Introduction

Our purpose is to analyze the true costs associated with preoperative CT scans performed for robotic assisted TKA planning and also to determine the value of a formal radiologist reading of these studies.

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. Methods. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map. Results. After screening of 5,660 articles, we included 166 studies reporting prognostic factors for outcomes after rTKA, with a median sample size of 319 patients (30 to 303,867). Overall, 50% of the studies reported prospectively collected data, and 61% of the studies were performed in a single centre. In some studies, multiple associations were reported; 180 different prognostic factors were reported in these studies. The three most frequently studied prognostic factors were reason for revision (213 times), sex (125 times), and BMI (117 times). Studies focusing on functional scores and patient-reported outcome measures as prognostic factor for the outcome after surgery were limited (n = 42). The studies reported 154 different outcomes. The most commonly reported outcomes after rTKA were: re-revision (155 times), readmission (88 times), and reinfection (85 times). Only five studies included costs as outcome. Conclusion. Outcomes and prognostic factors that are routinely registered as part of clinical practice (e.g. BMI, sex, complications) or in (inter)national registries are studied frequently. Studies on prognostic factors, such as functional and sociodemographic status, and outcomes as healthcare costs, cognitive and mental function, and psychosocial impact are scarce, while they have been shown to be important for patients with osteoarthritis. Cite this article: Bone Jt Open 2023;4(5):338–356

Aims. With up to 40% of patients having patellofemoral joint osteoarthritis (PFJ OA), the two arthroplasty options are to replace solely the patellofemoral joint via patellofemoral arthroplasty (PFA), or the entire knee via total knee arthroplasty (TKA). The aim of this study was to assess postoperative success of second-generation PFAs compared to TKAs for patients treated for PFJ OA using patient-reported outcome measures (PROMs) and domains deemed important by patients following a patient and public involvement meeting. Methods. MEDLINE, EMBASE via OVID, CINAHL, and EBSCO were searched from inception to January 2022. Any study addressing surgical treatment of primary patellofemoral joint OA using second generation PFA and TKA in patients aged above 18 years with follow-up data of 30 days were included. Studies relating to OA secondary to trauma were excluded. ROB-2 and ROBINS-I bias tools were used. Results. A total of nine studies were included, made up of four randomized controlled trials (domain 1) and five cohort studies (domain 2). PROMs and knee function specific scores developed for reporting TKA were unable to detect any difference between PFA and TKA. There was no significant difference in complications between PFA and TKA. PFAs were found to have a better postoperative range of motion. Conclusion. TKA and PFA are both viable options for patients with primary PFJ OA. Over time, we have seen an emphasis on patient satisfaction and better quality of life. Recommending sacrificing healthy medial and lateral compartments to treat patellofemoral joint arthritis should be given further thought. Cite this article: Bone Jt Open 2023;4(12):948–956

Aims. Loosening of components after total knee arthroplasty (TKA) can be associated with the development of radiolucent lines (RLLs). The aim of this study was to assess the rate of formation of RLLs in the cemented original design of the ATTUNE TKA and their relationship to loosening. Methods. A systematic search was undertaken using the Cochrane methodology in three online databases: MEDLINE, Embase, and CINAHL. Studies were screened against predetermined criteria, and data were extracted. Available National Joint Registries in the Network of Orthopaedic Registries of Europe were also screened. A random effects model meta-analysis was undertaken. Results. Of 263 studies, 12 were included with a total of 3,861 TKAs. Meta-analysis of ten studies showed high rates of overall tibial or femoral RLLs for the cemented original design of the ATTUNE TKA. The overall rate was 21.4% (95% confidence interval (CI) 12.7% to 33.7%) for all types of design but was higher for certain subgroups: 27.4% (95% CI 13.4% to 47.9%) for the cruciate-retaining type, and 29.9% (95% CI 15.6% to 49.6%) for the fixed-bearing type. Meta-analysis of five studies comparing the ATTUNE TKA with other implants showed a significantly higher risk of overall tibial or femoral RLLs (odds ratio (OR) 2.841 (95% CI 1.219 to 6.623); p = 0.016) for the ATTUNE. The rates of loosening or revision for loosening were lower, at 1.2% and 0.9% respectively, but the rates varied from 0% to 16.3%. The registry data did not report specifically on the original ATTUNE TKA or on revision due to loosening, but ‘all-cause’ five-year revision rates for the cemented ATTUNE varied from 2.6% to 5.9%. Conclusion. The original cemented ATTUNE TKA has high rates of RLLs, but their clinical significance is uncertain given the overall low associated rates of loosening and revision. However, in view of the high rates of RLLs and the variation in the rates of loosening and revision between studies and registries, close surveillance of patients who have undergone TKA with the original ATTUNE system is recommended. Cite this article: Bone Joint J 2023;105-B(6):610–621

