The experience of patients undergoing aseptic, elective revision knee joint replacement surgery: a qualitative study.

BACKGROUND: Around 6,000 revision knee replacement procedures are performed in the United Kingdom each year. Three-quarters of procedures are for aseptic, elective reasons, such as progressive osteoarthritis, prosthesis loosening/wear, or instability. Our understanding of how we can best support these patients undergoing revision knee replacement procedures is limited. This study aimed to explore patients' experiences of having a problematic knee replacement and the impact of undergoing knee revision surgery for aseptic, elective reasons. METHODS: Qualitative semi structured interviews with 15 patients (8 women, 7 men; mean age 70 years: range 54-81) who had undergone revision knee surgery for a range of aseptic, elective indications in the last 12 months at an NHS Major Revision Knee Centre. Interviews were audio-recorded, transcribed, de-identified and analysed using reflexive thematic analysis. RESULTS: We developed six themes: Soldiering on; The challenge of navigating the health system; I am the expert in my own knee; Shift in what I expected from surgery; I am not the person I used to be; Lingering uncertainty. CONCLUSIONS: Living with a problematic knee replacement and undergoing knee revision surgery has significant impact on all aspects of patients' lives. Our findings highlight the need for patients with problematic knee replacements to be supported to access care and assessment, and for long-term psychological and rehabilitation support before and after revision surgery.

Risk Factors for Peripheral Nerve Injury Following Revision Total Knee Arthroplasty in 132,960 Patients.

BACKGROUND: Peripheral nerve injury (PNI) following revision total knee arthroplasty (rTKA) is a potentially devastating injury for patients. This study assessed the frequency of and risk factors for postoperative PNI following rTKA. METHODS: Patients who underwent rTKA from 2003 to 2015 were identified using the National Inpatient Sample. Demographics, medical histories, surgical details, and complications were compared between patients who sustained a PNI and those who did not to identify risk factors for the development of PNI after rTKA. RESULTS: Overall, 132,960 patients who underwent rTKA were identified, and 737 (0.56%) sustained a postoperative PNI. After adjusting for confounders, patients with a history of a spine condition (adjusted odds ratio [aOR]: 1.7, 95%-confidence interval 1.2 to 2.4, P = .003) and postoperative anemia (aOR: 1.3, 95%-CI: 1.1 to 1.5, P = .004) had higher risk of PNI following rTKA. Intraoperative periprosthetic fracture (aOR: 1.3, 0.78 to 2.2, P = .308), rheumatoid arthritis (aOR: 1.0, 95%-CI: 0.68 to 1.6, P = .865), and history of knee dislocation (aOR: 1.1, 95%-CI: 0.85 to 1.5, P = .412), were not significantly associated with higher risk for PNI. CONCLUSIONS: This study found a 0.56% incidence of PNI following rTKA, and patients who had preexisting spine conditions or postoperative anemia were at an increased risk for this complication. Orthopedic surgeons may use the results of this study to appropriately counsel patients on the potential for a PNI following rTKA.

Indications and techniques for non-articulating spacers in massive bone loss following prosthetic knee joint infection: a scoping review.

INTRODUCTION: Prosthetic joint infection (PJI) is a destructive complication of knee replacement surgery (KR). In two-stage revision a spacer is required to maintain limb length and alignment and provide a stable limb on which to mobilise. Spacers may be articulating or static with the gold standard spacer yet to be defined. The aims of this scoping review were to summarise the types of static spacer used to treat PJI after KR, their indications for use and early complication rates. METHODS: We conducted a scoping review based on the Joanna Briggs Institute's "JBI Manual for Evidence Synthesis" Scoping review reported following Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. MEDLINE, EMBASE and CINAHL were searched from 2005 to 2022 for studies on the use of static spacers for PJI after KR. RESULTS: 41 studies (1230 patients/knees) were identified describing 42 static spacer constructs. Twenty-three (23/42 [54.2%]) incorporated cement augmented with metalwork, while nineteen (19/42, [45.9%]) were made of cement alone. Spacers were most frequently anchored in the diaphysis (22/42, [53.3%]), particularly in the setting of extensive bone loss (mean AORI Type = F3/T3; 11/15 studies 78.3% diaphyseal anchoring). 7.1% (79 of 1117 knees) of static spacers had a complication requiring further surgery prior to planned second stage with the most common complication being infection (86.1%). CONCLUSIONS: This study has summarised the large variety in static spacer constructs used for staged revision KR for PJI. Static spacers were associated with a high risk of complications and further work in this area is required to improve the quality of care in this vulnerable group.

