Introduction: Stiffness is a disabling problem following TKR surgery. The overall incidence is 1–3%. Though multiple factors have been implicated in development of stiffness, it still remains an incompletely understood condition. Furthermore, opinion is divided about the efficacy, timing and the number of MUA’s post TKR surgery, as there are no definitive guidelines.

Aims & Objectives: The aim of this study was to assess the predisposing factors for stiffness following TKR surgery, to determine the efficacy of single and multiple manipulations and to investigate the most appropriate timing for manipulation.

Material &Methods: We retrospectively reviewed 86 patients who underwent manipulation for stiffness post-primary TKR surgery with at least one-year follow up. The number of manipulations, predisposing factors, the flexion gain at different intervals, final gain in flexion and range of movement was noted till the end of 1 year.

Results: Results were assessed by timing and number of MUA’s performed. Sixty five patients underwent single MUA and 21 had multiple MUA. At the end of one year the single MUA group showed 310 of sustained gain in flexion and in the multiple MUA group only 90 flexion gain was noted (p=0.003). MUA within 20 weeks of primary surgery showed 300 of flexion gain, whereas only 70 of flexion gain was seen when MUA was undertaken after 20 weeks (p=0.004). Patients on warfarin (9.5%) and with previous major surgeries to the knee prior to TKR (11.5%) had increase incidence of stiffness and poor flexion gain.

Conclusion: The timing of the 1st MUA is crucial, with better results achieved in MUA performed less than 20 weeks (particularly between 12–14 weeks) from primary surgery. Age, sex and type of disease do not influence the severity of stiffness in this study. There appears to be no added benefit in re-manipulation.


  • Correspondence should be addressed to: BASK c/o BOA, at the Royal College of Surgeons, 35–43 Lincoln’s Inn Fields, London, WC2A 3PE, England.