Purpose. Whether the presence of knee effusion in individuals with knee osteoarthritis (OA) affects periarticular neuromuscular control during gait and thus the joint loading environment is unknown. The purpose was to test the hypothesis that knee effusion presence alters periarticular neuromuscular patterns during gait in individuals with moderate knee OA. Method. 40 patients with medial compartment knee OA participated after giving informed consent. Patients were assessed for the presence of effusion using a brush test and were assigned to the knee effusion (n=20) and no knee effusion (n=20) groups. Surface electrodes were placed in a bipolar configuration over the lateral and medial gastrocnemius, vastus lateralis and medialis, rectus femoris and the lateral and medial hamstrings of the affected limb. Five trials of self-selected walking were completed. Electromyograms (EMG) were collected using an AMT-8 EMG system (Bortec Inc.). An Optotrak motion capture system (Northern Digital Inc.) recorded leg motion. Euler rotations were used to derive knee angles. EMG waveforms were low-pass filtered and amplitude normalized to maximal effort voluntary isometric contractions. Quadriceps, gastrocnemius and hamstring strength was measured from torques produced against a Cybex dynamometer. Principal Component Analysis extracted the predominant waveform features and weighting scores were calculated for each measured waveform. Analysis of variance models test for main effects (group, muscle) and interactions (alpha = 0.05). Bonferonni post hoc testing was employed. Results. No differences in age, body mass index, knee pain, Western Ontario McMaster Osteoarthritis Index scores, gait velocity and muscle strength were found between groups (p>0.05). Gastrocnemius activation was not influenced by the presence of effusion (p>0.05). For individuals with effusion, a greater overall quadriceps activation was found and a prolonged hamstring activation into mid-stance only (p<0.05). Range of motion excursion from heel strike to peak extension during terminal stance was greater with effusion (p<0.05). Conclusion. The hypothesis that knee effusion in those with moderate knee OA is associated with alterations in quadricep and hamstring muscle activation patterns and sagittal plane knee motion during gait was supported. Quadriceps muscle inhibition during the normalization exercises may provide a partial explanation, consistent with results from acute effusion models. However, the hamstring alteration during mid-stance only, no strength differences between the two groups and altered kinematics support that mechanisms other than muscle inhibition are responsible for the altered patterns. These novel findings are a first step at understanding the effects of knee effusion on periarticular muscle function during gait that subsequently can affect the mechanical environment of the joint in those with a more chronic effusion

Aim. Adverse tissue reactions have been a concern in relation to metal components, particularly in hip replacements. We look at a possible correlation between hip joint effusion and metal ion levels. Materials and methods. 56 patients,(42M, 14F) agreed to the study. All had metal-on-mental arthroplasties. Average age was 64.2 (SD 9.8). All patients were asymptomatic. Ultrasound examination performed by one ultrasonographer, using a Sonosite M-Turbo machine with a C60X/5-2 MHz transducer. Cobalt levels were assessed using an inductively coupled plasma mass spectrometer. Chromium levels were assessed using a graphite furnace atomic absorption spectrometer. Results. Average blood ion levels were:. Cobalt 39.02 nmol/L. (SD41.18) range 3 to 215. Chromium 52.51 nmol/L (SD47.48) range 5 to 284. Average Volume: 10.38ml (SD21.3) Range 0 to 219. Conclusion. There was no statistically significant correlation between joint effusion and metal ion levels

Background. Exebacase, an antistaphylococcal lysin in Phase 3 of development as a treatment for S. aureus bacteremia/right-sided endocarditis has demonstrated antibiofilm activity in vitro and has previously been used as salvage therapy in four patients with relapsing multidrug-resistant (MDR) S. epidermidis knee prosthetic joint infection (PJI) using a procedure called LysinDAIR (administration of the lysin during the performance of an arthroscopic DAIR). Materials/methods. We performed a single center, exploratory, open-label prospective study using the LysinDAIR procedure in patients with chronic (inoculation >3 months prior to treatment) coagulase-negative staphylococci (CNS) PJI of the knee with two different clinical presentations and treatment paradigms. Cohort A: first episode of CNS knee PJI, for whom the LysinDAIR was followed by clindamycin + levofloxacin planned to be prescribed for three months and then stopped; and Cohort B: relapsing episodes of MDR CNS knee PJI for whom the LysinDAIR was followed by primary antimicrobial therapy for three months, followed by suppressive antimicrobial therapy (SAT). Exebacae susceptibility testing was performed before treatment for each patient. In agreement with the French Health authority, exebacase (2 to 3.5 total mg in 30–50 ml (∼0.067 – 0.075 mg/m) was administered directly into the joint during arthroscopy. Results. Eight patients were treated. Exebacase administration was well tolerated by all patients and no serious adverse drug reactions to exebacase were reported. In cohort A (n=4), patients had susceptible S. epidermidis PJI, a painful joint effusion without fistula and without loosening, and received three months of levofloxacin + clindamycin (one patient received an alternative regimen following antibiotic adverse events) and then antibiotics were stopped. During a follow-up of 14, 19, 26 and 36 months, no relapse, no recurrence of the joint effusion and no loosening occurred. In cohort B (n=4), patients had MDR CNS, clinical signs of septic arthritis with a joint effusion without fistula and without loosening and received daptomycin + linezolid or doxycycline. One patient died from COVID-19 at week 4. SAT (tedizolide, n=2; doxycycline, n=1) was then prescribed to other patients. One experienced an infection relapse involving S. caprae under tedizolid therapy at six months. The two other patients continue to do well under SAT 8 and 12 months after the LysinDAIR procedure. Conclusions. The LysinDAIR procedure is a minimally invasive procedure, which has been shown to be easy-to-perform, safe, and has the potential for use as initial treatment or salvage therapy in patients with CNS chronic knee PJI

