Most unicompartmental knee replacement revisions could be avoided: a radiographic evaluation of revised Oxford knees in the National Joint Registry.

PURPOSE: The purpose of this study was to understand why the revision rate of unicompartmental knee replacement (UKR) in the National Joint Registry (NJR) is so high. Using radiographs, the appropriateness of patient selection for primary surgery, surgical technique, and indications for revision were determined. In addition, the alignment of the radiographs was assessed. METHODS: Oxford UKR registered with the NJR between 2006 and 2010 and subsequently revised were identified by the NJR. A blinded review was undertaken of pre-primary, post-primary, and pre-revision anteroposterior and lateral radiographs of a sample of 107 cases from multiple centres. RESULTS: The recommended indications were satisfied in 70%, with 29% not demonstrating bone-on-bone arthritis. Major technical errors, likely leading to revision, were seen in 6%. Pre-revision radiographs were malaligned and, therefore, difficult to interpret in 53%. No reason for revision was seen in 67%. Reasons for revision included lateral compartment arthritis (10%), tibial loosening (7%), bearing dislocation (7%), infection (6%), femoral loosening (3%), and peri-prosthetic fracture (2%, one femoral, one tibial). CONCLUSIONS: Only 20% of the revised UKR were implanted for the recommended indications, using appropriate surgical technique and had a mechanical problem necessitating revision. One-third of primary surgeries were undertaken in patients with early arthritis, which is contraindicated. Two-thirds were presumably revised for unexplained pain, which is not advised as it tends not to help the pain. This study suggests that variable and inappropriate indications for primary and revision surgery are responsible for the high rates of revision seen in registries. LEVEL OF EVIDENCE: III, Therapeutic study.

Total Knee Arthroplasty for Osteoarthritis in Patients Less Than Fifty-Five Years of Age: A Systematic Review.

BACKGROUND: The proportion of younger patients undergoing total knee arthroplasty (TKA) is increasing and predictions state that the <55 age group will be the fastest growing group by 2030. We aim to collate data across studies to assess functional outcomes following TKA in patients <55 years of age using a systematic review. METHODS: The search identified 980 studies for title and abstract review. Forty-three full texts were then assessed. Thirteen studies underwent quality assessment and data extraction. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed throughout. Outcomes extracted included pre-operative and post-operative functional scores, range of motion, and patient satisfaction. Clinical complications and survival were also recorded. RESULTS: Across 13 studies we were able to demonstrate 54-point improvement in clinical Knee Society Score and a 46-point improvement on functional Knee Society Score. A 2.9° improvement in range of motion was found at final follow-up. Satisfaction rate was 85.5%. Cumulative percentage all-cause revision rate was 5.4% across 1283 TKAs at a mean 10.8 years of follow-up. Ten-year survival, for aseptic loosening alone, was 98.2%. CONCLUSION: TKA is an excellent treatment option for the young osteoarthritic knee with a >50% improvement in functional knee scores. Satisfaction is high and the revision rate remains 0.5% per year.

Systematic review of proximal femoral arthroplasty for non-neoplastic conditions.

Proximal femoral arthroplasty (PFA) is an established treatment modality following oncological resection. Increasingly, these prostheses are being used for non-neoplastic conditions such as fractures and bone loss associated with septic or aseptic loosening. We performed a systematic review of the literature to determine the failure rates, mortality rates and hip outcome scores when PFAs were used in non-neoplastic conditions. There were 14 studies with an average follow-up of 3.8 years (range 0-14 years) describing 356 PFAs. Re-operation for any reason occurred in 23.8% (85/356) of cases. The most common complications were dislocation (15.7%) and infection (7.6%). The mortality rate ranged from 0% to 40%. PFA provides an acceptable surgical solution when confronted with massive bone loss, but it has a high re-operation rate for dislocation and infection.

Conversion of unicompartmental knee arthroplasty to total knee arthroplasty: the challenges and need for augments.

