Revision knee arthroplasty is a complex procedure with the number and cost of knee revision procedures performed per year expected to rise. Few studies have examined adverse events following revision arthroplasty. The objective of this study was to determine rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications) and to compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the UK Hospital Episode Statistics. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes including infection (undergoing surgery), pulmonary embolism, myocardial infarction, stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications were included in the elective indications cohort. 939,021 primary knee arthroplasty cases were included of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75-2.35; odds ratio [OR] 3.54; 95% CI 2.81-4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. These findings highlight the burden of complications associated with revision knee arthroplasty. They will inform shared decision-making for patients considering revision knee arthroplasty for elective indications. Patients presenting with infection of a knee arthroplasty or a periprosthetic fracture are at very high risk of adverse events. It is important that acute hospital services and tertiary referral centres caring for these patients are appropriately supported to ensure appropriate urgency and an anticipation for increased care requirements

Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various protocols exist for treating these infections, each with its own advocates. In this series we report the one to five year follow-up of infected TKA that were treated with a two-stage revision knee replacement at the Glasgow Royal Infirmary between December 2003 and March 2009. 48 patients were identified from the hospital database. 6 of these were excluded as they did not meet the stipulated infection criteria. Another patient was excluded as no notes were available thereby the infection status could not be determined. Another 8 patients were excluded as these only had a first stage. 33 patients (16 male) average age 67y (49–88) met the inclusion criteria. Mean BMI was of 31.62 (19–47) and 8 patients suffered from rheumatoid arthritis. At presentation, the median for the ESR, CRP and WCC were 70.5, 133 and 8.5 respectively. The infective organism was identified in 22 patients. Following the first stage, the patients were treated with antibiotics (initially intravenous followed by oral) for an average of 11.8 weeks (4–52 weeks). This procedure failed to eliminate the infection in 6 patients (18.18%) who had further re-admissions for infection of the affected prosthesis. The resultant success rate is of over 80% which is comparable to literature data (success rates of 41% to 96% quoted). For these patients, the average time to review was 25.13 months (12–67months). At review these patients had a mean extension of 2.17° (0–10°) and a mean flexion of 98.26 (70–120°). These patients were all satisfied with their outcome. Our results show a high successful rate of elimination of infection when a two-stage revision is used for infected knee prosthesis with over 80% of patients free of infection

Abstract

Fractures of the prosthetic components after total knee arthroplasty (TKA) are rare but dangerous complications, sometimes difficult to diagnose and to manage. Aim of this study is to evaluate the incidence of component breakage and its treatment in our single institution's experience. We retrospectively review our institution registry. From 605 revision knee arthroplasties since 2000 to 2018, we found 8 cases of component breakage, of these 3 belonged to UKA, and 5 belonged to TKA. The UKA fractures were all on the metal tibial component; while 4 TKA fractures were ascribed to the liner (2 Posterior-Stabilized designs and 2 constrained designs) and only one case was on the femoral component. For every patient a revision procedure was performed, in two cases a tibial tubercle osteotomy was performed, while in one case (where the fracture was of the post cam) an arthroscopy was performed prior to the arthrotomy. All of the UKA fractures were treated with a standard revision implant. As regard the TKA, 2 liner fractures were treated with the only liner exchange, while the other 2 liner fractures and the fracture of the metallic component were treated with total knee revision. No intra- and post-operative complications were found. Component breakage after TKA is a serious complication. Its treatment, always surgical, can hide pitfalls, especially if the timing is not correct; indeed apart from the revision of one or more components, the surgeons must address any issues of management of bone defect and ligamentous stability

