Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline.

BACKGROUND: The burden of knee replacement prosthetic joint infection (KR PJI) is increasing. KR PJI is difficult to treat, outcomes can be poor and it is financially expensive and limited evidence is available to guide treatment decisions. AIM: To provide guidelines for surgeons and units treating KR PJI. METHODS: Guideline formation by consensus process undertaken by BASK's Revision Knee Working Group, supported by outputs from UK-PJI meetings. RESULTS: Improved outcomes should be achieved through provision of care by revision centres in a network model. Treatment of KR PJI should only be undertaken at specialist units with the required infrastructure and a regular infection MDT. This document outlines practice guidelines for units providing a KR PJI service and sets out: CONCLUSIONS: KR PJI patients treated within the NHS should be provided the best care possible. This report sets out guidance and support for surgeons and units to achieve this.

Revision knee complexity classification-RKCC: a common-sense guide for surgeons to support regional clinical networking in revision knee surgery.

PURPOSE: There is considerable variation in practice throughout Europe in both the services provided and in the outcomes of Revision Knee Surgery. In the UK, a recent report published called get it right first time (GIRFT) aims to improve patient outcomes through providing high quality, cost-effective care, and reducing complications. This has led to the development of a classification system that attempts to classify the complexity of revision knee surgery, aiming to encourage and support regional clinical networking. METHODS: The revision knee classification system (RKCC) incorporates not only complexity, but also patient factors, the presence of infection, the integrity of the extensor mechanism, and the soft tissues. It then provides guidance for clinical network discussion. Reliability and reproducibility testing have been performed to establish the inter- and intra-observer variabilities using this classification. RESULTS: Good correlation between first attempt non-expert and experts, good intra-observer variability of non-expert, and an excellent correlation between second attempt non-expert and experts has been achieved. This supports the use of RKCC by both inexperienced and experienced surgeons. CONCLUSIONS: The revision knee complexity classification has been proposed that offers a common-sense approach to recognize the increasing complexity in revision TKR cases. It provides a methodological assessment of revision knee cases and support regional clinical networking and triage of appropriate cases to revision units or specialist centres. LEVEL OF EVIDENCE: Expert opinion, Level V.

Patellar reconstruction following previous patellectomy: a review of the literature and a case series using distal femoral autograft during total knee arthroplasty.

During total knee arthroplasty, the reconstruction of the patella following a previous patellectomy is challenging, and is undertaken to improve functional outcomes and patient satisfaction. In this case series, we have reconstructed the patella using a femoral condyle resected during total knee arthroplasty. The resected femoral condyle with best available bone stock is selected and secured to the extensor mechanism. We reviewed the preoperative indications and postoperative outcomes of two patients who underwent the above procedure at our Institute, and compared this to the literature. The cases include a 68-year old male (6 months follow-up) who sustained a multi-fragmentary fracture of his right patella and underwent a patellectomy 30 years previously, and a 45-year old female (4 years follow-up) who underwent a left-sided patellectomy 15 years previously following polytrauma. As a result of progressive osteoarthritis they required total knee arthroplasty, and simultaneous patella reconstruction with a femoral condyle autograft. Compared to their preoperative range of motion, both patients demonstrated an improvement post-operatively with successful pain-free knee function, with no radiological signs of graft resorption. In this limited, small series we have reported two patients who are clinically and functionally satisfied by the outcome of surgery, with comparable outcomes to alternative methods. We believe the use of a femoral condyle autograft for patellar reconstruction is a safe and simple technique that optimises knee kinematics, without associated donor morbidity.

Endoscopic cystic duct stent as primary treatment for intrahepatic gallbladder perforation with abscess formation.

Intrahepatic gallbladder perforation with abscess formation is an uncommon presentation of biliary disease. There is no consensus on how to treat this condition, with strategies varying from percutaneous drainage to open cholecystectomy and washout. We present a case of a novel, minimally invasive treatment, using endoscopic retrograde cholangiopancreatography to place a transcystic drain as a bridge to laparoscopic cholecystectomy.

International consensus on the definition and classification of fibrosis of the knee joint.

