Revision Knee Arthroplasty Research Articles

Tramadol as a patient-initiated component of multimodal pain management: a pilot study of 364 lower limb arthroplasty cases.

Multimodal therapy (MMT) for analgesia following joint arthroplasty continues to reduce cost and the requirement of strong opioids post-operatively. Tramadol immediate release is an important MMT component providing synergistic pain relief via dual μ-opioid agonism and serotonin and noradrenaline reuptake inhibition. Case reports have shown tramadol when combined with antidepressants cause serotonin syndrome, but this has yet to be demonstrated in larger studies. We undertook a pilot study assessing the functional outcomes and incidence of side effects associated with tramadol in lower limb arthroplasty patients with a focus on those taking concomitant antidepressants. Primary and revision hip and knee arthroplasties performed in 2018-2019 by a senior surgeon were included (n=364). Patient records were assessed to determine pain scores, length of hospitalization, prescription of tramadol and antidepressants, self-reported side effects and previous adverse reactions associated with tramadol. Nine-five percentage of patients had been prescribed tramadol, and 16% had concurrent prescription of tramadol and one or more antidepressants. The total rate of adverse effects associated with tramadol before and during the study was 7% (n=25) including two cases of concomitant tramadol and antidepressant use. For patients on tramadol, median 2-week post-operative pain score was 1.5 (IQR 1-2.5) out of 10 and hospitalization length was 1 (IQR 1-2) days. Tramadol immediate release appears to be well tolerated among our patient population with no significantly increased prevalence of side effects when co-administered with low and moderate dose antidepressants.

Outcomes of Total Knee Arthroplasty Revisions in Obese and Morbidly Obese Patient Populations

BackgroundThe obese population is at higher risk for complications following primary total knee arthroplasty (TKA), but little data is available regarding revision outcomes. This study aimed to investigate the role of body mass index (BMI) in the cause for revision TKA and whether BMI classification is predictive of outcomes. MethodsA multi-institutional database was generated, including revision TKAs from 2012 to 2019. Data collection included demographics, comorbidities, surgery types (primary revision, repeat revision), reasons for revision, lengths of hospital stay, and surgical times. Patients were compared using 3 BMI categories: nonobese (18.5 to 29.9), obese (30 to 39.9), and morbidly obese (≥40). Categorical and continuous variables were analyzed using chi-square and 1-way analysis of variance tests, respectively. Regression analyses were used to compare reasons for revision among weight classes. ResultsObese and morbidly obese patients showed significant risk for repeat revision surgery in comparison to normal weight patients. Obese patients were at higher risk for primary revision due to stiffness/fibrosis and repeat revision due to malposition. In comparison to the obese population, morbidly obese patients were more likely to require primary revision for dislocation and implant loosening. ConclusionSignificant differences in primary and repeat revision etiologies exist among weight classes. Furthermore, obese and morbidly obese patients have a greater risk of requiring repeat revision surgery. These patients should be informed of their risk for multiple operations, and surgeons should be aware of the differences in revision etiologies when anticipating complications following primary TKA.

Perioperative Complications after Hip and Knee Revision Arthroplasty in the over 80 Years Old Population: A Retrospective Observational Case-Control Study.

The number of joint revision arthroplasties has increased in the elderly population, which is burdened by several perioperative risks. Patients who underwent hip and knee revision arthroplasty were retrospectively included, and they were divided into two groups by age: <80 years old (Group 1) and ≥80 years old (Group 2). The primary outcome was to compare perioperative complication rates. The secondary outcome was to compare the 30-day, 90-day, and 1-year readmission rates. In total, 74 patients in Group 1 and 75 patients in Group 2 were included. Postoperative anemia affected 13 patients in Group 1 (17.6%) and 25 in Group 2 (33.3%, p 0.027); blood units were transfused in 20 (26.7%) and 11 (14.9%, p 0.076) patients, respectively. In Group 1, two (2.7%) patients reported wound infection. In Group 2, eight (10.7%) patients presented hematomas, and two (2.7%) patients reported dislocations. No significant differences in the two groups were observed for 30-day (p 0.208), 90-day (p 0.273), or 1-year readmission rates (p 0.784). The revision arthroplasty procedure in patients over 80 years old is not associated with a higher risk of perioperative complications, or higher readmission rate compared with younger patients undergoing hip and knee revision surgery.

