Aims. To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. Methods. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map. Results. After screening of 5,660 articles, we included 166 studies reporting prognostic factors for outcomes after rTKA, with a median sample size of 319 patients (30 to 303,867). Overall, 50% of the studies reported prospectively collected data, and 61% of the studies were performed in a single centre. In some studies, multiple associations were reported; 180 different prognostic factors were reported in these studies. The three most frequently studied prognostic factors were reason for revision (213 times), sex (125 times), and BMI (117 times). Studies focusing on functional scores and patient-reported outcome measures as prognostic factor for the outcome after surgery were limited (n = 42). The studies reported 154 different outcomes. The most commonly reported outcomes after rTKA were: re-revision (155 times), readmission (88 times), and reinfection (85 times). Only five studies included costs as outcome. Conclusion. Outcomes and prognostic factors that are routinely registered as part of clinical practice (e.g. BMI, sex, complications) or in (inter)national registries are studied frequently. Studies on prognostic factors, such as functional and sociodemographic status, and outcomes as healthcare costs, cognitive and mental function, and psychosocial impact are scarce, while they have been shown to be important for patients with osteoarthritis. Cite this article: Bone Jt Open 2023;4(5):338–356

Between 1987 and 2006 we performed a modified Thompson’s quadricepsplasty on 40 fracture-related stiff knees and followed the patients for a mean of 7.9 years (2 to 11.1). The factors affecting the final gain of movement were investigated. A total of 15 knees required lengthening of the rectus femoris. The mean flexion gain was 70.2° (42.3° to 112.5°). According to Judet’s criteria, the results were excellent in 30 knees, good in seven, and fair in three. The range of movement which was achieved intra-operatively was related to the gain of knee flexion on univariate analysis. Five patients had complications: deep infection in one, recurrent patellar dislocation in one, and rupture of the extensor mechanism in three. This modified technique gives satisfactory results. Achieving maximum knee flexion intra-operatively seems to be the most important factor in enhancing the outcome in patients with stiffness of the knee following fracture.

Abstract. INTRODUCTION. Geniculate nerve blocks (GNB) and ablation (GNA) are increasing in popularity as strategies for the management of knee pain in patients unsuitable for surgical intervention. Typically these simple blocks have been performed by specialists in pain medicine. We present the results of a GNB clinic run by a surgical care practitioner (SCP). METHODOLOGY. An SCP clinic was created where ultrasound-guided GNBs comprising local anaesthetic and steroid were administered. Patients considered unsuitable for surgery were referred with knee pain by orthopaedic knee surgeons and specialist physiotherapists. A VAS pain score and an Oxford Knee Score (OKS) were completed prior to and immediately following blockade. Serial VAS diaries were completed. Further OKS were requested at 6 weeks and 6 months. Patients could request GNA at any point during follow-up and their follow-up ceased at this stage. RESULTS. 50 patients were identified between December 2020 and 2021. Patients are followed up until 6 months post-block or until referral for GNA. Pre-blockade mean OKS was 13.4, mean VAS 8.6, post procedure mean VAS 2.7. Six-week mean OKS was 20.9 in those not referred for ablation, mean improvement of 7.3. Of the cohort of 50, 25 have progressed to ablation. CONCLUSION. GNB is a simple procedure which can provide both lasting symptomatic relief and prognostic information in the treatment of patients with knee pain not amenable to surgical intervention, a growing subset of patients. This SCP-led clinic increases capacity for the provision of GNBs, helping to identify patients suitable for GNA