The potential advantages of unicompartmental knee arthroplasty (UKA) include lower morbidity and mortality, quicker recovery, good range of motion, good medium and long-term survival results, potential bone conservation and perceived easier revision. Converting a UKA to a total knee arthroplasty (TKA) may be challenging due to issues of bone loss, need for augmentation, restoring joint line and rotation. We present the intraoperative findings of 201 cases of failed UKA's from the Trent Wales arthroplasty audit group (TWAAG) register. The objectives of the study were to determine the modes of failure, number of cases requiring augments and bone grafting, types of augments and implants used in revision surgery. This study does not include the clinical outcomes after revision knee surgery. The average age of the cohort at revision surgery was 67 years. There were 111 females and 90 males. The commonest modes of failure in young patients were unexplained pain/instability and aseptic loosening and in older patients they were aseptic loosening and progression of the disease. The survivorship of the implant was higher in the less than 55 years age group in comparison to the older patients. A total of 49 patients (25.9%) required bone grafting commonest in the 60 years and above age group (79.6%). Fifty patients (26.4%) required some form of augmentation, with the commonest site being tibia and commonest augment being tibial stem (35 cases). Only 8% of the cohort required revision knee implants whereas 78% of the cases received a cruciate retaining primary knee implant. To the author's knowledge, this is one of the largest studies in the literature which signifies the technical difficulties that might be experienced in revising the UKA's which will require appropriate pre-operative planning.

Effects of combining electrical stimulation of the calf and thigh muscles in patients with osteoarthritis of the knee: protocol for a double-blind, randomised, sham-controlled trial.

INTRODUCTION: Knee osteoarthritis (KOA) is a leading cause of disability and is characterised by degenerative changes causing pain and loss of function. Neuromuscular electrical stimulation (NMES) has been shown to influence muscle size and strength in healthy subjects. A novel self-administered NMES device has been developed to help manage the symptoms of KOA. This study aims to investigate the effects of combining NMES of the calf and quadriceps on individuals with KOA. METHODS AND ANALYSIS: 193 individuals with KOA will be recruited to a single-centre, double-blind, randomised, sham-controlled trial at the Respiratory Biomedical Research Centre, Leicester, UK. Participants will be randomised (1:1) to follow an 8-week home-based intervention using a NMES device or sham device. The NMES device consists of footplate electrodes and two quadriceps electrodes. Footplate stimulation will be completed daily for 30 min and quadriceps stimulation for 20 min, five times a week (compliance is recorded in a self-reported participant diary). The primary outcome is the Western Ontario and McMaster Universities Arthritis Index pain domain, taken at 8 weeks follow-up. Secondary outcomes will explore quadriceps muscle strength, swelling, health-related quality of life, exercise capacity, anxiety and depression, sleep, physical activity and self-reported compliance. A powered subgroup analysis for compliance to the active device will be complete for the primary outcome. Participant focus groups will be completed following recruitment of half of the participants and after all participants have been recruited. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the North-West Preston ethics committee (17/NW/0081). Participants are required to provide informed consent following review of the participant information sheet and discussion regarding study procedures with a member of the research team. The study results will be disseminated to the appropriate stakeholders through presentations, conferences and peer-reviewed journals. Results will be presented to participants following study completion at the Biomedical Research Centre-Respiratory, Glenfield Hospital, Leicester. TRIAL REGISTRATION NUMBER: ISRCTN registry, ISRCTN12112819 (date registered 1 May 2019). IRAS registry 219 693. University Hospitals of Leicester registry 91 017. Protocol Version 8.

The outcome of secondary resurfacing of the patella following total knee arthroplasty: Results from the Trent and Wales Arthroplasty Register.

