Purpose. To establish the reliability of reporting and recording revision hip and knee arthroplasties by comparing data in the National Joint Registry (NJR), Hospital Episode Statistics (HES) and our local theatre records. Methods. The paper theatre registers for all orthopaedic theatres in the Royal Derby Hospitals NHS Trust were examined for details of revision hip and knee replacements carried out in 2007 and 2008. This was then cross-checked and merged with the local electronic theatre data to obtain a definitive local record of all revision hip and knee arthroplasties. Data for the same period was requested from the NJR and HES and these data were checked against our definitive local record for discrepancies. The HES codes used were the same codes used to compile the recent NJR annual reports. Results. The theatre registers and ORMIS identified 271 revision hip and knee arthroplasties in the study period. The NJR had corresponding data for 176 (65%) of these, and HES had 250 (92%). 10 cases (4%) were not recorded by either NJR or HES: 8 secondary resurfacings of patellae and 2 posterior lip augmentations in hips. Of those operations “missed” by HES, most had been assigned a correct “W” code, but had a “Y” or “Z” OPCS code not used in the NJR annual reports. Conclusion. When HES and the NJR data are combined, they are an accurate representation of real practice. More robust methods of reporting revision arthroplasty to the NJR are required. The OPCS codes used to indicate a revision need to be reviewed

Aims

The aim of this study was to determine if a three-month course of microorganism-directed oral antibiotics reduces the rate of failure due to further infection following two-stage revision for chronic prosthetic joint infection (PJI) of the hip and knee.

Introduction. Infection after total joint arthroplasty is a challenging problem. Clinical symptoms, Erythrocyte sedimentation rate, C-reactive protein level, and cultures of synovial fluid obtained by means of percutaneous aspiration are commonly used to rule out the possibility of persistent infection before reimplantation. However, the sensitivity and specificity of the tests are low. Some authors have suggested that frozen-section analysis should always be performed during the reimplantation in order to rule out persistent infection. Methods. Retrospective review of 126 revision hip and knee arthroplasty procedure performed from 2002 - 2007 in Derriford Hospital, Plymouth NHS truts, UK. Frozen section was performed in 86 procedures out of the 126 procedures reviewed(68.2 %). A positive frozen section with more than 10 PNLs per HPF was compared with intra operative cultures results. The preoperative CRP results were recorded as well. Results. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for frozen section were 45.5 %, 93.1%,50%, 95%, 94% respectively. Combining the intraoperative frozen section with the CRP results, the specificity was 100%. Discussion. A negative finding on intra operative analysis of frozen sections has a high predictive value with regard to ruling out the presence of infection; However, the sensitivity of the test for the detection of persistent infection is low. The data support the conclusion that the Frozen Section is reasonably specific but not a sensitive. Combining it with the preoperative CRP results led to increasing the specificity to 100% in our series

Aims. In patients with a “dry” aspiration during the investigation of prosthetic joint infection (PJI), saline lavage is commonly used to obtain a sample for analysis. The aim of this study was to investigate prospectively the impact of saline lavage on synovial fluid analysis in revision arthroplasty. Methods. Patients undergoing revision hip (THA) or knee arthroplasty (TKA) for any septic or aseptic indication were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry tap (pre-lavage) followed by the injection with 20 ml of normal saline and re-aspiration (post-lavage). Pre- and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared. Results. A total of 78 patients had data available for analysis; 17 underwent revision THA and 61 underwent revision TKA. A total of 16 patients met modified Musculoskeletal Infection Society (MSIS) criteria for PJI. Pre- and post-lavage %PMNs were similar in septic patients (87% vs 85%) and aseptic patients (35% vs 39%). Pre- and post-lavage synovial fluid WBC count were far more disparate in septic (53,553 vs 8,275 WBCs) and aseptic (1,103 vs 268 WBCs) cohorts. At a cutoff of 80% PMN, the post-lavage aspirate had a sensitivity of 75% and specificity of 95%. At a cutoff of 3,000 WBCs, the post-lavage aspirate had a sensitivity of 63% and specificity of 98%. As the post-lavage synovial WBC count increased, the difference between pre- and post-lavage %PMN decreased (mean difference of 5% PMN in WBC < 3,000 vs mean difference 2% PMN in WBC > 3,000, p = 0.013). Of ten positive pre-lavage fluid cultures, only six remained positive post-lavage. Conclusion. While saline lavage aspiration significantly lowered the synovial WBC count, the %PMN remained similar, particularly at WBC counts of > 3,000. These findings suggest that in patients with a dry-tap, the %PMN of a saline lavage aspiration has reasonable sensitivity (75%) for the detection of PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):138–144

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Background. In the setting of a “dry” aspiration, saline lavage is commonly used to obtain a sample for analysis. The purpose of this study is to prospectively determine the impact of saline lavage on synovial fluid markers in revision arthroplasty. Methods. 79 patients undergoing revision hip (19) and knee (60) arthroplasty were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry-tap (“pre-lavage”) followed by subsequent injection with 20 mL of normal saline and re-aspiration (“post-lavage”). Pre and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared. Statistical analyses utilized the Wilcoxon signed-rank test. Results. Nine patients met modified MSIS criteria for prosthetic joint infection (PJI). Pre and post-lavage %PMN were similar in septic patients (90.1% vs. 88.2%, p=0.40 for septic). Pre and post-lavage WBC counts were different in both cohorts (69,432 vs. 6,547 WBCs, p=0.008 for septic; 1,850 vs. 449 WBCs for aseptic, p<0.001). Using a pre-lavage cutoff of >80% PMN, the post-lavage aspirate correctly identified 84.6% of true positives (sensitivity) and 98.5% of true negatives (specificity). Using a pre-lavage cutoff of >3000 WBCs, the post-lavage aspirate correctly identified only 38.1% of true positives (sensitivity). As the synovial fluid WBC count increased, the correlation between pre and post-lavage %PMN was stronger (mean difference of 7.0% PMN in WBC <3000 vs. mean difference −2.9% PMN in WBC >3000, p=0.002). Of seven positive pre-lavage fluid cultures, 4 remained positive post-lavage. Conclusion. While saline lavage aspiration significantly lowers the synovial WBC count, the %PMN is well maintained, particularly at WBC counts >3000. Our findings suggest that in the setting of a dry tap where saline lavage is required to obtain a sample, the %PMN has reasonable sensitivity and specificity for the detection of PJI. For figures, tables, or references, please contact authors directly

