Introduction. The purpose of this study was to examine the effects of baseline mental health on functional outcomes after primary knee arthroplasty by reviewing the data collected in a multi-centre prospective observational cohort study. We hypothesised that those patients with lower baseline mental health status would demonstrate significantly worse outcomes vs their counterparts with higher mental status following primary total knee arthroplasty. Methods. Data from a multi-centre prospective cohort study of PS (posterior stabilising implant) and CR (cruciate retaining implant) primary knee arthroplasty were compared to determine the relationship between baseline mental health status and functional outcomes post-surgery. Subjects were followed from the time of the index surgery to monitor outcomes and complications. Validated quality of life instruments, including SF-36, WOMAC, Knee Society Score, and an activity scale were used. Changes from baseline to 1 year on the SF-36 and WOMAC were evaluated. Regression analysis was completed to assess changes in WOMAC based on baseline SF-36 scores. All analyses were adjusted for age, BMI, gender, and implant type. Results. Baseline data was available for 436 subjects in the primary PS study and 493 subjects in the primary CR study. Patients improved significantly on all SF-36 and WOMAC components between baseline and 12 months post-surgery. Correlation and regression analysis between WOMAC and SF-36 showed that Global Health (GH), Mental Health (MH), Role-Emotional (RE), and Mental Component Score (MCS) subscales on the SF-36 were significantly associated with positive post-operative changes in WOMAC scores. Conclusion. This study examined the effects of baseline mental health on functional outcomes after primary knee arthroplasty and found that baseline mental health was a significant predictor of functional outcomes twelve months after surgery. This relationship between mental health and outcomes needs to be examined carefully to help surgeons better prepare their patients for surgery

Infection after total knee replacement, which is a serious and expensive complication, often represent a diagnostic and therapeutic problem. The current incidence of infection after the primary procedure is 1 to 3%, depending on the published series. A correct and timely diagnosis, classification between early and delayed infection, and which microorganisms are involved, are crucial steps in defining prevention and treatment strategies. Determination of the annual and three years incidence of infection after primary total knee replacement; evaluation of the microorganisms involved and its resistance patterns; assessment of treatment – surgical approach and selection of antibiotics. Collection of clinical and laboratorial data of all patients who underwent primary total knee arthroplasty between 2011 and 2013 in our hospital; definition of periprosthesic infection cases following the Musculoskeletal Infection Society (MSIS) criteria. During the study period, 526 primary knee replacements were performed in 521 patients; with 41 patients having bilateral replacements. The mean follow-up period was 30 months; 5 patients had no follow up and 1 died in the post operatory. We reported 9 prosthetic infections, of which 2 did not reached the MSIS criteria, but were also considered based on high clinical suspicion. The majority of the cases (6) were delayed infections. The calculated 3 year incidence of infection after primary knee replacement was 1,6%, with annual rates of 3,0% (2011), 1,7% (2012) and 0,9% (2013). The microorganisms isolated were as follows: Staphylococcus aureus and coagulase-negative staphylococci, resistant to penicillin; Streptococcus agalactiae and one isolate of Serratia marcescens, both showing multiple antibiotic resistances. Only one case was treated with surgical debridement and conservation of prosthesis, in the other 8 cases a two-stage implant revision procedure was performed. The antibiotics selected were vancomycin, fluoroquinolones and association of gentamicin and clindamycin. Our local infection rates are in line with the published series from reference surgical centers. The annual incidence is decreasing, probably because the majority of our infection cases are delayed (recent years, shorter follow up period) and our preventive measures are improving. The microorganisms identified are also in agreement with published data, and our antibiotic resistance pattern is a valuable information to consider in a first empirical approach. Treatment options suitable to each case, and antibiotic protocols need to be improved in our local practice. Preventive measures in delayed infections are still under debate, and represent another future challenge

