Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are recognised and proven interventions for patients with advanced arthritis. Studies to date have demonstrated a steady increase in the requirement for primary and revision procedures. Projected estimates made for the United States show that by 2030 the demand for primary TKA will grow by 673% and for revision TKA by 601% from the level in 2005. For THA the projected estimates are 174% and 137% for primary and revision surgery, respectively. The purpose of this study was to see if those predictions were similar for England and Wales using data from the National Joint Registry and the Office of National Statistics.

Analysis of data for England and Wales suggest that by 2030, the volume of primary and revision TKAs will have increased by 117% and 332%, respectively between 2012 and 2030. The data for the United States translates to a 306% cumulative rate of increase between 2012 and 2030 for revision surgery, which is similar to our predictions for England and Wales.

The predictions from the United States for primary TKA were similar to our upper limit projections. For THA, we predicted an increase of 134% and 31% for primary and revision hip surgery, respectively.

Our model has limitations, however, it highlights the economic burden of arthroplasty in the future in England and Wales as a real and unaddressed problem. This will have significant implications for the provision of health care and the management of orthopaedic services in the future.

Cite this article: Bone Joint J 2015;97-B:1076–1081.

We compared the length of hospitalisation, rate of infection, dislocation of the hip and revision, and mortality following primary hip and knee arthroplasty for osteoarthritis in patients with Alzheimer’s disease (n = 1064) and a matched control group (n = 3192). The data were collected from nationwide Finnish health registers. Patients with Alzheimer’s disease had a longer peri-operative hospitalisation (median 13 days vs eight days, p < 0.001) and an increased risk for hip revision with a hazard ratio (HR) of 1.76 (95% confidence interval (CI) 1.03 to 3.00). Dislocation was the leading indication for revision. There was no difference in the rates of infection, dislocation of the hip, knee revision and short-term mortality. In long-term follow-up, patients with Alzheimer’s disease had a higher mortality (HR 1.43; 95% CI 1.22 to 1.70), and only one third survived ten years post-operatively. Increased age and comorbidity were associated with longer peri-operative hospitalisation in patients with Alzheimer’s disease.

Cite this article: Bone Joint J 2015;97-B:654–61.

Metaphyseal bone loss is common with revision total knee replacement (RTKR). Using the Anderson Orthopaedic Research Institute (AORI) classification, type 2-B and type 3 defects usually require large metal blocks, bulk structural allograft or highly porous metal cones. Tibial and femoral trabecular metal metaphyseal cones are a unique solution for large bone defects. These cones substitute for bone loss, improve metaphyseal fixation, help correct malalignment, restore the joint line and may permit use of a shorter stem. The technique for insertion involves sculpturing of the remaining bone with a high speed burr and rasp, followed by press-fit of the cone into the metaphysis. The fixation and osteoconductive properties of the porous cone outer surface allow ingrowth and encourage long-term biological fixation. The revision knee component is then cemented into the porous cone inner surface, which provides superior fixation compared with cementing into native but deficient metaphyseal bone. The advantages of the cone compared with allograft include: technical ease, biological fixation, no resorption, and possibly a lower risk of infection. The disadvantages include: difficult extraction and relatively short-term follow-up. Several studies using cones report promising short-term results for the reconstruction of large bone defects in RTKR.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):118–21.

Infection is a leading indication for revision arthroplasty. Established criteria used to diagnose prosthetic joint infection (PJI) include a range of laboratory tests. Leucocyte esterase (LE) is widely used on a colorimetric reagent strip for the diagnosis of urinary tract infections. This inexpensive test may be used for the diagnosis or exclusion of PJI. Aspirates from 30 total hip arthroplasties (THAs) and 79 knee arthroplasties (KA) were analysed for LE activity. Semi-quantitative reagent strip readings of 15, 70, 125 and 500 white blood cells (WBC) were validated against a manual synovial white cell count (WCC). A receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off point for the semi-quantitative results. Based on established criteria, six THAs and 15 KAs were classified as infected. The optimal cut-off point for the diagnosis of PJI was 97 WBC. The closest semi-quantitative reading for a positive result was 125 WBC, achieving a sensitivity of 81% and a specificity of 93%. The positive and negative predictive values of the LE test strip were 74% and 95% respectively.

