Aims

The aim of this consensus was to develop a definition of post-operative fibrosis of the knee.

Introduction

Due to the predictability of outcomes achieved with reverse shoulder arthroplasty (rTSA), rTSA is increasingly being used in patients where glenoid fixation is compromised due to presence of glenoid wear. There are various methods to achieve glenoid fixation in patients with glenoid wear, including the use of bone grafting behind the glenoid baseplate or the use of augmented glenoid baseplates. This clinical study quantifies clinical outcomes achieved using both techniques in patients with severe glenoid wear at 2 years minimum follow-up.

At first-stage revision surgery for infection of total knee arthroplasties, antibiotic-impregnated cement spacers are frequently implanted. Two types of cement spacers are commonly used, “static” and “articulating” cement spacers. Advocates of cement spacers state that they deliver high doses of antibiotics locally, increase patient comfort, allow mobility and provide joint stability. They also minimize contracture of collateral ligaments, thereby facilitating re-implantation of a definitive prosthesis at a later stage. The use of these cement spacers, however, are not without significant complications, including patella tendon injuries.

We describe a series of three patients who sustained patella tendon injuries in infected total knee arthroplasties following the use of a static cement spacer at first-stage knee revision.

The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12–20

Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used, we recommend that they should be keyed in the bone to prevent patella tendon injuries.

Honey has been used as a topical antiseptic for at least 5,000 years. SurgiHoney is a CE licensed sterile product, which has been proven to be non-toxic and effective when used topically in the treatment of chronically infected wounds. The key difference from other medical grade honey is the broad spectrum antimicrobial characteristics with activity against Gram +ve, Gram –ve and multi-resistant organisms. Its novel role against the bacterial bioburden and biofilm associated with periprosthetic infections around total knee arthroplasties (TKA's) is therefore considered.

SurgiHoney was used as an implant coating immediately prior to wound closure after implantation of salvage endoprosthesis for multiply revised, infected TKA's undergoing staged reconstruction.

We report a consecutive series of multi-revised, infected revision TKA's where SurgiHoney was used as an active antimicrobial coating. We discuss its intra-operative application and early clinical outcomes.

The use of Surgihoney as a novel anti-microbial is established in the management of complex wound infections. This is the first reported use of SurgiHoney as a deep, implant coating in the salvage of prosthetic joint infection.

Joint degeneration may make a total knee arthroplasty (TKA) a requirement for pain relief and function. However, the presence of ipsilateral limb osteomyelitis (OM) makes surgical management extremely challenging.

We report the experience of a high volume revision knee surgeon managing ipsilateral limb multi resistant OM and the outcome of subsequent TKA.

Four consecutive patients were identified who had either ipsilateral femoral or tibial chronic osteomyelitis treated prior to undergoing TKA. Surgery to eradicate the osteomyelitis involved a Lautenbach compartmental debridement, and where necessary, healing by secondary intention. The decision to proceed to a TKA was based on history, clinical examination and radiological findings of advanced osteoarthritic change.

The patients had a mean age of 50 years. They had a background of multi-organism OM and underwent single-stage TKAs at an average of 63 months following eradication of the underlying OM.

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 results for the four cases are summarised in Table 1.

We have highlighted that patients with ipsilateral limb multi resistant OM are a difficult cohort to manage.

A common step to revision surgery for infected total knee replacement (TKR) is a thorough debridement. Whilst surgical and mechanical debridement are established as the gold standard, we investigate a novel adjuvant chemical debridement using an Acetic Acid (AA) soak that seeks to create a hostile environment for organisms, further degradation of biofilm and death of the bacteria.

We report the first orthopaedic in vivo series using AA soak as an intra-operative chemical debridement agent for treating infected TKR's. We also investigate the in vitro efficacy of AA against bacteria isolated from infected TKR's.

A prospective single surgeon consecutive series of patients with infected TKR were treated according to a standard debridement protocol. Patients in the series received sequential debridement of surgical, mechanical and finally chemical debridement with a 10 minute 3% AA soak.

