Angular proximal femoral deformities increase the technical complexity of primary total hip arthroplasties (THAs). The goals were to determine the long-term implant survivorship, risk factors, complications, and clinical outcomes of contemporary primary THAs in this difficult cohort. Our institutional total joint registry was used to identify 119 primary THAs performed in 109 patients with an angular proximal femoral deformity between 1997 and 2017. The deformity was related to previous femoral osteotomy in 85%, and developmental or metabolic disorders in 15%. 53% had a predominantly varus angular deformity. The mean age was 44 years, mean BMI was 29 kg/m. 2. , and 59% were female. An uncemented metaphyseal fixation stem was used in 30%, an uncemented diaphyseal fixation stem in 28%, an uncemented modular body stem with metaphyseal fixation sleeve in 24%, and a cemented stem in 18%. Simultaneous corrective femoral osteotomy was performed in 18%. Kaplan-Meier survivorships and Harris hip scores were reported. Mean follow-up was 8 years. The 10-year survivorships free of femoral loosening, aseptic femoral revision, any revision, and any reoperation were 95%, 93%, 90% and 88%, respectively. Revisions occurred in 13 hips for: aseptic femoral component loosening (3), stem fracture (2), dislocation (2), aseptic acetabular loosening (2), polyethylene liner exchange (2), and infection (2). Preoperative varus angular deformities were associated with a higher risk of any revision (HR 10, p=0.03), and simultaneous osteotomies with a higher risk of any reoperation (HR 3.6, p=0.02). Mean Harris hip scores improved from 52 preoperatively to 82 at 10 years (p<0.001). In the largest series to date of primary THAs in patients with angular proximal femoral deformities, we found a good 10-year survivorship free from any revision. Varus angular deformities, particularly those treated with a simultaneous osteotomy due to the magnitude or location of the deformity, had a higher reoperation rate. Keywords: Proximal femoral deformity; dysplasia; femoral osteotomy; survivorship; revision. Level of evidence: Level III, comparative retrospective cohort

Abstract. Approximately 20% of primary and revision Total Knee Arthroplasty (TKA) patients require multiple revisions, which are associated with poor survivorship, with worsening outcomes for subsequent revisions. For revision surgery, either endoprosthetic replacements or metaphyseal sleeves can be used for the repair, however, in cases of severe defects that are deemed “too severe” for reconstruction, endoprosthetic replacement of the affected area is recommended. However, endoprosthetic replacements have been associated with high complication rates (high incidence rates of prosthetic joint infection), while metaphyseal sleeves have a more acceptable complication profile and are therefore preferred. Despite this, no guidance exists as to the maximal limit of bone loss, which is acceptable for the use of metaphyseal sleeves to ensure sufficient axial and rotational stability. Therefore, this study assessed the effect of increasing bone loss on the primary stability of the metaphyseal sleeve in the proximal tibia to determine the maximal bone loss that retains axial and rotational stability comparable to a no defect control. Methods. to determine the pattern of bone loss and the average defect size that corresponds to the clinically defined defect sizes of small, medium and large defects, a series of pre-operative x-rays of patients with who underwent revision TKA were retrospectively analysed. Ten tibiae sawbones were used for the experiment. To prepare the bones, the joint surface was resected the typical resection depth required during a primary TKA (10mm). Each tibia was secured distally in a metal pot with perpendicular screws to ensure rotational and axial fixation to the testing machine. Based on X-ray findings, a fine guide wire was placed 5mm below the cut joint surface in the most medial region of the plateau. Core drills (15mm, 25mm and 35mm) corresponding to small, medium and large defects were passed over the guide wire allowing to act at the centre point, before the bone defect was created. The test was carried out on a control specimen with no defect, and subsequently on a Sawbone with a small, medium or large defect. Sleeves were inserted using the published operative technique, by trained individual using standard instruments supplied by the manufacturers. Standard axial pull-out (0 – 10mm) force and torque (0 – 30°) tests were carried out, recording the force (N) vs. displacement (mm) curves. Results. A circular defect pattern was identified across all defects, with the centre of the defect located 5mm below the medial tibial base plate, and as medial as possible. Unlike with large defects, small and medium sized defects reduced the pull-out force and torque at the bone-implant interface, however, these reductions were not statistically significant when compared to no bony defect. Conclusions. This experimental study demonstrated that up to 35mm radial defects may be an acceptable “critical limit” for bone loss below which metaphyseal sleeve use may still be appropriate. Further clinical assessment may help to confirm the findings of this experimental study. This study is the first in the literature to aim to quantify “critical bone loss” limit in the tibia for revision knee arthroplasty. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Aims

