Satisfactory primary wound healing following total joint replacement is essential. Wound healing problems can have devastating consequences for patients. Assessment of their healing capacity is useful in predicting complications. Local factors that influence wound healing include multiple previous incisions, extensive scarring, lymphoedema, and poor vascular perfusion. Systemic factors include diabetes mellitus, inflammatory arthropathy, renal or liver disease, immune compromise, corticosteroid therapy, smoking, and poor nutrition. Modifications in the surgical technique are necessary in selected cases to minimise potential wound complications. Prompt and systematic intervention is necessary to address any wound healing problems to reduce the risks of infection and other potential complications. Cite this article: Bone Joint J 2013;95-B, Supple A:144–7

Aims. The anterior cruciate ligament (ACL) is known to have a poor wound healing capacity, whereas other ligaments outside of the knee joint capsule such as the medial collateral ligament (MCL) apparently heal more easily. Plasmin has been identified as a major component in the synovial fluid that varies among patients. The aim of this study was to test whether plasmin, a component of synovial fluid, could be a main factor responsible for the poor wound healing capacity of the ACL. Methods. The effects of increasing concentrations of plasmin (0, 0.1, 1, 10, and 50 µg/ml) onto the wound closing speed (WCS) of primary ACL-derived ligamentocytes (ACL-LCs) were tested using wound scratch assay and time-lapse phase-contrast microscopy. Additionally, relative expression changes (quantitative PCR (qPCR)) of major LC-relevant genes and catabolic genes were investigated. The positive controls were 10% fetal calf serum (FCS) and platelet-derived growth factor (PDGF). Results. WCS did not differ significantly among no plasmin versus each of the tested concentrations (six donors). The positive controls with PDGF and with FCS differed significantly from the negative controls. However, we found a trend demonstrating that higher plasmin concentrations up-regulate the expression of matrix metalloproteinase 13 (MMP13), 3 (MMP3), and tenomodulin (TNMD). Conclusion. The clinical relevance of this study is the possibility that it is not solely the plasmin, but also additional factors in the synovial fluid of the knee, that may be responsible for the poor healing capacity of the ACL. Cite this article: Bone Joint Res 2020;9(9):543–553

We prospectively randomised 78 patients into two groups, ‘drains’ or ‘no drains’ to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient. Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing

Introduction. Vancomycin is a commonly used antibiotic for prophylaxis in total joint replacement surgery. Several studies have reported superior local tissue concentration of vancomycin using intraosseous (IO) infusion compared with standard intravenous (IV) administration in total knee arthroplasty (TKA). We reviewed patients undergoing primary TKA who received IO vancomycin to a group receiving IV vancomycin. Methods. A retrospective review of 1038 patient who underwent primary TKA at our institution was performed from May 1, 2016 to May 1, 2019. This was a consecutive series of patients before and after we adopted this technique. IO vancomycin administration technique has been previously reported from our institution (500mg vancomycin in 200mL solution). Comparisons included preoperative and postoperative creatinine values, adverse reaction to vancomycin, tourniquet time, re-operation rates, periprosthetic joint infection rate at 1 year. Results. There were 482 patients in IO vancomycin group and 572 patients in IV vancomycin group. No differences between groups were present for patient age, sex, or BMI. No differences in creatinine values or tourniquet time were present and there were no adverse reactions to vancomycin in either group. Eight periprosthetic joint infections (1.4%) were reported in the IV group, and 1 (0.2%) periprosthetic joint infection was reported in the IO group at 1 year follow up, and this was statistically significant (p = 0.04, Fishers exact test). The overall reoperation rate was 1.7% (10 patients) in the IV group and 1.1% (5 patients), however, this was not statistically significant (p = 0.4371). The additional reoperations were for retained suture or small areas of poor superficial wound healing and were considered minor. Conclusion. Our study demonstrated that IO vancomycin in primary TKA reduced periprosthetic joint infection and is a safe and effective alternative to IV administration. Furthermore, IO infusion also eliminates the logistical challenges of timely prophylactic antibiotic administration before TKA

Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an ambulatory surgery center (ASC). Methods. Among a single-surgeon cohort of 721 patients who underwent arthroplasty at a free-standing ASC, 611 (84.7%) were matched one-to-one to inpatients based on age, gender, American Society of Anesthesiologists (ASA) score, and Body Mass Index (110 patients could not be adequately matched). The cohort included 208 total hip arthroplasties (34.0%), 196 total knee arthroplasties (32.1%), 178 unicompartmental knee arthroplasties (29.1%), 25 hip resurfacings (4.1%), two revision hip arthroplasties (0.3%) and two revision knee arthroplasties (0.3%). Post-operative outcomes including readmissions, reoperations, unplanned clinic visits, emergency department visits, and complications were compared. Complications were classified as either major (i.e. death, periprosthetic joint infection, pulmonary embolism) or as minor (i.e. delayed wound healing, rashes, urinary retention). Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The rates of any complications (4.1% outpatient vs. 5.1% inpatient, p=0.41), minor complications (2.6% vs. 3.4%; p=0.40), readmissions (1.6% vs. 2.0%; p= 0.67), reoperations (0.7% vs. 1.1%; p=0.36), and unplanned clinic visits (5.4% vs 6.7%; p=0.34) were all lower amongst the outpatient group but did not reach significance with the sample size studied. The rate of major complications was the same in both groups (1.6% for both; p=1.0) while patients who underwent surgery at an ASC had significantly fewer emergency department visits (1.0% vs. 3.1%; p=0.009). Conclusions. Arthroplasty performed in the ambulatory setting appears to be safe in properly selected patients. However, this finding may be partly due to selection bias and intangible characteristics that were not adequately controlled for through matching

