Matched-Pair Analysis of Magnetic Resonance Images for Location of the Common Peroneal Nerve in Valgus Knees: Comparison with the Varus Knees.

This study aimed to assess the distance and angular location of the common peroneal nerve (CPN) on axial magnetic resonance imaging (MRI) in the valgus knees and compare the measurements with those obtained from the control group. We compared the location of the CPN according to the type of alignment by performing a subgroup analysis. From January 2009 to December 2019, we identified 41 knees with preoperative MRI in patients who underwent total knee arthroplasty (TKA) for valgus deformity (valgus group). We performed one-to-two matched-pair analysis to a cohort of patients who underwent MRI but were not candidates for TKA (control group), according to sex and age. The valgus group was classified according to the grading system reported by Ranawat et al, and the control group was also subdivided according to the hip-knee-ankle (HKA) angle obtained from lower extremity scanography: neutral (-3 to +3 degrees from the neutral mechanical axis), valgus (> +3 degrees), and varus alignment (< -3 degrees). Distance between the CPN and posterolateral cortex of the tibia at the knee joint (distance J) and tibial cut level (distance C) were measured. Angle of the CPN from the central anteroposterior axis of the tibia (angle α) was measured. We compared the measurements between the groups. Distance J was significantly closer in the valgus group (p < 0.001), whereas angle α was significantly smaller in the valgus group (p < 0.001). However, no significant differences were found in the subgroup analysis. Moreover, a significant correlation was found between distance J and the HKA angle (p < 0.001). The location of the CPN in the valgus knees was closer to the posterolateral cortex of the tibia at the joint level and showed a smaller angle than that in the other aligned knees. We recommend that lateral soft tissue release for valgus knees should not be performed at the joint line. The results of this study suggest that this would be less safe than a release performed at the level of the proximal tibial bone resection.

Patellar Impingement on Tibial Polyethylene after Primary Total Knee Arthroplasty without Patellar Resurfacing.

Patellar impingement on tibial polyethylene (PIP) is one potential complication of total knee arthroplasty (TKA). When PIP occurs, it is often related to inaccurate restoration of the joint line or due to soft-tissue contracture. We investigated the prevalence and etiology of PIP in Asian patients with deeply flexed knees following posterior stabilized (PS)-TKA. We retrospectively reviewed 54 patients (65 knees) with PIP after primary PS-TKAs without patellar resurfacing performed between 2008 and 2011. These patients were compared with a group of 124 patients (130 knees) without PIP matched for age, sex, and body mass index (BMI). The minimum follow-up was 5 years (range, 5-8.1 years). Patients were evaluated by blinded, independent observers using the Oxford knee score, the Waters score, and radiographic parameters. Impingement between the patella and the tibial polyethylene had a mean onset of 13.5 months after PS-TKA. The development of PIP was significantly associated with change in patellar tendon length (odds ratio [OR] = 11.4, 95% confidence interval [CI]: 11.2-11.6%), shorter postoperative patellar tendon length (OR = 2.1, 95% CI: 1.8-2.5%), change in the Insall-Salvati ratio (OR = 0.9, 95% CI: 0.8-1.0%), and joint line elevation (OR = 5.3, 95% CI: 4.8-5.8%) on multiple logistic regression analysis. Our findings reinforce the importance of accurate joint line restoration and the avoidance of iatrogenic injury to the patellar tendon, which can lead to shortening of the patellar tendon. This is a retrospective comparative study and its level of evidence is III.

A novel technique of reshaping the post of a constrained liner to avoid post and primary box mismatch in a case of recurrent dislocation after total knee arthroplasty.

Knee dislocation after total knee arthroplasty, although rare, is a dangerous injury that can lead to neurovascular compromise and permanent disability. With the increase in number of total knee arthroplasty, more and more cases of dislocations are being reported. We describe a novel technique of reshaping the post of a constrained liner to fit into the box of a vanguard primary knee system in a patient with recurrent posterior knee dislocation after a PS TKA with a follow-up of 5 years.

