Aims. Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined. Methods. This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up. Results. The mean duration from initial revision TAA to last follow-up was 15.0 years (SD 3.0; 11.2 to 20.5). The cumulative survival rates of the revised ankles were 81% (95% confidence interval (CI) 74% to 88%), 74% (65% to 82%), and 70% (61% to 79%) at five, ten, and 15 years, respectively. Comorbidities prior to primary TAA, aseptic loosening, instability, or grafting of cysts were found to be the most common risk factors for secondary revision. The median value for preoperative pain, as assessed using the visual analogue scale, declined from 6 (interquartile range (IQR) 5 to 8) to 2 (IQR 0 to 5) (p < 0.001) and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 43 (SD 17) preoperatively to 70 (SD 20) (p < 0.001) at last follow-up. Conclusion. Revision TAA offers acceptable survival rates after 15 years; it therefore offers a valuable option for treatment of implant failure in carefully selected cases. Although patient-reported outcomes improve substantially, the degree of improvement reported following primary TAA is not achieved. Cite this article: Bone Joint J 2024;106-B(1):46–52

Aims

Unicompartmental knee arthroplasty (UKA) is the preferred treatment for anterior medial knee osteoarthritis (OA) owing to the rapid postoperative recovery. However, the risk factors for UKA failure remain controversial.

The April 2023 Foot & Ankle Roundup³⁶⁰ looks at: Outcomes following a two-stage revision total ankle arthroplasty for periprosthetic joint infection; Temporary bridge plate fixation and joint motion after an unstable Lisfranc injury; Outcomes of fusion in type II os naviculare; Total ankle arthroplasty versus arthrodesis for end-stage ankle osteoarthritis; Normal saline for plantar fasciitis: placebo or therapeutic?; Distraction arthroplasty for ankle osteoarthritis: does it work?; Let there be movement: ankle arthroplasty after previous fusion; Morbidity and mortality after diabetic Charcot foot arthropathy.

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

We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre.

Aims

This study aims to determine the proportion of patients with end-stage knee osteoarthritis (OA) possibly suitable for partial (PKA) or combined partial knee arthroplasty (CPKA) according to patterns of full-thickness cartilage loss and anterior cruciate ligament (ACL) status.

Aims

Commonly performed unicompartmental knee arthroplasty (UKA) is not designed for the lateral compartment. Additionally, the anatomical medial and lateral tibial plateaus have asymmetrical geometries, with a slightly dished medial plateau and a convex lateral plateau. Therefore, this study aims to investigate the native knee kinematics with respect to the tibial insert design corresponding to the lateral femoral component.

Aims

The primary aim of this study was to determine the surgical team’s learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA.

Objectives

This study reports on a secondary exploratory analysis of the early clinical outcomes of a randomised clinical trial comparing robotic arm-assisted unicompartmental knee arthroplasty (UKA) for medial compartment osteoarthritis of the knee with manual UKA performed using traditional surgical jigs. This follows reporting of the primary outcomes of implant accuracy and gait analysis that showed significant advantages in the robotic arm-assisted group.