Paper 19: Evidence-Based Machine Learning Algorithm to Predict Failure Following Cartilage Preservation Procedures in the Knee

Objectives: To develop machine learning algorithms to predict failure of surgical procedures that address cartilage defects of the knee and detect the most valuable variables associated with failure. Methods: A single institution prospectively collected database of cartilage procedures was queried for procedures performed between 2000 and 2018. Failure was defined as revision cartilage surgery and/or knee arthroplasty. One hundred and one preoperative and intraoperative features were evaluated as potential predictors. The dataset was randomly divided into training (70%) and independent testing (30%) sets. Four machine learning algorithms were trained and internally validated. Algorithm performance was assessed using area under curve (AUC) and the Brier score. Local Interpretable Model-agnostic Explanations (LIME) was utilized to assess the optimized algorithm fidelity. Results: A total of 1091 patients who underwent surgical procedures addressing cartilage defects in the knee with a minimum of 2-years of follow-up were included. The mean follow-up was 3.5 ± 2.8 years. The mean age was 40.5 ± 15 years. There were 205 (18.8%) patients who failed at final follow-up. The Random Forest algorithm was found to be the best performing algorithm, with an AUC of 0.765 and a Brier score of 0.135. The 10 most important features for predicting failure following surgical procedures addressing cartilage defects of the knee were: symptom duration, age, body mass index (BMI), lesion grade, total lesion area (sum of all lesion areas), number of previous surgeries, number of lesions in the knee, gender, athletic level, and traumatic etiology. LIME analysis allowed for assessment of the optimized algorithm fidelity, as well as provided a patient-specific comparison for the risk of failure of an individual patient being assigned various types of cartilage procedures. Conclusions: Machine learning algorithms were accurate in predicting the risk of failure following cartilage procedures of the knee, with the most important features being symptom duration, age, BMI, lesion grade, and total lesion area. Machine learning algorithms may be used to compare the risk of failure of specific patient-procedure combinations in the treatment of cartilage defects of the knee. Integrated human and machine learning decision-making may improve patient selection and bring about the new era of patient-tailored evidence-based clinical care. [Table: see text][Table: see text][Figure: see text][Figure: see text]

Rotating hinge knee as a means of limb salvage in a patient operated on five times for periprosthetic joint infection: from despairs of darkness to lights of joy!

The demand for revision knee arthroplasty is increasing daily with the increase in the number of patients undergoing primary knee arthroplasty. The aim of revision arthroplasty therefore should be the restoration of the mechanical alignment of the limb with the restoration of joint line and biomechanics and these goals should be accomplished with the least possible use of constrained implants which otherwise depends on the degree of bone defects and integrity of collateral ligaments. We have hereby reported a case of a 51-year-old lady operated on five times before who was financially drained, mentally and psychologically depressed with the patient and her relative’s considering amputation of the limb as a last resort!

Research progress of failure and revision of unicompartmental knee arthroplasty

To conclude the failure factors of unicompartmental knee arthroplasty (UKA), and summarize the research progress of revision surgery. The literature on UKA at home and abroad in recent years was reviewed to summarize its risk factors, treatment methods, including the evaluation of bone loss, prosthesis selection, and surgical techniques. The factors inducing UKA failure mainly include improper indications, technical errors, and others. The application of digital orthopedic technology can reduce failures caused by surgical technical errors and shorten the learning curve. There are a variety of options for revision surgery after UKA failure, including polyethylene liner replacement, revision with UKA or total knee arthroplasty, with adequate preoperative evaluation prior to implementation. The biggest challenge in revision surgery is the management and reconstruction of bone defects. There is a risk of failure in UKA, which needs to be treated with caution and should be determined according to the type of failure.