Is end-stage lateral osteoarthritic knee always valgus? Mechanical alignment analysis and radiographic severity assessment.

BACKGROUND: We hypothesized that not all persons with end-stage lateral osteoarthritis (OA) have valgus malalignment and that full extension radiographs may underreport radiographic disease severity. The purpose of this study was to examine the demographic and radiographic features of end-stage lateral compartment knee OA. MATERIALS AND METHODS: We retrospectively studied 133 knees in 113 patients who had undergone total knee arthroplasty between June 2008 and August 2010. All patients had predominantly lateral idiopathic compartment OA according to the compartment-specific Kellgren-Lawrence grade (KLG). The mechanical axis angle (MAA), compartment-specific KLG and joint space narrowing (JSN) of the tibiofemoral joint at extension and 30° of knee flexion, tibia vara angle, tibial slope angle, body mass index, age, and sex were surveyed. RESULTS: End-stage lateral compartment knee OA has varus (37.6 %), neutral (22.6 %), and valgus (39.8 %) MAA on both-leg standing hip-knee-ankle radiographs. KLGs at 30° of knee flexion (fKLG) were grades 3 and 4 in all patients. However, for KLGs at full extension (eKLG), 54 % of all patients had grades 3 and 4. The others (46 %) showed grades 1 and 2. We observed significant differences in lateral compartment eKLG/eJSN (2.3/2.3 mm in varus, 2.5/1.9 mm in neutral, 2.9/1.6 mm in valgus, p = 0.01 and 0.03, respectively), tibia vara angle (4.9° in varus, 4.1° in neutral, 3.0° in valgus, p < 0.01), and medial compartment eKLG/eJSN (2.1/3.1 mm in varus, 2.0/3.4 mm in neutral, 1.8/4.3 mm in valgus, p < 0.01 and 0.01, respectively) between MAA groups, except for the tibial slope angle (9.7° in varus, 10.1° in neutral, 9.8° in valgus, p = 0.31). CONCLUSION: Varus alignment was paradoxically shown in approximately one-third of those with end-stage lateral knee OA on both-leg standing hip-knee-ankle radiographs. Films taken in full extension underreported the degree of OA radiographic severity. LEVEL OF EVIDENCE: Level IV, observational study.

Asymptomatic peripheral vascular disease in total knee arthroplasty: preoperative prevalence and risk factors.

BACKGROUND: Although vascular disease is commonly accepted as a risk factor for wound complications and prosthetic joint infections, little is known about the preoperative prevalence of lower-extremity peripheral vascular disease in patients undergoing total knee arthroplasty (TKA). In this study, we investigated the prevalence of asymptomatic vascular disease and its risk factors. MATERIALS AND METHODS: A total of 1,000 knees of 692 patients who underwent primary TKA due to osteoarthritis were preoperatively evaluated by experienced musculoskeletal radiologists using Doppler ultrasonography of the lower extremity vessels. The mean age of the patients was 74.1 years (range 65-81). Risk factors for development of peripheral vascular disease were investigated. RESULTS: Abnormal findings were identified in 38 knees of 32 patients (4.6 %); atherosclerotic changes in 31 knees of 25 patients (3.6 %), deep vein thrombosis (DVT) in two knees, and anomalous vessels in five knees. Three out of 31 knees with atherosclerotic changes showed severe luminal stenosis. Two knees were moderate and 26 knees showed mild changes according to our institutional criteria. Multivariate logistic regression analysis showed that age and diabetes mellitus were positively associated with vascular pathology. CONCLUSION: The prevalence of incidentally detected peripheral vascular disease was significant. Three of 31 knees had severe arterial stenosis and two knees had DVT. All patients with vascular pathologies had one or more risk factors related to vascular disease. Out of those patients, age was the most important risk factor. Understanding the prevalence of vascular pathology and related risk factors in TKA candidates may be important for successful TKA. LEVEL OF EVIDENCE: Level III.

