Intraosseous Regional Administration of Vancomycin Prophylaxis for Primary and Revision Total Knee Arthroplasty.

The advantages of prophylaxis with intraosseous regional administration (IORA) of vancomycin for periprosthetic joint infection (PJI) in primary and revision total knee arthroplasty (TKA) include the ability to deliver antibiotics directly to the surgical bed and avert systemic delivery; the ability to precisely time and quickly administer vancomycin to achieve the highest concentrations at the beginning and throughout the surgical procedure; and the ability to avert several common and potentially serious adverse effects of intravenous vancomycin. Indications for IORA of vancomycin prophylaxis include the following clinical scenarios: revision TKA; obesity; diabetes; beta-lactam allergy; known colonization with methicillin-resistant Staphylococcus aureus (MRSA); individuals coming from institutions with a high MRSA incidence; previous ligamentous surgical procedure or osteotomy; current or recent smokers; in the primary TKA setting if the individual is considered high-risk as defined by the criteria above; and during reimplantation following 2-stage exchange for PJI.

Complications of ankle arthroscopy: frequency, prevention, and treatment.

The complication rate of ankle arthroscopy (AA) ranges from 3.5% to 14%. To avoid such complications, it is essential to have a thorough understanding of the anatomy of the ankle, to perform the procedure very carefully and with appropriate instrumentation, and to use a non-invasive distraction technique. The most frequent complications are neurological (cutaneous nerve injuries), which are usually caused by direct injury during arthroscopic portals or by a distracting pin when using an invasive distraction technique. They usually resolve spontaneously within a few months. The iatrogenic formation of a pseudoaneurysm is a severe but extremely rare complication (an incidence of 0.008%). There are several treatments for pseudoaneurysms: external compression; direct thrombin injection, surgical intervention (resection of the damaged segment of the artery and reconstruction with a reversed long saphenous vein interposition graft), and endovascular embolisation. Other rare complications include wound infections (localised superficial infection), problems at the portal incisions (prolonged portal drainage, residual pain in the portal, portal scar dehiscence, cyst at the portal site), type I complex regional pain syndrome, instrument breakage, painful scars and nodules, and a number of other rarer complications. In conclusion, when performing AA, it is important to remember the potential complications and try to avoid them. When they do occur, it is essential to diagnose and treat them appropriately.

Orthopedic surgical procedures in people with hemophilia.

People with hemophilia tend to develop joint lesions secondary to the recurrent hemarthroses typical of their condition. These usually include chronic synovitis and arthropathy chiefly affecting their ankles, knees, and elbows. In addition, muscular hematomas, albeit less frequently, may also result in complications such as acute compartment syndrome, pseudotumors, bone cysts and peripheral nerve compression. Joint lesions may require some of the following surgical interventions: arthroscopic synovectomy (in cases of synovitis), arthroscopic joint debridement, radial head resection, opening-wedge tibial osteotomy, arthrodesis, arthrodiastasis (of the ankle), tendon lengthening (hamstrings, Achilles tendon), progressive extension of the knee by placing an external fixator in cases of flexion contracture of the knee, supracondylar femoral extension osteotomy in cases of knee flexion contracture and, eventually, a total joint arthroplasty when the affected joint has been destroyed and the patient experiences severe joint pain. Total knee arthroplasty in hemophilic patients is associated with a high infection risk (7% on average). As regards the complications following muscle hematomas, acute compartment syndrome requires urgent performance of a fasciotomy when hematological treatment is incapable of resolving the problem. Surgical resection of hemophilic pseudotumors is the best solution, with those affecting the pelvis (secondary to iliopsoas hematomas) being particularly difficult to resolve. Peripheral nerve lesions can often be effectively addressed with hematological treatment, although a surgical neurolysis of the ulnar nerve is indicated if nonoperative treatment fails.

Knee Osteoarthritis Following Anterior Cruciate Ligament Reconstruction: Frequency, Contributory Elements, and Recent Interventions to Modify the Route of Degeneration.