In parallel, we isolated, cultured and identified bacteria from infected TKR's and assessed the in vitro efficacy of AA. Susceptibility testing was performed with AA solutions of different concentrations as well as with a control of a gentamicin sulphate disc. The effect of AA on the pH of tryptone soya was also monitored in an attempt to understand its potential mechanism of action.

Physiological responses during the AA soak were unremarkable. Intraoperatively, there were no tachycardic or arrythmic responses, any increase in respiratory rate or changes in blood pressure. This was also the case when the tourniquet was released. In addition, during the post-operative period no increase in analgesic requirements or wound complications was noted. Wound and soft tissue healing was excellent and there have not been any early recurrent infections at mean of 18 months follow up.

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 clinical isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19%v/v.

This study has shown that the use of 3% AA soak, as part of a debridement protocol, is safe. Whilst the exact mechanism of action of acetic acid is yet to be determined, we have demonstrated that concentrations as low as 0.19%v/v in solution in vitro is sufficient to completely inhibit bacterial growth from infected TKR's.

Obtaining primary wound healing in Total Joint Arthroplasty (TJA) is essential to a good result. Wound healing problems can occur and the consequences can be devastating to the patient and to the surgeon. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as Type A: no healing compromises and Type B: systemic or local healing compromises factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphedema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immunocompromise, steroids, smoking, and poor nutrition. In high risk situations the surgeon should encourage positive patient choices such as smoking cessation and nutritional supplementation to elevate the total lymphocyte count and total albumin.

Careful planning of incisions, particularly in patients with scarring or multiple previous operations, is productive. Around the knee the vascular viability is better in the medial flap. Thusly, use the most lateral previous incision, do minimal undermining, and handle tissue meticulously. We do all potentially complicated TKAs without tourniquet to enhance blood flow and tissue viability. The use of peri-operative anticoagulation will increase wound problems.

If wound drainage or healing problems do occur immediate action is required. Deep sepsis can be ruled out with a joint aspiration and cell count [less than 2500], differential [less than 60% polys], and negative culture and sensitivity. All hematomas should be evacuated and necrosis or dehiscence should be managed by debridement to obtain a live wound.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation.

The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic: Nerve damage; Altered hemodynamics with limb exsanguinations (15–20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3× greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances.

Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-operative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation; avoid IR of the femoral and ER of the tibial components; maintain correct joint line position; achieve symmetrical soft tissue balance.

Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilization of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues.

When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall Procedure).

Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation.

The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic - Nerve damage; Altered hemodynamics with limb exsanguinations (15‐20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances.

Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less postoperative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Revision knee arthroplasty presents a number of challenges, not least of which is obtaining solid primary fixation of implants into host bone. Three anatomical zones exist within both femur and tibia which can be used to support revision implants. These consist of the joint surface or epiphysis, the metaphysis and the diaphysis. The methods by which fixation in each zone can be obtained are discussed. The authors suggest that solid fixation should be obtained in at least two of the three zones and emphasise the importance of pre-operative planning and implant selection.

Cite this article: Bone Joint J 2015;97-B:147–9.

Summary

This study shows a significant reduction in knee adduction moment in patients with medial compartment osteoarthritis, in both the symptomatic and asymptomatic knees. Long-term follow-up studies are required to confirm the effect of treating the asymptomatic side on disease progression.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation.

The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic.

Nerve damage

Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-op pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Infection after total knee arthroplasty poses formidable challenges to the surgeon. Once an infection is diagnosed, the identification of the organism and its sensitivity to antibiotics is essential. The host's healing capacity is vital. Optimisation of modifiable comorbidities, supplemental nutrition and cessation of smoking can improve wound healing. Surgical goals include debridement of necrotic tissue and elimination of the dead space. Intravenous antibiotics and a two-stage protocol are the standard of care. At our institution, the first stage is performed with an implant and antibiotic-cement composite. This articulating spacer maintains limb length and tissue compliance. The patient can maintain a functional status between stages. Definitive reconstruction is more readily accomplished with this method in contrast to the static spacer approach. The clinical efficacy of this protocol has been well documented in the literature.