Introduction. In total knee arthroplasty, the alignment of leg depends on the alignment of the component. In unicompartmental knee arthroplasty, it is determined by the thickness of the implant relative to the bone excised mostly. After initial scepticism, UKA is increasingly accepted as a reliable procedure for unicompartmental knee osteoarthritis with the improvements in implant design, surgical technique and appropriate patient selection. Recently, computer assisted UKA is helpful in accuracy and less invasive procedure. But, fixed bearing or mobile bearing in UKA is still controversy. We compared the early clinical and radiological results of robot-assisted unicompartmental knee arthroplasty using a fixed bearing design versus a mobile type bearing design. Materials and Methods. A data set of 50 cases of isolated compartmental degenerative disease that underwent robot-assisted UKA using a fixed bearing design were compared to a data set of 50 cases using a mobile bearing type design. The operations were performed by one-senior author with the same robot system. The clinical evaluations included the Knee Society Score (knee score, functional score) and postoperative complications. The radiological evaluations was assessed by 3-foot standing radiographs using the technique of Kennedy and White to determine the mechanical axis and femoro-tibial angle for knee alignment. Operative factors were evaluated including length of skin incision, operation time, blood loss, hospital stay and intraoperative complications. Results. There were no statistically significant differences in operation time, skin incision size, blood loss and hospital stay. (p > 0.05) There were no significant differences in Knee Society Scores at last follow up. An average preoperative femorotibial alignment was varus alignment of −1° in both groups. Postoperative patients with fixed-bearing implants had an average +2.1° valgus and the patients with mobile bearing implants had +5.4° valgus in femorotibial alignment, which was different.(p<0.05) There was one case of medial tibia plateau fracture in fixed bearing group in 3 months postoperatively. And there were one case of liner dislocation with unstable knee in 6 weeks postoperatively and one case of femoral component loosening in 1 year postoperatively in mobile bearing group. There was no intraoperative complication. The average preoperative knee score was 45.8, which improved to 89.5 in fixed bearing group and 46.5, which improved to 91.2 in mobile bearing group at last followup. The average preoperative function score was 62.4 which improved to 86.5 in fixed bearing group and 60.7 which improved to 88.2 in mobile bearing group at last followup. Conclusion. In ourearly experience, two types of bearing of robot-assisted UKA groups showed no statistical differences in clinical assessment but there was statistical difference in postoperative radiological corrected alignment. But in aspect of early complications, we think that mobile bearing seems to be requiring more attention in surgery

The February 2015 Foot & Ankle Roundup³⁶⁰ looks at: Syndesmosis screw removal in randomised controlled trial; Diagnostic value of Hawkins sign; Chevron rules supreme?; Diabetes and ankle replacement; Fixed-bearing ankle replacement; Fusion for osteomyelitis of the ankle; ‘Reformed’ fallers.

Objectives

This systematic review and meta-analysis was conducted to determine the mid- to long-term clinical outcomes for a medial-pivot total knee replacement (TKR) system. The objectives were to synthesise available survivorship, Knee Society Scores (KSS), and reasons for revision for this system.

There is conflicting evidence about the merits of mobile bearings in total knee replacement, partly because most randomised controlled trials (RCTs) have not been adequately powered. We report the results of a multicentre RCT of mobile versus fixed bearings. This was part of the knee arthroplasty trial (KAT), where 539 patients were randomly allocated to mobile or fixed bearings and analysed on an intention-to-treat basis. The primary outcome measure was the Oxford Knee Score (OKS) plus secondary measures including Short Form-12, EuroQol EQ-5D, costs, cost-effectiveness and need for further surgery.

There was no significant difference between the groups pre-operatively: mean OKS was 17.18 (sd 7.60) in the mobile-bearing group and 16.49 (sd 7.40) in the fixed-bearing group. At five years mean OKS was 33.19 (sd 16.68) and 33.65 (sd 9.68), respectively. There was no significant difference between trial groups in OKS at five years (-1.12 (95% confidence interval -2.77 to 0.52) or any of the other outcome measures. Furthermore, there was no significant difference in the proportion of patients with knee-related re-operations or in total costs.

In this appropriately powered RCT, over the first five years after total knee replacement functional outcomes, re-operation rates and healthcare costs appear to be the same irrespective of whether a mobile or fixed bearing is used.

Cite this article: Bone Joint J 2013;95-B:486–92.