In this paper, we consider wound healing after total knee arthroplasty

We have investigated whether the thigh tourniquet used during total knee replacement (TKR) influenced the development of postoperative wound hypoxia and was a cause of delayed wound healing. We allocated randomly 31 patients (31 TKRs) to one of three groups: 1) no tourniquet; 2) tourniquet inflated at low pressure (about 225 mmHg); and 3) tourniquet inflated to high pressure of about 350 mmHg. Wound oxygenation was measured using transcutaneous oxygen electrodes. In the first week after surgery, patients with a tourniquet inflated to a high pressure had greater wound hypoxia than those with a low pressure. Those without a tourniquet also had wound hypoxia, but the degree and duration were less pronounced than in either of the groups with a tourniquet. Use of a tourniquet during TKR can increase postoperative wound hypoxia, especially when inflated to high pressures. Our findings may be relevant to wound healing and the development of wound infection

Introduction. Closed suction intraarticular drain (CSD) use after total knee arthroplasty (TKA) has been studied with regards to wound healing and range of motion, however, no data exist on how CSD use impacts knee joint effusion and quadriceps strength. The primary purpose of this study was to determine whether CSD use influences recovery of quadriceps strength. Secondary outcomes examined effects of CSD on intraarticular effusion, lower limb swelling, knee range of motion (ROM), pain and wound healing complications. Methods. Twenty-nine patients undergoing same-day bilateral TKA were enrolled in a prospective, randomized blinded study. Subjects were randomized to receive a CSD on one lower extremity while the contralateral limb had the use of a subcutaneous drain (SCDRN) without the use of suction. Isometric quadriceps strength was collected as the primary outcome. Secondary outcomes consisted of quadriceps muscle activation, intraarticular effusion measured via ultrasound, lower extremity swelling measured with bioelectrical impendence, lower extremity girth, ROM, and pain. Outcomes were assessed preoperatively and postoperatively at day 2, 2 and 6 weeks and 3 months. Differences in limbs were determined using paired t-tests or Wilcoxon signed rank tests. Results. No significant differences were identified between limbs prior to surgery for the primary or secondary outcomes. No significant differences in quadriceps strength were seen between CSD and SCDRN limbs at postoperative day 2 (p = 0.09), two weeks (p=0.7), six weeks (p=0.3), or three months (p=0.5). Secondary outcomes, of quadriceps activation battery, intraarticular effusion, lower extremity swelling, ROM, and pain were not found to significantly differ at any time point following surgery. Conclusion. The use of CSD during TKA did not influence quadriceps strength, quadriceps activation, intraarticular effusion, bioelectrical measure of swelling, ROM, or pain. The results of this study have limited drain use by the authors in primary uncomplicated TKA

Aims

In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility.

Aims

To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.

Aims

This multicentre retrospective observational study’s aims were to investigate whether there are differences in the occurrence of radiolucent lines (RLLs) following total knee arthroplasty (TKA) between the conventional Attune baseplate and its successor, the novel Attune S+, independent from other potentially influencing factors; and whether tibial baseplate design and presence of RLLs are associated with differing risk of revision.

Smoking is known to have an adverse effect on wound healing and musculoskeletal conditions. This case-controlled study looked at whether smoking has a deleterious effect in the outcome of autologous chondrocyte implantation for the treatment of full thickness chondral defects of the knee. The mean Modified Cincinatti Knee score was statistically significantly lower in smokers (n = 48) than in non-smokers (n = 66) both before and after surgery (p < 0.05). Smokers experienced significantly less improvement in the knee score two years after surgery (p < 0.05). Graft failures were only seen in smokers (p = 0.016). There was a strong negative correlation between the number of cigarettes smoked and the outcome following surgery (Pearson’s correlation coefficient −0.65, p = 0.004). These results suggest that patients who smoke have worse pre-operative function and obtain less benefit from this procedure than non-smokers. The counselling of patients undergoing autologous chondrocyte implantation should include smoking, not only as a general cardiopulmonary risk but also because poorer results can be expected in smokers following this procedure

Aims

Revision total knee arthroplasty (rTKA) is a technically challenging and costly procedure. It is well-documented that primary TKA (pTKA) have better survivorship than rTKA; however, we were unable to identify any studies explicitly investigating previous rTKA as a risk factor for failure following rTKA. The purpose of this study is to compare the outcomes following rTKA between patients undergoing index rTKA and those who had been previously revised.

Aims

The aim was to assess whether robotic-assisted total knee arthroplasty (rTKA) had greater knee-specific outcomes, improved fulfilment of expectations, health-related quality of life (HRQoL), and patient satisfaction when compared with manual TKA (mTKA).

Aims

The primary aim was to assess whether robotic total knee arthroplasty (rTKA) had a greater early knee-specific outcome when compared to manual TKA (mTKA). Secondary aims were to assess whether rTKA was associated with improved expectation fulfilment, health-related quality of life (HRQoL), and patient satisfaction when compared to mTKA.

Aims

It remains difficult to diagnose early postoperative periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). We aimed to validate the optimal cutoff values of ESR, CRP, and synovial fluid analysis for detecting early postoperative PJI in a large series of primary TKAs.

Aims

Infection complicating primary total knee arthroplasty (TKA) is a common reason for revision surgery, hospital readmission, patient morbidity, and mortality. Increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) is a particular concern. The use of vancomycin as prophylactic agent alone or in combination with cephalosporin has not demonstrated lower periprosthetic joint infection (PJI) rates, partly due to timing and dosing of intravenous (IV) vancomycin administration, which have proven important factors in effectiveness. This is a retrospective review of a consecutive series of primary TKAs examining incidence of PJI, adverse reactions, and complications using IV versus intraosseous (IO) vancomycin at 30-day, 90-day, and one-year follow-up.

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.

Aims

Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients.

Aims

The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA.