There are special circumstances in which revision total knee arthroplasty is not an option. The relative indications for the alternatives to revision TKA are: - Recurrent deep infection - Immunocompromised patient - Extensor mechanism loss - Extensive, non-reconstructable soft tissue loss - High functional demand, young age Remember the three A's as alternatives to revision TKA: arthrodesis, arthroplasty (resection), and amputation. Successful arthrodesis requires elimination of infection, coaptation of bone surfaces and rigid immobilisation. The proper position for arthrodesis is 15 degrees of knee flexion to allow foot clearance. If bone loss is greater than 3 cm fuse the knee in full extension. Avoid hyperextension. Achieve 5 degrees of valgus in correct rotation and use intramedullary instruments from TKA sets for best cuts. External fixation techniques as well as intramedullary internal fixation techniques will be described. Resection arthroplasty is indicated for salvage of an infected total knee when the patient is not a candidate for reimplantation. These patients usually have extensive soft and hard tissue loss. Procedure may be well tolerated and functional. Ancillary support with a long leg drop- lock KAFO increases stability and provides motion. Patients finding resection unacceptable are more likely to accept fusion or amputation; therefore resection may be a staging procedure. Amputation is indicated for failed multiple revisions, intractable or life threatening infection. Also should be indicated when there is a low chance of a successful arthrodesis. Ablate at the lowest level for infection eradication but good maintenance of function. Pedicle muscle flaps can be useful to fill dead spaces. Remember, elderly patients have limited ambulation potential because of high energy requirements of above knee amputation.
This study provides recommendations on the position
of the implant in reverse shoulder replacement in order to minimise
scapular notching and osteophyte formation. Radiographs from 151
patients who underwent primary reverse shoulder replacement with
a single prosthesis were analysed at a mean follow-up of 28.3 months
(24 to 44) for notching, osteophytes, the position of the glenoid
baseplate, the overhang of the glenosphere, and the prosthesis scapular
neck angle (PSNA). A total of 20 patients (13.2%) had a notch (16 Grade 1 and four
Grade 2) and 47 (31.1%) had an osteophyte. In patients without either
notching or an osteophyte the baseplate was found to be positioned
lower on the glenoid, with greater overhang of the glenosphere and
a lower PSNA than those with notching and an osteophyte. Female patients
had a higher rate of notching than males (13.3% Based on these findings we make recommendations on the placement
of the implant in both male and female patients to avoid notching
and osteophyte formation. Cite this article:
The knee is the commonest joint to be affected by osteoarthritis, with the medial compartment commonly affected. Knee osteoarthritis is commonly bilateral, yet symptoms may initially present unilaterally. Higher knee adduction moment has been associated with the development and progression of medial compartment knee osteoarthritis. To assess the effect of lateral wedge insoles on the asymptomatic knee of patients with unilateral symptoms of medial compartment knee osteoarthritis.Background
Objectives
This study was undertaken to evaluate the early results of a new implant system - the metaphyseal sleeve - in revision total knee replacement. The femoral and tibial metaphyseal sleeves are a modular option designed to deal with metaphyseal bone loss and achieve cementless fixation over a relatively wide area in the metaphysis. Over three years, femoral and/or tibial metaphyseal sleeves were implanted in 104 knees in 103 patients (54 male and 49 female). The clinical notes and radiographs of these patients were reviewed retrospectively. Thirty one patients had revision for infection, 42 for aseptic loosening, and 31 for instability, pain or stiffness. Eighty nine knees were revised as a single stage and 15 were done as two stage procedure. Minimum follow up is 12 months (average 18.5 months).Introduction
Methods
Despite interest, the current rate of day-case anterior cruciate ligament reconstruction (ACLR) in the UK remains low. Although specialised care pathways with standard operating procedures (SOPs) have been effective in reducing length of stay following some surgical procedures, this has not been previously reported for ACLR. We evaluate the effectiveness of SOPs for establishing day-case ACLR in a specialist unit. Fifty patients undergoing ACLR between May and September 2010 were studied prospectively (“study group”). SOPs were designed for pre-operative assessment, anaesthesia, surgical procedure, mobilisation and discharge. We evaluated length of stay, readmission rates, patient satisfaction and compliance to SOPs. A retrospective analysis of 50 patients who underwent ACLR prior to implementation of the day-case pathway was performed (“standard practice group”).Background
Methods
We describe the results for the management of chronic osteomyelitis in long bones using a new single stage procedure, the Cardiff technique. Fourteen consecutive patients were treated prospectively. The patients had a mean age of 52; all patients had a mean stay in hospital of 5 days with outpatient dressings. All patients had tibial fractures, 2 were infected non unions. The origin of infection was traumatic in 13 cases and haematogenous in 1 case. This one stage procedure or The Cardiff technique, uses techniques described by both Papineau's 3 stage method and Lautenbach's procedure. It involves removal of all avascular and infected tissue via marginal debridement, opening of the medullary cavity proximally and distally, compartmental debridement and copious saline irrigation. The wound is then packed with Jelonet and kaltostat and fresh dressings applied weekly. The wound is left to heal via secondary intention. There is no routine use of antibiotics. Antibiotics were only used when required, i.e. Clinical evidence of cellulitis or infection. 11 patients healed with no further surgery, no skin grafting, no bone grafting and no flap coverage. Mean time to healing was 5 months; both non unions united giving results similar to other accepted techniques. There were 3 residual infections, 2 due to inadequate debridement which required a single further compartmental debridement (Lautenbach method), 1 had an avascular bone edge requiring further local debridement. We feel this procedure confers the following advantages; minimal surgical insult, early discharge, out patient management, good outcomes and most importantly, high patient satisfaction. It also serves as a reminder that simple wounds do well with simple solutions.