Plasma D-Dimer Is Noninferior to Serum C-Reactive Protein in the Diagnosis of Periprosthetic Joint Infection.

No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools in the workup of patients with suspected PJI. This study aimed to determine the diagnostic utility of plasma D-dimer for PJI in a variety of clinical scenarios. This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty. PJI was defined per a modified version of the 2018 International Consensus Meeting (ICM) criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Receiver operating characteristic curves were used to assess the utility of each biomarker in the diagnosis of PJI. Pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the markers were significant. Of the 412 patients included, 317 (76.9%) did not have an infection (aseptic group) and 95 (23.1%) had an infection (PJI group). All 4 serological markers, D-dimer (AUC, 0.860; sensitivity, 81.3%; specificity, 81.7%), CRP (AUC, 0.862; sensitivity, 90.4%; specificity, 70.0%), ESR (AUC, 0.833; sensitivity, 73.9%; specificity, 85.2%), and fibrinogen (AUC, 0.798; sensitivity, 74.7%; specificity, 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all p > 0.05). When examining the performance of the different inflammatory markers in diagnosing infection caused by indolent organisms, D-dimer demonstrated the highest sensitivity at 93.8%. We found that plasma D-dimer was noninferior to serum CRP and ESR in the diagnosis of PJI and may be a useful adjunct when screening patients undergoing revision total joint arthroplasty. Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Intraosseous Vancomycin May Not Be Helpful in Aseptic Revision Knee Arthroplasty: A Single-Surgeon Consecutive Case Series

BackgroundInfection after aseptic revision total knee arthroplasty (TKA) has been reported from 9% to 14%. Intraosseous (IO) vancomycin infusion has decreased the risk of infection after primary TKA. The results of this additional prophylaxis were evaluated in aseptic revision TKA. MethodsIn this prospective, single-surgeon study of 20 consecutive patients having aseptic revision TKA, 500 milligrams of vancomycin in 120 mL of saline were infused into the tibia prior to incision, in addition to intravenous (IV) cefazolin. There were 18 men and 2 women who had a mean age of 67 years (range, 47-79), and mean body mass index of 34.4 (range, 25.9-51.2). The knees were aspirated in the operating room prior to IV and IO antibiotics. The outcomes were infections at 90 days requiring reoperation and complications from the infusion. ResultsThree of the 20 aseptic revisions had early prosthetic joint infection, 2 with gram-negative organisms and one with coagulase-negative Staphylococcus. All had debridement, liner exchange and IV antibiotic treatment, but 1 patient eventually had an above knee amputation. No patient had total body “erythema syndrome”, but 1 patient had transient facial flushing. Six patients had a transient elevation of serum creatinine including 3 with an abnormal preoperative serum creatinine. ConclusionIn this small series of aseptic revision TKA, there was no added benefit of IO vancomycin infusion, but there were no infections with methicillin-resistant Staphylococcus aureus. Additional studies are needed before this technique should be routinely recommended.

COMPARISON OF REVISION ‘THRESHOLDS’ USING PATIENT-REPORTED OUTCOMES FOLLOWING TOTAL AND UNICOMPARTMENTAL KNEE ARTHROPLASTY

