Aims

This study aimed to determine outcomes of isolated tibial insert exchange (ITIE) during revision total knee arthroplasty (TKA).

Using the General Practice Research Database, we examined the temporal changes in the rates of primary total hip (THR) and total knee (TKR) replacement, the age at operation and the female-to-male ratio between 1991 and 2006 in the United Kingdom. We identified 27 113 patients with THR and 23 843 with TKR. The rate of performance of THR and TKR had increased significantly (p < 0.0001 for both) during the 16-year period and was greater for TKR, especially in the last five years. The mean age at operation was greater for women than for men and had remained stable throughout the period of study. The female-to-male ratio was higher for THR and TKR and had remained stable. The data support the notion that the rate of joint replacement is increasing in the United Kingdom with the rate of TKR rising at the highest rate. The perception that the mean age for TKR has decreased over time is not supported

Although the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index was originally developed for the assessment of non-operative treatment, it is commonly used to evaluate patients undergoing either total hip (THR) or total knee replacement (TKR). We assessed the importance of the 17 WOMAC function items from the perspective of 1198 patients who underwent either THR (n = 704) or TKR (n = 494) in order to develop joint-specific short forms. After these patients were administered the WOMAC pre-operatively and at three, six, 12 and 24 months’ follow-up, they were asked to nominate an item of the function scale that was most important to them. The items chosen were significantly different between patients undergoing THR and those undergoing TKR (p < 0.001), and there was a shift in the priorities after surgery in both groups. Setting a threshold for prioritised items of ≥ 5% across all follow-up, eight items were selected for THR and seven for TKR, of which six items were common to both. The items comprising specific WOMAC-THR and TKR function short forms were found to be equally responsive compared with the original WOMAC function form. . Cite this article: Bone Joint J 2013;95-B:239–43

Aims

Varus-valgus constrained (VVC) devices are typically used in revision settings, often with stems to mitigate the risk of aseptic loosening. However, in at least one system, the VVC insert is compatible with the primary posterior-stabilized (PS) femoral component, which may be an option in complex primary situations. We sought to determine the implant survivorship, radiological and clinical outcomes, and complications when this VVC insert was coupled with a PS femur without stems in complex primary total knee arthroplasties (TKAs).

Aims

Uncemented mobile bearing designs in medial unicompartmental knee arthroplasty (UKA) have seen an increase over the last decade. However, there are a lack of large-scale studies comparing survivorship of these specific designs to commonly used cemented mobile and fixed bearing designs. The aim of this study was to evaluate the survivorship of these designs.

Aims

Unicompartmental knee arthroplasty (UKA) is a bone-preserving treatment option for osteoarthritis localized to a single compartment in the knee. The success of the procedure is sensitive to patient selection and alignment errors. Robotic arm-assisted UKA provides technological assistance to intraoperative bony resection accuracy, which is thought to improve ligament balancing. This paper presents the five-year outcomes of a comparison between manual and robotically assisted UKAs.

Aims

The purpose of this study is to evaluate early outcomes with the use of a smartphone-based exercise and educational care management system after total hip arthroplasty (THA) and demonstrate decreased use of in-person physiotherapy (PT).

The aim of this study was to perform a cost–utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health–utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions. Cite this article: Bone Joint J 2013;95-B:115–21

High-flexion total knee replacement (TKR) designs have been introduced to improve flexion after TKR. Although the early results of such designs were promising, recent literature has raised concerns about the incidence of early loosening of the femoral component. We compared the minimum force required to cause femoral component loosening for six high-flexion and six conventional TKR designs in a laboratory experiment. Each TKR design was implanted in a femoral bone model and placed in a loading frame in 135° of flexion. Loosening of the femoral component was induced by moving the tibial component at a constant rate of displacement while maintaining the same angle of flexion. A stereophotogrammetric system registered the relative movement between the femoral component and the underlying bone until loosening occurred. Compared with high-flexion designs, conventional TKR designs required a significantly higher force before loosening occurred (p < 0.001). High-flexion designs with closed box geometry required significantly higher loosening forces than high-flexion designs with open box geometry (p = 0.0478). The presence of pegs further contributed to the fixation strength of components. We conclude that high-flexion designs have a greater risk for femoral component loosening than conventional TKR designs. We believe this is attributable to the absence of femoral load sharing between the prosthetic component and the condylar bone during flexion

The management of nonunion following high tibial osteotomy by total knee replacement (TKR) has been reported previously. We have extended the treatment to embrace cases with an infected high tibial osteotomy by performing an initial debridement with a period of antibiotic treatment followed by TKR. We have reviewed the results of seven knees in six patients with a mean follow-up of 40.5 months (20 to 57) after the staged TKR. At the latest follow-up, all the pseudarthroses had healed and there had been no recurrence of infection. The mean Hospital for Special Surgery knee score improved from 51.2 (35 to 73) to a mean of 91.7 (84 to 98) at final review. Management of nonunion following high tibial osteotomy with a TKR can be extended to infected cases when treated in two stages with a debridement and antibiotic therapy prior to TKR