Revision Total Knee Arthroplasty Using an Uncemented Metaphyseal Sleeve, Rotating Hinge Prosthesis: A Case Series of 99 Patients.

BACKGROUND: Hinge knee replacement is a salvage procedure with historically high failure and complication rates. We aim to analyze the use of an uncemented metaphyseal sleeve revision knee replacement in our unit-a third-generation rotating hinge knee prosthesis. This is the largest reported series of this implant with longest follow up. METHODS: We retrospectively identified 99 revision cases performed (2002-2018). In total, 67 of 99 (68%) cases were performed for aseptic etiology, whereas 32 of 99 (32%) cases were performed for infection. Clinical outcomes were assessed using the Oxford Knee Score, survivorship analysis, and incidence of revision/reoperations. Mean follow-up was 7 years (range 1.5-18). RESULTS: At follow-up, the mean Oxford Knee Score had improved from 10 points to 25 points. At mean 7 years of follow up, 18 of 99 cases had undergone revision giving a survivorship of 81% (90% aseptic). In total, 10 of 18 cases were performed for infection (10%) and 9 of 18 cases were performed for aseptic reasons (9%), of which 5 were for patella resurfacing (2 revision), 2 for failure of bony ingrowth, and 1 for fracture. Twenty-six patients (26%) had complications postoperatively, with patella disorders and reduced range of movement the most common. Patients who did not undergo patella resurfacing were significantly more likely to need revision of any cause (P = .01). CONCLUSION: This is the largest study of this prosthesis with longest follow-up. It demonstrates good survivorship and improvement in knee pain. Those with infection are at greatest risk of revision. Significant numbers have patella dysfunction/anterior knee symptoms therefore patella resurfacing should be considered when using this implant. LEVEL OF EVIDENCE: IV.

What is the patient experience following revision knee replacement: A systematic review and meta-analysis of the medium term patient reported outcomes.

AIMS: Revision knee replacement is an increasingly common procedure, however, information on patient-focused outcomes is limited. This systematic review and meta-analysis aimed to investigate the medium-term patient reported outcomes following a revision knee replacement. METHODS: We performed a systematic review of MEDLINE and EMBASE (from inception to 1st March 2021) for articles reporting five year or greater patient reported outcome measures (PROMs) following revision knee replacement. A meta-analysis of PROMs data was undertaken using the Standardised Mean Difference (SMD). Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROPSERO (CRD42021199289). RESULTS: A total of 23 studies met the inclusion criteria containing 2414 patients at a mean minimum follow-up of 74 months (60-122). The reporting of PROMs were poorly standardised with several PROMs being used. The most commonly reported patient reported outcome was the Knee Society Score reported in 65% of studies (15/23). A meta-analysis of 629 eligible patients undergoing revision knee replacement revealed a significant improvement in pre-operative state with a SMD 2·05 95% CI 0.87, 3.23. CONCLUSION: This systematic review has found a significant and sustained improvement in patient-reported outcomes following a revision knee arthroplasty beyond five years. We found a variation in the usage and administration of PROMs which hinders a clear synthesis of results. Furthermore, the PROMs have not been robustly tested for validity in the context of a revision knee replacement.

The '2-in-1' stage: indications, technique & results.