Periprosthetic supracondylar femoral fractures following total knee arthroplasty: clinical comparison and related complications of the femur plate system and retrograde-inserted supracondylar nail.

BACKGROUND: The purpose of this study is to analyze the clinical results and related complications of the femur plate system (FP) and the retrograde-inserted supracondylar nail (RISN). MATERIALS AND METHODS: The study included 42 cases of periprosthetic supracondylar femoral fractures (PSF) proximal to posterior stabilized total knee arthroplasty between 2005 and 2009. Twenty-four cases of PSF were treated with the FP, and the other 18 cases were treated with the RISN. This study cohort was divided into subgroups according to the AO classification. We retrospectively compared the clinical results between the FP and RISN group. RESULTS: There were no significant differences between the two groups in terms of time of clinical union (p = 0.649). In the subgroup analysis, the mean operation time was significantly different only in subgroup A1 (p = 0.03). Complications were seen in 29.2 % (7/24) of patients in the FP group and 27.8 % (5/18) in the RISN group. The age during the index TKA and fracture fixation was a significant risk (p = 0.008) factor for complications between the two groups. No significant differences were found in the other factors between the two groups. The p value for operative time (p = 0.223), immobilization period (p = 0.129), ROM (p = 0.573), KSS (p = 0.379), KSS functional scores (p = 0.310) and time to union (p = 0.649). CONCLUSION: Clinical results did not differ according to the treatment methods used. Fixation method and fracture type did not cause an increase in the complication rate, but there was a trend toward higher non-union rates with the FP method and higher re-fracture rate with the RISN method. Noting the fact that only increasing age correlated with an increased complication rate, more careful attention should be paid to elderly patients in terms of both prevention and surgical care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does spinal alignment influence acetabular orientation: a study of spinopelvic variables and sagittal acetabular version.

OBJECTIVE: Although hip alignment and spinal alignment have been studied individually, there is little information concerning the relationship between them. The questions addressed in this study are: (i) Is there a reproducible measure of sagittal plane acetabular orientation; (ii) Is sagittal plane acetabular orientation determined more by pelvic incidence (PI) or acetabular wall coverage? METHODS: Data on patients who had undergone screening by CT scan of the pelvis for non-orthopedic indications from 2005-2010 were retrospectively studied. There were 164 patients of mean age 59 years (range, 27-87). Patients with pelvic trauma, hip arthroplasty or other hip pathology were excluded. Measurements of relevant acetabular and spinopelvic variables were made in the sagittal plane. The sacro-acetabular angle (SA) was defined as the angle between a tangent line to the anterior and posterior walls of the acetabulum and the S1 endplate. Multiple regression analysis was used to determine which factors contribute to SA angle. RESULTS: The mean sacro-acetabular angle was 72° (SD = 14.8°). Center edge angles (CEAs) were measured at the anterior and posterior walls of the acetabulum. Mean anterior CEA was 69° (SD = 8.3°) and posterior CEA 107° (SD = 16.4°). Regression analysis revealed the largest significant predictors of SA angle were PI and A-CEA. CONCLUSIONS: Sagittal acetabular orientation is related to spino-pelvic balance and morphological characteristics. Increased PI or posterior wall coverage corresponds to a more vertical acetabular orientation. Sagittal plane acetabular alignment may be an important variable in achieving favorable results after reconstruction.

Disassembly of threaded junction between stem extension and femoral component in a total stabilizer revision total knee arthroplasty.

We report an unusual case of disassembly of threaded junction between stem extension and femoral component in a 6-year-old total stabilizer revision total knee arthroplasty. Aseptic loosening of femur component will tend to cause increased stresses at the stem-condylar junction of a modular femoral prosthesis, especially if femur component is flexed. The modular junction may therefore be unable to withstand the concentrated force and lead to disassembly.

