Aims. Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA), and has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA. Methods. A UK-based, three-round, online modified Delphi Expert Consensus Study was completed focusing on cementation technique in TKA. Experts were identified as having a minimum of five years’ consultant experience in the NHS and fulfilling any one of the following criteria: a ‘high volume’ knee arthroplasty practice (> 150 TKAs per annum) as identified from the National joint Registry of England, Wales, Northern Ireland and the Isle of Man; a senior author of at least five peer reviewed articles related to TKA in the previous five years; a surgeon who is named trainer for a post-certificate of comletion of training fellowship in TKA. Results. In total, 81 experts (round 1) and 80 experts (round 2 and 3) completed the Delphi Study. Four domains with a total of 24 statements were identified. 100% consensus was reached within the cement preparation, pressurization, and cement curing domains. 90% consensus was reached within the cement application domain. Consensus was not reached with only one statement regarding the handling of cement during initial application to the tibial and/or femoral bone surfaces. Conclusion. The Cementing Techniques In Knee Surgery (CeTIKS) Delphi consensus study presents comprehensive recommendations on the optimal technique for component cementing in TKA. Expert opinion has a place in the hierarchy of evidence and, until better evidence is available these recommendations should be considered when cementing a TKA. Cite this article: Bone Jt Open 2023;4(9):682–688

Abstract. Introduction. In patients with bilateral unicompartmental knee osteoarthritis, simultaneous bilateral surgery is cost effective, with both patient-specific and wider socioeconomic benefits. There are concerns however regarding higher complication rates with bilateral knee surgery. This study compares simultaneous bilateral unicompartmental knee arthroplasty (UKA), to single side UKA in terms of complications and outcomes. Methodology. This is a retrospective case-control study of single side medial UKA patients (controls) and simultaneous bilateral medial UKA patients (cases). All patients underwent surgery between 2018 and 2022 by a single surgeon. The two cohorts were compared for perioperative blood loss (PBL), length of stay (LOS), complications (infections, blood clots, wound problems), Oxford Knee Score improvement (OKS) and revision surgery, with a follow-up period of up to 5 years. Results. 64 patients were followed up comprising 55 controls and 9 cases. Average length of stay for controls was 1.55 days and 2.22 days for cases (p=0.03). Average haemoglobin drop was 7.5g/l in controls and 12.8g/l in cases (p=0.04). The OKS improvement was comparable in both groups (p=0.95) with no complications and no revision surgery in either group. Conclusion. The statistically significant differences in PBL and LOS were not clinically relevant. There were no blood transfusions and postoperative haemoglobin was within normal range in more than 60% of cases. Simultaneous bilateral unicompartmental knee arthroplasty is a financially favourable and safe option for patients with bilateral knee medial unicompartmental osteoarthritis

Aims. There is limited information on outcomes of revision ACL reconstruction (rACLR) in soccer (association football) athletes, particularly on return to sport and the rate of additional knee surgery. The purpose of this study was to report return to soccer after rACLR, and to test the hypothesis that patient sex and graft choice are associated with return to play and the likelihood of future knee surgery in soccer players undergoing rACLR. Methods. Soccer athletes enrolled in a prospective multicentre cohort were contacted to collect ancillary data on their participation in soccer and their return to play following rACLR. Information regarding if and when they returned to play and their current playing status was recorded. If they were not currently playing soccer, they were asked the primary reason they stopped playing. Information on any subsequent knee surgery following their index rACLR was also collected. Player demographic data and graft choice were collected from their baseline enrolment data at rACLR. Results. Soccer-specific follow-up was collected on 76% (33 male, 39 female) of 95 soccer athletes. Subsequent surgery information was collected on 95% (44 male, 46 female). Overall, 63% of athletes returned to soccer a mean 9.6 months (SD 5.8) after index revision surgery but participation in soccer decreased to 19% at a mean of 6.4 years (SD 1.3) after surgery. There was no significant association of patient sex or graft choice with return to play, time of return to play, or long-term return to play. Females were more likely than males to have subsequent knee surgery following rACLR (20% (9/46) vs 5% (2/44); p = 0.050). The rate of recurrent graft tear (5.6%; 5/90) was similar between males and females. Conclusion. Approximately two-thirds of soccer players return to sport after rACLR, but the rate of participation drops significantly over time. Neither patient sex nor graft choice at the time of rACLR were associated with return to play. Female soccer players face a higher risk for additional knee surgery after rACLR than male soccer players. Cite this article: Bone Jt Open 2021;2(12):1043–1048

Aims. Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery. Methods. Using the ClinicalTrials.gov (CTG) and the International Clinical Trials Registry Platform (ICTRP) databases, we comprehensively surveyed clinical trials of decellularized tissue use in orthopaedic surgeries registered before 1 September 2022. We evaluated the clinical results, tissue processing methods, and commercial availability of the identified products using academic literature databases and manufacturers’ websites. Results. We initially identified 4,402 clinical trials, 27 of which were eligible for inclusion and analysis, including nine shoulder surgery trials, eight knee surgery trials, two ankle surgery trials, two hand surgery trials, and six peripheral nerve graft trials. Nine of the trials were completed. We identified only one product that will be commercially available for use in knee surgery with significant mechanical load resistance. Peracetic acid and gamma irradiation were frequently used for sterilization. Conclusion. Despite the demand for decellularized tissue, few decellularized tissue products are currently commercially available, particularly for the knee joint. To be viable in orthopaedic surgery, decellularized tissue must exhibit biocompatibility and mechanical strength, and these requirements are challenging for the clinical application of decellularized tissue. However, the variety of available decellularized products has recently increased. Therefore, decellularized grafts may become a promising option in orthopaedic surgery. Cite this article: Bone Joint Res 2023;12(3):179–188

Femoral nerve block is a reliable and effective method of providing anaesthesia and analgesia in the peri-operative period but there remains a small but serious risk of neurological complication. We aimed to determine incidence and outcome of neurological complications following femoral nerve block in patients who had major knee surgery. During the period January 2003 to August 2008, medical records of all patients undergoing knee surgery by Dr Myles Coolican and Dr David Parker, who had been administered femoral block for peri-operative analgesia, were evaluated. Patients with a neurological complication were invited take part in the study. A detailed physical examination including sensory responses, motor response and reflexes in both limbs was performed by an independent orthopaedic surgeon. Subjective outcome and pain specific questionnaires as well as clinical measurements were also collected. Out of 1393 patients administered with femoral nerve block anaesthesia during this period, 28 subjects (M:F= 5:23) were identified on the basis of persistent symptoms (more than three months) of femoral nerve dysfunction. All the patients had sensory dysfunction in the autonomous zone of femoral nerve sensory distribution. The incidence of neurological complications was 2.01%. One patient was deceased of unrelated causes and five patients declined to participate in the study. 14 patients out of the 22 have been examined so far. Nine cases had a one shot nerve block and five had continuous peripheral nerve block catheter. Areas of hypoesthesia/anaesthesia involving femoral nerve distribution occurred in 7 subjects and hyperaesthesia/paresthesia occurred in four. One subject had a combination of hypoesthesia and hyperesthesia in different areas of the femoral nerve distribution. Three subjects had bilateral symptoms following bilateral simultaneous nerve blocks. Dysesthesias in the affected dermatomes were found in seven cases and paresthesias were found in eight cases. Douleur Neuropathique en 4 questions (DN4) score of ï. 3. 4 was found in all the patients (average value: 5.55). The average scores for tingling, pins and needles and burning sensation (in a scale from 0 to 10) are 3.8, 3.1 and 2.9 respectively. The incidence of persistent neurological complication after femoral nerve block in our series is much higher compared to the reported incidence in the contemporary literature (Auroy Y. et al. Major complications of regional anesthesia in France: Anesthesiology 2002; 97:1274 80). The symptoms significantly influence the quality of life in the affected cases and question the value of the femoral nerve block in knee surgery

Purpose: To review the existing coding for knee surgery and ascertain its appropriateness & accuracy for surgical procedures, associated co-morbidities and complications. Methods: A retrospective review of 100 consecutive knee surgeries (50 arthroplasties and 50 arthroscopies) performed between July-August 2007 was undertaken. The coding data excel sheet and comprehensive hospital records were analysed. Results: The accuracy of primary procedural codes was 100% & 88% respectively for arthroplasty & arthroscopy. However this respectively fell down to 56 & 60% when the accuracy for entire description of surgical procedure was taken into consideration. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility esp. for arthroscopies. In arthroplasties, patients had similar codes irrespective of whether they had patellar resurfacing or not. Co-morbidities were coded appropriately in 24% of arthroplasty & 36% of arthroscopy patients. The common co-morbidities missed were drug allergies, hypercholesterolemia, heart conditions (IHD, MI, AF, valvular pathologies) and h/o malignancy & deep vein thrombosis. Post-op adverse events were coded in only 2/5 arthroplasties (40%) and 0/3 arthroscopies (0%) respectively. Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for reimbursement but also for data quality and audit. Coding database also serves as a powerful research tool. The financial implications with respect to generation of appropriate reimbursement i.e. healthcare resource group (HRG) codes (which are dictated by official population and census survey procedural [OPCS4.4] & international classification of diseases [ICD–10] co-morbidity codes) are discussed. The limitations of the existing coding system are highlighted and discussed. Literature emphasizes on the qualification of coders, legible & comprehensive documentation of surgeries & co-morbidities by treating physicians and regular interaction between coders and clinicians. Reimbursement for arthroscopy is less in the NHS unlike in BUPA where it is on par with open surgeries