Background. Bacteriophages are natural viruses of interest in the field of PJI. A paper previously reported the PhagoDAIR procedure (use of phages during DAIR) in three patients with PJI for whom explantation was not desirable. As the need to isolate the pathogen before surgery to perform phage susceptibility testing is a strong hindrance for the development of this procedure, we developed post-operative phage injections using ultrasound, in patients infected with S. aureus and/or P. aeruginosa who were eligible for the PhagoDAIR procedure, but for whom phages were not available at the time of surgery. Materials/Methods. We performed a single center, exploratory, prospective cohort study including patients with knee PJI who received phage therapy with ultrasound after performance of a DAIR or a partial prosthesis exchange. All patients had PJI requiring conservative surgery and suppressive antimicrobial therapy (SAT) as salvage procedure. Each case was discussed in multidisciplinary meetings in agreement with French health authority, based on the clinical presentation, and the phage susceptibility testing. The cocktail of highly concentrate active phages (5 mL; about 10. e. 9 PFU/mL) was extemporaneous prepared and administered three times directly into the joint using sonography (1 injection per week during 3 weeks) during the postoperative period, before switching antibiotics to SAT. Results. Seven patients received phages under sonography after the DAIR, and one after a partial exchange (mean age 71 years). All had resection prosthesis or constrained knee prosthesis. Among these seven patients, three were infected with S. aureus (including one MRSA), two were infected with P. aeruginosa (one was a multidrug-resistant isolate), one was infected with both S. aureus and P. aeruginosa and the last one was infected with MRSA, S. epidermidis and Corynebacterium spp.. All patients received a cocktail of active phages provided by Pherecydes Pharma targeting S. aureus or P. aeruginosa. No adverse event was recorded during or after the local injections. All patients were switched to SAT after a primary postoperative antimicrobial therapy of three months. Under SAT, the patient with S. epidermidis co-infection developed a relapse due to the S. epidermidis. With a mean follow-up of 13 months after surgery (from 9 to 24 months), the outcome was favorable for all patients without any sign of infection; none of them had abnormal pain, joint effusion or loosening. Conclusions. Postoperative administration of phages using sonography is a potentially useful procedure in patients with complex PJI for whom a conservative approach is desirable

The etiology of the flexion contracture is related to recurrent effusions present in a knee with end-stage degenerative joint disease secondary to the associated inflammatory process. These recurrent effusions cause increased pressure in the knee causing pain and discomfort. Patients will always seek a position of comfort, which is slight flexion. Flexion decreases the painful stimulus by reducing pressure in the knee and relaxing the posterior capsule. Unfortunately, this self-perpetuating process leads to a greater degree of contracture as the disease progresses. Furthermore, patients rarely maintain the knee in full extension. Even during the gait cycle the knee is slightly flexed. As their disease progresses, patients limit their ambulation and are more frequently in a seated position. Patients often report sleeping with a pillow under their knee or in the fetal position. All of these activities increase flexion contracture deformity. Patients with excessive deformity >40 degrees should be counseled regarding procedural complexity and that increasing constraint may be required. Patients are seen preoperatively by a physical therapist and given a pre-arthroplasty conditioning program. Patients with excessive flexion contracture are specifically instructed on stretching techniques, as well as quadriceps rehabilitation exercises. The focus in the postoperative physiotherapy rehabilitation program continues toward the goal of full extension. Patients are instructed in appropriate stretching regimes. Patients are immobilised for the first 24 hours in full extension with plaster splints, such as with a modified Robert Jones dressing. This dressing is removed on postoperative day one. The patient is then placed in a knee immobiliser and instructed to wear it at bed rest, during ambulation and in the evening, only removing for ROM exercises. In cases of severe flexion deformity >30 degrees, patients are maintained in full extension for 3–4 weeks until ROM is begun. Patients are encouraged to use a knee immobiliser for at least the first 6 weeks postoperatively. Treating patients with flexion contracture involves a combination of bone resection and soft tissue balance. One must make every effort to preserve both the femoral and tibial joint line. In flexion contracture the common error is to begin by resecting additional distal femur, which may result in joint line elevation and mid-flexion instability. The distal femoral resection should remove that amount of bone being replaced with metal. Attention should be directed at careful and meticulous balance of the soft tissues and release of the contracted posterior capsule with re-establishment of the posterior recess, which will correct the majority of flexion contractures. Inability to achieve ROM after TKA represents a frustrating complication for both patient and surgeon. Non-operative treatments for the stiff TKA include shoe lift in contralateral limb, stationery bicycle with elevated seat position, extension bracing, topical application of hand-held instruments to areas of soft tissue-dysfunction by a trained physical therapist over several outpatient sessions, and use of a low load stretch device. Manipulation under anesthesia is indicated in patients after TKA having less than 90 degrees ROM after 6 weeks, with no progression or regression in ROM. Other operative treatments range from a downsizing exchange of the polyethylene bearing to revision with a constrained device and low-dose irradiation in cases of severe arthrofibrosis

