Robotic assistance in knee arthroplasty has become increasingly popular due to improved accuracy of prosthetic implantation. However, literature on the mid-term outcomes is limited especially that of hand-held robotic-assisted devices. We present one of the longest follow-up series to date using this novel technology and discuss the learning curve for introducing robotic technology into our practice. The purpose of this single-surgeon study is to evaluate the survival, patient-reported outcomes and learning curve for handheld boundary-controlled robotic-assisted unicompartmental knee arthroplasties (HBRUKAs) at our hospital. This retrospective study evaluates 100 cases (94 Medial, 6 Lateral) performed by a single surgeon between October 2012 and July 2018. 52% were males, mean age was 64.5y (range 47.3y-85.2y) and mean BMI was 31.3 (range 21.8–43). Both inlay (40%) and onlay (60%) designs were implanted. Patients were followed up routinely at 1 and 5 years with Oxford Knee Scores (OKS) recorded. The learning curve was determined by tourniquet times. At a mean follow-up of 4.3 years (range 1.6y–7.3y), survivorship was 97%. There were three revisions: One case of aseptic loosening (1.5y), one case of deep-infection (3.8y) and one case of contralateral compartment osteoarthritis progression (5y). Mean 5-year OKS was 39.8. A 14.3% reduction in mean tourniquet times between the first 25 cases (105.5minutes) and subsequent cases (90.4minutes) was seen. This single-surgeon study showed good survivorship and patient-reported outcomes for HBRUKAs at our hospital. A learning curve of approximately 25 cases was shown, with significant decreases in tourniquet times with respect to increased surgeon experience

With increasing numbers of total joint arthroplasties being performed, peri-prosthetic fracture incidence is rising, and operative management remains the gold standard. Short-term survivorship up to 12 months has been well-documented but medium to long-term is almost unknown. We present survivorship review from a district general hospital, undertaking 800 primary hip and knee arthroplasties per year. Patients with peri-prosthetic fractures and background total knee replacements were identified using our computer database between 2006–2011. All patients were operated on our site; methods used include open reduction, internal fixation (ORIF) using Axsos (Stryker Newbury) locking plates (28), intra-medullary nailing (1) or complex revision (6) depending on fracture and patient factors and surgeon's preference. Mortality was assessed at 30 days, 12 months and 5 years. Thirty-four patients were identified with a 7:1 female to male ratio and mean age of 76. 75% of patients had their primary arthrodesis at our hospital. There was only 1 plate failure noted requiring revision plating. Mortality at 30 days, 12 months and 5 years were 3.2, 12.5% and 50% respectively. When compared to the literature our time interval from index surgery to fracture is considerably longer (115 vs 42 months). Further multi-centre reviews are required to further asses this unexpected finding. Overall mortality is better than our hip fracture cohort, suggesting that good results can be achieved in District Hospital. The longer-term results are encouraging and can act as a guide for patients with this injury. We recommend that patients are managed in consultant-led, multi-disciplinary teams

Solid organ transplant (SOT) recipients present an increased medical risk; however, few studies analyze the outcomes of these patients undergoing hip fracture surgery. This study aimes to determine the incidence of hip fracture in SOT patients and to compare the outcomes of SOT patients with matched non-SOT controls after hip fracture fixation.

A retrospective review identified 20 SOT patients with hip fracture at a single center from 2016 to 2021 and were matched (1:1) with a cohort of 20 patients with hip fracture without SOT. Patient outcomes, mortality/survival and clinical outcomes were compared between two groups.

The incidence of hip fracture in SOT patients was 20/1787, 1.1%. There were significant differences in mortality rate (73.3% SOT group vs. 26.7% non-SOT group; p<0.05). There were no differences in survival time (p=0.746). There were no differences in time to surgery (5.0 days SOT group vs. 3.1 days non-SOT group; p=0.109), however, there were significant differences in the hospital length of stay (14 days SOT group vs. 8.6 days non-SOT group; p=0.018). There were no differences regarding the complication rate between the two groups (9/20, 45% vs. 6/20, 30% in the SOT and non-SOT groups, respectively).