Not all knee surgery cases are created equal is a maxim that holds true for both primary and revision scenarios. Complex cases involve patients presenting with compromised bone and/or soft tissue. For primary knees, these include cases with bony deformity or deficiency, severe malalignment, arthrofibrosis, ligamentous instability or contracture, prior fracture or trauma with or without failed fixation, prior hardware complicating component placement, or compromised extensor mechanism. In revision surgery, complex scenarios include cases compromised by bone loss, deterioration of the soft tissues and resulting instability, periprosthetic fracture, leg length discrepancy, infection, and more recently, hypersensitivity reactions. In this interactive session, a moderator and team of experts will discuss strategies for evaluation and management of a variety of challenging knee case scenarios

Aim. To evaluate the costs of performing revision hip and knee surgery at a District General Hospital. Methods. A retrospective review of all revision hip and knee surgery between October 2004 and October 2006 was performed. Information was obtained from the notes and theatre log books. Each case was fully costed. The breakdown costs included implant choice, theatre time, length of stay, allograft, blood products and post-operative physiotherapy/OT. The costs were obtained from the hospital financial department and theatre invoices. Payment to the hospital is based on a specific tariff which in turn is determined by coding each patient episode. We individually coded every case, using the OPCS 4.3 coding system, and applied the appropriate tariff. The tariffs that the financial department had applied to each case were also available. A comparison was made between actual costs incurred, the expected reimbursement (from our study coding) and the actual reimbursement received (from finance department). Results. 167 revision procedures were performed (108 hips and 59 knees). The total incurred cost of revision hip surgery was £930,156 (mean £8,613 per case). The expected total reimbursement according to our coding was £938,325 (mean £8,688). The total reimbursement actually received was £806,836 (mean £7,471). The total incurred cost of revision knee surgery was £493,357 (mean £8,362). The expected total reimbursement according to our coding was £499,042 (mean £8,458). The total reimbursement was £419,157 (mean £7,104). Conclusions. Inadequate coding results in reduced income. If strict coding practices are adhered to then performing revision hip and knee surgery should be financially viable at a district general hospital

Introduction. In major orthopaedic departments, typically several total knee systems are used. Each system requires several sets of instruments, each set with many trays of complicated and expensive parts. The logistics and costs of maintainance are considerable. Our overall goal is to investigate the feasibility of autoclavable single-use 3D printed instruments made from a polymeric material, used for any type of total knee design. The procedure will be standardized and adjustments easy to implement. Each set will be packaged individually, and used for a single case. There are many aspects to this study; in this part, the aims are to identify suitable materials for autoclavability and strength, and then to compare the accuracy of a novel design of 3D printed tibial cutting guide with a current metallic guide. Methods. Test samples were designed to simulate shapes in current instruments, such as mating pegs and holes, threaded screws, and slotted blocks. Each set was produced in biocompatible materials, ABS-M30i, VeroClear (MED610), Ultem1010, and Nylon 12. Each part was laser scanned, and then imaged virtually using a reverse engineering software (GeoMagic). Manual measurements of key dimensions were also made using calipers. The parts were autoclaved using a standardized protocol, 30 minutes at 250° F. All parts were re-scanned and measured to determine any changes in dimensions. To test for strength and abrasion resistance, the slotted blocks were pinned to sawbones model tibias, and an oscillating saw used to cut through the slot. A compact 3D printed tibial cutting guide was then designed which fitted to the proximal tibia and allowed varus-valgus, tibial slope and height adjustments. A small laser attached to the guide projected to a target at the ankle. Tests were made on 20 sawbones, and compared with 20 with a standard metal cutting guide. Digitization was used to measure the angles of the cuts. Results. Prior to autoclaving, the mating parts of all parts were congruent, except for Nylon 12 which had processing debris in slots and screw threads. The ABS-M30i shapes became grossly deformed after autoclaving. The other materials experienced only small changes in dimensions without loss of overall shape, but the slot of the Nylon 12 block was stenotic, 1.4 mm compared to 0.9 mm before autoclaving. In saw blade testing, the VeroClear block fractured through the corner of the slot, while the Nylon 12 block deformed due to heating. The Ultem1010 block produced a small amount of debris, but maintained its shape without any structural damage. In the tests of the tibial cutting guide the 3D printed laser-guided tibial cutting guide resulted in a mean absolute error of 1.72°±1.31° and 1.19°±0.93°, for the tibial slope and varus-valgus respectively. For the conventional guides, these values were 3.78°±1.98° and 2.33°±0.98°, respectively. These measurements were found to be statistically significant with p values of 0.004 and 0.001, respectively. Conclusions. Thus far, apart from patient specific cutting guides and trial components, 3D printing has had limited applications in total knee surgery. As cost containment remains prominent, the use of 3D printing to produce standardized instruments may become viable. These instruments would not require pre-op planning such as CT or MRI, yet allow patient-specific angular settings. Our results indicated that Ultem1010 is a promising material, while a novel tibial cutting guide showed higher accuracy than standard, as well as being quicker to use. These initial tests indicated the viability of 3D printed instruments, but further work will include design and evaluation of the other cutting guides, manufacturing logistics such as in-house or company- based, and economics