Abstract. Customised individually made implants(CIM) total knee arthroplasty(TKA) are custom-made to better fit patients native anatomy and aim to improve outcomes which can be variable with conventional off-the-shelf(OTS). A systematic review and meta-analysis was conducted searching the MEDLINE and Embase databases. Studies reporting on patient reported outcome measures, clinical or radiological outcomes were included. 23 studies satisfied the search criteria (case-control studies14, case series8, cross-sectional studies1). There were 2,856(CIM) and 1,877(OTS) implants. The overall revision-rate was higher in CIM 5.9%vs3.7%OTS [OR 1.46(95% CI 0.82–2.62)]. MUA was higher in the CIM group 2.2%vs.1.1%OTS [OR 2.95(95% CI 0.95–9.13)] and overall complications rate was also higher in the CIM group 5% vs. 4.5%OTS [OR 1.45(95% CI 0.53–3.96)]. LOS was significantly shorter in the CIM group 2.9 days vs. 3.5 days [MD −0.51(95% CI −0.82–0.20)]. Pooled analysis for KSS showed no difference between CIM and OTS groups(Knee=90.5 vs. 90.6 [MD-0.27,(95% CI −4.27–3.73)] and Function=86.1 vs. 90.6[MD 1.51 (95% CI −3.69–6.70)] component of the scores. There was no significant difference in post-operative ROM between CIM and OTS groups 117.3° vs. 115.0° [MD 0.02,(95% CI −1.70–1.74)]. CIM TKAs has theoretical benefits over OTS TKAs however in this review they were associated with higher complication, MUA and revision rates with no difference in outcome scores and no improvement in target alignment. The findings of this review does not support the use of CIM over OTS prosthesis in total knee arthroplasty

Aims. This systematic review and meta-analysis aimed to compare the influence of patellar resurfacing following cruciate-retaining (CR) and posterior-stabilized (PS) total knee arthroplasty (TKA) on the incidence of anterior knee pain, knee-specific patient-reported outcome measures, complication rates, and reoperation rates. Methods. A systematic review of MEDLINE, PubMed, and Google Scholar was performed to identify randomized controlled trials (RCTs) according to search criteria. Search terms used included: arthroplasty, replacement, knee (Mesh), TKA, prosthesis, patella, patellar resurfacing, and patellar retaining. RCTs that compared patellar resurfacing versus unresurfaced in primary TKA were included for further analysis. Studies were evaluated using the Scottish Intercollegiate Guidelines Network assessment tool for quality and minimization of bias. Data were synthesized and meta-analysis performed. Results. There were 4,135 TKAs (2,068 resurfaced and 2,027 unresurfaced) identified in 35 separate cohorts from 33 peer-reviewed studies. Anterior knee pain rates were significantly higher in unresurfaced knees overall (odds ratio (OR) 1.84; 95% confidence interval (CI) 1.20 to 2.83; p = 0.006) but more specifically associated with CR implants (OR 1.95; 95% CI 1.0 to 3.52; p = 0.030). There was a significantly better Knee Society function score (mean difference (MD) -1.98; 95% CI -1.1 to -2.84; p < 0.001) and Oxford Knee Score (MD -2.24; 95% CI -0.07 to -4.41; p = 0.040) for PS implants when patellar resurfacing was performed, but these differences did not exceed the minimal clinically important difference for these scores. There were no significant differences in complication rates or infection rates according to implant design. There was an overall significantly higher reoperation rate for unresurfaced TKA (OR 1.46 (95% CI 1.04 to 2.06); p = 0.030) but there was no difference between PS or CR TKA. Conclusion. Patellar resurfacing, when performed with CR implants, resulted in lower rates of anterior knee pain and, when used with a PS implant, yielded better knee-specific functional outcomes. Patellar resurfacing was associated with a lower risk of reoperation overall, but implant type did not influence this. Cite this article: Bone Joint J 2023;105-B(6):622–634