AIMS: The aim of this consensus was to develop a definition of post-operative fibrosis of the knee. PATIENTS AND METHODS: An international panel of experts took part in a formal consensus process composed of a discussion phase and three Delphi rounds. RESULTS: Post-operative fibrosis of the knee was defined as a limited range of movement (ROM) in flexion and/or extension, that is not attributable to an osseous or prosthetic block to movement from malaligned, malpositioned or incorrectly sized components, metal hardware, ligament reconstruction, infection (septic arthritis), pain, chronic regional pain syndrome (CRPS) or other specific causes, but due to soft-tissue fibrosis that was not present pre-operatively. Limitation of movement was graded as mild, moderate or severe according to the range of flexion (90° to 100°, 70° to 89°, < 70°) or extension deficit (5° to 10°, 11° to 20°, > 20°). Recommended investigations to support the diagnosis and a strategy for its management were also agreed. CONCLUSION: The development of standardised, accepted criteria for the diagnosis, classification and grading of the severity of post-operative fibrosis of the knee will facilitate the identification of patients for inclusion in clinical trials, the development of clinical guidelines, and eventually help to inform the management of this difficult condition. Cite this article: Bone Joint J 2016;98-B:1479-88.

Current Evidence for the Use of Laminar Flow in Reducing Infection Rates in Total Joint Arthroplasty.

Since the introduction of laminar air flow in orthopaedic theatres by Sir John Charnley, it has widely become accepted as the standard during orthopaedic procedures such as joint arthroplasty. We present a review of available current literature for the use of laminar flow operating theatre ventilation during total joint arthroplasty and examines the effectiveness of laminar flow ventilated operating theatres in preventing post-operative wound infection. Results of our findings suggest that while bacterial and air particulate is reduced by laminar air flow systems, there is no conclusive effect on the reduction of post-operative wound infections following total joint arthroplasty. We conclude that a combination of strict aseptic technique, prophylactic antibiotics and good anaesthetic control during surgery remains crucial to reduce post-operative surgical infections.

Single Stage Knee Arthroplasty Revision Surgery: A Systematic Review of the Literature.

Total Knee Arthroplasty is an increasingly common procedure and revision surgery, particularly for infection, is associated with significant morbidity and healthcare costs. The current gold standard is a two stage revision procedure but single stage revision is increasingly being used in some departments to improve patient outcomes. We conducted a systematic review of the literature to determine the up-to-date evidence underlying the use of a single stage knee approach in revision surgery. A total of 12 studies were included in this review amounting to 433 revision surgeries. This is the largest review of single stage knee revision surgery. The procedures described were heterogenous and included the 'two-in-one' technique as well as other single stage revision procedures. There were also differences in implants and antibiotic regimens. The mean re-infection rates described in 10 studies was 9.4% (range 0-19.2%) after a mean follow-up of 40.3 months (range 7-180 months). The re-infection rates in the studies published over the last 30 years are falling, and this is not accounted for by any significant change in duration of follow-up during this period. The outcome scores varied, but patients generally showed an improvement. The Knee Society Score and the Oxford Knee Score were the most commonly used in five and three studies respectively. We conclude that the current evidence for single stage revision is variable and there is a lack of good quality evidence to address whether single stage revisions is thorough enough to eradicate deep infection and is able to restore adequate function. There is a need for larger prospective studies with standardised procedures and protocol, and with adequate follow-up. Till then, patients considered for a single stage approach should be thoroughly assessed and the surgery should be performed by a senior surgeon with experience in single stage knee revisions.

[Knee revision arthroplasty : cementless, metaphyseal fixation with sleeves]. / Revisionsendoprothetik des Kniegelenks : Zementfreie, metaphysäre Fixation mittels Sleeves.