To determine the tensile forces across the knee extensor mechanism during walking, in simulated conditions of treatment. Gait analysis of six normal subjects was performed, with full weight bearing unilateral immobilisation of the knee during walking. Measurements were taken without then with a brace, unlocked then locked at 0°, 0-10°, 0-20° and 0-30° of flexion. Mean and maximum knee flexion angles were measured, followed by calculation of the mean and maximum forces across the extensor mechanism during loading, supporting and propulsion phases of gait.Aim
Methods
This study was undertaken to evaluate the early results of a new implant system - the metaphyseal sleeve - in revision total knee replacement. The femoral and tibial metaphyseal sleeves are a modular option designed to deal with metaphyseal bone loss and achieve cementless fixation over a relatively wide area in the metaphysis. Over three years, femoral and/or tibial metaphyseal sleeves were implanted in 104 knees in 103 patients (54 male and 49 female). The clinical notes and radiographs of these patients were reviewed retrospectively. Thirty one patients had revision for infection, 42 for aseptic loosening, and 31 for instability, pain or stiffness. Eighty nine knees were revised as a single stage and 15 were done as two stage procedure. Minimum follow up is 12 months (average 18.5 months).Purpose of the study
Methods
This review summarises the opinions and conclusions
reached from a symposium on infected total knee replacement (TKR)
held at the British Association of Surgery of the Knee (BASK) annual
meeting in 2011. The National Joint Registry for England and Wales
reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused
by infection. The diagnosis of infection beyond the acute post-operative
stage relies on the identification of the causative organism by
aspiration and analysis of material obtained at arthroscopy. Ideal
treatment then involves a two-stage surgical procedure with extensive
debridement and washout, followed by antibiotics. An articulating
or non-articulating drug-eluting cement spacer is used prior to
implantation of the revision prosthesis, guided by the serum level
of inflammatory markers. The use of a single-stage revision is gaining popularity
and we would advocate its use in certain patients where the causative
organism is known, no sinuses are present, the patient is not immunocompromised,
and there is no radiological evidence of component loosening or
osteitis. It is our opinion that single-stage revision produces high-quality
reproducible results and will soon achieve the same widespread acceptance
as it does in infected hip arthroplasty.
The mechanical disadvantage and detrimental effect to articular cartilage following meniscectomy has been well documented in the literature. Meniscal repair in the avascular (white on white zone) is controversial and would be deemed inappropriate by many. Prospective data collection on all meniscal repairs between 1999 and 2008. 423 patients underwent meniscal repair at our unit during this time. We identified 88 patients who underwent a meniscal repair of a non peripheral tear (white on white zone) where there was no co-existent ACL injury or instability. There were 74 males and 14 females with a mean age of 26 years (13-54). There were 50 medial meniscal tears and 38 lateral tears, all in the non peripheral area of the meniscus. The criterion for failure was any reoperation on the same meniscus requiring excision or re fixation.Background
Methods
Avascular meniscal tears can be repaired with good clinical outcomes. The mechanical disadvantage and detrimental effect to articular cartilage following meniscectomy has been well documented in the literature. Meniscal repair in the avascular (white on white zone) is controversial and would be deemed inappropriate by many.Hypothesis
Background
Review the results of modified Lautenbach procedure (new method) to treat chronic osteomyelitis of the long bones. Retrospective analysis of sixty-seven patients with osteomyelitis of the long bones treated over 5-year period with modified Lautenbach procedure. Four patients were excluded from this study, as we were unable to retrieve the case notes. 48 men and 16 women were included and the average age was 33 years. All these patients had prior operative intervention including plating, intramedullary nailing or external fixator. Forty-seven patients had discharging sinuses and deformed leg. We noted the pre-operative inflammatory markers, bacteriology and pain score. We also recorded the duration of the hospital stay, post-operative recovery, deformity and the ability of the patient to resume his prior occupation.Introduction
Patients and methods
Simultaneous bilateral Total Knee Arthroplasty (TKA) has been reported to bring greater patient satisfaction, reduce in-patient stay and recovery, with similar outcomes to single sided or staged TKA, but higher complication rates. No validated selection criteria exist. We report the results of a single surgeon's experience of simultaneous bilateral TKA, using set guidelines for patient selection. A prospectively maintained database of all simultaneous bilateral TKA performed between 2002 and 2008 was retrospectively analysed, supplemented by case-note review. Outcome measures included length of stay, blood loss and transfusion rates, complications and functionality and validated outcome scores. 40 patients were included, 23 male and 17 female, all with osteoarthritis. Mean age was male 64.9 and female 61.3 years. Mean ASA grade was 1.8. All fitted selection criteria. Mean tourniquet time was right 79.1 minutes and left 83.6 minutes. Preoperative mean haemoglobin level was 141.8 g/dl and mean post operative level of 87.3 g/dl. 13 patients received purely autologous blood transfusion, 16 patients purely allogenic and 6 patients received both. There was 1 intraoperative complication (Medial collateral injury), 3 minor post operative complications which recovered prior to discharge. There were no thromboembolic events or deaths. Mean follow-up was 32.7 months (range 3-79 months). Mean in-patient stay was 7.5 days. Mean range of movement at most recent follow up was right 1.0 to 119.1 degrees flexion and left 1.0 to 120.8 degrees flexion. Mean Knee Society Scores pre- versus post-operatively were: 67 knee/62 function versus 90 knee/82 function. Oxford Knee Scores, Pre- versus post-operatively were: 43 versus 35 (Scoring 0-60, lowest best outcome). We demonstrate that with appropriate selection criteria, simultaneous bilateral TKA is safe and successful, giving excellent functional outcomes.