Introduction. The precise indications for tibial component metal backing and modularity remain controversial in routine primary total knee arthroplasty. This is particularly true in elderly patients where the perceived benefits of metal backing such as load redistribution and the reduction of polyethylene strain may be clinically less relevant. The cost implications for choosing a metal-backed design over an all-polyethylene design may exceed USD500 per primary knee arthroplasty case. Methods. A prospective randomised clinical trial was carried out at the QEII Health Sciences Centre, Halifax, Nova Scotia, to compare modular metal-backed versus an all-polyethylene tibial component. Outcome measures included clinical range of motion, radiographs, survivorship, Knee Society Clinical Rating System, WOMAC and SF-12. Results. 116 patients requesting primary knee arthroplasty were recruited and randomised between the Smith & Nephew Genesis I non-modular (57) and modular (59) tibial designs between September 1995 and August 1997. At 10 years clinical follow-up, 4 implant revisions or intention-to-revise decisions were recorded in the metal-tray/modular group of which 2 were for aseptic tibial component loosening. 2 implant revisions in the all-polyethylene non-modular group were recorded, neither of which were for tibial component loosening. At 5, 7 and 10 year review; the KSCRS, WOMAC and SF12 scores were similar in both groups. As most patients randomised were over seventy years of age, this impacted significantly on the numbers available for longer term review and data was analysed by comparing pre- and post-operative scores for individual patients. Conclusion. There was no difference in performance between the all-polyethylene tibial component and the metal-backed tibial component. The case for using the all-polyethylene tibia in elderly patients is justified on both clinical efficacy and cost-containment grounds

This study aimed to analyze the effect of two different techniques of cement application: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term effect of radiolucent lines (RLL) in primary fully cemented total knee arthroplasties (TKA) with patella resurfacing.

379 fully cemented TKAs (318 patients) were included in this monocentric study. Preoperative and postoperative at week 4 and 12 month after surgery all patients had a clinical and radiological examination and were administered the Oxford Knee Score (OKS). Cement was applied in two different ways among the two study groups: cement on bone surface (CoB group) or cement on bone surface and implant surface (CoBaI group). The evaluation of the presence of RLL or osteolysis was done as previously described using the updated Knee Society Radiographic Evaluation System.

The mean OKS and range of motion improved significantly in both groups at the 4-week and 12-month follow-up, with no significant difference between the groups (CoB vs. CoBaI). RLL were present in 4.7% in the whole study population and were significantly higher in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up RLL were seen in 29.8% of the TKAs in the CoBaI group, whereas the incidence was lower in the CoB group (24.0% (n.s.)). There were two revisions in each group. None of these due to aseptic loosening.

Our study indicated that the application of bone cement on bone surface only might be more beneficial than onto the bone surface and onto the implant surface as well in respect to the short-term presence of RLL in fully cemented primary TKA.

The long-term results will be of interest, especially in respect to aseptic loosening and might guide future directions of bone cement applications in TKA.

Introduction

The purpose of this study was to characterize the recovery of physical activity following knee arthroplasty by means of step counts and flight counts (flights of stairs) measured using a smartphone-based care platform.

Background

Performing total knee replacement needs both bony & soft tissue consideration. Late John Insall advocating spacer blocks with concept of balanced & equal flexion – extension Gap. Although we usually excise both ACL & PCL, still it is possible to retain more soft tissue. Both PCL retaining & sacrificing Require intact collaterals for stability. Superficial MCL & LCL should be preserved, if possible. After PCL removal the following advantages could obtain: More correction of fixed varus or valgus deformity, More surgical exposure. but there are no proved disadvantages like; increasing in stress & loosening of bone-cement-prosthesis interface, specific clinical difference in ROM, forward lean during stepping up, proprioception inferiority. In other hand over tight PCL cause excessive rollback of tibia & knee hinges open, preventing flexion (booking), and Severe posteromedial poly wear in poor balance PCL might be happened. Mid range laxity when Post. Capsule is tight, even with correct tensioning in full extension & 90 degree flexion, may occur (and secondary collateral ligaments imbalance throughout ROM). There is a major effect of capsular contracture in coronal mal alignment with flexion contracture. Full MCL releases not only correct fixed varus but also open the medial space in flexion. MCL & post. Capsule has combined valgus resistant effect in extension. PCL release increase flexion gap more, May be necessary to release something that affect extension gap as compensated balancing (Post.medial capsule). Any flexion contracture need to posterior capsulotomy & post. Condyle osteophyte removal before femoral recut. So it is possible to perform posteromedial capsulotomy prior to superficial MCL release.

