Aims. Multiligament knee injuries (MLKI) are devastating injuries that can result in significant morbidity and time away from sport. There remains considerable variation in strategies employed for investigation, indications for operative intervention, outcome reporting, and rehabilitation following these injuries. At present no study has yet provided a comprehensive overview evaluating the extent, range, and overall summary of the published literature pertaining to MLKI. Our aim is to perform a methodologically rigorous scoping review, mapping the literature evaluating the diagnosis and management of MLKI. Methods. This scoping review will address three aims: firstly, to map the current extent and nature of evidence for diagnosis and management of MLKI; secondly, to summarize and disseminate existing research findings to practitioners; and thirdly, to highlight gaps in current literature. A three-step search strategy as described by accepted methodology will be employed to identify peer-reviewed literature including reviews, technical notes, opinion pieces, and original research. An initial limited search will be performed to determine suitable search terms, followed by an expanded search of four electronic databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Web of Science). Two reviewers will independently screen identified studies for final inclusion. Dissemination. We will map key concepts and evidence, and disseminate existing research findings to the wider orthopaedic and sports medicine community, through both peer-reviewed and non-peer-reviewed literature, and conference and in-person communications. We will highlight gaps in the current literature and determine future priorities for further research. Cite this article: Bone Jt Open 2022;3(11):894–897

The term mid-flexion instability has entered the orthopaedic literature as a concept, but has not been confirmed as a distinct clinical entity. The term is used freely, sometimes as a synonym for flexion instability. However, the terms need to be clearly separated. A cadaver study published in 1990 associated joint line elevation with decreased stability at many angles of flexion, but that model was not typical of clinical scenarios. The literature is considered and it is proposed that the more common entity of an uncorrected flexion contracture after a measured resection arthroplasty technique is more likely to produce clinical findings that suggest instability mid-flexion.

It is proposed that the clinical scenario encountered is generalised instability, with the appearance of stability in full extension from tight posterior structures.

This paper seeks to clarify whether mid-flexion instability exists as an entity distinct from other commonly recognised forms of instability.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):84–8.

Introduction. Rupture of the anterior cruciate ligament (ACL) is a common injury and often presents with a typical injury pattern. Historic literature has shown that the accuracy of diagnosis of ACL ruptures is poor at the initial medical consultation despite the history of injury strongly suggesting an ACL injury. The aims of this study were to determine: if the accuracy of diagnosis of ACL ruptures at initial presentation has improved over the last decade; grade of medical staff at initial and subsequent consultations; the mechanism of injury; and the subsequent delay in diagnosis and definitive treatment. Materials and Methods. One hundred and thirty two consecutive patients who underwent ACL reconstruction between January 2005 and January 2009 were analysed using prospective collected data. The mean age of the patients was 29 years (12-57). Sixteen patients were excluded due to chronic ACL injury (15). Results. One hundred and sixteen patients (117 ACL ruptures) were included in the analysis. A typical injury pattern was documented in 87 (75%) of cases. The most common sporting activities associated with an ACL injury were football (35.3%), skiing (21.6%), rugby (10.3%) and other (32.8%). The vast majority of patients (68.1%) sought medical attention within 1 week from time of injury. The diagnosis of an ACL rupture was made in 33 cases (28%) at the initial medical consultation. The diagnosis was made in 13 (11%) of cases with the use of MRI and 6 (5%) cases at arthroscopy. The most common diagnoses made in cases of failed ACL rupture diagnosis were medial meniscal tear (10.3%), medial collateral ligament injury (7.8%) and none (33.6%). The mean time to diagnosis was 21 weeks (0-192) and the mean time to ACL reconstruction was 44 weeks (1-240). Conclusions. Despite a typical mechanism of injury leading to ACL rupture the rate of initial diagnosis remains poor. This often leads to an unnecessary delay in diagnosis and subsequent treatment. Possible reasons for this are discussed