The aim of this study was to evaluate medium-term outcomes and complications of the S-ROM NOILES Rotating Hinge Knee System (DePuy, USA) in revision total knee arthroplasty (rTKA) at a tertiary unit.

Aims

Periprosthetic joint infection (PJI) occurs in approximately 1% to 2% of total knee arthroplasties (TKA) presenting multiple challenges, such as difficulty in diagnosis, technical complexity, and financial costs. Two-stage exchange is the gold standard for treating PJI but emerging evidence suggests 'two-in-one' single-stage revision as an alternative, delivering comparable outcomes, reduced morbidity, and cost-effectiveness. This study investigates five-year results of modified single-stage revision for treatment of PJI following TKA with bone loss.

Aims

Single-stage revision total knee arthroplasty (rTKA) is gaining popularity in treating chronic periprosthetic joint infections (PJIs). We have introduced this approach to our clinical practice and sought to evaluate rates of reinfection and re-revision, along with predictors of failure of both single- and two-stage rTKA for chronic PJI.

Aims

Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics.

Aims

Stemmed tibial components are frequently used in revision total knee arthroplasty (TKA). The purpose of this study was to evaluate patient satisfaction, overall pain, and diaphyseal tibial pain in patients who underwent revision TKA with cemented or uncemented stemmed tibial components.

Aims

Debridement, antibiotics, and implant retention (DAIR) remains one option for the treatment of acute periprosthetic joint infection (PJI) despite imperfect success rates. Intraosseous (IO) administration of vancomycin results in significantly increased local bone and tissue concentrations compared to systemic antibiotics alone. The purpose of this study was to evaluate if the addition of a single dose of IO regional antibiotics to our protocol at the time of DAIR would improve outcomes.

Aims. Enhanced perioperative protocols have significantly improved patient recovery following primary total knee arthroplasty (TKA). Little has been investigated the effectiveness of these protocols for revision TKA (RTKA). We report on a matched group of aseptic revision and primary TKA patients treated with an identical pain and rehabilitation programmes. Methods. Overall, 40 aseptic full-component RTKA patients were matched (surgical date, age, sex, and body mass index (BMI)) to a group of primary cemented TKA patients. All RTKAs had new uncemented stemmed femoral and tibial components with metaphyseal sleeves. Both groups were treated with an identical postoperative pain protocol. Patients were followed for at least two years. Knee Society Scores (KSS) at six weeks and at final follow-up were recorded for both groups. Results. There was no difference in mean length of stay between the primary TKA (1.2 days (0.83 to 2.08)) and RTKA patients (1.4 days (0.91 to 2.08). Mean oral morphine milligram (mg) equivalent dosing (MED) during the hospitalization was 42 mg/day for the primary TKA and 38 mg/day for the RTKA groups. There were two readmissions: gastrointestinal disturbance (RTKA) and urinary retention (primary TKA). There no were reoperations, wound problems, thromboembolic events or manipulations in either group. Mean overall KSS for the RTKA group was 87.3 (45 to 99) at six-week follow-up and 89.1 (52 to 100) at final follow-up (mean 3.9 years, (3.9 to 9.0)). Mean overall KSS for the primary group was 89.9 (71 to 100) at six-week follow-up and 93.42 (73 to 100) at final follow-up (mean 3.5 years (2.5 to 9.2)). Conclusion. An identical pain and rehabilitation protocol used for primary TKA patients can enable certain full-component aseptic RTKA patients to have a similar early functional outcome. Cite this article: Bone Joint J 2020;102-B(6 Supple A):96–100

Aims

Aseptic loosening of the tibial component is a frequent cause of failure in primary total knee arthroplasty (TKA). Management options include an isolated tibial revision or full component revision. A full component revision is frequently selected by surgeons unfamiliar with the existing implant or who simply wish to “start again”. This option adds morbidity compared with an isolated tibial revision. While isolated tibial revision has a lower morbidity, it is technically more challenging due to difficulties with exposure and maintaining prosthetic stability. This study was designed to compare these two reconstructive options.