Thirty-five patients were followed prospectively from their referral to the Problem Fracture Service with chronic osteomyelitis of diaphyseal bone between November 1994 and June 1999. The patients were treated using a closed double-lumen suction irrigation system following reaming and arthroscopic debridement of the intramedullary canal; this is a modified system based on the work of Charles Lautenbach. Results of these procedures were regularly followed up in clinic, and between June and July 2007 the whole cohort was reviewed via postal questionnaire, telephone and case note review. At a mean follow up of 101 months, 26 were living with no evidence of recurrence, 4 had died of unrelated causes with no evidence of recurrent infection. Four patients had persisting problems with sinus discharge requiring intermittent antibiotic therapy and 1 patient had his limb amputated for recurrent metaplastic change. These results gave this cohort an 86% clearance of infection, with recurrence in 12%, which is comparable to the Papineau and Belfast techniques with significantly less surgical insult to the patient.
To assess the outcome of knee “arthrodesis” using cemented Endo-Model knee fusion nail in failed Total Knee Replacement (TKR) with significant bone loss due to infection. This is a retrospective case study of seven patients with infected TKR and multiple surgeries with significant bone loss. All patients had antibiotic loaded cement with a temporary K-nail as a first stage procedure to eradicate infection. All seven patients had “arthrodesis” performed using cemented modular Endo-Model Knee Fusion nail (Waldemar Link, Hamburg) by the senior author. Cement was used to hold the stems in the diaphyses and not used around the coupling mechanism. The “arthrodesis” relied entirely on the coupling mechanism which has been shown to have good axial and torsional rigidity by mechanical testing. Outcome was assessed using pre and post Visual Analogue Score (VAS). Mean age was 72.3 years(62–86). Mean follow up was 39.6 months (7–68). The VAS pain score improved from pre-operative mean score of 7.9 to a postoperative score of 1.5. One patient suffered fracture of femoral cement mantle at 50 months who underwent a technically easy exchange revision. One patient had recurrent infection with distal femoral fracture at 36 months and was revised to distal femoral replacement. The Endo-Model knee arthrodesis nail restores limb lengths, has good early results in terms of pain relief and provides a stable knee “arthrodesis” in cases where there is significant bone loss and extensor mechanism insufficiency following an infected TKR.
At the latest follow-up, none of the patients had recurrence of the infection nor did they need any further surgical procedure. There was no radiographic evidence of loosening of the prosthesis. The OKS had improved from a mean of 17 pre-operative to 41 at the latest follow-up. All the patients were extremely satisfied with the outcome.
The treatment of bony defects of the tibia at the time of revision total knee replacement is controversial. The place of compacted morsellised bone graft is becoming established, particularly in contained defects. It has previously been shown that the initial stability of impaction-grafted trays in the contained defects is equivalent to that of an uncemented primary knee replacement. However, there is little biomechanical evidence on which to base a decision in the treatment of uncontained defects. We undertook a laboratory-based biomechanical study comparing three methods of graft containment in segmental medial tibial defects and compared them with the use of a modular metal augment to bypass the defect. Using resin models of the proximal tibia with medial defects representing either 46% or 65% of the medial cortical rim, repair of the defect was accomplished using mesh, cement or a novel bag technique, after which impaction bone grafting was used to fill the contained defects and a tibial component was cemented in place. As a control, a cemented tibial component with modular metal augments was used in identical defects. All specimens were submitted to cyclical mechanical loading, during which cyclical and permanent tray displacement were determined. The results showed satisfactory stability with all the techniques except the bone bag method. Using metal augments gave the highest initial stability, but obviously lacked any potential for bone restoration.