Introduction. Next generation sequencing (NGS) has been shown to facilitate detection of microbes in a clinical sample, particularly in the setting of culture-negative periprosthetic joint infection (PJI). However, it is unknown whether every microbial DNA signal detected by NGS is clinically relevant. This multi-institutional study was conceived to 1) identify species detected by NGS that may predict PJI, then 2) build a predictive model for PJI in a developmental cohort; and 3) validate the predictive utility of the model in a separate multi-institutional cohort. Methods. This multicenter investigation involving 15 academic institutions prospectively collected samples from 194 revision total knee arthroplasties (TKA) and 184 revision hip arthroplasties (THA) between 2017–2019. Patients undergoing reimplantation or spacer exchange procedures were excluded. Synovial fluid, deep tissue and swabs were obtained at the time of surgery and shipped to MicrogenDx (Lubbock, TX) for NGS analysis. Deep tissue specimens were also sent to the institutional labs for culture. All patients were classified per the 2018 Consensus definition of PJI. Microbial DNA analysis of community similarities (ANCOM) was used to identify 17 candidate bacterial species out of 294 (W-value >50) for differentiating infected vs. noninfected cases. Logistic Regression with LASSO model selection and random forest algorithms were then used to build a model for predicting PJI. For this analysis, ICM classification was the response variable (gold standard) and the species identified through ANCOM were the predictor variables. Recruited cases were randomly split in half, with one half designated as the training set, and the other half as the validation set. Using the training set, a model for PJI diagnosis was generated. The optimal resulting model was then tested for prediction ability with the validation set. The entire model-building procedure and validation was iterated 1000 times. From the model set, distributions of overall assignment rate, specificity, sensitivity, positive predictive value (PPV) and negative predicative value (NPV) were assessed. Results. The overall predictive accuracy achieved in the model was 75.9% (Figure 1). There was a high accuracy in true-negative and false-negative classification of patients using this predictive model (Figure 2), which has previously been a criticism of NGS interpretation and reporting. Specificity was 97.1%, PPV was 75.0%, and NPV was 76.2%. On comparison of the distribution of abundances between ICM-positive and ICM-negative patients, Staphylococcus aureus was the strongest contributor (F=0.99) to the predictive power of the model (Figure 3). In contrast, Cutibacterium acnes was less predictive (F=0.309) and noted to be abundant across both infected and noninfected revision TJA samples. Discussion. This study is the first to utilize predictive modeling algorithms on a large prospective multicenter database in order to transform analytic NGS data into a clinically relevant diagnostic signal. Our collaborative findings suggest the microbial DNA signal identified on NGS may be an independent useful adjunct for the diagnosis of PJI, as well as help identify causative organisms. Further work applying artificial intelligence tools will improve accuracy, predictive power and clinical utility of high-throughput sequencing technology. For figures, tables, or references, please contact authors directly

Introduction. Periprosthetic joinTt infection (PJI) remains an uncommon, yet devastating complication of total hip arthroplasty (THA) and total knee arthroplasty (TKA). Debridement with antibiotics and implant retention (DAIR) provides an alternative to staged revision. Chronic infection is considered to be a contraindication to DAIR, however, outcomes stratified by chronicity have not been documented. Methods. We performed a retrospective review of all DAIR cases performed at our institution between 2008–2015. Timeframe to treatment was categorized as acute (< 6 weeks since surgery), chronic (>6 weeks since surgery) or acute hematogenous (previously well-functioning prosthesis). Treatment failure was defined as reoperation during the first 90-days following DAIR. Univariate analysis (Mann-Whitney U and Chi-square; p<0.05) and generalized estimating equations (GEE) were used with multiple comparison adjustment by Tukey-Kramer method (α = 0.05). Results. 282 patients underwent DAIR; 52.8% female; 37.6% THA; 62.4% TKR; mean age: 66.6 (+/−12); mean BMI: 30.3 (+/−7). There were 68 acute (24.1%) patients, 64 (22.7%) chronic and 150 (53.2%) acute hematogenous patients. There was no difference in failure rate between THA and TKA (p=0.09). The data demonstrated that DAIR was more likely to fail in acute (45.6%) compared to chronic (20.3%) or acute hematogenous (25.3%) (OR=4.05; 95 % CI: 2.25 – 7.3, p<0.0001). Staph aureus was the causative organism in 47.1% acute, 18.8% chronic and 28% acute hematogenous. Microbial diagnosis influenced the effect of DAIR results; staph aureus independently increased the failure rate for acute (OR=4.17; 95% CI:1.3–14.3; p=0.02) and chronic (OR=5.89; 95%CI: 1.6–20.0; p=0.01) but not acute hematogenous (OR=1.96; 95% CI: 0.88–4.38; p=0.096). Discussion. 90-day failure of DAIR was higher in the acute compared to chronic or acute hematogenous infection groups. Infection with staph aureus conferred a higher risk of failure for acute and chronic but not for acute hematogenous. DAIR may be more efficacious in chronic PJI than previously considered, particularly for non-staph aureus cases