The LE reagent strip had a high specificity and negative predictive value. A negative result may exclude PJI and negate the need for further diagnostic tests.

Cite this article: Bone Joint J 2015;97-B:1232–6.

The August 2015 Knee Roundup360 looks at: Two days as good as three in TKA; Bilateral TKA: minimising the risks; Tranexamic acid in knee arthroplasty: everyone should be using it, but how?; Initial follow-up for knee arthroplasty?; Navigation finds its niche?; Another take on navigation?; Multimodal care for early knee osteoarthritis; ACL graft fixation methods under the spotlight

A retrospective review was performed of patients undergoing primary cementless total knee replacement (TKR) using porous tantalum performed by a group of surgical trainees. Clinical and radiological follow-up involved 79 females and 26 males encompassing 115 knees. The mean age was 66.9 years (36 to 85). Mean follow-up was 7 years (2 to 11). Tibial and patellar components were porous tantalum monoblock implants, and femoral components were posterior stabilised (PS) in design with cobalt–chromium fibre mesh. Radiological assessments were made for implant positioning, alignment, radiolucencies, lysis, and loosening. There was 95.7% survival of implants. There was no radiological evidence of loosening and no osteolysis found. No revisions were performed for aseptic loosening. Average tibial component alignment was 1.4° of varus (4°of valgus to 9° varus), and 6.2° (3° anterior to 15° posterior) of posterior slope. Mean femoral component alignment was 6.6° (1° to 11°) of valgus. Mean tibiofemoral alignment was 5.6° of valgus (7° varus to 16° valgus). Patellar tilt was a mean of 2.4° lateral (5° medial to 28° lateral). Patient satisfaction with improvement in pain was 91%. Cementless TKR incorporating porous tantalum yielded good clinical and radiological outcomes at a mean of follow-up of seven-years.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):87–92.

There are many reasons why a total knee replacement (TKR) may fail and qualify for revision. Successful revision surgery depends as much on accurate assessment of the problem TKR as it does on revision implant design and surgical technique. Specific modes of failure require specific surgical solutions. Causes of failure are often presented as a list or catalogue, without a system or process for making a decision. In addition, strict definitions and consensus on modes of failure are lacking in published series and registry data. How we approach the problem TKR is an essential but neglected aspect of understanding knee replacement surgery. It must be carried out systematically, comprehensively and efficiently. Eight modes of failure are described: 1) sepsis; 2) extensor discontinuity; 3) stiffness; 4) tibial- femoral instability; 5) patellar tracking; 6) aseptic loosening and osteolysis; 7) periprosthetic fracture and 8) component breakage. A ninth ‘category’, unexplained pain is an indication for further investigation but not surgery.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):105–11.

Objectives

Orthopaedic surgeons use stems in revision knee surgery to obtain stability when metaphyseal bone is missing. No consensus exists regarding stem size or method of fixation. This in vitro study investigated the influence of stem length and method of fixation on the pattern and level of relative motion at the bone–implant interface at a range of functional flexion angles.

We evaluated the duration of hospitalisation, occurrence of infections, hip dislocations, revisions, and mortality following primary hip and knee replacement in 857 patients with Parkinson’s disease and compared them with 2571 matched control patients. The data were collected from comprehensive nationwide Finnish health registers. The mean follow-up was six years (1 to 13). The patients with Parkinson’s disease had a longer mean length of stay (21 days [1 to 365] vs 13 [1 to 365] days) and an increased risk for hip dislocation during the first post-operative year (hazard ratio (HR) 2.33, 95% confidence intervals (CI) 1.02 to 5.32). There was no difference in infection and revision rates, and one-year mortality. In longer follow-up, patients with Parkinson’s disease had higher mortality (HR 1.94, 95% CI 1.68 to 2.25) and only 274 (34.7%) were surviving ten years after surgery. In patients with Parkinson’s disease, cardiovascular and psychiatric comorbidity were associated with prolonged hospitalisation and cardiovascular diseases also with increased mortality.

Cite this article: Bone Joint J 2014;96-B:486–91.