Arthroscopic intervention for early symptoms of arthrosis of the knee was a well-established procedure until Moseley cited his study showing no difference in outcomes when compared to “sham” surgery. Now there is no opportunity for reimbursement with arthroscopic debridement unless mechanical internal derangement can be documented. There are, however, several specific lesions of arthrosis which respond well to arthroscopic intervention and are reimbursed by third party payers.

Arthroscopic three compartment microfracture with non-weight bearing and passive motion for eight weeks post- op has significantly relieved symptoms. Second look biopsies have confirmed type II hyaline cartilage and increased joint interval. Proper patient selection is paramount and guidelines will be discussed.

Isolated severe patellofemoral arthrosis with patella subluxation responds to arthroscopic patella lateral facetectomy. Jones has reported significant pain relief up to two years with this excellent option for a difficult patient problem. The technique and results will be presented in detail.

Loss of terminal extension in the arthritic knee can accelerate deterioration and force earlier decision for TKA. Parson's third tubercle is an osteophyte that forms just anterior to the ACL insertion on the tibia and is the frequent cause of extension loss. Arthroscopic resection of the tubercle results in increased extension and diminishes the stress concentration assuring better longevity for the native knee. The diagnostic characteristics, resection techniques and results of the Dallas series will be presented.

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation, avoid IR of the femoral and ER of the tibial components, maintain correct joint line position, and achieve symmetrical soft tissue balance

Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilisation of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues.

When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall Procedure).

Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function.

Bone loss in the proximal tibia and distal femur is frequently encountered in revision knee replacement surgery. The various options for dealing with this depend on the extent of any bone loss. We present our results with the use of cementless metaphyseal metal sleeves in 103 patients (104 knees) with a mean follow-up of 43 months (30 to 65). At final follow-up, sleeves in 102 knees had good osseointegration. Two tibial sleeves were revised for loosening, possibly due to infection.

The average pre-operative Oxford Knee Score was 23 (11 to 36) and this improved to 32 (15 to 46) post-operatively. These early results encourage us to continue with the technique and monitor the outcomes in the long term.

Cite this article: Bone Joint J 2013;95-B:1640–4.

This article provides an overview of the role of genomics in sarcomas and describes how new methods of analysis and comparative screening have provided the potential to progress understanding and treatment of sarcoma. This article reviews genomic techniques, the evolution of the use of genomics in cancer, the current state of genomic analysis, and also provides an overview of the medical, social and economic implications of recent genomic advances.

Obtaining primary wound healing in Total Joint Arthroplasty (TJA) is essential to a good result. Wound healing problems can occur and the consequences can be devastating to the patient and to the surgeon. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as Type A: no healing compromises and Type B: systemic or local healing compromises factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphedema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immune compromise, steroids, smoking, and poor nutrition. In high risk situations the surgeon should encourage positive patient choices such as smoking cessation and nutritional supplementation to elevate the total lymphocyte count and total albumin.

Careful planning of incisions, particularly in patients with scarring or multiple previous operations, is productive. Around the knee the vascular viability is better in the medial flap. Thus, use the most lateral previous incision, do minimal undermining, and handle tissue meticulously. We do all potentially complicated TKAs without tourniquet to enhance blood flow and tissue viability. The use of perioperative anticoagulation will increase wound problems.

If wound drainage or healing problems do occur immediate action is required. Deep sepsis can be ruled out with a joint aspiration and cell count, and negative culture and sensitivity. All hematomas should be evacuated and necrosis or dehiscence should be managed by debridement to obtain a live wound. Options available for coverage of complex wound problems include myocutaneous flaps, pedicled skin flaps, and skin grafts. Wet, occlusive dressings and wound VACs encourage epithelisation of chronic wounds.