BACKGROUND: We sought to determine whether patients undergoing secondary patella resurfacing (SPR) benefited from the procedure by assessing postoperative satisfaction via a postal questionnaire. METHODS: All such patients included in the Trent and Wales Arthroplasty Register were invited to participate using patient-reported outcome measures (PROMs). We identified 223 patients who had undergone SPR over a 20-year period. Forty-two had died according to death register checks. Eighty-eight of 181 (48.6%) questionnaires were completed. The mean age at resurfacing was 67 (min. 42, max. 81); 52% were female. The median time to follow-up was 55months (interquartile range (IQR) 41-111). Median time to SPR was 28months (IQR 20-42). RESULTS: Thirty-nine patients (44%) felt that SPR resolved the problem of pain in the front of their knee. All PROMs were significantly better for those who felt that the resurfacing had worked (Oxford Knee Score 29 vs. 16, P<0.05, modified Kujala 51 vs. 32, P<0.05, EQ5D-3L 0.616 vs. 0.384, P<0.05). Based on PROMs, SPR produces a satisfactory outcome in two of every five patients. CONCLUSIONS: Surgeons must be clear on the cause of anterior knee pain post-total knee replacement, and patients must be made aware of what outcomes can be reasonably expected from this procedure.

A regional registry study of 216 patients investigating if patient satisfaction after total knee arthroplasty changes over a time period of five to 20years.

AIMS: To determine the temporal changes in patient dissatisfaction following primary knee arthroplasty surgery (TKA). PATIENTS AND METHODS: Three hundred and ninety patients that had previously indicated they were either dissatisfied or unsure with their TKA at one-year post-surgery in our region were mailed a simple questionnaire in addition to the Oxford Knee Score and EQ-5D. RESULTS: A 55% response rate was achieved. The mean follow-up time period was 9.1years. Of the 120 patients who were initially dissatisfied, 46.7% remained so. Of the 96 patients who were initially unsure, 20.8% remained so, 21.9% and 57.3% became dissatisfied and satisfied, respectively. The primary reason for continued dissatisfaction was persistent pain. Of the 19.4% of patients who had revision surgery, 47.6% remained dissatisfied. 54.2% of patients stated that they would be happy to have a primary TKA again and 55.6% indicated that they would recommend one to a friend. Patients who had concurrent hip pain were six times more likely to remain unsure or dissatisfied over time (OR 6.7, p-value 0.0000). Patients who had back pain or contralateral knee pain were two or three times as likely to remain unsure or dissatisfied. CONCLUSION: In time half of the patients who stated that they were not satisfied with their arthroplasty, at one year, go on to be satisfied with their knee.

Trends in total hip arthroplasty in young patients - results from a regional register.

INTRODUCTION: In the United Kingdom, over 83,000 primary total hip arthroplasties (THAs) were performed last year, of which 20% are in patients under the age of 60 years. These patients generally have a longer life expectancy and a higher activity level than an older cohort, which may potentially translate to higher revision rates. METHODS: We reviewed our Trent regional arthroplasty register to assess current surgical practice in younger patients undergoing total hip arthroplasty. The results were compared to a previous study published in 2005. RESULTS: Between 2010 and 2012, 1,097 primary THAs were performed on patients aged 54 or less. There was an equal cohort of males to females with a mean age of 46 years of patients undergoing THA. Osteoarthritis was the commonest aetiology for patients having surgery. Reviewing the components used there were 32 different femoral and 30 different acetabular types along with 70 different combinations of components. There were 608 uncemented THAs, 313 hybrid THRs, 98 cemented THAs, 67 resurfacing arthroplasties and 11 reverse hybrid THAs. DISCUSSION: The majority of implants were uncemented in both femur and acetabulum with consultants performing most of the procedures. There is a clear preference for uncemented femoral and acetabular fixation in the younger patient, and the trend towards uncemented components has increased over the last 10 years amongst the same surgeons. There continues to be a wide variety of cup and stem usage along with many different combinations of components, with no consensus on the ideal combination.

A systematic review of endoprosthetic replacement for non-tumour indications around the knee joint.