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New ZealandPatient reported outcome measures (PROMs) are predictors of knee arthroplasty revision. Unicompartmental knee arthroplasty (UKA) is effective for patients with the correct indications, however has higher revision rates than total knee arthroplasty (TKA). Different revision thresholds for the procedures have been postulated. Our aims were to investigate: 1) if PROMs could predict knee arthroplasty revision within two years of the score at six months, five years and ten years follow-up, and 2) if revision ‘thresholds’ differed between TKA and UKA.All TKAs and UKAs captured by the New Zealand Joint Registry between 1999 and 2019 with at least one OKS response at six months (TKA n=27,708, UKA n=8,415), five years (TKA n=11,519, UKA n=3,365) or ten years (TKA n=6,311, UKA n=1,744) were included. were propensity-score matched 2:1 with UKAs for comparison of revision thresholds.Logistic regression indicated that for every one-unit decrease in OKS, the odds of TKA and UKA revision decreased by 10% and 11% at six months, 10% and 12% at five years and 9% and 5% at ten years. Fewer TKA patients with ‘poor’ outcomes (≤25) subsequently underwent revision compared with UKA at six months (5.1% vs. 19.6%, p&lt;0.001), five years (4.3% vs. 12.5%, p&lt;0.001) and ten years (6.4%vs. 15.0%, p=0.02). Compared with TKA, UKA patients were 2.5 times more likely to undergo revision for ‘unknown’ reasons, bearing dislocations and disease progression.The OKS is a strong predictor of subsequent knee arthroplasty revision within two years of the score from early to late term. A lower revision threshold was found with UKA when compared with a matched TKA cohort. Higher revision rates of UKA are associated with both lower clinical thresholds for revision and additional modes of UKA failure.

C-reactive protein/albumin and C-reactive protein/fibrinogen ratios for the diagnosis of periprosthetic joint infection in revision total joint arthroplasty.

Testing for systemic inflammation markers is considered a simpler method for diagnosing periprosthetic joint infection (PJI). Changes in the C-reactive protein/albumin ratio (CRP/Alb ratio) and C-reactive protein/fibrinogen ratio (CRP/Fib ratio) are associated with PJI. This study aimed to evaluate the application of CRP/Alb and CRP/Fib ratios as novel inflammation-based markers for the diagnosis of PJI. We retrospectively evaluated 445 patients who underwent total hip and knee revision arthroplasties between January 2010 and February 2021. Of these, 129 patients were also independently evaluated for PJI with coagulation-related comorbidities. The patients were divided into two groups: the aseptic revision (268 patients) and PJI revision groups (187 patients). Subsequently, we evaluated the diagnostic value of the CRP/Alb and CRP/Fib ratios compared to other inflammation-based diagnoses using the area under the curve (AUC) values. The AUC values of the CRP/Alb and CRP/Fib ratios were 0.880 and 0.872, respectively, suggesting similar diagnostic potentials for PJI. The CRP/Alb and CRP/Fib ratios were better than the erythrocyte sedimentation rate (ESR), Alb, and Fib, whose AUC values were 0.765, 0.352, and 0.730, respectively, for the diagnosis of PJI. The optimal cut-off for the CRP/Alb ratio was 0.13, with good sensitivity (85.0%) and specificity (78.4%). The optimal cut-off CRP/Fib ratio was 2.04, with good sensitivity (81.3%) and specificity (80.6%). Notably, the CRP/Alb and CRP/Fib ratios had the highest sensitivity, followed by four conventional inflammatory markers, namely, CRP, ESR, Alb, and Fib, which had sensitivities of 80.2%, 67.4%, 50.8%, and 54.0%, respectively. Similar findings were observed in patients with coagulation-related comorbidities. Both the CRP/Alb and CRP/Fib ratios were significantly higher in patients with PJI than in those with aseptic failure and showed better sensitivity and specificity for diagnosing PJI than classical inflammatory markers.

‘OVERALL PAIN’, ‘LIMPING WHEN WALKING’, AND ‘KNEE GIVING WAY’ ARE THE STRONGEST OXFORD KNEE SCORE PREDICTORS OF SUBSEQUENT REVISION WITHIN TWO YEARS