Introduction. Post-meniscectomy syndrome is broadly characterised by intractable pain following the partial or total removal of a meniscus. There is a large treatment gap between the first knee pain after meniscectomy and the eligibility for a TKA. Hence, there is a strong unmet need for a solution that will relieve this post-meniscectomy pain. Goal of this first-in-man study was to evaluate the safety and performance of an anatomically shaped artificial medial meniscus prosthesis and the accompanying surgical technique. Methods. A first-in-man, prospective, multi-centre, single arm clinical investigation was intended to be performed on 18 post-medial meniscectomy syndrome patients with limited underlying cartilage damage (Kellgren Lawrence scale 0–3) in the medial compartment and having a normal lateral compartment. Eventually 5 patients received a polycarbonate urethane mediale meniscus prosthesis (Trammpolin® medial meniscus prosthesis; ATRO Medical B.V., the Netherlands) which was clicked onto two titanium screws fixated at the native horn attachments on the tibia. PROMs were collected at baseline and at 6 weeks, 3, 6, 12 and 24 months following the intervention including X-rays at 6, 12 and 24 Months. MRI scans were repeated after 12 and 24 months. Results. The surgical technique to select the appropriately sized implant and correct positioning of the fixation screws and meniscus prosthesis onto the tibia was demonstrated feasible and reproducible. The surgeries showed that in particular the positioning of the posterior screw is crucial for correct positioning of the prosthesis. Inclusion stopped after 5 patients, who reached the 6 months evaluation. The PROMs did not improve in the first 6 months after surgery. All patients reported knee joint stiffness and slight effusion in their knee at 6 months follow-up. In case of symptomatic patients an evaluation of the device position and integrity was performed by MRI. In three patients the implants were removed because of implant failure and in one patient the implant was removed because of persistent pain and extension deficit. At present one patient has the implant still in situ. The explantations of the implants demonstrated no articular cartilage damage and the fixation screws were securely anchored. Discussion. This is the first clinical study with an artificial meniscus-like prosthesis. Except one, all implants were removed due to implant breakage or discomfort of the patient. Analysis of the torn implants showed fatigue failure resulting from the lack of loadsharing between implant and cartilage: the implant was too stiff and carried all the load in the medial compartment of the knee. Furthermore, the fixation with screws seemed too rigid which restricted the motion of the posterior horn. Based on previous in vitro and animal experiments, we expected more creep of the material and more motion on the screw fixation. Conclusion. This first-in-man clinical study demonstrates that the investigated device design is not safe and did not perform as expected. Therefore, modification of the meniscus prosthesis design and fixation technique is required to allow for more motion of the meniscus prosthesis during knee joint movement

The etiology of the flexion contracture is related to recurrent effusions present in a knee with end-stage degenerative joint disease secondary to the associated inflammatory process. These recurrent effusions cause increased pressure in the knee causing pain and discomfort. Patients will always seek a position of comfort, which is slight flexion. Flexion decreases the painful stimulus by reducing pressure in the knee and relaxing the posterior capsule. Unfortunately, this self-perpetuating process leads to a greater degree of contracture as the disease progresses. Furthermore, patients rarely maintain the knee in full extension. Even during the gait cycle the knee is slightly flexed. As their disease progresses, patients limit their ambulation and are more frequently in a seated position. Patients often report sleeping with a pillow under their knee or in the fetal position. All of these activities increase flexion contracture deformity. Patients with excessive deformity >40 degrees should be counseled regarding procedural complexity and that increasing constraint may be required. Patients are seen pre-operatively by a physical therapist and given a pre-arthroplasty conditioning program. Patients with excessive flexion contracture are specifically instructed on stretching techniques, as well as quadriceps rehabilitation exercises. Avoiding Pitfalls and Complications: Treating patients with flexion contracture involves a combination of bone resection and soft tissue balance. One must make every effort to preserve both the femoral and tibial joint line. In flexion contracture the common error is to begin by resecting additional distal femur, which may result in joint line elevation and mid-flexion instability. The distal femoral resection should remove that amount of bone being replaced with metal. Attention should be directed at careful and meticulous balance of the soft tissues and release of the contracted posterior capsule with re-establishment of the posterior recess, which will correct the majority of flexion contractures. Residual Flexion Contracture: Inability to achieve ROM after TKA represents a frustrating complication for both patient and surgeon. Non-operative treatments for the stiff TKA include shoe lift in contralateral limb, stationery bicycle with elevated seat position, extension bracing, topical application of hand-held instruments to areas of soft tissue-dysfunction by a trained physical therapist over several outpatient sessions, and use of a low load stretch device. Manipulation under anesthesia is indicated in patients after TKA having less than 90 degrees ROM after 6 weeks, with no progression or regression in ROM. Other operative treatments range from a downsizing exchange of the polyethylene bearing to revision with a constrained device and low-dose irradiation in cases of severe arthrofibrosis

