Aims. The outcome of repeat septic revision after a failed one-stage exchange for periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat septic revision after a failed one-stage exchange, and to determine whether the Musculoskeletal Infection Society (MSIS) stage is associated with subsequent infection-related failure. Methods. We retrospectively reviewed all repeat septic revision TKAs which were undertaken after a failed one-stage exchange between 2004 and 2017. A total of 33 repeat septic revisions (29 one-stage and four two-stage) met the inclusion criteria. The mean follow-up from repeat septic revision was 68.2 months (8.0 months to 16.1 years). The proportion of patients who had a subsequent infection-related failure and all-cause revision was reported and Kaplan-Meier survival for these endpoints was determined. Patients were categorized according to the MSIS staging system, and the association with subsequent infection was analyzed. Results. At the most recent follow-up, 17 repeat septic revisions (52%) had a subsequent infection-related failure and the five-year infection-free survival was 59% (95% confidence interval (CI) 39 to 74). A total of 19 underwent a subsequent all-cause revision (58%) and the five-year all-cause revision-free survival was 47% (95% CI 28 to 64). The most common indication for the first subsequent aseptic revision was loosening. The MSIS stage of the host status (p = 0.663) and limb status (p = 1.000) were not significantly associated with subsequent infection-related failure. Conclusion. Repeat septic revision after a failed one-stage exchange TKA for PJI is associated with a high rate of subsequent infection-related failure and all-cause revision. Patients should be counselled appropriately to manage expectations. The host and limb status according to the MSIS staging system were not associated with subsequent infection-related failure. Cite this article: Bone Joint J 2022;104-B(3):386–393

Aims

Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium.

Previous studies of failure mechanisms leading to revision total knee replacement (TKR) performed between 1986 and 2000 determined that many failed early, with a disproportionate amount accounted for by infection and implant-associated factors including wear, loosening and instability. Since then, efforts have been made to improve implant performance and instruct surgeons in best practice. Recently our centre participated in a multi-centre evaluation of 844 revision TKRs from 2010 to 2011. The purpose was to report a detailed analysis of failure mechanisms over time and to see if failure modes have changed over the past 10 to 15 years. Aseptic loosening was the predominant mechanism of failure (31.2%), followed by instability (18.7%), infection (16.2%), polyethylene wear (10.0%), arthrofibrosis (6.9%) and malalignment (6.6%). The mean time to failure was 5.9 years (ten days to 31 years), 35.3% of all revisions occurred at less than two years, and 60.2% in the first five years. With improvements in implant and polyethylene manufacture, polyethylene wear is no longer a leading cause of failure. Early mechanisms of failure are primarily technical errors. In addition to improving implant longevity, industry and surgeons must work together to decrease these technical errors. All reports on failure of TKR contain patients with unexplained pain who not infrequently have unmet expectations. Surgeons must work to achieve realistic patient expectations pre-operatively, and therefore, improve patient satisfaction post-operatively. Cite this article: Bone Joint J 2014;96-B(11 Suppl A):101–4

Aims

Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients.

Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of single-stage knee arthrodesis using an intramedullary cemented coupled nail without bone-on-bone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA. Cite this article: Bone Joint J 2015;97-B:649–53

The management of failed autologous chondrocyte implantation (ACI) and matrix-assisted autologous chondrocyte implantation (MACI) for the treatment of symptomatic osteochondral defects in the knee represents a major challenge. Patients are young, active and usually unsuitable for prosthetic replacement. This study reports the results in patients who underwent revision cartilage transplantation of their original ACI/MACI graft for clinical or graft-related failure. We assessed 22 patients (12 men and 10 women) with a mean age of 37.4 years (18 to 48) at a mean of 5.4 years (1.3 to 10.9). The mean period between primary and revision grafting was 46.1 months (7 to 89). The mean defect size was 446.6 mm. 2. (150 to 875) and they were located on 11 medial and two lateral femoral condyles, eight patellae and one trochlea. . The mean modified Cincinnati knee score improved from 40.5 (16 to 77) pre-operatively to 64.9 (8 to 94) at their most recent review (p < 0.001). The visual analogue pain score improved from 6.1 (3 to 9) to 4.7 (0 to 10) (p = 0.042). A total of 14 patients (63%) reported an ‘excellent’ (n = 6) or ‘good’ (n = 8) clinical outcome, 5 ‘fair’ and one ‘poor’ outcome. Two patients underwent patellofemoral joint replacement. This study demonstrates that revision cartilage transplantation after primary ACI and MACI can yield acceptable functional results and continue to preserve the joint. Cite this article: Bone Joint J 2014;96-B:54–8

