The kinematic alignment (KA) approach to total knee arthroplasty (TKA) has recently increased in popularity. Accordingly, a number of derivatives have arisen and have caused confusion. Clarification is therefore needed for a better understanding of KA-TKA. Calipered (or true, pure) KA is performed by cutting the bone parallel to the articular surface, compensating for cartilage wear. In soft-tissue respecting KA, the tibial cutting surface is decided parallel to the femoral cutting surface (or trial component) with in-line traction. These approaches are categorized as unrestricted KA because there is no consideration of leg alignment or component orientation. Restricted KA is an approach where the periarthritic joint surface is replicated within a safe range, due to concerns about extreme alignments that have been considered ‘alignment outliers’ in the neutral mechanical alignment approach. More recently, functional alignment and inverse kinematic alignment have been advocated, where bone cuts are made following intraoperative planning, using intraoperative measurements acquired with computer assistance to fulfill good coordination of soft-tissue balance and alignment. The KA-TKA approach aims to restore the patients’ own harmony of three knee elements (morphology, soft-tissue balance, and alignment) and eventually the patients’ own kinematics. The respective approaches start from different points corresponding to one of the elements, yet each aim for the same goal, although the existing implants and techniques have not yet perfectly fulfilled that goal.

Abstract. Introduction. Secondary osteonecrosis of the knee affects young population and causes bilateral extensive lesions. Arthroplasty is the last resort in younger population and joint preserving options questionable in pathological bone. Conservative measures have shown failure in multiple studies and hence no gold standard treatment advocated. We aimed at identifying and analysing various treatment options for secondary osteonecrosis with respect to the outcomes and studying features of symptomatic secondary osteonecrosis with regards to demographic pattern, radiological features and causative factors. Methods. A systematic review of literature was performed in accordance with the Cochrane handbook for systematic reviews and reported according to the PRISMA guidelines. Results. Six studies which included a total of 192 patients with data on 240 knee joints were included in the final review. Follow up period ranged from 1 year to 16 years. The mean age of the patients was 34.7. 3 studies were on arthroplasty and 3 on joint preserving interventions. Majority of patients were in Stage 2 or Stage 4 of osteonecrosis. Steroid induced osteonecrosis was the majority followed by SLE and sickle cell disease. The pooled analysis showed an improvement of pre-operative knee score from 50.47 to 89.21 post-operatively. The pooled effect size for failure rate was 8.7% in joint preserving interventions and 9.2% in joint replacement group. Conclusion. Joint preserving techniques with bone marrow aspirate infiltration showed promising functional outcome and to a certain extent reversal of the pathological process. For advanced stages with subchondral collapse cemented arthroplasty showed satisfactory functional outcomes

Abstract. Introduction. Recent research has questioned the role of arthroscopic meniscectomy in patients with a meniscal tear leading to the development of treatment recommendations for these patients. There is a clear need to understand patient perceptions of living with a meniscal tear in order to plan future research and treatment guidelines. Aims. To explore the experiences and expectations of treatment of young patients with a meniscal tear of the knee. Methodology. Ten participants diagnosed with a meniscal tear were recruited from the METRO cohort study using a purposive sampling strategy. These patients underwent semi-sructured interviews between April and May 2021. Thematic analysis was used to code the transcripts and generate key themes in order to describe the data. Results. Themes identified relate to the broad areas of: the effect of symptoms, the expericne of the clinical consultation and the experience of the treatment modality undertaken. Meniscal tears have a profound impact on pain and many patients experience effects on their family and financial life in addition to physical symptoms. Participants expected the majority of their management to occur in secondary care and most thought surgery would be a definitive treatment, while the effectiveness of physiotherapy could not be guaranteed as it would not fix the physical tear. Conclusion. Patient experience of meniscal tear may not correspond with current available clinical evidence. Clinicians should consider the common misconceptions highlighted in this study when conducting a consultation and pre-empt them to optimally manage patient expectations

