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Revision total knee arthroplasty (rTKA) is a technically challenging and costly procedure. It is well-documented that primary TKA (pTKA) have better survivorship than rTKA; however, we were unable to identify any studies explicitly investigating previous rTKA as a risk factor for failure following rTKA. The purpose of this study is to compare the outcomes following rTKA between patients undergoing index rTKA and those who had been previously revised.

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The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution.

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In total knee arthroplasty (TKA), blood loss continues internally after surgery is complete. Typically, the total loss over 48 postoperative hours can be around 1,300 ml, with most occurring within the first 24 hours. We hypothesize that the full potential of tranexamic acid (TXA) to decrease TKA blood loss has not yet been harnessed because it is rarely used beyond the intraoperative period, and is usually withheld from ‘high-risk’ patients with a history of thromboembolic, cardiovascular, or cerebrovascular disease, a patient group who would benefit greatly from a reduced blood loss.

Aims. This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure. Methods. A total of 59 participants with symptomatic Kellgren-Lawrence grade 2 knee OA were randomly allocated to TAE or a sham procedure. The intervention group underwent TAE of one or more genicular arteries. The control group received a blinded sham procedure. The primary outcome was knee pain at 12 months according to the Knee injury and Osteoarthritis Outcome Score (KOOS) pain scale. Secondary outcomes included self-reported function and quality of life (KOOS, EuroQol five-dimension five-level questionnaire (EQ-5D-5L)), self-reported Global Change, six-minute walk test, 30-second chair stand test, and adverse events. Subgroup analyses compared participants who received complete embolization of all genicular arteries (as distinct from embolization of some arteries) (n = 17) with the control group (n = 29) for KOOS and Global Change scores at 12 months. Continuous variables were analyzed with quantile regression, adjusting for baseline scores. Dichotomized variables were analyzed with chi-squared tests. Results. Overall, 58 participants provided questionnaire data at 12 months. No significant differences were found for the primary and secondary outcomes, with both groups improving following the procedure. At 12 months, KOOS pain scores improved by 41.3% and 29.4% in the intervention and control groups, respectively. No adverse events occurred. Subgroup analysis indicated that the complete embolization group had significantly better KOOS Sports and Recreation, KOOS Quality of Life, and Global Change scores than the control group; 76.5% of participants who received complete embolization reporting being moderately or much better compared to 37.9% of the control group. Conclusion. TAE might produce benefits above placebo, but only when complete embolization of all genicular arteries is performed. Further comparative studies are required before definitive conclusions regarding the effectiveness of TAE can be made. Level of evidence: I. Cite this article: Bone Jt Open 2023;4(3):158–167

Introduction. The ideal type of total knee arthroplasty (TKA) prosthesis remains a debatable topic with many different options available. Uncemented TKA has been a viable option due to its decreased operating room (OR) time but also because of its proposed improved long term fixation. Unfortunately, in the past uncemented TKA was associated with increased blood loss. Surgical technique and perioperative treatments have changed since these original studies and tranexamic acid (TXA) has become the gold standard for TKA blood loss management. The objective of this study was to evaluate if there was a difference in hemoglobin and hematocrit change, along with blood loss volume during surgery between cemented and cementless TKA when modern blood loss techniques are utilized. Methods. We retrospectively reviewed data from TKAs performed by three high volume surgeons between 2016 and 2019. We excluded bilateral TKA, revisions, hardware removal intraoperatively and other indications for TKA than primary OA. Power analysis determined 85 patients in both the cementless and cemented TKA groups. Patients were matched 1:1 for age, sex, BMI and surgeon. Use of TXA, intraoperative blood loss, differences in hemoglobin and hematocrit pre- and postoperatively days one, two, and three were recorded. Continuous variables were analyzed using T-tests and categorical variables were evaluated using Chi-squared tests. Results. No significant difference was observed between the cementless and cemented groups for hemoglobin (p=0.214), hematocrit (p=0.164), or intraoperative blood loss volume (p=0.343). A trend towards significantly shorter OR time was seen in the cementless group (p = 0.058). Conclusion. With modern TKA surgery, including the use of TXA, there is no difference in perioperative blood loss between cemented and cementless TKA. Unlike previous studies, the use of modern blood loss salvage techniques in conjunction with cementless TKA fixation, does not result in more blood loss during the perioperative period