Aims

Metaphyseal fixation during revision total knee arthroplasty (TKA) is important, but potentially difficult when using historical designs of cone. Material and manufacturing innovations have improved the size and shape of the cones which are available, and simplified the required bone preparation. In a large series, we assessed the implant survivorship, radiological results, and clinical outcomes of new porous 3D-printed titanium metaphyseal cones featuring a reamer-based system.

Aims

Metaphyseal tritanium cones can be used to manage the tibial bone loss commonly encountered at revision total knee arthroplasty (rTKA). Tibial stems provide additional fixation and are generally used in combination with cones. The aim of this study was to examine the role of the stems in the overall stability of tibial implants when metaphyseal cones are used for rTKA.

Introduction. The primary aim of this study was to describe a baseline comparison of early knee-specific functional outcomes following revision total knee arthroplasty (TKA) using metaphyseal sleeves with a matched cohort of patients undergoing primary TKA. The secondary aim was to compare incidence of complications and length of stay (LOS) between the two groups. Methods. Patients undergoing revision TKA for all diagnoses between 2009 and 2016 had patient-reported outcome measures (PROMs) collected prospectively. PROMs consisted of the American Knee Society Score (AKSS) and Short-Form 12 (SF-12). The study cohort was identified retrospectively and demographics were collected. The cohort was matched to a control group of patients undergoing primary TKA. Results. Overall, 72 patients underwent revision TKA and were matched with 72 primary TKAs with a mean follow-up of 57 months (standard deviation (SD) 20 months). The only significant difference in postoperative PROMs was a worse AKSS pain score in the revision group (36 vs 44, p = 0.002); however, these patients still produced an improvement in the pain score. There was no significant difference in improvement of AKSS or SF-12 between the two groups. LOS (9.3 days vs 4.6 days) and operation time (1 hour 56 minutes vs 1 hour 7 minutes) were significantly higher in the revision group (p < 0.001). Patients undergoing revision were significantly more likely to require intraoperative lateral release and postoperative urinary catheterisation (p < 0.001). Conclusion. This matched-cohort study provides results of revision TKA using modern techniques and implants and outlines what results patients can expect to achieve using primary TKA as a control. This should be useful to clinicians counselling patients for revision TKA

Introduction. Enhanced pain and rehabilitation protocols have significantly improved patient recovery following primary TKR. Little has been written on how the protocols have affected the revision TKR patient. We report on a matched group of revision and primary TKR patients treated with the identical pain and rehab program. Materials and Methods. 40 aseptic RTKR patients who underwent a full femoral and tibial revision were matched by age, sex, and BMI to a group of patients who underwent a cemented tri-compartmental primary TKR. All revision knees had uncemented stemmed femurs and tibias. All 40 patients had either a metaphyseal sleeve on either the femur or tibia or both. Patients in both groups were treated with an identical post op pain protocol (Spinal anesthetic, local infiltrative analgesia and multimodal oral pain management along with rapid rehabilitation). All patients were mobilized on POD1 and allowed weight bearing as tolerated. Patients were followed for a minimum of 1 year. KSS at 6 weeks and 1 year were recorded for both groups. Results. There was no significant difference in length of stay between the RTKR and the primary TKR (1.2 days versus 1.1 days). Average oral morphine equivalents used during the hospitalization was 38 for the RTKR and 42 for the primary group. There was 1 readmission in each group: GI distress in the RTKR and urinary retention in the primary group. There no were reoperations, wound healing problems, identified thromboembolic events or manipulations under anesthesia in either group. KSS for the RTKR group averaged 87.3 at 6 weeks (range 45 to 99) and 89.1at minimum 1 year (range 52 to100). KSS for the primary group averaged 89.9 (range 71 to 100) at 6 week follow-up and 93.2 (range 54 to 100) at minimum follow-up. Range of motion at final follow up averaged1.2 (0–10) to 114.1 (55–135) for the RTKR group and 1 (0–8) to 121.3 (85–140) for the primary group. Conclusion. Despite more complex surgery in the revision total knee patient, enhanced pain and rehabilitation protocols have enabled the RTKR patient to have a similar recovery and outcome compared to the primary TKR patient. For figures, tables, or references, please contact authors directly

