Aims

To evaluate the concurrent use of vancomycin and ε-aminocaproic acid (EACA) in primary total hip arthroplasty (THA).

Aims. Over time, the locking mechanism of Modular Universal Tumour and Revision System (MUTARS) knee arthroplasties changed from polyethylene (PE) to polyether-ether-ketone Optima (PEEK) and metal-on-metal (MoM) in an attempt to reduce the risk of mechanical failure. In this study, we aimed to assess the cumulative incidence of locking mechanism revision for symptomatic instability by type of material, and assess potential associated risk factors. Methods. The MUTARS Orthopaedic Registry Europe was used for a retrospective review of 316 patients (54% male (n = 170), median age 44 years (IQR 23 to 61)) who underwent a MUTARS knee arthroplasty for oncological indications between December 1995 and January 2023. The minimum follow-up was 12 months, and the median follow-up was 7.9 years (IQR 3.3 to 13.0). A competing risk model was used to estimate the cumulative incidence of first locking mechanism revision with death and revision for any other reason as competing events. Possible risk factors were assessed employing a univariate cause-specific hazards regression model. Results. Symptomatic instability of the hinge or locking mechanism due to wear (n = 20) or breakage (n = 14) occurred in 34 patients (11%): 9% of PE (n = 4/45), 20% of PEEK (n = 9/44), and 9% of MoM locking mechanisms (n = 21/227). The cumulative incidences of revision for instability due to wear or locking mechanism breakage at two, five, and ten years were 0%, 5% (95% CI 1 to 15), and 5% (95% CI 1 to 15) for PE, 5% (95% CI 1 to 14), 14% (95% CI 5 to 26), and 16% (95% CI 7 to 29) for PEEK, and 0%, 3% (95% CI 1 to 6), and 10% (95% CI 5 to 16) for MoM. With PE as the reference category, the cause-specific hazard ratio for PEEK and MoM were 3.6 (95% CI 1.1 to 11.9; p = 0.036) and 3.2 (95% CI 1.1 to 9.5; p = 0.043), respectively. Age, BMI, resection length, and extra-articular resections were not associated with the time to locking mechanism revision. Conclusion. Alterations in prosthetic materials have not decreased the revision risk for locking mechanism failure. Besides locking mechanism material, no other patient- or prosthesis-related risk factors for locking mechanism failure were identified. Improvement of the locking mechanism is warranted since revision exposes patients to the risk of serious secondary complications. Cite this article: Bone Joint J 2025;107-B(2):239–245

Aims. Tibial fixation in revision total knee arthroplasty (rTKA) can present surgical challenges. It has been suggested that appropriate fixation in at least two of the three anatomical zones (epiphysis, metaphysis, and diaphysis) is essential for implant survival. However, supporting clinical data are lacking. In this retrospective case-control study, we investigated the relationship between zonal fixation of hybrid rTKA tibial components and re-revision total knee arthroplasty for aseptic loosening (rrTKA-AL). Methods. All consecutive rTKAs with hybrid tibial components (May 2006 to December 2020) were screened for subsequent rrTKA-AL. A control group was randomly selected from the remaining cohort. Postoperative radiographs of rTKAs were scored in random order by three blinded observers for zonal fixation in the epiphysis (bone resection level below, at, or above fibular head; 0 to 2), metaphysis (number of sufficiently cemented zones; 0 to 4), and diaphysis (canal filling ratio (CFR); %). The intraclass correlation coefficient (ICC) was calculated to quantify the agreement between observers. Multivariate logistic regression analysis was performed to assess the relationship between zonal fixation and rrTKA-AL. Results. Overall, 33 patients underwent a further rrTKA-AL from a total of 1,173 rTKAs where hybrid tibial components (2.8%) were used. Patients requiring rrTKA-AL had a significantly lower epiphyseal bone resection level (OR 0.43; 95% CI 0.23 to 0.76; p = 0.006), lower number of adequately cemented zones (OR 0.50; 95% CI 0.30 to 0.79; p = 0.004), but no difference in CFR (p = 0.858). Furthermore, patients needing rrTKA-AL had more frequently previous revisions (p = 0.047), a higher rate of a prior use of a stemmed tibial component (p = 0.011), and a higher Anderson Orthopaedic Research Institute classification (p < 0.001). Agreement of zonal fixation between observers was good (ICC 0.79 to 0.87). Conclusion. Patients in need of subsequent rrTKA-AL had lower epiphyseal bone resection levels and a lower number of sufficiently metaphyseal cemented zones following rTKA. These results emphasize the importance of appropriate metaphyseal fixation at rTKA. With this information, orthopaedic surgeons can identify patients at greater risk for rrTKA-AL and optimize their surgical technique in revision knee arthroplasty surgery. Cite this article: Bone Joint J 2025;107-B(1):65–71