Aims. The aim of this study was to present data on 11 459 patients who underwent total hip (THA), total knee (TKA) or unicompartmental knee arthroplasty (UKA) between November 2002 and April 2014 with aspirin as the primary agent for pharmacological thromboprophylaxis. . Patients and Methods. We analysed the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) then compared the 90-day all-cause mortality with the corresponding data in the National Joint Registry for England and Wales (NJR). . Results. The incidence of PE was 0.6% after THA, 1.47% after TKA and 1.2% after UKA. The 90-day mortality was 0.39% after THA and 0.44% after TKA. No deaths occurred after UKA. The main causes of death were ischaemic heart disease and respiratory failure. PE was responsible for only 18% of deaths. There was a decline in 90-day mortality, from 0.64% between 2002 and 2007, to 0.21% between 2008 and 2013 after THA, and from 0.47% to 0.39% after TKA for the corresponding period. The standardised mortality ratio (SMR) declined from 86.5 (confidence interval (CI) 63.0 to 137.7) to 39.7 (CI 31.2 to 54.3) p = 0.024. The incidence of proximal DVT was 0.3%. . Take home message: With individualised risk assessment and as part of a multimodal approach, Aspirin is safe to use as the main thromboprophylactic agent in primary arthroplasty. It is not associated with an increased incidence of symptomatic DVT, PE or death. . Cite this article: Bone Joint J 2016;98-B:341-8

The June 2015 Knee Roundup360 looks at: Cruciate substituting versus retaining knee replacement; What’s behind the psychology of anterior cruciate ligament (ACL) reconstruction?; Is there a difference in total knee arthroplasty risk of revision in highly crosslinked versus conventional polyethylene?; Unicompartmental knee arthroplasty: is age the missing variable?; Satisfaction rates following total knee arthroplasty; Is knee alignment dynamic?; Unicompartmental knee arthroplasty: cemented or cementless?; Can revision knee services pay?

Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of hip (THR) and knee replacement (TKR). The aim of this prospective cohort study was to examine the expectations of patients undergoing THR and TKR, and to identify differences in expectations, predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures. During the study period, patients who underwent 346 THRs and 323 TKRs completed an expectation questionnaire, Oxford score and Short-Form 12 (SF-12) score pre-operatively. At one year post-operatively, the Oxford score, SF-12, patient satisfaction and expectation fulfilment were assessed. Univariable and multivariable analysis were performed. Improvements in mobility and daytime pain were the most important expectations in both groups. Expectation level did not differ between THR and TKR. Poor Oxford score, younger age and male gender significantly predicted high pre-operative expectations (p < 0.001). The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome. THR better met the expectations identified as important by patients. TKR failed to meet expectations of kneeling, squatting and stair climbing. High fulfilment of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores. The fulfilment of expectations was highly correlated with satisfaction

Patients who have undergone total hip or knee replacement (THR and TKR, respectively) are at high risk of venous thromboembolism. We aimed to determine the time courses of both the incidence of venous thromboembolism and effective prophylaxis. Patients with elective primary THR and TKR were enrolled in the multi-national Global Orthopaedic Registry. Data on the incidence of venous thromboembolism and prophylaxis were collected from 6639 THR and 8326 TKR patients. The cumulative incidence of venous thromboembolism within three months of surgery was 1.7% in the THR and 2.3% in the TKR patients. The mean times to venous thromboembolism were 21.5 days (. sd. 22.5) for THR, and 9.7 days (. sd. 14.1) for TKR. It occurred after the median time to discharge in 75% of the THR and 57% of the TKA patients who developed venous thromboembolism. Of those who received recommended forms of prophylaxis, approximately one-quarter (26% of THR and 27% of TKR patients) were not receiving it seven days after surgery, the minimum duration recommended at the time of the study. The risk of venous thromboembolism extends beyond the usual period of hospitalisation, while the duration of prophylaxis is often shorter than this. Practices should be re-assessed to ensure that patients receive appropriate durations of prophylaxis

Aims. The aim of this study was to identify the most effective regimen of multiple doses of oral tranexamic acid (TXA) in achieving maximum reduction of blood loss in total knee arthroplasty (TKA). Patients and Methods. In this randomized controlled trial, 200 patients were randomized to receive a single dose of 2.0 g of TXA orally two hours preoperatively (group A), a single dose of TXA followed by 1.0 g orally three hours postoperatively (group B), a single dose of TXA followed by 1.0 g three and nine hours postoperatively (group C), or a single dose of TXA followed by 1.0 g orally three, nine, and 15 hours postoperatively (group D). All patients followed a routine enhanced-recovery protocol. The primary outcome measure was the total blood loss. Secondary outcome measures were hidden blood loss (HBL), reduction in the level of haemoglobin, the rate of transfusion and adverse events. Results. Groups C (661.1 ml, . sd. 262.4) and D (597.7 ml, . sd. 219.6) had significantly lower mean total blood loss compared with groups A and B. The mean HBL was significantly lower in groups B (699.2 ml), C (533.1 ml) and D (469.9 ml) than in group A (p = 0.006, p < 0.001, and p < 0.001, respectively). Groups C (2.22 ml, . sd. 0.91) and D (2.04 ml, . sd. 0.95) had a lower reduction in the level of haemoglobin than groups A and B. However, there were no differences between groups C and D in relation to the three parameters. Conclusion. The addition of two or three postoperative doses of TXA to one preoperative dose produced a significant reduction in blood loss. The two-dose postoperative regimen is the least necessary regimen for clinical efficacy in primary unilateral TKA. The three-dose regimen produced maximum reduction of blood loss. Cite this article: Bone Joint J 2018;100-B:1025–32