Prosthetic joint infections provide complex management, due to often-difficult diagnosis, need for multiple surgeries and increased technical and financial requirements. “2 in 1” single stage approaches have been advocated due to reduction in risks, costs and complications. This study aimed to investigate the results of single stage revision using metaphyseal sleeves for infected primary Total Knee Replacement (TKR). Prospective data was collected on all patients presenting with an infected primary TKR over an 8-year period (2009–17). All revision procedures were undertaken in a single stage using metaphyseal sleeves. 26 patients were included, 2 of which had previously failed 2 stage revision and 3 failed DAIR procedures. Mean age was 72.5. Mean BMI was 33.4. Median ASA 2. Mean time to revision was 3.5 years range 3 months to 12 years. Six patients had actively discharging sinuses at the time of surgery. Only 4 of the 26 patients had no positive microbiological cultures from deep tissue samples or joint aspirates. Only one patient has a recurrence of infection. This patient did not require further surgery and is treated on long term antibiotic suppression and is systemically well. There were statistically significant improvements in both the pain and function component of AKSS scores. There was no significant improvement in flexion, however mean extension and total range of movement both showed statistically significant improvements. Using Metaphyseal sleeves in single stage revision for infected TKR are safe and lead to an improvement in pain, function and have excellent efficacy for eradication of infection

The management of bone loss in revision total knee replacement (TKA) remains a challenge. To accomplish the goals of revision TKA, the surgeon needs to choose the appropriate implant design to “fix the problem,” achieve proper component placement and alignment, and obtain robust short- and long-term fixation. Proper identification and classification of the extent of bone loss and deformity will aid in preoperative planning. Extensive bone loss may be due to progressive osteolysis (a mechanism of failure), or as a result of intraoperative component removal. The Anderson Orthopaedic Research Institute (AORI) is a useful classification system that individually describes femoral and tibial defects by the appearance, severity, and location of bone defects. This system provides a guideline to treatment and enables preoperative planning on radiographs. In Type 1 defects, femoral and tibial defects are characterised by minor contained deficiencies at the bone-implant interface. Metaphyseal bone is intact and the integrity of the joint line is not compromised. In this scenario, the best reconstruction option is to increase the thickness of bone resection and to fill the defect with cancellous bone graft or cement. Type 2 defects are characterised by deficient metaphyseal bone involving one or more femoral condyle(s) or tibial plateau(s). The peripheral rim of cortical bone may be intact or partially compromised, and the joint line is abnormal. Reconstruction options for a Type 2A defect include impaction bone grafting, cement, or more commonly, prosthetic augmentation (e.g. sleeves, augments or wedges). In Type 2B defects, metaphyseal bone of both femoral condyles or both tibial plateaus is deficient. The peripheral rim of cortical bone may be intact or partially compromised, and the joint line is abnormal. Options for a Type 2B defect include impaction grafting, bulk structural allograft, prosthetic augmentation, metaphyseal sleeves (in some cases), or metaphyseal cones. Finally, in the presence of a Type 3 deficiency, both metaphyseal and cortical bone is deficient and there is partial or complete disruption of the collateral ligament attachments. In this case, the most commonly used reconstruction options include hinged implants or megaprostheses with or without bulk structural allograft, prosthetic augmentation, and/or metaphyseal/diaphyseal sleeves or cones. Today, we are fortunate to have a wide variety of options available to aid in reconstruction of a revision TKA with massive bone loss. Historically, use of cement, bone grafting, or use of a tumor-type or hinged implant were considered the main options for reconstruction. The development and adoption of highly porous sleeves and cones has given the surgeon a new and potentially more durable option for reconstruction of previously difficult to treat defects. Using radiographs and computed tomography, surgeons are able to preoperatively classify bone loss and anticipate a reconstruction plan based upon the classification; however, it is always important to have several back-up options on hand during revision surgery in the event bone loss is worse than expected