Introduction. Despite several preventive strategies, periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is still a devastating complication. Early diagnosis and appropriate treatment are crucial to achieve successful infection control, but challenging since there is no test with 100% sensitivity and 100%. Therefore, several national and international guidelines include synovial analysis of joint aspirates as important diagnostic criteria, but cut-off levels for synovial cell count (CC) and polymorphonuclear (granulocyte) percentage (PMN%) are still debatable. The current investigation was performed to analyze the overall accuracy and optimal cut-off of synovial CC and PMN% following total knee (TKA) and total hip arthroplasty (THA). Methods. Between October 2012 and June 2017, all patients with painful TKA or THA, who underwent joint aspiration before revision arthroplasty were included in this retrospective study. From aspirated synovial fluid, leukocyte esterase activity, leukocyte CC and PMN% were determined, and specimens were sent for bacterial culture. A total of 524 preoperative joint aspirations (255 hips, 269 knees) were enrolled for final analysis. For 337 patients, the synovial CC and PMN% could be measured by the laboratory. From those patients, 203 patients were scheduled for aseptic revision, and 134 patients for septic revision arthroplasty according to the MSIS criteria for PJI. Specificity (SP), sensitivity (SE), positive predictive value (PPV), negative predictive and overall accuracy were measured for CC and PMN%. The optimum cut-off value was calculated by the ROC and the value giving the AUC, achieving the best possible level of sensitivity and specificity. Results. The best cut-off level for PJI of all study patients was 2582 leukocytes/μL (Se 80.6%, Sp 85.2%) and a PMN% of 66.1% (Se 80.6%, Sp 83.3%). The chosen cut-off levels for PJI of TKA was 1630 leukocytes/μL (Se 83.6%, Sp 82.2%) and a PMN% of 60.5% (Se 80.3%, Sp 77.1%). The optimal cut-off values for PJI of THA was 3063 leukocytes/μL (Se 78.1%, Sp 80.0%) and a PMN% of 66.1% (Se 82.2%, Sp 82.4%). Conclusions. Synovial cell count and polymorphonuclear percentage are sensitive methods for diagnosing PJI with differences in cut-off levels for THA and TKA. We suggest considering the cut-off levels of CC and PMN% from aspirates of TKA at 1600/μL and 60%, respectively, as possible PJI. For THA, the cut-off levels of CC and PMN% are at 3000/μL and 66%, respectively

We analysed the serum C-reactive protein level, synovial fluid obtained by joint aspiration and five synovial biopsies from 145 knee replacements prior to revision to assess the value of these parameters in diagnosing late peri-prosthetic infection. Five further synovial biopsies were used for histological analysis. Samples were also obtained during the revision and incubated and analysed in an identical manner for 14 days. A total of 40 total knee replacements were found to be infected (prevalence 27.6%). The aspiration technique had a sensitivity of 72.5% (95% confidence interval (CI) 58.7 to 86.3), a specificity of 95.2% (95% CI 91.2 to 99.2), a positive predictive value of 85.3% (95% CI 73.4 to 100), a negative predictive value of 90.1% (95% CI 84.5 to 95.7) and an accuracy of 89%. The biopsy technique had a sensitivity of 100%, a specificity of 98.1% (95% CI 95.5 to 100), a positive predictive value of 95.2% (95% CI 88.8 to 100), a negative predictive value of 100% and an accuracy of 98.6%. C-reactive protein with a cut-off-point of 13.5 mg/l had a sensitivity of 72.5% (95% CI 58.7 to 86.3), a specificity of 80.9% (95% CI 73.4 to 88.4), a positive predictive value of 59.2% (95% CI 45.4 to 73.0), a negative predictive value of 88.5% (95% 81.0 to 96.0 CI) and an accuracy of 78.1%. We found that biopsy was superior to joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements

