Aims. The use of high tibial osteotomy (HTO) to delay total knee arthroplasty (TKA) in young patients with osteoarthritis (OA) and constitutional deformity remains debated. The aim of this study was to compare the long-term outcomes of TKA after HTO compared to TKA without HTO, using the time from the index OA surgery as reference (HTO for the study group, TKA for the control group). Methods. This was a case-control study of consecutive patients receiving a posterior-stabilized TKA for OA between 1996 and 2010 with previous HTO. A total of 73 TKAs after HTO with minimum ten years’ follow-up were included. Cases were matched with a TKA without previous HTO for age at the time of the HTO. All revisions were recorded. Kaplan-Meier survivorship analysis was performed using revision of metal component as the endpoint. The Knee Society Score, range of motion, and patient satisfaction were assessed. Results. Mean follow-up was 13 years (SD 3) after TKA in both groups. The 20-year Kaplan-Meier survival estimate was 98.6% in TKA post-HTO group (HTO as timing reference) and 81.4% in control group (TKA as timing reference) (p = 0.030). There was no significant difference in clinical outcomes, radiological outcomes, and complications at the last follow-up. Conclusion. At the same delay from index surgery (HTO or TKA), a strategy of HTO followed by TKA had superior knee survivorship compared to early TKA at long term in young patients. Level of evidence: III. Cite this article: Bone Jt Open 2023;4(2):62–71

Abstract. Introduction. Secondary osteonecrosis of the knee affects young population and causes bilateral extensive lesions. Arthroplasty is the last resort in younger population and joint preserving options questionable in pathological bone. Conservative measures have shown failure in multiple studies and hence no gold standard treatment advocated. We aimed at identifying and analysing various treatment options for secondary osteonecrosis with respect to the outcomes and studying features of symptomatic secondary osteonecrosis with regards to demographic pattern, radiological features and causative factors. Methods. A systematic review of literature was performed in accordance with the Cochrane handbook for systematic reviews and reported according to the PRISMA guidelines. Results. Six studies which included a total of 192 patients with data on 240 knee joints were included in the final review. Follow up period ranged from 1 year to 16 years. The mean age of the patients was 34.7. 3 studies were on arthroplasty and 3 on joint preserving interventions. Majority of patients were in Stage 2 or Stage 4 of osteonecrosis. Steroid induced osteonecrosis was the majority followed by SLE and sickle cell disease. The pooled analysis showed an improvement of pre-operative knee score from 50.47 to 89.21 post-operatively. The pooled effect size for failure rate was 8.7% in joint preserving interventions and 9.2% in joint replacement group. Conclusion. Joint preserving techniques with bone marrow aspirate infiltration showed promising functional outcome and to a certain extent reversal of the pathological process. For advanced stages with subchondral collapse cemented arthroplasty showed satisfactory functional outcomes

Aims

The mean age of patients undergoing total knee arthroplasty (TKA) has reduced with time. Younger patients have increased expectations following TKA. Aseptic loosening of the tibial component is the most common cause of failure of TKA in the UK. Interest in cementless TKA has re-emerged due to its encouraging results in the younger patient population. We review a large series of tantalum trabecular metal cementless implants in patients who are at the highest risk of revision surgery.

