We identified 26 tibial tubercle osteotomies (TTOs) performed in 23 revision knee arthroplasties between 2009 and 2013. Average age at last operation was 66 (33–92). Mean follow-up period was 14 months (3–33). Eleven TTOs were performed in 10 knees for single stage revisions and 15 TTOs were performed in 13 knees for 2 stage revisions in the setting of deep infection. In this infected subset 11 patients had a TTO performed at the first stage. This osteotomy was left unfixed to avoid leaving metalwork in a potentially contaminated wound, reopened, and then definitively secured with screws at the second stage. Our technique involves fashioning a long 7×1cm tibial tuberosity osteotomy without a proximal step-cut. All osteotomies united with no fractures. Minor proximal migration was noted in one case associated with screw loosening. There was no proximal migration noted in the 2 stage cases where the osteotomy had been left initially unfixed. There were no extensor lags. We conclude that TTO is a safe and reproducible procedure when adequate exposure cannot be obtained in revision knee arthroplasty. In 2 stage revisions sequential osteotomies does not decrease union rates and leaving the osteotomy unfixed after the first stage does not cause any issues

Purpose. Although classic teaching holds that the least amount of constraint should be implanted, there is very little in the literature to substantiate this. This study attempts to quantify the influence of constraint and various indications upon functional outcome following aseptic first time revision knee arthroplasty. The null hypothesis was that the level of constraint and indication for surgery would not influence the functional outcome following revision knee replacement. Methods. A single centre prospective study was performed to examine the outcome for 175 consecutive total revision knee replacements performed between 2003 and 2008 with a minimum follow-up of two years. Patient reported outcome data was used to determine the influence of final level of component constraint and its relationship with primary indication for surgery. Results. All patients were found to have a significant improvement for WOMAC pain, function and stiffness score (p< 0.001) and physical functioning, role physical, bodily pain and social functioning components of SF-36 score (p< 0.05). 69% were satisfied with the overall procedure. WOMAC function, pain and stiffness score was significantly worse for patients revised for instability (27%) compared to that for aseptic loosening (46%). A significantly higher proportion of patients were satisfied with the procedure (p< 0.001), had a better quality of life (p=0.004) and would have the surgery (p=0.005) again in the aseptic loosening group as compared to the instability group. Revision to a higher level of constraint did not improve knee function irrespective of the primary indication for surgery. Conclusion. Revision for an instability pattern irrespective of choice of new device was met with significantly poorer functional outcome

Introduction. Bone loss in the distal femur and proximal tibia is frequently encountered with both complex primary and revision knee replacement surgery. Metaphyseal sleeves provide a good option for enhanced fixation in managing such defects on both the tibia and femur. We present our results in 48 patients (50 knees) with a minimum 12 month follow up (range 12 to 45). Methods. 48 patients (50 knees) who had revision knee arthroplasty for either septic or aseptic loosening. All were graded Type II or III using the Anderson Orthopaedic Research Institute (AORI) grading system of both femoral and tibial defects. A large portion of aseptic loosening revisions were for extreme osteolysis of a bicondylar knee prosthesis. Results. 52% had tibial sleeves only, 38% had both tibial and femoral sleeves and the remainder had only femoral sleeves inserted. All knee radiographs at final follow-up showed well-fixed osteointegrated components without component migration or clinically significant osteolysis. Two knees were treated with multiple arthroscopic washouts for infection. Two knees subsequently underwent manipulation under anaesthesia with good improvement in range of movement. One subsequently developed Complex Regional Pain Syndrome. No femoral or tibial components were revised. The average pre-operative Oxford Knee Score was 22 (12 to 38) and subsequently improved to 38 (12 to 45) post-operatively. Discussion and conclusions. Our early results show encouraging signs that porous titanium sleeves are a good option when managing large metaphyseal bone loss in both femur and tibia especially in revision arthroplasty. Post operative complications were low and functional outcome scores were comparable with more traditional knee revision arthroplasty techniques in the presence of bone loss

Patient reported outcome measures (PROMs) after total knee arthroplasty (TKA) are typically used to assess longitudinal change in pain and function after total knee arthroplasty (TKA). The Patient's Knee Implant Performance (PKIP) score was developed to evaluate outcomes more broadly including function, stability, confidence, and satisfaction. Although validated in patients having a primary TKA, the PKIP has not been evaluated as an outcome measure for patients having revision TKA. This study examined patient outcomes at one year following primary and revision TKA measured using the PKIP, compared to Oxford Knee Scores.