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New ZealandThe Oxford Knee Score (OKS) is a 12-item questionnaire used to track knee arthroplasty outcomes. Validation of such patient reported outcome measures is typically anchored to a single question based on patient ‘satisfaction’, however risk of subsequent revision surgery is also an important outcome measure. The OKS can predict subsequent revision risk within two years, however it is not known which item(s) are the strongest predictors. Our aim was to identify which questions were most relevant in the prediction of subsequent knee arthroplasty revision risk. All primary TKAs (n=27,708) and UKAs (n=8,415) captured by the New Zealand Joint Registry between 1999 and 2019 with at least one OKS response at six months, five years or ten years post-surgery were included. Logistic regression and receiver operating characteristics (ROC) curves were used to assess prediction models at six months, five years and ten years.Q1 ‘overall pain’ was the strongest predictor of revision within two years (TKA: 6 months, odds ratio (OR) 1.37; 5 years, OR 1.80; 10 years, OR 1.43; UKA: 6 months, OR 1.32; 5 years, OR 2.88; 10 years, OR 1.85; all p&lt;0.05). A reduced model with just three questions (Q1, Q6 ‘limping when walking’, Q10 ‘knee giving way’) showed comparable or better diagnostic ability with the full OKS (area under the curve (AUC): TKA: 6 months, 0.77 vs. 0.76; 5 years, 0.78 vs. 0.75; 10 years, 0.76 vs. 0.73; UKA: 6 months, 0.80 vs. 0.78; 5 years: 0.81 vs. 0.77; 10 years, 0.80 vs. 0.77).The three questions on overall knee pain, limping when walking, and knee ‘giving way’ were the strongest predictors of subsequent revision within two years. Attention to the responses for these three key questions during follow-up may allow for prompt identification of patients most at risk of revision.

Long Pentraxin 3 as a New Biomarker for Diagnosis of Hip and Knee Periprosthetic Joint Infections.

Preoperative diagnosis of periprosthetic joint infections (PJIs) poses an unmet clinical challenge. The long pentraxin PTX3 is a component of the innate immune system involved in infection immunity. This study evaluated the potential of synovial and plasmatic PTX3 in the diagnosis of hip and knee PJIs. Consecutive total hip and knee arthroplasty (THA/TKA) revisions were prospectively included and classified as septic or aseptic according to the European Bone and Joint Infection Society (EBJIS) and Musculoskeletal Infection Society (MSIS) criteria. The concentration of PTX3 in plasma and synovial fluid samples was measured with ELISA. The AUC, threshold value, sensitivity, specificity, and positive and negative likelihood ratios were calculated using the ROC (receiver operating characteristic) curve method. The study population included 128 patients (94 THAs; 34 TKAs). The AUC of the synovial PTX3 based on EBJIS criteria was 0.85 (p < 0.0001), with a sensitivity of 81.13% and a specificity of 93.33%. The AUC based on MSIS criteria was 0.95 (p < 0.001), with a sensitivity of 91.43% and a specificity of 89.25%. Plasmatic PTX3 failed to discriminate infected from non-infected patients. Synovial PTX3 demonstrated an excellent diagnostic potential in hip and knee PJIs, with a very high specificity irrespective of the diagnostic criteria for PJI.

Замещение дефектов бедренной и большеберцовой костей при ревизионном эндопротезировании коленного сустава с применением не биодеградируемых материалов: обзор литературы.

