The aim of this retrospective cohort study was to investigate the reasons for total knee arthroplasty (TKA) revisions at a tertiary hospital over a four-year period. The study aimed to identify the primary causes of TKA revisions and shed light on the implications for patient care and outcomes. The study included 31 patients who underwent revisions after primary knee arthroplasty between January 2017 and December 2020. A retrospective approach was employed, utilizing medical records and radiological findings to identify the reasons for TKA revisions. The study excluded oncology patients to focus on non-oncologic indications for revision surgeries. Patient demographics, including age and gender, were recorded. Data analysis involved categorizing the reasons for revision based on clinical assessments and radiological evidence. Among the 31 patients included in the study, 9 were males and 22 were females. The age of the patients ranged from 43 to 81, with a median age of 65 and an interquartile range of 18.5. The primary reasons for TKA revisions were identified as aseptic loosening (10 cases) and prosthetic joint infection (PJI) (13 cases). Additional reasons included revision from surgitech hemicap (1 case), patella osteoarthritis (1 case), stiffness (2 cases), patella maltracking (2 cases), periprosthetic fracture (1 case), and patella resurfacing (1 case). The findings of this retrospective cohort study highlight aseptic loosening and PJI as the leading causes of TKA revisions in the examined patient population. These results emphasize the importance of optimizing surgical techniques, implant selection, and infection control measures to reduce the incidence of TKA revisions. Future research efforts should focus on preventive strategies to enhance patient outcomes and mitigate the need for revision surgeries in TKA procedures.
In recent years, many studies on We investigated the reported Aim
Methods
Little is known about microbiological spectrum and resistance patterns as well as the clinical outcome in patients who undergo a repeat first stage procedure as part of a 2-stage revision arthroplasty for the treatment of periprosthetic hip and knee joint infections. Between 2011 and 2019, a total of 327 2-stage revision arthroplasties were performed on 312 patients with PJI of the knee and hip at our institution. We performed a retrospective analysis of all patients, who underwent a repeat first stage procedure regarding re-revision rate, host factors, culture negative and positive stages, monomicrobial and polymicrobial infections as well as microbiological spectrum and antimicrobial resistance patterns.Aim
Methods
One of the major concerns of hinge knees have been reported in literature is mechanical failure. Failure in the form of component fracture (2–10%) and hinge dislocation/ failure are worrisome. In addition, higher risk of aseptic loosening with hinge knee prosthesis has been attributed to stress transfer at bone cement interface. Retrospective review of clinical and radiological results of 71 consecutive patients operated at single centre using Smiles hinge knee (Stanmore implants) between 2010 and 2014. Data was collected till the latest follow up. Mechanical failure due to any reason was considered as primary end point. Radiological evidence of aseptic loosening was considered to be one of the surrogate end points.Background
Methods
The unacceptable failure rate of cemented femoral revisions led to many different cementless femoral designs employing fixation in the damaged proximal femur with biological coatings limited to this area. The results of these devices were uniformly poor and were abandoned for the most part by the mid-1990's. Fully porous coated devices employing distal fixation in the diaphysis emerged as the gold standard for revisions with several authors reporting greater than 90% success rate 8–10 years of follow-up. Surgical techniques and ease of insertion improved with the introduction of the extended trochanteric osteotomy as well as curved, long, fully porous coated stems with diameters up to 23mm. The limits of these stems were stretched to include any stem diameter in which even 1–2cm of diaphyseal contact could be achieved. When diaphyseal fixation was not possible (Type IV), the alternatives were either impaction grafting or allograft prosthetic composite (APC). As the results of fully porous coated stems were very carefully scrutinised, it became apparent that certain types of bone loss did not yield the most satisfactory results both clinically and radiographically. When less than 4cm of diaphyseal press fit (Type IIIB) was achieved, the mechanical failure rate (MFR) was over 25%. It also became apparent that even when there was 4–6cm diaphyseal contact (Type IIIA), and the stem diameter was 18mm or greater, post-operative pain and function scores were significantly less than those with smaller diameter stems. This was probably due to poorer quality bone. Many of these Type IIIA and Type IIIB femurs had severe proximal torsional remodeling leading to marked distortion of anteversion. This made judging the amount of anteversion to apply to the stem at the time of insertion very difficult, leading to higher rates of dislocation. These distortions were not present in Type I and Type II femurs. This chain of events which was a combination of minimal diaphyseal fixation, excessively stiff stems and higher dislocation rates led to the conversion to modular type stems when these conditions existed. For the past 13 years, low modulus taper stems of the Wagner design have been used for almost all Type IIIA and Type IIIB bone defects. The taper design with fluted splines allows for fixation when there is less than 2cm of diaphysis. The results in these femurs even with diameters of up to 26mm have led to very low MFRs and significantly less thigh pain. Independent anteversion adjustment is also a huge advantage in these modular stems. Similar success rates, albeit with less follow-up, have been noted in Type IV femurs.
