One hundred and three sequential Stanmore knee replacements were reviewed retrospectively on two occasions with a maximal follow-up period of nine years three months. This knee prosthesis, which is hinged, was successful in alleviating pain, stabilising an unstable knee and modestly increasing the arc of flexion. Walking capacity was increased and flexion contractures were reduced. There were seven cases of infection and four of fracture around the prosthesis. All these proved difficult to treat and two knees with both fracture and infection needed amputation. Eight knees were revised for aseptic loosening and a further 14 were found to have radiological signs of loosening. The results have been analysed by the methods advocated by Tew and Waugh and give a cumulative success rate of 80 per cent at seven years, provided success is judged solely by whether the prosthesis is still in situ. The role of the Stanmore knee as a primary arthroplasty is discussed.

Aims. Simultaneous bilateral total knee arthroplasty (TKA) has been used due to its financial advantages, overall resource usage, and convenience for the patient. The training model where a trainee performs the first TKA, followed by the trainer surgeon performing the second TKA, is a unique model to our institution. This study aims to analyze the functional and clinical outcomes of bilateral simultaneous TKA when performed by a trainee or a supervising surgeon, and also to assess these outcomes based on which side was done by the trainee or by the surgeon. Methods. This was a retrospective cohort study of all simultaneous bilateral TKAs performed by a single surgeon in an academic institution between May 2003 and November 2017. Exclusion criteria were the use of partial knee arthroplasty procedures, staged bilateral procedures, and procedures not performed by the senior author on one side and the trainee on another. Primary clinical outcomes of interest included revision and re-revision. Primary functional outcomes included the Oxford Knee Score (OKS) and patient satisfaction scores. Results. In total, 315 patients (630 knees) were included for analysis. Of these, functional scores were available for 189 patients (378 knees). There was a 1.9% (n = 12) all-cause revision rate for all knees. Overall, 12 knees in ten patients were revised, and both right and left knees were revised in two patients. The OKS and patient satisfaction scores were comparable for trainees and supervising surgeons. A majority of patients (88%, n = 166) were either highly likely (67%, n = 127) or likely (21%, n = 39) to recommend bilateral TKAs to a friend. Conclusion. Simultaneous bilateral TKA can be used as an effective teaching model for trainees without any significant impact on patient clinical or functional outcomes. Excellent functional and clinical outcomes in both knees, regardless of whether the performing surgeon is a trainee or supervising surgeon, can be achieved with simultaneous bilateral TKA. Cite this article: Bone Jt Open 2022;3(1):29–34

The February 2023 Research Roundup. 360. looks at: Clinical and epidemiological features of scaphoid fracture nonunion; Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh); Characterization of genetic risk of end-stage knee osteoarthritis treated with total knee arthroplasty; Platelet-rich plasma or autologous blood injection for plantar fasciitis; Volume and outcomes of joint arthroplasty; The hazards of absolute belief in the p-value laid bare

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. Methods. This study used two discrete choice experiments (DCEs) to determine which features of RCT-Ps of knee procedures influence surgeon and patient participation. A mixed-methods approach informed the DCE development. The DCEs were analyzed with a baseline category multinomial logit model. Results. The proportion of respondents (surgeons n = 103; patients n = 140) who would not participate in any of the DCE choice sets (surgeons = 31%; patients = 40%), and the proportion who would participate in all (surgeons = 18%; patients = 30%), indicated strong views regarding the conduct of RCT-Ps. There were three main findings: for both surgeons and patients, studies which involved an arthroscopic procedure were more likely to result in participation than those with a total knee arthroplasty; as the age (for patients) and years of experience (for surgeons) increased, the overall likelihood of participation decreased; and, for surgeons, offering authorship and input into the RCT-P design was preferred for less experienced surgeons, while only completing the procedure was preferred by more experienced surgeons. Conclusion. Patients and surgeons have strong views regarding participation in RCT-Ps. However, understanding their preferences can inform future trial designs and feasibility assessments with regard to recruitment rates. Cite this article: Bone Joint J 2024;106-B(12):1408–1415

We performed a prospective study of 54 patients (76 knees) who underwent Osteonics series 3000 cruciate-retaining cementless total knee arthroplasty between December 1990 and June 1993. Five patients (seven knees) were lost to follow-up (90.7% completion). One patient required revision at 10.5 years after operation.

The rate of survival was 100% at ten years and 96.7% at 13 years. The mean ten-year knee and function scores were 79 and 59 respectively. Both were significantly better than the pre-operative scores. The range of movement also improved. Although a radiolucent line around the tibial component enlarged in six knees (20.7%) at ten years, the clinical outcome was generally good. In a patient who died after 5.5 years, post-mortem examination of the knee showed no bony ingrowth into the tibial component. Despite poor bony ingrowth, press-fit fixation was satisfactory and good results can be obtained with this cementless, cruciate-retaining prosthesis.