Aim. Bone loss is a severe problem in septic revision total knee arthroplasty (RTKA). The use of porous coated metaphyseal sleeves is a promising treatment option for extended bone defects. The currently published mid-term results remain limited and no study has been focused exclusively on septic cases. Our aim was to determine the implant survivorship (with special focus on osseointegration) and the clinical and radiological mid-term outcome of metaphyseal sleeve fixation in septic RTKA surgery (minimum follow-up of 2 years). Method. Between January 2005 and September 2015, 57 patients underwent septic RTKA surgery using metaphyseal sleeves. In 56 patients (98,2 %) who underwent a total of 69 two stage revision procedures, clinical and radiological follow-up examinations were conducted. One patient (1,8 %) was lost to follow-up. The examinations included the American Knee Society Score (KSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the SF-36 Health survey as well as radiographic measurement to determine if successful osseointegration had been achieved. Results. Thirteen knees (18.8%) had to be re-revised at the time of follow-up (mean 5.3 years, min. 2 – max. 11.2), all due to reinfection (Figure 1). We did not encounter any cases of aseptic loosening. The mean range of motion (92° ± 21°), SSS (7 ± 2), KSS (76 ± 19), WOMAC (70 ± 20), SF-36 MCS (55 ± 14) and SF-36 PCS (35 ± 9) have shown satisfying results. Conclusions. Metaphyseal sleeves have shown very promising mid-term results regarding clinical scores, osseointegration, and aseptic loosening. Our results are the first analysing the performance of metaphyseal sleeves in exclusively septic cases and show that they are a reliable fixation option in septic RTKA patients with severe bone loss

Introduction. Extraction of implants due to periprosthetic infection (PJI) following complex revision total knee arthroplasty (rTKA) with extensive hardware can be a daunting undertaking for surgeon and patient alike. We question whether irrigation and debridement (I&D) has a role in this difficult situation with respect to infection control, reoperation, and function. Methods. rTKAs for PJI from 2005–2016 were reviewed. Extensive hardware was defined as: metaphyseal cone/sleeve fixation, distal femoral replacement, periprosthetic fracture hardware, or stems >75mm. Cases were categorized by treatment (I&D or 2-stage exchange). Results. 87 patients were identified with extensive hardware and PJI − 63 I&Ds and 42 2-stages. Follow-up was 3.7 years. Success defined as no re-operation for infection was similar − 38/63 (60.3%) I&D vs 28/42 (66.7%) 2-stage (p=0.54). 26/42 (61.9%) 2-stages required static spacers for post-extraction bone loss or wound problems. Only 14/42 (33%) 2-stages were successfully replanted without re-infection. 11/42 (26.1%) 2-stages had retained spacers while 7/42 (16.7%) 2-stages were eventually fused. In contrast, 38/63 (60.3%) I&Ds maintained original implants without further surgery. 8/63 (12.7%) required repeat I&D; 9/63 (14.3%) underwent eventual 2-stage. Chronic antibiotic suppression was utilized in 53/63 (84.1%) I&Ds and 17/42 (40.5%) 2-stages (p<0.001). Amputation rates were similar − 9/63 (14.3%) I&D vs 7/42 (16.7%) 2-stage (p=0.79). Ambulatory rates were similar − 46/63 (73.0%) I&D vs 24/42 (57.1%) 2-stage (p=0.09). More patients who underwent I&D had a functional TKA at final follow-up (53/63 (84.1%) I&D vs 20/42 (47.6%) 2-stage; p<0.001). Mortality was high − 22/59 (37.3%) I&D vs 13/37 (35.1%) 2-stage (p=1.00). Conclusion. In the setting of PJI following rTKA with extensive hardware, morbidity and mortality is high. I&D with chronic suppression appears as effective as 2-stage procedures in preventing reoperation for infection and maintaining ambulatory status while avoiding the morbidity of 2-stage exchange