Prosthetic joint infections remain an ongoing challenge for orthopaedic surgeons with an interest in knee arthroplasty, which relates to their often difficult diagnoses, need for multiple surgeries, increased technical and financial requirements. Peri-prosthetic joint infection is devastating complication for the patient and with the current literature unable to either demonstrate superiority of one or two stage revision then we should continue to assess on a case by case basis. The use of a '2 in 1' single-stage approach has been recently been promoted as a form of single stage revision for infection on account of the potential for reduction in risks, costs, and complications. Where it is safe to do so, a single stage procedure can avoid several of the drawbacks which may occur with a formal two stage approach. Particularly, it can reduce the risk of post-operative stiffness and arthrofibrosis which can be associated with two stage surgery. Use of a single stage may be more cost effective, by saving the patient having to undergo a second major procedure. This article reviews the indications for its use, technique and results. The use of '2-in-1' single-stage revision can be considered as an effective option for treating infection following TKR and cases with associated bone loss.

The biomechanics of metaphyseal cone augmentation in revision knee replacement.

The demand for revision knee replacement (RKR) has increased dramatically with rising patient life expectancy and younger recipients for primary TKR. However, significant challenges to RKR arise from osseous defects, reduced bone quality, potential bone volume loss from implant removal and the need to achieve implant stability. This study utilizes the outcomes of an ongoing RKR clinical trial using porous metaphyseal cones 3D-printed of titanium, to investigate 1) bone mineral density (BMD) changes in three fixation zones (epiphysis, metaphysis, and diaphysis) over a year and 2) the biomechanical effects of the cones at 6 months post-surgery. It combines dual-energy x-ray absorptiometry (DXA), computed tomography (CT) with patient-specific based finite element (FE) modelling. Bone loss (-0.086 ± 0.05 g/cm2) was found in most patients over the first year. The biomechanical assessment considered four different loading scenarios from standing, walking on a flat surface, and walking downstairs, to a simulated impact of the knee. The patient-specific FE models showed that the cones marginally improved the strain distribution in the bone and shared the induced load but played a limited role in reducing the risks of bone fracture or cement debonding. This technique of obtaining real live data from a randomized clinical trial and inserting it into an in-silico FE model is unique and innovative in RKR research. The tibia RKR biomechanics examined open up further possibilities, allowing the in-silico testing of prototypes and implant combinations without putting patients at risk as per the recommended IDEAL framework standards. This process with further improvements could allow rapid innovation, optimization of implant design, and improve surgical planning.

Modular Total Femur Replacement for Staged Total Femur Replacement.

As the numbers of arthroplasties performed worldwide increase, so do complications such as prosthetic joint infection. Cases that require a two-stage revision of a total femur replacement in the femur pose an ongoing challenge to the modern orthopedic surgeon. Unlike antibiotic spacers in hip and knee arthroplasty, there lacks a commercially available cement spacer for use in total femur replacements. We describe a novel technique for the intraoperative fabrication of a total femur spacer which uses modular components. As such, our technique is unique as it is modular and, therefore, highly customisable to each individual patient. Individual components can be made by different members of the team simultaneously and then assembled to make the final construct, thereby minimizing operative time. Furthermore, the inherent stability of the spacer allows immediate partial weightbearing and functional rehabilitation while patients are waiting for their second-stage procedure.

Infected prosthetic knee replacement: What to do and what not to do.

This article is an expansion of a lecture given in the British Orthopaedic Association (BOA) Congress in Liverpool in 2019 as part of a symposium on infected knee replacement. It is designed to provide pointers and advice to surgeons on how these patients can be referred, investigated, and managed. The management of periprosthetic infection necessitates many decisions to be made to provide the patient with the best advice and treatment. This is a discussion of the philosophies of periprosthetic knee infection. It is not a definitive guide nor a metanalysis of scientific papers. These are the subjective views of the author and generalise decision making. All decisions should remain tailored to the patient's needs.

Open Periprosthetic Knee Fracture: A Case Report and Review of the Literature.