Aim

Patients reporting penicillin allergy do often receive clindamycin as systemic antibiotic prophylaxis. The effect of clindamycin has however not been compared to antibiotics with proven effect in joint arthroplasty surgery. The aim of the study was to reveal if there were differences in the rate of revision due to infection after total knee arthroplasty (TKA) depending on which antibiotic was used as systemic prophylaxis.

Aims

To devise a simple clinical risk classification system for patients undergoing primary total knee arthroplasty (PTKR) to facilitate risk and cost estimation, and aid pre-operative planning.

The Oxford Knee Score (OKS) is a valid and reliable self-administered patient questionnaire that enables assessment of the outcome following total knee replacement (TKR). There is as yet no literature on the behavioral trends of the OKS over time. Our aim is to present a retrospective audit of the OKS for patients who have undergone TKR during the past ten years.

We retrospectively analysed 3276 OKS of patients who had a primary TKR and had been registered as part of a multi-surgeon, outcome-monitoring program at St. Helier hospital. The OKS was gathered pre-operatively and post-operatively by means of postal questionnaires at annual intervals. Patients were grouped as per their age at operation into four groups: 60, 61-70, 71- 80 and >80. A cross-sectional analysis of OKS at different time points was performed.

The numbers of OKS available for analysis were 504 pre-operatively, 589 at one-year, 512 at two-year and gradually decreasing numbers with 87 knees ten-year post-operatively. There was as expected a significant decrease (improvement) of the OKS between pre-operative and one-year post-operative period and then reached a plateau. Beyond eight years, there is a gradual rise in the score (deterioration). The younger patients (60) showed a significant increase in their average OKS between one and five-years post-operatively. However beyond five years, they followed the trend of their older counterparts. When the twelve questions in the OKS were analysed, certain components revealed greater improvement (e.g. description of knee pain and limping) than others (e.g. night pain).

The OKS is seen to plateau a year after TKR. According to the OKS the outcome of the TKR is not as good in the younger age group as compared to the older age group. Further investigation is required to ascertain the cause of this observed difference.

Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

The aim of this retrospective cohort study was to investigate the reasons for total knee arthroplasty (TKA) revisions at a tertiary hospital over a four-year period. The study aimed to identify the primary causes of TKA revisions and shed light on the implications for patient care and outcomes. The study included 31 patients who underwent revisions after primary knee arthroplasty between January 2017 and December 2020. A retrospective approach was employed, utilizing medical records and radiological findings to identify the reasons for TKA revisions. The study excluded oncology patients to focus on non-oncologic indications for revision surgeries. Patient demographics, including age and gender, were recorded. Data analysis involved categorizing the reasons for revision based on clinical assessments and radiological evidence. Among the 31 patients included in the study, 9 were males and 22 were females. The age of the patients ranged from 43 to 81, with a median age of 65 and an interquartile range of 18.5. The primary reasons for TKA revisions were identified as aseptic loosening (10 cases) and prosthetic joint infection (PJI) (13 cases). Additional reasons included revision from surgitech hemicap (1 case), patella osteoarthritis (1 case), stiffness (2 cases), patella maltracking (2 cases), periprosthetic fracture (1 case), and patella resurfacing (1 case). The findings of this retrospective cohort study highlight aseptic loosening and PJI as the leading causes of TKA revisions in the examined patient population. These results emphasize the importance of optimizing surgical techniques, implant selection, and infection control measures to reduce the incidence of TKA revisions. Future research efforts should focus on preventive strategies to enhance patient outcomes and mitigate the need for revision surgeries in TKA procedures