The term mid-flexion instability has entered the orthopaedic literature as a concept, but has not been confirmed as a distinct clinical entity. The term is used freely, sometimes as a synonym for flexion instability. However, the terms need to be clearly separated. A cadaver study published in 1990 associated joint line elevation with decreased stability at many angles of flexion, but that model was not typical of clinical scenarios. The literature is considered and it is proposed that the more common entity of an uncorrected flexion contracture after a measured resection arthroplasty technique is more likely to produce clinical findings that suggest instability mid-flexion.

It is proposed that the clinical scenario encountered is generalised instability, with the appearance of stability in full extension from tight posterior structures.

This paper seeks to clarify whether mid-flexion instability exists as an entity distinct from other commonly recognised forms of instability.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):84–8.

Abstract. Introduction. The popularity of all-inside meniscal repair devices has led to a shift away from inside-out meniscus repair without comparative studies to support the change. The aim of this study was to compare the failure rate and time to failure of all-inside and inside-out meniscus repair performed in elite athletes. Methodology. A retrospective review was performed of all elite athletes who underwent meniscal repair, with a minimum of two-year follow-up between 2013 and 2019. Repairs were classified as all-inside or inside-out according to the repair technique. Failure was defined as undergoing a subsequent surgery to address a persistent meniscal tear. Results. 192 (135 lateral and 57 medial) meniscal repairs in elite athletes were included and 41 (21%) failed. Medial meniscus tears repaired with the all-inside technique failed at a significantly higher rate (58%) than medial meniscus tears repaired with the inside-out (23%) or lateral meniscus tears repaired with the all-inside (12%) or inside-out (14%) technique (p<.001). At 1 year following repair, 8% of lateral meniscus repairs had failed regardless of technique. Medial meniscus repairs failed at an approximate rate of 15% for inside-out technique and 42% for all-inside technique. By 2 years, approximately 54% of all-inside medial meniscus repairs had failed and by 5 years over 60% of repairs had failed. Conclusion. All-inside medial meniscal repair led to a higher rate of failure compared to inside-out medial or lateral meniscus repair in elite athletes. Medial meniscus repairs failed at a high rate than lateral meniscal repairs

Abstract. Aims. We studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients. Methodology. Prospective cohort study. Over a 4-year period (2016 to 2020), 35 adult patients presented with a bucket handle tear of the meniscus. Arthroscopic meniscal repair was performed using either the all inside technique or a combination of all-inside and inside-out techniques. 15 patients also underwent simultaneous arthroscopic anterior cruciate ligament reconstruction. Functional knee scores were assessed using IKDC and Lysholm scores. Results. Mean patient age at surgery was 27 years (range, 17 to 53years). Medial meniscus was torn in 20 and lateral in 15 cases. Zone of tear was white on white in 19, red on white in 9 and red on red in 7 cases. Average delay from injury to surgery was 4 months. At a mean follow-up of 4.5 years, the meniscus repair failed in 3 patients (8.5 %). Outcome following re-tear was meniscus excision. Average IKDC scores in patients with intact repair were 74.04 against 56.67 in patients with a failed repair (p< 0.0001). Similarly, Lyshlom scores were 88.96 and 67.333, respectively (p<0.0001). Conclusion. The survivorship of primary repair of bucket handle meniscus tears in our series was 91.5% at medium term follow-up. Functional outcomes were significantly poor in patients with a failed repair compared to those with an intact repair