Half of the individuals who experience an anterior cruciate ligament reconstruction (ACLR) suffer from knee osteoarthritis (OA) 12-14 years later. Elements that make a contribution to the appearance of OA following ACLR are anomalous anterior tibial displacement and anomalous tibial rotation in the course of the stance phase of walking (exhibited in 85% of operated knees). Individuals who undergo an early ACLR (5 days on average following anterior cruciate ligament [ACL] breakage) have an inferior frequency of radiographically apparent tibiofemoral OA at 32-37 years of follow-up than individuals with ACL rupture who did not experience the procedure. Nevertheless, the percentage of symptomatic OA, radiographically apparent patellofemoral OA and knee symptoms are alike in both groups. At 15 years of follow-up, 23% of knees that experienced an anatomic ACLR suffer from OA, while this percentage augments to 44% if the ACLR was non-anatomic. Knees of individuals who experience ACLR need total knee arthroplasty at an earlier age than healthy knees. Intra-articular injections of interleukin-1 receptor antagonist and corticosteroids may reduce the risk of OA after ACLR.

Complications and Implant Survival of Total Knee Arthroplasty in People with Hemophilia.

Total knee arthroplasty (TKA) is a commonly used option in advanced stages of knee arthropathy in people with hemophilia (PWH). The objective of this article is to determine what the complication rates and implant survival rates in PWH are in the literature. A literature search was carried out in PubMed (MEDLINE), Cochrane Library, Web of Science, Embase and Google Scholar utilizing the keywords "hemophilia TKA complications" on 20 October 2022. It was found that the rate of complications after TKA in PWH is high (range 7% to 30%), although it has improved during the last two decades, possibly due to better perioperative hematologic treatment. However, prosthetic survival at 10 years has not changed substantially, being in the last 30 years approximately 80% to 90% taking as endpoint the revision for any reason. Survival at 20 years taking as endpoint the revision for any reason is 60%. It is possible that with a precise perioperative control of hemostasis in PWH, the percentage of complications after TKA can be diminished.

Osteochondral Allografts for Large Osteochondral Lesions of the Knee Joint: Indications, Surgical Techniques and Results.

The main indications for osteochondral allografts (OCA) transplantation of the knee are the following: Symptomatic full-thickness cartilage lesions greater than 3 cm2; deep lesions with subchondral damage; and revision techniques when a previous surgical procedure has failed. Dowel and shell techniques are the two most commonly used for OCA transplantation. The dowel technique is appropriate in most cartilage lesions; however, geometrically irregular lesions may need the shell technique. Factors related to better outcomes after OCA transplantation are the following: unipolar lesions; patients younger than 30 years; traumatic lesions; and when the treatment is carried out within 12 months from the onset of symptoms. A systematic review found a survivorship rate of 89% at 5 years. Other systematic review showed a mean failure rate of 25% at 12 years with a reoperation rate of 36%. Seventy-two per cent of the failures were conversion to total knee arthroplasty (TKA) (68%) or unicompartmental knee arthroplasty (UKA) (4%). Twenty-eight per cent of failures were graft removal, graft fixation, and graft revision. In this systematic review, patellofemoral lesions (83%) had a higher reoperation rate than lesions affecting the tibial plateau or the femoral condyles. Overall, OCA transplantation showed a successful result in 75% of patients at 12 years follow-up.

Total knee arthroplasty in hemophilia: lessons learned and projections of what's next for hemophilic knee joint health.

INTRODUCTION: The purpose of this article has been to review the literature on total knee arthroplasty (TKA) in people with hemophilia (PWH), to mention the lessons we have learned from our own experience and to try to find out what the future of this type of surgery will be. AREAS COVERED: A Cochrane Library and PubMed (MEDLINE) search of studies related to TKA PWH was analyzed. In PWH, the complication rate after TKA can be up to 31.5%. These include infection (7.1%) and bleeding in the form of hematoma, hemarthrosis or popliteal artery injury (8.9%). In a meta-analysis the revision arthroplasty rate was 6.3%. One-stage or two-stage revision arthroplasty due to infection (septic loosening) is not always successful despite providing correct treatment (both hematological and surgical). In fact, the risk of prosthetic re-infection is about 10%. It is necessary to perform a re-revision arthroplasty, which is a high-risk and technically difficult surgery that can sometimes end in knee arthrodesis or above-the-knee amputation of the limb. EXPERT OPINION: TKA (both primary and revision) should be performed in centers specialized in orthopedic surgery and rehabilitation (knee) and hematology (hemophilia), and with optimal coordination between the medical team.

