Aims. The aim of the British Association for Surgery of the Knee (BASK) Meniscal Consensus Project was to develop an evidence-based treatment guideline for patients with meniscal lesions of the knee. Materials and Methods. A formal consensus process was undertaken applying nominal group, Delphi, and appropriateness methods. Consensus was first reached on the terminology relating to the definition, investigation, and classification of meniscal lesions. A series of simulated clinical scenarios was then created and the appropriateness of arthroscopic meniscal surgery or nonoperative treatment in each scenario was rated by the group. The process was informed throughout by the latest published, and previously unpublished, clinical and epidemiological evidence. Scenarios were then grouped together based upon the similarity of clinical features and ratings to form the guideline for treatment. Feedback on the draft guideline was sought from the entire membership of BASK before final revisions and approval by the consensus group. Results. A total of 45 simulated clinical scenarios were refined to five common clinical presentations and six corresponding treatment recommendations. The final guideline stratifies patients based upon a new, standardized classification of symptoms, signs, radiological findings, duration of symptoms, and previous treatment. Conclusion. The 2018 BASK Arthroscopic Meniscal Surgery Treatment Guidance will facilitate the consistent identification and treatment of patients with meniscal lesions. It is hoped that this guidance will be adopted nationally by surgeons and help inform healthcare commissioning guidance. Validation in clinical practice is now required and several areas of uncertainty in relation to treatment should be a priority for future high-quality prospective studies. Cite this article: Bone Joint J 2019;101-B:652–659

Abstract

Abstract. Introduction. Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons. Methods. At a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centering and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies, and meniscectomy. Pre and post-experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement. Results. Comparing pre and post-experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were noted in time taken to complete, distance covered in metres and roughness of instruments used on the simulated exercises on repeat performance (p<0.05). Conclusion. With only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience

Abstract. Introduction. Knee braces are limited to providing passive support. There is currently no brace available providing both continuous monitoring and active robot-assisted movements of the knee joint. This project aimed to develop a wearable intelligent motorised robotic knee brace to support and monitor rehabilitation for a range of knee conditions including post-surgical rehabilitation. This brace can be used at home providing ambulatory continuous passive movement obviating the need for hospital admissions. Methodology. A wearable sensing system monitoring knee range of motion was developed to provide remote feedback to clinicians and real-time guidance for patients. A prototype of an exoskeleton providing dynamic motion assistance was developed to help patients complete their exercise goals and strengthen their muscles. The accuracy and reliability of those functions were validated in human participants during exercises including knee flexion/extension (FE) in bed and in chair, sit-to-stand and stand-to-sit. Results. The knee FE measurement from the sensing system showed high accuracy (correlation coefficient of 0.99°) in human participants. The real-time FE data during exercises showed that the desired exoskeleton rotation fitted well with the participant's knee rotation. This indicated the exoskeleton could coordinate with the participant's knee motion by providing consistent motion assistance. The development of user interfaces to provide feedback is currently underway. Conclusion. A wearable robotic knee brace to monitor and support knee rehabilitation exercises was successfully developed. Further development of this device with the use of artificial intelligence has the potential to aid patient rehabilitation in a variety of knee conditions

Aims. Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up. Methods. This prospective study included 16 patients undergoing robotic arm-assisted revision of UKA to TKA versus 35 matched patients receiving robotic arm-assisted primary TKA. In all study patients, the following data were recorded: operating time, polyethylene liner size, change in haemoglobin concentration (g/dl), length of inpatient stay, postoperative complications, and hip-knee-ankle (HKA) alignment. All procedures were performed using the principles of functional alignment. At most recent follow-up, range of motion (ROM), Forgotten Joint Score (FJS), and Oxford Knee Score (OKS) were collected. Mean follow-up time was 21 months (6 to 36). Results. There were no differences between the two treatment groups with regard to mean change in haemoglobin concentration (p = 0.477), length of stay (LOS, p = 0.172), mean polyethylene thickness (p = 0.065), or postoperative complication rates (p = 0.295). At the most recent follow-up, the primary robotic arm-assisted TKA group had a statistically significantly improved OKS compared with the revision UKA to TKA group (44.6 (SD 2.7) vs 42.3 (SD 2.5); p = 0.004) but there was no difference in the overall ROM (p = 0.056) or FJS between the two treatment groups (86.1 (SD 9.6) vs 84.1 (4.9); p = 0.439). Conclusion. Robotic arm-assisted revision of UKA to TKA was associated with comparable intraoperative blood loss, early postoperative rehabilitation, functional outcomes, and complications to primary robotic TKA at short-term follow-up. Robotic arm-assisted surgery offers a safe and reproducible technique for revising failed UKA to TKA. Cite this article: Bone Joint J 2024;106-B(7):680–687