Abstract. Introduction. Knee arthrodesis is one of the treatment options for limb salvage of a failed total knee replacement (TKR) when further revisions were contraindicated. The aim of this study is to determine patient outcomes after knee arthrodesis (KA) following a failed TKR. Methodology. A literature search was conducted for studies published from January 2000 through January 2022 via Medline, Web of Science, Embase and Cochrane databases. Only primary research studies were included with independent extraction of articles by two reviewers. Results were synthesised by narrative review according to PRISMA guidelines, with full tabulation of all included study results. Results. A total of 34 studies with 1,034 patients were included in the review; all were longitudinal observational studies, and none were conducted as randomised controlled trials. Reporting methods were very inconsistent in the included studies, and this heterogeneity led to pooled data totals that varied widely in different categories. The mean follow-up was 3.5 years. Overall, 72.0% (167 of 232) of patients used a walking stick and 12.5% (36 of 287) remained non-ambulatory after KA. Only 7.7% (58 of 752) of patients subsequently underwent above-knee amputation. Conclusion. KA is a potential limb salvage procedure after revision arthroplasties have been attempted in cases of failed TKR. Most patients were able to ambulate both at home and in the community, although with an increased rate of using a walking stick after the operation. However, in the absence of randomised controlled trials, these data may allow for a more accurate counselling and decision making

Aims. Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context. Methods. A retrospective analysis was conducted of 94 patients undergoing first-stage revision of an infected knee prosthesis between September 2007 and January 2020 at a single institution. Radiographs and clinical records were used to assess and classify the incidence and causes of static spacer failure. Of the 94 cases, there were 19 primary total knee arthroplasties (TKAs), ten revision TKAs (varus-valgus constraint), 20 hinged TKAs, one arthrodesis (nail), one failed spacer (performed elsewhere), 21 distal femoral endoprosthetic arthroplasties, and 22 proximal tibial arthroplasties. Results. A total of 35/94 patients (37.2%) had spacer-related complications, of which 26/35 complications (74.3%) were because of mechanical failure of the spacer construct, while 9/35 (25.7%) were due to recurrence of infection. Risk factors for internal failure were a construct where the total intramedullary spacer length was less than twice the length of the central osseous defect (p = 0.009), where proximal or distal intraosseous spacer contact was < 10%, and after tibial tubercle osteotomy (p = 0.005). The incidence of spacer complications significantly increased the time to second stage: mean 157 days (42 to 458) in those without complications versus 227 days (11 to 528) with complications (p = 0.014). Conclusion. The failure rate of static antibiotic-loaded cement spacers is much higher than anticipated. Complications of the spacer significantly increased the time to second-stage revision. The risk of mechanical failure is significantly increased if the spacer is less than double the size of the segmental defect, or if inadequate reinforcement is inserted into the residual bone. These findings serve as a guide for surgeons to avoid mechanical complications with static spacers. Cite this article: Bone Joint J 2024;106-B(10):1067–1073

Aims. 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. Methods. This prospective study included 16 patients undergoing robotic arm-assisted revision of UKA to TKA versus 35 matched patients receiving robotic arm-assisted primary TKA. In all study patients, the following data were recorded: operating time, polyethylene liner size, change in haemoglobin concentration (g/dl), length of inpatient stay, postoperative complications, and hip-knee-ankle (HKA) alignment. All procedures were performed using the principles of functional alignment. At most recent follow-up, range of motion (ROM), Forgotten Joint Score (FJS), and Oxford Knee Score (OKS) were collected. Mean follow-up time was 21 months (6 to 36). Results. There were no differences between the two treatment groups with regard to mean change in haemoglobin concentration (p = 0.477), length of stay (LOS, p = 0.172), mean polyethylene thickness (p = 0.065), or postoperative complication rates (p = 0.295). At the most recent follow-up, the primary robotic arm-assisted TKA group had a statistically significantly improved OKS compared with the revision UKA to TKA group (44.6 (SD 2.7) vs 42.3 (SD 2.5); p = 0.004) but there was no difference in the overall ROM (p = 0.056) or FJS between the two treatment groups (86.1 (SD 9.6) vs 84.1 (4.9); p = 0.439). Conclusion. Robotic arm-assisted revision of UKA to TKA was associated with comparable intraoperative blood loss, early postoperative rehabilitation, functional outcomes, and complications to primary robotic TKA at short-term follow-up. Robotic arm-assisted surgery offers a safe and reproducible technique for revising failed UKA to TKA. Cite this article: Bone Joint J 2024;106-B(7):680–687

Aims. Obtaining solid implant fixation is crucial in revision total knee arthroplasty (rTKA) to avoid aseptic loosening, a major reason for re-revision. This study aims to validate a novel grading system that quantifies implant fixation across three anatomical zones (epiphysis, metaphysis, diaphysis). Methods. Based on pre-, intra-, and postoperative assessments, the novel grading system allocates a quantitative score (0, 0.5, or 1 point) for the quality of fixation achieved in each anatomical zone. The criteria used by the algorithm to assign the score include the bone quality, the size of the bone defect, and the type of fixation used. A consecutive cohort of 245 patients undergoing rTKA from 2012 to 2018 were evaluated using the current novel scoring system and followed prospectively. In addition, 100 first-time revision cases were assessed radiologically from the original cohort and graded by three observers to evaluate the intra- and inter-rater reliability of the novel radiological grading system. Results. At a mean follow-up of 90 months (64 to 130), only two out of 245 cases failed due to aseptic loosening. Intraoperative grading yielded mean scores of 1.87 (95% confidence interval (CI) 1.82 to 1.92) for the femur and 1.96 (95% CI 1.92 to 2.0) for the tibia. Only 3.7% of femoral and 1.7% of tibial reconstructions fell below the 1.5-point threshold, which included the two cases of aseptic loosening. Interobserver reliability for postoperative radiological grading was 0.97 for the femur and 0.85 for the tibia. Conclusion. A minimum score of 1.5 points for each skeletal segment appears to be a reasonable cut-off to define sufficient fixation in rTKA. There were no revisions for aseptic loosening at mid-term follow-up when this fixation threshold was achieved or exceeded. When assessing first-time revisions, this novel grading system has shown excellent intra- and interobserver reliability. Cite this article: Bone Joint J 2024;106-B(5):468–474

Aims. The aim of this study was to compare a bicruciate-retaining (BCR) total knee arthroplasty (TKA) with a posterior cruciate-retaining (CR) TKA design in terms of kinematics, measured using fluoroscopy and stability as micromotion using radiostereometric analysis (RSA). Methods. A total of 40 patients with end-stage osteoarthritis were included in this randomized controlled trial. All patients performed a step-up and lunge task in front of a monoplane fluoroscope one year postoperatively. Femorotibial contact point (CP) locations were determined at every flexion angle and compared between the groups. RSA images were taken at baseline, six weeks, three, six, 12, and 24 months postoperatively. Clinical and functional outcomes were compared postoperatively for two years. Results. The BCR-TKA demonstrated a kinematic pattern comparable to the natural knee’s screw-home mechanism in the step-up task. In the lunge task, the medial CP of the BCR-TKA was more anterior in the early flexion phase, while laterally the CP was more posterior during the entire movement cycle. The BCR-TKA group showed higher tibial migration. No differences were found for the clinical and functional outcomes. Conclusion. The BCR-TKA shows a different kinematic pattern in early flexion/late extension compared to the CR-TKA. The difference between both implants is mostly visible in the flexion phase in which the anterior cruciate ligament is effective; however, both designs fail to fully replicate the motion of a natural knee. The higher migration of the BCR-TKA was concerning and highlights the importance of longer follow-up. Cite this article: Bone Joint J 2023;105-B(1):35–46

Abstract. Introduction. Active, middle-aged patients with symptomatic cartilage or osteochondral defects can find themselves in a treatment gap when they have failed conservative measures but are not yet eligible for conventional arthroplasty. Data from various cohort studies suggests that focal knee resurfacing implants such as HemiCAP, UniCAP, Episealer or BioBoly are cost-effective solutions to alleviate pain, improve function and delay or eliminate the need for conventional replacement. A systematic review and meta-analysis were conducted in order to(i) evaluate revision rates and implant survival of focal resurfacing; (ii) explore surgical complications; and (iii) evaluate various patient reported clinical outcome measures. Methodology. PubMED, Cochrane Library and Medline databases were searched in February 2022 for prospective and retrospective cohort studies evaluating any of the available implant types. Data on incidence of revision, complications and various patient reported outcome measures was sourced. Results. A total of 24 unique studies were identified with a total of 1465 enrolled patients. A revision rate of 12.97% over a 5.9 year weighted mean follow-up period was observed across all implant types. However, in one series a Kaplan-Meir survival as high as 92.6% at a 10-year follow-up period was noted. A statistically significant improvement was documented across multiple subjective clinical outcomes scores. There was a low reported incidence of post-operative complications such as aseptic loosening or deep wound infection. Conclusions. Focal femoral resurfacing appears to be a viable treatment option for focal symptomatic chondral lesions in patients beyond biological reconstruction, with low revision rates and high patient satisfaction

Abstract. Introduction. This study compared biomechanical and functional parameters of a total knee arthroplasty (TKA) implant (Cemented Zimmer Hi-Flex) against healthy older adults to determine whether knee biomechanics was restored in this patient population. Methodology. Patients with a primary TKA and healthy adults >55 years old with no musculoskeletal deficits or arthritis participated. Bilateral knee range of motion (RoM) was assessed with a goniometer, then gait patterns were analysed with a 3D motion-capture system. An arthrometer then quantified anterior-posterior laxity of each knee. Statistical analyses were performed in SPSS (α=0.05; required sample size: n=21 per group). Results. 25 knees were replaced in 21 patients. Nine presented with fixed flexion deformities (FFD) (13.3±5.6°). FFDs were abolished intraoperatively, and the average flexion increased from 124.8±9.1° to 130.9±5.8°. At 9.6±3.2 years postoperatively, the patients achieved poorer RoM than healthy controls (n=23); p<0.0001. These differences were due to limited flexion in the knee. Patients also failed to achieve the same degree of flexion as controls bilaterally during gait. No differences were observed during mid-flexion; a state that has been associated with instability (p=0.614). There were no differences between groups in knee laxity. Conclusion. Patients in this study had similar gait patterns to healthy older adults during mid-flexion, and were no more likely to exhibit anterior-posterior translation of the knee >7mm; a known risk factor of instability. However, the flexion range was poorer. This led to bilateral pathological knee flexion patterns during gait. Further research should identify the cause of these limitations

Aims. The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR). Methods. We performed a prospective study on patients who underwent primary ACLR by a single surgeon at a single centre between October 2010 and January 2018. Preoperative preinjury scores were collected at time of first assessment after the index injury. Preoperative (pre- and post-injury), one-year, and two-year postoperative functional outcomes were assessed by using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score, and Tegner Activity Scale. Results. We enrolled 308 males and 263 females of mean age 27 years (19 to 46). The mean preinjury and preoperative post-injury Lysholm Knee Scores were 94 (73 to 100) and 63 (25 to 85), respectively, while the respective mean scores at one and two years postoperatively were 84 (71 to 100) and 89 (71 to 100; p < 0.001). The mean Tegner preinjury and preoperative post-injury scores were 7 (3 to 9) and 3 (0 to 6), respectively, while the respective mean scores at one and two years postoperatively were 6 (1 to 8) and 6 (1 to 9) (p < 0.001). The mean KOOS scores at preinjury versus two years postoperatively were: symptoms (96 vs 84); pain (94 vs 87); activities of daily living (97 vs 91), sports and recreation function (84 vs 71), and quality of life (82 vs 69), respectively (p < 0.001). Conclusion. Functional scores improved following ACLR surgery at two years in comparison to preoperative post-injury scores. However, at two-year follow-up, the majority of patients failed to achieve their preinjury scores. The evaluation of ACLR outcomes needs to consider the preinjury scores rather than the immediate preoperative score that is usually collected. Cite this article: Bone Jt Open 2023;4(1):46–52

