Aims

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up.

Aims. Meniscal injuries are common and often induce knee pain requiring surgical intervention. To develop effective strategies for meniscus regeneration, we hypothesized that a minced meniscus embedded in an atelocollagen gel, a firm gel-like material, may enhance meniscus regeneration through cell migration and proliferation in the gel. Hence, the objective of this study was to investigate cell migration and proliferation in atelocollagen gels seeded with autologous meniscus fragments in vitro and examine the therapeutic potential of this combination in an in vivo rabbit model of massive meniscus defect. Methods. A total of 34 Japanese white rabbits (divided into defect and atelocollagen groups) were used to produce the massive meniscus defect model through a medial patellar approach. Cell migration and proliferation were evaluated using immunohistochemistry. Furthermore, histological evaluation of the sections was performed, and a modified Pauli’s scoring system was used for the quantitative evaluation of the regenerated meniscus. Results. In vitro immunohistochemistry revealed that the meniscus cells migrated from the minced meniscus and proliferated in the gel. Furthermore, histological analysis suggested that the minced meniscus embedded in the atelocollagen gel produced tissue resembling the native meniscus in vivo. The minced meniscus group also had a higher Pauli’s score compared to the defect and atelocollagen groups. Conclusion. Our data show that cells in minced meniscus can proliferate, and that implantation of the minced meniscus within atelocollagen induces meniscus regeneration, thus suggesting a novel therapeutic alternative for meniscus tears. Cite this article: Bone Joint Res 2021;10(4):269–276

Aims. Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). Methods. We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. Results. A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. Conclusion. This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients. Level of evidence: IV. Cite this article: Bone Joint Open 2020;2(1):3–8

Aims

Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties.

Aims

Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients.

Aims

Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasty (TKA). However, if the diaphysis has been previously violated, the resultant sclerotic canal can impair cemented stem fixation, which is vital for bone ingrowth into the cone, and long-term fixation. We report the outcomes of our solution to this problem, in which impaction grafting and a cemented stem in the diaphysis is combined with an uncemented metaphyseal cone, for revision TKA in patients with severely compromised bone.

Aims

The purpose of this study was to determine the impact of the removal of total knee arthroplasty (TKA) from the Medicare Inpatient Only (IPO) list on our Bundled Payments for Care Improvement (BPCI) Initiative in 2018.

Aims

The treatment of patients with allergies to metal in total joint arthroplasty is an ongoing debate. Possibilities include the use of hypoallergenic prostheses, as well as the use of standard cobalt-chromium (CoCr) alloy. This non-designer study was performed to evaluate the clinical outcome and survival rates of unicondylar knee arthroplasty (UKA) using a standard CoCr alloy in patients reporting signs of a hypersensitivity to metal.

Fractures around total knee arthroplasties pose a significant surgical challenge. Most can be managed with osteosynthesis and salvage of the replacement. The techniques of fixation of these fractures and revision surgery have evolved and so has the assessment of outcome. This specialty update summarises the current evidence for the classification, methods of fixation, revision surgery and outcomes of the management of periprosthetic fractures associated with total knee arthroplasty.

Cite this article: Bone Joint J 2016;98-B:1489–96.

Structural allografts may be used to manage uncontained bone defects in revision total knee replacement (TKR). However, the availability of cadaver grafts is limited in some areas of Asia. The aim of this study was to evaluate the mid-term outcome of the use of femoral head allografts for the reconstruction of uncontained defects in revision TKR, focusing on complications related to the graft.

We retrospectively reviewed 28 patients (30 TKRs) with Anderson Orthopaedic Research Institute (AORI) type 3 bone defects, who underwent revision using femoral head allografts and stemmed components. The mean number of femoral heads used was 1.7 (1 to 3). The allograft–host junctions were packed with cancellous autograft.

At a mean follow-up of 76 months (38 to 136) the mean American Knee Society knee score improved from 37.2 (17 to 60) pre-operatively to 90 (83 to 100) (p < 0.001). The mean function score improved from 26.5 (0 to 50) pre-operatively to 81 (60 to 100) (p < 0.001). All the grafts healed to the host bone. The mean time to healing of the graft was 6.6 months (4 to 16). There have been no complications of collapse of the graft, nonunion, infection or implant loosening. No revision surgery was required.

The use of femoral head allografts in conjunction with a stemmed component and autogenous bone graft in revision TKR in patients with uncontained bone defects resulted in a high rate of healing of the graft with minimal complications and a satisfactory outcome. Longer follow-up is needed to observe the evolution of the graft.

Cite this article: Bone Joint J 2013;95-B:643–8.

Improvements in the surgical technique of total knee replacement (TKR) are continually being sought. There has recently been interest in three-dimensional (3D) pre-operative planning using magnetic resonance imaging (MRI) and CT. The 3D images are increasingly used for the production of patient-specific models, surgical guides and custom-made implants for TKR.

The users of patient-specific instrumentation (PSI) claim that they allow the optimum balance of technology and conventional surgery by reducing the complexity of conventional alignment and sizing tools. In this way the advantages of accuracy and precision claimed by computer navigation techniques are achieved without the disadvantages of additional intra-operative inventory, new skills or surgical time.