Aims. This study aims to evaluate a new home medical stretching device called the Self Treatment Assisted Knee (STAK) tool to treat knee arthrofibrosis. Methods. 35 patients post-major knee surgery with arthrofibrosis and mean range of movement (ROM) of 68° were recruited. Both the STAK intervention and control group received standard physiotherapy for eight weeks, with the intervention group additionally using the STAK at home. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at all timepoints. An acceptability and home exercise questionnaire capturing adherence was recorded after each of the interventions. Results. Compared to the control group, the STAK intervention group made significant gains in mean ROM (30° versus 8°, p < 0.0005), WOMAC (19 points versus 3, p < 0.0005), and OKS (8 points versus 3, p < 0.0005). The improvements in the STAK group were maintained at long-term follow-up. No patients suffered any complications relating to the STAK, and 96% of patients found the STAK tool ‘perfectly acceptable’. Conclusion. The STAK tool is effective in increasing ROM and reducing pain and stiffness. Patients find it acceptable and adherence to treatment was high. This study indicates that the STAK tool would be of benefit in clinical practice and may offer a new, cost-effective treatment for arthrofibrosis. Cite this article: Bone Joint Open 2020;1-8:465–473

Computer-aided surgery (CAS) aims not to replace the surgeon but to assist him in difficult areas. The cost of the system means it has to produce markedly improved clinical results. CAS gained acceptance in neurosurgery. In knee surgery, CAS has improved the accuracy of tibiofemoral alignment and bone cuts. It has also helped deal with problems such as soft tissue balancing. This report of our experiences looks at intra-articular and extra-articular forces around the knee, the use of spacer blocks, surgical techniques and results

Introduction The aim of the study was to investigate the incidence, in Australia, of popliteal artery injury during knee surgery; to assess the distance from the popliteal artery to the posterior tibia in flexion and extension; and to investigate the influence of major trauma or surgery on the anatomy. Methods A questionnaire was sent to Australian members of the ANZ Society of Vascular Surgeons. Duplex ultrasound studies were obtained through the Vascular Laboratory University of Melbourne. Studies in extension and 90° of flexion assessed the distance from the popliteal artery to the posterior tibia. Twelve persons with normal knees were assessed bilaterally. Eight patients with a posterior cruciate ligament deficient knee were assessed bilaterally. Seventy vascular surgeons responded documenting 115 popliteal artery injuries occurring during knee surgery. There were 69 lacerations, 27 thromboses, 13 AV fistula and 19 false aneurysms. In 12 normal people (24 knees) the popliteal artery was 5.5 mm (2.9 to 9.9) from the tibia in extension and 5.7 mm (2.9 to 10.0) in 90° of flexion. In ten of 24 knees the artery moved closer in flexion. In the eight posterior cruciate ligament deficient knees the artery was 4.7 mm (2.7 to 6.9) from the tibia in extension and 3.8 mm (2.6 to 4.5) at 90° of flexion. In all eight PCL knees the artery moved closer in flexion. In normal knees the popliteal artery may move closer to the tibia in flexion, the average distance being about 5.5 mm. Conclusions The popliteal artery is closer to the knee joint following trauma or surgery and specifically closer in flex-ion than in extension. Risks of injury are significant