A retrospective analysis of pre-operative and one-year post-operative outcomes was completed for 39 patients (21 female) who had primary (n=27) or revision (n=12) TKA with a single surgeon between 2017 and 2020. The mean age was 69.2±7.4 years, and mean weight 87.4± 5.1kg. The change over time and correlation between the self-reported outcome measures was evaluated.

There was a significant improvement in the PKIP overall score at the 12-month follow-up (32± 13 v 69± 15, p= <0.001), with no significant difference between groups (3.3 points, p=0.50). Among the PKIP sub-scores, there was a significant improvement in knee confidence (3.5±2 vs 7.7±2; p<0.001), stability (3.4±2 vs 7.4±3; p<0.001) and satisfaction (2.5±1.7 vs 6.6±3, p<0.001). Between group differences in PKIP sub-scores one year after surgery were small and non-significant. For all patients, the OKS and PKIP scores were moderately correlated before surgery (r=0.64, p=<0.05), and at 1 year after surgery (r=0.61, p= <0.001).

Significant improvements in knee confidence, stability, and satisfaction one year after TKA were identified from the PKIP responses, with no significant difference between primary and revision surgery. The moderate correlation with the OKS suggests these questionnaires measure difference constructs and may provide complementary outcome information in this patient cohort.

Background. Both surgeon and hospital volume influence patient outcomes following revision knee arthroplasty. Purpose. To audit all centres performing revision knee procedures in England and Wales over a 2-year period. All centres were audited against two pre-defined standards linked to hospital volume. Operative volume should be greater than 10 revisions per year;. More than 2.5 revisions should be performed for every 100 primary arthroplasties implanted. Methods. Data for 9659 knee revisions performed in 359 different centres between 01/07/08 and 30/06/10 was accessed from the National Joint Registry for England and Wales. For each centre information on the volume of primary and revision knee procedures undertaken during this period was available and was used as the basis for audit. Results. During the 2-year study period 396 different centres performed 153133 primary knee arthroplasties. Of these 359 (91%) performed 9659 knee revisions, equivalent to 6.2 revisions for every 100 primary arthroplasties performed. Revision centres included 208 (58%) NHS hospitals performing 8148 revisions, 141 (39%) independent hospitals performing 1258 revisions and 10 (3%) Independent Sector Treatment Centres (ISTC) performing 253 revisions. The median number of revisions performed per hospital was 7 per year (Range 1 to 144). Volume differed dependent upon hospital type (NHS=14/year vs. Independent=3/year, p< 0.001). Two hundred and twelve (59%) centres performed < 10 revisions per year and thus fell below the audit standard. Eighty of these centres also performed < 2.5 revisions per 100 primaries. Of the 141 independent hospitals 128 (91%) fell below the suggested standards for revision volume. Conclusions. A significant number of institutions are performing only a small volume of knee revision procedures. To ensure safe and sustainable practice with better outcomes, consideration should be given to rationalising the revision service in fewer centres

Infection after knee arthroplasty is a devastating complication. Our aim is to present our outcomes of treating infected knee replacements at a tertiary referral centre. We performed a consecutive, retrospective case series of all revision knee arthroplasty for infection between January 2006 and December 2008. Case notes were reviewed and data collated on the date and institution of primary arthroplasty, procedures undertaken at our institution, microbiology and bone loss post first stage, serological markers (C-reactive protein, ESR) prior to second stage and outcome. During this three year period we performed 430 knee revision operations. 51 were in the presence of deep chronic infection. 90% were referred from other hospitals. Overall infection was successfully eradicated in 69%. Nineteen patients underwent repeat two-stage and overall eleven (58%) patients had successful eradication of infection with multiple two-stages. Of these 47% had F3/T3, the highest grading of Anderson Orthopaedic Research Institute bone loss indicating no metaphyseal bone. A further 12% had bicondylar deficiency on the tibia and no femoral metaphyseal bone (F3/T2b). Multidrug resistance present in 69% and 47% were infected with multiple organisms. All members of the unsuccessful outcome group had at least one multidrug resistant organism compared to 43% in the successful cohort (P=0.0002). Multiple organisms are associated with an unsuccessful outcome (P=0.056). Serological markers were not significantly different between the successful and unsuccessful outcome groups. Where the referring hospital had attempted revision and failed, the chance of eradicating infection dropped from 75% to 58% and the rate of above knee amputation was twelve times higher (3% vs. 36%). Custom constrained, rotating hinge prostheses enable aggressive soft tissue debridement including ligaments. Successful two-stage requires a multidisciplinary approach including tissue viability nurses, microbiologists and plastic surgeons. Where units lack revision expertise this series suggests early referral increases the chance of limb salvage

