Proceedings of the United Kingdom Periprosthetic Joint Infection Meeting 2022: Combined and Arthroplasty Sessions.

Considerable variation in practice exists in the prevention, diagnosis, and treatment of periprosthetic joint infection (PJI), which is a devastating complication for patients and surgeons. The consensus principle has been increasingly embraced by the orthopaedic community to help guide practice, especially where high-level evidence remains unavailable. The third United Kingdom Periprosthetic Joint Infection (UK PJI) Meeting was held in Glasgow on April 1, 2022, with more than 180 delegates in attendance, representing orthopaedics, microbiology, infectious diseases, plastic surgery, anesthetics, and allied health professions, including pharmacy and arthroplasty nurses. The meeting comprised a combined session for all delegates, and separate breakout sessions for arthroplasty and fracture-related infection. Consensus questions for each session were prepared in advance by the UK PJI working group, based upon topics that were proposed at previous UK PJI Meetings, and delegates participated in an anonymized electronic voting process. We present the findings of the combined and arthroplasty sessions of the meeting in this article, and each consensus topic is discussed in relation to the contemporary literature.

A cross-sectional evaluation of the current state of wound healing education in the United Kingdom's undergraduate medical curriculum.

Between 2013 and 2018, there has been a 71% increase in the number of patients who have required wound care in the NHS and such large numbers has placed a significant burden on healthcare systems. However, there is currently no evidence as to whether medical students are equipped with the necessary skills to deal with an increasing number of wound care related issues that patients present with. A total of 323 medical students across 18 UK medical schools completed an anonymous questionnaire evaluating the wound education received at their medical school, encompassing the volume, content, format and efficacy of teaching. 68.4% (221/323) of respondents had received some form of wound education during their undergraduate studies. On average students received 2.25 h of structured, preclinical teaching and only 1 h of clinical based teaching in total. All students that received wound education reported undertaking teaching on the physiology of, and factors affecting wound healing, with only 32.2% (n = 104) of students receiving clinically based wound education There was very weak correlation and no significant association in student's ability to assess wounds (R2 = 0.190, p = 0.013), manage wounds (R2 = 0.060, p = 0.37), and prescribe wound care products (R2 = 0.093, p = 0.18) with their stage of training. Students strongly agreed that wound education is an important part of the undergraduate curriculum and post graduate practice, and do not feel their learning needs have been met. This is the first study to assess the provision of wound education in the United Kingdom, demonstrating a clear deficit in the provision of wound education compared to expectation of junior doctors. Wound education is largely overlooked in the medical curriculum, lacks a clinical focus and does not prepare junior doctors with the necessary clinical abilities to deal with wound related pathology. Expert opinion to direct changes to future curriculum and further evaluation of teaching methodology is required to address this deficit and ensure students have the necessary clinical skills to excel as newly graduated doctors.

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.

Patellar complications following total knee arthroplasty: a review of the current literature.

Total knee arthroplasty is a common operation for treating patients with end-stage knee osteoarthritis and generally has a good outcome. There are several complications that may necessitate revision of the implants. Patella-related complications are difficult to treat, and their consequences impact the longevity of the implanted joint and functional outcomes. In this review, we explore the current literature on patellar complications in total knee arthroplasty and identify risk factors as well as strategies that can help in preventing these complications. We present pertinent findings relating to patellar complications. They can be classified into bony or soft tissue complications and include bone loss, aseptic loosening, periprosthetic fractures, patella fracture, patellar clunk syndrome, patellofemoral instability, extensor mechanism complications, maltracking, patella baja and malrotation. We conclude that patellar complications in total knee arthroplasty are common and have significant implications for the functional outcome of total knee arthroplasty. A high index of suspicion should be maintained in order to avoid them. Implant malpositioning and other forms of intraoperative technical error are the main cause of these complications, and therefore, primary prevention is crucial. When dealing with these established problems, a clear plan of action should be formulated in advance to allow appropriate management as well as anticipation of adverse outcomes.

Total knee arthroplasty in patients with prior adjacent multi-organism osteomyelitis.