Popliteal artery injury (PAI) is a feared complication during knee replacement. Our aim was to investigate those injuries that occurred in association with knee replacement in terms of the type of injury, treatment and outcomes.

From our national vascular registry (Swedvasc) and the Swedish Patient Insurance databases a total of 32 cases were identified. Prospective data from the registries was supplemented with case-records, including long-term follow-up.

We estimated the incidence during 1998 to 2010 to be 0.017%. In our series of 32 patients with PAI occurring between 1987 and 2011, 25 (78%) were due to penetrating trauma and seven were caused by blunt trauma. The patients presented in three ways: bleeding (14), ischaemia (7) and false aneurysm formation (11), and five occurred during revision surgery. A total of 12 injuries were detected intra-operatively, eight within 24 hours (3 to 24) and 12 at more than 24 hours post-operatively (2 to 90 days). Treatment comprised open surgery in 28 patients. Patency of the vascular repair at 30 days was 97% (31 of 32, one amputation). At the time of follow-up (median 546 days, mean 677 days (24 to 1251)), 25 patients had residual symptoms. Of seven patients with a complete recovery, six had had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital.

PAI is a rare adverse event during knee replacement surgery. The outcome following such events is often adversely affected by diagnostic and therapeutic delay. Bleeding and false aneurysm were the most common clinical presentations.

Cite this article: Bone Joint J 2013;95-B:1645–9.

The February 2013 Hip & Pelvis Roundup³⁶⁰ looks at: amazing alumina; dual mobility; white cells and periprosthetic infection; cartilage and impingement surgery; acetabulum in combination; cementless ceramic prosthesis; metal-on-metal hips; and whether size matters in failure.

Staphylococcus aureus is one of the leading causes of surgical site infection (SSI). Over the past decade there has been an increase in methicillin-resistant S. aureus (MRSA). This is a subpopulation of the bacterium with unique resistance and virulence characteristics. Nasal colonisation with either S. aureus or MRSA has been demonstrated to be an important independent risk factor associated with the increasing incidence and severity of SSI after orthopaedic surgery. Furthermore, there is an economic burden related to SSI following orthopaedic surgery, with MRSA-associated SSI leading to longer hospital stays and increased hospital costs. Although there is some controversy about the effectiveness of screening and eradication programmes, the literature suggests that patients should be screened and MRSA-positive patients treated before surgical admission in order to reduce the risk of SSI.

Cite this article: Bone Joint J 2013;95-B:4–9.

The management of bone loss in revision replacement of the knee remains a challenge despite an array of options available to the surgeon. Bone loss may occur as a result of the original disease, the design of the prosthesis, the mechanism of failure or technical error at initial surgery. The aim of revision surgery is to relieve pain and improve function while addressing the mechanism of failure in order to reconstruct a stable platform with transfer of load to the host bone. Methods of reconstruction include the use of cement, modular metal augmentation of prostheses, custom-made, tumour-type or hinged implants and bone grafting.

The published results of the surgical techniques are summarised and a guide for the management of bone defects in revision surgery of the knee is presented.

Treatment of an infected total elbow replacement (TER) is often successful in eradicating or suppressing the infection. However, the extensor mechanism may be compromised by both the infection and the surgery. The goal of this study was to assess triceps function in patients treated for deep infection complicating a TER. Between 1976 and 2007 a total of 217 TERs in 207 patients were treated for infection of a TER at our institution. Superficial infections and those that underwent resection arthroplasty were excluded, leaving 93 TERs. Triceps function was assessed by examination and a questionnaire. Outcome was measured using the Mayo Elbow Performance Score (MEPS).

Triceps weakness was identified in 51 TERs (49 patients, 55%). At a mean follow-up of five years (0.8 to 34), the extensor mechanism was intact in 13 patients, with the remaining 38 having bone or soft-tissue loss. The mean MEPS was 70 points (5 to 100), with a mean functional score of 18 (0 to 25) of a possible 25 points.

Infection following TER can often be eradicated; however, triceps weakness occurs in more than half of the patients and may represent a major functional problem.

Cite this article: Bone Joint J 2014;96-B:82–7.