The femoral diaphysis presents the best opportunity for fixation during revision THA. Both fully coated cylindrical and modular fluted tapered titanium stems have demonstrated excellent results. Cylindrical stems have demonstrated concerning rates of failure when used in larger, osteopenic canals or in canals with post-isthmal divergent morphologies. Modular stems offer the advantage of separating distal fixation needs from proximal version, leg length, and offset needs via a modular junction. Although early designs demonstrated some breakages at the taper or through thin proximal bodies, newer generation implants have not demonstrated such mechanical concerns. Additionally, the modular junctions do not appear to be having any problems with corrosion. Mid- to long-term data with various designs now support the safety and efficacy of these constructs that can handle a wide variety of challenges during femoral revision. Careful attention to detail is necessary to minimise the risk of subsidence and intra-operative fracture or femoral perforation.
Distal femoral replacement is an operation long considered as salvage operation for neoplastic conditions. Outcomes of this procedure for difficult knee revisions with bone loss of distal femur have been sparsely reported. We present the early results of complex revision knee arthroplasty using distal femoral replacement implant, performed for severe osteolysis and bone loss. Retrospective review of clinic and radiological results of 25 consecutive patients operated at single centre between January 2010 and December 2014. All patients had single type of implant. All data was collected till the latest follow up. Re-revision for any reason was considered as primary end point. Mean age at surgery was 72.2 years (range 51 – 85 years). Average number of previous knee replacements was 2.28 (range 1 to 6). Most common indications were infection, aseptic loosening and peri-prosthetic fracture. Average follow up was 24.5 months (range: 3–63 months). 1 patient died 8 months post-op due to unrelated reasons. Re-revision rate was 2/25 (8%) during this period. One was re-revised for aseptic loosening and one was revised for peri-prosthetic fracture of femur. Two other peri-prosthetic fractures were managed by open reduction and internal fixation. All 3 peri-prosthetic fractures occurred with low energy trauma. It is noteworthy that there was no hinge or mechanical failures of the implant. Peri-prosthetic fracture in 12% of patients in this series is of concern. There are no similar studies to compare this data with. The length of the stem, type of fixation of the stem, weight of the distal femoral component of implant can be postulated as factors contributing to risk of peri-prosthetic fracture.