SOT patients with associated hip fracture required longer hospital length of stay than non-SOT patients. SOT patients did not show greater clinical complications; however, they presented higher mortality rate compared to non-SOT patients.

The Columbus is a relatively new implant with no published medium or long term follow-up. Its extensive use within our department led to this study to review the five-year clinical outcomesof patients who had a navigated Columbus primary total knee arthroplasty (TKA) implanted between March 2005 and December 2006.

Case notes, departmental and hospital databases and PACS were used to identify patients and collect routine five-year review data. Information Services Division was approached for all cases of re-admission and associated complications anywhere in Scotland.

219 (90 male, 116 left) patients were identified. Mean age was 69 years (48–89) and mean BMI 32.2 (SD 5.8). Of the 219 patients operated on, twenty-one had a complication; ten still had intermittent mild to moderate pain, three had wound problems, one had a washout, one had DVT/PE within ninety days and one was diagnosed with patellar clunk syndrome. The remaining five patients had revision TKA (revision rate 2.3%), four for infection and only one due to aseptic loosening (revision rate excluding infection 0.5%). 115 patients returned to clinic at five years. Of these 96.4% were satisfied with their operation. The mean Oxford knee score had reduced from 42.5 (SD 8.2) pre-operatively to 23.6 (SD 9.2). Mean fixed flexion was 1° (SD 2.8°, range 0° to 15°) with four patients having a fixed flexion of 6° or more. Mean maximum flexion was 100° (SD 10.2°, range 60° to 120°) with two patients having flexion less than 80°. X-ray analysis showed that fourteen patients had a radiolucent line. Nine of these were not present at one year, six being at the tibial component.

These results are satisfactory. The revision rate is similar to that cited by the National Joint Registry report 2011 (2.5%). Furthermore, the revision rate excluding infection is very low.

Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty, particularly for low volume surgeons. The recent introduction of robotic-arm assisted systems has allowed for increased accuracy, however new systems typically have learning curves. The objective of this study was to determine the learning curve of a robotic-arm assisted system for UKA. Methods A total of 152 consecutive robotic-arm assisted primary medial UKA were performed by five surgeons between 2017 and 2021. Operative times, implant positioning, reoperations and patient-reported outcome measures (PROMS; Oxford Knee Score, EuroQol-5D, and Forgotten Joint Score) were recorded. There was a learning curve of 11 cases with the system that was associated with increased operative time (13 minutes, p<0.01) and improved insert sizing over time (p=0.03). There was no difference in implant survival (98.2%) between learning and proficiency phases (p = 0.15), and no difference in survivorship between ‘high’ and ‘low’ usage surgeons (p = 0.23) at 36 months. There were no differences in PROMS related to the learning curve. This suggested that the learning curve did not lead to early adverse effects in this patient cohort. The introduction of a robotic-arm assisted UKA system led to learning curves for operative time and implant sizing, but there was no effect on patient outcomes at early follow- up. The short learning curve was independent of UKA usage and indicated that robotic-arm assisted UKA may be particularly useful for low-usage surgeons

Dual mobility (DM) total hip replacements (THRs) were introduced to reduce dislocation risk, which is the most common cause of early revision. Although DM THRs have shown good overall survivorship and low dislocation rates, the mechanisms which describe how these bearings function in-vivo are not fully understood. Therefore, the study aim was to comprehensively assess retrieved DM polyethylene liners for signs of damage using visual inspection and semi-quantitative geometric assessment methods. Retrieved DM liners (n=18) were visually inspected for the presence of surface damage, whereby the internal and external surfaces were independently assigned a score of one (present) or zero (not present) for seven damage modes. The severity of damage was not assessed. The material composition of embedded debris was characterised using energy-dispersive x-ray analysis (EDX). Additionally, each liner was geometrically assessed for signs of wear/deformation [1]. Scratching and pitting were the most common damage modes on either surface. Additionally, burnishing was observed on 50% of the internal surfaces and embedded debris was identified on 67% of the external surfaces. EDX analysis of the debris identified several materials including titanium, cobalt-chrome, iron, and tantalum. Geometric analysis demonstrated highly variable damage patterns across the liners. The incidence of burnishing was three times greater for the internal surfaces, suggesting that this acts as the primary articulation site. The external surfaces sustained more observable damage as evidenced by a higher incidence of embedded debris, abrasion, delamination, and deformation. In conjunction with the highly variable damage patterns observed, these results suggest that DM kinematics are complex and may be influenced by several factors (e.g., soft tissue fibrosis, patient activities) and thus further investigation is warranted