OBJECTIVE: Primary and long-term fixation of cementless metaphyseal implants in knee revision arthroplasty cases with large bone defects. INDICATIONS: All tibial and femoral bone defects AORI grade 2 and 3. CONTRAINDICATIONS: Cases where stable uncemented fixation of the metaphyseal implant is not possible. SURGICAL TECHNIQUE: Pre-operative evaluation of the failure mode and implant fixation planning. After opening the joint, a synovectomy and mobilisation of medial and lateral recesses routinely performed. Testing of ligamentous stability and implant fixation undertaken before explantation. Removal of the bearing, femoral and tibial components with osteotomes or oscillating saw. Tibial diaphysis prepared with reamers, and metaphyseal preparation with broaches and stem extension. Placement of the metaphyseal broach for height with respect to the tibial joint line and rotational stability assessed. Tibial tray size and position determined before implanting the sleeve, stem and tray trial. The tibial trial provides a stable platform for analysis of the extension and flexion gaps with spacer blocks. Diaphyseal reamers used to identify the anterior femoral bow. Metaphyseal broaches used to achieve stable fixation up to the resection line marked on the handle. Distal femoral freshening cut in 5° or 7° of valgus made to accommodate distal augments as needed. Positioning of the 4-in-1 block with reconstruction of the posterior off-set and cutting for posterior augmentation. Selection of a box cut corresponding to the amount of constraint needed. Trial insert with appropriate, stem, sleeve, condylar femur and augments introduced. Bearing size, joint stability and ROM assessed. Patella alignment and the need for patella replacement or revision determined. The definitive implants are cemented at the joint surface, with metaphyseal sleeves and diaphyseal stems are uncemented. POSTOPERATIVE MANAGEMENT: Full weight bearing as tolerated, physiotherapy, lymph drainage and pain therapy are routine with no specific post-operative management required. RESULTS: Between 2007 and 2011, 193 sleeves (119 tibial/74 femoral) were implanted in 121 aspetic knee revision arthroplasties. After average of 3.6 years they were analysed clinically and radiographically. The AKSS (American Knee Society Score) increased from 88 ± 18 to 147 ± 23 points (p < 0.01). ROM (range of motion) increased from 89 ± 6° to 114 ± 4°. Overall revision rate was 11.6 %. Only 4 sleeves revised for aseptic loosening (2 % of total sleeves). An additional 10 revisions performed mainly for infection (3.3 %) or ligament instability (3.3 %).

Zonal fixation in revision total knee arthroplasty.

Revision knee arthroplasty presents a number of challenges, not least of which is obtaining solid primary fixation of implants into host bone. Three anatomical zones exist within both femur and tibia which can be used to support revision implants. These consist of the joint surface or epiphysis, the metaphysis and the diaphysis. The methods by which fixation in each zone can be obtained are discussed. The authors suggest that solid fixation should be obtained in at least two of the three zones and emphasise the importance of pre-operative planning and implant selection.

Two-stage revision for infected total knee arthroplasty: our experience with interval prosthesis.

INTRODUCTION: To review our practice of performing two-stage revision for infected total knee arthroplasty using articulating interval prosthesis and to compare the incidence of the recurrence of infection and re-operation rate in patients undergoing two-stage revision as planned with the group of patients who choose not to proceed to the second stage. METHOD: This study is a retrospective review of 60 consecutive patients undergoing a two-stage revision for infected total knee arthroplasty using articulating interval prosthesis. All cases managed by a single surgeon using a uniform peri-operative protocol, and short-course parenteral antibiotic therapy. RESULT: Thirty-four patients (57%) (Group 1) underwent the two-stage revision as planned. However, twenty-six patients (43%) (Group 2) opted not to have a second-stage procedure as the first-stage and interval prosthesis had eradicated the infection, resolved the pain and achieved good functional outcome. There were five cases of recurrent infection in the 60 patients (8%) at a mean follow-up 5 years. In those completing the two-stage revision, two patients had recurrent infection. Of the patients who retained the interval prosthesis, there were three recurrent infections. There was no statistically significant difference between the groups in terms of recurrence of infection or re-revision. CONCLUSION: Two-stage revision with interval prostheses represents a safe and reliable method of treating infected knee prosthesis; however, there may be a role for one-stage revision in selected cases.

Metal metaphyseal sleeves in revision total knee replacement.