Patient-reported outcome measures (PROMs) have failed to highlight differences in function or outcome when comparing knee replacement designs and implantation techniques. Ankle-worn inertial measurement units (IMUs) can be used to remotely measure and monitor the bi-lateral impact load of patients, augmenting traditional PROMs with objective data. The aim of this study was to compare IMU-based impact loads with PROMs in patients who had undergone conventional total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and robotic-assisted TKA (RA-TKA). 77 patients undergoing primary knee arthroplasty (29 RA-TKA, 37 TKA, and 11 UKA) for osteoarthritis were prospectively enrolled. Remote patient monitoring was performed pre-operatively, then weekly from post-operative weeks two to six using ankle-worn IMUs and PROMs. IMU-based outcomes included: cumulative impact load, bone stimulus, and impact load asymmetry. PROMs scores included: Oxford Knee Score (OKS), EuroQol Five-dimension with EuroQol visual analogue scale, and the Forgotten Joint Score. On average, patients showed improved impact load asymmetry by 67% (p=0.001), bone stimulus by 41% (p<0.001), and cumulative impact load by 121% (p=0.035) between post-operative week two and six. Differences in IMU-based outcomes were observed in the initial six weeks post-operatively between surgical procedures. The mean change scores for OKS were 7.5 (RA-TKA), 11.4 (TKA), and 11.2 (UKA) over the early post-operative period (p=0.144). Improvements in OKS were consistent with IMU outcomes in the RA-TKA group, however, conventional TKA and UKA groups did not reflect the same trend in improvement as OKS, demonstrating a functional decline. Our data illustrate that PROMs do not necessarily align with patient function, with some patients reporting good PROMs, yet show a decline in cumulative impact load or load asymmetry. These data also provide evidence for a difference in the functional outcome of TKA and UKA patients that might be overlooked by using PROMs alone

Malnutrition is considered a risk factor for postoperative complications in total hip and knee arthroplasty, though prospective studies investigating this assumption are lacking. The aim of this study was to prospectively analyse the 90-day postoperative complications, postoperative length of stay (LOS) and readmission rates of patients undergoing primary total hip and total kneearthroplasty using albumin, total lymphocyte count (TLC) and transferrin as serum markers of potential malnutrition. 603 primary hip and 823 primary knee arthroplasties over a 3-year period from a single centre wereprospectively analysed. BMI, demographic and comorbidity data were recorded. Complications werecategorised as surgical site infection, venous thromboembolism (deep vein thrombosis andpulmonary embolus), implant related (such as dislocation), and non-implant related (such aspneumonia). Outcomes were compared between groups, with malnutrition defined as serumalbumin <3.5g/dL, transferrin <200 mg/dL, or TLC <1,500 cells/mm³. Potential malnutrition was present in 9.3% of the study population. This group experienced a longeraverage LOS at 6.5 days compared to the normal albumin group at 5.0 days (p=0.003). Surgical siteinfection rate was higher in the malnourished group (12.5 vs 7.8%, p=0.02). There was no differencebetween the two groups in implant related complications (0.8 vs 1.0%, p=0.95) medicalcomplications (7.8 vs 13.3%, p=0.17), rate of venous thromboembolism (2.3 vs 2.7%) or 90-dayreadmission rate (14.1 vs 17.0%, p=0.56). TLC and transferrin were not predictive of any of theprimary outcomes measured (p<0.05). Pacific Island (p<0.001), Indian (p=0.02) and Asian (p=0.02) patients had lower albumin than NZ European. This study demonstrates an association between low albumin levels and increased postoperativeLOS and surgical site infection in total joint arthroplasty, providing rationale for consideration ofpreoperative nutritional screening and optimisation