Joint degeneration may make a total knee replacement a requirement for pain relief and function, however the presence of adjacent osteomyelitis makes management extremely challenging. We describe a series of four patients with a mean age of 50 with multi-organism osteomyelitis who underwent single-stage total knee replacements at an average of 63 months following eradication. Three patients did well but had complications associated with poor skin and soft tissues, and abnormal bone anatomy. One patient developed an infection and following a re-revision had an arthrodesis. The final mean Knee Society Score and Oxford Knee Score was 62 (54-66) and 34 (29-38) respectively. We have highlighted that these are a difficult cohort of patients to manage and their care is optimised through a multi-disciplinary approach by a high volume surgeon.

Acetic Acid as Part of a Debridement Protocol During Revision Total Knee Arthroplasty.

BACKGROUND: Thorough debridement is mandatory in revision for infected total knee arthroplasties (TKA). We investigated a novel adjuvant chemical debridement strategy using acetic acid (AA) that seeks to create a hostile environment for microorganisms. We report the first orthopedic in vivo series using an AA soak in infected TKAs. We also investigated the in vitro efficacy of AA against bacteria isolated from these knees. METHODS: Twenty-three patients with infected TKA were treated with a standard debridement protocol and chemical debridement with a 20-minute AA soak. In parallel, bacteria from infected TKAs were cultured for in vitro susceptibility testing with AA solutions of different concentrations to understand its potential mechanism of action. RESULTS: Intraoperatively, there were no physiological responses during the AA soak or on release of the tourniquet. Postoperatively, there was no increase in analgesic requirements or wound or soft-tissue complications. Clinical follow-up continued for 24 months to monitor recurrent infection. In vitro, zones of inhibition were formed on less than 40% of the organisms, demonstrating that AA was not directly bactericidal against the majority of the isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19% vol/vol. CONCLUSION: This study has shown that the use of 3% AA soak, as part of a debridement protocol is safe in patients. While the exact mechanism of action is yet to be determined, AA concentrations as low as 0.19% vol/vol in vitro are sufficient to completely inhibit bacterial growth.

Tibial Crest Osteotomy in Extensile Knee Exposure-A Modified, Low-Energy, Suture Technique.

BACKGROUND: Tibial crest osteotomy is an established extensile knee approach. Complications include mal-union, non-union, and fixation problems.We have designed a technique aimed at reducing complications through the principles of low-energy osteotomy and suture repair. METHODS: We reviewed our clinical and radiological results in 159 consecutive patients 181 osteotomies with a mean age of 66 years, and an average follow up of 22 months. RESULTS: Union occurred in all osteotomies (100%) at a mean period of 11 weeks. Proximal migration averaging 11.5 mm occurred in 6 osteotomies (3%). Crest fragmentation occurred in 11 osteotomies (6%), with all cases resulting in uncomplicated union. No extensor mechanism failure or complications related to the suture material occurred. CONCLUSION: We conclude that this technique results in satisfactory outcomes whilst avoiding hardware-related problems.

Knee arthrodesis with a long intramedullary nail as limb salvage for complex periprosthetic infections.

BACKGROUND: Periprosthetic infection following total knee arthroplasty is a devastating complication, which is not always satisfactorily resolved by revision surgery. Arthrodesis is a salvage alternative to above-knee amputation or permanent resection arthroplasty. Fixation options include internal compression plating, external fixation, and intramedullary nails. METHODS: We retrospectively reviewed twelve consecutive cases (9 males, 3 females; mean age, 67 years) of knee arthrodesis with a long intramedullary nail, performed at a single institution between 2003 and 2014. Desired outcomes were the ability to mobilize without pain, solid radiographic fusion, and the eradication of infection. RESULTS: Mean follow-up was 48.5 months (range, 9-120 months). Eleven patients (92 %) demonstrated stable fusion, ten patients (83 %) were ambulatory without pain, and ten patients (83 %) remained without infection at most recent follow-up. Eight patients (67 %) achieved union at an average of 12 months; three required repeat procedures, achieving union at an average of 9 months. There was a significant difference (P < 0.01) between the numbers of previous operations amongst the eight patients who initially achieved union (mean, 3.25) and three who subsequently required repeat procedures (mean, 8.33). CONCLUSIONS: In contrast to similar studies, we performed a single-stage exchange where possible, while comparable ambulatory and fusion rates were observed. Numerous previous attempts at revision arthroplasty, co-morbidities, and infections with highly resistant organisms have been associated with further complications. Although technically challenging, knee arthrodesis with a long intramedullary nail offers an acceptable limb salvage procedure for carefully selected patients with complex periprosthetic infections.