Abstract. Approximately 20% of primary and revision Total Knee Arthroplasty (TKA) patients require multiple revisions, which are associated with poor survivorship, with worsening outcomes for subsequent revisions. For revision surgery, either endoprosthetic replacements or metaphyseal sleeves can be used for the repair, however, in cases of severe defects that are deemed “too severe” for reconstruction, endoprosthetic replacement of the affected area is recommended. However, endoprosthetic replacements have been associated with high complication rates (high incidence rates of prosthetic joint infection), while metaphyseal sleeves have a more acceptable complication profile and are therefore preferred. Despite this, no guidance exists as to the maximal limit of bone loss, which is acceptable for the use of metaphyseal sleeves to ensure sufficient axial and rotational stability. Therefore, this study assessed the effect of increasing bone loss on the primary stability of the metaphyseal sleeve in the proximal tibia to determine the maximal bone loss that retains axial and rotational stability comparable to a no defect control. Methods. to determine the pattern of bone loss and the average defect size that corresponds to the clinically defined defect sizes of small, medium and large defects, a series of pre-operative x-rays of patients with who underwent revision TKA were retrospectively analysed. Ten tibiae sawbones were used for the experiment. To prepare the bones, the joint surface was resected the typical resection depth required during a primary TKA (10mm). Each tibia was secured distally in a metal pot with perpendicular screws to ensure rotational and axial fixation to the testing machine. Based on X-ray findings, a fine guide wire was placed 5mm below the cut joint surface in the most medial region of the plateau. Core drills (15mm, 25mm and 35mm) corresponding to small, medium and large defects were passed over the guide wire allowing to act at the centre point, before the bone defect was created. The test was carried out on a control specimen with no defect, and subsequently on a Sawbone with a small, medium or large defect. Sleeves were inserted using the published operative technique, by trained individual using standard instruments supplied by the manufacturers. Standard axial pull-out (0 – 10mm) force and torque (0 – 30°) tests were carried out, recording the force (N) vs. displacement (mm) curves. Results. A circular defect pattern was identified across all defects, with the centre of the defect located 5mm below the medial tibial base plate, and as medial as possible. Unlike with large defects, small and medium sized defects reduced the pull-out force and torque at the bone-implant interface, however, these reductions were not statistically significant when compared to no bony defect. Conclusions. This experimental study demonstrated that up to 35mm radial defects may be an acceptable “critical limit” for bone loss below which metaphyseal sleeve use may still be appropriate. Further clinical assessment may help to confirm the findings of this experimental study. This study is the first in the literature to aim to quantify “critical bone loss” limit in the tibia for revision knee arthroplasty. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

The number of revision knee arthroplasties performed is projected to rise dramatically in the coming years. Primary knee arthroplasties are also being performed in younger patients increasing the likelihood of multiple revision procedures. Reconstruction can be challenging with bone stock deficiencies and ligament incompetence. The aim of this study was to present our results of revision total knee arthroplasty using metaphyseal sleeve components to aid reconstruction. Sixty seven patients underwent revision total knee arthroplasty between September 2005 and November 2010 using metaphyseal sleeves. There were thirty one male and thirty six female patients. The indication for revision was aseptic loosening in thirty nine, sepsis in fifteen, malalignment in eight and instability in five patients. Thirty four patients had tibial sleeves, thirty patients had both tibial and femoral sleeves and three patients had femoral sleeves during revision. The patients were followed up for a mean of 32 months (Range 12–60) with outcome data collected prospectively. The mean revised oxford knee scores for the patients improved from 15 (Range 2 to 29) preoperatively to 33 (Range 20 to 45) postoperatively. Mean arc of flexion following revision was 87 degrees (Range 55 to 120). Seventy six percent of patients were satisfied or very satisfied with the result of the revision surgery. There have been no radiographic complications specific to the sleeves and no re-operations. There has been one recurrence of infection in a patient revised for sepsis. This has been managed with suppressive antibiotics due to patient co-morbidities. Metaphyseal sleeves are an effective adjunct in revision knee arthroplasty. We have had good results with their use. To our knowledge no larger series has been presented or published

Introduction. As the demand for primary total knee arthroplasty (TKA) has been on the rise, so will be the demand for revision knee surgery. Nevertheless, our knowledge on the modes of failure and factors associated with failure of knee revision surgery is considerably lower to that known for primary TKA. To date, this has been mostly based on case series within the literature. Therefore, the aim of this study was to evaluate the survivorship of revision TKA and determine the reasons of failure. Methods. A retrospective study was conducted with prior approval of the institutional audit department. This involved evaluation of existing clinical records and radiographs of patients who underwent revision knee surgery at our institution between 2003 and 2015. Re-revision was identified as the third or further procedure on the knee in which at least one prosthetic component was inserted or changed. Results. 95 patients were identified who had re-revision knee replacement. Of these, there were 46 men (48%) and 49 women (52%) with an average age of 65 yrs. Infection was the main cause of failure (35.8%) followed by aseptic loosening (27.4%) and extensor mechanism problems leading to reduced range of motion (7.4%). Other causes included MCL Laxity (3.2%), oversized implants (3.2%) and fracture of the cement mantle (1.1%). The mean survivorship of revision knee replacements in our cohort was 31 months (Range between 1 – 119 months). Conclusion. The survival of knee re-revision implants is considerably different from primary TKA implants. The results of our study provide an improved understanding of the modes of failure of re-revision knee replacements, enabling orthopaedic surgeons the opportunity to better understand the current problems associated with revision knee surgery and the potential to improve our outcomes by tackling these issues

