Aims. Two-stage exchange arthroplasty is the most common definitive treatment for prosthetic joint infection (PJI) in the USA. Complications that occur during treatment are often not considered. The purpose of this study was to analyze complications in patients undergoing two-stage exchange for infected total knee arthroplasty (TKA) and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI of the knee from January 2010 to December 2018 at a single institution. We categorized complications as medical versus surgical. The intervals for complications were divided into: interstage; early post-reimplantation (three months); and late post-reimplantation (three months to minimum one year). Minimum follow-up was one year. In total, 134 patients underwent a first stage of a two-stage exchange. There were 69 males and 65 females with an mean age at first stage surgery of 67 years (37 to 89). Success was based on the new Musculoskeletal Infection Society (MSIS) definition of success reporting. Results. Overall, 70 (52%) patients experienced a complication during the planned two-stage treatment, 36 patients (27%) experienced a medical complication and 47 (41%) patients experienced a surgical complication. There was an 18% mortality rate (24/134) at a mean of 3.7 years (0.09 to 8.3). During the inter-stage period, 28% (37/134) of patients experienced a total of 50 complications at a median of 47 days (interquartile range (IQR) 18 to 139). Of these 50 complications, 22 were medical and 28 required surgery. During this inter-stage period, four patients died (3%) and an additional five patients (4%) failed to progress to the second stage. While 93% of patients (125/134) were reimplanted, only 56% (77/134) of the patients were successfully treated without antibiotic suppression (36%, 28/77) or with antibiotic suppression (19%, 15/77) at one year. Conclusion. Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment. Cite this article: Bone Joint J 2020;102-B(6 Supple A):145–150

We systematically reviewed the published literature on the complications of closing wedge high tibial osteotomy for the treatment of unicompartmental osteoarthritis of the knee. Publications were identified using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases up to February 2012. We assessed randomised (RCTs), controlled group clinical (CCTs) trials, case series in publications associated with closing wedge osteotomy of the tibia in patients with osteoarthritis of the knee and finally a Cochrane review. Many of these trials included comparative studies (opening wedge versus closing wedge) and there was heterogeneity in the studies that prevented pooling of the results.

Introduction. Two-stage exchange arthroplasty remains the gold standard for treatment of PJI with reported success rates of 85–90%. Complications that occur during treatment are often not reported or considered in the success rate. The purpose of this study was to analyze complications in patients undergoing two-stage exchange and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of chronic PJI of the knee from 2010 to 2018. We categorized complications as medical vs. surgical. The intervals for complications were divided into: interstage, early post re-implant (3 months) and late post re-implant (3 months to minimum 1 year). Minimum follow-up to evaluate complications was one year. Results. Overall, 132 patients underwent a first stage of a two-stage exchange. There were 63 males and 59 females with an average age at first stage surgery of 66.6 years (SD: 8.9). Ten patients (7.6%) did not undergo re-implantation following resection arthroplasty (8 retained spacers and 2 deaths). 122 patients underwent the planned second stage of a two-stage exchange arthroplasty of the knee. The overall success rate (re-implant without recurrence of infection) was 78%. Overall mortality was 1.6% at one year and 9% at 5 years after treatment. Fifty-six patients (46%) experienced at least one complication. 43 patients had an orthopaedic related complication that required additional surgery and 13 patients had a medical complication. 33% of the total complications occurred during the interstage period, 18% within 90 days of reimplant, and 37% greater than three months from reimplant (p=0.0287). Discussion. Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment and the need for in-depth patient counseling, careful surgical technique, and close follow up. For figures, tables, or references, please contact authors directly