BACKGROUND. High-dose antibiotic cement spacers are commonly used to treat prosthetic joint infections following knee arthroplasties. Several clinical studies have shown a high success rate with antibiotic cement spacers, however there is little data on the systemic complications of high-dose antibiotic spacers, particularly acute kidney injury (AKI). This study aims to determine the incidence of AKI and identify risk factors predisposing patients undergoing staged revision arthroplasty with antibiotic cement spacers. METHODS. A single-institution, retrospective review was used to collect and analyze clinical and demographic data for patients who underwent staged revision total knee arthroplasty with placement of an antibiotic-impregnated cement spacer from 2006 to 2016. A search was made through specific procedure (DRG) and diagnostic (CD) codes. Baseline descriptive data were collected for all patients including age, sex, medical comorbidities, type and quantity of antibiotics used in the cement spacer, pre- and postoperative hemoglobin (Hg), BMI, smoking status, peak creatinine levels, and random vancomycin levels. Acute kidney injury was defined as a more than 50% rise in serum creatinine from a preoperative baseline within 90 days postoperatively. RESULTS. A total of 54 staged revision TKA surgeries performed by 5 different surgeons between 2006 and 2016. The total incidence of AKI was 31% (n=17). There was a significant positive association between change in creatinine level and use of oral/intravenous antibiotics (p=0.03, Spearman's rho=0.33) and a significant positive association between AKI and the use of tobramycin cement (p=0.01, Spearman's rho=0.38). Factors that were not significantly associated with AKI include presence of preexisting hypertension (p = 0.26), hyperlipidemia (p = 0.83), coronary artery disease (p = 0.86), chronic kidney disease (p=0.56), and smoking status (p=.35). There was a trend towards increased risk of AKI in patients with diabetes mellitus (p= 0.12), however this was not significant. CONCLUSION. In single staged revision knee arthroplasty there is a significant association between acute kidney injury and type of oral/intravenous antibiotic used in the treatment. Both the use of intravenous vancomycin and tobramycin cement are independently associated with higher rates of AKI. Preexisting medical comorbidities are not independent risk factors for development of AKI. Serum creatinine and measurement of serum aminoglycoside and vancomycin levels should be performed after placement of an aminoglycoside-containing antibiotic cement spacer in a staged revision arthroplasty

INTRODUCTION. Conventional surgical exposures are usually inadequate for 2-stage revision knee replacement ofinfected implants. Reduced range of motion, extensor mechanism stiffness, peripatellar contracture and soft tissue scarring make patellar eversion difficult and forced eversion places the integrity of the extensor mechanism at risk. On the contrary, a wide exposure is fundamental to allow complete cement spacer removal, soft tissue balancing, management of bone loss and reimplantation without damaging periarticular soft tissues. OBJECTIVES. To compare the long-term clinical, functional and radiographic results and the reinfection rate of the quadriceps snip approach and the tibial tubercle osteotomy in 2-stage revision knee replacement performed for septic loosening of the primary implant. METHODS. In our department, 87 patients had a 2 stage revision knee replacement for septic loosening of the primary implant between 1996 and 2008. In all patients, first stage consisted of primary implant removal, extensive soft tissue debridement and positioning of a static antibiotic loaded cement spacer. The timing for reimplantation was decided basing on negative clinical and laboratory (ESR, CRP) signs and negative Leukoscan results. For reimplantation, a quadriceps snip was used in patients with an intraoperative flexion >90° (Group A) while a tibial tubercle osteotomy (Group B) was used in patients with an intraoperative flexion <90°. RESULTS. At observation point, 4 patients died for reasons unrelated to surgery, leaving 42 patients in Group A and 41 in Group B. We had a total amount of 10 recurrent infections (11%) after reimplantation, 7 patients in Group A and 3 patients in Group B (p<0.005). Patients with a reinfection in Group A were treated with a knee fusion in 4 cases, a rerevision in 2 cases and an amputation above the knee in 1 case, while all those with a reinfection in Group B had a knee fusion. According to HSS score, 11 patients were rated as Excelent/Good in Group A and 9 patients in Group B (p=n.s.). Three patients had a major complication in Group A and 0 patients in Group B (p=0.005). No differences were found between the two groups regarding range of motion and subjective satisfaction. CONCLUSION. Tibial tubercle osteotomy is a safe procedure to obtain a wide exposure in 2-stage revision knee replacement performed for septic loosening of the primary implant and it is effective in reducing reinfection rate without compromising clinical results and range of motion