Infections in spine surgery are relatively common and devastating complications, a significant burden to the patient and the healthcare system. Usually, the treatment of SSIs consists of aggressive and prolonged antibiotic therapy, multiple debridements, and in chronic cases, hardware removal. Infections are correlated with worse subjective outcomes and even higher mortality. Depending on the type of spine surgery, the infection rate has been reported to be as higher as 20%. Recently silver-coated implants have been introduced in spine surgery to reduce the incidence of post-operative infections and to improve implant survivorship. The aim of the present study is to evaluate complications and outcomes in patients treated with silver-coated implants because of spine infection. All consecutive patients who had spine stabilization with a silver-coated implant from 2018 to 2021 were screened for inclusion in the study. Inclusion criteria were: (1) six months of minimum follow-up; (2) previous surgical site infection; hematogenous spondylodiscitis requiring surgical stabilization. Demographic and surgical information were obtained via chart review, all the device-related complications and the reoperation rate were also reported. A total of 57 patients were included in the present study. The mean age was 63.4 years, and there were 36 (63%) males and 21 (37%) females. Among the included cases, 57% were SSIs, 33% were spondylodiscitis, and 9% were hardware mobilization. Comorbidities such as diabetes mellitus, obesity, smoke, and oncological history were significant risk factors. In addition, the organisms cultured were Staphylococcus species in most of the cases. At six months of follow-up, 40% of patients were considered free from infection, while 20% needed multiple surgeries. The present research showed satisfactory results of silver-coated implants for the treatment of spine infection

Total knee replacement (TKR) design aims to restore normal kinematics with emphasis on flexion range. The survivorship of a TKR is dependent on the kinematics in six-degrees-of-freedom (6-DoF). Stepping up, such as stair ascent is a kinematically demanding activity after TKR. The debate about design choice has not yet been informed by 6-DoF in vivo kinematics. This prospective randomised controlled trial (RCT) compared kneeling kinematics in three TKR designs. 68 participants were randomised to receive either cruciate retaining (CR-FB), rotating platform (CR-RP) or posterior stabilised (PS-FB) prostheses. Image quality was sufficient for 49 of these patients to be included in the final analysis following a minimum 1-year follow-up. Patients completed a step-up task while being imaged using single-plane fluoroscopy. Femoral and tibial computer-aided design (CAD) models for each of the TKR designs were registered to the fluoroscopic images using bespoke software OrthoVis to generate six-degree-of-freedom kinematics. Differences in kinematics between designs were compared as a function of flexion. There were no differences in terminal extension between the groups. The CR-FB was further posterior and the CR-RP was more externally rotated at terminal extension compared to the other designs. Furthermore, the CR-FB designs was more posteriorly positioned at each flexion angle compared to both other designs. Additionally, the CR-RP design had more external femoral rotation throughout flexion when compared with both fixed bearing designs. However, there were no differences in total rotation for either step-up or down. Visually, it appears there was substantial variability between participants in each group, indicating unique patient-specific movement patterns. While use of a specific implant design does influence some kinematic parameters, the overall patterns are similar. Furthermore, there is high variability indicating patient-specific kinematic patterns. At a group level, none of these designs appear to provide markedly different step-up kinematic patterns. This is important for patient expectations following surgery. Future work should aim to better understand the unique patient variability