The posterior-stabilized knee prosthesis is designed specifically to provide the posterior stability to a knee arthroplasty when PCL is deficient or has to be sacrificed. Posterior dislocation of such prosthesis is rare but dreaded complication. There are several causes of postoperative dislocation such as malposition of the prosthesis, preoperative valgus deformity, a defect of the extensor mechanism and overwidening of the flexion gap. Posterior-stabilized rotating-platform mobile-bearing knee implants have been widely used to further improve the postoperative range of motion by incorporation of the post and cam mechanism to improve the posterior roll back during flexion and to overcome the wear and osteolysis problems due to significant undersurface micromotion of posterior-stabilized fixed-bearing knees. But, spin-out or rotatory dislocation of the polyethylene insert can occurs as result of excessive rotation of the rotating platform accompanied by translation of the femur on the tibia after mobile-bearing total knee arthroplasty, but that is very rare. Here, authors describe an unusual case of acute 180° rotatory dislocation of the rotating platform after posterior dislocation of a posterior-stabilized mobile-bearing total knee arthroplasty. A 71-year-old male with knee osteoarthritis underwent a TKRA using posterior-stabilized mobile-bearing prosthesis. The posterior dislocation of the total knee arthroplasty occurred 5 weeks postoperatively(Fig. 1). We underwent closed reduction of posterior dislocated total knee arthroplasty resulting in a complete 180° rotatory dislocation of the rotating platform (Fig. 2). He was treated with open exploration and polyethylene exchange with a larger component. This case illustrates that dislocation of a posterior-stabilized mobile-bearing total knee arthroplasty can occur with valgus laxity, cause 90° spin-out of the polyethylene insert and closed reduction attempts may contribute to complete 180° rotatory dislocation of the rotating platform. Special attention needs to be paid to both AP and lateral view to ensure that the platform is truly reduced and not just rotated 180° as was in this case

There is ample data to confirm that Computer-assisted total knee replacement improves alignment of the limb when compared with the conventional technique. There is also published evidence that optimum alignment correlates with longevity of implants. CAS enables accurate component alignment of both femoral and tibial components. It enables accurate restoration of the posterior tibial slope which has important consequences for flexion range and stability of the component in flexion especially if mobile bearing implants are considered. CAS also aids in correctly orienting rotation of the femoral component; this has value in minimizing patellar maltracking. We will present our data showing accurate restoration of joint line and posterior femoral offset. As CAS ensures alignment, rotation, sizing and positioning of components, the surgeon is free to devote his efforts to ensuring soft-tissue balance and stability, since TKA is really a ‘soft-tissue’ operation. How CAS is of immense value in deformity correction and soft-tissue balancing will be illustrated with examples. It helps in better understanding and quantification of the effects of soft-tissue release on flexion-extension gaps and this is of great value not only for minimal deformities (to minimise releases) but also for severe deformities (to ensure complete correction by adequate release). CAS is invaluable in helping equalize flexion-extension gaps; how it can help balance the flexion gap to the extension gap by ‘virtual surgery’ will be depicted with examples. It is particularly useful in presence of hardware in the femur or tibia and for concomitant extra-articular deformity. We have also found a consistent improvement in recovery of functional milestones with CAS with similar results for both unilateral and bilateral TKAs. Furthermore, there is evidence to support that ensuring alignment has important benefits in improving functional and quality of life scores. In addition, those with alignment of mechanical axis within 3 degrees of normal have been shown to have a shorter stay in hospital by 2 days. Studies have shown reduced blood loss and incidence of emboli after CAS TKA. Using CAS routinely for all cases, the author is ‘time neutral’. While there is always room for improvement with evolving technologies and CAS is no exception, it already has enormous benefits in the performance and outcome of TKA, and is an important part of the surgical armamentarium for a successful knee arthroplasty