Introduction. The demands placed upon joint surgeons are perhaps greatest when treating the revision arthroplasty patient, who present with complications demanding skill in diagnosis and evaluation, interpersonal communication and the technical aspects of the revision procedure. However, little information exists identifying which specific tasks in revision arthroplasty are most difficult for surgeons to master, and whether the greatest challenges arise from clinical, cognitive or technical facets of patient treatment. This study was undertaken to identify which tasks associated with revision total knee replacement (TKR) are perceived as most challenging to young surgeons and trainees to guide future efforts in surgical training and curriculum development. Methods. We developed an online survey instrument consisting of 69 items encompassing pre-operative, intraoperative, and post-operative tasks that preliminary studies identified as the essential components of revision TKR. These tasks encompassed 4 domains: clinical decision-making skills (n=9), interpersonal assessment and communication (n=7), surgical decision-making (n=35) and procedural surgical tasks (n=18). Respondents rated the difficulty of each item on a 5-level Likert scale, with an ordinal score ranging from 1 (“very easy”) to 5 (“very difficult”. The survey instrument was administered to a cohort of 109 US surgeons: 31 trainees enrolled in a joint fellowship program (Fellows) and 78 surgeons who had graduated from a joint fellowship program within the previous 10 years (Joint Surgeons). Using appropriate parametric and non-parametric tests, the responses were analyzed to examine the variation of reported difficulty of each of the 69 items, in addition to the nature of the task (cognitive, surgical, clinical and interpersonal), and differences between Fellows and Surgeons. Results. Both Fellows and Surgeons reported a wide variation in the difficulty of performing the tasks identified in each f the 4 domains. Fellows reported a higher average difficulty score than Surgeons (2.94 vs 2.74; p=0.032), corresponding to a greater frequency of tasks entailing some degree of difficulty (34.9% vs 24.4%, p<0.0001). Both groups experienced difficulty in performing tasks involving interpersonal interaction with patients (Fellows: 34.6% vs Surgeons: 34.3%, p=0.93). Fellows also found the technical aspects of revision surgery most challenging with 38.5% of items considered difficult compared to 28.7% for the Surgeon group (p<0.001). Highly significant differences between Fellows and Surgeons were also observed in facility with surgical decision making (p<0.001) and to a lesser extent, clinical decisions relating to patient care (% difficulty: p=0.0251). A compilation of the specific items cited as most difficult by the participants appears in Table 2. Conclusions. The young surgeons surveyed in this study reported difficulty in performing some tasks within both the clinical, cognitive and technical domains of revision knee arthroplasty. The high incidence of difficulty in tasks involving clinical decision-making and operative performance are characterized by a lack of accepted guidelines and the lack of a standard surgical practice. In general, our findings highlight the need for improvements in surgeon training to improve decision-making and procedural skills as part of the comprehensive management of patients undergoing revision knee arthroplasty. For any figures or tables, please contact authors directly

The aim of this study was to compare the long-term outcome from total knee replacement (TKR) in young versus old patients in terms of pain and functional outcome. We used our arthroplasty database which recorded prospectively pain and American Knee Society scores at regular intervals over ten years after TKR. The procedures used a modern, cemented resurfacing type cruciate retaining prosthesis. A cohort of young patients (≤55 years) were identified. A control group of patients > 56 was identified, matching for ASA, body mass index and underlying condition. Change over time was analysed using a factorial repeated measures ANOVA test, which allowed for investigation of difference between groups. 40 Knees in 26 patients were identified. 2 patients died prior to follow up, 2 were revised within the study period. (1 for infection at 2 years and one for change of poly at 7 years) and a further 4 were lost to follow up. 7 knees could not be matched and were excluded. This left a study group of 24 young and 24 older knees. Pain scores (p=0.025) and American Knee Society “Knee” (p<0.001) and “Function” (p<0.001) scores changed significantly over time. There were however no statistical differences over the 10 year period in pain (p=0.436) and knee performance (0.618) but overall function was higher throughout the period in the younger group (=0.004). Knee replacement in younger patients produces similar outcomes in terms of pain and function compared with older patients and TKR should not be withheld purely on account of age

We set out to demonstrate the 10-year survivorship of the PFC sigma TKA in a young patient group. Demographic and clinical outcome data were collected prospectively at 6 months, 18 months, 3 years, 5 years and 8-10 years post surgery. The data were analysed using Kaplan Meier survival statistics with end point being regarded as death or revision for any reason. 203 patients were found to be ≤55 years at the time of surgery. Four patients required revision and four patients died. Another four patients moved away from the region and were excluded from the study. A total of 224 knees in 199 patients (101 male and 98 females.) 168 patients had a diagnosis of Osteoarthritis and 28 with inflammatory arthritis. Average age 50.6 years range 28-55 years (median 51). Ten-year survivorship in terms of revision 98.2% at ten years 95% confidence interval. Our results demonstrate that the PFC Sigma knee has an excellent survival rate in young patients over the first 10 years. TKR should not be withheld from patients on the basis of age

We carried out a prospective study of 118 hydroxyapatite-coated, cementless total knee replacements in patients who were ≤ 55 years of age and who had primary (92; 78%) or post-traumatic (26; 22%) osteoarthritis. The mean period of follow-up was 7.9 years (5 to 12.5). The Knee Society clinical scores improved from a pre-operative mean of 98 (0 to 137) to a mean of 185 (135 to 200) at five years, and 173 (137 to 200) at ten years. There were two revisions of the tibial component because of aseptic loosening, and one case of polyethylene wear requiring further surgery. There was no osteolysis or progressive radiological loosening of any other component. At 12 years, the overall rate of implant survival was 97.5% (excluding exchange of spacer) and 92.1% (including exchange of spacer). Cementless total knee replacement can achieve excellent long-term results in young, active patients with osteoarthritis. In contrast to total hip replacement, polyethylene wear, osteolysis and loosening of the prosthesis were not major problems for these patients, although it is possible that this observation could change with longer periods of follow-up