Results in patients undergoing total hip arthroplasty (THA) for femoral head osteonecrosis (ON) when compared with primary osteoarthritis (OA) are controversial. Different factors like age, THA type or surgical technique may affect outcome. We hypothesized that patients with ON had an increased revision rate compared with OA. We analysed clinical outcome, estimated the survival rate for revision surgery, and their possible risk factors, in two groups of patients. In this retrospective cohort analysis of our prospective database, we assessed 2464 primary THAs implanted between 1989 and 2017. Patients with OA were included in group 1, 2090 hips; and patients with ON in group 2, 374 hips. In group 2 there were more men (p<0.001), patients younger than 60 years old (p<0.001) and with greater physical activity (p<0.001). Patients with lumbar OA (p<0.001) and a radiological acetabular shape type B according to Dorr (p<0.001) were more frequent in group 1. Clinical outcome was assessed according to the Harris Hip Score and radiological analysis included postoperative acetabular and femoral component position and hip reconstruction. Kaplan-Meier survivorship analysis was used to estimate the cumulative probability of not having revision surgery for different reasons. Univariate and multivariate Cox regression models were used to assess risk factors for revision surgery. Clinical improvement was better in the ON at all intervals. There were 90 hips revised, 68 due to loosening or wear, 52 (2.5%) in group 1, and 16 (4.3%) in group 2. Overall, the survival rate for revision surgery for any cause at 22 years was 88.0 % (95% CI, 82-94) in group 1 and 84.1% (95% CI, 69 – 99) in group 2 (p=0.019). Multivariate regression analysis showed that hips with conventional polyethylene (PE), compared with highly-cross linked PEs or ceramic-on-ceramic bearings, (p=0.01, Hazard Ratio (HR): 2.12, 95% CI 1.15-3.92), and cups outside the Lewinnek´s safe zone had a higher risk for revision surgery (p<0.001, HR: 2.57, 95% CI 1.69-3.91). Modern highly-cross linked PEs and ceramic-on-ceramic bearings use, and a proper surgical technique improved revision rate in patients undergoing THA due to ON compared with OA