Abstract. Introduction. Failing total knee replacement management has included isotope bone scan to identify infection or loosening. BASK guidance suggests bone scans have a poor positive predictive value and are not advised. We assessed isotope bone scanning as a negative predictor to exclude loosening or infection in failing total knee replacement. Methodology. Retrospective review of consecutive bone scans performed to investigate painful total knee replacements for a one-year period (June 2017 to June 2018). 166 bone scans performed. 33 excluded (no notes or scan for other reasons). Demographic information, age of prosthesis, clinic review date, serological markers, results of aspiration and subsequent intraoperative findings also recorded. Results. 133 patients, mean age 72.7, average age of prosthesis 6.8 years. 45% scans performed showed evidence of infection or loosening. Of those positive scans, 70% had aspiration and consideration for revision surgery. 73 patients had negative scans. 2 patients had subsequent aspiration and in 1 patient, S. Epidermidis isolated (1 patient had patellar revision and further samples clear of and other patient declined further surgery). Conclusion. Isotope bone scan had a 97.2% negative predictive value making it a very useful tool to evaluate the failing knee replacement and exclude significant loosening or infection

Abstract. Introduction. Spinal local anaesthesia and opioids have long been used as peri-operative analgesia for patients undergoing arthroplasty procedures. However, intrathecal opioids are associated with numerous complications. ERAS. ®. society guidelines for elective knee replacement (2019) strongly discourage the use of spinal opioids. This study aims to report the impact of low-dose spinal and local infiltrative analgesia on patients undergoing elective knee replacement. Methodology. Retrospective cohort study of patients undergoing knee replacement under the ERAS protocol over 2 years, at a district general hospital under the care of a single surgeon. Results. A total of 80 knee replacements were included in the study (M38:F42, mean age=72.7, mean BMI=31, ASA: 1=8, 2=54, 3=18). 91% received neuroaxial anaesthesia, 89% without intrathecal opioids. Local infiltrative analgesia was used in 99% of patients. The mean length of stay was significantly shorter (2 days), when compared to patients undergoing elective knee replacements without adherence to ERAS. ®. guidance (3.8 days), P<0.001. The average maximum pain score in PACU was 0.8 (0=no pain, 10=maximum pain). All patients were mobilised within 24 hours of surgery. No patients were readmitted within 30 days. 2 patients returned to theatre (retained surgical clip and MUA for stiffness). Conclusions. The implementation of ERAS. ®. guidelines has demonstrated significantly reduced admission days following elective knee arthroplasty. Combined with low complication rates, the reduction in admission days may result in increased hospital bed availability. This has the potential to positively impact elective arthroplasty waiting lists. Further research is underway to evaluate patient-reported outcome measures in this group

Abstract. Introduction. The NHS long term plan endorses ‘personalised’, ‘digitally enabled’, ‘out of hospital’ care. Multiagency guidance (CPOC(2021)/NICE(2021)/GIRFT(2021)/NHSX(2021)) advocates an integrated ‘pathway’ approach to information sharing, shared-decision making and patient support. Digital solutions are the vehicle to deliver these agendas. Methods. In 2018 we developed a digital joint pathway (DJP) spanning the surgical care pathway (prehabilitation to rehabilitation) using the GoWellHealth platform. Patients listed for joint replacement are offered the DJP as routine care. Activity and engagement are monitored using the DJP data library. We sought to evidence our DJP by assessing patient engagement, experience and outcomes (OKS/EQ5D/Readmission). Results. Engagement. Consecutive cohort of the first 1195 patients registered. Activation rates were >85% and >70% viewed content within the DJP (median=15 access/pt; mean=83 minutes on DJP/pt). Engagement was similar irrespective of age and gender (p=NS). Older patients preferred to access via a computer. Experience. Qualitative interviews (n=14) demonstrated patients felt the DJP impacted positively on their health behaviours and contributed to their recovery. They spoke positively about the use of technology and the accessibility of the DJP. Outcomes. Comparison of patients on the DJP versus those not on the DJP using adjusted regression models demonstrated improved EQ5D=0.070 (95%CI=0.004-0.135,p=0.04), OKS=5.0 (95%CI=2.2-7.8,p<0.001) and readmission rates (3.6% versus 5.6%,p<0.01) for DJP patients. Conclusions. A DJP model for information delivery and patient support, across the entirety of the surgical pathway, is feasible and demonstrates high levels of patient engagement, experience and improved patient outcomes

Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Abstract. Introduction. The paediatric population present unique challenges to the knee surgeon, particularly when treating recurrent patellofemoral instability(PFI), the management of which is poorly standardised. Through the EPPIC BASK National Trainee Collaborative, we aimed to identify which procedures (and in which combination) are being used to surgically manage recurrent PFI in skeletally immature patients across the UK. Methods. A retrospective national service evaluation via a trainee collaborative analysing local trust data between 1st January 2014 and 31st December 2019. Data from institutions registered for EPPIC was compiled and compared to the national guidelines for adults. Results. A total of 333 patients were classified as skeletally immature(radiologically open physes) across 28 hospitals. Mean age was 14.1 years(+/- 4.5) with 64.9% being female. Mean number of procedures performed was 11.9 (+/-16.4). Isolated medial patellofemoral ligament reconstruction (MPFLR) was the most common procedure, performed in 65.8% of patients. Combined MPFLR and TTO was undertaken in 13.2% of patients. Proximal realignment surgery was performed in 5.1% of patients. Lateral releases were performed in 18.3% of patients with 8.4% performed in isolation. Conclusion. This study highlights the national variation in surgical treatment of PFI in skeletally immature patients. The guidance for adults cannot be applied universally to the skeletally immature, and it not always acceptable to delay treatment until physes close. This lack of standardisation within the UK in the management of recurrent PFI in skeletally immature patients highlights the need for a national consensus in appropriate surgical management of this patient population

Aims

Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA), and has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA.

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Knee osteoarthritis (OA) is characterized by a chronic inflammatory process involving multiple cytokine pathways, leading to articular cartilage degeneration. Intra-articular therapies using pharmaceutical or autologous anti-inflammatory factors offer potential non-surgical treatment options. Autologous protein solution (APS) is one such product that uses the patient’s blood to produce a concentrate of cells and anti-inflammatory cytokines. This study evaluated the effect of a specific APS intra-articular injection (nSTRIDE) on patient-reported outcome measures compared to saline in moderate knee OA.

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To assess the cost-effectiveness of a two-layer compression bandage versus a standard wool and crepe bandage following total knee arthroplasty, using patient-level data from the Knee Replacement Bandage Study (KReBS).

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Obtaining solid implant fixation is crucial in revision total knee arthroplasty (rTKA) to avoid aseptic loosening, a major reason for re-revision. This study aims to validate a novel grading system that quantifies implant fixation across three anatomical zones (epiphysis, metaphysis, diaphysis).

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Patient dissatisfaction is not uncommon following primary total knee arthroplasty. One proposed method to alleviate this is by improving knee kinematics. Therefore, we aimed to answer the following research question: are there significant differences in knee kinematics based on the design of the tibial insert (cruciate-retaining (CR), ultra-congruent (UC), or medial congruent (MC))?

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The aim of this study was to assess factors associated with the estimated lifetime risk of revision surgery after primary knee arthroplasty (KA).

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Blood transfusion and postoperative anaemia are complications of total knee arthroplasty (TKA) that are associated with substantial healthcare costs, morbidity, and mortality. There are few data from large datasets on the risk factors for these complications.

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Fungal periprosthetic joint infections (PJIs) are rare, but their diagnosis and treatment are highly challenging. The purpose of this study was to investigate the clinical outcomes of patients with fungal PJIs treated with two-stage exchange knee arthroplasty combined with prolonged antifungal therapy.

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This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults.

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Around the world, the emergence of robotic technology has improved surgical precision and accuracy in total knee arthroplasty (TKA). This territory-wide study compares the results of various robotic TKA (R-TKA) systems with those of conventional TKA (C-TKA) and computer-navigated TKA (N-TKA).