Transepicondylar axes for femoral component rotation might produce flexion asymmetry during total knee arthroplasty in knees with proximal tibia vara.

BACKGROUND: Adequate rotation of the femoral component in total knee arthroplasty is mandatory for prevention of numerous adverse sequelae. Therefore, we investigate whether there is the distal femoral deformity in knees with tibia vara. The purpose of this study was to evaluate the reliability of the transepicondylar axis as a rotational landmark in knees with tibia vara. METHODS: We retrospectively reviewed and selected 101 osteoarthritic knees with proximal tibia vara and 150 osteoarthritic knees without tibia vara for inclusion in this study. The transepicondylar axis (TEA), anteroposterior (AP) axis and posterior condylar (PC) line were measured using the axial image from magnetic resonance imaging axial images. We compared the external rotation angle of the TEA relative to the PC line between groups in order to investigate the presence of distal femoral anatomical adaptation in the tibia vara group. RESULTS: The TEA in the tibia vara group had 6.1º of external rotation relative to the PC line, which was not significantly different from the 6.0º of external rotation in the non-tibia vara group. The line perpendicular to the AP axis in the tibia vara group had 6.1º of external rotation relative to the PC line, which was not significantly different from the 5.4º of external rotation in the non-tibia vara group. Distal femoral geometry was unaffected by the tibia vara deformity. CONCLUSIONS: The use of transepicondylar axes in determining femoral rotation may produce flexion asymmetry in knees with tibia vara. LEVEL OF EVIDENCE: Level III.

Meniscectomy of horizontal tears of the lateral meniscus anterior horn using the joystick technique.

Unstable inferior leaves of the anterior horn in horizontal tears of the lateral meniscus are challenging lesions for most orthopedic surgeons due to the poor viewing angle and the instability of these lesions. Resection of an exact volume is required for the successful treatment of horizontal tears in the lateral meniscus anterior horn. We report a method based on the joystick technique.

Patellar resurfacing versus no resurfacing in two-stage revision of infected total knee arthroplasty.

BACKGROUND: Cartilage debridement and staged reimplantation are the most common treatments for infected total knee arthroplasty (TKA). Very few studies have focused on the management of primarily non-resurfaced patellae in infected TKA. The purpose of this study was to compare the outcomes of patellar resurfacing and non-resurfacing in two-stage revision of infected TKA. METHODS: This study involved a retrospective comparison of the reinfection rate and clinical outcomes of revision TKA patients managed with patellar resurfacing (22 patients, 23 knees) and patients managed without patellar resurfacing (26 patients) at a minimum two-year follow-up. The mean age in the resurfacing group was 69.4years old, and the mean age in the non-resurfacing group was 67.3years old. Three scales were used in the assessment: the Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index, and the Anterior Knee Pain Scale. RESULTS: Three knees had recurrent infections. All infections occurred in patients who had received patellar resurfacing. There were no significant differences between groups in clinical results and on the Anterior Knee Pain Scale. A lack of patellar resurfacing did not increase recurrence of infection and did not result in significant clinical differences compared to patellar resurfacing. CONCLUSIONS: This study indicates that preservation of the original patellar bone is a feasible option for patellar management in revision of septic TKA. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Evaluation of the alpha angle in asymptomatic adult hip joints: analysis of 994 hips.