Total Knee Arthroplasty in Patients With Prior Ipsilateral Hip Fusion: A Surgical Technique.

BACKGROUND: In patients with severe osteoarthritis of the knee with prior ipsilateral hip fusion who require total knee arthroplasty (TKA), a controversial issue is whether to first convert the hip fusion to a total hip arthroplasty (THA) or to perform TKA without reconstruction of the hip. Also, immobility of the ipsilateral, fused hip adds significant technical challenge because the usual positioning of the leg requires modification in order to gain access needed for the TKA. TECHNIQUE: In such cases, we position the patient with the knee suspended, similar to how we perform knee arthroscopy. In our experience, the ipsilateral knee has significant deformity and is best addressed with a constrained, hinged TKA. RESULTS: In 3 patients with severe knee osteoarthritis with prior ipsilateral hip fusion-a 72-year-old man and a 79-year-old woman with hip arthrodesis due to posttraumatic arthritis and an 81-year-old woman with hip arthrodesis due to congenital dislocation of the hip-rotating-hinge knee prostheses were implanted due to severe knee instability. All 3 patients had satisfactory results, without complications, after follow-up of 1 to 5 years. CONCLUSIONS: We obtained satisfactory results in the short and medium term without previously converting the hip arthrodesis to THA by positioning patients with the knee suspended, in a way similar to when knee arthroscopy is performed, and implanting rotating hinge TKAs due to severe preoperative knee instability.

Management of bone loss in revision total knee arthroplasty: therapeutic options and results.

The treatment of small to moderate size defects in revision total knee arthroplasty (rTKA) has yielded good results with various techniques (cement and screws, small metal augments, impaction bone grafting and modular stems). However, the treatment of severe defects remains problematic.Severe defects have typically been treated with large allograft and metaphyseal sleeves. The use of structural allograft has decreased in recent years due to increased long-term failure rates and the introduction of highly porous metal augments (cones and sleeves).A systematic review of level IV evidence studies on the outcomes of rTKA metaphyseal sleeves found a 4% rate of septic revision, and a rate of septic loosening of the sleeves of 0.35%. Aseptic re-revision was required in 3% of the cases. The rate of aseptic loosening of the sleeves was 0.7%, and the rate of intraoperative fracture was 3.1%. The mean follow-up was 3.7 years.Another systematic review of tantalum cones and sleeves found a reoperation rate of 9.7% and a 0.8% rate of aseptic loosening per sleeve. For cones, the reoperation rate was 18.7%, and the rate of aseptic loosening per cone was 1.7%.The reported survival of metal sleeves was 99.1% at three years, 98.7% at five years and 97.8% at 10 years. The reported survival free of cone revision for aseptic loosening was 100%, and survival free of any cone revision was 98%. Survival free of any revision or reoperation was 90% and 83%, respectively. Cite this article: EFORT Open Rev 2021;6:1073-1086. DOI: 10.1302/2058-5241.6.210007.

Complications of surgical reconstruction of multiligament injuries of the knee joint: diagnosis, prevention and treatment.

The main complications of surgical reconstruction of multiligament injuries of the knee joint are residual or recurrent instability, arthrofibrosis, popliteal artery injury, common peroneal nerve injury, compartment syndrome, fluid extravasation, symptomatic heterotopic ossification, wound problems and infection, deep venous thrombosis, and revision surgery.Careful surgical planning and execution of the primary surgical reconstruction of multiligament injuries of the knee joint can minimize the risk of the aforementioned complications.Careful postoperative follow-up is required to detect complications. Early recognition and prompt treatment are of paramount importance.To obtain good results in the revision surgery of failed multiligamentary knee reconstructions, it is crucial to perform a thorough and exhaustive evaluation to detect all the causes of failure.Addressing all associated injuries during revision surgery will lead to the best possible subjective and objective results, although functional outcomes are often modest.However, advanced age and high-energy injuries have been associated with the poorest functional outcomes after revision surgery of failed multiligament injuries of the knee joint. Cite this article: EFORT Open Rev 2021;6:973-981. DOI: 10.1302/2058-5241.6.210057.