Aims. Prolonged waits for hip and knee arthroplasty have raised questions about the equity of current approaches to waiting list prioritization for those awaiting surgery. We therefore set out to understand key stakeholder (patient and surgeon) preferences for the prioritization of patients awaiting such surgery, in order to guide future waiting list redesign. Methods. A combined qualitative/quantitative approach was used. This comprised a Delphi study to first inform which factors patients and surgeons designate as important for prioritization of patients on hip and knee arthroplasty waiting lists, followed by a discrete choice experiment (DCE) to determine how the factors should be weighed against each other. Coefficient values for each included DCE attribute were used to construct a ‘priority score’ (weighted benefit score) that could be used to rank individual patients waiting for surgery based on their respective characteristics. Results. In total, 43 people participated in the initial round of the Delphi study (16 patients and 27 surgeons), with a 91% completion rate across all three rounds. Overall, 73 surgeons completed the DCE. Following the final consensus meeting of the Delphi component, the seven final factors designated for inclusion were Pain, Mobility/Function, Activities of Daily Living, Inability to Work/Care, Length of Time Waited, Radiological Severity, and Mental Wellbeing. Output from the adjusted multinomial regression revealed radiological severity to be the most significant factor (coefficient 2.27 (SD 0.31); p < 0.001), followed by pain (coefficient 1.08 (SD 0.13); p < 0.001) and time waited (coefficient for one month additional wait 0.12 (SD 0.02); p < 0.001). Conclusion. These results present a new robust method for determining comparative priority for those on primary hip and knee hip arthroplasty waiting lists. Evaluation of potential implementation in clinical practice is now required. Cite this article: Bone Joint J 2025;107-B(1):89–96

Aims. The Clavien-Dindo (CD) classification and Comprehensive Complication Index (CCI) have been validated primarily among general surgical procedures. To date, the validity of these measures has not been assessed in patients undergoing arthroplasty. Methods. This retrospective cohort study included patients undergoing primary total hip and knee arthroplasty between April 2013 and December 2019. Complications within 90 days of surgery were graded using the CD classification and converted to CCI. Validity was established by assessing the association between both measures and discharge to inpatient rehabilitation, length of stay, and costs. Results. Among 2,884 patients, 414 (14.4%) had an in-hospital complication and 643 (22.3%) had a complication within 90 days. Each increase in CD grade was associated with USD$1,895.48 (95% CI 1,734.77 to 2,056.18) of additional costs, an additional 1.24 days’ length of stay (95% CI 1.15 to 1.33), and 43% (95% CI 26 to 62%) greater odds of discharge to inpatient rehabilitation. Each ten-unit increase in CCI score was associated with USD$1,698.55 (95% CI 1,561.8 to 1,835.3) higher costs, an additional 1.09 days’ length of stay (95% CI 1.02 to 1.17), and 33% (95% CI 19% to 49%) greater odds of discharge to inpatient rehabilitation. Conclusion. Both the CD classification and CCI appear valid and applicable to patients undergoing total joint replacement. Cite this article: Bone Joint J 2025;107-B(1):81–88

Aims

The aim of this study was to perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted medial unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).

Aims

Surgeon and patient reluctance to participate are potential significant barriers to conducting placebo-controlled trials of orthopaedic surgery. Understanding the preferences of orthopaedic surgeons and patients regarding the design of randomized placebo-controlled trials (RCT-Ps) of knee procedures can help to identify what RCT-P features will lead to the greatest participation. This information could inform future trial designs and feasibility assessments.