INTRODUCTION: Numerous studies on cam femoroacetabular impingement (FAI) causing osteoarthritis have been conducted in Western populations, but not in Asian populations. The alpha angle in cam type FAI can be measured by routine hip AP and axial radiographs. The purpose of this study was to determine the range of alpha angles in an asymptomatic Asian cohort. MATERIALS AND METHODS: We performed a retrospective examination on 500 asymptomatic Asian adults (1000 hips) who underwent simultaneous spine MRI and hip coronal survey MRI for evaluation of back pain from December 2009 to March 2010. The alpha angle was measured on anteroposterior (AP) pelvic survey images. According to inclusion criteria, 372 hips of 186 men and 622 hips of 311 women were analysed. RESULTS: The mean alpha angles for men and women were 50.61° ± 7.61° and 49.82° ± 4.14°, respectively with no statistically significant differences (p = 0.063). Alpha angles of the two age groups (≥50 years old and <50 years old) were similar in both genders: 49.90° ± 6.88° versus 51.40° ± 8.30° in men (p = 0.060), and 50.61° ± 7.61° versus 49.82° ± 4.14° in women (p = 0.71). The frequency of pathologic alpha angle of men and women was 0.5% and 3.1%, respectively. CONCLUSIONS: After review of 994 asymptomatic adult hips, we found neither gender-specific nor age-specific differences in the alpha angle. The frequency of the pathological range of the alpha angle was notably rare, as compared to those of Western countries. We assume that these findings could be related to a low prevalence of FAI and idiopathic osteoarthritis of the hip in the Asian population.

An early sign of intraarticular fracture of the lateral tibial plateau during opening wedge high tibial osteotomy.

Intraarticular fracture of the lateral tibial plateau is one of the serious complications in medial opening wedge high tibial osteotomy (HTO). We present a case of fracture of the lateral tibial plateau during medial opening wedge HTO. The authors have found the early fracture sign, uneven divergence gap of proximal and distal parts during enlargement of the osteotomy site with a dilatator, a useful marker for early detection and prevention of fracture extending.

Is further treatment necessary for patellar crepitus after total knee arthroplasty?

BACKGROUND: Patellar crepitus may occur with posterior-stabilized (PS) TKAs. Several studies have suggested numerous etiologies of patellar crepitus after PS-TKA with patellar resurfacing. However, it is unclear whether and to what degree crepitus influences pain and function without or with patellar resurfacing. QUESTIONS/PURPOSES: We therefore determined (1) the frequency of crepitus; (2) which factors predicted the occurrence of crepitus; and (3) whether crepitus influenced pain and function. METHODS: We retrospectively reviewed 41 patients (54 knees) with painful or painless patellar crepitus after primary PS-TKAs without patellar resurfacing performed from 2007 to 2008. These patients were compared with a group of 73 patients (94 knees) without patellar crepitus matched for age, sex, and BMI. The minimum followup was 2 years (mean, 2.8 years; range, 2-4.5 years). RESULTS: Five (9%) of the 54 knees with patellar crepitus also had peripatellar pain. Mean time from primary TKA to the onset of patellar crepitus was 4 months. All patients in the patellar crepitus group were asymptomatic within 1 year of onset of symptoms without additional surgical treatment. The development of patellar crepitus was associated with an Outerbridge patellar cartilage Grade 4 (odds ratio [OR], 11.9; 95% CI, 2.2-65.3) and joint line elevation (OR, 5.1; 95% CI, 1.9-8.6). CONCLUSIONS: Patellar crepitus is typically benign and self-limited. We continue not to resurface arthritic patellae and counsel patients with patellar crepitus that their symptoms will improve without intervention. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Risk factors for medial meniscus posterior root tear.