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required

Abstract. Introduction. Total knee replacement (TKR) aims to reduce pain and functional limitations. Despite a good outcome for many, 15–20% patients report chronic pain three months after TKR. The STAR Care Pathway is a clinically important and cost effective treatment to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery. The care pathway is delivered by specially trained Extended Scope Practitioners (ESPs). There is a gap between research findings and translation into practice. This work shows how the STAR trial findings were implemented into NHS practice at a single centre and the further work required to enable national implementation. Methodology. Trial findings were presented to NHS managers with a business case for an implementation pilot. Trial documentation was adapted for use in usual care using the COM-B model for behaviour change and evidence-based approaches to increase the return of postal questionnaires. Trial sites were contacted to understand their capacity to implement the intervention locally. Results. The STAR care pathway was successfully implemented into NHS practice with a screening response rate of 83%. It is now permanently part of usual care at North Bristol NHS Trust. Trial centres indicated that lack of availability of STAR trained ESPs as a barrier to implementation. The trial manual and training session were adapted for online delivery in partnership with Health Education England. Conclusion. The STAR care pathway has been successfully embedded into NHS care. A toolkit and online clinician training package enables national implementation

Abstract. Introduction. The prevalence of recurrent infection following two-stage exchange arthroplasty following failure of a total knee arthroplasty (TKA) has been reported to be 10% to 25%. There is limited literature available on repeat two stage revisions for TKA infection with only small cohorts and variable success rates. Methodology. A retrospective cohort study investigating the outcome of two stage revision arthroplasty for treatment of TKA infection was conducted with the aim of identifying factors linked to recurrence of infection. A consecutive cohort of all microbiology intra-operative periprosthetic knee samples from a single revision arthroplasty centre between January 2010 and December 2016 was identified. The final cohort consisted of 658 samples taken during 64 patients undergoing two stage revision knee surgery for infection. Patient demographics, medical and orthopaedic history data including post-operative outcomes and subsequent treatment was obtained from the electronic records system and medical notes. Results. 65.6% of the cohort (N=42) had successful eradication of their infection. For the twenty-two patients that had failure of their two stage revision, twenty patients had samples available from further surgical intervention. Sixteen patients (80%) had different organisms isolated when they had repeat surgical samples taken when compared to their first stage samples. Overall, for subsequent treatments there was a success rate of 75% if the same organism was identified and 62.5% if there were new isolated organisms. Conclusion. These findings may have implications for the treatment strategies chosen for re-infection after two stage TKA revisions if new causative organisms are isolated

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.

Abstract. Introduction. Approximately 15–20% of patients report chronic pain three months after total knee replacement (TKR). The STAR care pathway is a clinically important and cost-effective personalised intervention for patients with pain 3 months after TKR. The pathway comprises screening, assesment, onward referral for treatment and follow-up over one year. In a multicentre randomised controlled trial comparing the pathway with usual care, the pathway improved pain at 6 and 12 months. This study examined the longer-term clinical and cost-effectiveness of the STAR care pathway. Methodology. STAR trial participants were followed-up at a median of 4 years post-randomisation. Co-primary outcomes were self-reported pain severity and interference in the replaced knee, assessed with the Brief Pain Inventory (BPI). Resource use from electronic hospital records was valued with UK reference costs. Results. Of the 337 participants active at trial completion, 326 had confirmed vital status, and 226 (69%) provided outcome data at a median of 4 years. The between-group difference in mean BPI severity score was −0.42 (95% CI −1.07, 0.23; p=0.20) and for BPI interference was −0.64 (95% CI −1.41, 0.12; p=0.10), favouring the intervention. Multiple imputation analyses led to attenuations of about 0.2 points. Mean hospital admission costs over four years were £2461.49 (95% CI £1354.42, £3568.57) in the intervention arm and £3791.68 (95% CI £2095.12, to £5488.24) in usual care. Conclusion. These data are consistent with sustained benefits from the STAR care pathway at 4 years, albeit attenuated and with wider confidence intervals, in part attributable to attrition after 1 year

Aims. Two-stage exchange arthroplasty is the most common definitive treatment for prosthetic joint infection (PJI) in the USA. Complications that occur during treatment are often not considered. The purpose of this study was to analyze complications in patients undergoing two-stage exchange for infected total knee arthroplasty (TKA) and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI of the knee from January 2010 to December 2018 at a single institution. We categorized complications as medical versus surgical. The intervals for complications were divided into: interstage; early post-reimplantation (three months); and late post-reimplantation (three months to minimum one year). Minimum follow-up was one year. In total, 134 patients underwent a first stage of a two-stage exchange. There were 69 males and 65 females with an mean age at first stage surgery of 67 years (37 to 89). Success was based on the new Musculoskeletal Infection Society (MSIS) definition of success reporting. Results. Overall, 70 (52%) patients experienced a complication during the planned two-stage treatment, 36 patients (27%) experienced a medical complication and 47 (41%) patients experienced a surgical complication. There was an 18% mortality rate (24/134) at a mean of 3.7 years (0.09 to 8.3). During the inter-stage period, 28% (37/134) of patients experienced a total of 50 complications at a median of 47 days (interquartile range (IQR) 18 to 139). Of these 50 complications, 22 were medical and 28 required surgery. During this inter-stage period, four patients died (3%) and an additional five patients (4%) failed to progress to the second stage. While 93% of patients (125/134) were reimplanted, only 56% (77/134) of the patients were successfully treated without antibiotic suppression (36%, 28/77) or with antibiotic suppression (19%, 15/77) at one year. Conclusion. Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment. Cite this article: Bone Joint J 2020;102-B(6 Supple A):145–150