Over recent years chondrocyte implantation (MACI) has become a recognised procedure. This paper presents the results of two players in the national rugby league competition who play first grade football and have undergone the procedure. Professional sports medical care can be difficult. Demands from players, the public and coaches are beyond our normal requirements as surgeons. Faced with two high-profile players with career ending focal grade 4 chondral lessions and not responding to our normal treatment methods, I performed chondrocyte implantation (MACI) to deal with this. Both players have responded well to treatment and returned to first grade football. The two players in question had focal grade 4 chondral lesions. They had not responded to treatment and had recurrent effusions restricting their ability to play. Player A required a revision acl reconstruction as he was to be away from the game for a year. I treated his chondral lesion with MACI. His effusion settled and he returned to play with no further delays other than those expected from the acl surgery. Encouraged by this result, I performed the second procedure on a very high- profile player who had recurrent pain and effusion and had been treated with arthroscopies with little improvement. Faced with retirement, he opted for the procedure and returned to first grade the following season

Total Knee Arthroplasty (TKA) patients may present with effusion, pain, stiffness and functional impairment. A positive metal hypersensitivity (positive LTT) may be an indication for a revision surgery with a custom-made implant devoid of any hypersensitivity-related metal or an implant with the least possible ion content of the metal hypersensitivity, if no custom-made is available. The purpose of the current study is to assess the prevalence of metal hypersensitivity in subjects requiring a primary TKA and assess their early functional outcomes. We are recruiting 660 subjects admitted for TKA. Subjects are randomly assigned to 2 groups: oxidized zirconium implant group or cobalt-chrome implant group. Functional outcomes and quality of life (QoL) are measured pre operatively, 3, 6 and 12 months post operatively with WHOQOL-BREF (domain1-Physical Health, domain 2- Psychological, domain 3- Social relationships, domain 4-Environment), KSS, KOOS and pain Visual Analog Scale (VAS). LTT and metal ions are evaluated pre operatively and 12 months post-surgery. One hundred-sixty patients, 98 women, were enrolled in the study. Mean age was 65.6±8.9. Mean follow up (FU) was 7.1±3.8 months. Eighty-one (50.6%) were randomised in the cobalt-chrome group. Infection rate was 1.9%, one patient required debridement. Three patients (1.9%) presented with contracture at three months FU. At 12 months, WHOQOL-BREF domain 1, 2 and 4 improved significantly (p0,05). Overall, all 160 patients improved their functional outcomes and QoL. At 12 months, VAS scores decreased from 7±2.06 at baseline to 1.95±2.79. Furthermore, the high prevalence of positive LTT (27/65) do not seem to affect early functional outcomes and QoL on patients that may have received a potential implant with hypersensitivity (18/27)

Tropical pyomyosistis is an uncommon condition in the United Kingdom. Early diagnosis and appropriate treatment are crucial for a good outcome. We had seen 13 cases in our previously published series from 1998 to 2009. This is an update showing a significantly increased incidence from 2010 to 2016. A retrospective review of all cases of pelvic pyomyositis in our centre from January 2010 to April 2016 was undertaken from case notes and radiology reports. All children with clinical and radiographic evidence of pyomyositis were included. Since our previous publication we had changed our practice to get an MRI scan in all children who presented with a limp, fever and raised inflammatory markers, and had no effusion in the hip ultrasound scan. We identified 24 children with a mean age of 7 years (range, 1 week to 14 years). MSSA (Methicillin-Sensitive Staphylococcus aureus) was the most common cultured organism (n=8). Median hospital stay was 9 days (3 to 12). Obturator internus was the most common muscle affected. All patients had appropriate antibiotics with 2 patients requiring surgical drainage of abscesses. The majority of children (n=22) showed a complete recovery with antibiotics only. Incidence of pyomyositis has increased dramatically in our population and early diagnosis can result in a good outcome. We recommend MRI scan in all patients who present with a clinical picture of septic arthritis of the hip but with no effusion