BACKGROUND: Medial meniscus posterior root tears (MMPRT) have a different clinical effect from other types of meniscal tears. These tears are very common among Asian people and may be related to the frequent use of postures such as the lotus position or squatting. PURPOSE: The present study was designed to identify the risk factors for MMPRT among an Asian sample. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: An observational study was performed of 476 consecutive patients undergoing an arthroscopic procedure on their medial meniscus from January 2010 to December 2010. One hundred four patients had MMPRT (group 1), and the other patients had other types of medial meniscal tears (group 2). Demographic characteristics (age, sex, body mass index [BMI]), radiographic features (mechanical axis angle, tibia vara angle, tibial slope angle, Kellgren-Lawrence grade [KLG]), and environmental factors (occupation, trauma history, sports activity level, table use or not, bed use or not-variables that are representative of the oriental lifestyle of lotus position and squatting) were surveyed. We assessed the relation of these risk factors to the type of meniscal tear (group 1 or 2). RESULTS: In group 1, there were 7 male and 97 female patients, with an average age of 58.2 years (range, 39-78 years) and BMI of 26.7 ± 3.4 kg/m2. In group 2, there were 136 male and 236 female patients (P < .01 compared with group 1), with an average age of 54.3 years (range, 17-77 years; P < .01) and a BMI of 24.9 ± 3.1 kg/m2 (P < .01). With regard to radiographic features, the mechanical axis angle demonstrated a significantly increased varus alignment in group 1 (4.5° ± 3.4°) compared with group 2 (2.4° ± 2.7°; P < .01), and the KLG was 1.4 ± 0.8 in group 1 and 0.9 ± 0.6 in group 2 (P < .01). Environmental factors showed no differences in occupation, table use or not, and bed use or not, except sports activity level. There were 41 patients (42.7%) in group 1 and 77 patients (20.6%) in group 2 who did not participate in any recreational activity (P < .01). Multiple logistic regression analysis showed that female sex was associated with a 5.9-fold increase in risk (95% confidence interval [CI], 2.138-16.575), a varus mechanical axis angle with a 3.3-fold increase (95% CI, 1.492-7.153), a BMI more than 30 kg/m2 with a 4.9-fold increase (95% CI, 1.160-20.955), and lower sports activity level with a 2.7-fold increase (95% CI, 1.011-7.163) for MMPRT. CONCLUSION: Persons with MMPRT had significantly increased age, female sex predominance, higher BMI, increased KLG, greater varus mechanical axis angle, and lower sports activity level compared with persons with other types of meniscal tear. After adjusting for other factors, sex, BMI, mechanical axis angle, and lower sports activity level remained strong determinants of MMPRT. Interestingly, oriental postural positions including the lotus position and squatting showed no contribution to increased risk of MMPRT. This suggests that intrinsic risk factors (similar to those that predispose to osteoarthritis) predispose to MMPRT.

Mark B. Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection.

BACKGROUND: C-reactive protein (CRP) serum assays are a standard element of the diagnostic workup for periprosthetic joint infection (PJI). However, because CRP is a marker for systemic inflammation, this test is not specific to PJI. QUESTIONS/PURPOSES: Our purpose was to assess whether synovial fluid and serum assays alone could differentiate between infected and uninfected revision knee arthroplasties and to determine which of these methods had the greatest diagnostic accuracy. METHODS: We collected synovial fluid specimens from 66 patients undergoing revision total knee arthroplasty. Patients were judged uninfected or infected by standardized criteria. Synovial CRP levels were measured using an individual CRP assay (15 samples; 10 infected, five uninfected) and a multiplex immunoassay platform (59 samples; 25 infected, 34 uninfected). Results from preoperative standard serum CRP assays conducted were also collected (55 samples; 25 infected, 30 uninfected). Sensitivity, specificity, and receiver operating characteristic curve analyses were performed for each assay with a diagnosis of infection based on previously established criteria. RESULTS: Synovial CRP concentrations differed between infected and uninfected joints in the multiplex and serum analyses. The area under the curve was 0.84 for the individual assay, 0.91 for the multiplex assay, and 0.88 for the serum CRP assay. Sensitivity and specificity were 70.0% and 100.0% for the individual enzyme-linked immunosorbent assay, 84.0% and 97.1% for the multiplex assay, and 76.0% and 93.3% for the serum CRP assay. CONCLUSIONS: An assay measuring CRP in synovial fluid may be more accurate in diagnosing PJI than the standard serum CRP assay. We believe such an assay holds promise as a new diagnostic marker for PJI.