Introduction. Recent focus has queried whether of deoxyribonucleic acid (DNA) sequencing modalities of bacterial DNA found in periarticular fluid and tissues will improve in periprosthetic joint infection (PJI) diagnosis and organism identification diagnostic accuracy for periprosthetic joint infection The purpose of this study was to compare the diagnostic accuracy of next generation sequencing (NGS) to polymerase chain reaction (PCR) multiplex, and culture, the Musculoskeletal Infection Society (MSIS) criteria, and the recently proposed criteria by Parvizi et al. [1] in the diagnosis of periprosthetic knee infections. Methods. In this retrospective study, aspirate or tissue samples were collected in 70 revision and 58 primary knee arthroplasties for routine diagnostic workup for PJI and sent to the laboratory for NGS and PCR multiplex. Concordance along with statistical differences between diagnostic studies were calculated using Chi-squared test for categorical data. Results. When comparing to the MSIS criteria, concordance was 78.1% for NGS, 66.4% for PCR, and 85.9% for culture (p<0.001). There was no significant difference based on prior infection (p=0.825), or sample collection method (tissue swab or synovial fluid) (p=0.986). Fifteen samples were culture positive and NGS negative, of which 10 (66.7%) met both criteria for PJI. Thirteen patients were culture negative but NGS positive, of which 2 (15.4%) met both criteria. Concordance was 100% between the MSIS criteria and criteria proposed by Parvizi et al. [1]. Conclusion. In this initial cohort NGS was more accurate than 16s subunit PCR techniques, but less accurate than culture in the diagnosis of PJI determining the presence or absence of PJI. What is not clear is how NGS will perform against culture in terms of identifying the specific bacterial strain. Currently, laboratory tests used for either criteria for PJI diagnosis should be obtained regardless of NGS along with the overall clinical picture to help guide decision making for PJI treatment. For figures, tables, or references, please contact authors directly

Objectives. Normal sagittal spine-pelvis-lower extremity alignment is crucial in humans for maintaining an ergonomic upright standing posture, and pathogenesis in any segment leads to poor balance. The present study aimed to investigate how this sagittal alignment can be affected by severe knee osteoarthritis (KOA), and whether associated changes corresponded with symptoms of lower back pain (LBP) in this patient population. Methods. Lateral radiograph films in an upright standing position were obtained from 59 patients with severe KOA and 58 asymptomatic controls free from KOA. Sagittal alignment of the spine, pelvis, hip and proximal femur was quantified by measuring several radiographic parameters. Global balance was accessed according to the relative position of the C7 plumb line to the sacrum and femoral heads. The presence of chronic LBP was documented. Comparisons between the two groups were carried by independent samples t-tests or chi-squared test. Results. Patients with severe KOA showed significant backward femoral inclination (FI), hip flexion, forward spinal inclination, and higher prevalence of global imbalance (27.1% versus 3.4%, p < 0.001) compared with controls. In addition, patients with FI of 10° (n = 23) showed reduced lumbar lordosis and significant forward spinal inclination compared with controls, whereas those with FI > 10° (n = 36) presented with significant pelvic anteversion and hip flexion. A total of 39 patients with KOA (66.1%) suffered from LBP. There was no significant difference in sagittal alignment between KOA patients with and without LBP. Conclusions. The sagittal alignment of spine-pelvis-lower extremity axis was significantly influenced by severe KOA. The lumbar spine served as the primary source of compensation, while hip flexion and pelvic anteversion increased for further compensation. Changes in sagittal alignment may not be involved in the pathogenesis of LBP in this patient population. Cite this article: W. J. Wang, F. Liu, Y.W. Zhu, M.H. Sun, Y. Qiu, W. J. Weng. Sagittal alignment of the spine-pelvis-lower extremity axis in patients with severe knee osteoarthritis: A radiographic study. Bone Joint Res 2016;5:198–205. DOI:10.1302/2046-3758.55.2000538

Introduction. There is little published evidence regarding cannabis or cannabinoid use among orthopedic patients, yet there is increasing public attention on its possible role in treating various medical conditions including pain. California passed legislation legalizing cannabis for medical treatment in 2003 and recreational use in 2018. All patients undergoing total joint arthroplasty (TJA) at our institution are screened preoperatively with a urine toxicology (UTox) screen. Though a positive test for other substances triggers surgery cancellation, a positive screen for cannabis and/or opiates does not impact whether surgery is performed. We sought to quantify the prevalence of cannabinoid and opioid use among patients with chronic pain from end-stage hip and knee osteoarthritis who underwent arthroplasty at our institution in 2012 and 2017. Methods. Institutional Review Board approval was obtained. A retrospective chart review was performed for all patients with severe arthritis who underwent total hip and knee arthroplasty (THA and TKA) at our institution during the calendar years 2012 and 2017. Patients were excluded if TJA was performed for acute trauma or if no pre-operative UTox screen was obtained. The UTox screen was used to determine preoperative cannabis and opioid use. Chi-squared testing was performed, and significance was defined as p<=0.05. Results. In the two years studied, 546 of 560 primary TJA surgeries (98%) had a pre-operative UTox screen performed. These 546 operations in 525 patients were reviewed (359 TKAs and 187 THAs). Comparing 2012 to 2017, the prevalence of preoperative cannabis use increased from 9% to 15% (p =.05) while the prevalence of opioid use decreased from 24% to 17% (p=.04). The proportion of patients who tested positive for both cannabis and opioids was low (3%) and did not change between 2012 and 2017 (p=.50). With the numbers available, patients who were using cannabis were no more or less likely to be taking opioids than non-cannabis users (p=.24). Discussion and Conclusion. To our knowledge, this is the first study to identify the prevalence and trends of cannabis use in patients undergoing TJA. At our institution, cannabis use increased more than 60% while opioid use decreased about 30% over a 5-year interval. Whether these findings are related remains unclear. Future directions will include studying postoperative opioid requirements, disposition, complications, and readmissions in TJA patients who use cannabis