This review describes the terminology used in this area and debates the advantages and disadvantages of PSI.

Disruption of the extensor mechanism in total knee arthroplasty may occur by tubercle avulsion, patellar or quadriceps tendon rupture, or patella fracture, and whether occurring intra-operatively or post-operatively can be difficult to manage and is associated with a significant rate of failure and associated complications. This surgery is frequently performed in compromised tissues, and repairs must frequently be protected with cerclage wiring and/or augmentation with local tendon (semi-tendinosis, gracilis) which may also be used to treat soft-tissue loss in the face of chronic disruption. Quadriceps rupture may be treated with conservative therapy if the patient retains active extension. Component loosening or loss of active extension of 20° or greater are clear indications for surgical treatment of patellar fracture. Acute patellar tendon disruption may be treated by primary repair. Chronic extensor failure is often complicated by tissue loss and retraction can be treated with medial gastrocnemius flaps, achilles tendon allografts, and complete extensor mechanism allografts. Attention to fixing the graft in full extension is mandatory to prevent severe extensor lag as the graft stretches out over time.

Most problems encountered in complex revision total knee arthroplasty can be managed with the wide range of implant systems currently available. Modular metaphyseal sleeves, metallic augments and cones provide stability even with significant bone loss. Hinged designs substitute for significant ligamentous deficiencies. Catastrophic failure that precludes successful reconstruction can be encountered. The alternatives to arthroplasty in such drastic situations include knee arthrodesis, resection arthroplasty and amputation. The relative indications for the selection of these alternatives are recurrent deep infection, immunocompromised host, and extensive non-reconstructible bone or soft-tissue defects.

Patient-reported outcome measures (PROMs) are increasingly being used to assess functional outcome and patient satisfaction. They provide a framework for comparisons between surgical units, and individual surgeons for benchmarking and financial remuneration. Better performance may bring the reward of more customers as patients and commissioners seek out high performers for their elective procedures. Using National Joint Registry (NJR) data linked to PROMs we identified 22 691 primary total knee replacements (TKRs) undertaken for osteoarthritis in England and Wales between August 2008 and February 2011, and identified the surgical factors that influenced the improvements in the Oxford knee score (OKS) and EuroQol-5D (EQ-5D) assessment using multiple regression analysis. After correction for patient factors the only surgical factors that influenced PROMs were implant brand and hospital type (both p < 0.001). However, the effects of surgical factors upon the PROMs were modest compared with patient factors. For both the OKS and the EQ-5D the most important factors influencing the improvement in PROMs were the corresponding pre-operative score and the patient’s general health status. Despite having only a small effect on PROMs, this study has shown that both implant brand and hospital type do influence reported subjective functional scores following TKR. In the current climate of financial austerity, proposed performance-based remuneration and wider patient choice, it would seem unwise to ignore these effects and the influence of a range of additional patient factors.

This review summarises the opinions and conclusions reached from a symposium on infected total knee replacement (TKR) held at the British Association of Surgery of the Knee (BASK) annual meeting in 2011. The National Joint Registry for England and Wales reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused by infection. The diagnosis of infection beyond the acute post-operative stage relies on the identification of the causative organism by aspiration and analysis of material obtained at arthroscopy. Ideal treatment then involves a two-stage surgical procedure with extensive debridement and washout, followed by antibiotics. An articulating or non-articulating drug-eluting cement spacer is used prior to implantation of the revision prosthesis, guided by the serum level of inflammatory markers. The use of a single-stage revision is gaining popularity and we would advocate its use in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no radiological evidence of component loosening or osteitis.

It is our opinion that single-stage revision produces high-quality reproducible results and will soon achieve the same widespread acceptance as it does in infected hip arthroplasty.

We have previously developed a radiographic technique, the oblique posterior condylar view, for assessment of the posterior aspect of the femoral condyles after total knee arthroplasty. The purpose of this study was to confirm the validity of this radiographic view based upon intra-operative findings at revision total knee arthroplasty. Lateral and oblique posterior condylar views were performed for 11 knees prior to revision total knee arthroplasty, and radiolucent lines or osteolysis of the posterior aspect of the femoral condyles were identified. These findings were compared with the intra-operative appearance of the posterior aspects of the femoral condyles. Statistical analysis showed that sensitivity and efficacy were significantly better for the oblique posterior condylar than the lateral view. This method can, therefore, be considered as suitable for routine follow-up radiographs of the femoral component and in the pre-operative planning of revision surgery.

We investigated the changes in surface roughness of retrieved femoral components in 18 men and four women at revision knee surgery. The mean age at revision was 68.4 years and the mean period of implantation was for 55.6 months. Eighteen implants were retrieved for aseptic loosening and four for infection. The surface changes in the articulating areas were inspected visually and the roughness (Ra) analysed with a profilometer. Parallel scratching and burnishing were the two main forms of damage. The mean Ra measurements in the articulating areas showed no statistically significant difference when compared with those in a control area on either side of the patellar groove at the apex of the femoral flange. This suggests that it is not essential to revise a well-fixed and correctly aligned femoral component where the polished surface has become burnished or bears fine parallel scratches, if the revision is conducted solely for failure of the tibial component.