We report the ten-year survival of a cemented total knee replacement (TKR) in patients aged < 55 years at the time of surgery, and compare the functional outcome with that of patients aged > 55 years. The data were collected prospectively and analysed using Kaplan-Meier survival statistics, with revision for any reason, or death, as the endpoint. A total of 203 patients aged < 55 years were identified. Four had moved out of the area and were excluded, leaving a total of 221 TKRs in 199 patients for analysis (101 men and 98 women, mean age 50.6 years (28 to 55)); 171 patients had osteoarthritis and 28 had inflammatory arthritis. Four patients required revision and four died. The ten-year survival using revision as the endpoint was 98.2% (95% confidence interval 94.6 to 99.4). Based on the Oxford knee scores at five and ten years, the rate of dissatisfaction was 18% and 21%, respectively. This was no worse in the patients aged < 55 years than in patients aged > 55 years.

These results demonstrate that the cemented PFC Sigma knee has an excellent survival rate in patients aged < 55 ten years post-operatively, with clinical outcomes similar to those of an older group. We conclude that TKR should not be withheld from patients on the basis of age.

Abstract

Introduction. The management of young patients with painful medial compartment osteoarthritis remains controversial. Opening wedge medial high-tibial osteotomy using a locking plate has shown good results in selected patients. This cohort of patients has high physical demands and previous studies have warned against operating on patients with increased body mass index (BMI). Patients and Methods. Thirty-five patients undergoing valgus high tibial osteotomy between Oct 2004 and Feb 2010. Surgical outcome was assessed using Oxford Knee score, pre- and post-operative pain scores, change in employment and patient satisfaction. Results. Mean age at the time of surgery was 41 (22 to 62), mean BMI was 30.9 (21 to 43) and mean Oxford score was 37/48 (16 to 48). Patients rated their overall satisfaction as 7.9/10. Three patients were lost to follow-up, two patients died of unrelated disease. Fifteen (50%) patients had heavy manual jobs and of these 12 (80%) returned to their previous employment post-operatively within 6 months. Seven patients had a BMI > 35 (Mean 39) with a mean weight of 126 Kg (105Kg to 144Kg). These patients had a mean Oxford Score of 42/48 and overall satisfaction of 90%. Pain improved from 8.4/10 pre-op to 1.5/10 post-op (P < 0.0001). None had further procedures. Conclusion. Opening wedge high-tibial osteotomy offers a successful alternative treatment of medial osteoarthritis in young patients with high BMI who place high demands on their knees

Aims. The success of total knee arthroplasty (TKA) is usually measured using functional outcome scores and revision-free survivorship. However, reporting the lifetime risk of revision may be more meaningful to patients when gauging risks, especially in younger patients. We aimed to assess the lifetime risk of revision for patients in different age categories at the time of undergoing primary TKA. Methods. The New Zealand Joint Registry database was used to obtain revision rates, mortality, and the indications for revision for all primary TKAs performed during an 18-year period between January 1999 and December 2016. Patients were stratified into age groups at the time of the initial TKA, and the lifetime risk of revision was calculated according to age, sex, and the American Society of Anesthesiologists (ASA) grade. The most common indications for revision were also analyzed for each age group. Results. The overall ten-year survival rate was 95.6%. This was lowest in the youngest age group (between 46 and 50 years) and increased sequentially with increasing age. The lifetime risk of requiring revision was 22.4% in those aged between 46 and 50 years at the time of the initial surgery, and decreased linearly with increasing age to 1.15% in those aged between 90 and 95 years at the time of surgery. Higher ASA grades were associated with increased lifetime risk of revision in all age groups. The three commonest indications for revision were aseptic loosening, infection, and unexplained pain. Young males, aged between 46 and 50 years, had the highest lifetime risk of revision (25.2%). Conclusion. Lifetime risk of revision may be a more meaningful measure of outcome than implant survival at defined time periods when counselling patients prior to TKA. This study highlights the considerably higher lifetime risk of revision surgery for all indications, including infection, in younger male patients. Cite this article: Bone Joint J 2022;104-B(2):235–241

Aims

Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty (TKA), particularly for younger patients. The outcome of knee arthroplasty is typically defined as implant survival or revision incidence after a defined number of years. This can be difficult for patients to conceptualize. We aimed to calculate the ‘lifetime risk’ of revision for UKA as a more meaningful estimate of risk projection over a patient’s remaining lifetime, and to compare this to TKA.