Reasons for revision of metal-on-metal hip resurfacing arthroplasty (MoMHRA) have evolved with improving surgical experience and techniques. Early revisions were often due to fracture of the femoral neck while later revisions are associated with loosening and/or adverse local tissue reactions (ALTR) to wear debris. In some studies, revisions of MoMHRA with ALTR have been complicated by an increased risk of rerevision and poor outcome. The purpose of this study was to investigate the causes of failure and to identify factors that improve outcome following revision of a failed HRA. From 2001 to May 2015, 180 consecutive HRA revisions were performed in 172 patients. Ninety-nine primary surgeries were done at a HRA specialist centre (99/4211, revision rate: 2.4%), 81 elsewhere. Eight different HRA designs were revised mainly in females (60%). Components’ orientation was measured from radiographs using EBRA. Ion levels were used as a diagnostic tool since 2006 (n=153). Harris-Hip-Score (HHS) was obtained prerevision and at latest follow-up. The initial experience of the first 42 cases (Initial Group) was compared to cases 43–180 (Later Group). Patients of the Later group were noted to have less soft tissue damage, had significantly bigger THA heads implanted at surgery, were educated of the increased complication risk and some wore an abduction brace for 6 weeks.Background
Methods
Managing severe periacetabular bone loss during revision total hip arthroplasty (THA) is a challenging task. Multiple treatment options have been described. Delta Revision Trabecular Titanium™ (TT) cup is manufactured by Electron Beam Melting (EBM) technology that allows modulating cellular solid structures with an highly porous structure were conceived to rich the goals of high bone ingrowth and physiological load transfer. The caudal hook and fins ensure additional stability and the modular system allows the surgeon to treat bone defects in the most complex revisions. Entirely modular, the system can meet all intra-operative needs thanks to a customized implant construction. The aim of this prospective study is to evaluate the short to mid-term clinical and radiographic outcomes of this acetabular revision cups. We prospectively assessed clinical and radiographic results of 31 cases of acetabular revisions that were performed from June 2007 and March 2012 by Delta TT Lima Revision system. The mean age of patients was 69.5 years (range 29–90). The causes of revision were aseptic loosening in 22 cases (71.0%), periprosthetic acetabular fractures in 4 cases (13.0%), multiple dislocation of the primary implant in 3 cases (9.6%) and outcome of infection in 2 cases (6.4%). Stem revision was performed in 11 cases (35,4%). In 24 cases bone impaction grafting was used to fill cavitary defects (Paprosky 2B-3A); in 7 cases TT augments were used with the same aim. The average follow-up was 32 months (range 12–69).INTRODUCTION
MATERIALS AND METHODS
In an effort to understand the role of metal ion analysis and how it relates to revision surgery and implant wear, four revised MOM cases were reviewed. The first case was revised for acute infection and is representative of the low bearing wear predicted by MOM simulator studies. Two of the four cases had apparent anterior subluxation as a result of hip hyperextension occurring with long stride gaits. The last case is a true hypersensitivity response to CoCr ions. All four MOM prostheses were implanted by one surgeon and revised by the same surgeon approximately 6–8 years postoperatively. The implants had been positioned satisfactorily with inclination angles 45°–55° and anteversion angles 28°–42°. Patient A (76 y/o female) with bilateral MOM hip replacements, was revised at approximately 8 years due to infection and had moderately elevated ions at the time of revision surgery (Co = 5, Cr = 2.3, Ti = 4). Only the femoral head was retrieved in this case. Retrieval analysis identified a well defined main-wear zone and one polar stripe. The CMM indicated there was minimal wear overall (form factor = 11 μm). Patient B (33 y/o male) with bilateral MOM hip replacements, was revised at approximately 8 years due to pain, popping/catching sensations, and elevated ions (Co = 33, Cr = 17, Ti = 90). Intraoperatively, the implant was observed subluxing superiorly from the acetabular cup with anterior rotation of the leg. Both the femoral head and acetabular cup were retrieved. Retrieval analysis identified a well defined main-wear zone and multi-directional polar stripe formations similar to those reported on dislocated implants (Figure 1)[McPherson 2012, 2013]. The CMM indicated that overall wear was significant (form factor > 100 μm). Patient C (77 y/o female) was revised at approximately 6 years due to pain, suspected implant loosening, osteolytic cysts determined by CT, and highly elevated ions (co = 164, Cr = 45, Ti = 33). Intraoperatively, there was evidence of wear including darkly stained tissue and osteolytic cysts. Both the femoral head and acetabular cup were retrieved. Retrieval analysis identified a well defined main-wear zone and one polar stripe. CMM indicated considerable wear (head form factor > 200, cup form factor >300). Patient D (45 y/o female) was revised at approximately 6 years due to pain, apparent reactive response joint effusion, and moderately elevated ions (Co = 5, Cr = 6, Ti = 71). Only the femoral head was retrieved. Retrieval analysis identified a well defined main-wear zone and one polar stripe. Minimal wear was indicated by CMM (form factor = 21). These four cases demonstrate distinct failure models of MOM hips and their respective metal ion results. Due to the diversity of patient location, a variety of clinical labs were utilized for this patient population. Caution should be used in interpreting metal ion analysis, as there are still no standards. Figure 1: Retrieval analysis of stripe wear identified on femoral head from patient B. Figure 2: Femoral head from patient C showing broader polar stripe associated with anterior subluxation in comparison to narrow polar stripe found on femoral head from patient A.