Aims. As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment. Methods. This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee procedure during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery. Results. Overall, 58 patients (56.8%) wanted to continue with planned surgical care at the earliest possibility. Patients classified as ASA I and ASA II were more likely to agree to surgery (60.5% and 60.0%, respectively) compared to ASA III and ASA IV patients (44.4% and 0.0%, respectively) (p = 0.01). In addition, patients undergoing soft tissue knee surgery were more likely to consent to surgery (90.0%) compared to patients undergoing primary hip arthroplasty (68.6%), primary knee arthroplasty (48.7%), revision hip or knee arthroplasty (0.0%), or hip and knee injections (43.8%) (p = 0.03). Conclusion. Restarting elective orthopaedic services during the COVID-19 pandemic remains a significant challenge. Given the uncertain environment, it is unsurprising that only 56% of patients were prepared to continue with their planned surgical care upon resumption of elective services. Cite this article: Bone Joint Open 2020;1-6:267–271

Aim. In surgeries on patients with advanced ligament instabilities or severe bone defects modern-generation of rotating hinged knee prostheses are one of the main options. The objective of our study is to evaluate the mid-term functional results and complications of several surgeries using this form of prosthesis. Material and Method. The rotating hinged knee prosthesis (RHKP) was applied to 208 knees of 204 patients in primary surgeries between September 2009 and December 2017, the minimum followup was 15 months (mean, 65 months; range, 15–115 months). Of the total number of female patients there were 152 (74.5%), men − 52 (25.5%). The average age of the patients was 64,6 years (from 32 to 85). The main indications for using RHKP were severe varus deformity with flexion contracture in 107 knees (51,4%), severe valgus deformity (from 20 to 50 degrees) in 54 knees (26,0 %), severe ligamentous deficiencies in 24 knees (11,5%) and ankylosis in the flexion position in 23 cases (11,1%). Patients were evaluated clinically (Knee Society score) and radiographically (positions of components, signs of loosening, bone loss). Results. The average Knee Society Knee Scores, and Knee Society Functional Scores were 27, and 18, respectively, before the surgery; and 86, and 77 in the final post-surgery follow-ups. In addition, the average range of motion increased from the pre-operative level of 46 to 104 degrees at the final evaluation. Four patients (2%) had various complications after the surgery : two patients had deep infection, in one case took place fracture of the hinge mechanism and in one - post-operative rupture of the patellar tendon. Conclusions. Primary knee arthroplasty using RKHP can be successful in cases with advanced ligament instability or severe bone defects. Modern-generation of the kinematic rotating-hinge total knee prostheses allow to achieve in difficult primary cases the same consistently good results as commonly used constructions in standard situations