Revision total knee arthroplasty for failure of primary treatment of periprosthetic knee fractures.

Periprosthetic knee fractures and their complications are expected to increase as the numbers of knee arthroplasties continue to rise. We report our experience with revision knee arthroplasty for failure of primary fracture treatment. Five periprosthetic knee non-unions and 1 mal-union in 6 patients, with ages ranging from 65 to 83years (average 74.6years) were treated with revision total knee arthroplasty, and were followed up for 3 to 10years (average 4.5years). Union occurred in 8 to 18weeks (average 12.5weeks). All patients were ambulatory at the latest follow-up, with a range of motion averaging 84.2° (P = 0.03), and an Oxford Knee Score averaging 35 (P = 0.03). We conclude that union complications of periprosthetic knee fractures can be satisfactorily addressed with revision arthroplasty.

Management of septic arthritis and prosthetic joint infection.

Management of joint infection is an evolving topic. This article reviews the literature on the management of native and prosthetic joint infection and suggests some areas of improvement in short- and long-term management which could lead to better patient outcomes. Surgical management is the mainstay of treatment for native or prosthetic knee infection and aspiration should only be used for diagnostic purposes. A multidisciplinary team approach and compliance with national guidelines, alongside referral networks and pooling of expertise, should be mandatory to improve patient outcomes.

Permanent Resection Arthroplasty of the Knee as Limb Salvage Following Recurrent Periprosthetic Infection Complicated with Osteomyelitis.

Introduction: Permanent resection or excision arthroplasty of the knee involves the removal of any infected prosthetic material and thorough debridement, with no further reimplantation. The more common alternatives to permanent resection arthroplasty include knee arthrodesis or above-knee amputation (AKA). Case Report: We describe two cases of complex periprosthetic infections of the knee associated with subsequent osteomyelitis, which were unsuitable for re-revision arthroplasty. Both patients chose to remain with an excision arthroplasty, rather than undergo arthrodesis or AKA, respectively, and were satisfied with their quality of life at long-term follow-up. Conclusion: Although permanent resection arthroplasty of the knee is rarely performed, it remains a limb salvage option in certain cases where bone loss is limited, functional demands are low, and further surgery may present a significant risk.

Infected total knee replacement: How I do a one-stage revision.

BACKGROUND: As part of a session on the infected knee replacement at the British Orthopaedic Association congress in Liverpool, 2019, this topic was delivered as a lecture. The content and ideas of the lecture have been expanded to produce this article. METHODS: One-stage revision total knee replacement is not a new concept but remains controversial. This article is not written to persuade any surgeon to undertake the procedure but to simply give a working framework for how one surgeon performs the operation. We will cover the philosophy underpinning the rationale for single-stage revision (not 2-in-1 revision) including extensile exposure, a defined debridement protocol, reconstruction and fixation, antibiotic delivery and exclusion criteria. RESULTS: None. CONCLUSION: The techniques outlined in this article should give confidence that one-stage revision knee replacement is a viable option when working within a multi-disciplinary team structure.

Balance and constraint in revision TKR: A classification for instability management.

Instability is an increasingly common cause and symptom of failure of Total Knee Arthroplasty (TKA). Patients seek 'Functional Stability', which is the sum of both a balanced joint and, if necessary, mechanical constraint. The objective of this paper is to classify the different types of TKA instability and their causes. Based on this classification, the authors give methodical recommendations for instability management. INSTABILITY CLASSIFICATION: Instability in revision TKA can be classified into 3 types based on the management of bone loss and ligamentous deficiency which directs the level of constraint required to achieve functional stability. TYPE 1: Bone deficiency: Revision with restoration of joint line and rebuilding the bony anatomy results in a balanced joint. No increased constraint is needed. TYPE 2: Ligament and soft tissue deficiency: Requires increased constraint to overcome instability. TYPE 3: Composite (Total) deficiency: (combined Type 1 and 2).The multiple causes of instability are outlined for each Instability type along with an algorithm for restoring the joint line and adding titrated constraint to restore functional stability.

Metaphyseal Sleeve Failure in Revision Total Knee Arthroplasty.