Background. Septic arthritis diagnostic is an emergency which implies a treatment with antibiotics and hospitalization. The diagnosis is based on the cytobacteriological examination of the synovial fluid (SF), but direct bacteriological examination is insensitive, and the result of the culture is obtained only after several days. Therefore, there is still a need for a rapid, simple and reliable method for the positive diagnosis of septic arthritis. Such method must allow avoiding both unrecognized septic arthritis leading to major functional consequences, and overdiagnosis that will induce unnecessary expensive hospitalization and unjustified treatment. Mid-infrared (MIR) spectroscopy, that gives a metabolic profiling of biological fluids, has been proposed for early and fast diagnosis. Objectives. To confirm the MIR spectroscopy to discriminate SF samples from patients with septic arthritis from other causes of joint effusion. Methods. Synovial fluids from 402 patients referred for suspected arthropathies were prospectively collected in six hospitals and stored at °80°C. The infrared absorption spectrum was acquired for each of the frozen samples using a chalcogenide fiber biosensor. The most informative spectral variables were selected and then used to develop an algorithm. Then, the algorithm has been validated on independent synovial fluids collected straight after arthrocentesis from 86 patients. Results. The calibration (n=402) and validation (n=86) cohorts consists of synovial fluid samples from patients exhibiting various etiologies. These samples (n=488), by using SF bacteriological analysis and culture and 16S PCR analysis were classified as septic arthritis (n=43) or non-septic arthritis (n=443). On the calibration cohort, the performances of the algorithm show a sensitivity of 90%, a specificity of 90%, a NPV of 99% and a PPV of 41%, the area under the ROC curve (AUROC) was 0.95. On the validation cohort, the performances of the algorithm show a sensitivity of 92%, a specificity of 81%, a NPV of 98% and a PPV of 46%, the area under the ROC curve (AUROC) was 0.90. Conclusions. This study confirms the diagnostic performances of MIR spectroscopy for the discrimination between septic and non-septic synovial fluids. The high negative predictive value and the very short time (within ten minutes) required to obtain the result makes it possible to quickly rule out an infection diagnosis

Introduction. Adverse reaction to metal debris (ARMD) is an increasingly recognised complication of metal-on-metal hip arthroplasty. A previous study described poor results following revision and recommended early intervention. 1. We determined the outcome of revision for ARMD and present the largest case series to date. Methods. Between 2005 and 2010, 98 patients (101 hips) underwent revision for ARMD. The diagnosis of ARMD was based on clinical history, examination, appearance at revision and histology. Patients were reviewed at 3, 6 and 12 months and annually thereafter. Patient satisfaction, Harris hip scores (HHS) and metal ions were analysed. Results. 54 patients (55 hips) with an average age of 58 years (29 to 81 years) completed minimum one year follow-up (range 1 to 5 years). The mean HHS improved from 49.7 (10 to 79) to 86.3 (40 to 100). Forty-five (81%) patients were satisfied and nine (16%) patients were not satisfied with the outcome. The mean serum cobalt 24.5 (1.65 to 96.6) improved to 1.17 (0.31 to 6.99). Two patients died from unrelated diseases. There were 8 (14%) dislocations and one (1.8%) sciatic nerve palsy that has not recovered. Eight (14%) patients needed re-revision (dislocation: 5 and pain: 3). 26 % had severe soft tissue damage. Six patients have persistent pain and four had recurrent effusions. There were no dislocations in the most recent 50 cases. Discussion. Treatment of ARMD is technically demanding because extensive soft tissue damage can compromise stability. Early results in the current study were promising. Early intervention reduced the dislocation rate and appeared to have a positive impact on outcome. A small group of patients may have persistent pain and recurrent effusions that may require re-revision

Introduction. Metal on metal hip resurfacing arthroplasty (MoM HR) has the highest revision rates according to the UK National Joint Registry. Revisions for lesions associated with soft tissue necrosis (pseudotumors) have been associated with poor outcomes. There is a relative paucity of information on early revision of painful HR prostheses. We present the results of a series of patients who underwent early revision of painful MoM HR procedures. Methods. This prospective study involved a consecutive series of patients undergoing revision of HR to THA. The diagnoses leading to revision are discussed. Clinical and radiological assessments were performed pre operatively as well as 6 weeks, 12 months postoperatively and yearly thereafter. Pre and post operative Harris Hip Score, Oxford Hip Score and WOMAC scores were calculated. Patient satisfaction was assessed using a visual analogue scale. Results. Revisions were performed for recurrent pain and effusion, infection and proximal femoral fractures. Both components were revised in 20 cases. There were 12 male and 13 female patients with average time to revision of 34.4 and 26.4 months respectively. The mean follow up period was 12.7 months (3 to 31). All patients reported relief of pain and excellent satisfaction scores (9/10 compared to 2/10 pre-operatively). Two patients experienced stiffness up to three months post operatively. Pre operative Oxford, Harris and WOMAC hip scores were 39.1, 36.4 and 52.2 respectively. Mean post operative scores at last follow up were 17.4, 89.8 and 6.1 respectively (p< 0.0001 for each score). All patients except those with femoral neck fractures had at least a small effusion. Conclusion. These results show that conversion of painful hip resurfacing prostheses to total hip arthroplasty is associated with improved function, pain relief and high levels of patient satisfaction