Introduction. Systemic metal ion monitoring (Co;Cr) has proven to be a useful screening tool for implant performance to detect failure at an early stage in metal-on-metal hip arthroplasty. Several clinical studies have reported elevated metal ion levels after total knee arthroplasty (TKA), with fairly high levels associated with rotating hinge knees (RHK) and megaprostheses. 1. In a knee simulator study, Kretzer. 2. , demonstrated volumetric wear and corrosion of metallic surfaces. However, prospective in vivo data are scarce, resulting in a lack of knowledge of how levels evolve over time. The goal of this study was to measure serum Co and Cr levels in several types TKA patients prospectively, evaluate the evolution in time and investigate whether elevated levels could be used as an indicator for implant failure. Patients and Methods. The study was conducted at Ghent University hospital. 130 patients undergoing knee arthroplasty were included in the study, 35 patients were lost due to logistic problems. 95 patients with 124 knee prostheses had received either a TKA (primary or revision) (69 in 55 patients), a unicompartimental knee arthroplasty (7 UKA), a RHK (revision −7 in 6 patients) or a megaprosthesis (malignant bone tumours − 28 in 27 patients) (Fig 1). The TKA, UKA and RHK groups were followed prospectively, with serum Co and Cr ions measured preoperatively, at 3,6 and 12 months postoperatively. In patients with a megaprosthesis, metal ions were measured at follow-up (cross-sectional study design). Results (Fig 2 and 3). In primary knees, we did not observe an increase in serum metal ion levels at 3, 6 or 12 months. Two patients with a hip arthroplasty had elevated preTKA Co and Cr levels. There was no difference between unilateral and bilateral knee prostheses. In the revision group, elevated pre-revision levels were found in 2 failures for implant loosening. In both cases, ion levels decreased postoperatively. In revisions with a standard TKA, there was no significant increase in metal ions compared to primary knee arthroplasty. RHK were associated with a significant increase in Co levels even at short-term (3–12 months). The megaprosthesis group had the highest metal ion levels and showed a significant increase in Co and Cr with time in patients followed prospectively. With the current data, we could not demonstrate a correlation between metal ion levels, size of the implant or length of time in situ. Discussion. In primary knee arthroplasty with a standard TKA or UKA, metal ion levels were not elevated till one year postoperatively. This suggests a different mechanism of metal ion release in comparison to metal-on-metal hip arthroplasties. In two cases of revision for implant loosening, pre-revision levels were elevated, possibly associated with component wear, and decreased after revision. With RHK, slightly elevated ion levels were found prospectively. Megaprostheses had significantly elevated Co and Cr levels, due to corrosion of large metallic surfaces and/or wear of components which were not perfectly aligned during difficult reconstruction after tumour resection. Further research is needed to assess the clinical relevance of metal ion levels in knee arthroplasty. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aim. The primary aim of this study was to examine whether the use of iodine impregnated incision drape (IIID) decreased the risk of periprosthetic joint infections (PJIs). The secondary aim was to investigate whether intraoperative contamination could predict postoperative infection. PJI is a devastating incident for the patients and in a population that is getting older and the incidence of arthroplasty surgery is rising it is vital to keep the infection rate as low as possible. Despite prophylactic measures as pre-operative decontamination, antisepsis and prophylactic antibiotics the infection rate has been constant at 1–2%. Method. We performed a transregional, prospective, randomized two arm study (IIID vs control group) of 1187 patients undergoing primary knee arthroplasty surgery. A database with patient demographics and surgical observations was established with the purpose of following the patients for ten years. Patients, who developed an infection within the first year of surgery were analyzed for correlation with the intraoperative bacterial findings and the use of IIID. Results. 31/1187 (3.6%) patients were re-operated during the follow-up period. 18/1187 (1.5%) patients were deemed infected and received antibiotic treatment. 9/18 patients deemed infected were male. Of the 18 infected patients 2 were contaminated at the primary surgery. Chi square test showed no correlation between contamination and infection (OR 0.97, 95% CI 0.38–2.46, p=0.95). 9 of the 18 infected patients were operated with IIID at the primary surgery. No correlation was found between the use of IIID at primary surgery and subsequent infection (OR 0.86, 95% CI 0.20–3.79, p=1). Conclusions. We found no effect of the use of IIID and subsequent development of PJI. Nor did we find a correlation between the intraoperative contamination and development of PJI within the first year of follow-up. Acknowledgements. University of Copenhagen and 3M Health Care (St. Paul, Minnesota) funded the study. 3M did not participate in the design of the study, data collection, data analysis or data interpretation