In order to restore the function of the knee joint in the terminal stages of arthrosis, primary total knee arthroplasty is used. Primary total knee arthroplasty consists in replacing the femoral and tibial (in some cases, patellar) components of the knee joint with metal and polyethylene (ceramics are used in some types of endoprostheses). This operation has established itself as a method that improves the function of the knee joint in the later stages of gonarthrosis. But in cases of development of aseptic instability of the endoprosthesis components or septic instability of the endoprosthesis components due to periprosthetic infection, it is necessary to resort to revision arthroplasty. During revision arthroplasty, there are frequent cases of the formation of defects in the femur and tibia, which can become an obstacle to stabilization and return of knee joint function. To replace such defects at the present stage, the following methods are used, which relate to non-biodegradable materials: cementing, cementing with screw reinforcement, factory cement spacers with augments, modular metal augments, metaphyseal bushings with pressed porous titanium coating and structural cones made of porous tantalum, megaendoprostheses or individual endoprostheses. This review article analyzes sources describing methods for replacing defects in the bones forming the knee joint during revision knee arthroplasty and consisting of non-biodegradable materials from the PubMed, Google Scholar, SCOPUS, Web of Science databases. The analyzed methods of bone defect replacement are widely used in everyday practice, but also have a number of disadvantages. The use of thick layers of bone cement increases the risk of thermal necrosis and worsens the pressure of bone cement. Factory cement spacers with augment allow only the full defect of the plateau to be replaced. Modular metal augments are associated with corrosion and the development of instability. Metaphyseal bushings and structural cones can cause bone fracture upon insertion and are difficult to remove during revision. Mega endoprostheses or individual endoprostheses are associated with a high risk of infection. Modular metal augments, metaphyseal sleeves, structural cones, mega endoprostheses or individual endoprostheses also have a high cost. At this time, there is a need to develop new methods of defect replacement that will improve the function of the knee joint, improve the quality of life of patients, will be widely available and cost-effective.

Замещение дефектов бедренной и большеберцовой костей при ревизионном эндопротезировании коленного сустава с применением не биодеградируемых материалов

In order to restore the function of the knee joint in the terminal stages of arthrosis, primary total knee arthroplasty is used. Primary total knee arthroplasty consists in replacing the femoral and tibial (in some cases, patellar) components of the knee joint with metal and polyethylene (ceramics are used in some types of endoprostheses). This operation has established itself as a method that improves the function of the knee joint in the later stages of gonarthrosis. But in cases of development of aseptic instability of the endoprosthesis components or septic instability of the endoprosthesis components due to periprosthetic infection, it is necessary to resort to revision arthroplasty. During revision arthroplasty, there are frequent cases of the formation of defects in the femur and tibia, which can become an obstacle to stabilization and return of knee joint function. To replace such defects at the present stage, the following methods are used, which relate to non-biodegradable materials: cementing, cementing with screw reinforcement, factory cement spacers with augments, modular metal augments, metaphyseal bushings with pressed porous titanium coating and structural cones made of porous tantalum, megaendoprostheses or individual endoprostheses. This review article analyzes sources describing methods for replacing defects in the bones forming the knee joint during revision knee arthroplasty and consisting of non-biodegradable materials from the PubMed, Google Scholar, SCOPUS, Web of Science databases. The analyzed methods of bone defect replacement are widely used in everyday practice, but also have a number of disadvantages. The use of thick layers of bone cement increases the risk of thermal necrosis and worsens the pressure of bone cement. Factory cement spacers with augment allow only the full defect of the plateau to be replaced. Modular metal augments are associated with corrosion and the development of instability. Metaphyseal bushings and structural cones can cause bone fracture upon insertion and are difficult to remove during revision. Mega endoprostheses or individual endoprostheses are associated with a high risk of infection. Modular metal augments, metaphyseal sleeves, structural cones, mega endoprostheses or individual endoprostheses also have a high cost. At this time, there is a need to develop new methods of defect replacement that will improve the function of the knee joint, improve the quality of life of patients, will be widely available and cost-effective

Associations of the Oxford Knee Score and knee arthroplasty revision at long-term follow-up.