The role of arthroscopy in the treatment of soft-tissue injuries associated with proximal tibial fractures remains debatable. Our hypothesis was that MRI over-diagnoses clinically relevant associated soft-tissue injuries. This prospective study involved 50 consecutive patients who underwent surgical treatment for a split-depression fracture of the lateral tibial condyle (AO/OTA type B3.1). The mean age of patients was 50 years (23 to 86) and 27 (54%) were female. All patients had MRI and arthroscopy. Arthroscopy identified 12 tears of the lateral meniscus, including eight bucket-handle tears that were sutured and four that were resected, as well as six tears of the medial meniscus, of which five were resected. Lateral meniscal injuries were diagnosed on MRI in four of 12 patients, yielding an overall sensitivity of 33% (95% confidence interval (CI) 11 to 65). Specificity was 76% (95% CI 59 to 88), with nine tears diagnosed among 38 menisci that did not contain a tear. MRI identified medial meniscal injuries in four of six patients, yielding an overall sensitivity of 67% (95% CI 24 to 94). Specificity was 66% (95% CI 50 to 79), with 15 tears diagnosed in 44 menisci that did not contain tears.

MRI appears to offer only a marginal benefit as the specificity and sensitivity for diagnosing meniscal injuries are poor in patients with a fracture. There were fewer arthroscopically-confirmed associated lesions than reported previously in MRI studies.

Cite this article: Bone Joint J 2014;96-B:1631–6.

Aims. The diagnosis of periprosthetic joint infection (PJI) can be challenging as the symptoms are similar to other conditions, and the markers used for diagnosis have limited sensitivity and specificity. Recent research has suggested using blood cell ratios, such as platelet-to-volume ratio (PVR) and platelet-to-lymphocyte ratio (PLR), to improve diagnostic accuracy. The aim of the study was to further validate the effectiveness of PVR and PLR in diagnosing PJI. Methods. A retrospective review was conducted to assess the accuracy of different marker combinations for diagnosing chronic PJI. A total of 573 patients were included in the study, of which 124 knees and 122 hips had a diagnosis of chronic PJI. Complete blood count and synovial fluid analysis were collected. Recently published blood cell ratio cut-off points were applied to receiver operating characteristic curves for all markers and combinations. The area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values were calculated. Results. The results of the analysis showed that the combination of ESR, CRP, synovial white blood cell count (Syn. WBC), and polymorphonuclear neutrophil percentage (PMN%) with PVR had the highest AUC of 0.99 for knees, with sensitivity of 97.73% and specificity of 100%. Similarly, for hips, this combination had an AUC of 0.98, sensitivity of 96.15%, and specificity of 100.00%. Conclusion. This study supports the use of PVR calculated from readily available complete blood counts, combined with established markers, to improve the accuracy in diagnosing chronic PJI in both total hip and knee arthroplasties. Cite this article: Bone Jt Open 2023;4(11):881–888

Aims. To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults. Methods. The James Lind Alliance (JLA) methodology for Priority Setting Partnerships was followed. An initial survey invited patients and healthcare professionals from the UK to submit any uncertainties regarding soft-tissue knee injury prevention, diagnosis, treatment, and rehabilitation and delivery of care. Over 1,000 questions were received. From these, 74 questions (identifying common concerns) were formulated and checked against the best available evidence. An interim survey was then conducted and 27 questions were taken forward to the final workshop, held in January 2023, where they were discussed, ranked, and scored in multiple rounds of prioritization. This was conducted by healthcare professionals, patients, and carers. Results. The top ten included questions regarding prevention, diagnosis, treatment, and rehabilitation. The number one question was, ‘How urgently do soft-tissue knee injuries need to be treated for the best outcome?’. This reflects the concerns of patients, carers, and the wider multidisciplinary team. Conclusion. This validated process has generated ten important priorities for future soft-tissue knee injury research. These have been submitted to the National Institute for Health and Care Research. All 27 questions in the final workshop have been published on the JLA website. Cite this article: Bone Joint J 2024;106-B(3):232–239