In years past, the most common reason for revision following knee replacement was polyethylene wear. A more recent study indicates that polyethylene wear is relatively uncommon as a cause for total knee revision counting for only 10% or fewer of revisions. The most common reason for revision currently is aseptic loosening followed closely by instability and infection. The time to revision was surprisingly short. In a recent series only 30% of knees were greater than 5 years from surgery at the time of revision. The most common time interval was less than 2 years. This is likely because of the higher incidence of infection and instability that occurs most commonly at a relatively early time frame. Evaluation of a painful total knee should take into account these findings. All total knees that are painful within 5 years of surgery should be assumed to be infected until proven otherwise. Therefore, virtually all should be aspirated for cell count, differential, and culture. Alpha-defensin is also available in cases in which a patient may have been on antibiotics within a month or less, as well as cases in which diagnosis is a challenge for some reason. Instability can be diagnosed with physical exam focusing on mid-flexion instability which can be usually determined with the patient seated and the knee in mid-flexion, with the foot flat on the floor at which point sagittal plane laxity can be discerned. This is also frequently associated with symptoms of giving way and recurring effusions and difficulty descending stairs. A new phenomenon of tibial de-bonding has been described, which can be a challenge to diagnose. Radiographs can appear normal when loosening occurs between the implant and the cement mantle. This seems to be more common with the use of higher viscosity cement. Obviously this is technique dependent since good results have been reported with the use of high viscosity cement. Component malposition can cause stiffness and pain and relatively good results have been reported by component revision when malrotation has been confirmed with CT scan. When infection, instability and loosening are not present, extra-articular causes should be ruled out including lumbar spine, vascular compromise, complex regional pain syndromes and fibromyalgia, and peri-articular causes such as bursitis, tendonitis, tendon impingement among others. One of the most common causes of pain following total knee is unrealistic patient expectations. Performing total knee replacement in early stages of arthritis with only mild to moderate symptoms and radiographic changes has been associated with persistent pain and dissatisfaction. It may be prudent to obtain the immediate preoperative x-rays to determine if early intervention was undertaken and patients have otherwise normal appearing total knee x-rays and a negative work up. A recent study indicated that this was likely a cause or a major contributing factor to persistent pain following otherwise a well performed knee replacement. A national multicenter study of the appropriateness of indications for TKA also indicated that early intervention was a major cause of persistent pain, dissatisfaction, and failure to improve following total knee replacement

Uncemented metal-on-polyethylene total hip arthroplasties (THAs) have had a modular cobalt-chrome alloy head since their introduction in the early 1980's. Retrieval analysis studies and case reports in the early 1990's first reported corrosion between the femoral stem trunnion (usually titanium alloy) and cobalt-chrome alloy femoral head. However, then this condition seemed to disappear for about two decades? There are now numerous recent case series of this problem after metal-on-polyethylene THA, with a single taper or dual taper modular femoral component. Metal ion elevation, corrosion debris, and effusion are caused by mechanically assisted crevice corrosion (MACC). These patients present with diffuse hip pain, simulating trochanteric bursitis, iliopsoas tendinitis, or even deep infection. Trunnion corrosion, with adverse local tissue reaction, is a diagnosis of exclusion, after infection, loosening, or fracture. The initial lab tests recommended are: ESR, CRP, and serum cobalt and chromium ions. With a metal-on-polyethylene THA, a cobalt level > 1ppb is abnormal. Plain radiographs are usually negative, but may show calcar osteolysis or acetabular erosion or cyst. MARS MRI may be the best imaging study to confirm the diagnosis. Hip aspiration for culture and cell-count may be necessary. The operative treatment is empiric, with debridement, and head exchange with a ceramic head-titanium sleeve (or oxidised zirconium head) placed on the cleaned trunnion. The femoral component may have to be removed if there is “whole trunnion failure”. This usually relieves the symptoms, but the complication rate of this procedure may be high