Aims. Social determinants of health (SDOHs) may contribute to the total cost of care (TCOC) for patients undergoing total knee arthroplasty (TKA). The aim of this study was to investigate the association between demographic data, health status, and SDOHs on 30-day length of stay (LOS) and TCOC after this procedure. Methods. Patients who underwent TKA between 1 January 2018 and 31 December 2019 were identified. A total of 234 patients with complete SDOH data were included. Data were drawn from the Chesapeake Regional Information System, the Centers for Disease Control social vulnerability index (SVI), the US Department of Agriculture, and institutional electronic medical records. The SVI identifies areas vulnerable to catastrophic events with four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. Food deserts were defined as neighbourhoods located one or ten miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine associations with LOS and costs after controlling for various demographic parameters. Results. Divorced status was significantly associated with an increased LOS (p = 0.043). Comorbidities significantly associated with an increased LOS included chronic obstructive pulmonary disease/asthma and congestive heart failure (p = 0.043 and p = 0.001, respectively). Communities with a higher density of tobacco stores were significantly associated with an increased LOS (p = 0.017). Comorbidities significantly associated with an increased TCOC included chronic obstructive pulmonary disease (p = 0.004), dementia (p = 0.048), and heart failure (p = 0.007). Increased TCOCs were significantly associated with patients who lived in food deserts (p = 0.001) and in areas with an increased density of tobacco stores (p = 0.023). Conclusion. Divorced marital status was significantly associated with an increased LOS following TKA. Living in food deserts and in communities with more tobacco stores were significant risk factors for increased LOS and TCOC. Food access and ease of acquiring tobacco may both prove to be prognostic of outcome after TKA and an opportunity for intervention. Cite this article: Bone Joint J 2021;103-B(6 Supple A):113–118

Introduction. Social determinants of health (SDOH) may contribute markedly to the total cost of care (COC) for patients undergoing elective total knee arthroplasty (TKA). This study investigated the association between demographics, health status, and SDOH on lengths of stay (LOS) and 30-day COC. Methods. Patients who underwent TKA between January 2018 and December 2019 were identified. Those who had complete SDOH data were utilized, leaving 234 patients. Data elements were drawn from the Chesapeake Regional Information System, the Center for Disease Control social vulnerability index (SVI), the Food Access Research Atlas (FARA). The SVI identifies areas vulnerable to catastrophic events, with 4 themed scores including: (1) socioeconomic status; (2) household composition and disability; (3) minority status and language; and (4) housing and transportation. Food deserts were defined as neighborhoods located 1 or 10 miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine an association with LOS and cost, after controlling for demographics. Results. Increased 30-day COC associated with SVI theme 3, (3.074 days; p=0.001) and patients who lived in a food desert ($53,205; p=0.001), as well as those who had anemia ($16,112; P = 0.038), chronic obstructive pulmonary disease ($32,570, P = 0.001), congestive heart failure ($30,927, P = 0.003), and dementia ($33,456, P = 0.008). Longer hospital lengths of stay were associated with SVI theme 3. In addition, patients who had anemia and congestive heart failure were at risk for longer hospital lengths of stay (P < 0.001, P = 0.001, respectively). Conclusion. Higher SVI theme 3 scores and living in food deserts were risk factors for increased LOS and costs, respectively. Identifying social factors including a patient's transportation options, living situation and access to healthy foods may prove to be both prognostic of outcomes and an opportunity for intervention

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Despite new technologies for total knee arthroplasty (TKA), approximately 20% of patients are dissatisfied. A major reason for dissatisfaction and revision surgery after TKA is persistent pain. The radiological grade of osteoarthritis (OA) preoperatively has been investigated as a predictor of the outcome after TKA, with conflicting results. The aim of this study was to determine if there is a difference in the intensity of pain 12 months after TKA in relation to the preoperative radiological grade of OA alone, and the combination of the intensity of preoperative pain and radiological grade of OA.

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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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The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr).

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. Methods. Patients undergoing TKA between 2005 and 2015 were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were stratified based on preoperative hypoalbuminemia (<3.5 g/dL) and ASA score (≤ 2 vs. > 2). Multivariable regression analysis adjusted for age, sex, BMI, and smoking status was utilized to determine predictive potential of hypoalbuminemia and ASA score on each postoperative complication. Results. Of the 79,661 patients included in the cohort, 4.3% had preoperative hypoalbuminemia. Univariate regression analysis found significant predictive abilities of both serum albumin and ASA score on numerous postoperative complications, such as superficial infection, deep infection, MI, pneumonia, renal insufficiency, reintubation, transfusion, readmission, reoperation, and death. Interestingly, multivariable regression analysis demonstrated that hypoalbuminemia more robustly predicted postoperative deep infection than ASA. Discussion and Conclusion. Hypoalbuminemia and ASA each individually predict numerous postoperative complications following TKA. However, this study suggests that while ASA score more accurately predicts post-operative medical complications, hypoalbuminemia may be a more accurate predictor of periprosthetic infection following TKA. Ultimately, preoperative albumin should be incorporated in the pre-operative work-up routine to stratify patient risk, especially regarding postoperative infection

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The outcome of repeat septic revision after a failed one-stage exchange for periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat septic revision after a failed one-stage exchange, and to determine whether the Musculoskeletal Infection Society (MSIS) stage is associated with subsequent infection-related failure.