Abstract. Introduction. Anterior cruciate ligament reconstruction (ACLR) can be performed with a number of different autografts including all soft tissue quadriceps autograft. (QT). QT has several advantages including decreased donor site morbidity, reduced anterior knee pain and comparable revision rates compared to other autografts. The primary aim of this review was to assess all complications of QT in adult population. Methodology. A systematic review of the literature was conducted on in accordance with the PRISMA guidelines using the online databases Medline and EMBASE. Clinical studies or reporting on soft tissue QT were included and appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results. Twelve studies were eligible, giving a total of 774 cases of QT ACLR. The mean age ranged from 18 to 45 years. The mean follow-up ranged from 12 to 55.6 months. Nine studies report on patients’ functional outcomes with mean IKDC score was 90.9 ±22.6 and Lysholm score of 88.6 ±6.5. Seven studies reported on complications which was overall 12.3% including 4.1% for graft site morbidity. Infection was reported in 0.4% of the patients. Seven studies reported on failure rate which was reported in 5.3%. Re-operation rate for any reason was 3.2 %. Conclusion. All soft tissue QT for ACLR has a low complication rate and revision rate. There is less graft site morbidity

Abstract. Purpose. Recently several authors have suggested a correlation between posterior tibial slope (PTS) and sagittal stability of the knee. However, there is a lack of consensus in the literature relating to measurement, normal values and important values to guide treatment. We performed a systematic literature review looking at PTS and cruciate ligament surgery. Our aim was to define a gold standard measurement technique, determine normal ranges and important values for consideration during cruciate ligament surgery. Methods. Electronic searches of MEDLINE (PubMed), CINAHL, Cochrane, Embase, ScienceDirect, and NICE in June 2020 were completed. Inclusion criteria were original studies in peer-reviewed English language journals. A quality assessment of included studies was completed using the Methodological Index for Non-Randomized Studies (MINORS) Criteria. Results. Two-hundred and twenty-one papers were identified; following exclusions 34 papers were included for data collection. The mean MINORS score for non-comparative studies was 13.8 and for comparative studies 20.4, both indicating fair to good quality studies. A large variation in PTS measurement technique was identified, resulting in a wide range of values reported. In addition, there appears to be significant variation between different races, ages and genders. Conclusion. We demonstrated a lack of consensus in the literature relating to various facets of PTS. Cautiously, we suggest normal ranges of 6–12º using the proximal tibia axis at 5 and 15cms below the joint. Potentially 12º is an important cute-off for slope reducing osteotomy as an adjunct to revision ACL reconstruction

Abstract. Introduction. This study aimed to assess the effect of PRP on knee articular cartilage content (thickness and/or volume) and establish if there is a correlation between changes in cartilage and clinical outcomes in patients with knee osteoarthritis. Methodology. A systematic review was performed following the Cochrane methodology. Studies were included if they reported on cartilage content with MRI or Ultrasound before and after the injection. A random-effects model meta-analysis was performed. Results. 11 studies (n=786) from 1,453 records met the inclusion criteria, with five (n=444) being RCTs. The PRP treatment protocol varied widely. Follow-up ranged from 6–12 months. Eight studies reported increase in cartilage content in the PRP group as compared to control (four showing significant difference). In meta-analysis: PRP treatment was not associated with a significant increase in cartilage thickness in medial and lateral femoral condyle, or in the overall cartilage content (4 studies, n=187, Hedges’ g: 0.079; 95%CI: 0.358-0.516; p=0.723). Meta-analysis of 3 RCTs (n=112) showed no significant difference in increasing cartilage content overall with PRP injections compared with no PRP (Hedges’ g: 0.217; 95%CI: -0.177 – 0.611; P=0.281). There was no correlation between changes in cartilage and clinical outcomes following PRP treatment. Conclusion. Treatment of knee osteoarthritis with PRP is not associated with a significant increase in articular cartilage content and any effect on cartilage is not associated with better clinical outcomes. A multi-centre, adequately powered RCT, with a standardized preparation / administration protocol assessing long-term effect of PRP in knee osteoarthritis is needed to guide clinical care