Acetabular revision for cavitary defects in failed total hip replacement remains a challenge for the orthopaedic surgeon. Bone graft with cemented or uncemented revision is the primary solution; however, there are cases where structural defects are too large. Cup cage constructs have been successful in treating these defects but they do have their problems with early loosening and metalwork failure. Recently, highly porous cups that incorporate metal augments have been developed to achieve greater intra-operative stability showing encouraging results. Retrospective analysis of twenty-six consecutive acetabular revisions with Trabecular Titanium cups. Inclusion criteria included aseptic cases, adult patients, end-stage disease with signs of loosening, no trauma nor peri-prosthetic fractures. Data was obtained for patient demographics, Paprosky classification, use of bone graft, use of acetabular augment, and Moore index of osseointegration.Introduction
Methods
Aim of the study was to find out whether patients with positive minor criteria but without meeting the MSIS definition have a difference in the outcome after revision-surgery compared to patients without any MSIS-criteria? And does the reason for revision-surgery (eg. loosening) have an additional influence on the outcome parameters in patients with positive minor criteria? A retrospective matched-pair analysis with 98 patients who had undergone revision-surgery after TJA was performed. Forty-nine patients who showed 1 to 3 positive minor criteria (PMC) whereas 49 patients without any positive minor criteria (aseptic complications control group) were compared regarding re-revision-rate and revision-free survival. Patients were matched regarding sex, age, joint and comorbidities using the classification system by McPherson et al. Reasons for revisions were categorized in loosening, body wear, periprosthetic fracture/mechanical failure and soft-tissue complication. Endpoints were defined as re-revision for any cases.Aim
Method
Currently, despite a thorough diagnostic work up, around ten percent of the presumed aseptic revisions turn out to have unexpected positive cultures during the revision procedure. The purpose of this study was to evaluate the negative predictive value (ruling out) of the automated multiplex PCR Unyvero i60 implant and tissue infection (ITI) cartridge (U-ITI) system for the detection of microorganisms in synovial fluid obtained intraoperatively. A prospective study was conducted with 200 patients undergoing a one-stage knee or hip revision. In all patients six intraoperative tissue cultures were taken and a sample of synovial fluid which was analyzed as a culture and with the multiplex PCR U-ITI system. The primary outcome measure was the negative predictive value (NPV) of the multiplex PCR U-ITI system compared to the intraoperative tissue cultures to reliable rule out an infection.Aim
Methods
Despite a preoperative workup with no evidence to suspect a prosthetic joint infection (PJI) before revision surgery, routinely obtained intraoperative cultures still can be unexpectedly positive. The purpose of this study was (1) to assess the incidence of unexpected positive intraoperative cultures in presumed aseptic knee and hip revisions and (2) to determine whether a difference exists between the infection-free implant survival rate of patients with and without unexpected positive intraoperative cultures. We selected patients who underwent a one-stage revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) for different reasons. Three or more separate intraoperative cultures were obtained during each procedure. A negative result was defined as less than two positive cultures with the same microorganism. An unsuspected PJI was defined as having two or more positive cultures with the same microorganism. Patients’ medical records were reviewed to collect demographics, preoperative laboratory results, culture results, and the occurrence of infection during follow-up.Aim
Method
Two-stage revision is considered the gold standard for treatment of knee prosthetic joint infections. Current guidelines for selecting the most appropriate procedure to eradicate knee prosthetic joint infections are based upon the duration of symptoms, the condition of the implant and soft tissue evaluated during surgery and the infecting organism. A more robust tool to identify candidates for two-stage revision and who are at high risk for treatment failure might improve preoperative risk assessment and increase a surgeon's index of suspicion, resulting in closer monitoring, optimization of risk factors for failure and more aggressive management of those patients who are predicted to fail. Charts from 3,809 revision total joint arthroplasties were reviewed. Demographic data, clinical data and disease follow-up on 314 patients with infected total knee arthroplasty treated with two-stage revision were collected. Univariate analyses were performed to determine which variables were independently associated with failure of the procedure to eradicate the prosthetic joint infections. Cox regression was used to construct a model predicting the probability of treatment failure and the results were used to generate a nomogram which was internally validated using bootstrapping.Background