Bone loss in the proximal tibia and distal femur is frequently encountered in revision knee replacement surgery. The various options for dealing with this depend on the extent of any bone loss. We present our results with the use of cementless metaphyseal metal sleeves in 103 patients (104 knees) with a mean follow-up of 43 months (30 to 65). At final follow-up, sleeves in 102 knees had good osseointegration. Two tibial sleeves were revised for loosening, possibly due to infection. The average pre-operative Oxford Knee Score was 23 (11 to 36) and this improved to 32 (15 to 46) post-operatively. These early results encourage us to continue with the technique and monitor the outcomes in the long term.

Developing a strategy to treat established infection in total knee replacement: a review of the latest evidence and clinical practice.

This review summarises the opinions and conclusions reached from a symposium on infected total knee replacement (TKR) held at the British Association of Surgery of the Knee (BASK) annual meeting in 2011. The National Joint Registry for England and Wales reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused by infection. The diagnosis of infection beyond the acute post-operative stage relies on the identification of the causative organism by aspiration and analysis of material obtained at arthroscopy. Ideal treatment then involves a two-stage surgical procedure with extensive debridement and washout, followed by antibiotics. An articulating or non-articulating drug-eluting cement spacer is used prior to implantation of the revision prosthesis, guided by the serum level of inflammatory markers. The use of a single-stage revision is gaining popularity and we would advocate its use in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no radiological evidence of component loosening or osteitis. It is our opinion that single-stage revision produces high-quality reproducible results and will soon achieve the same widespread acceptance as it does in infected hip arthroplasty.

Bilateral total knee replacement in a congenital amputee with bilateral fibular deficiency.

We present the first ever reported case of bilateral total knee replacements in a congenital amputee with bilateral fibular deficiency. A 60 year old woman with bilateral fibular hemimelia presented with advanced osteoarthritis in both her knees for which bilateral total knee replacements was performed. The left knee replacement was followed up at 12 months and the right knee at 7 years. Oxford knee scores improved from 14 to 40 for the left knee and were 37 for the right knee. She was able to walk independently to a distance beyond 400 m. Modification in the surgical procedure and postoperative rehabilitation is discussed. Mid-term follow-up of 7 years reaffirms total knee replacement as a viable option for below knee amputees with knee osteoarthritis.

Closed double-lumen suction irrigation in the management of chronic diaphyseal osteomyelitis: long-term follow-up.

Between November 1994 and June 1999, 35 patients referred to our Problem Fracture Service with chronic diaphyseal osteomyelitis were treated using a closed double-lumen suction irrigation system after reaming and arthroscopic debridement of the intramedullary canal. This is a modified system based on that of Lautenbach. Between June and July 2007 the patients were reviewed by postal questionnaire and telephone and from the case notes. At a mean follow-up of 101 months (2 to 150), 26 had no evidence of recurrence and four had died from unrelated causes with no evidence of recurrent infection. One had been lost to follow-up at two months and was therefore excluded. Four had persisting problems with sinus discharge and one had his limb amputated for recurrent metaplastic change. Our results represent a clearance of infection of 85.3% (29 of 34), with recurrence in 11.8% (4 of 34). They are comparable to the results of the Papineau and Belfast techniques, but with considerably less surgical insult to the patient.

Meniscal bearing uncemented total knee arthroplasty: early clinical results at a minimum 2-year review.

A prospective study of early clinical and radiologic outcome of the Motus (Osteo, Selzach, Switzerland) meniscal bearing total knee arthroplasty was performed. We reviewed the first 75 consecutive prostheses in 62 patients, implanted over a 4-year period. The mean follow-up was 2.5 years. Average preoperative knee score was 97 out of 200 (Knee Society score, 43; functional score, 54) and at 2-year review was 179 out of 200 (Knee Society score, 87; functional score, 92). Average postoperative flexion at 2 years was 113 degrees. No meniscal bearing subluxation, dislocation, or breakages occurred. Radiologically, there was no evidence of subsidence or osteolysis. Our results support the continued use of this meniscal bearing knee prosthesis. It is important to confirm, however, an equal flexion and extension gap without proximal joint line migration.