Aims. The aims of this study were to report the efficacy of revision surgery for patients with co-infective bacterial and fungal prosthetic joint infections (PJIs) presenting to a single institution, and to identify prognostic factors that would guide management. Patients and Methods. A total of 1189 patients with a PJI were managed in our bone infection service between 2006 and 2015; 22 (1.85%) with co-infective bacterial and fungal PJI were included in the study. There were nine women and 13 men, with a mean age at the time of diagnosis of 64.5 years (47 to 83). Their mean BMI was 30.9 kg/m. 2. (24 to 42). We retrospectively reviewed the outcomes of these PJIs, after eight total hip arthroplasties and 14 total knee arthroplasties. The mean clinical follow-up was 4.1 years (1.4 to 8.8). Results. The median number of risk factors for PJI was 5.5 (interquartile range (IQR) 3.25 to 7.25). All seven patients who initially underwent debridement and implant retention (DAIR) had a recurrent infection that led to a staged revision. All 22 patients underwent the first of a two-stage revision. None of the nine patients with negative tissue cultures at the second stage had a recurrent infection. The rate of recurrent infection was significantly higher in the presence of multidrug-resistant bacteria (p = 0.007), a higher C-reactive protein (CRP) at the time of presentation (p = 0.032), and a higher number of co-infective bacterial organisms (p = 0.041). The overall rate of eradication of infection after two and five years was 50% (95% confidence interval (CI) 32.9 to 75.9) and 38.9% (95% CI 22.6 to 67), respectively. Conclusion. The risk of failure to eradicate infection with the requirement of amputation associated with this diagnosis is much higher than in patients with PJI without bacterial and fungal co-infection, and this risk is heightened when the fungal organism is joined by polymicrobial and multidrug-resistant bacterial organisms. Cite this article: Bone Joint J 2019;101-B:582–588

We hypothesised there was no clinical value in using an autologous blood transfusion (ABT) drain in either primary total hip (THR) or total knee replacement (TKR) in terms of limiting allogeneic blood transfusions when a modern restrictive blood management regime was followed. A total of 575 patients (65.2% men), with a mean age of 68.9 years (36 to 94) were randomised in this three-arm study to no drainage (group A), or to wound drainage with an ABT drain for either six hours (group B) or 24 hours (group C). The primary outcome was the number of patients receiving allogeneic blood transfusion. Secondary outcomes were post-operative haemoglobin (Hb) levels, length of hospital stay and adverse events. This study identified only 41 transfused patients, with no significant difference in distribution between the three groups (p = 0.857). The mean pre-operative haemoglobin (Hb) value in the transfused group was 12.8 g/dL (9.8 to 15.5) versus 14.3 g/dL (10.6 to 18.0) in the non-transfused group (p < 0.001, 95% confidence interval: 1.08 to 1.86). Post-operatively, the median of re-transfused shed blood in patients with a THR was 280 mL (Interquartile range (IQR) 150 to 400) and in TKR patients 500 mL (IQR 350 to 650) (p <  0.001). ABT drains had no effect on the proportion of transfused patients in primary THR and TKR. The secondary outcomes were also comparable between groups. Cite this article: Bone Joint J 2014;96-B:765–71

Patient specific instrumentation (PSI) uses advanced imaging of the knee (CT or MRI) to generate individualised cutting blocks aimed to make the procedure of total knee arthroplasty (TKA) more accurate and efficient. However, in this era of healthcare cost consciousness, the value of new technologies needs to be critically evaluated. There have been several comparative studies looking at PSI versus standard instrumentation. Most compare PSI with conventional instrumentation in terms of alignment in the coronal plane, operative time and surgical efficiency, cost effectiveness and short-term outcomes. Several systematic reviews and meta-analyses have also been published. PSI has not been shown to be superior compared with conventional instrumentation in its ability to restore traditional mechanical alignment in primary TKA. Most studies show comparative efficacy and no decrease in the number of outliers in either group. In terms of operative time and efficiency, PSI tended towards decreasing operative time, saving a mean of five minutes per patient (0 to 20). Furthermore, while some cost savings could be realised with less operative time and reduced instrumentation per patient, these savings were overcome by the cost of the CT/MRI and the cutting blocks. Finally, there was no evidence that PSI positively affected clinical outcomes at two days, two months, or two years. Consequently, current evidence does not support routine use of PSI in routine primary TKA. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):78–80

Aims

Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.