Aims. Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure. Methods. Between January 2010 and September 2020, 695 rTKAs were performed and data were entered into a prospective database. Inclusion criteria were rTKAs with concomitant TTO, without extensor mechanism allograft, and a minimum of two years’ follow-up. A total of 135 rTKAs were included, with a mean age of 65 years (SD 9.0) and a mean BMI of 29.8 kg/m. 2. (SD 5.7). The most frequent indications for revision were infection (50%; 68/135), aseptic loosening (25%; 34/135), and stiffness (13%; 18/135). Patients had standardized follow-up at six weeks, three months, six months, and annually thereafter. Complications and revisions were evaluated at the last follow-up. Functional outcomes were assessed using the Knee Society Score (KSS) and range of motion. Results. The mean follow-up was 51 months (SD 26; 24 to 121). Bony union was confirmed in 95% of patients (128/135) at a mean of 3.4 months (SD 2.7). The complication rate was 15% (20/135), consisting of nine tibial tubercle fracture displacements (6.7%), seven nonunions (5%), two delayed unions, one tibial fracture, and one wound dehiscence. Seven patients (5%) required eight revision procedures (6%): three bone grafts, three osteosyntheses, one extensor mechanism allograft, and one wound revision. The functional scores and flexion were significantly improved after surgery: mean KSS knee, 48.8 (SD 17) vs 79.6 (SD 20; p < 0.001); mean KSS function, 37.6 (SD 21) vs 70.2 (SD 30; p < 0.001); mean flexion, 81.5° (SD 33°) vs 93° (SD 29°; p = 0.004). Overall, 98% of patients (n = 132) had no extension deficit. The use of hinge implants was a significant risk factor for tibial tubercle fracture (p = 0.011). Conclusion. TTO during rTKA was an efficient procedure to improve knee exposure with a high union rate, but had significant specific complications. Functional outcomes were improved at mid term. Cite this article: Bone Joint J 2023;105-B(10):1078–1085

Introduction. Although we know that smoking damages health, we do not know impact of smoking on a patient's outcome following primary knee arthroplasty (KA). In the UK, clinical commissioning groups (CCGs) have the authority (& funds) to commission healthcare services for their communities. Over the past decade, an increasing number of CCGs are using smoking as a contraindication for patients with end-stage symptomatic knee arthritis being referred to a specialist for due consideration of KA without any clear evidence of the associated risks & benefits. The overall objective of this study is to compare clinical outcomes after knee arthroplasty surgery in smokers, ex-smokers & non-smokers. Methods. We obtained data from the UK Clinical Research Practice Datalink (CPRD) that contains information on over 11 million patients (7% of the UK population) registered at over 600 general practices. CPRD data was linked to Hospital Episode Statistics, hospital admissions & Patient Reported Outcome Measures (PROMs) data. We collected data on all KAs (n=64,071) performed over a 21-year period (1995 to 2016). Outcomes assessed included: local & systemic complications (at 6-months post-surgery): infections (wound, respiratory, urinary), heart attack, stroke & transient ischaemic attack, venous thromboembolism, hospital readmissions & GP visits (1-year), analgesic use (1-year), surgical revision (up to 20-years), mortality (90-days and 1-year), & 6-month change from pre-operative scores in Oxford Knee Score (OKS). Regression modelling is used to describe the association of smoking on outcomes, adjusting for confounding factors. Results. Smoking was associated with an increased risk of lower respiratory tract infections (LRTI) (4.2% smokers vs. 2.7% non-smokers) (Odds Ratio (OR) 0.76, p-value 0.017). LRTI were similar in ex-smokers & smokers at 3.9%. There was no association with any of the other 6-month complications. Pain medication use over 1-year post surgery was higher in smokers compared to non-smokers: gabapentinoids 7.4% vs. 5.2% (OR 0.74, p< 0.001), opioids 45.9% vs. 35.3% (OR 0.79, p< 0.001), NSAIDs 51.6% vs. 46.1% (OR 0.91, p = 0.044). Mortality was higher in smokers at 1-year compared to non-smokers (hazard ratio (HR) 0.53, p<0.001) & ex-smokers (HR 0.65, p = 0.037), but there was no difference observed at 90-days. There was no association of smoking on revision surgery over 20-years follow up. Smoking was associated with worse postoperative OKS being 3.1 points higher in non-smokers (p<0.001) & 3.0 points higher in ex-smokers (p<0.001). The overall change in OKS before & after surgery was 13.9 points in smokers versus 16.3 points in non-smokers (p<0.001) & 15.7 points in ex-smokers (p<0.001). Over the year following surgery, smokers were more likely to visit their GP, but there was no association with hospital readmission rates. Conclusion. This is the largest study with linked primary care & secondary care data highlighting impact of a preventable patient factor on outcome of a routinely performed planned intervention. Smokers achieved clinical meaningful improvements in patient reported pain & function (OKS) following KA, although their attained post-operative OKS was lower than in non-smokers & ex-smokers. Levels of pain medication use were notably higher in both smokers & ex-smokers. As smokers achieved good clinical outcomes following KA surgery, smoking should not be a barrier to referral for or consideration of KA. However, the study does highlight particular risks a patient is taking if he/she continues to smoke when being considered for elective knee arthroplasty. This study will help the family physicians as well as patients to make an informed decision on whether to go ahead with a planned intervention whilst patient continues to be an active smoker or not. Key Words: Knee Arthroplasty, Smoking, Patient Reported Outcomes, Epidemiology, Complications