Methods
The surgical treatment of young adults with end-stage hip disease has been a challenge. Inferior THA survival in the young, perceived advantages of hip resurfacing versus THA and advancements in tribology, led to the introduction of 3rd generation Metal-on-Metal-Hip-Resurfacing-Arthroplasty (MoMHRA). To-date, thousands of such prostheses have been implanted worldwide in younger patients, yet little is known regarding long-term outcome. The only studies reporting greater than 10 year outcome come from designer centres with survivorship varying between 88.5–96% at 12 years. Arthroplasty Registries (AR) have reported less favourable survivorships with female gender and size having a negative effect on survival. In our independent hip resurfacing centre in Ghent, Belgium, a single surgeon has implanted more than 3500 HRA over more than 12 years. A cohort of 149 patients who received a Birmingham Hip Resurfacing (BHR) at a mean age of 50 years at surgery have now reached a minimum 10 years follow-up. The overall 12-year survival in these young adults is 93.1% (95% CI: 88.3–98.0), 99% in males and 87.3% in females. These survivorship data are superior to registry reported figures of THA amongst young patients and correspond well with previous reports from designer centres. The long-term survivorship and clinical outcome of the BHR are excellent in men, uninfluenced by preoperative diagnosis or age. However, survivorship in women is inferior and usually related to increased wear and reactions to metal debris. Malpositioning of components with associated wear-induced soft tissue fluid collections is the most frequent factor leading to failure of a HRA. In our experience, mid-term outcome following revision is good and complication and re-revision rates can be low. Surgical experience, early intervention in cases of mal-positioned implants, clinical use of ion levels, implantation of larger ceramic-on-ceramic THA femoral heads and patient education are factors in improving outcome and reducing complication and re-revisions following HRA revision.
The aim of the study is to determine reimbursement cost of treating periprosthetic joint infection (PJI) in Poland, the rate of THR and TKA septisc revisions in the years 2009–2013, the type of revision, comparison of the costs of septic and aseptic revisions. Data published on the website of the National Health Fund (NHF) were analysed on revision arthroplasty for aseptic and septic recisions in the years 2009–2013. To calculate the cost of revision NHF report for 2013 was analysed giving the average cost of the group of septic and aseptic revision. According to NHF „point system”, in therapy of PJI three types of revisions can by choosen: partial revision (305 points), one-stage revision (490 points), and two-stage revision with spacer (728 points for two stages). In the years 2009–2013 a total of 260030 THR and TKA were performer, including 23027 revisions. There were 4221 septic revisions: 1677 hips and 1430 knees. In 2013 septic revisions stated 1.38% (556 of 40152) of all hip and 2.56% (325 of 12654) of all knee replacements. Septic revisions constituted 14.67% of all hip revisions and 30.23% of all knee revisions. The average refund of the NHF for a minor revision for PJI in 2013 was 3889 Euro and the average cost for hospital was 4127 Euro. The average refund of the NHF for a one-stege revision (for any reason) in 2013 was 6124 Euro, and the average cost for hospital was 6339 Euro. The average refund of the NHF for a two-stage revision (for two stages) in 2013 was 10013 Euro, and the average cost for hospital was 10466 Euro for two hospital stays. Data revealed that in 2013 all 921 revisions performed for PJI were reimbursed as „minor revisions” for 3889 Euro. In 2013 the difference between the average cost incurred by the hospital and the refund of the NHF for septic revision was at least 238 Euro and for the entire year undervalued refund for treatment of 921 infected prostheses was at least 219198 Euros. The reimbursement for revision due to infection encourages surgeons to perform two-stage septic revision instead of debridement or one-step, because two-step treatment in the final bill is better paid.