Aims. The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears. Methods. We conducted a multicentre, open-labelled, randomized controlled trial in patients aged 18 to 45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up. We performed a cost-utility analysis on the randomization groups to compare both treatments over a 24-month follow-up period. Cost utility was calculated as incremental costs per quality-adjusted life year (QALY) gained of arthroscopic partial meniscectomy compared to physical therapy. Calculations were performed from a healthcare system perspective and a societal perspective. Results. A total of 100 patients were included: 49 were randomized to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during follow-up. Over 24 months, patients in the arthroscopic partial meniscectomy group had a mean 0.005 QALYs lower quality of life (95% confidence interval -0.13 to 0.14). The cost-utility ratio was €-160,000/QALY from the healthcare perspective and €-223,372/QALY from the societal perspective, indicating that arthroscopic partial meniscectomy incurs additional costs without any added health benefit. Conclusion. Arthroscopic partial meniscectomy is arthroscopic partial meniscectomy is unlikely to be cost-effective in treating young patients with isolated traumatic meniscal tears compared to physical therapy as a primary health intervention. Arthroscopic partial meniscectomy leads to a similar quality of life, but higher costs, compared to physical therapy plus optional delayed arthroscopic partial meniscectomy. Cite this article: Bone Joint J 2023;105-B(11):1177–1183

Aims

Unicompartmental knee arthroplasty (UKA) has higher revision rates than total knee arthroplasty (TKA). As revision of UKA may be less technically demanding than revision TKA, UKA patients with poor functional outcomes may be more likely to be offered revision than TKA patients with similar outcomes. The aim of this study was to compare clinical thresholds for revisions between TKA and UKA using revision incidence and patient-reported outcomes, in a large, matched cohort at early, mid-, and late-term follow-up.

Abstract. Purpose. Unicompartmental knee arthroplasty (UKA) is an effective treatment for late knee osteoarthritis (OA). However, its indications remain controversial. Young age (< 60 years) has been associated with worse outcomes. The goal of this systematic review and meta-analysis is to study the effect of age on UKA outcomes. Methods. The primary objective was to compare the UKA revision rate in young patients with that of old patients, using the age thresholds of 60 and 55 years. Secondary objectives were patient-reported outcome measures (PROMs) and implant design. PubMed, Ovid, Web of Science, Google Scholar, and Cochrane library were searched in June 2021. This review was conducted in accordance with the PRISMA guidelines (PROSPERO registration number: CRD42021248322). Results. A total of 12 observational studies with 6,448 knees were included. A mean MINORS score of 19 was assigned to the review. The mean age of patients was 64.32 years, with follow-up ranging from 0.2 to 15 years. There was no significant difference in revision rate, incident or PROMs between young and old patients in the analysis for each age threshold. Further sub-analysis adjusting for implant type in mobile- and fixed-bearing prostheses also showed similar results between those above and under 60 and 55 years. Conclusion. Young age was not associated with a higher revision rate or lower functional scores. Thus, this review provides evidence that performing UKA at a younger age (< 60 years) should not be considered suboptimal. However, this finding should be applied in context, as other confounding factors need to be explored

Abstract. Introduction. Revision total knee arthroplasty (rTKA) in elderly patients (>85 years) is associated with increased mortality, hospital stay and a high rate (55%) of complications. The objective was to assess PROMs in elderly patients undergoing rTKA. Methods. A retrospective cohort study of consecutive patients undergoing rTKA at an arthroplasty centre from 2001–2022 were compared to a control group (aged 50–79y) matched for gender, diagnosis & surgery year. The commonest reasons for revision in elderly patients was aseptic loosening (53/100), infection (21/100) and fracture (7/100). One-year patient-reported outcome data was available for 64%. Results. 100 patients underwent rTKA with a mean age of 84 years (range 80–97 years, SD 3) compared to a matched control group of younger patients (mean age 69y). Preoperative function was poor, with a mean Oxford knee score (OKS) of 40/100 in elderly and 43/100 in younger patients (p=0.164). At one-year postop, mean OKS was comparable between elderly and young patients (81 and 84/100 respectively, p=0.289). The number of patients with severe pain at one year was also comparable (4% elderly and 7% young respectively, p=0.177). The improvement in OKS for elderly patients was sustained at three (82 95% CI 58–100, 14/100 known) and five years. Overall complication rate was 54%. 14% were dead at 1 year and 56% were dead at five-years. Conclusion. Elderly patients undergoing elective revision TKA show a mean improvement in Oxford knee score of +38 at one year. This is the same as younger patients and is sustained at three and five years

Aims

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.