Abstract

Introduction. Pulmonary embolism (PE) complicates up to 1% of total joint arthroplasties (TJA). Many PE treatment guidelines call for immediate initiation of therapeutic anticoagulation. Options include Xa inhibitors, Enoxaparin, and Warfarin. Deciding between these is a balance of the efficacy and the risks. Little data exists regarding the risks of each of these treatment options for treating PE in arthroplasty patients. Methods. We examined the records of 29,270 patients who underwent a primary total joint arthroplasty (TJA), defined as a unilateral total knee arthroplasty (TKA) (18,987) or total hip arthroplasty (THA) (10,283), between 2/2016 and 12/2018 at our institution and identified 338 (242 TKA, 96 THA) patients who developed an in-hospital PE treated with therapeutic anticoagulation. The patients were treated with therapeutic doses of Xa inhibitors, enoxaparin or warfarin. The type and frequency of complications were determined and classified as major or minor. Major complication included: bleeding requiring surgery, GI bleed requiring treatment, >2 unit transfusion and mortality. Minor complications included wound drainage, bleeding not requiring surgery, and thrombocytopenia. Results. Overall complication rates were high for all treatments. Xa inhibitors had the lowest complication rate at 14% compared to 20% for enoxaparin and 20.7% for warfarin though the difference did not quite reach statistical significance (p=.054). Both major and minor complication were lower with Xa inhibitors, but again the difference was not statistically significant (p=0.67). There was no significant difference in complications between TKA groups (p=0.73) or THA groups (p=0.83). Gender and body mass index were not predictive of major or minor complications. Discussion. Our results demonstrate high complication rates associated with modern therapeutic anticoagulation protocols for perioperative PE following TJA. Patients who receive therapeutic anticoagulation postoperatively are at high risk for complication. Xa inhibitors may decrease these risks, but larger studies are required

Introduction. Two-stage exchange arthroplasty remains the gold standard for treatment of PJI with reported success rates of 85–90%. Complications that occur during treatment are often not reported or considered in the success rate. The purpose of this study was to analyze complications in patients undergoing two-stage exchange and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of chronic PJI of the knee from 2010 to 2018. We categorized complications as medical vs. surgical. The intervals for complications were divided into: interstage, early post re-implant (3 months) and late post re-implant (3 months to minimum 1 year). Minimum follow-up to evaluate complications was one year. Results. Overall, 132 patients underwent a first stage of a two-stage exchange. There were 63 males and 59 females with an average age at first stage surgery of 66.6 years (SD: 8.9). Ten patients (7.6%) did not undergo re-implantation following resection arthroplasty (8 retained spacers and 2 deaths). 122 patients underwent the planned second stage of a two-stage exchange arthroplasty of the knee. The overall success rate (re-implant without recurrence of infection) was 78%. Overall mortality was 1.6% at one year and 9% at 5 years after treatment. Fifty-six patients (46%) experienced at least one complication. 43 patients had an orthopaedic related complication that required additional surgery and 13 patients had a medical complication. 33% of the total complications occurred during the interstage period, 18% within 90 days of reimplant, and 37% greater than three months from reimplant (p=0.0287). Discussion. Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment and the need for in-depth patient counseling, careful surgical technique, and close follow up. For figures, tables, or references, please contact authors directly