Abstract. Introduction. The knee is the most commonly injured joint in sporting accidents. They cause substantial disability, time off work and long-term problems. There remains a limited number of high-quality randomised controlled trials assessing first time, acute soft tissue knee injuries. Key areas requiring answers include prevention, diagnosis, treatment, rehabilitation and delivery of care. In association with the James Lind Alliance, this BASK, BOSTAA and BOA supported prioritising exercise was undertaken over a year. Methodology. The James Lind Alliance methodology was followed. An initial survey invited patients and healthcare professionals to submit their uncertainties regarding soft tissue knee injury prevention, diagnosis, treatment, rehabilitation and delivery of care. Over 1000 questions were submitted. Seventy-four questions were formulated to encompass common concerns. These were checked against best available evidence. Following the interim survey, 27 questions were taken forward to the final workshop in January 2023, where they were discussed, ranked and scored in multiple rounds of prioritisation by groups of healthcare professionals, patients and carers. Results. The Top 10 includes prevention, diagnosis, treatment and rehabilitation questions, reflecting the concerns of patients, carers and a wider multidisciplinary team. These will be presented and explained. Conclusion. This validated process has generated an important Top 10, which has been submitted to the National Institute for Health and Care Research. All 27 questions will be published, thus being available for researchers to investigate. The questions in the Top 10 will lead to future high quality research, thus improving patient outcomes

Aims. The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods. A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results. Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion. The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed. Cite this article: Bone Joint J 2023;105-B(12):1259–1264

Aims. This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection. Methods. This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality. Results. A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute length of stay, and surgeon volume < 30 TKAs/year. Early-onset deep SSI was not associated with increased 90-day mortality. Conclusion. This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis using robust Infection Prevention and Control surveillance data, and identifies several potentially modifiable risk factors. Cite this article: Bone Joint J 2023;105-B(9):971–976

Aims. Achievement of accurate microbiological diagnosis prior to revision is key to reducing the high rates of persistent infection after revision knee surgery. The effect of change in the microorganism between the first- and second-stage revision of total knee arthroplasty for periprosthetic joint infection (PJI) on the success of management is not clear. Methods. A two-centre retrospective cohort study was conducted to review the outcome of patients who have undergone two-stage revision for treatment of knee arthroplasty PJI, focusing specifically on isolated micro-organisms at both the first- and second-stage procedure. Patient demographics, medical, and orthopaedic history data, including postoperative outcomes and subsequent treatment, were obtained from the electronic records and medical notes. Results. The study cohort consisted of 84 patients, of whom 59.5% (n = 50) had successful eradication of their infection at a mean follow-up of 4.7 years. For the 34 patients who had recurrence of infection, 58.8% (n = 20) had a change in isolated organism, compared to 18% (n = 9) in the infection eradication group (p < 0.001). When adjusting for confound, there was no association when the growth on the second stage was the same as the first (odd ratio (OR) 2.50, 95% confidence interval (CI) 0.49 to 12.50; p = 0.269); however, when a different organism was identified at the second stage, this was independently associated with failure of treatment (OR 8.40, 95% CI 2.91 to 24.39; p < 0.001). There were no other significant differences between the two cohorts with regard to patient demographics or type of organisms isolated. Conclusion. Change in the identified microorganism between first- and second-stage revision for PJI was associated with failure of management. Identification of this change in the microorganism prior to commencement of the second stage may help target antibiotic management and could improve the success of surgery in these patients. Cite this article: Bone Jt Open 2023;4(9):720–727

Aims. The diagnosis of periprosthetic joint infection (PJI) continues to present a significant clinical challenge. New biomarkers have been proposed to support clinical decision-making; among them, synovial fluid alpha-defensin has gained interest. Current research methodology suggests reference methods are needed to establish solid evidence for use of the test. This prospective study aims to evaluate the diagnostic accuracy of high-performance liquid chromatography coupled with the mass spectrometry (LC-MS) method to detect alpha-defensin in synovial fluid. Methods. Between October 2017 and September 2019, we collected synovial fluid samples from patients scheduled to undergo revision surgery for painful total knee arthroplasty (TKA). The International Consensus Meeting criteria were used to classify 33 PJIs and 92 aseptic joints. LC-MS assay was performed to measure alpha-defensin in synovial fluid of all included patients. Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristic curve (AUC) were calculated to define the test diagnostic accuracy. Results. The AUC was 0.99 (95% confidence interval (CI) 0.98 to 1.00). Receiver operating characteristic (ROC) analysis showed that the optimal cut-off value of synovial fluid alpha-defensin was 1.0 μg/l. The sensitivity of alpha-defensin was 100% (95% CI 96 to 100), the specificity was 97% (95% CI 90 to 98), the positive predictive value was 89.2% (95% CI 82 to 94), and negative predictive value was 100% (95% CI 96 to 100). ROC analysis demonstrated an AUC of 0.99 (95% CI 0.98 to 1.0). Conclusion. The present study confirms the utility of alpha-defensin in the synovial fluid in patients with painful TKA to select cases of PJI. Since LC-MS is still a time-consuming technology and is available in highly specialized laboratories, further translational research studies are needed to take this evidence into routine procedures and promote a new diagnostic approach. Cite this article: Bone Joint J 2022;104-B(9):1047–1051