Introduction: With the increase in knee and hip implants, these periprosthetic fractures will become more common especially as the population ages. Open periprosthetic fractures are rare and severe injuries and are more likely to be seen in high-energy injuries. They present challenges to the treating physician due to soft tissue damage, contamination of the existing implants, and the effects of polytrauma in the geriatric patient. Methods Case review report and review of literature Results: A 72-year-old woman was involved in a motor vehicle collision with multiple injuries including an open periprosthetic tibia and femur fracture. This was treated with initial washout and removal of loose tibial component with placement of a cement spacer. The knee was treated with staged revision using a protocol like that used after prosthetic joint infection. After complete soft tissue healing, the patient underwent successful revision with a megaprosthesis. The literature on open periprosthetic fractures is reviewed. Discussion and Conclusion: Open periprosthetic fractures present multiple challenges to the orthopedic surgeon. In the presences of poly trauma and soft tissue injury, we present an approach using staged surgery like that used for prosthetic joint infection.

The Role of One-Stage Exchange for Prosthetic Joint Infection.

PURPOSE OF REVIEW: In an era of increasing numbers of hip and knee replacements, strategies to manage prosthetic joint infection (PJI) that are effective at infection control with good patient-reported outcomes and cost containment for health systems are needed. Interest in single-stage exchange for PJI is rising and we assess evidence from the last 5 years related to this treatment strategy. RECENT FINDINGS: Only five series for total knee replacement and ten series for total hip replacement have been reported in the last five years. More review articles and opinion pieces have been written. Reinfection rates in these recent studies range from 0 to 65%, but a meta-analysis and systematic review of all studies showed a reinfection rate of 7.6% (95% CI 3.4-13.1) and 8.8% (95% CI 7.2-10.6) for single-stage and two-stage revisions respectively. There is emerging evidence to support single-stage revision in the setting of significant bony deficiency and atypical PJIs such as fungal infections. Prospective randomised studies are recruiting and are necessary to guide the direction of single-stage revision selection criteria. The onus of surgical excellence in mechanical removal of implants, necrotic tissue, and biofilms lies with the arthroplasty surgeon and must remain the cornerstone of treatment. Single-stage revision may be considered the first-line treatment for all PJIs unless the organism is unknown, the patient is systemically septic, or there is a poor tissue envelope.

Description of the rates, trends and surgical burden associated with revision for prosthetic joint infection following primary and revision knee replacements in England and Wales: an analysis of the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.

OBJECTIVES: To describe the prevalence rates of revision surgery for the treatment of prosthetic joint infection (PJI) for patients undergoing knee replacement, their time trends, the cumulative incidence function of revision for PJI and estimate the burden of PJI at health service level. DESIGN: We analysed revision knee replacements performed due to a diagnosis of PJI and the linked index procedures recorded in the National Joint Registry from 2003 to 2014 for England and Wales. The cohort analysed consisted of 679 010 index primary knee replacements, 33 920 index revision knee replacements and 8247 revision total knee replacements performed due to a diagnosis of PJI. The prevalence rates, their time trends investigated by time from index surgery to revision for PJI, cumulative incidence functions and the burden of PJI (total procedures) were calculated. Overall linear trends were investigated with log-linear regression. RESULTS: The incidence of revision total knee replacement due to PJI at 2 years was 3.2/1000 following primary and 14.4/1000 following revision knee replacement, respectively. The prevalence of revision due to PJI in the 3 months following primary knee replacement has risen by 2.5-fold (95% CI 1.2 to 5.3) from 2005 to 2013 and 7.5-fold (95% CI 1.0 to 56.1) following revision knee replacement. Over 1000 procedures per year are performed as a consequence of knee PJI, an increase of 2.8 from 2005 to 2013. Overall, 75% of revisions were two-stage with an increase in use of single-stage from 7.9% in 2005 to 18.8% in 2014. CONCLUSIONS: Although the risk of revision due to PJI following knee replacement is low, it is rising, and coupled with the established and further predicted increased incidence of both primary and revision knee replacements, this represents an increasing and substantial treatment burden for orthopaedic service delivery in England and Wales. This has implications for future service design and the funding of individual and specialist centres.