Total Knee Arthroplasty (TKA) necessitates disruption of well vascularised tissue during exposure and soft tissue release as well as from the cutting of bone, and thus bleeding into the joint space routinely occurs to some degree following TKA. Defining a complication from bleeding is not necessarily straightforward, but includes 3 different conditions: hemarthrosis, hematoma, and bloody wound drainage. All of these conditions can be seen in the normal post-operative setting, and when mild may be simply observed. However, persistent swelling resulting in clinical symptoms should be appropriately treated. A hemarthrosis is defined as blood being contained in the knee capsule. Although some bleeding is expected, “excessive” hemarthrosis results in increased pain limiting or difficulty regaining motion. If high levels of fluid pressure are present, rupture of the arthrotomy may occur. A hematoma occurs when intra-articular blood escapes the arthrotomy and drains into the overlying soft tissues. This may occur following performance of a large lateral release or an insufficient arthrotomy closure or simply secondary to a large hemarthrosis under tension. Symptoms include ecchymosis, soft tissue swelling, and potential skin complications. Increased pain and limited range of motion frequently accompany these symptoms. Wound drainage may present as a knee that continues to have bloody or serous drainage that continues long after the first or second dressing change. It is this continued wound drainage that is most worrisome with increased wound infection rates when prolonged drainage is allowed to persist. The incidence of post-operative hemarthrosis as a clinical problem is not well studied, but the need for surgical treatment is uncommon. Recurrent hemarthrosis is also relatively rare after total knee arthroplasty and has been reported at rates between 0.3% and 1.6%. The etiology of this complication can be systemic or local, and initial work-up should include coagulation studies to rule out any underling systemic coagulopathy. Conservative therapy including rest, cooling, and elevation is the preferred treatment for mild cases. If conservative treatment is not successful, or the acute hemarthrosis is clinically tense, interfering with recovery, or threatening wound healing, drainage may be the preferable option. This can be done by opening the arthrotomy in the operating room or through a large bore arthroscopy cannulae. Careful attention to debridement of clotted blood must be followed by a meticulous search for potential sources of bleeding which should be managed appropriately. Recurrent hemarthrosis may occur at any time after surgery. Repeated bleeding episodes may lead to an inflammatory cascade that propagates bleeding events more readily. If coagulation studies are normal, the most common source is the impingement of proliferative synovium or other retained soft tissue between the articulating components of the knee prosthesis. Other causes include damage to the geniculate or popliteal vessels with pseudo aneurysm formation. Mild to moderate clinical knee instability may be associated with bloody synovial effusions but limited clinical complaint specific to instability. Other causes may be multifactorial and synergistic but are not well understood, making diagnosis and treatment more difficult. If symptoms persist, and the resulting disability is sufficient, classical treatment has consisted of open or arthroscopic synovectomy. Over the past decade angiography and angiographic embolization of the source of bleeding has been shown to be successful. Radio-active synovectomy has also been successful

A total knee replacement (TKR) with instability is one in which the supporting soft tissues have failed or are unable to function due to component size and/or position. Instability following TKR can lead to the need for surgery in 10–22% of revision cases. Patients may complain of symptoms of giving way, difficulty climbing stairs, and the sensation that their knee may buckle under stress. Physical findings may include soft-tissue tenderness in the peripatellar and pes anserine regions, recurrent joint effusions, and joint laxity. The cause of instability after TKR should be determined pre-operatively so the problem may be corrected at the time of revision. Instability after TKR may be due to component loosening, ligament rupture/incompetence, component malposition, mismatched flexion/extension gaps, or failure to correct ligament imbalance at the time of the index procedure. A common scenario after a cruciate-retaining TKR is that of PCL rupture, thus leading to instability in flexion and excessive posterior translation of the tibia. Other scenarios leading to TKR instability are pre-operative valgus alignment with MCL stretching, resulting in the post-operative recurrence of medial instability; or excessive resection of the posterior femoral condyles from undersizing of the femoral component, leading to laxity in flexion. The treatment of instability after TKR generally requires component revision and balancing of the flexion and extension gaps. Isolated ligament reconstruction is not successful in the setting of a prosthetic joint due to the lack of inherent joint stability. At the time of revision, the surgeon must carefully assess the flexion gap; often posterior femoral augments must be used to upsize the femoral component and tighten the flexion space relative to the extension space; for this reason, isolated polyethylene exchange is not successful for flexion instability. For instability in the varus/valgus plane, rebalancing the knee by performing ligament releases and using a more stabilizing polyethylene insert may by sufficient. The results of revision TKR for instability has been successful in the majority of cases, decreasing the symptoms of giving way and difficulty stairclimbing. A careful assessment of the varus/valgus stability of the prosthetic knee and the flexion/extension spaces at the time of revision TKR, along with the use of augments and more stabilised articulations, is mandatory in order to achieve good results