Aims. The aim of this study was to assess the effects of transferring patients to a specialized arthroplasty centre between the first and second stages (interstage) of prosthetic joint infection (PJI) of the knee. Patients and Methods. A search of our institutional database was performed to identify patients having undergone two-stage revision total knee arthroplasty (TKA) for PJI. Two cohorts were created: continuous care (CC) and transferred care (TC). Baseline characteristics and outcomes were collected and compared between cohorts. Results. A total of 137 patients were identified: 105 in the CC cohort (56 men, 49 women; mean age 67.9) and 32 in the TC cohort (17 men, 15 women; mean age 67.8 years). PJI organism virulence was greater in the CC cohort (36.2% vs 15.6%; p = 0.030). TC patients had a higher rate of persisting or recurrent infection (53.6% vs 13.4%; p < 0.001), soft-tissue complications (31.3 vs 14.3%; p = 0.030), and reduced requirement for porous metal augments (78.1% vs 94.3%; p = 0.006). Repeat first stage debridement after transfer led to greater need for plastic surgical procedures (58.3% vs 0.0%; p < 0.001). Conclusion. Patient transfer during the interstage of treatment for infected TKA leads to poorer outcomes compared with patients receiving all their treatment at a specialized arthroplasty centre. Cite this article: Bone Joint J 2019;101-B:1087–1092

Abstract

The treatment of osteochondral lesions is of great interest to orthopaedic surgeons because most lesions do not heal spontaneously. We present the short-term clinical outcome and MRI findings of a cell-free scaffold used for the treatment of these lesions in the knee. A total of 38 patients were prospectively evaluated clinically for two years following treatment with an osteochondral nanostructured biomimetic scaffold. There were 23 men and 15 women; the mean age of the patients was 30.5 years (15 to 64). Clinical outcome was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Tegner activity scale and a Visual Analgue scale for pain. MRI data were analysed based on the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system at three, 12 and 24 months post-operatively. There was a continuous significant clinical improvement after surgery. In two patients, the scaffold treatment failed (5.3%) There was a statistically significant improvement in the MOCART precentage scores. The repair tissue filled most of the defect sufficiently. We found subchondral laminar changes in all patients. Intralesional osteophytes were found in two patients (5.3%). We conclude that this one-step scaffold-based technique can be used for osteochondral repair. The surgical technique is straightforward, and the clinical results are promising. The MRI aspects of the repair tissue continue to evolve during the first two years after surgery. However, the subchondral laminar and bone changes are a concern. Cite this article: Bone Joint J 2015; 97-B:318–23

This study looks at the use of rotating hinge Total Knee Replacement (TKR) as a treatment option when dealing with fractures involving the knee. The treatment of complex intra-articular fractures involving the knee has always proved challenging. Studies have investigated the outcome of various forms of treatment for such injuries, including internal fixation and primary knee arthroplasty. Recent advances in technology have brought about more sophisticated implants for both internal fixation and arthroplasty, including rotating hinge TKR. The initial non-rotating hinged prostheses for total knee arthroplasty did not enjoy a good reputation. The cumulative survival rate has been quoted as 65% at 6 years, significantly lower than that of conventional prostheses. Therefore the use of such implants was restricted to complex primary or revision arthroplasty, and tumour surgery. Studies have been published advocating the use of hinged prostheses for distal femoral fractures in elderly patients. The average age in the most recent study was 82, of whom 42% had died within the first post-operative year. This study is a case series of 16 patients with fractures who were treated with rotating hinge TKR. The age range is 36 to 92, with a mean of 69, lower than that of earlier studies. Outcome data as measured by the Oxford knee scoring system has been retrospectively collected. At follow up the range of Oxford knee scores was 14 to 52, with a mean of 36. We discuss the indications, experiences and outcomes in the management of these patients, and conclude that this is a valid treatment option in certain circumstances

Objectives. Matrix-assisted autologous chondrocyte transplantation (MACT) has been developed and applied in the clinical practice in the last decade to overcome most of the disadvantages of the first generation procedures. The purpose of this systematic review is to document and analyse the available literature on the results of MACT in the treatment of chondral and osteochondral lesions of the knee. Methods. All studies published in English addressing MACT procedures were identified, including those that fulfilled the following criteria: 1) level I-IV evidence, 2) measures of functional or clinical outcome, 3) outcome related to cartilage lesions of the knee cartilage. Results. The literature analysis showed a progressively increasing number of articles per year. A total of 51 articles were selected: three randomised studies, ten comparative studies, 33 case series and five case reports. Several scaffolds have been developed and studied, with good results reported at short to medium follow-up. Conclusions. MACT procedures are a therapeutic option for the treatment of chondral lesions that can offer a positive outcome over time for specific patient categories, but high-level studies are lacking. Systematic long-term evaluation of these techniques and randomised controlled trials are necessary to confirm the potential of this treatment approach, especially when comparing against less ambitious traditional treatments