The battle of revision TKA is won or lost with safe, effective, and minimally bony-destructive implant removal, protecting all ligamentous stabilisers of the knee and, most importantly, the extensor mechanism. For exposure, incisions should be long and generous to allow adequate access. A standard medial parapatellar capsular arthrotomy is preferred. A synovectomy is performed followed by debridement of all scar tissue, especially in the medial and lateral gutters. All peripatellar scar tissue is excised followed by release of scar tissue within the patellar tendon, allowing for displacement or everting of the patella. As patellar tendon avulsion at any time of knee surgery yields disastrous results, the surgeon should be continuously evaluating the patellar tendon integrity, especially while displacing/everting the patella and bringing the knee into flexion. If displacement/eversion is difficult, consider rectis-snip, V-Y quadricepsplasty, or tibial tubercle osteotomy. The long-held requisite for patellar eversion prior to component removal is inaccurate. In most cases simple lateral patellar subluxation will provide adequate exposure.

If a modular tibial system is involved, removal of the tibial polyethylene will decompress the knee, allowing for easier access to patellar, femoral, and tibial components. For patellar component removal, first identify the border of the patella, then carefully clean and debride the interface, preferably with electrocautery. If the tibial component is cemented all-polyethylene, remove using an oscillating saw at the prosthetic-bone interface. Debride the remaining cement with hand tools, ultrasonic tools, or burrs. Remove the remaining peg using a low-speed burr. If the tibial component is metal-backed, then utilise a thin saw blade or reciprocating saw to negotiate the undersurface of the component between the pegs. If pegs are peripherally located, cut with a diamond disc circular cutting tool. Use a trephine to remove the pegs.

For femoral component removal, identify the prosthetic-bone/prosthetic-cement interface then remove soft tissue from the interface, preferably with electrocautery. Disrupt the interface around all aspects of the component, using any of following: Gigli saw for cementless components only, micro saw, standard oscillating saw, reciprocating saw, a series of thin osteotomes, or ultrasonic equipment. If the femoral component is stemmed, remove the component in two segments using an appropriate screwdriver to remove the screw locking the stem to the component. Remove the femoral component with a retrodriver or femoral component extractor. Debride cement with hand tools or burr, using care to avoid bone fracture. If a stem is present, then remove with the appropriate extraction device. If “mismatch” exists, where femoral (or likewise, tibial) boss is smaller in diameter than the stem, creating a cement block prohibiting stem removal, remove the cement with hand tools or burr. If the stem is cemented, use hand tools, ultrasonic tools, or a burr to debride the cement. Curette and clean the canals.

For tibial component removal, disrupt the prosthetic-cement/prosthetic-bone interface using an oscillating or reciprocating saw. Gently remove the tibial component with a retrodriver or tibial extractor. If stem extensions are utilised, disengage and debride all proximal cement prior to removing the stem. If stem is present, then remove stem with appropriate extraction device. If stem is grit-blasted and well-fixed, create 8mm burr holes 1.5 to 2.5cm distal to tibial tray on medial aspect and a small divot using burr, then drive implant proximally with Anspach punch. Alternatively, a tibial tubercle osteotomy may be performed. If the stem is cemented, use hand tools, ultrasonic tools or burr to debride cement.

Introduction

Several options exist for the treatment of periprosthetic osteolysis in revision knee surgery. We describe our preliminary short-term experiences using trabecular metal (TM) technology in order to fill bony defects either on the femoral or on the tibial side.