Aims. Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity. Methods. A systematic literature search was performed in the databases PubMed, EMBASE, Cochrane Library, and Web of Science. Search terms consisted of “total knee arthroplasty/replacement” combined with “hindfoot/ankle alignment”. Inclusion criteria were all English language studies analyzing the association between TKA and the alignment of the hindfoot, including the clinical or radiological outcomes. Exclusion criteria consisted of TKA performed with a concomitant extra-articular osteotomy and case reports or expert opinions. An assessment of quality was conducted using the modified Methodological Index for Non-Randomized Studies (MINORS). The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the PROSPERO database (CRD42019106980). Results. A total of 17 studies were found to be eligible for review. They included six prospective and ten retrospective studies, and one case-control study. The effects of TKA showed a clinical improvement in the hindfoot deformity in three studies, but did not if there was osteoarthritis (OA) of the ankle (one study) or a persistent deformity of the knee (one study). The radiological alignment of the hindfoot corrected in 11 studies, but did not in the presence of a rigid hindfoot varus deformity (in two studies). The effects of a hindfoot deformity on TKA included a clinical association with instability of the knee in one study, and a shift in the radiological weightbearing axis in two studies. The mean MINORS score was 9.4 out of 16 (7 to 12). Conclusion. TKA improves both the function and alignment of the hindfoot in patients with a preoperative deformity of the hindfoot. This may not apply if there is a persistent deformity of the knee, a rigid hindfoot varus deformity, or OA of the ankle. Moreover, a persistent deformity of the hindfoot may adversely affect the stability and longevity of a TKA. These findings should be interpreted with caution due to the moderate methodological quality of the studies which were included. Therefore, further prospective studies are needed in order to determine at which stage correction of a hindfoot deformity is required to optimize the outcome of a TKA. Cite this article: Bone Joint J 2021;103-B(1):87–97

Aims. For many designs of total knee arthroplasty (TKA) it remains unclear whether cemented or uncemented fixation provides optimal long-term survival. The main limitation in most studies is a retrospective or non-comparative study design. The same is true for comparative trials looking only at the survival rate as extensive sample sizes are needed to detect true differences in fixation and durability. Studies using radiostereometric analysis (RSA) techniques have shown to be highly predictive in detecting late occurring aseptic loosening at an early stage. To investigate the difference in predicted long-term survival between cemented, uncemented, and hybrid fixation of TKA, we performed a randomized controlled trial using RSA. Methods. A total of 105 patients were randomized into three groups (cemented, uncemented, and hybrid fixation of the ACS Mobile Bearing (ACS MB) knee system, implantcast). RSA examinations were performed on the first day after surgery and at scheduled follow-up visits at three months, six months, one year, and two years postoperatively. Patient-reported outcome measures (PROMs) were obtained preoperatively and after two years follow-up. Patients and follow-up investigators were blinded for the result of randomization. Results. RSA secondary stabilization did not show a significant difference between the three types of fixation. A maximum total point motion of less than 0.2 mm in the second postoperative year was shown in each group, which suggests stabilization of the implant. At 24 months after surgery, PROMs significantly improved compared to baseline in all treatment groups. No significant difference was observed between the three groups. Conclusion. Secondary stabilization measurements in this study demonstrated no significant difference between the groups. In all groups migration stabilized after initial settling of the implant. For this implant the long-term outcome is not expected to be influenced by the type of fixation to the bone. Cite this article: Bone Joint J 2021;103-B(1):98–104

Aims. Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties. Methods. Well-functioning primary TKAs (n = 11), failed non-fibrotic TKAs (n = 5), and patients with a clinical diagnosis of fibrosis. 1. (n = 8) underwent an MRI scan with advanced metal suppression (Slice Encoding for Metal Artefact Correction, SEMAC) with gadolinium contrast. Fibrotic tissue (low intensity on T1 and T2, low-moderate post-contrast enhancement) was quantified (presence and tissue thickness) in six compartments: supra/infrapatella, medial/lateral gutters, and posterior medial/lateral. Results. Fibrotic tissue was identified in all patients studied. However, tissue was significantly thicker in fibrotic patients (4.4 mm ± 0.2 mm) versus non-fibrotic (2.5 mm ± 0.4 mm) and normal TKAs (1.9 mm ± 0.2 mm, p = < 0.05). Significant (> 4 mm thick) tissue was seen in 26/48 (54%) of compartments examined in the fibrotic group, compared with 17/30 (57%) non-fibrotic, and 10/66 (15%) normal TKAs. Although revision surgery did improve range of movement (ROM) in all fibrotic patients, clinically significant restriction remained post-surgery. Conclusion. Stiff TKAs contain intra-articular fibrotic tissue that is identifiable by MRI. Studies should evaluate whether MRI is useful for surgical planning of debridement, and as a non-invasive measurement tool following interventions for stiffness caused by fibrosis. Revision for stiffness can improve ROM, but outcomes are sub-optimal and new treatments are required. Cite this article: Bone Joint J 2020;102-B(10):1331–1340