Enhanced recovery principles applied to revision hip and knee arthroplasty reduces length of stay and blood transfusion.

INTRODUCTION: This is the first study reporting the application of Enhanced Recovery Principles (ERP) to revision arthroplasty. METHOD: Retrospective series of 132 revision hip and knee replacements treated with ERP. RESULTS: Infiltration was associated with reduced LOS in knees (6 vs 8.5 days), lower PCA usage and incidence of transfusion in knees (2 vs 3 days) and hips (1 vs 6 days). Revisions for infection had a longer LOS (5.4 vs 11.5 days p = 0.001), a greater use of PCA and a higher incidence of transfusion (5 vs 0) in both knees and hips. DISCUSSION: The application of ERPs to revision arthroplasty is safe. Infiltration appears to be an important factor in improving outcome measures.

[Non traumatic posterior instability in primary total knee replacement and its revision]. / Inestabilidad posterior no traumática de prótesis de rodilla primaria y su revisión.

BACKGROUND: Dislocation after total knee arthroplasty is a rare complication and a difficult problem to address. When the flexion gap is larger than the extension gap and the collateral ligaments are injured, instability and knee arthroplasty dislocation can occur. MATERIAL AND METHODS: We report the case of a patient presenting with a posterior dislocation of a posterior-stabilized prosthesis without trauma. Frank instability in varus stress test and a positive anterior drawer test with tibial internal rotation dismissed the conservative treatment. RESULTS: A constrained condylar prosthesis was used for the revision. He suffered a similar episode after a month, which demonstrated that the increase in the level of constraint was not enough to correct the severe asymmetric instability in flexion due to the damaged external structures. A rotating-hinge prosthesis was then implanted and the patient reported no additional episodes of instability. CONCLUSIONS: We made an exhaustive review of the literature, analyzed the possible causes that can lead to the tibiofemoral instability after a total knee arthroplasty and described some technical considerations.

La luxación tras la artroplastía de rodilla es una complicación poco frecuente y de difícil manejo. Una brecha en flexión demasiado grande asociada a una laxitud de los ligamentos colaterales puede llevar a la inestabilidad y a la luxación en flexión.

Tranexamic Acid in a Multimodal Blood Loss Prevention Protocol to Decrease Blood Loss in Revision Total Knee Arthroplasty: A Cohort Study.

PURPOSE: To clarify if blood loss and transfusion requirements can be decreased in revision knee surgery through a multimodal blood loss approach with tranexamic acid (TXA). PATIENTS AND METHODS: A retrospective study was designed in 87 knees (79 patients) that received a knee revision between 2007 and 2013. To avoid heterogeneity in the surgical technique, only revisions with one single implant system were included. A treatment series of 44 knees that received TXA and other techniques in a multimodal blood loss protocol was compared to a control series of 43 knees that received neither TXA nor the rest of the multimodal blood loss protocol. No differences in the complexity of surgeries or case severity were detected. RESULTS: A significant decrease was observed from 58% transfusion rate in the control group to 5% in the treated group. The postoperative haemoglobin drop was also significantly different. Although the use of a blood loss prevention approach including TXA was the most relevant factor in the transfusion risk (OR=15), longer surgical time also associated an increased risk of transfusion (OR=1.15). CONCLUSION: This study supports the use of a two-dose intravenous TXA under a multimodal blood loss prevention approach in revision knee replacement with significant reduction in the transfusion rate, postoperative blood loss and haemoglobin drop.

Management of extreme patella baja using in-situ hamstring tendon autograft.