Background. No study compared the clinical results of the posterior-stabilized mobile-bearing knee with those of nonposterior-stabilized mobile-bearing knee in the same patients. The purpose of this study was to examine whether the clinical and radiographic results, range of motion, patients satisfaction, and complication rates would be better in the knees with a posterior-stabilized mobile-bearing knee than in the knees with a nonposterior-stabilized mobile-bearing knee. Methods. One hundred and fourteen patients (mean age, 67.9 years) received a nonposterior-stabilized mobile-bearing knee prosthesis in one knee and a posterior-stabilized mobile-bearing knee prosthesis in the contralateral knee. Seven patients were men, and 107 were women. At the time of each follow-up (mean, 7.3 years; range, seven to 7.6 years), the patients were assessed clinically and radiographically. Results. The mean postoperative Knee Society knee score (95 points versus 96 points, p=0.176), Hospital for Special Surgery knee score (92 points versus 93 points, p=0.077), and Western Ontario and McMaster University Osteoarthritis score (21 versus 20 points, p=0.785) were similar between the two group. At the final follow-up, the average range of motion was 27.7° (range, 70° to 150°) in the knees with a nonposterior stabilized mobile-bearing prosthesis and it was 132° (range, 90 to 150 °) in the knees with a posterior-stabilized mobile-bearing prosthesis. Complication rates (2.6% versus 1.8%) were similar between the two groups. The estimated survival rate was 97.4% at eight years with an overall revision rate of 2.6% (three of 114 knees) in the nonposterior-stabilized mobile-bearing prosthesis group and 98.2% at eight years with an overall revision rate of 1.8% (two of 114 knees) in the posterior-stabilized mobile-bearing prosthesis group. Conclusions. After a minimum duration of follow-up of seven years, we found no significant differences between the two groups with regard to the clinical and radiographic results, or patient satisfaction, or complication rate. However, the posterior-stabilized mobile-bearing prosthesis group had a greater range of knee motion than the nonposterior-stabilized mobile-bearing prosthesis group

Purpose. Total Ankle Replacement (TAR) is increasingly being offered to patients as an alternative to arthrodesis for the operative management of debilitating end-stage ankle arthritis. The Mobility Total Ankle System is a third-generation design consisting of a three component, cementless, unconstrained, mobile-bearing prosthesis. This study reports the early results of a multi-centre prospective study of the Mobility prosthesis. This is the first such report by independent researchers. Method. The senior authors implanted 86 consecutive Mobility prostheses. The underlying diagnosis was primary OA in 24 ankles, secondary OA in 47 ankles and inflammatory arthritis in 15 ankles. There were 41 males (Mean age 67 / Range 51–87) and 44 females (Mean age 60 / Range 29–72). The mean BMI was 28 (Range 22–36) for males, and 28 (Range 20–39) for females. Previous ankle operations were performed in 24 patients, 22 of which were for fracture fixation. Ankles were classified according to the COFAS end-stage ankle arthritis classification system. Coronal plane deformity was quantified pre-operatively. Clinical outcome was assessed using the AOFAS hindfoot score. Radiological assessment was performed from weight-bearing radiographs, documenting post-operative alignment, osseous integration, edge-loading and heterotopic bone formation. The mean follow-up time was 40 months (Range 30–60). Survival analysis was calculated according to the Kaplan-Meier method. Failure was defined as exchange of any component of the TAR, arthrodesis or amputation. Results. Type 1 ankle arthritis was demonstrated in 54 ankles (63%). No patient had pre-operative coronal plane angulation > 20. In 30 ankles (35%), the pre-operative coronal alignment was neutral, and in 32 ankles (37%), the deformity was < 10. The mean AOFAS hindfoot score improved from 37.4 (Range 12–59) pre-operatively to 77.9 (Range 51–100) post-operatively. 78 (90%) of prosthetic components were implanted within 5 of the optimal position. Bone-implant interface abnormalities were identified in 16 ankles (18%). In total, 5 TARs required revision, 4 for aseptic loosening and one for component malpositioning. There was one conversion to arthrodesis, and one BKA for CRPS. 30 simultaneous procedures were performed in 28 patients. The most common was gastrocnemius recession. There were 8 re-operations, most commonly for impingement due to peri-articular ossifications. Delayed wound healing occurred in 3 patients, and there was one case of deep infection. There were 5 patients that sustained fractures of the medial malleolus: 2 were intra-operative, and underwent internal fixation. There are 6 patients being investigated for ongoing pain. The 2-year survival was 96.4% (95% CI 89.4–99.1) and 3-year survival was 91.7% (95% CI 83.3–96.3). Conclusion. Although early results of the Mobility TAR are encouraging for independent researchers, they do not match those reported by designer surgeons. Most patients achieve good pain relief and improved function post-operatively