Abstract. Approximately 20% of primary and revision Total Knee Arthroplasty (TKA) patients require multiple revisions, which are associated with poor survivorship, with worsening outcomes for subsequent revisions. For revision surgery, either endoprosthetic replacements or metaphyseal sleeves can be used for the repair, however, in cases of severe defects that are deemed “too severe” for reconstruction, endoprosthetic replacement of the affected area is recommended. However, endoprosthetic replacements have been associated with high complication rates (high incidence rates of prosthetic joint infection), while metaphyseal sleeves have a more acceptable complication profile and are therefore preferred. Despite this, no guidance exists as to the maximal limit of bone loss, which is acceptable for the use of metaphyseal sleeves to ensure sufficient axial and rotational stability. Therefore, this study assessed the effect of increasing bone loss on the primary stability of the metaphyseal sleeve in the proximal tibia to determine the maximal bone loss that retains axial and rotational stability comparable to a no defect control. Methods. to determine the pattern of bone loss and the average defect size that corresponds to the clinically defined defect sizes of small, medium and large defects, a series of pre-operative x-rays of patients with who underwent revision TKA were retrospectively analysed. Ten tibiae sawbones were used for the experiment. To prepare the bones, the joint surface was resected the typical resection depth required during a primary TKA (10mm). Each tibia was secured distally in a metal pot with perpendicular screws to ensure rotational and axial fixation to the testing machine. Based on X-ray findings, a fine guide wire was placed 5mm below the cut joint surface in the most medial region of the plateau. Core drills (15mm, 25mm and 35mm) corresponding to small, medium and large defects were passed over the guide wire allowing to act at the centre point, before the bone defect was created. The test was carried out on a control specimen with no defect, and subsequently on a Sawbone with a small, medium or large defect. Sleeves were inserted using the published operative technique, by trained individual using standard instruments supplied by the manufacturers. Standard axial pull-out (0 – 10mm) force and torque (0 – 30°) tests were carried out, recording the force (N) vs. displacement (mm) curves. Results. A circular defect pattern was identified across all defects, with the centre of the defect located 5mm below the medial tibial base plate, and as medial as possible. Unlike with large defects, small and medium sized defects reduced the pull-out force and torque at the bone-implant interface, however, these reductions were not statistically significant when compared to no bony defect. Conclusions. This experimental study demonstrated that up to 35mm radial defects may be an acceptable “critical limit” for bone loss below which metaphyseal sleeve use may still be appropriate. Further clinical assessment may help to confirm the findings of this experimental study. This study is the first in the literature to aim to quantify “critical bone loss” limit in the tibia for revision knee arthroplasty. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Abstract. OBJECTIVES. Dual mobility (DM) total hip replacements (THRs) were introduced to reduce the risk of hip dislocation in at-risk patients. DM THRs have shown good overall survivorship and low rates of dislocation, however, the mechanisms which describe how these bearings function in-vivo are not fully understood. This is partly due to a lack of suitable characterisation methodologies which are appropriate for the novel geometry and function of DM polyethylene liners, whereby both surfaces are subject to articulation. This study aimed to develop a novel semi-quantitative geometric characterisation methodology to assess the wear/deformation of DM liners. METHODS. Three-dimensional coordinate data of the internal and external surfaces of 14 in-vitro tested DM liners was collected using a Legex 322 coordinate measuring machine. Data was input into a custom Matlab script, whereby the unworn reference geometry was determined using a sphere fitting algorithm. The analysis method determined the geometric variance of each point from the reference surface and produced surface deviation heatmaps to visualise areas of wear/deformation. Repeatability of the method was also assessed. RESULTS. Semi-quantitative analysis of the surface deviation heatmaps revealed circumferential damage patterns similar to those reported in the literature. Additionally, the location of the damaged regions corresponded between the internal and external surfaces. Comparing five repeat measurements of the same liner, the maximum geometric variance of each surface varied by 1 µm (standard deviation) suggesting a high repeatability of the method. CONCLUSIONS. This study presents an effective and highly repeatable characterisation methodology to semi-quantitatively assess the wear/deformation of in-vitro tested DM liners. This method is suitable for the analysis of retrieved DM liners whereby no pre-service information is available, which may provide information about the complex in-vivo kinematics and mechanical failure mechanisms of these bearings

Abstract. Objectives. The objective of this proof of concept study was to explore whether some total hip arthroplasty (THA) patients with well-functioning implants achieve normal sagittal plane hip kinematics during walking gait. Methods. Sagittal plane hip kinematics were recorded in eleven people with well-functioning THA (71 ± 8 years, Oxford Hip Score = 46 ± 3) and ten healthy controls (61 ± 5 years) using a three-dimensional motion capture system as they walked over-ground at a self-selected velocity. THA patients were classified as high- or low-functioning (HF and LF, respectively) depending on whether the mean absolute difference between their sagittal plane hip kinematics was within one standard deviation of the control group (5.4°) or not. Hedge's g effect size was used to compare the magnitude of the difference from the control group for the HF and LF THA groups. Results. Five THA patients were identified as HF and 6 as LF. The mean absolute difference in sagittal plane hip kinematics between the THA groups and the control group was on average 6.2° larger for the LF THA patients compared to the HF, with this difference associated with a large effect size (g = 1.84). Conclusions. The findings of this study challenge the findings of previous work which suggests THA patients do not achieve normal sagittal plane hip kinematics. Five patients were classified as HR and achieved motion patterns that were on average within the variance of the asymptomatic control group, suggesting normative sagittal plane hip kinematics. Understanding why some THA patients achieve motion patterns more comparable to healthy controls than others would help to develop means of maximising functional recovery, and potentially enhance both patient quality of life and implant survivorship through more normal loading of the implant