Aims. The aim of this study was to assess factors associated with the estimated lifetime risk of revision surgery after primary knee arthroplasty (KA). Methods. All patients from the Scottish Arthroplasty Project dataset undergoing primary KA during the period 1 January 1998 to 31 December 2019 were included. The cumulative incidence function for revision and death was calculated up to 20 years. Adjusted analyses used cause-specific Cox regression modelling to determine the influence of patient factors. The lifetime risk was calculated as a percentage for patients aged between 45 and 99 years using multiple-decrement life table methodology. Results. The estimated lifetime risk of revision ranged between 32.7% (95% confidence interval (CI) 22.6 to 47.3) for patients aged 45 to 49 years and 0.6% (95% CI 0.1 to 4.5) for patients aged over 90 years. At 20 years, the overall cumulative incidence of revision (6.8% (95% CI 6.6 to 7.0)) was significantly less than that of death (66.3% (95% CI 65.4 to 67.1)). Adjusted analyses demonstrated converse effect of increasing age on risk of revision (hazard ratio (HR) 0.5 (95% CI 0.5 to 0.6)) and death (HR 3.6 (95% CI 3.4 to 3.7)). Male sex was associated with increased risks of revision (HR 1.1 (95% CI 1.1 to 1.2); p < 0.001) and death (HR 1.4 (95% CI 1.3 to 1.4); p < 0.001). Compared to patients undergoing primary KA for osteoarthritis, patients with inflammatory arthropathy had a higher risk of death (HR 1.7 (95% CI 1.7 to 1.8); p < 0.001), but were less likely to be revised (HR 0.9 (95% CI 0.7 to 1.0); p < 0.001). Patients with a greater number of comorbidities (HR 1.4 (95% CI 1.3 to 1.4)) and greater levels of socioeconomic deprivation (HR 1.4 (95% CI 1.4 to 1.5)) were at increased risk of death, but neither increased the risk of revision. Conclusion. The estimated lifetime risk of revision KA varied depending on patient sex, age, and underlying diagnosis. Patients aged between 45 and 49 years had a one in three risk of undergoing revision surgery within their lifetime, which decreased with age to one in 159 in those aged 90 years or more. Cite this article: Bone Joint J 2022;104-B(12):1313–1322

Aims. Fungal periprosthetic joint infections (PJIs) are rare, but their diagnosis and treatment are highly challenging. The purpose of this study was to investigate the clinical outcomes of patients with fungal PJIs treated with two-stage exchange knee arthroplasty combined with prolonged antifungal therapy. Methods. We reviewed our institutional joint arthroplasty database and identified 41 patients diagnosed with fungal PJIs and treated with two-stage exchange arthroplasty after primary total knee arthroplasty (TKA) between January 2001 and December 2020, and compared them with those who had non-fungal PJIs during the same period. After propensity score matching based on age, sex, BMI, American Society of Anesthesiologists grade, and Charlson Comorbidity Index, 40 patients in each group were successfully matched. The surgical and antimicrobial treatment, patient demographic and clinical characteristics, recurrent infections, survival rates, and relevant risk factors that affected joint survivorship were analyzed. We defined treatment success as a well-functioning arthroplasty without any signs of a PJI, and without antimicrobial suppression, at a minimum follow-up of two years from the time of reimplantation. Results. The fungal PJI group demonstrated a significantly worse treatment success rate at the final follow-up than the non-fungal PJI group (65.0% (26/40) vs 85.0% (34/40); p < 0.001). The mean prosthesis-free interval was longer in the fungal PJI group than in the non-fungal PJI group (6.7 weeks (SD 5.8) vs 4.1 weeks (SD 2.5); p = 0.020). The rate of survivorship free from reinfection was worse in the fungal PJI group (83.4% (95% confidence interval (CI) 64.1 to 92.9) at one year and 76.4% (95% CI 52.4 to 89.4) at two years) than in the non-fungal PJI group (97.4% (95% CI 82.7 to 99.6) at one year and 90.3% (95% CI 72.2 to 96.9) at two years), but the differences were not significant (p = 0.270). Cox proportional hazard regression analysis identified the duration of the prosthesis-free interval as a potential risk factor for failure (hazard ratio 1.128 (95% CI 1.003 to 1.268); p = 0.043). Conclusion. Fungal PJIs had a lower treatment success rate than non-fungal PJIs despite two-stage revision arthroplasty and appropriate antifungal treatment. Our findings highlight the need for further developments in treating fungal PJIs. Cite this article: Bone Joint J 2023;105-B(12):1286–1293