Aim. The aim of this study was to determine the factors which were responsible for differences between patients achieving the Trust target of discharge on post-operative day 5 after a primary total knee replacement and those not achieving it, in the cohort of over 75 year olds. Methods and Results. Of all the patients undergoing a TKR at Addenbrooke's Hospital in 2008, those over 75 were identified (n=103). From the literature pre-, intra- and post-operative factors that had previously been shown to affect length of stay were identified. Patient notes were examined for details on each of these and the patients divided into 2 groups according to whether their discharge was achieved by day 5 or not. Data from 74 operations was available at the time of submission of this abstract. Pearson's Chi-squared test, student's independent t-test or the Mann-Whitney U test were performed on the data depending on the nature of the variable analysed. The following factors were found to be significantly different between the 2 groups at the 95% confidence level: pre-operative use of a walking aid (p=0.033), pre-operative Hb (p=0.003), post-operative Hb (p=0.001), post-operative requirement of a blood transfusion, post-operative complication (p<0.001), post-operative day on which active knee flexion to 90° was achieved (p=0.003). In addition the following factors were found to be significant at the 90% confidence level: age (p=0.082), comorbidity (p=0.086), marital status (p=0.095) and mobilisation by post-operative day 2 (p=0.082). Conclusion. Pre-operative use of any walking aid, peri-operative haemoglobin concentration and post-operative complications (including the need for a blood transfusion) seem to be the significant factors associated with a prolonged stay in hospital in the over 75 year olds. A few other factors are bordering on significance and they warrant further investigation in a larger patient cohort

Purpose. To review the Five year survivorship of Kinnemax TKA performed at the NHS Treatment Cantre, Weston-Super-Mare (WSM), and compare it to a similar cohort from our institution. Introduction. As part of the government's initiative to reduce waiting times for major joint surgery in Wales, the Cardiff and Vale NHS Trust (CAVOC) sent 224 patients (258 knees) to the NHS Treatment Centre in Weston-Super-Mare (WSM) for total knee arthroplasty. Controversy remains as to the unexpectedly high revision rates previously seen. Method. Between April 2004 and January 2006, 224 patients (258 TKAs) were performed at WSM. 90% have been followed up to five years. The WSM Cohort was compared to a similar cohort of 260 consecutive TKAs from CAVOC over a similar time period (2004/5) performed by a number of surgeons. Oxford Knee Score, EQ5D, VAS for pain, re-operation and overall satisfaction were obtained. Statistical testing was performed with chi-squared tests using SPSS v16.0 (a=0.05). Results. Mean age in years at date of operation was 68 (36-85) from WSM and 70 (41 to 87) fromCAVOC. The 5 year cumulative survival rate using ‘revision any cause’ as the endpoint, was 79.9% (95% CI 72.46 to 85.9) in the WSM cohort and 96.4% (95%CI 94.1 to 99.1) in the CAVOC cohort. The relative risk for revision at the ISTC as opposed to the referring centre was 3.76 (p<0.001). The mean Oxford Knee Score was 27.5 (range 2-48) for the WSM cohort. The average, non-revised, oxford knee score for the WSM cohort lower than expected at 29. This is lower than other published series of primary TKA. Conclusion. This is the first published five year survivorship for total knee arthroplasty performed at a first generation ISTC in the UK. Revision rates, functional outcomes, and overall health status results are below expected when compared to a similar cohort from a standard NHS Orthopaedic Unit

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Unicompartmental knee arthroplasty (UKA) has higher revision rates than total knee arthroplasty (TKA). As revision of UKA may be less technically demanding than revision TKA, UKA patients with poor functional outcomes may be more likely to be offered revision than TKA patients with similar outcomes. The aim of this study was to compare clinical thresholds for revisions between TKA and UKA using revision incidence and patient-reported outcomes, in a large, matched cohort at early, mid-, and late-term follow-up.

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In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA).

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Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality.

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The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

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The aim was to assess whether robotic-assisted total knee arthroplasty (rTKA) had greater knee-specific outcomes, improved fulfilment of expectations, health-related quality of life (HRQoL), and patient satisfaction when compared with manual TKA (mTKA).

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In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations.

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The primary aim was to assess whether robotic total knee arthroplasty (rTKA) had a greater early knee-specific outcome when compared to manual TKA (mTKA). Secondary aims were to assess whether rTKA was associated with improved expectation fulfilment, health-related quality of life (HRQoL), and patient satisfaction when compared to mTKA.

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Fungal periprosthetic joint infections (PJIs) are rare, but their diagnosis and treatment are highly challenging. The purpose of this study was to investigate the clinical outcomes of patients with fungal PJIs treated with two-stage exchange knee arthroplasty combined with prolonged antifungal therapy.

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Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up.

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This study investigates whether primary knee arthroplasty (KA) restores health-related quality of life (HRQoL) to levels expected in the general population.