Self-reported outcome measures are increasingly being collected for healthcare evaluation therefore it is prudent to understand their associations with patient outcomes. Our aims were to investigate: (1) if Oxford Knee Score (OKS) is associated with impending revision at long-term (5 and 10 years) follow-up, and (2) if decreased OKS at subsequent follow-ups is associated with higher risk of revision. All total knee (TKAs) and unicompartmental knee arthroplasties (UKAs) between 1999 and 2019 in the New Zealand Joint Registry with an OKS at 6 months (TKA n=27 708, UKA n=8415), 5 years (TKA n=11 519, UKA n=3365) or 10 years (TKA n=6311, UKA n=1744) were included. Logistic regression determined associations of the OKS with revision within 2 years of each score. Change in OKS between timepoints were compared with revision risk. For every one-unit increase in OKS, the odds of TKA and UKA revision decreased by 10% and 11% at 6 months, 10% and 12% at 5 years and 9% and 5% at 10 years. For both procedures a decrease of seven or more OKS points from previous follow-up was associated with higher risk of revision (5 years: TKA 4.7% versus 0.5%, UKA 8.7% versus 0.9%; 10 years: TKA 4.4% versus 0.7%, UKA 11.3% versus 1.5%; all P < 0.01). The OKS had a strong negative association with risk of impending TKA and UKA revision from early to long-term (10+ years) follow-up. A decrease of seven or more points when compared with the previous follow-up was also associated with higher revision risk.

Risk factors for recurrence of periprosthetic joint infection following operative management: a cohort study with average 5-year follow-up.

Periprosthetic joint infections (PJIs) remain challenging to eradicate even after surgical management, which in most cases involves either debridement, antibiotics and implant retention (DAIR) or single- or two-staged revision. The purpose of this study is to determine predictors of PJI recurrence after operative management for PJI, and to determine differences in recurrence-free survival between DAIR and staged revision. This is a retrospective analysis of prospectively collected data of revision hip and knee arthroplasty surgeries due to PJI between 2011 and 2018 at an academic hospital. Any patient undergoing revision surgery for PJI was included except if the index surgery information was unknown. The primary outcome was confirmed PJI recurrence. Multivariable logistic regression analysis was utilized to determine the relationship between the predictor variables and outcome variable. Log rank testing was used to compare recurrence-free survival between DAIR and staged revision. A total of 89 patients (91 joints) underwent revision surgery due to PJI. Younger age and presence of a sinus tract were statistically significant for risk of PJI recurrence. A multivariable logistic regression model including both variables was significant for predicting recurrence of PJI (χ2=10.2, P=0.006). Survival was not significantly different between patients who underwent DAIR versus a staged revision. Younger patients and those with a chronic sinus tract are at significantly higher risk of recurrent PJI. This study also demonstrated that PJI can be successfully managed in the majority of cases with DAIR or staged revision.

C-Reactive Protein-to-Albumin Ratio (CAR) and C-Reactive Protein-to-Lymphocyte Ratio (CLR) are Valuable Inflammatory Biomarker Combination for the Accurate Prediction of Periprosthetic Joint Infection.

Periprosthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty (TJA). Timely and accurate diagnosis is important for the management of PJI. Currently, many biomarkers are available for the diagnosis of PJI, but which inflammatory biomarker combination has the best diagnostic value has not been reported. We retrospectively analyzed 244 patients who underwent revision knee or hip arthroplasty in our institution. They were divided into two groups: 87 in the PJI group and 157 in the aseptic failure (AF) group. The preoperative C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), CRP-to-albumin ratio (CAR), CRP-to-lymphocyte ratio (CLR), neutrophil-to-albumin ratio (NAR) and platelet-to-albumin ratio (PAR) were determined and compared between the two groups. Receiver operating characteristic curve (ROC) and area under the curve (AUC) were used to assess the diagnostic value of all biomarkers, and the optimal cut-off value, positive predictive value (PPV) and negative predictive value (NPV) were further calculated by the Youden index. The NLR, PLR, CAR, CLR, NAR and PAR of the PJI group were significantly higher than those of the AF group (P<0.001). According to the ROC and AUC results, the diagnostic value of CAR and CLR was considered excellent with AUCs of 0.931 and 0.935, respectively. The diagnostic value of NAR (0.739) and PAR (0.785) were fair, the diagnostic value of NLR (0.694) was poor, and PLR (0.535) had no diagnostic ability. Subgroup analysis showed no significant differences in combined inflammatory biomarkers between the two groups. CAR and CLR are valuable combined inflammatory biomarkers for diagnosing PJI, while other markers were of limited value for the diagnosis of PJI.