Abstract. Introduction. There is currently very little evidence which can be used to guide surgeons treating skeletally immature patients with suspected meniscal injury. The aim of our modified Delphi study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children. Methodology. An international, two round, modified Delphi consensus was completed. Included ‘experts’ were identified as having an established adult and/or paediatric knee practice and either: 1) Faculty at the international kid's knee meeting, 2) Active member of the complex national paediatric MDT group, or 3) faculty on recognised national course aimed at teaching knee surgeons regarding the management of meniscal lesions. A threshold of 70% was used to identify consensus. Results. A total of 43 experts (Round 1) and 41 experts (Round 2) took part in the Delphi study. Surgeons from the UK, Europe, USA and South America took part. 34 statements were identified exploring 4 main domains – clinical diagnosis, investigation, management and specialist tears. Following round 1 consensus was reached on 17 (50%) statements, subsequently after completion of round 2 consensus was reached on 28 (82%) statements, leaving 6 (18%) with no consensus. Conclusions. This is the first modified delphi consensus which provides evidence for surgeons treating skeletally immature children with isolated meniscal tears. Further studies are required to provide evidence for the areas where no consensus was reached

Abstract. Introduction. Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures, used for the management of end-stage arthritis. With the recent introduction of robotic assisted joint replacement, Computed Tomography (CT) has become part of required pre-operative planning. The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on planned joint arthroplasty. Methodology. All consecutive patients undergoing an elective TJR (hip or knee arthroplasty) were retrospectively identified, over a 3-year period (December 2019 and December 2022). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation. Results. A total of 624 patients (637 studies, 323 (51.8%) female, 301 (48.2%) male) were identified of which 163 (25.6%) showed incidental findings within the long bones or pelvis. Of these 52 (8.2%) were significant, potentially requiring further management, 32 (5.0%) represented potential malignancy and 4 (0.6%) resulted in a new cancer diagnosis. Conclusion. It is not currently national standard practice to report planning CT imaging as it is deemed an unnecessary expense and burden on radiology services. Within the study cohort 52 (8.2%) of patients had a significant incidental finding that required further investigation or management and 4 (0.6%) had a previously undiagnosed malignancy. In order to avoid the inevitability of a missed malignancy on a planning CT, we must advocate for formal reports in all cases

Abstract. Introduction. There is little published literature to support the claim that a successful total knee replacement (TKR) is predictive of future good outcomes on the contralateral side. The objective was to identify whether outcome from the first of staged TKRs could be used to predict the outcome of the contralateral TKR. Methodology. This was a retrospective cohort study of 1687 patients over a 25-year period undergoing staged bilateral TKRs in a UK arthroplasty centre. A control group of 1687 patients undergoing unilateral TKR with matched characteristics was identified. Primary outcomes: satisfaction and Knee Society Score (KSS) at one year. Results. Preoperative status was comparable for pain, ROM and KSS (mean 41, 45, 43±14). At one year, dissatisfaction was similar for all groups (4% first of staged TKR, 4% second of staged TKR, 5% controls). If the first TKR had a good outcome, the relative risk of a contralateral bad outcome was 20% less than controls (95% CI 0.6–1.2). If the first TKR had a poor outcome, the risk of a second poor outcome was 4 times higher (95% CI 2.8–6.1), increasing from 6% to 28% (absolute risk). Conclusion. Patients undergoing the second of staged TKRs with a previous good outcome are likely to do well in their second procedure (94 in 100 will go on to have a second good outcome). Of those with a previous poor outcome, 28 in 100 will have a second poor outcome. The trend was persistent despite correcting for gender, age, BMI, and diagnosis