Aims. The International Consensus Meeting on Musculoskeletal Infection (ICM, Philadelphia 2018) recommended histology as one of the diagnostic tests although this is not routinely used in a number of UK hospitals. This study aims to explore the role of histology in the diagnosis of infection and whether it is of practical use in those cases where the microbiology samples are either diagnostically unclear or do not correspond to the pre-operative diagnosis or the clinical picture. Patients and Methods. We identified 85 patients who underwent revision knee arthroplasty for either septic or aseptic loosening and for whom both microbiology and histology samples were taken. The procedures were performed by the senior experienced surgeons specialised in revision knee arthroplasty in two centres from Liverpool. Each patient had a minimum of five tissue samples taken, using separate knife and forceps and each sample was divided in half and sent for microbiology and histology in different containers. Fifty-four patients (63.5%) underwent a single-staged revision; ten patients (11.8%) underwent the 1. st. stage of a two staged revision; eleven patients (12.9%) underwent the 2. nd. stage of a two staged revision; one patient (1.2%) underwent an additional revision stage; three patients (3.5%) were treated with a DAIR; three patients (3.5%) had a 2-in-1 revision; two patients (2.4%) had a debridement and polyethylene exchange; and one patient (1.2%) had an arthroscopy biopsy of knee replacement. The cost to process five microbiology samples for each patient was £122.45 on average and for the five histology samples was £130. Results. In 63.5% (n=54) the histology and microbiology confirmed an aseptic joint as suspected beforehand. In 8.2% (n=7) the histology result was the same as the microbiology result confirming infection as suspected beforehand. In 15.3% (n=13) where asepsis was suspected beforehand, one of the five microbiology samples unexpectedly grew an organism but all the histological samples showed no evidence of infection. In these cases, the histology result supported the diagnosis of the likelihood of a contaminant. In 5.9% (n=5) we found differences in the microbiology and histology in one sample and in 7.1% (n=6) the histology was different to the microbiology in more than one sample. Conclusions. In cases where the diagnosis of sepsis within a knee replacement is not in doubt due to pre-operative microbiology, we found no benefit in additional histology sampling. In 28.3% of the cases, the histology was of use in the diagnosis of infection in complex cases and a useful tool in the decision process for further management. In over half of the cases where the revision was for aseptic loosening, the histology result did not alter the management but 28.3% of cases that were thought to be aseptic, microbiology revealed at least one positive sample hence the histology was of use in making a final diagnosis, be that of infection, contamination or to rule out infection. Whilst histology is of use in the latter groups but not the aseptic group, these outcomes are not predictable until after the post-operative period hence histology is required in all these cases. Overall, the histology is a cheap test which is of benefit in the diagnosis of complex peri-prosthetic joint infection in one–third of cases and we support the ICM recommendation

Aim. The number of periprosthetic joint infections (PJI) is increasing due to ageing population and increasing numbers of arthroplasty procedures and treatment is costly. Aim of the study was to analyze the direct healthcare costs of PJI in Europe for total hip arthroplasties (THA) and total knee arthroplasties (TKA). Method. A systematic review in PubMed with search of direct costs of PJI in European countries was performed. Thereby the term cost* AND (infection OR PJI) AND (prosthesis OR knee OR hip OR “TKA” OR “THA” OR arthroplast*) was combined with each European country to detect relevant publications. Publications with definition of performed procedure and joint localization were included into further analysis. The mean value of direct healthcare cost was calculated for the respective joint and the respective operation performed. Results. Screening revealed 1,274 eligible publications. After review of abstracts and full-texts n=11 manuscripts were included into final analysis (Figure 1). The mean combined direct hospital costs for revision for PJI after TKA and THA was 26,311€. Mean costs for revision procedures for PJI after TKA were 24,617€. Direct costs for TKA-PJI treated with debridement, antibiotics and implant retention (DAIR) were on average 10,121€. For two-stage revisions in knee arthroplasties total average costs were 30,829€. Referring to revision surgery for PJI in THA, the mean hospital costs in Europe were 28,005€. For a DAIR procedure direct healthcare costs of 5,528€ were identified. Two-stage revision cost on average 31,217€. Conclusions. PJIs are associated with significant direct healthcare costs. The financial burden of up to 30,000 € per case underlines the impact of the disease for European health care system. However, the number of detailed reports on PJI costs is limited and the quality of the literature is limited. There is a strong need for more detailed financial data on the costs of PJI treatment. For any tables or figures, please contact the authors directly

Introduction. We aim to assess the functional outcome, patient perceived satisfaction and implant survival at a mean follow up of 13[10–16] years following revision knee replacement. Patients and Methods. Between 1995 and 2001, 243 revision knee replacements were performed in 230 patients using Endolink [Link, Hamburg] or TC3 [Depuy, Leeds] prosthesis at Wrightington hospital, Wrightington, were consented to take part in this study. Data was collected prospectively which includes complications and functional assessment by Oxford knee score, WOMAC, HSS, UCLA, SF12 scores, and patient satisfaction questioner. The scores were obtained pre-operatively and post-operatively at 1 year, 5 years and at the latest follow-up. The mean age was 69 yrs, 51% were males, TC3 prosthesis as used in 175 and Endolink in 68, the revision was for Infection in 71[29%], 53 patients had intra-operative positive culture, 35 had 2 stage revision. Results. At a mean follow up of 13 years [10–16] the survival of revision knee replacement in our patient group is 86%. Further surgery was performed in 35[14%], which includes 5 patients who had above knee amputation. The re-revision rate in the non-infected group [13%] was significantly lower compared to the re-revision in infected group [18%]. The Oxford scores improved at 1 year which continued to improve up to 5 years following which there was a gradual deterioration in the scores. There was no significant improvement in the generic HSQ, SF12 and UCLA scores following surgery. The functional scores improved to a lesser extent in patients with proven infection. Discussion and Conclusion. At a mean follow up of 13 years the implant survival for revision knee replacement using endolink or TC3 prosthesis is 86%. The non-infected group had lower re-revision rates. The improvement in functional scores is lower following revision for infection