We report a case of fatal heart failure caused by cobalt intoxication after revision THR in the patient who successfully underwent re-revision THR. 53-year old male presented to emergency room in our hospital with progressive shortness of breath. Symptom was started about 6 months ago so he visited local hospital. He worked up for worsening dyspnea. Simple chest radiograph and enhanced heart MRI study were performed and they showed bilateral pericardial and pleural effusion. There was no evidence of ischemic change. Transthoracic echocardiogram showed the evidence of heart failure, left ventricular ejection fraction(EF) was 40%. He was admitted at local hospital and started on vasopressors but urine output was decreased and follow-up echocardiogram showed a 25% of EF. Patient recommended heart transplantation and transferred our hospital emergency room. He underwent sequential bilateral total hip arthroplasties using CoP bearing surfaces. At 12 years postoperatively, he presented to the other hospital with acute onset of left hip pain. He was diagnosed ceramic head fracture on his left hip. Head and liner change revision surgery was performed using Cobalt-Chrome alloy 28mm metal head and Protruded cross-linked polyethylene liners. In our hospital, the patient admitted cardiovascular department of internal medicine. Patient complained nonspecific fatigue and general weakness but had no other symptoms such as visual and hearing loss, cognitive dysfuction. During work-up, patient presented progressive left hip pain and complaint of discomfort for the mass on the left groin. He also complained Left leg weakness and numbness. Simple radiograph and enhanced CT study was done. Simple radiograph image shows radiodense area around the hip joint and radiologist suspected heterotopic ossification. The cardiovascular department consulted orthopedic department. In the image findings showed huge mass combined hemorrhagic component lining acetabular component extending psoas compartment and eccentric wear on cobalt-chrome alloy metal head. Also highly radiodense material was seen around neck inferor portion and severly deformed metal head was seen. It was highly suspected that metal related granuloma, which means severe metallosis. Performed heavy metals screen, cobalt levels were 397,800 μg/Land chrome levels were 236,000 μg/L suggesting cobalt toxicity. Hip joint aspiration was done for decompression as radiologic intervention and EDTA (ethylenediamine tetraacetate) chelation therapy started immediately. After 10 cycle chelating therapy, metal level was lowered cobalt levels by 255.2μg/L and chrome levels by 39.5 μg/L. When hospital day after 134, Medical condition of the patient was getting improved, we underwent revision surgery using ceramic on ceramic bearing surface. The patient discharged postoperative 79 days. Final heavy metals screen results were 27.79μg/L on cobalt and 22.17μg/L on chrome. Although there were also reported a good clinical result of revision surgery using MoP bearing, and some surgeons reluctant to use CoC articulation because of concerns about re-fracture of ceramic. But take into account like this devastating complication after cobalt-chrome wear caused by remained ceramic particles, we should carefully select which bearing is safer

In the knee, involvement is mainly synovial, with local extension eroding the bone. Pure tuberculous osteitis is rare, with a few occasional reports. Patella tuberculosis is extremely rare. We report the case of patella tuberculosis with 7-years decline. A 10-years old boy suffered from knee siftness and pain. The patient had correct BCG vaccination. Clinical examination was relatively unrevealing, with tenderness on palpation of the medial joint surface of the patella, patellar crepitation, and slight effusion. On standard X-ray, the lateral view showed a circumferential rosette form with a light peripheral halo. The patient underwent open surgery with a medial parapatellar approach and arthrotomy. Joint fluid was sampled. Direct exploration of the medial side of the patella found soft but continuous cartilage on palpation. The histoligical examination confirmed the diagnosis of tuberculosis. The patient had 12 month anti-tuberculosis chemotherapy. After 7 years of the treatement, the patient had no recurrence and good clinical result. Bone tuberculosis remains difficult to diagnose. Certain locations should always be borne in mind, however rare, in case of pandemic or immunodeficiency. In case of osteolysis, associated with abscess or not, infectious etiology is to be considered and appropriate samples should be taken. Diagnosis is confirmed by histology and bacteriology. The slow evolution of bone tuberculosis requires local treatment of lesions and abscesses. Antibiotherapy regularly ensures recovery

We all aware about overuse syndrome, as compensation of other parts of body. Our famous poet Sa'adi: when part of our body sustains become painful, the other parts can't tolerate and reciprocate. Among our patients who underwent total Knee arthroplasty few of them have pain especially in 1st 3 months (Anterior Knee pain, effusion, ….) but almost 15 – 20 percents are not satisfied enough by this Procedure. In a Cohort historic study on 301 TKA with at least 2 years follow up 47 patients had not enough satisfaction in our clinic we tried to visit them to find out why?. Criteria's we chose, were:. Age. Osteopenia. Sarcopenia. Low back pain. Spinal canal stenosis. Shoulders. Unstable blood pressure. Neuropathy. Eyes dysfunction. We exclude those who had problem by their new knees. 11 patients, all have been over age 68 years, and duration of start of symptoms in knee (s) to the surgery were more than 12 years, clearly showed painful arch of shoulder motion or frozen shoulder or established gleno humeral alone or G.H. and A.C. joints OA. Conclusion. Because of abnormal stand up of long lasting knee OA patients, they start to put pressure on their shoulder to climb on their body. Even their cane or crutches use are not in regular and academic rules. So, we nominate this entity: shoulder knee syndrome as a negative criteria that interferes in out come