Management of severe bone loss in total knee arthroplasty presents a formidable challenge. This situation may arise in neglected primary knee arthroplasty with large deformities and attritional bone loss, in revision situations where osteolysis and loosening have caused large areas of bone loss and in tumor situations. Another area of large bone loss is frequently seen in periprosthetic fractures. Trabecular metal (TM) with its dodecahedron configuration and modulus of elasticity between cortical and cancellous bone offers an excellent bail out option in the management of these very difficult situations. Severe bone loss in the distal femur and proximal tibia lend themselves to receiving the TM cones. The host bone surfaces need to be prepared to receive these cones using a high speed burr. The cones acts as a filler with an interference fit through which the stemmed implant can be introduced and cemented. All areas of bone void is filled with morselised cancellous bone fragments. We present our experience of 64 TM cones (28 femoral, 36 tibial cones) over a 10-year period and our results and outcomes for the same. We have had to revise only one patient for recurrence of the tumor for which the cone was implanted in the first place. We also describe our technique of using two stacked cones for massive distal femoral bone loss and its outcomes. We found excellent osteointegration and new host bone formation around the TM construct. The purported role of possible resistance to infection in situations using the TM cones is also discussed. In summary we believe that the use of the TM cones offers an excellent alternative to massive allografts, custom and/or tumor implants in the management of massive bone loss situations

Background. The Enhanced Recovery Programme (ERP) is an evidence based initiative aimed at speeding up patient recovery after major surgery and improving their outcomes. The Royal National Orthopaedic Hospital, Stanmore (RNOH) is a specialist orthopaedic and implemented an ERP for primary knee arthroplasties from October 2010. Aims. To analyse the initial results of patients participating in our ERP for primary knee arthroplasty to identify what factors predict their Length of Stay (LoS) and establish where changes can be made to improve outcomes further. Method. We interrogated our prospective ERP database and determined which patients achieved and which ones exceeded the 5-day LoS target. We then performed a further retrospective notes review to gather supplementary information including non-modifiable patient factors to identify factors which influenced their LoS. Results. 261 patients participated in the Knee ERP at the RNOH between October 2010 and December 2011 including patients undergoing complex procedures and bilateral procedures during the same in-patient episode. Mean age was 64 years (32–85 years). Mean LoS was 6.1 days (2–29 days). ASA grade and attendance at the multidisciplinary Joint School all had a positive influence on the LoS, particularly when combined. The day of mobilisation had the greatest correlation with those mobilising early. Mean LoS was 2.8 (Day 0), 4.41 (Day 1), 6.38 (Day 2), 9.23 (Day 3) and 12.95 (Day 4 or later). Conclusion. Identifying and targeting modifiable variables can further improve the outcomes for this particular group of patients. ASA grade and attendance at the multidisciplinary Joint School are among the positive influences on patient LoS. Adjusting analgesia to reduce unwanted effects may facilitate earlier engagement with the physiotherapy service and thus earlier mobilisation. Early results suggest encouraging patients to attend Joint School with subsequently early postoperative mobilisation can positively influence safe return to the home environment

Periprosthetic joint infection (PJI) is one of the most feared complications following total knee arthroplasty (TKA). Despite improved peri-operative antibiotic management and local antibiotic-loaded bone cement PJI is reported in about 0.5–1.9 % of primary knee replacement. In case of revision knee arthroplasty the infection rate even occurs at about 8–10 %. Depending on an acute or late PJI several surgical methods are used to treat the infection. However, suffering of a late PJI, the only surgical procedure remains the exchange of the TKA in combination with a radical debridement and removal of all foreign material. In order to achieve complete debridement of the joint, the soft tissue must be radically excised. Frequently, the debridement of the posterior capsule causes severe difficulties, therefore it might be necessary to resect the collateral ligaments to be able to reach the posterior parts of the capsule. But this necessitates the use of a higher level of constraint such as a rotating or total hinge and fully cemented long stemmed revision implants. Furthermore, due to the cemented stems, a sufficient amount of antibiotic-loaded cement may be delivered to the bone as topical therapy. Up to now, several studies have shown excellent functional long-term results for hinge knee prostheses after PJI and a very good infection control rate. Advantages of the hinge knee prosthesis in cases of PJI are the opportunity for a complete debridement especially while addressing the posterior capsule after resection of the collateral ligaments and for delivering antibiotic-loaded bone cement at the stems of the prosthesis for topic therapy. Disadvantages are the need for a higher level of constraint and a possible higher blood loss due to the radical debridement