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

Aims

Varus-valgus constrained (VVC) implants are often used during revision total knee arthroplasty (TKA) to gain coronal plane stability. However, the increased mechanical torque applied to the bone-cement interface theoretically increases the risk of aseptic loosening. We assessed mid-term survivorship, complications, and clinical outcomes of a fixed-bearing VVC device in revision TKAs.

Aims

Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA. The purpose of this multicentre randomized clinical trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA.

Aims

There are comparatively few randomized studies evaluating knee arthroplasty prostheses, and fewer still that report longer-term functional outcomes. The aim of this study was to evaluate mid-term outcomes of an existing implant trial cohort to document changing patient function over time following total knee arthroplasty using longitudinal analytical techniques and to determine whether implant design chosen at time of surgery influenced these outcomes.

Between April 2004 and July 2007, we performed 241 primary total knee replacements in 204 patients using the e.motion posterior cruciate-retaining, multidirectional mobile-bearing prosthesis. Of these, 100 were carried out using an image-free navigation system, and the remaining 141 with the conventional technique. We conducted a retrospective study from the prospectively collected data of these patients to assess the early results of this new mobile-bearing design. At a mean follow-up of 49 months (32 to 71), 18 knees (7.5%) had mechanical complications of which 13 required revision. Three of these had a peri-prosthetic fracture, and were removed from the study. The indication for revision in the remaining ten was loosening of the femoral component in two, tibiofemoral dislocation in three, disassociation of the polyethylene liner in four, and a broken polyethyene liner in one. There were eight further mechanically unstable knees which presented with recurrent disassociation of the polyethylene liner. There was no significant difference in the incidence of mechanical instability between the navigation-assisted procedures (8 of 99, 8.1%) and the conventionally implanted knees (10 of 139, 7.2%). In our view, the relatively high rate of mechanical complications and revision within 30 months precludes the further use of new design of knee replacement

Aims

Anterior cruciate ligament (ACL) and multiligament knee (MLK) injuries increase the risk of development of knee osteoarthritis and eventual need for total knee arthroplasty (TKA). There are limited data regarding implant use and outcomes in these patients. The aim of this study was to compare the use of constrained implants and outcomes among patients undergoing TKA with a history of prior knee ligament reconstruction (PKLR) versus a matched cohort of patients undergoing TKA with no history of PKLR.

Aims

Our unit was identified as a negative outlier in the national patient-reported outcome measures (PROMs) programme, which has significant funding implications. As a centre that carries out a high volume of unicompartmental knee arthroplasty (UKA), our objectives were: 1) to determine whether the PROMs programme included primary UKA when calculating the gain in Oxford Knee Score (OKS); and 2) to determine the impact of excluding primary UKA on calculated OKS gains for primary knee arthroplasty.

In Scotland, the number of primary total knee replacements performed annually has been increasing steadily. The price of the implant is fixed but the length of hospital stay is variable. We prospectively investigated all patients who underwent primary unilateral total knee replacement in the Scottish region of Fife, between December 1994 and February 2007 and assessed their recorded pre-operative details. The data were analysed using univariate and multiple linear regression statistical analysis. Data on the length of stay were available from a total of 2106 unilateral total knee replacements. The median length of hospital stay was eight days. The significant pre-operative risk factors for an increased length of stay were the year of admission, details of the consultant looking after the patient, the stair score, the walking-aid score and age. Awareness of the pre-operative factors which increase the length of hospital stay may provide the opportunity to influence them favourably and to reduce the time in hospital and the associated costs of unilateral total knee replacement