Aim. To determine the effect of the use of radial extracorporeal shockwave therapy (rESWT) in the treatment of patellar tendinopathy. Methods. Between 2005 and 2010, twenty eight patients (34 knees), who showed poor or no result from conservative management, had rESWT for patellar tendinopathy. The device used is Swiss Dolorclast¯(EMS, Switzerland). All patients received three weekly sessions of 2000 impulses at 3.0 bar (energy flux density = 0.14 mJ/mm. 2. ) and a frequency of 15 Hz. We assessed pain, function and activity and quality of life of the patient before and three months after treatment using KOOS (Knee Injury and Osteoarthritis Outcome Score). Results. There were 21 males (25 knees) and 7 females (9 knees) with a median age of 31 years (18 - 60). Twenty two of the 28 patients (78.6%) reported excellent or good improvement. After three months of treatment with rESWT, the average KOOS score increased from 50.4 to 71.1 (p = 0.004). Conclusion. This study has shown that radial extracorporeal shockwave therapy demonstrated an improvement in the functional activity and reduction in the pain. Patellar tendinopathy that does not respond to conservative management can be successfully treated with rESWT

Introduction. Autologous chondrocyte implantation presents a viable alternative to microfracture in the repair of damaged articular cartilage of the knee; however, outcomes for patellar lesions have been less encouraging. ChondroCelect (CC) is an innovative, advanced cell therapy product consisting of autologous cartilage cells expanded ex vivo through a highly controlled and consistent manufacturing process. Purpose. To assess the effect of CC in the treatment of patellofemoral lesions, for which standard treatment options had failed and/or no other treatment options were considered feasible. Methods. CC was administered to 61 patients with patellar lesions (predominantly secured with a biological membrane; mean lesion size: 3.6 cm. 2. ; aged 32.4 years). Efficacy was assessed with validated scales of Clinical Global Impression for Improvement (CGI-I) and Therapeutic Effect (CGI-E) and stratified by the postoperative follow-up period (<18 months vs >18 months). Results. CC resulted in therapeutic and clinical improvement in 87% of patients. Long-term follow-up showed a modest shift towards worse CGI-I and CGI-E scores, with the ‘very much improved’ subgroup (CGI-I) during the first 18 months (38.5%) moderately reduced after 18 months (25.0%); however, the proportion of improved patients remained consistent. The most commonly reported adverse events (knee pain [23%], joint crepitation [13.1%], joint range of motion decreased [13.1%], arthrofibrosis [8.2%] and tendon disorder [8.2%]) were reported at incidences higher than those associated with femoral condyle and trochlea lesions. There were no reports of cartilage hypertrophy. Conclusion. CC was effective in the treatment of patellofemoral lesions, with results comparable to outcomes for femoral condyle and trochlear lesions. The higher incidence of some adverse events suggests that the risk-benefit balance of CC varies with lesion location. However, there were no major safety concerns and the safety profile of CC was greatly enhanced by absence of cartilage hypertrophy, demonstrating that collagen membranes can eliminate periosteum-associated events

As part of the national initiative to reduce waiting times for joint replacement surgery in Wales, the Cardiff and Vale NHS Trust referred 224 patients to the NHS Treatment Centre in Weston-Super-Mare for total knee replacement (TKR). A total of 258 Kinemax TKRs were performed between November 2004 and August 2006. Of these, a total of 199 patients (232 TKRs, 90%) have been followed up for five years. This cohort was compared with 258 consecutive TKRs in 250 patients, performed at Cardiff and Vale Orthopaedic Centre (CAVOC) over a similar time period. The five year cumulative survival rate was 80.6% (95% confidence interval (CI) 74.0 to 86.0) in the Weston-Super-Mare cohort and 95.0% (95% CI 90.2 to 98.2) in the CAVOC cohort with revision for any reason as the endpoint. The relative risk for revision at Weston-Super-Mare compared with CAVOC was 3.88 (p < 0.001). For implants surviving five years, the mean Oxford knee scores (OKS) and mean EuroQol (EQ-5D) scores were similar (OKS: Weston-Super-Mare 29 (2 to 47) vs CAVOC 29.8 (3 to 48), p = 0.61; EQ-5D: Weston-Super-Mare 0.53 (-0.38 to 1.00) vs CAVOC 0.55 (-0.32 to 1.00), p = 0.79). Patients with revised TKRs had significantly lower Oxford knee and EQ-5D scores (p < 0.001). The results show a higher revision rate for patients operated at Weston-Super-Mare Treatment Centre, with a reduction in functional outcome and quality of life after revision. This further confirms that patients moved from one area to another for joint replacement surgery fare poorly