Successful total knee arthroplasty requires a functioning extensor mechanism. Patella baja following total knee arthroplasty can cause extensor mechanism dysfunction and produce poor outcomes. We present a case of severe patella tendon shortening following revision total knee arthroplasty with almost complete ankylosis of the distal pole of the patella to the proximal tibia. This resulted in effective extensor mechanism dysfunction with pain and severely limited knee flexion. We report a novel method of reconstruction of the patella tendon at the time of revision arthroplasty together with the one-year clinical outcome and review of the literature.

Tantalum cones for major osteolysis in revision knee replacement.

We report the results of revision total knee replacement (TKR) in 26 patients with major metaphyseal osteolytic defects using 29 trabecular metal cones in conjunction with a rotating hinged total knee prosthesis. The osteolytic defects were types II and III (A or B) according to the Anderson Orthopaedic Research Institute (AORI) classification. The mean age of the patients was 72 years (62 to 84) and there were 15 men and 11 women. In this series patients had undergone a mean of 2.34 previous total knee arthroplasties. The main objective was to restore anatomy along with stability and function of the knee joint to allow immediate full weight-bearing and active knee movement. Outcomes were measured using Knee Society scores, Oxford knee scores, range of movement of the knee and serial radiographs. Patients were followed for a mean of 36 months (24 to 49). The mean Oxford knee clinical scores improved from 12.83 (10 to 15) to 35.20 (32 to 38) (p < 0.001) and mean American Knee Society scores improved from 33.24 (13 to 36) to 81.12 (78 to 86) (p < 0.001). No radiolucent lines suggestive of loosening were seen around the trabecular metal cones, and by one year all the radiographs showed good osteo-integration. There was no evidence of any collapse or implant migration. Our early results confirm the findings of others that trabecular metal cones offer a useful way of managing severe bone loss in revision TKR.

Inestabilidad posterior no traumática de prótesis de rodilla primaria y su revisión / Non traumatic posterior instability in primary total knee replacement and its revision

Resumen: Antecedentes: La luxación tras la artroplastía de rodilla es una complicación poco frecuente y de difícil manejo. Una brecha en flexión demasiado grande asociada a una laxitud de los ligamentos colaterales puede llevar a la inestabilidad y a la luxación en flexión. Material y métodos: Informamos del caso de un paciente que tuvo una luxación posterior de su prótesis de rodilla posteroestabilizada sin antecedente traumático. La inestabilidad franca al forzar el varo en flexión y un cajón anterior positivo que aumentaba en rotación interna condujeron a la revisión quirúrgica sin plantear un tratamiento conservador. Resultados: Se implantó una prótesis condilar constreñida tras lo cual sufrió un nuevo episodio de las mismas características un mes después, que puso de manifiesto que el nivel de constricción no fue suficiente para la inestabilidad severa en flexión asimétrica por insuficiencia de las estructuras externas. Luego de implantarle una prótesis tipo bisagra rotatoria, no ha tenido nuevos episodios de inestabilidad. Conclusiones: A través de un repaso exhaustivo de la bibliografía, se describen los posibles factores que pueden conducir a la inestabilidad tibiofemoral tras la artroplastía total de rodilla, así como las consideraciones técnicas para su manejo.

Abstract: Background: Dislocation after total knee arthroplasty is a rare complication and a difficult problem to address. When the flexion gap is larger than the extension gap and the collateral ligaments are injured, instability and knee arthroplasty dislocation can occur. Material and methods: We report the case of a patient presenting with a posterior dislocation of a posterior-stabilized prosthesis without trauma. Frank instability in varus stress test and a positive anterior drawer test with tibial internal rotation dismissed the conservative treatment. Results: A constrained condylar prosthesis was used for the revision. He suffered a similar episode after a month, which demonstrated that the increase in the level of constraint was not enough to correct the severe asymmetric instability in flexion due to the damaged external structures. A rotating-hinge prosthesis was then implanted and the patient reported no additional episodes of instability. Conclusions: We made an exhaustive review of the literature, analyzed the possible causes that can lead to the tibiofemoral instability after a total knee arthroplasty and described some technical considerations.