Background. Surgical wound closure is not the surgeon”s favorite part of the total knee arthroplasty (TKA) surgery however it has vital rule in the success of surgery. Knee arthoplasty wounds are known to be more prone to infection, breakdown or delayed healing compared to hip arthroplasty wounds, and this might be explained by the increased tensile force applied on the wound with knee movement. This effect is magnified by the enhanced recovery protocols which aim to obtain high early range of movement. Most of the literature concluded that there is no difference between different closure methods. Objectives. We conducted an independent study comparing the complication rate associated with using barbed suture (Quill-Ethicon), Vicryl Rapide (polyglactins910-Ethicon) and skin staples for wound closure following TKA. Study Design & Methods. Retrospective study where the study group included all the patients admitted to our unit for elective primary knee arthroplasty in 2015, we excluded patients admitted for partial knee arthroplasty, revision knee arthroplasty or arthroplasty for treatment of acute trauma due to the relatively higher complication rates. All the patients notes were reviewed to identify wound related problems such as wound dehiscence, wound infection and delayed healing (defined as delayed wound healing more than 6 weeks). Results. 327 patients were included in this study; 151 in Quill group, 99 in staples group and 77 in the last group where the wound closed with Rapide. We identified 9 (5.9%) cases of wound dehiscence in the Quill group, 3 cases of wound dehiscence in each of other two groups (3.8%) with Rapide and (3%) with staples. On the other hand superficial wound infection was higher with staples with 6 (6%) cases of wound infection compared to the other groups, wound infection occurred in 2 patients (2.5%) with Rapide and 5 patients (3.3%) in the Quill”s group. Most of the delayed wound healing happened after using Quill where it is reported in 5 patients (3.3%) and the lowest was in staples group with 1 patient (1%) and slightly higher percentage in Rapide group 2 patients (2.5%). The total figure of wound related problems was the highest in Quill”s group with 19 reported cases (12.5%), lower in staples” group with 10 cases (1.1%) and the lowest in Rapide”s group with 7 cases (9%). Conclusions. Our study showed different results to the reported literature suggesting that each closure method has its own advantages and disadvantages. Quill is quick, knotless and absorbable but on the other side it is significantly more expensive than other alternatives and it is associated with the highest complication rates. On the other hand Rapide is cheap absorbable alternative with the lowest percentage of wound problems but on the negative side it is time consuming. Finally staples method is the quickest, relatively cheap and rarely associated with wound dehiscence but it is not absorbable which might cause inconvenience to patients

Patient function is poorly characterised following revision TKA. Modern semi-constrained implants are suggested to offer high levels of function, however, data is lacking to justify this claim. 52 consecutive aseptic revision TKA procedures performed at a single centre were prospectively evaluated; all were revision of a primary implant to a Triathlon total stabiliser prosthesis. Patients were assessed pre-operatively and at 6, 26, 52 and 104 weeks post-op. Outcome assessments were the Oxford Knee Score (OKS), range of motion, pain rating scale and timed functional assessment battery. Analysis was by repeated measures ANOVA with post-hoc Tukey HSD 95% simultaneous confidence intervals as pairwise comparison. Secondary analysis compared the results of this revision cohort to previously reported primary TKA data, performed by the same surgeons, with identical outcome assessments at equivalent time points. Mean age was 73.23 (SD 10.41) years, 57% were male. Mean time since index surgery was 9.03 (SD 5.6) years. 3 patients were lost to follow-up. All outcome parameters improved significantly over time (p <0.001). Post-hoc analysis demonstrated that all outcomes changed between pre-op, 6 week and 26 weeks post-op assessments. No difference was seen between primary and revision cohorts in OKS (p = 0.2) or pain scores (p=0.19). Range of motion and functional performance was different between groups over the 2 year period (p=0.03), however this was due to differing pre-operative scores, post-hoc analysis showed no difference between groups at any post-operative time point. Patients undergoing aseptic revision TKA with semi-constrained implants made substantial improvements in OKS, pain scores, knee flexion, and timed functional performance, with the outcomes achieved comparable to those of primary TKA. High levels of function can be achieved following revision knee arthroplasty, which may be important considering the changing need for, and demographics of, revision surgery