Background. Currently there are various knee prosthesis designs available each with its plus and minus points; there is no general consensus on whether mobile-bearing knees are functionally better than fixed-bearing ones. This study is designed to compare outcomes after total knee arthroplasty with both of the above prostheses. Materials & Methods. 50 patients (68 knees) who'd had a total knee arthroplasty between April 1999 and April 2008 at both Akhtar and Kian Hospitals for primary osteoarthritis were selected. In 30 cases a fixed-bearing knee (Scorpio(r), Stryker) and in the remaining 38 a mobile-bearing prosthesis (Rotaglide(r), Corin Group) was used. Patients' knees were scored before and after the operation according to the Knee Society Scoring System. The mobile-bearing group had an average age of 65 and 34 months' follow-up; in the fixed-bearing group the average age was 69 and the average follow-up 30 months. Results. The average knee score in the mobile-bearing group rose from 29 to 64 while in the fixed-bearing group the score changed from 31 to 68. The average functional score moved from 45 to 67 in the mobile-bearing group and from 34 to 57 in the fixed-bearing group. The average overall score, for the fixed-bearing group, moved from 65 to 125 and in the mobile-bearing group from 75 to 128. Conclusion. In both groups the average knee/functional knee scores increased after the operation and all patients were happy with the results, however statistically there was no meaningful relationship between pre-and post-operation scores. So regarding to our findings, there is no preference between these two types of prosthesis

This study compared the outcome of total knee replacement (TKR) in adult patients with fixed- and mobile-bearing prostheses during the first post-operative year and at five years’ follow-up, using gait parameters as a new objective measure. This double-blind randomised controlled clinical trial included 55 patients with mobile-bearing (n = 26) and fixed-bearing (n = 29) prostheses of the same design, evaluated pre-operatively and post-operatively at six weeks, three months, six months, one year and five years. Each participant undertook two walking trials of 30 m and completed the EuroQol questionnaire, Western Ontario and McMaster Universities osteoarthritis index, Knee Society score, and visual analogue scales for pain and stiffness. Gait analysis was performed using five miniature angular rate sensors mounted on the trunk (sacrum), each thigh and calf. The study population was divided into two groups according to age (≤ 70 years versus > 70 years).

Improvements in most gait parameters at five years’ follow-up were greater for fixed-bearing TKRs in older patients (> 70 years), and greater for mobile-bearing TKRs in younger patients (≤ 70 years). These findings should be confirmed by an extended age controlled study, as the ideal choice of prosthesis might depend on the age of the patient at the time of surgery.

The efficacy of circumpatellar electrocautery in reducing the incidence of post-operative anterior knee pain is unknown. We conducted a single-centre, outcome-assessor and patient-blinded, parallel-group, randomised, controlled trial to compare circumpatellar electrocautery with no electrocautery in total knee replacement in the absence of patellar resurfacing. Patients requiring knee replacement for primary osteoarthritis were randomly assigned circumpatellar electrocautery (intervention group) or no electrocautery (control group). The primary outcome measure was the incidence of anterior knee pain. A secondary measure was the standardised clinical and patient-reported outcomes determined by the American Knee Society scores and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. A total of 131 knees received circumpatellar electrocautery and 131 had no electrocautery.

The overall incidence of anterior knee pain at follow-up at one year was 26% (20% to 31%), with 19% (12% to 26%) in the intervention group and 32% (24% to 40%) in the control group (p = 0.02). The relative risk reduction from electrocautery was 40% (9% to 61%) and the number needed to treat was 7.7 (4.3 to 41.4). The intervention group had a better mean total WOMAC score at follow-up at one year compared with the control group (16.3 (0 to 77.7) versus 21.6 (0 to 76.7), p = 0.04). The mean post-operative American Knee Society knee scores and function scores were similar in the intervention and control groups (knee score: 92.4 (55 to 100) versus 90.4 (51 to 100), respectively (p = 0.14); function score: 86.5 (15 to 100) versus 84.5 (30 to 100), respectively (p = 0.49)).

Our study suggests that in the absence of patellar resurfacing electrocautery around the margin of the patella improves the outcome of total knee replacement.