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected knee arthroplasty experts. The primary cases will include challenges such as patient selection and setting expectations, exposure, alignment correction and balancing difficulties. In the revision knee arthroplasty scenarios issues such as bone stock loss, fixation challenges, instability and infection management will be discussed. This will be an interactive case-based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues

Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion. We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The “SMILES spacer” was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24–70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery. Above knee amputation for persistent infection was performed in two patients. In this particularly difficult to treat population, the SMILES spacer two-stage technique has demonstrated encouraging results and presents an attractive alternative to arthrodesis or amputation

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected knee arthroplasty experts. The primary cases will include challenges such as patient selection and setting expectations, exposure, alignment correction and balancing difficulties. In the revision knee arthroplasty scenarios issues such as bone stock loss, fixation challenges, instability, and infection management will be discussed. This will be an interactive case based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues

Introduction. We aim to assess the functional outcome, patient satisfaction and implant survival at a mean follow up of 13[10–16] years following revision for infected total knee replacement. Patients and Methods. Between 1995 and 2001, 71 revision knee replacements were performed for infection, at Wrightington hospital, Wrightington. Data was collected prospectively which includes intra-operative cultures, complications and functional assessment by Oxford knee score, WOMAC, HSS, UCLA, SF12 scores, and patient satisfaction questioner. The scores were obtained pre-operatively and post-operatively at 1 year, 5 years and at the latest follow-up. Mean age was 69 yrs, 70% were Females, 31[44%] had 2 stage revisions and intra-operative culture was positive in 53 patients. Most common organism was staphylococcus aureus in 30% and staphylococcus epidermides in 18%. Results. At a mean follow up of 13[10–16] years, the survival of revision knee replacement for infection in our patient group is 82%. 4 patients had above knee amputation 4 had conversion to Pseudo, 1 had Arthrodesis, further revisions in 4 patients 2 for wear and 2 for loosening. Two patients have chronic infection and are on long term suppressive antibiotics. The Oxford scores improved at 1 year which continued to improve up to 5 years following which there was a gradual deterioration in the scores. There was no significant improvement in the generic HSQ, SF12 and UCLA scores following surgery. There was a significant improvement in HSS scores, Oxford scores and patient satisfaction following surgery. There was no difference in functional outcome between the single stage revision and 2 stage revision group. Discussion and Conclusion. In our study group the implant survival for revision of infected total knee replacement is 82%. There was an improvement in functional scores following surgery; however the total scores are still low suggesting lower levels of function

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

Aims

Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons.

Aim. The aim of our study was to evaluate culture-negative prosthetic joint infections in patients who were pre-operatively evaluated as aseptic failure. Method. For the purpose of the study we included patients planed for revision surgery for presumed aseptic failure. Intraoperatively acquired samples of periprosthetic tissue and explanted prosthesis were microbiologicaly evaluated using standard microbiologic methods and sonication. If prosthetic joint infection was discovered, additional therapy was introduced. Results. Between October 2010 and June 2016 265 cases were operated as aseptic loosenings (66 revision knee arthroplasty, 199 revision hip arthroplasty). 69 (26,0%) cases had positive sonication and negative periprosthetic tissue sample, 24 (9,1%) cases had positive tissue samples, but negative sonication, in 27 (10,2%) cases both tests were positive and in 145 (54,7%) cases all microbiologic tests were negative. In both groups coagulase-negative staphylococci and P.acnes were most common, followed by mixed flora. Conclusions. With the increasing number of patients requiring revision arthroplasty, a clear differentiation between aseptic failure and prosthetic joint infection is crucial for the optimal treatment. Sonication of explanted material is more successful in the isolation of pathogens compared to periprosthetic tissue cultures. Sonication of explanted prosthetic material is helpful in the detection of culture-negative prosthetic joint infections