Abstract. Introduction. Recent research has questioned the role of arthroscopic meniscectomy in patients with a meniscal tear leading to the development of treatment recommendations for these patients. There is a clear need to understand patient perceptions of living with a meniscal tear in order to plan future research and treatment guidelines. Aims. To explore the experiences and expectations of treatment of young patients with a meniscal tear of the knee. Methodology. Ten participants diagnosed with a meniscal tear were recruited from the METRO cohort study using a purposive sampling strategy. These patients underwent semi-sructured interviews between April and May 2021. Thematic analysis was used to code the transcripts and generate key themes in order to describe the data. Results. Themes identified relate to the broad areas of: the effect of symptoms, the expericne of the clinical consultation and the experience of the treatment modality undertaken. Meniscal tears have a profound impact on pain and many patients experience effects on their family and financial life in addition to physical symptoms. Participants expected the majority of their management to occur in secondary care and most thought surgery would be a definitive treatment, while the effectiveness of physiotherapy could not be guaranteed as it would not fix the physical tear. Conclusion. Patient experience of meniscal tear may not correspond with current available clinical evidence. Clinicians should consider the common misconceptions highlighted in this study when conducting a consultation and pre-empt them to optimally manage patient expectations

Abstract. Introduction. Isolated patellofemoral osteoarthritis accounts for 10% of knee osteoarthritis. Many of these will not require arthroplasty solutions, but for those who are sufficiently symptomatic, patellofemoral joint (PFJ) replacement has been shown to be an effective procedure. The National Joint Registry (NJR) has shown a higher revision rate for this operation, particularly in younger patients (males <55 years 13.3% failure at 5 years, females 9.6%). The aim of this study is to report on the medium-term outcome of the Avon patellofemoral joint arthroplasty in patients under 55 from a non-design centre. There is no other published case series on this young patient cohort. Methodology. 50 Avon PFJ replacements (Stryker, Kalamazoo USA) were undertaken in 46 patients under 55 years old (range 35 – 54, mean 48.8) between 2010 and 2022 for end-stage isolated PFJ arthritis shown on Xray and MRI scan. The outcome measure was all-cause revision rate. This was assessed by review of clinical notes, imaging and NJR data. Results. The mean follow up was 5.8 years (range 6 months to 12.9 years). Only one patient had a revision procedure (for progressive osteoarthritis) which was 3 years after the primary procedure. This patient has had no further surgery. The implant survival rate was 97.2% at 5 years and 97.2% at 10 years. Conclusion. This study shows that patellofemoral joint replacement with the Avon prosthesis can give a satisfactory revision rate in the medium term in patients under 55 if carefully selected

Abstract. Background. Oxidized zirconium (OxZr) has been introduced as an alternative bearing for femoral components in Total Knee Arthroplasty (TKA). It has a ceramic-like zirconium oxide outer layer with a low coefficient of friction. Early studies have found OxZr TKA to have a low incidence of early failure in young high demand patients. Currently no study has reported on the outcome of these implants beyond ten years. Objectives. The purpose of our study was to present an in-depth 15-year survival analysis of cemented Profix II OxZr TKA. Study Design & Methods. Data was collected prospectively and survival analysis undertaken with multiple strict end points. Complication rates were recorded and patient reported outcomes were measured. Results. 617 Profix II OxZr TKAs were performed over four years. Forty-nine patients underwent reoperation. Aseptic tibial loosening was the most common cause of failure (32.7%) on average occurring 2.8 years post primary procedure. There was one recorded failure due to loosening of the zirconium femoral component. Revision rate at 15-years was 6.38%. Cumulative survivorship was 91.52% with failure considered to be reoperation for any reason. WOMAC score improved in 86% of patients by year 1. The average score improved by 21.2 points and met the standard for minimum clinically important difference. Conclusions. This study presents the first 15-year survival analysis of cemented Profix II OxZr TKA. Our data supports current literature on the long-term survivorship of oxidised zirconium total knee replacements