Methods:
- Utilized a national claims database (2010-2022) to identify TKA and MUA cases.
- Employed ICD codes to identify PJI and validated risk factors.
- Performed chi-square and logistic regression analyses.
Main Results:
- Over 1.6 million TKA cases were analyzed; MUA was performed in 57,113 cases.
- The PJI rate was significantly higher in patients undergoing MUA (0.26%) compared to those who did not (0.197%).
- MUA within 16 weeks was independently associated with PJI within one year (OR=1.34, p<0.001). Male gender, anemia, rheumatoid arthritis, and blood transfusion were also risk factors.
Conclusions:
- MUA within 16 weeks of TKA is independently associated with an increased risk of PJI within one year.
- Further research is needed to determine if MUA causes infection or if stiffness indicates pre-existing infection.