BACKGROUND: Endoprosthetic replacement (EPR) for limb salvage is an established treatment modality for orthopaedic malignancies around the knee. Increasingly, they are being used for non-tumour indications such as fractures, bone loss associated with aseptic loosening, septic loosening and ligament insufficiencies. METHODS: We reviewed the evolution and biomechanics of knee EPRs. MEDLINE was searched using the PubMed interface to identify relevant studies pertaining to the use of knee EPRs in non-tumour conditions. Failures, mortality and knee scores were the main outcome measures. Subgroup analysis in the non-tumour conditions was also performed. RESULTS: There were nine studies with an average follow-up of 3.3years (Range 1-5years) describing 241 EPRs used in non-tumour conditions. Re-operation for any reason occurred in 17% (41/241) of cases. The most common complication was infection (15%) followed by aseptic loosening (5%) and periprosthetic fractures (5%). The mortality rate averaged 22%. Infected knee arthroplasties were less likely to have a successful outcome when salvaged with an EPR with failure rates up to 33%. CONCLUSIONS: Endoprosthetic replacement is a limb salvage option when other surgical options are unfeasible, especially in low demand elderly patients with limited life expectancy. They have low rates of failure in the medium term. LEVEL OF EVIDENCE: Level 1.

Ganglia arising from the transverse acetabular ligament: a report of two cases.

Ganglia arising from the hip are rare. Its diagnosis is difficult owing to the anatomic location. A high index of suspicion and high-resolution imaging is essential to make the diagnosis. Treatment depends on the size, location, and symptoms. This report is of 2 patients with ganglia arising from the transverse acetabular ligament.

Long-term outcome of total hip replacement in patients with or without femoral head contamination.

PURPOSE: To compare long-term outcomes of total hip replacement (THR) in patients with or without contamination of the femoral head. METHODS: After a mean period of 12 (range, 8-17) years, 104 female and 71 male THR patients aged 47 to 96 (mean, 77) years were reassessed via a self-administered questionnaire, and 25 other THR patients were reassessed by review of case notes. The questionnaires comprised the 12-item Oxford hip score and the European Quality Of Life (EuroQOL). 87 and 88 patients had positive and negative cultures in the donated femoral heads, respectively. The 2 groups were compared with respect to the Oxford hip score, the EuroQOL, and rates of complication and revision surgery. RESULTS: Long-term outcomes of THR patients with or without femoral head contamination were not significantly different. Respectively, the mean Oxford hip scores were 36 and 39 (p=0.4); 16 and 14 patients had the maximum score of 48; 2 and 3 patients scored <10 (mostly owing to aseptic loosening). The respective mean visual analogue scale score of the EuroQOL were 65 and 73 (p=0.07); only the dimension of self care was significantly different between groups (p=0.04). Respectively, 14 and 12 patients had complications (16% vs. 15%, χ²=0.05, p=0.8), whereas 11 and 5 patients had revision surgery (13% vs. 6%, χ²=2.2, p>0.1). CONCLUSION: Microbiological screening of donated femoral heads plays no role in predicting long-term failure of THR in the donors.

Mortality following hip fracture surgery in patients with recent myocardial infarction.

INTRODUCTION: In an elective setting, surgery is best avoided for at least 6 months following myocardial infarction. However, in the presence of a femoral neck fracture, this would most probably lead to significant complications in relation to prolonged immobilisation. There is no published mortality data for patients undergoing surgery for hip fracture following a recent myocardial infarction. The aim of this retrospective study was to assess the mortality of hip fracture patients with a recent myocardial infarction that have undergone surgery at our institution. PATIENTS AND METHODS: Between January 2003 and October 2005, 2270 patients were admitted to our unit with a proximal femoral fracture. Of these, 11 patients were found to have a recent myocardial infarction. RESULTS: Of these 11 patients, 8 were female. The average age was 78.2 years (range, 59-90 years). Average delay from the time of infarction to operation was 11.2 days (range, 3-23 days). Mortality at 1 and 6 months was 45.4% and 63.5%, respectively. DISCUSSION: This is much higher than the overall reported mortality following proximal femur fracture. This information may be useful when planning future peri-operative care and discussing overall prognosis with patients and their relatives.