The lateral subvastus approach combined with an osteotomy of the tibial tubercle is a recognised, but rarely used approach for total knee replacement (TKR). A total of 32 patients undergoing primary TKR was randomised into two groups, in one of which the lateral subvastus approach combined with a tibial tubercle osteotomy and in the other the medial parapatellar approach were used. The patients were assessed radiologically and clinically using measurement of the range of movement, a visual analogue patient satisfaction score, the Western Ontario McMasters University Osteoarthritis Index and the American Knee Society score. Four patients were lost to the complete follow-up at two years. At two years there were no significant differences between the groups in any of the parameters for clinical outcome. In the lateral approach group there was one complication due to displacement of the tibial tubercle osteotomy and two osteotomies took more than six months to unite. In the medial approach group, one patient had a partial tear of the quadriceps. There was a significantly greater incidence of lateral patellar subluxation in the medial approach group (3 of 12) compared with the lateral approach group (0 of 16) (p = 0.034), but without any apparent clinical detriment. We conclude that the lateral approach with tibial tubercle osteotomy is a safe technique with an outcome comparable with that of the medial parapatellar approach for TKR, but the increased surgical time and its specific complications do not support its routine use. It would seem to be more appropriate to reserve this technique for patients in whom problems with patellar tracking are anticipated

Aims

Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation.

To assess migration of the tibial component we used roentgen stereophotogrammetric analysis in 40 patients who had had a total knee arthroplasty after failure of a closing wedge osteotomy and compared them with 40 matched patients after primary total knee arthroplasty. We found no difference in migration over time or in the tendency for continuous migration between the two groups. There were no differences in alignment or position of the knee prosthesis or in the clinical outcome. Our findings show that revision of a failed high tibial osteotomy to a total knee arthroplasty is effective

Aims

Unicompartmental knee arthroplasty (UKA) provides improved early functional outcomes and less postoperative morbidity and pain compared with total knee arthroplasty (TKA). Opioid prescribing has increased in the last two decades, and recently states in the USA have developed online Prescription Drug Monitoring Programs to prevent overprescribing of controlled substances. This study evaluates differences in opioid requirements between patients undergoing TKA and UKA.

The Kinematic Stabilizer is a posterior-cruciate-substituting design of total knee replacement. We have reviewed 109 primary total knee replacements in 95 patients at a mean follow-up time of 12.7 years (10 to 14). We used survival analysis with failure defined as revision of the implant. This gave a cumulative survival rate of 95% (95% CI± 5%) at ten years and 87% (± 10%) at 13 years. These results from an independent centre confirm the value of an established design of cemented total knee replacement and question the wisdom of the introduction of modifications and new designs without properly controlled trials

Aims

It is unknown whether kinematic alignment (KA) objectively improves knee balance in total knee arthroplasty (TKA), despite this being the biomechanical rationale for its use. This study aimed to determine whether restoring the constitutional alignment using a restrictive KA protocol resulted in better quantitative knee balance than mechanical alignment (MA).

Aims

There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome.

We have reviewed nine patients with Parkinson's disease who had 12 primary total knee arthroplasties and one revision. Deformities were corrected by conventional techniques and semi-constrained resurfacing arthroplasties were used. Follow-up ranged from two to eight years (average 4.3 years). Nine of the 12 primary arthroplasties were rated as excellent by the Hospital for Special Surgery knee score system, and three were rated as good. Contrary to previous reports, we feel that total knee arthroplasty performed on patients with Parkinson's disease, is a highly satisfactory procedure, alleviating knee pain and improving function

A technique for performing allograft-augmented revision total knee replacement (TKR) using computer assistance is described, on the basis of the results in 14 patients. Bone deficits were made up with impaction grafting. Femoral grafting was made possible by the construction of a retaining wall or dam which allowed pressurisation and retention of the graft. Tibial grafting used a mixture of corticocancellous and morsellised allograft. The position of the implants was monitored by the computer system and adjusted while the cement was setting. The outcome was determined using a six-parameter, quantitative technique (the Perth CT protocol) which measured the alignment of the prosthesis and provided an objective score. The final outcomes were not perfect with errors being made in femoral rotation and in producing a mismatch between the femoral and tibial components. In spite of the shortcomings the alignments were comparable in accuracy with those after primary TKR. Computer assistance shows considerable promise in producing accurate alignment in revision TKR with bone deficits