Especially in young patients, total hip implants with proven long-term follow-up data should be used. Despite this, almost all patients under 30 years old will face a revision of their hip prosthesis during their life time because of their life expectancy. Therefore, all the used implants should be revisable with reliable outcome. Although, several studies have evaluated the outcome of different THA implants in patients under 30, only few report the long term follow-up of 10 years or more. None of them present the outcome of the revised total hips. We retrospectively reviewed prospectively collected data of 48 consecutive patients (69 hips), all received a cemented implant and in case of acetabular bone stock deficiency (29 hips), a reconstruction with bone impaction grafting (BIG) was performed. Mean age at surgery was 24.6 years (range, 16.0–29.0 years). Two patients were lost to follow-up. As far as we know, no revisions are performed in these two patients and their data are included in the study up to their last radiographic control. All failed hips were revised with again cemented implants and, if needed, bone impaction grafting. For the primary THA Kaplan-Meier survival curves at 10- and 15-year endpoint revision for any reason and revision for aseptic loosening were calculated. Separate survival rates at 10- and 15- year were calculated for the BIG group versus the non-BIG group. The outcome of the revised hips was studied and reported with re-revision as the endpoint.Introduction
Methods
The Rejuvenate modular neck stem (Stryker, Mahwah, NJ) was recently recalled due to corrosion at the neck-stem junction. The purpose of this study was to investigate the rate of corrosion related failures and survivorship of this implant, and analyze the correlation between the implant and patient factors with serum metal ion levels. Between June 2009 and July 2012, 123 Rejuvenate stems (97 modular and 26 non-modular) THAs were implanted in 104 patients by a single surgeon via a modified anterolateral approach. Serum Cobalt (Co) and Chromium (Cr) levels (microgram per liter [μg/L]) were obtained in all patients. In cases of elevated serum metal ion levels or symptomatic hip, patients underwent magnetic resonance imaging (MRI) for assessment of osteolysis or adverse local tissue reactions (ALTR). Correlation between implant factors (implant size, head size, head length, offset), patient factors (age, gender, BMI) with serum metal ion levels and revisions were analyzed using logistic regression models.Background:
Material and Methods:
To evaluate a innovate one stage procedure of the PJI knee treatment using computed assisted guidance. Our objectives; to increase the functional results by optimizing the anatomical joint reconstruction and to verifie if CAS help to simplifie and standardize these complex surgeries It's a prospective, single surgeon study. Since septembre 2011, 41 patients treated for chronic knee PJI in a one stage revision (one of them had a ipsilateral chronic knee arthritis). For all of them, a computed assisted guidance, the ExactechGPS® system was used. This system offers the possibility to define specific profiles to performe primary TKA surgeries. A personnalized profile of revision was created. All surgeries were performed with the same protocole; independently of the type of germ, with no use of tourniquet, no drainage by performing the same debridement procedure step by step and by using the same knee components 27 males, 14 female with 26 PJI of primary TKA, one infected unicompartimental prosthesis and 15 PJI of first revised TKA has been treated. The average age was 71 years old (55–87). The time of surgery was on average 135 mn (120 – 195 mn). The average time of hospitalization was 10 days (7–16). The average follow up was 20,9 months (6–47 months). The ROM were on average 114,7% (90°–130°), None post operative HKA outliers were reported. 3 patients presented a failure of the PJI treatment (one after a local open traumatism, one diabetic patient, one after a early revision for mechanical complication). None specific CAS complications and no failure of the CAS procedures are reported. As surgeon, CAS simplified the management of the bone loss after debridement and the control of the differents parameters (HKA, external femoral rotation, ligamentary balancing, lign joint…) by a real time feedback. we changed our practise by using more constraint condylar component instead hinge prostheses With a rate of success of 92,7% at this follow up, the one stage option appears to be valided. Using CAS is a safe option with no specific complication. It increases the quality of the ROM, a earlier functional recovery and a better middle term clinical result. Both combined, It should be a optimal medicoeconomical solution. compared revision using mechanical ancillary.