We investigated the prognostic indicators for collagen-covered autologous chondrocyte implantation (ACI-C) performed for symptomatic osteochondral defects of the knee. We analysed prospectively 199 patients for up to four years after surgery using the modified Cincinnati score. Arthroscopic assessment and biopsy of the neocartilage was also performed whenever possible. The favourable factors for ACI-C include younger patients with higher pre-operative modified Cincinnati scores, a less than two-year history of symptoms, a single defect, a defect on the trochlea or lateral femoral condyle and patients with fewer than two previous procedures on the index knee. Revision ACI-C in patients with previous ACI and mosaicplasties which had failed produced significantly inferior clinical results. Gender (p = 0.20) and the size of the defect (p = 0.97) did not significantly influence the outcome

Aims. While medial unicompartmental knee arthroplasty (UKA) is indicated for patients with full-thickness cartilage loss, it is occasionally used to treat those with partial-thickness loss. The aim of this study was to investigate the five-year outcomes in a consecutive series of UKAs used in patients with partial thickness cartilage loss in the medial compartment of the knee. Patients and Methods. Between 2002 and 2014, 94 consecutive UKAs were undertaken in 90 patients with partial thickness cartilage loss and followed up independently for a mean of six years (1 to 13). These patients had partial thickness cartilage loss either on both femur and tibia (13 knees), or on either the femur or the tibia, with full thickness loss on the other surface of the joint (18 and 63 knees respectively). Using propensity score analysis, these patients were matched 1:2 based on age, gender and pre-operative Oxford Knee Score (OKS) with knees with full thickness loss on both the femur and tibia. The functional outcomes, implant survival and incidence of re-operations were assessed at one, two and five years post-operatively. A subgroup of 36 knees in 36 patients with partial thickness cartilage loss, who had pre-operative MRI scans, was assessed to identify whether there were any factors identified on MRI that predicted the outcome. Results. Knees with partial thickness cartilage loss had significantly worse functional outcomes at one, two and five years post-operatively compared with those with full thickness loss. A quarter of knees with partial thickness loss had a fair or poor result and a fifth failed to achieve a clinically significant improvement in OKS from a baseline of four points or more; double that seen in knees with full thickness loss. Whilst there was no difference in implant survival between the groups, the rate of re-operation in knees with partial thickness loss was three times higher. Most of the re-operations (three-quarters), were arthroscopies for persistent pain. Compared with those achieving good or excellent outcomes, patients with partial thickness cartilage loss who achieved fair or poor outcomes were younger and had worse pre-operative functional scores. However, there were no other differences in the baseline demographics. MRI findings of full thickness cartilage loss, subchondral oedema, synovitis or effusion did not provide additional prognostic information. Conclusion. Medial UKA should be reserved for patients with full thickness cartilage loss on both the femur and tibia. Whilst some patients with partial thickness loss achieve a good result we cannot currently identify which these will be and in this situation MRI is unhelpful and misleading. Cite this article: Bone Joint J 2017;99-B:475–82

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This study aimed to determine outcomes of isolated tibial insert exchange (ITIE) during revision total knee arthroplasty (TKA).

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The objective of this study was to compare the two-year migration pattern and clinical outcomes of a total knee arthroplasty (TKA) with an asymmetrical tibial design (Persona PS) and a well-proven TKA with a symmetrical tibial design (NexGen LPS).

Aim. To assess the survival of revision knee replacements at our institution and to identify prognostic factors that predict failure in revision knee surgery. Materials and methods. This was a retrospective review of 52 patients who had undergone revision knee surgery as identified by hospital clinical coding. Patient demographics, physiological parameters, reason for revision, type of revision implant and last date of follow up were recorded from the medical records. Implant survival was analysed both from the index primary procedure to revision and from definitive reconstruction at revision to re-operation for any cause. Results. The median time from index primary to first revision was 1428 days (331-5000). A P value of 0.05 was set as the significance level. Patients with a diagnosis of inflammatory arthropathy had a significantly shorter time to revision compared to those with osteoarthritis. Time to revision was not significantly different for those being revised for infection and those not infected. Following reconstruction, there was no significant difference in the reoperation rates for infected vs non-infected implants. The 5-year implant survival for all revision knee replacements with re-operation for any cause as the end point was 72.2% (95%CI 52.3-87.9). At 5 years there was no significant difference in implant survival of infected and non-infected revisions. Conclusion. The implant survival of revision knee replacements for all causes in our institute was 72.2% at 5 years. There was no significant difference in 5-year survival between infected and non-infected revisions. Patients with an inflammatory arthropathy had a significantly shorter time to revision compared to those with osteoarthritis