Abstract. Background/Objectives. The incidence of reverse total shoulder replacement (rTSR) implantation is increasing globally, but apprehension exists regarding complications and associated challenges. We retrospectively analysed the senior author's series of rTSR from a tertiary centre using the VAIOS shoulder system, a modular 4th generation implant. We hypothesised that the revision rTSR cohort would have less favourable outcomes and more complications. Methods. 114 patients underwent rTSR with the VAIOS system, over 7 years. The primary outcome was implant survival. Secondary outcomes were Oxford shoulder scores (OSS), radiographic analysis (scapular notching, tuberosity osteolysis, and periprosthetic radiolucent lines) and complications. Results. There were 55 Primary rTSR, 31 Revision rTSR and 28 Trauma rTSR. Implant survival: Primary rTSR- 0 revisions, average 3.35-year follow-up. Revision rTSR-1 revision (4.17%), average 3.52-year follow-up. Trauma rTSR- 1 revision (3.57%), average 4.56-year follow-up OSS: Average OSS improved from 15.39 to 33.8 (Primary rTSR) and from 15.11 to 29.1 (Revision rTSR). Average post-operative OSS for the Trauma rTSR was 31.4 Radiological analysis and complications: Low incidence of scapular notching One hairline fracture below the tip of stem, noted incidentally, which required no treatment. One periprosthetic fracture after alcohol related fall. Treated non-surgically One joint infection requiring two-stage revision to rTSR. One dislocation noted at 2 year follow up. This patient had undergone nerve grafting within 6 months of rTSR for axillary nerve injury sustained during the original fracture dislocation. One acromial fracture with tibial and distal humeral fracture after a fall. Conclusions. The 4th generation modular VAIOS implant is a reliable option for various indications. The revision rTSR cohort had favourable outcomes with low complication rates. In this series, early-to-medium term results suggest lower revision rates and good functional outcomes when compared to published reports. We plan to monitor long-term implant survivorship and patient reported outcomes. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

The aim of this study was to determine the outcomes and survivorship of the Triathlon knee replacement at 7 years after surgery. A cohort of 266 patients receiving a Triathlon knee replacement were assessed before surgery and at 3 months, 1 year, 2 years, 3 years, 5 years and 7 years post-operation. Patient-reported outcomes were assessed using the WOMAC, KOOS Knee-Related Quality of Life scale, Satisfaction Scale and questions on kneeling ability and whether they regretted having the operation. Data on survivorship was collected from self-report and medical records. At 7 years after surgery, 32 patients were deceased, and 17 patients were withdrawn. Of the 217 patients remaining in the study, 164 (76%) returned a completed study questionnaire. At 7 years after surgery, 92% of patients reported an improvement in their WOMAC Pain score greater than the minimally clinically important improvement (defined as improvement of ≥9 points from before surgery) and 82% reported this in their WOMAC Function score (defined as improvement of ≥12 points). Knee-related quality of life was good, with a mean score of 66.8 (SD 26.0) (0–100 scale, worst to best). A high percentage of patients (89%) were somewhat or very satisfied with their outcome at 7 years. Survivorship with revision as the endpoint was 96.4% (95% CI 93.2–98.1%) at 7 years post-operation. Five percent of patients regretted having their operation and 68% reported much difficulty or an inability to kneel. In conclusion, this study observed good long-term patient outcomes and survivorship of the Triathlon knee replacement