Aims. The use of cementless total knee arthroplasty (TKA) components has increased during the past decade. The initial design of cementless metal-backed patellar components had shown high failure rates due to many factors. The aim of this study was to evaluate the clinical results of a second-generation cementless, metal-backed patellar component of a modern design. Methods. This was a retrospective review of 707 primary TKAs in 590 patients from a single institution, using a cementless, metal-backed patellar component with a mean follow-up of 6.9 years (2 to 12). A total of 409 TKAs were performed in 338 females and 298 TKAs in 252 males. The mean age of the patients was 63 years (34 to 87) and their mean BMI was 34.3 kg/m. 2. (18.8 to 64.5). The patients were chosen to undergo a cementless procedure based on age and preoperative radiological and intraoperative bone quality. Outcome was assessed using the Knee Society knee and function scores and range of motion (ROM), complications, and revisions. Results. A total of 24 TKAs (3.4%) in 24 patients failed and required revision surgery, of which five were due to patellar complications (0.71%): one for aseptic patellar loosening (0.14%) and four for polyethylene dissociation (0.57%). A total of 19 revisions (2.7%) were undertaken in 19 patients for indications which did not relate to the patella: four for aseptic tibial loosening (0.57%), one for aseptic femoral loosening (0.14%), nine for periprosthetic infection (1.3%), one for popliteus impingement (0.14%), and four for instability (0.57%). Knee Society knee and function scores, and ROM, improved significantly when comparing pre- and postoperative values. Survival of the metal-backed patellar component for all-cause failure was 97.5% (95% confidence interval 94.9% to 100%) at 12 years. Conclusion. The second-generation cementless TKA design of metal-backed patellar components showed a 97.5% survival at 12 years, with polyethylene dissociation from the metal-backing being the most common cause of patellar failure. In view of the increased use of TKA, especially in younger, more active, or obese patients, these findings are encouraging at mean follow-up of seven years. Cite this article: Bone Joint J 2023;105-B(12):1279–1285

Abstract. Introduction. The Wells score is commonly used to assess the risk of proximal Deep Vein Thrombosis (DVT) following Knee Arthroplasty (KA). The National Institute for Health and Care Excellence (NICE) guidelines recommend an Ultrasound scan in patients with a Wells score of 2 points or more. We wanted to assess how often this protocol resulted in a scan being done and how many were negative. Methodology. Details of all postoperative Ultrasound scans performed up to 90 days were audited in a high-volume unit between 1st January 2016 and 31st December 2020. This included all Lower Limb Arthroplasty patients. Results. Out of a total of 4955 KA (4506 Total Knee Arthroplasty, 449 Unilateral Knee Arthroplasty), 449 (9.1%) had a total of 561 scans, with 17 (3.0%) scans demonstrating a proximal DVT. Thus 97.0% of Ultrasound scans were negative. Conclusion. The present NICE guidelines with the two-Level DVT Wells score are inappropriate for the management of suspected proximal DVT following KA. We propose that swelling that fails to reduce after 4 hours of elevation, or new swelling after a period of recumbent rest, would be more appropriate indications for a scan and negative scans should not be repeated without a change in symptoms. Unless there are pressing clinical indications, therapeutic anticoagulation should not commence in the absence of a diagnosis

Abstract. 20% of patients are severely dis-satisfied following total knee arthroplasty (TKA). Arthrofibrosis is a devastating complication preventing normal knee range of motion (ROM), severely impacting patient's daily living activities. A previous RCT demonstrated superiority of a high intensity stretching programme using a novel device the STAK tool compared with standard physiotherapy in TKA patients with arthrofibrosis. This study analyses the results when the previous “standard physiotherapy” group were subsequently treated with the STAK tool. Methods. 15 patients post TKA with severe arthrofibrosis and mean ROM 71° were recruited, (three cases had previously failed manipulation under anaesthetic (MUA). Patients received 8 weeks standard physiotherapy, then treatment with the STAK at home for 8 weeks. ROM, extension, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at various time-points. Results. Following standard physiotherapy there were small improvements in ROM (8°) (p<0.01), but no significant improvements in extension, OKS or WOMAC (p=0.39). Following the STAK treatment all outcomes significantly improved (p<0.01). STAK group; mean ROM (21° versus 8°, p < 0.001), extension 9° versus 2° (p < 0.01), WOMAC (18 points versus 3, p < 0.01), and OKS (8 points versus 4, p<0.01). No patients suffered any complications relating to the STAK. Conclusions. The STAK is effective in increasing ROM, extension and function, whilst reducing pain and stiffness. The device can be considered a cost-effective and valuable treatment following TKA. This is likely to increase the overall satisfaction rate and has potential to reduce the need for MUA