Cerebral fat embolism syndrome after simultaneous bilateral total knee arthroplasty: a case series.

Total knee arthroplasty (TKA), particularly when performed as a simultaneous bilateral procedure, theoretically increases the risk for entry of fat globules into the blood stream. The frequency of cerebral fat embolism syndrome (CFES) was retrospectively investigated among 2345 simultaneous bilateral TKA procedures performed from August 2006 to May 2010. During that period, 9 patients presented with neurologic deficits after surgery and underwent brain magnetic resonance imaging. For identification of CFES among them, we used both magnetic resonance imaging findings and clinical criteria modified from the original one of Gurd and Wilson (J Bone Joint Surg Br 1974; 56B:408). Four patients fulfilled the modified criteria. The overall incidence of CFES occurring after simultaneous bilateral TKA was 0.17%. Cerebral fat embolism syndrome should be ruled out, although rare, in patients who present with neurologic impairment after TKA.

Anterior dislocation after a posterior stabilized total knee arthroplasty.

Dislocation of a total knee arthroplasty is a rare but serious complication. In previous literature, when dislocation does occur, it is usually in the posterior direction in cases with a posterior stabilized total knee arthroplasty due to cam jump. We report an unusual case of anterior dislocation of an 11-year-old posterior stabilized total knee arthroplasty in a 55-year-old woman with rheumatoid arthritis occurred after a slip.

Definition of periprosthetic joint infection: is there a consensus?

BACKGROUND: The diagnosis of periprosthetic joint infection (PJI) continues to pose a challenge. While many diagnostic criteria have been proposed, a gold standard for diagnosis is lacking. Use of multiple diagnostic criteria within the joint arthroplasty community raises concerns in patient treatment and comparison of research pertaining to PJI. QUESTIONS/PURPOSES: We (1) determined the variation in existing diagnostic criteria, (2) compared the existing criteria to a proposed new set of criteria that incorporates aspirate cell count analysis, and (3) investigated the variations between the existing criteria and the proposed criteria. PATIENTS AND METHODS: We retrospectively identified 182 patients undergoing 192 revision knee arthroplasties who had a preoperative joint aspiration analysis at our institution between April 2002 and November 2009. We excluded 20 cases due to insufficient laboratory parameters, leaving 172 cases for analysis. We applied six previously published sets of diagnostic criteria for PJI to determine the variation in its incidence using each set of criteria. We then compared these diagnostic criteria to our proposed new criteria and investigated cases where disagreement occurred. RESULTS: We identified 41 cases (24%) in which at least one established criteria set classified the case as infected while at least one other criteria set classified the case as uninfected. With our proposed criteria, the infected/uninfected ratio was 92/80. The proposed criteria had a large variance in sensitivity (54%-100%), specificity (39%-100%), and accuracy (53%-100%) when using each of the established criteria sets as the reference standard. CONCLUSIONS: The discrepancy between definitions of infection complicates interpretation of the literature and the treatment of failed TKAs owing to PJI. Based on our findings, we suggest establishing a common set of diagnostic criteria utilizing aspirate analysis to improve the treatment of PJI and facilitate interpretation of the literature. LEVEL OF EVIDENCE: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Total knee arthroplasty using a hybrid navigation technique.

The use of computer navigation is becoming a well-recognized technical alternative to conventional total knee arthroplasty (TKA). However, computer navigation has a substantial learning curve and the use of commercially available navigation systems increases surgical time. In addition, the potential risks associated with the navigation TKA, such as, registration errors, notching of the anterior femoral cortex, oversizing of the femoral component, and overresection must be taken into consideration. On the other hand, conventional techniques are familiar and intuitive to most practicing surgeons, and thus, are easier to perform and are less prone to anterior notching and femoral component oversizing. However, conventional techniques have greater risks of inaccurate and inconsistent component alignment than computer navigation. This paper describes a novel technique that combines computer navigation and conventional TKA.