Abstract. Introduction. Long term survivorship in Total Knee Arthroplasty is significantly dependent on prosthesis alignment. The aim of this study was to determine, compare and analyse the coronal alignment of the tibial component of a single implant system using 3 different techniques. Method. Retrospective study of cases from a prospectively collected database. Radiological assessment included measurement of the coronal alignment of tibial components of total knee arthroplasties, and its deviation from the mechanical axis. A comparison study of intramedullary, extramedullary and tibial crest alignment methods was performed. Results. 66 consecutive patients (3 groups of 22 each). Mean BMI was 26. The mean angle of deviation from the mechanical axis was significantly lesser (p< 0.05) in the Tibial crest alignment group patients compared to the other 2 groups. Moreover, the number of outliers (+/-3 degrees) were 2 and 4 in the intra and extramedullary group, whereas there were none in the tibial crest group. The inter and intraclass correlation coefficient was 0.8 and 0.9 respectively. Conclusion. The Tibial Crest Alignment Technique is an effective technique to produce consistent results to achieve optimal coronal alignment of the tibial component in TKA, even in patients with high BMI. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. There is a paucity of long term data concerning the pre and postoperative patient reported function of total knee replacement. The aim of this study was to determine the mortality, implant survivorship, patient reported function and satisfaction in a cohort of 114 patients, from a single centre, who received a Kinemax total knee replacement more than 15 years ago. Methods. Patients completed a questionnaire incorporating validated disease- and joint-specific scores, patient satisfaction and overall health preoperatively, at 3 months, 1 year, 2 years and a minimum of 15 years following surgery. NHS National Strategic Tracing Service, hospital and primary care records were used to establish mortality and for implant survivorship in deceased patients. Results. 45 patients were alive at final follow up. The survivorship of the cohort with revision of the TKR as the endpoint was 84%. Four cases were revised for wear, three for loosening and one for peri-prosthetic fracture. There was a significant improvement in WOMAC Pain, Function and Stiffness Scores, Oxford Knee Score and Self-Administered Patient Satisfaction Scale between pre-operative and all post-operative time points, although patient satisfaction had decreased significantly by the time of final follow up. Conclusion. In this cohort, the Kinemax TKR showed satisfactory long term survivorship with functional scores demonstrating a high level of patient satisfaction at all follow up time points. Level of Evidence. 2

Introduction. As the demand for primary total knee arthroplasty (TKA) has been on the rise, so will be the demand for revision knee surgery. Nevertheless, our knowledge on the modes of failure and factors associated with failure of knee revision surgery is considerably lower to that known for primary TKA. To date, this has been mostly based on case series within the literature. Therefore, the aim of this study was to evaluate the survivorship of revision TKA and determine the reasons of failure. Methods. A retrospective study was conducted with prior approval of the institutional audit department. This involved evaluation of existing clinical records and radiographs of patients who underwent revision knee surgery at our institution between 2003 and 2015. Re-revision was identified as the third or further procedure on the knee in which at least one prosthetic component was inserted or changed. Results. 95 patients were identified who had re-revision knee replacement. Of these, there were 46 men (48%) and 49 women (52%) with an average age of 65 yrs. Infection was the main cause of failure (35.8%) followed by aseptic loosening (27.4%) and extensor mechanism problems leading to reduced range of motion (7.4%). Other causes included MCL Laxity (3.2%), oversized implants (3.2%) and fracture of the cement mantle (1.1%). The mean survivorship of revision knee replacements in our cohort was 31 months (Range between 1 – 119 months). Conclusion. The survival of knee re-revision implants is considerably different from primary TKA implants. The results of our study provide an improved understanding of the modes of failure of re-revision knee replacements, enabling orthopaedic surgeons the opportunity to better understand the current problems associated with revision knee surgery and the potential to improve our outcomes by tackling these issues

The development of an algorithm that provides accurate individualised estimates of revision risk could help patients make informed surgical treatment choices. This requires building a survival model based on fixed and modifiable risk factors that predict outcome at the individual level. Here we compare different survival models for predicting prosthesis survivorship after hip replacement for osteoarthritis using data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. In this comparative study we implemented parametric and flexible parametric (FP) methods and random survival forests (RSF). The overall performance of the parametric models was compared using Akaike information criterion (AIC). The preferred parametric model and the RSF algorithm were further compared in terms of the Brier score, concordance index (C index) and calibration. The dataset contains 327 238 hip replacements for osteoarthritis carried out in England and Wales between 2003 and 2015. The AIC value for the FP model was the lowest. The averages of survival probability estimates were in good agreement with the observed values for the FP model and the RSF algorithm. The integrated Brier score of the FP model and the RSF approach over 10 years were similar: 0.011 (95% confidence interval: 0.011–0.011). The C index of the FP model at 10 years was 59.4% (95% confidence interval: 59.4%–59.4%). This was 56.2% (56.1%–56.3%) for the RSF method. The FP model outperformed other commonly used survival models across chosen validation criteria. However, it does not provide high discriminatory power at the individual level. Models with more comprehensive risk adjustment may provide additional insights for individual risk