Introduction A significant percentage of patients require re-revision surgery regardless of the demonstrated durable short- and mid-term clinical results using metaphyseal sleeves in revision total knee arthroplasty (TKA). The aim of this study was to identify the association between sleeve alignment and contact zones, with loosening in patients with revision TKA. Materials & Methods Of a series of 103 patients who underwent revision TKA, at a mean follow-up of eight years, six patients were re-revised for tibial loosening. These patients were compared with 19 unrevised control subjects in a 1:3 ratio. We calculated and compared the cumulative number of contact zones between the porous-coated part of the sleeve and bone on immediate postoperative X-rays between re-revised and unrevised patients. The main hypothesis was that neutral positioning and absolute circumferential contact between trabecular metaphyseal bone and porous-coated part of the sleeve would lead to a better outcome. Results The use of a conservative (nonparametric) approach indeed revealed better circumferential contact between trabecular metaphyseal bone and porous-coated part of the sleeve among the survivors, i.e., survivors: median (interquartile range [IQR]): 3 (2-4); failures: 3 (1-3), p = 0.003 (Mann-Whitney [MW] test). The difference was borderline significant for coronal alignment, i.e., survivors: median (IQR): -1 (-4 to 2); failures: 0 (-1 to 3), p = 0.0569 (MW test). Conclusion A circumferential bony contact of the metaphyseal sleeve would lead to better survival of the revision implant, whereas the degree of varus fixation did not seem to influence the longevity of the implant.

Single-stage revision for the infected total knee arthroplasty : the Cardiff experience.

AIMS: Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up. METHODS: A total of 84 patients, with a mean age of 68 years (36 to 92), underwent single-stage revision TKA for confirmed PJI at a single institution between 2006 and 2016. In all, 37 patients (44%) were treated for an infected primary TKA, while the majority presented with infected revisions: 31 had undergone one previous revision (36.9%) and 16 had multiple prior revisions (19.1%). Contraindications to single-stage exchange included systemic sepsis, extensive bone or soft-tissue loss, extensor mechanism failure, or if primary wound closure was unlikely to be achievable. Patients were not excluded for culture-negative PJI or the presence of a sinus. RESULTS: Overall, 76 patients (90.5%) were infection-free at a mean follow-up of seven years, with eight reinfections (9.5%). Culture-negative PJI was not associated with a higher reinfection rate (p = 0.343). However, there was a significantly higher rate of recurrence in patients with polymicrobial infections (p = 0.003). The mean Oxford Knee Score (OKS) improved from 18.7 (SD 8.7) preoperatively to 33.8 (SD 9.7) at six months postoperatively (p < 0.001). The Kaplan-Meier implant survival rate for all causes of reoperation, including reinfection and aseptic failure, was 95.2% at one year (95% confidence interval (CI) 87.7 to 98.2), 83.5% at five years (95% CI 73.2 to 90.3), and 78.9% at 12 years (95% CI 66.8 to 87.2). CONCLUSION: One-stage exchange, using a strict debridement protocol and multidisciplinary input, is an effective treatment option for the infected TKA. This is the largest single-surgeon series of consecutive cases reported to date, with broad inclusion criteria. Cite this article: Bone Jt Open 2021;2(5):305-313.

Results of revision knee replacement for patients with isolated fixed flexion deformity after primary or revision knee replacement.

BACKGROUND: Postoperative fixed flexion deformity is a known complication of knee replacement surgery. We present our results of revision surgery for treatment of isolated fixed flexion deformity after knee replacement. METHODS: 32 patients had revision knee replacement for fixed flexion deformity and were included in this retrospective study. Minimum follow up period was 28 months. RESULTS: Two different surgical interventions had been done in these patients. Group 1 (15 patients) had revision of the femoral component, posterior capsular release and tibial component was not revised. Group 2 (18 Patients) had revision of both femoral and tibial components. One patient was included in both groups as she had both interventions. The extent of preoperative flexion deformity in group 1 was from 15 to 40 deg (mean 20.6 deg). Postoperative range of extension was 0 to 20 deg (mean 8.2 deg). In group 2, preoperative flexion deformity was 10 to 25 deg (mean 16.9 deg) and postoperative flexion deformity was 0 to 20 deg (mean 4.2 deg). The difference in improvement between the two groups was not statistically significant on Mann Whitney U test (two tailed p value 0.181) for non normal distribution. Improvement in Oxford knee score following surgery was only 1 point in both groups. CONCLUSION: Revision for isolated fixed flexion deformity leads to improvement in range of extension, but improvement in clinical score is marginal. The choice of preservation or revision of the tibial component did not make a significant difference to the outcome.