Introduction. Surgical management of PJI remains challenging with patients failing treatment despite the best efforts. An important question is whether these later failures reflect reinfection or the persistence of infection. Proponents of reinfection believe hosts are vulnerable to developing infection and new organisms emerge. The alternative hypothesis is that later failure is a result of an organism that was present in the joint but was not picked up by initial culture or was not a pathogen initially but became so under antibiotic pressure. This multicenter study explores the above dilemma. Utilizing next-generation sequencing (NGS), we hypothesize that failures after two stage exchange arthroplasty can be caused by an organism that was present at the time of initial surgery but not isolated by culture. Methods. This prospective study involving 15 institutions collected samples from 635 revision total hip (n=310) and knee (n=325) arthroplasties. Synovial fluid, tissue and swabs were obtained intraoperatively for NGS analysis. Patients were classified per 2018 Consensus definition of PJI. Treatment failure was defined as reoperation for infection that yielded positive cultures, during minimum 1-year follow-up. Concordance of the infecting pathogen cultured at failure with NGS analysis at initial revision was determined. Results. Among the total cohort, 203 revisions were considered infected and 432 were aseptic (based on ICM-criteria). Of the infected cases, 157 were NGS-positive and 46 NGS-negative. Twenty-nine ICM-positive patients (29/157;18.5%) failed by reoperation with an organism confirmed on culture. In 23 of these (23/29;79.3%), the organism at failure was present on NGS at initial revision. The remaining 6 cases detected discordant organisms between initial NGS and culture at failure. Of the 432 ICM-negative patients, NGS identified microbes in 48.1% (208/432) of “aseptic” revisions, and 17 of these failed. Thirteen of the 17 failures (76.5%) were due to an organism previously detected by NGS at initial revision. Conclusion. Our collaborative findings suggest that most failures (79.3%) by infection recurrence could be attributed to an organism previously detected by NGS at index revision surgery. For any figures or tables, please contact the authors directly

Aims

Thresholds of acceptable early migration of the components in total knee arthroplasty (TKA) have traditionally ignored the effects of patient and implant factors that may influence migration. The aim of this study was to determine which of these factors are associated with overall longitudinal migration of well-fixed tibial components following TKA.

Aims

To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty.

Aims

The aim of this study was to measure the effect of hospital case volume on the survival of revision total knee arthroplasty (RTKA).

Aims

Enhanced perioperative protocols have significantly improved patient recovery following primary total knee arthroplasty (TKA). Little has been investigated the effectiveness of these protocols for revision TKA (RTKA). We report on a matched group of aseptic revision and primary TKA patients treated with an identical pain and rehabilitation programmes.

Aims

The aim of this study was to determine if the local delivery of vancomycin and tobramycin in primary total knee arthroplasty (TKA) can achieve intra-articular concentrations exceeding the minimum inhibitory concentration thresholds for bacteria causing acute prosthetic joint infection (PJI).

We explored the literature surrounding whether allergy and hypersensitivity has a clinical basis for implant selection in total knee arthroplasty (TKA). In error, the terms hypersensitivity and allergy are often used synonymously. Although a relationship is present, we could not find any evidence of implant failure due to allergy. There is however increasing basic science that suggests a link between loosening and metal ion production. This is not an allergic response but is a potential problem. With a lack of evidence logically there can be no justification to use ‘hypoallergenic’ implants in patients who have pre-existing skin sensitivity to the metals used in TKA.

Cite this article: Bone Joint J 2016;98-B:437–41.

Obesity is an epidemic across both the developed and developing nations that is possibly the most important current public health factor affecting the morbidity and mortality of the global population. Obese patients have the potential to pose several challenges for arthroplasty surgeons from the standpoint of the influence obesity has on osteoarthritic symptoms, their peri-operative medical management, the increased intra-operative technical demands on the surgeon, the intra- and post-operative complications, the long term outcomes of total hip and knee arthroplasty. Also, there is no consensus on the role the arthroplasty surgeon should have in facilitating weight loss for these patients, nor whether obesity should affect the access to arthroplasty procedures.

We undertook a prospective randomised controlled trial to investigate the efficacy of autologous retransfusion drains in reducing the need for allogenic blood requirement after unilateral total knee replacement. We also monitored the incidence of post-operative complications. There were 86 patients in the control group, receiving standard care with a vacuum drain, and 92 who received an autologous drain and were retransfused postoperatively. Following serial haemoglobin measurements at 24, 48 and 72 hours, we found no difference in the need for allogenic blood between the two groups (control group 15.1%, retransfusion group 13% (p = 0.439)). The incidence of post-operative complications, such as wound infection, deep-vein thrombosis and chest infection, was also comparable between the groups. There were no adverse reactions associated with the retransfusion of autologous blood.

Based on this study, the cost-effectiveness and continued use of autologous drains in total knee replacement should be questioned.