Effectiveness of ankle fusion in patients with hemophilia, advanced ankle degeneration, and unbearable pain for whom nonsurgical and surgical treatments have been ineffective.

Introduction: In underdeveloped countries, patients with hemophilia often experience repetitive ankle joint hemorrhages due to a shortage of coagulation factors (factor VIII [FVIII] and factor IX [FIX] for hemophilia A and B, respectively).Areas covered: This is a narrative literature review in which we searched the Cochrane Library and PubMed for articles related to ankle arthrodesis in patients with hemophilia. The searches covered the period from the databases´ inception to 28 February 2021. In the event of unsuccessful hematologic prophylaxis and conservative measures (e.g. analgesics, cyclooxygenase-2 inhibitors, taping, intra-articular injections of hyaluronic acid and corticosteroids, physical and rehabilitation medicine, orthoses, radiosynovectomy, and joint-preserving surgery (e.g. removal of the distal tibia by open surgery or by arthroscopic surgery, joint debridement by arthroscopic surgery), the classical surgical solution is ankle arthrodesis, which does not preserve the ankle joint.Expert opinion: Ankle pain is reduced after ankle arthrodesis (75% of patients experience no pain). Approximately 5% of patients require reoperation due to lack of fusion, and deep infection occurs in 2.5%. After tibiotalar fusion, a self-reported activity scale shows that approximately 12% of patients improve, 9% worsen, and 79% show no improvement. The results of ankle arthrodesis therefore appear to be poor.Therefore, although 75% of the patients stopped having ankle pain after arthrodesis, according to a self-reported activity scale 88% of them did not improve or worsened.

Dislocation of rotating-hinge total knee arthroplasty.

The number of rotating-hinge total knee arthroplasties (RH-TKAs) is increasing. As a result, the number of complications related to these procedures will also increase.RH-TKAs have the theoretical advantage of reducing bone implant stresses and early aseptic loosening. However, these implants also have complication rates that cannot be ignored. If complications occur, the options for revision of these implants are limited.Dislocation of RH-TKAs is rare, with an incidence between 0.7% and 4.4%. If it occurs, this complication must be accurately diagnosed and treated quickly due to the high incidence of neurovascular complications.If the circulatory and neurological systems are not properly assessed or if treatment is delayed, limb ischemia, soft tissue death, and the need for amputation can occur.Dislocation of a RH-TKA is often a difficult problem to treat. A closed reduction should not be attempted, because it is unlikely to be satisfactory. In addition, in patients with dislocation of a RH-TKA, the possibility of component failure or breakage must be considered.Open reduction of the dislocation should be performed urgently, and provision should be made for revision (that is, the necessary instrumentation should be available) of the RH-TKA, if it proves necessary.The mobile part that allows rotation can have various shapes and lengths. This variance in design could explain why the reported outcomes vary and why there is a probability of tibiofemoral dislocation. Cite this article: EFORT Open Rev 2021;6:107-112. DOI: 10.1302/2058-5241.6.200093.

Intra-articular Tranexamic Acid in Primary Total Knee Arthroplasty Decreases the Rate of Post-operative Blood Transfusions in People with Hemophilia: A Retrospective Case-Control Study.

