Aim: To review results and complications of revision knee replacements.

Materials and Methods: We retrospectively reviewed 41 cases of cemented revision knee arthroplasty in 39 patients (15 male, 24 female) performed between 1993 and 2003. Data regarding clinical and functional outcomes and complications was recorded.

Results: Mean age at index (revision) operation was 67.8 years (32 to 86) and mean follow-up was 6.8 years (1.5 to 12). Average time to revision was 80 months (9 months to 23 years).

The indication for revision was aseptic loosening in 16 cases, and deep sepsis in 13 cases, (12 were done in 2 stages). Others included polyethylene wear in 4 knees, instability in 2, and 1 each of peri-prosthetic fracture, implant breakage and pain of undetermined origin. 3 revisions were performed for failed Link Lubinus patello-femoral replacement. Mean interval between staged procedures for sepsis was 2 months.

Reconstruction was performed using the Kinemax Revision system with the use of augments and stems. The modular rotating hinge was used in 4 cases. Surgical exposure included additional lateral release in 7 cases, tibial tubercle osteotomy in 4 and quadriceps snip in one.

Complications: Included 1 post-operative death due to haematemesis and 2 non-fatal cardiac complications. 1 patient was re-revised for aseptic loosening at 3.5 years, 1 needed an above knee amputation for intractable sepsis after multiple failed reconstructions and 1 is awaiting patellar revision.

At latest review, 7 patients had died due to unrelated causes with a pain free functioning knee prosthesis. Of the remaining 31, 26 patients had none or minimal pain. 21 were independently mobile with a satisfactory range of motion.10 patients needed a walking stick.

Conclusion: Revision total knee replacement can give satisfactory results in the short to medium term, although the complication rate can be significant. The procedure should be performed in specialist units. Revision in 2 stages for sepsis resulted in satisfactory control of infection in our study.

In the National Health Service although some units perform ACL reconstruction as a day case, others continue to admit patient’s overnight due to a possible medicolegal implication of complication including postoperative pain, nausea and vomiting and urinary retention. The aim of this study is to assess the safety, efficacy of post operative pain control, cost effectiveness of the day case procedure and the role of extended acute ‘hospitalcare in the community’ by a Rapid Response Team.

We carried out a retrospective review of data of fifty-seven patients who underwent day case ACL reconstruction with pre-emptive analgesia and postoperative pain control with analgesics and non-steroidal anti-inflammatory drugs. Rapid Response Team consisting of qualified nurses who provide intensive level of nursing cares in-patients home provided the postoperative community care. Aim of this team is to reduce the pressure of acute hospital beds.

Out of fifty-seven patients, adequate pain relief was achieved in 92.8%. One patient needed admission for pain relief, one patient needed admission for excessive bleeding and five patients had nausea and vomiting. Cost analysis showed that ACL reconstruction is cost effective. We conclude that ACL reconstruction is a safe procedure provided attention is given to patient selection, preadmission screening, patient education, preemptive analgesia with appropriate pain management and post operative community care.

Kneeling is an important aspect of daily living. Our goal was to describe the in vivo tibiofemoral kinematics during standing and kneeling after total knee arthroplasty (TKA).

Ten posterior substituting (PS) and 10 cruciate retaining (CR) TKA designs were studied in 18 patients. Radiographs were taken when standing, kneeling at 90°, and kneeling at maximal flexion. An image matching technique provided three-dimensional measurements of the femoral component position relative to the AP midpoint of the tibial baseplate.

When standing, the CR tibiofemoral contact position (medial: 7 mm ± 3; lateral: 6 mm ± 3) was more posterior than the PS design (medial: 5 mm ± 2; lateral: 5 mm ± 2). Movement from standing to kneeling at 90° produced different responses. CR knees translated anteriorly (medial: 4 mm ± 4; lateral: 2 mm ± 6), while PS knees translated posteriorly (medial: 0.2 mm ± 3; lateral: 1 mm ± 4). During kneeling, movement from 90° to maximum flexion produced posterior translation of the femur (CR medial: 5 mm ± 4: CR lateral: 5 mm ± 4; PS medial: 6 mm ± 4; PS lateral: 6 mm ± 3). The relationship between the tibiofemoral contact position and flexion angle during kneeling was more variable for CR knees (r2=0.38) than PS knees (r2=0.64), indicating that PS knees provide a more reliable AP position than CR knees.

PS knees dislocate when the arch of the femoral cam slides over the tibial post; CR knees sublux when the femoral contact position translates beyond the edge of the tibial baseplate. The distance to dislocation averaged 13 mm ± 2 for PS knees, and 20 mm±4 for CR knees.

Many patients wish to resume normal activities, including kneeling after TKA. This study provides information for surgeons and patients considering kneeling after TKA.