Allograft Extensor Mechanism Reconstruction in Salvage Revision Knee Arthroplasty: Surgical Technique.

Although extensor mechanism failure remains a catastrophic complication of knee arthroplasty, there are a number of contemporary techniques with reasonable outcomes that restore function. Chronic failures require advanced reconstruction techniques. Similar complication rates have been reported for the use of autografts, allografts, or mesh reconstructions. Here, we describe our surgical technique in allograft extensor mechanism reconstruction for chronic failures in salvage revision knee arthroplasty using a complete extensor mechanism allograft with a modified proximal fixation and case demonstrations.

Single-stage Bilateral Revision Knee Arthroplasty with Unilateral Tibial Tubercle Osteotomy

A revision total knee arthroplasty (Rev-TKA) for bilateral affection presents surgical complexities. Rev-TKA as a single stage has been rarely advocated. A 76-year-old woman presented with painful bilateral knees and a history of bilateral TKA done fourteen years ago. The right knee required unilateral tibial tubercle osteotomy with cerclage wire fixation to remove the incarcerated cemented tibial extension rod and extensile medial parapatellar approach for the left knee in single-stage. The osteotomy united at 14 weeks. At 2-year follow-up, range of movements improved, allowing pain-free walking without support and laxity. No radiological evidence of loosening or wear. Rev-TKA challenges include obtaining adequate joint exposure without compromising the integrity of the extensor mechanism. The crucial factors for achieving an uneventful single-stage surgery include thorough pre-operative planning, prophylactic thromboprophylaxis, measures to reduce blood loss, and meticulous execution of planned surgery. The bilateral Rev-TKA should be planned after the stratification of the risk-benefit ratio.

First-time revision knee arthroplasty using a hinged prosthesis : temporal trends, indications, and risk factors associated with re-revision using data from the National Joint Registry for 3,855 patients.

The aim of this study was to identify variables associated with time to revision, demographic details associated with revision indication, and type of prosthesis employed, and to describe the survival of hinge knee arthroplasty (HKA) when used for first-time knee revision surgery and factors that were associated with re-revision. Patient demographic details, BMI, American Society of Anesthesiologists (ASA) grade, indication for revision, surgical approach, surgeon grade, implant type (fixed and rotating), time of revision from primary implantation, and re-revision if undertaken were obtained from the National Joint Registry data for England, Wales, Northern Ireland, and the Isle of Man over an 18-year period (2003 to 2021). There were 3,855 patient episodes analyzed with a median age of 73 years (interquartile range (IQR) 66 to 80), and the majority were female (n = 2,480, 64.3%). The median time to revision from primary knee arthroplasty was 1,219 days (IQR 579 to 2,422). Younger age (p < 0.001), decreasing ASA grade (p < 0.001), and indications for revision of sepsis (p < 0.001), unexplained pain (p < 0.001), non-polyethylene wear (p < 0.001), and malalignment (p < 0.001) were all associated with an earlier time to revision from primary implantation. The median follow-up was 4.56 years (range 0.00 to 17.52), during which there were 410 re-revisions. The overall unadjusted probability of re-revision for all revision HKAs at one, five, and ten years after surgery were 2.7% (95% confidence interval (CI) 2.2 to 3.3), 10.7% (95% CI 9.6 to 11.9), and 16.2% (95% CI 14.5 to 17.9), respectively. Male sex (p < 0.001), younger age (p < 0.001), revision for septic indications (p < 0.001) or implant fracture (p = 0.010), a fixed hinge (p < 0.001), or surgery performed by a non-consultant grade (p = 0.023) were independently associated with an increased risk of re-revision. There were several factors associated with time to first revision. The re-revision rate was 16.2% at ten years; however, the risk factors associated with an increased risk of re-revision could be used to counsel patients regarding their outcome.Cite this article: Bone Joint J2023;105-B(1):47-55.