BACKGROUND: Blood transfusion rates after total knee arthroplasty (TKA) in patients without hemophilia have diminished with the use of a standardized multimodal blood loss prevention method (MBLPM) that includes intra-articular tranexamic acid (TXA) (MBLPM-TXA). However, the topic has not been addressed in people with hemophilia. QUESTIONS/PURPOSES: Our aim was to investigate whether the MBLPM-TXA prevents blood loss in patients with hemophilia A who undergo TKA, thereby decreasing the need for post-operative blood transfusion. METHODS: This retrospective case-control comparative study involved 30 TKA patients who had a severe degree of hemophilia A without inhibitions: one group treated with the MBLPM-TXA (n = 15) and a second group treated without it (n = 15). In all cases, the pre-operative hemoglobin level was greater than 13 g/dL. RESULTS: The MBLPM-TXA group had a transfusion rate of zero, whereas 46.6% of the patients (seven of 15) in the non-MBLPM-TXA group needed transfusion. CONCLUSION: This retrospective case-control study showed that the use of an MBLPM-TXA in patients with hemophilia A who underwent TKA was effective in reducing rates of transfusion. We recommend its use.

The use of external fixation in the emergency department: applications, common errors, complications and their treatment.

The use of an external fixator (EF) in the emergency department (ED) or the emergency theatre in the ED is reserved for critically ill patients in a life-saving attempt. Hence, usually only fixation/stabilization of the pelvis, tibia, femur and humerus are performed. All other external fixation methods are not indicated in an ED and thus should be performed in the operating room with a sterile environment.Anterior EF is used in unstable pelvic lesions due to anterior-posterior compression, and in stable pelvic fractures in haemodynamically unstable patients.Patients with multiple trauma should be stabilized quickly with EF.The C-clamp has been designed to be used in the ED to stabilize fractures of the sacrum or alterations of the sacroiliac joint in patients with circulatory instability.Choose a modular EF that allows for the free placement of the pins, is radiolucent and is compatible with magnetic resonance imaging (MRI).Planning the type of framework to be used is crucial.Avoid mistakes in the placement of EF. Cite this article: EFORT Open Rev 2020;5:204-214. DOI: 10.1302/2058-5241.5.190029.

Arthroscopic treatment of total knee arthroplasty complications.

The most frequent indications for arthroscopy in patients with total knee arthroplasty (TKA) are soft-tissue impingement, arthrofibrosis (knee stiffness), periprosthetic infection and removal of free bodies or cement fragments.When performing a knee arthroscopy in a patient with a symptomatic TKA, look for possible free/retained bone or cement fragments, which can be anywhere in the joint.Patellar tracking should be evaluated and soft-tissue impingement under the patella or between the femoral and tibial prosthetic components should be ruled out.Current data suggest that knee arthroscopy is an effective procedure for the treatment of some patients with symptomatic TKA.The approximate rates of therapeutic success vary according to the problem in question: 85% in soft-tissue impingement; 90% in arthrofibrosis; and 55% in periprosthetic infections.More clinical studies are needed to determine which patients with symptomatic TKA can be the best candidates for knee arthroscopy. Cite this article: EFORT Open Rev 2019;4:33-43. DOI: 10.1302/2058-5241.4.180035.

Isolated medial collateral ligament tears: An update on management.

Tears of the medial collateral ligament (MCL) are the most common knee ligament injury.Incomplete tears (grade I, II) and isolated tears (grade III) of the MCL without valgus instability can be treated without surgery, with early functional rehabilitation.Failure of non-surgical treatment can result in debilitating, persistent medial instability, secondary dysfunction of the anterior cruciate ligament, weakness, and osteoarthritis.Reconstruction or repair of the MCL is a relatively uncommon procedure, as non-surgical treatment is often successful at returning patients to their prior level of function.Acute repair is indicated in isolated grade III tears with severe valgus alignment, MCL entrapment over pes anserinus, or intra-articular or bony avulsion. The indication for primary repair is based on the resulting quality of the native ligament and the time since the injury. Primary repair of the MCL is usually performed within 7 to 10 days after the injury.Augmentation repair for the superficial MCL (sMCL) is a surgical technique that can be used when the resulting quality of the native ligament makes primary repair impossible.Reconstruction is indicated when MCL injuries fail to heal in neutral or varus alignment. Reconstruction might be advisable to correct chronic instability. Chronic, medial-sided knee injuries with valgus misalignment should be treated with a two-stage approach. A distal femoral osteotomy should be performed first, followed by reconstruction of the medial knee structures. Cite this article: EFORT Open Rev 2018;3:398-407. DOI: 10.1302/2058-5241.3.170035.