Aims. Approximately 10% to 20% of knee arthroplasty patients are not satisfied with the result, while a clear indication for revision surgery might not be present. Therapeutic options for these patients, who often lack adequate quadriceps strength, are limited. Therefore, the primary aim of this study was to evaluate the clinical effect of a novel rehabilitation protocol that combines low-load resistance training (LL-RT) with blood flow restriction (BFR). Methods. Between May 2022 and March 2024, we enrolled 45 dissatisfied knee arthroplasty patients who lacked any clear indication for revision to this prospective cohort study. All patients were at least six months post-surgery and had undergone conventional physiotherapy previously. The patients participated in a supervised LL-RT combined with BFR in 18 sessions. Primary assessments included the following patient-reported outcome measures (PROMs): Knee injury and Osteoarthritis Outcome Score (KOOS); Knee Society Score: satisfaction (KSSs); the EuroQol five-dimension five-level questionnaire (EQ-5D-5L); and the pain catastrophizing scale (PCS). Functionality was assessed using the six-minute walk Test (6MWT) and the 30-second chair stand test (30CST). Follow-up timepoints were at baseline, six weeks, three months, and six months after the start. Results. Six weeks of BFR with LL-RT improved all the PROMs except the sports subscale of the KOOS compared to baseline. Highest improvements after six weeks were found for quality of life (QoL) (mean 28.2 (SD 17.2) vs 19 (SD 14.7); p = 0.002), activities of daily living (mean 54.7 (SD 18.7) vs 42.9 (SD 17.3); p < 0.001), and KSSs (mean 17.1 (SD 8.8) vs 12.8 (SD 6.7); p < 0.001). PROMs improvements continued to be present at three-month and six-month follow-up compared to baseline. However, no significant differences were observed in the paired comparisons of the six-week, three-month, and six-month follow-up. The same trends are observed for the 6MWT and 30CST. Conclusion. The reported regime demonstrates improved QoL and function of dissatisfied knee arthroplasty patients. In light of this, the pathway described may provide a valuable and safe treatment option for dissatisfied knee arthroplasty patients for whom therapeutic options are limited. Cite this article: Bone Joint J 2024;106-B(12):1416–1425

Aims

Cutibacterium acnes (C. acnes; previously known as Propionibacterium acnes or P. acnes) periprosthetic hip and knee infections are under-reported. While culture contamination with C. acnes occurs, true infections are important to recognize and treat. We sought to describe the demographics and treatment outcomes of patients with C. acnes periprosthetic joint infections (PJIs) of the hip and knee.

Aims

A recent study used the RAND Corporation at University of California, Los Angeles (RAND/UCLA) method to develop anatomical total shoulder arthroplasty (aTSA) appropriateness criteria. The purpose of our study was to determine how patient-reported outcome measures (PROMs) vary based on appropriateness.

Aims

Day-case knee and hip replacement, in which patients are discharged on the day of surgery, has been gaining popularity during the last two decades, and particularly since the COVID-19 pandemic. This systematic review presents the evidence comparing day-case to inpatient-stay surgery.

Aims

The aim of this audit was to assess and improve the completeness and accuracy of the National Joint Registry (NJR) dataset for arthroplasty of the elbow.

As advancements in total knee arthroplasty progress at an exciting pace, two areas are of special interest, as they directly impact implant design and surgical decision making. Knee morphometry considers the three-dimensional shape of the articulating surfaces within the knee joint, and knee phenotyping provides the ability to categorize alignment into practical groupings that can be used in both clinical and research settings. This annotation discusses the details of these concepts, and the ways in which they are helping us better understand the individual subtleties of each patient’s knee.

Cite this article: Bone Joint J 2024;106-B(12):1363–1368.

Aims

The aim of this study was to review the provision of total elbow arthroplasties (TEAs) in England, including the incidence, the characteristics of the patients and the service providers, the types of implant, and the outcomes.

Aims

Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

Aims

Our aim was to estimate the total costs of all hospitalizations for treating periprosthetic joint infection (PJI) by main management strategy within 24 months post-diagnosis using activity-based costing. Additionally, we investigated the influence of individual PJI treatment pathways on hospital costs within the first 24 months.