Aim. To assess the ten year subjective knee function and activity level following four-strand semitendinosis and gracilis (STG) anterior cruciate ligament reconstruction. Methods. 86 patients underwent anterior cruciate reconstruction by two knee surgeons in the year 1999. 80 patients meet the inclusion criteria of STG reconstruction by a standard operative technique. Patient evaluation was by completion of a Lysholm Knee Score and Tegner Activity Level Scale at a minimum of ten years from reconstructive surgery. This was by initial postal questionnaire and subsequent telephone follow-up. Results. 80 patients underwent anterior cruciate reconstruction with average age 30.9 years +/− 8.8 (15 to 58 years). There was a 77.5% (62 patients) response at ten years to the questionnaire. The mean Lysholm Knee Score at ten years was 78.4 +/− 12.8 (39 to 90). The mean activity level had decreased from 8.3 to 5.3 at ten years according to the Tegner Activity Scale. 11 patients required medial and lateral partial menisectomies at the time of original reconstruction. This group of patients had a Lysholm Knee Score of 67.6 +/− 19.1 and Tegner Activity Scale of 3.9 at ten years following reconstruction. 17 of the 80 patients (21.25%) required re-operation because of further knee symptoms, with 4 patients requiring revision of the anterior cruciate following re-rupture. Conclusion. Anterior Cruciate Ligament Reconstruction with four-strand STG hamstring graft provides a reliable method of restoring knee function with a 5% revision rate for re-rupture at ten years. Combined partial medial and lateral menisectomy at the time of the initial reconstruction is a poor prognostic indicator for function at ten years

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For many designs of total knee arthroplasty (TKA) it remains unclear whether cemented or uncemented fixation provides optimal long-term survival. The main limitation in most studies is a retrospective or non-comparative study design. The same is true for comparative trials looking only at the survival rate as extensive sample sizes are needed to detect true differences in fixation and durability. Studies using radiostereometric analysis (RSA) techniques have shown to be highly predictive in detecting late occurring aseptic loosening at an early stage. To investigate the difference in predicted long-term survival between cemented, uncemented, and hybrid fixation of TKA, we performed a randomized controlled trial using RSA.

We studied the quality of fixation of the tibial component using radiostereometric analysis (RSA) in 40 patients who had undergone a cemented Freeman-Samuelson total knee arthroplasty. They were prospectively randomised to either a stemmed metal-backed (MB) or non-stemmed all-polyethylene (AP) tibial component. The articulating geometry of the implants was identical, as was the operative technique and the postoperative regime. The study showed no complications of fixation using AP tibial components, and the migration was the same as that of their metal-backed counterparts. There was no bony collapse or increased subsidence of any part of the tibial component or increased incidence of radiolucent lines in the knees with AP components. Most AP implants were stable between one and two years after surgery, a finding known to be of positive prognostic significance when predicting future aseptic loosening

The operative treatment of lesions of the anterior cruciate ligament (ACL) in athletes has been widely advocated and performed. We have investigated the outcome of non-operative management in a lower-demand, general population. We reviewed a consecutive group of 228 patients, which excluded professional and high-level athletes, for two to 12 years after an ACL lesion had been diagnosed by arthroscopy. There was a low incidence of secondary ACL and meniscal surgery, 5.4% and 3.5% respectively, and all these procedures were performed during the first three years after the ACL injury. We studied a subgroup of 109 patients with follow-up of at least five years (mean 8.5 years) and evaluated them using the IKDC score. The general outcome was reasonably satisfactory, with 23% in grade A, 50% in grade B, 21% in grade C and only 6.4% in grade D. We found no statistically significant prognostic effect within this group as regards age, activity levels, or the incidence of associated lesions

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Robotic-assisted total knee arthroplasty (RA-TKA) has been introduced to provide accurate bone cuts and help achieve the target knee alignment, along with symmetric gap balancing. The purpose of this study was to determine if any early clinical benefits could be realized following TKA using robotic-assisted technology.