Abstract

Introduction: Although knee athroplasty is a very successful operation, British knee surgeons have a wide variation in their methods of patient management. Aims: To determine current knee practice within the United Kingdom. Material and Methods: A postal survey was conducted of all members of the British Association of Knee Surgery. They were asked about pre-operative assessment, type of prosthesis used, antibiotic prophylaxis, DVT prophylaxis, bilateral arthroplasty, preferred anaesthetic, urinary catheter, patella replacement, autologous blood transfusion, mobilisation, duration of hospital stay and patient follow up. Results: 71% (221) members replied. The results and implications will be presented in full at the presentation. Some of the more interesting findings included: 18% did not have a pre-admission clinic, 18% use thromboprophylaxis for medicolegal reasons only (do not believe it works), 19% never replace the patella, 48% perform unicondlyar arthroplasty, 41% follow up patients indefinitely, one discharges patients at 6 weeks, 77% perform bilateral arthroplasty. Discussion and Conclusion: Comparison with a 1996 study of UK knee practice shows that most techniques are unchanged although slightly more surgeons routinely use an uncemented implant. (4.8% 1996, 12% 2001). There remains a wide variation in UK practice. The authors would be grateful if colleagues from other countries would contact them so that comparable studies of practice could be performed in their countries. This data may be used to compare international attitudes to knee arthroplasty

Preoperative anaemia and intraoperative blood loss result in ∼90% of individuals being anaemic following hip and knee arthroplasty. Reducing blood loss offers the opportunity to improve outcomes and reduce the risk of transfusion and costs. This review's aim was to determine the effectiveness of drugs for preventing blood loss, and identify optimal dose, route, and timing of administration.

Cochrane network meta-analysis of randomised controlled trials was conducted. Inclusion criteria: adults undergoing primary or revision elective hip or knee arthroplasty. Drugs studied: tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. Primary outcomes: need for allogenic blood transfusion, all• cause mortality (within 30 days). Secondary outcomes: mean number of transfusion episodes, re-operation, length of hospital stay and adverse events (DVT, PE, CVA, MI).

102 studies with 8418 participants. Trials included more women (63%). 47 studies (4398 participants) were included within the blood transfusion NMA. TXA given intra-articularly and orally at a total dose of greater than 3g pre-incision, intraoperatively and postoperatively ranked the highest, with anticipated absolute effect of 147 fewer transfusions per 1000 (53% chance ranking 1st) (relative risk(RR) 0.02, 95% credible interval(CrI) 0–0.31); moderate-certainty). Aprotinin (RR 0.59, 95%:CrI 0.36–0.86; low certainty evidence), fibrin (RR 0.86, CrI 0.25–2.93; very-low certainty) and EACA (RR 0.60, 95%:CrI 0.29–1.27; very-low certainty) were not shown to be as effective as TXA.

TXA was the most effective drug for preventing bleeding in lower limb arthroplasty. Aprotinin and EACA were not as effective. Currently, the optimal dose, route and timing of administration of TXA is unclear. However, TXA given at higher doses and via mixed routes ranked higher in the treatment hierarchy. Oral TXA may be as effective as intavenous. There was no evidence of harm associated with higher doses of TXA.

Introduction

Previous studies on Medicare populations have shown improved outcomes and decreased 90-day episode-of-care costs with robotic assisted total knee arthroplasty (rTKA). The purpose of this study was to evaluate the expenditures and utilization following rTKA in the under 65 y/o population.

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.

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected knee arthroplasty experts.

The primary cases will include challenges such as patient selection and setting expectations, exposure, alignment correction and balancing difficulties. In the revision knee arthroplasty scenarios issues such as bone stock loss, fixation challenges, instability and infection management will be discussed.

This will be an interactive case-based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.

Clinical cases will be presented to a panel of experienced arthroplasty surgeons to illustrate how principles tempered by experience, are applied to challenging problems. (request pertinent additional material from kellyvince@mac.com)

This session will present a series of challenging and complex primary and revision cases to a panel of internationally respected knee arthroplasty experts.

The primary cases will include challenges such as patient selection and setting expectations, exposure, alignment correction and balancing difficulties. In the revision knee arthroplasty scenarios issues such as bone stock loss, fixation challenges, instability, and infection management will be discussed.

This will be an interactive case based session that at its conclusion should leave the attendee with a more thorough approach to these challenging issues.