Abstract

Introduction

Pulmonary embolism (PE) complicates up to 1% of total joint arthroplasties (TJA). Many PE treatment guidelines call for immediate initiation of therapeutic anticoagulation. Options include Xa inhibitors, Enoxaparin, and Warfarin. Deciding between these is a balance of the efficacy and the risks. Little data exists regarding the risks of each of these treatment options for treating PE in arthroplasty patients.

Introduction

Previous research has indicated that preoperative modification of risk factors associated with obesity may reduce complications after TKA. However, the optimal method is still debated. This study aims to investigate whether a preoperative Risk Stratification Tool (RST) devised by our institution to optimize obese patients can reduce unexpected ICU transfers, and 90-day ED visits, readmissions, and reoperations.

Introduction

We designed this study to compare 30-day complications and length of hospital stay between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal, epidural anesthesia, or Monitored Anesthesia Care (MAC, a combination of local anesthesia with sedation and analgesia provided by an anesthesiologist) with or without regional nerve blocks.

Introduction

Hypoalbuminemia has previously been identified as an independent predictor of postoperative complications following total knee arthroplasty (TKA). Given the morbidity and financial burden associated with TKA complications, significant effort has gone into identifying patients at increased risk for perioperative complications. The American Society of Anesthesiologists (ASA) physical status score has been utilized for risk stratification of surgical patients for many years and is a measure of overall health. However, it is unclear how measures like albumin compare to the prognostic ability of this type of global health measure. This study aims to elucidate the utility of preoperative albumin compared with that of the ASA score in predicting complications following TKA.

Aims

Access to total knee arthroplasty (TKA) is sometimes restricted for patients with severe obesity (BMI ≥ 40 kg/m²). This study compares the cost per quality-adjusted life year (QALY) associated with TKA in patients with a BMI above and below 40 kg/m² to examine whether this is supported.

Aims

Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres.

Introduction

Revision total knee arthroplasty (revision TKA) occurs for a wide variety of indications and along with revision total hip arthroplasty is billed for using Diagnosis-Related Groups (DRGs) 466, 467, and 468 in the United States. However, DRGs do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision TKA costs and 30-day complications by indication, employing both local granular as well as national standardized databases.

Introduction

There is insufficient data on the trends of anticoagulation after total knee arthroplasty (TKA) in the USA, and the efficacy and safety of rivaroxaban, beyond randomized clinical trials and small cohort studies.

Aims

The aim of this study was to compare ten-year longitudinal healthcare costs and revision rates for patients undergoing unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA).

Aims

Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA.

Aims

To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty.

Aims

The primary aim of this study was to assess whether non-fatal postoperative venous thromboembolism (VTE) within six months of surgery influences the knee-specific functional outcome (Oxford Knee Score (OKS)) one year after total knee arthroplasty (TKA). Secondary aims were to assess whether non-fatal postoperative VTE influences generic health and patient satisfaction at this time.

Aims

The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred.

Aims

It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients.