One of the objectives of knee replacement is to correct flexion deformity, the frequent consequence of rheumatoid arthritis and osteoarthritis. A review of 697 primary and revision replacements carried out between 1969 and 1985 and followed up from 1 to 16 years found that such deformity was present in 61% of knees before the primary operation. Replacement reduced this to 17% and the improvement was usually maintained. The deformity was present in only 21% of the replacements which required revision and the second operation reduced this to 8%. Flexion contractures affected rheumatoid knees more often and more seriously than osteoarthritic knees, but arthroplasty was more successful in correcting the deformity in the former. All of the 11 types of prosthesis used achieved some degree of correction, but the Walldius hinge and the variants of the Freeman condylar design were the most successful. Surprisingly, the best outcome, in terms of pain and reduced need for revision, was found in the rheumatoid knees most seriously deformed before operation, but this association was absent in the osteoarthritic knees. Postoperative deformity in knees without pain or extreme weakness did not appear to influence the patients' ability to walk or to use stairs or a chair, as measured by unexacting tests in the clinic

Management of the failed total knee replacement is a formidable problem. In a 13-year period, 24 patients with above knee amputation following unsuccessful knee replacement were referred for prosthetic limb fitting. Adequate data was available for 23 patients. At review (or at the time of death), an average of 48.6 months after amputation, only seven of the 23 patients were regular daily walkers, although 10 patients had managed to walk for more than two years; 20 of the 23 used a wheelchair for some part of the day and 12 were confined to a wheelchair

There are many studies of long-term recovery from major joint arthroplasty, but little is known about the first days and weeks after operation. We measured function, emotional state and life evaluation before arthroplasty and at seven and 50 days after in a consecutive series of 40 hip and 23 knee replacements. Pain was relieved significantly at seven days after hip arthroplasty and even more at 50 days. In knee patients, pain relief was modest and was not apparent until 50 days. Functional ability was much improved by 50 days in hip patients, but hardly changed in knee patients. Positive mood and life satisfaction did not improve in either group. Our findings will help with more accurate information for patients before operation and also in judging the rate of recovery

We studied 4253 patients undergoing primary joint replacement between November 2002 and November 2007, of whom 4060 received aspirin only as chemical prophylaxis; 46 were mistakenly given low molecular weight heparin initially, which was stopped and changed to aspirin; 136 received no chemoprophylaxis and 11 patients received warfarin because of a previous history of pulmonary embolism. We identified the rate of clinical thromboembolism before and after discharge, and the mortality from pulmonary embolism at 90 days. The overall death rate was 0.31% (13 of 4253) and the rate of fatal pulmonary embolism was 0.07% (3 of 4253). Our data suggest that fatal pulmonary embolism is not common following elective primary joint replacement, and with modern surgical practice elective hip and knee replacement should no longer be considered high-risk procedures

Aims

The aim is to assess the cost-effectiveness of patellofemoral arthroplasty (PFA) in comparison with total knee arthroplasty (TKA) for the treatment of isolated patellofemoral osteoarthritis (OA) based on prospectively collected data on health outcomes and resource use from a blinded, randomized, clinical trial.

We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement. Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively. In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p < 0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors

Aims

A pragmatic, single-centre, double-blind randomized clinical trial was conducted in a NHS teaching hospital to evaluate whether there is a difference in functional knee scores, quality-of-life outcome assessments, and complications at one-year after intervention between total knee arthroplasty (TKA) and patellofemoral arthroplasty (PFA) in patients with severe isolated patellofemoral arthritis.

The radiolucent lines and the stability of the components of 66 knee arthroplasties were assessed by six orthopaedic surgeons on conventional anteroposterior and lateral radiographs and on fluoroscopic views which had been taken on the same day. The examiners were blinded as to the patients and clinical results. The interpretation of the radiographs was repeated after five months. On fluoroscopically-assisted radiographs four of the six examiners identified significantly more radiolucent lines for the femoral component (p < 0.05) and one significantly more for the tibial implant. Five examiners rated more femoral components as radiologically loose on fluoroscopically-assisted radiographs (p = 0.0008 to 0.0154), but none did so for the tibial components. The mean intra- and interobserver kappa values were higher for fluoroscopically-assisted radiographs for both components. We have shown that fluoroscopically-assisted radiographs allow more reproducible, and therefore reliable, detection of radiolucent lines in total knee arthroplasty. Assessment of the stability of the components is significantly influenced by the radiological technique used. Conventional radiographs are not adequate for evaluation of the stability of total knee arthroplasty and should be replaced by fluoroscopically-assisted films

Cephamandole levels in serum and drain fluid were measured in 32 knee replacement operations to determine the benefit of an intravenous dose of antibiotic at the time of tourniquet deflation. Concentrations of cephamandole in drain fluid were directly proportional to the serum concentration at the time of tourniquet release. A 'tourniquet-release' dose of antibiotic increased drain fluid concentration threefold

Aims. Medial unicompartmental knee arthroplasty (UKA) is associated with successful outcomes in carefully selected patient cohorts. We hypothesised that severity and location of patellofemoral cartilage lesions significantly influences functional outcome after Oxford medial compartmental knee arthroplasty. Patients and Methods. We reviewed 100 consecutive UKAs at minimum eight-year follow-up (96 to 132). A single surgeon performed all procedures. Patients were selected based on clinical and plain radiographic assessment. All patients had end-stage medial compartment osteoarthritis (OA) with sparing of the lateral compartment and intact anterior cruciate ligaments. None of the patients had end-stage patellofemoral OA, but patients with anterior knee pain or partial thickness chondral loss were not excluded. There were 57 male and 43 female patients. The mean age at surgery was 69 years (41 to 82). At surgery the joint was carefully inspected for patellofemoral chondral loss and this was documented based on severity of cartilage loss (0 to 4 Outerbridge grading) and topographic location (medial, lateral, central, and superior or inferior). Functional scores collected included Oxford Knee Score (OKS), patient satisfaction scale and University College Hospital (UCH) knee score. Intraclass correlation was used to compare chondral damage to outcomes. Results. All patients documented significant improvement in pain and improved functional scores at mid-term follow-up. There were four revisions (mean 2.9 years, 2 to 4; standard deviation (. sd). 0.9) in this cohort, three for tibial loosening and one for femoral loosening. There was one infection that was treated with debridement and insert exchange. The mean OKS improved from 23.2 (. sd. 7.1) to 39.1 (. sd. 6.9); p < 0.001. The cohort with central and lateral grade 3 patellofemoral OA documented lower mean satisfaction with pain (90, . sd.  11.8) and function (87.5, . sd. 10.3) on the patient satisfaction scale. On the UCH scale, patients reported significantly decreased mean overall scores (7.3, . sd. 1.2 vs 9, . sd. 2.3) as well as stair climb task (3.5, . sd. 0.3 vs 5, . sd. 0.1) when cartilage lesions were located centrally or laterally on the PFJ. Patients with medial chondral PFJ lesions behave similar to patients with no chondral lesions. Conclusion. Topographical location and severity of cartilage damage of the patella can significantly influence function after successful Oxford medial UKA. Surgeons should factor this in when making their operative decision, and undertake to counsel patients appropriately. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):11–15

Our study evaluated the accuracy of an image-guided total knee replacement system based on CT with regard to preparation of the femoral and tibial bone using nine limbs from five cadavers. The accuracy was assessed by direct measurement using an extramedullary alignment rod without radiographs. The mean angular errors of the femur and tibia, which represent angular gaps from the real mechanical axis in the coronal plane, were 0.3° and 1.1°, respectively. The CT-based system, provided almost perfect alignment of the femoral component with less than 1° of error and excellent alignment with less than 3° of error for the tibial component. Our results suggest that standardisation of knee replacement by the use of this system will lead to improved long-term survival of total knee arthroplasty

Objectives. We aimed first to summarise minimal clinically important differences (MCIDs) after total hip (THR) or knee replacement (TKR) in health-related quality of life (HRQoL), measured using the Short-Form 36 (SF-36). Secondly, we aimed to improve the precision of MCID estimates by means of meta-analysis. Methods. We conducted a systematic review of English and non-English articles using MEDLINE, the Cochrane Controlled Trials Register (1960–2011), EMBASE (1991–2011), Web of Science, Academic Search Premier and Science Direct. Bibliographies of included studies were searched in order to find additional studies. Search terms included MCID or minimal clinically important change, THR or TKR and Short-Form 36. We included longitudinal studies that estimated MCID of SF-36 after THR or TKR. Results. Three studies met our inclusion criteria, describing a distinct study population: primary THR, primary TKR and revision THR. No synthesis of study results can be given. Conclusions. Although we found MCIDs in HRQoL after THR or TKR have limited precision and are not validated using external criteria, these are still the best known estimates of MCIDs in HRQoL after THR and TKR to date. We therefore advise these MCIDs to be used as absolute thresholds, but with caution