Aims. This study aims to describe the pre- and postoperative self-reported health and quality of life from a national cohort of patients undergoing elective total conventional hip arthroplasty (THA) and total knee arthroplasty (TKA) in Australia. For context, these data will be compared with patient-reported outcome measures (PROMs) data from other international nation-wide registries. Methods. Between 2018 to 2020, and nested within a nationwide arthroplasty registry, preoperative and six-month postoperative PROMs were electronically collected from patients before and after elective THA and TKA. There were 5,228 THA and 8,299 TKA preoperative procedures as well as 3,215 THA and 4,982 TKA postoperative procedures available for analysis. Validated PROMs included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L; range 0 to 100; scored worst-best health), Oxford Hip/Knee Scores (OHS/OKS; range 0 to 48; scored worst-best hip/knee function) and the 12-item Hip/Knee disability and Osteoarthritis Outcome Score (HOOS-12/KOOS-12; range 0 to 100; scored best-worst hip/knee health). Additional items included preoperative expectations, patient-perceived improvement, and postoperative satisfaction. Descriptive analyses were undertaken. Results. For THA and TKA patients respectively, the patient profile was 2,850 (54.5%) and 4,684 (56.4%) female, mean age 66.8 years (SD 10.6) and 67.5 (SD 8.8), and mean BMI 29.9 kg/m. 2. (SD 7.7) and 32.5 kg/m. 2. (SD 7.0). The proportion of THA and TKA patients who reported their joint as ‘much better’ was 2,946 (92.6%) and 4,020 (81.6%) respectively, and the majority of patients were ‘satisfied’ or ‘very satisfied’ with their procedure (2,754 (86.5%) and 3,981 (80.8%)). There were 311 (9.7%) of THA patients and 516 (10.5%) of TKA patients who reported ‘dissatisfied’ or ‘very dissatisfied’ with their surgery. Conclusion. Large improvements in pain, function, and overall health were evident following primary THA and TKA. Approximately 10% of patients reported dissatisfaction with their surgery. Future analyses will focus on factors contributing to dissatisfaction after arthroplasty. Cite this article: Bone Jt Open 2021;2(6):422–432

Aims. Revision total knee arthroplasty (rTKA) is a technically challenging and costly procedure. It is well-documented that primary TKA (pTKA) have better survivorship than rTKA; however, we were unable to identify any studies explicitly investigating previous rTKA as a risk factor for failure following rTKA. The purpose of this study is to compare the outcomes following rTKA between patients undergoing index rTKA and those who had been previously revised. Methods. This retrospective, observational study reviewed patients who underwent unilateral, aseptic rTKA at an academic orthopaedic speciality hospital between June 2011 and April 2020 with > one-year of follow-up. Patients were dichotomized based on whether this was their first revision procedure or not. Patient demographics, surgical factors, postoperative outcomes, and re-revision rates were compared between the groups. Results. A total of 663 cases were identified (486 index rTKAs and 177 multiply revised TKAs). There were no differences in demographics, rTKA type, or indication for revision. Multiply revised patients had significantly longer rTKA operative times (p < 0.001), and were more likely to be discharged to an acute rehabilitation centre (6.2% vs 4.5%) or skilled nursing facility (29.9% vs 17.5%; p = 0.003). Patients who had been multiply revised were also significantly more likely to have subsequent reoperation (18.1% vs 9.5%; p = 0.004) and re-revision (27.1% vs 18.1%; p = 0.013). The number of previous revisions did not correlate with the number of subsequent reoperations (r = 0.038; p = 0.670) or re-revisions (r = −0.102; p = 0.251). Conclusion. Multiply revised TKA had worse outcomes, with higher rates of facility discharge, longer operative times, and greater reoperation and re-revision rates compared to index rTKA. Cite this article: Bone Jt Open 2023;4(5):393–398

Arterial complications occurring in association with knee replacement surgery are rare, even though most patients having this operation are elderly and therefore more likely to have peripheral vascular disease. We report a patient who developed an arterial complication during the course of a knee replacement operation, as well as the results of a survey of Fellows of the Australian Orthopaedic Association. Recommendations to minimise this serious complication are proposed.

Fifty-three failed knee replacements were revised using minimally constrained implants with smooth uncemented intramedullary stems and metal-backed tibial components. Polymethylmethacrylate was used only to replace lost bone near the surface of the implant. Excluding four knees which had serious postoperative complications, 91% had successful relief of pain, 84% had over 90 degrees of movement and 80% could walk for more than 30 minutes. Review of the radiographs showed that there were no progressive lucencies at the interface between bone and cement, and no subsidence of components or changes in alignment. At the uncemented stem-to-bone interface, thin white lines developed near the metal, and their significance is discussed. This revision technique is an effective treatment for aseptic failure of primary total knee arthroplasty.

Aims. Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. Methods. A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. Results. A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. Conclusion. Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702–1708

We studied the effects of the timing of tourniquet release in 88 patients randomly allocated for release after wound closure and bandaging (group A), or before the quadriceps layer had been closed allowing control of bleeding before suture (group B). The groups were similar in mean age, weight, gender, preoperative knee score, radiographic grading, and prosthesis implanted.

Patients in group B had less postoperative pain, achieved earlier straight-leg raising, and had fewer wound complications. Five patients in group A had to return to theatre, three for manipulation under anaesthesia, one for secondary closure of wound dehiscence, and one for drainage of a haematoma. The last patient later developed a deep infection, which was treated by a two-stage revision. There were no significant differences between the two groups in operating time, or the decrease in haemoglobin concentration at 48 hours postoperatively.

Some of the adverse effects of the use of a tourniquet for knee surgery can be significantly reduced by early tourniquet release, with haemostasis before the quadriceps mechanism and the wound are closed.