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip and knee replacement. We investigated the rates of revision surgery for the treatment of PJI following primary and revision hip and knee replacement, explored time trends, and estimated the overall surgical burden created by PJI. We analysed the National Joint Registry for England and Wales for revision hip and knee replacements performed for a diagnosis of PJI and their index procedures from 2003–2014. The index hip replacements consisted of 623,253 primary and 63,222 aseptic revision hip replacements with 7,642 revisions subsequently performed for PJI; for knee replacements the figures were 679,010 primary and 33,920 aseptic revision knee replacements with 8,031 revisions subsequently performed for PJI. Cumulative incidence functions, prevalence rates and the burden of PJI in terms of total procedures performed as a result of PJI were calculated. Revision rates for PJI equated to 43 out of every 10,000 primary hip replacements (2,705/623,253), i.e. 0.43%(95%CI 0.42–0.45), subsequently being revised due to PJI. Around 158 out of every 10,000 aseptic revision hip replacements performed were subsequently revised for PJI (997/63,222), i.e. 1.58%(1.48–1.67). For knees, the respective rates were 0.54%(0.52–0.56) for primary replacements, i.e. 54 out of every 10,000 primary replacements performed (3,659/679,010) and 2.11%(1.96–2.23) for aseptic revision replacements, i.e. 211 out of every 10,000 aseptic revision replacements performed (717/33,920). Between 2005 and 2013, the risk of revision for PJI in the 3 months following primary hip replacement rose by 2.29 fold (1.28–4.08) and after aseptic revision by 3.00 fold (1.06–8.51); for knees, it rose by 2.46 fold (1.15–5.25) after primary replacement and 7.47 fold (1.00–56.12) after aseptic revision. The rates of revision for PJI performed at any time beyond 3 months from the index surgery remained stable or decreased over time. From a patient perspective, after accounting for the competing risk of revision for an aseptic indication and death, the 10-year cumulative incidence of revision hip replacement for PJI was 0.62%(95%CI 0.59–0.65) following primary and 2.25%(2.08–2.43) following aseptic revision; for knees, the figures were 0.75%(0.72–0.78) following primary replacement and 3.13%(2.81–3.49) following aseptic revision. At a health service level, the absolute number of procedures performed as a consequence of hip PJI increased from 387 in 2005 to 1,013 in 2014, i.e. a relative increase of 2.6 fold. While 70% of those revisions were two-stage, the use of single stage revision increased from 17.6% in 2005 to 38.5% in 2014. For knees, the burden of PJI increased by 2.8 fold between 2005 and 2014. Overall, 74% of revisions were two-stage with an increase in use of single stage from 10.0% in 2005 to 29.0% in 2014. Although the risk of revision due to PJI following hip or knee replacement is low, it is rising. Given the burden and costs associated with performing revision joint replacement for prosthetic joint infection and the predicted increased incidence of both primary and revision hip replacement, this has substantial implications for service delivery

Recent projections expect the number of revision knee replacements performed to grow from 38,000 in 2005 to 270,000 by the year 2030. 1. Although the results of primary total knee arthroplasty are well documented, with overall implant survivorship at 15 years greater than 95%. 2. the results of revision procedures are not as well known. What if the revision TKR fails and what is the prevalence of failure of revision TKRs, the complications and re-operation rates? There are various studies which has either exclusively dealt with the causes or outcomes of revision with a particular prosthesis and survivorship analysis. The effectiveness of revision total knee replacement must be considered in the light of complications rates which could be either medical, orthopaedic surgery related complications or combination of both. The purpose of this study was to evaluate the prevalence of complications, reoperation rates and outcomes in a single surgeon's series between 1984 and 2008. Ninety nine index revision cases were studied. Incidences of surgical complications were 52.5%. The total reoperation rate was 34.3% whilst single re revision accounted for 19.9% whereas multiple re-revision incidences were 4%. The mean outcome in terms of Knee Society Score, Knee Society Function, and Knee society range of motion was statistically and clinically significant between pre operative and posts operative score at one year and remained consistent with time. These results suggest that modern revision total knee replacement are satisfactory operations and the outcomes perhaps can be improved if relatively simple strategies are followed by focusing these operations to specialized that accumulate enough experience from these demanding surgeries. Overall the results asserts that even in the hands of an experienced surgeon the complications do occur which is usually multi factorial, whilst in the light of complications and reoperation incidence the patients can be counselled thoroughly before the procedure

Objectives

To define Patient Acceptable Symptom State (PASS) thresholds for the Oxford hip score (OHS) and Oxford knee score (OKS) at mid-term follow-up.