Aims

Multiligament knee injuries (MLKI) are devastating injuries that can result in significant morbidity and time away from sport. There remains considerable variation in strategies employed for investigation, indications for operative intervention, outcome reporting, and rehabilitation following these injuries. At present no study has yet provided a comprehensive overview evaluating the extent, range, and overall summary of the published literature pertaining to MLKI. Our aim is to perform a methodologically rigorous scoping review, mapping the literature evaluating the diagnosis and management of MLKI.

Introduction. One of the more common complaints from patients in their post-operative total knee arthroplasty (TKA) is the perceived feeling of the operative leg feeling longer than the non-operative leg. Studies have shown that the leg length discrepancies may occur in up to 80% of patients following unilateral TKA patients. The purpose of this study was to determine the incidence of leg length discrepancy (LLD) after primary TKA as well as determine the correlation between deformity and incidence of LLD. Methods. We retrospectively reviewed 1108 patients who underwent a primary unilateral TKA at a single institution. 97 patients were excluded for lack of imaging, prior total hip replacement or body mass index greater than 40 kg/m2. Hip to ankle biplanar radiographs were obtained pre-operative and 6 weeks postoperatively for all patients. Two independent observers measures leg length, femur length, tibia length, overall alignment and deformity present for all radiographs. Results. 1,101 patients were included. Mean overall lengthening was 3.4 mm [Range −21 to 22.8mm; SD 7.4] with 81% of limbs lengthened. In our cohort, 9% of patients had LLD greater than 10 mm and 43% of patients had LLD of more than 5mm after TKA. Post-operative radiographic LLD was associated with increased pre-operative LLD (P<.001) and with female gender (p=0.03). Patients with pre-operative valgus deformity were more likely to have an increased lengthening of greater than 5mm compared to patients with varus deformity (OR:1.66). Conclusion. 43% of patients will have a LLD >5mm following correction of deformity and ligament balances in knee replacement surgery. Surgeons should be aware and this should be reviewed with patients as part of their expectations of surgery. For figures, tables, or references, please contact authors directly

Aims

The mean age of patients undergoing total knee arthroplasty (TKA) has reduced with time. Younger patients have increased expectations following TKA. Aseptic loosening of the tibial component is the most common cause of failure of TKA in the UK. Interest in cementless TKA has re-emerged due to its encouraging results in the younger patient population. We review a large series of tantalum trabecular metal cementless implants in patients who are at the highest risk of revision surgery.

Aims

While residual fixed flexion deformity (FFD) in unicompartmental knee arthroplasty (UKA) has been associated with worse functional outcomes, limited evidence exists regarding FFD changes. The objective of this study was to quantify FFD changes in patients with medial unicompartmental knee arthritis undergoing UKA, and investigate any correlation with clinical outcomes.

Aims

The use of high tibial osteotomy (HTO) to delay total knee arthroplasty (TKA) in young patients with osteoarthritis (OA) and constitutional deformity remains debated. The aim of this study was to compare the long-term outcomes of TKA after HTO compared to TKA without HTO, using the time from the index OA surgery as reference (HTO for the study group, TKA for the control group).

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To investigate the impact of consecutive perioperative care transitions on in-hospital recovery of patients who had primary total knee arthroplasty (TKA) over an 11-year period.

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Implantation of ultra-purified alginate (UPAL) gel is safe and effective in animal osteochondral defect models. This study aimed to examine the applicability of UPAL gel implantation to acellular therapy in humans with cartilage injury.

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Unicompartmental knee arthroplasty (UKA) is the preferred treatment for anterior medial knee osteoarthritis (OA) owing to the rapid postoperative recovery. However, the risk factors for UKA failure remain controversial.