Aims. The aim of this study was to determine if a three-month course of microorganism-directed oral antibiotics reduces the rate of failure due to further infection following two-stage revision for chronic prosthetic joint infection (PJI) of the hip and knee. Methods. A total of 185 patients undergoing a two-stage revision in seven different centres were prospectively enrolled. Of these patients, 93 were randomized to receive microorganism-directed oral antibiotics for three months following reimplantation; 88 were randomized to receive no antibiotics, and four were withdrawn before randomization. Of the 181 randomized patients, 28 were lost to follow-up, six died before two years follow-up, and five with culture negative infections were excluded. The remaining 142 patients were followed for a mean of 3.3 years (2.0 to 7.6) with failure due to a further infection as the primary endpoint. Patients who were treated with antibiotics were also assessed for their adherence to the medication regime and for side effects to antibiotics. Results. Nine of 72 patients (12.5%) who received antibiotics failed due to further infection compared with 20 of 70 patients (28.6%) who did not receive antibiotics (p = 0.012). Five patients (6.9%) in the treatment group experienced adverse effects related to the administered antibiotics severe enough to warrant discontinuation. Conclusion. This multicentre randomized controlled trial showed that a three-month course of microorganism-directed, oral antibiotics significantly reduced the rate of failure due to further infection following a two-stage revision of total hip or knee arthroplasty for chronic PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):3–9

Aims

Biopsy of the periprosthetic tissue is an important diagnostic tool for prosthetic joint infection (PJI) as it enables the detection of the responsible microorganism with its sensitivity to antibiotics. We aimed to investigate how often the bacteria identified in the tissue analysis differed between samples obtained from preoperative biopsy and intraoperative revision surgery in cases of late PJI; and whether there was a therapeutic consequence.

We carried out a prospective investigation into the radiological outcomes of uncemented Oxford medial compartment unicondylar replacement in 220 consecutive patients (231 knees) performed in a single centre with a minimum two-year follow-up. The functional outcomes using the mean Oxford knee score and the mean high-activity arthroplasty score were significantly improved over the pre-operative scores (p < 0.001). There were 196 patients with a two-year radiological examination performed under fluoroscopic guidance, aiming to provide images acceptable for analysis of the bone–implant interface. Of the six tibial zones examined on each knee on the anteroposterior radiograph, only three had a partial radiolucent line. All were in the medial aspect of the tibial base plate (zone 1) and all measured < 1 mm. All of these patients were asymptomatic. There were no radiolucent lines seen around the femoral component or on the lateral view. There was one revision for loosening at one year due to initial inadequate seating of the tibial component. These results confirm that the early uncemented Oxford medial unicompartmental compartmental knee replacements were reliable and the incidence of radiolucent lines was significantly decreased compared with the reported results of cemented versions of this implant. These independent results confirm those of the designing centre

Total hip and total knee arthroplasty both provide a considerable improvement in quality of life, but there is no evidence to suggest that one is more successful than the other. We studied 72 patients in a prospective trial before and after total hip or total knee replacement. We recorded scores for disability and distress derived from the Harris hip score and the British Orthopaedic Association knee assessment score, and used them to generate quality of life (QoL) scores using the Rosser Index Matrix immediately before and at one year after surgery. The patients awaiting knee replacement had significantly lower QoL scores than those awaiting hip replacement (p = 0.011). The QoL scores at one year were high and almost identical for both groups (p = 0.46). Further analysis showed that gender and weight were not significant predictors of improvement of QoL scores, but age (p = 0.03) and whether the hip or knee was replaced (p = 0.006) were significant factors

Aims

Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic PJI patients yield negative culture results. Although culture negativity has been thought of as a contraindication to one-stage revision, data supporting this assertion are limited. The aim of our study was to report on the clinical outcomes for one-stage and two-stage exchange arthroplasty performed in patients with chronic culture-negative PJI.

Aims

The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

We studied the time course of micro-embolism by recording high intensity transient signals (HITS) on Doppler venous blood flow studies during a 7-day period in 57 of 63 consecutive patients after hip or knee replacement. No HITS were found before surgery, or in the non-operated leg after surgery. In the operated leg, the median number of HITS per minute showed an exponential decrease with time; a 50% reduction in the number of HITS took 72 minutes. Regardless of the duration and severity of HITS, we found no clinically apparent embolic event. Colour Doppler imaging at days 8 to 10 after operation showed a deep venous thrombosis in 17% of our patients with one thrombosis of the long saphenous vein. The presence or severity of HITS did not predict the venous thrombi. Although we found no pulmonary complications, we detected micro-emboli over a longer period after surgery than is usually reported. Spectral analysis of the Doppler venous signal is a repeatable and non-invasive monitoring technique in the post-surgical period. We failed to prove a correlation between deep venous thrombi and micro-emboli detected by this method

The Denham knee replacement is a relatively simple unconstrained prosthesis. The design ensures good alignment and full extension, but does not allow flexion beyond 90 degrees or tibiofemoral rotation. The results after eight years' experience have been assessed in four different ways in over 600 cases. They show that for the limited needs of the elderly arthritic patient, the Denham arthroplasty provides a high proportion of satisfactory results with an unusually low rate of late failure