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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.

The aim of this study was to provide an overview of randomized controlled trials (RCTs) of surgical approaches in primary total hip arthroplasty (THA), summarizing the available high-quality evidence. Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, we performed the electronic searches in January 2021. We searched the Cochrane Central Register of Controlled Trials (2021, Issue 1), Ovid MEDLINE (including e-pub ahead of print, in-process, and other non-indexed citations, Ovid MEDLINE Daily, Ovid MEDLINE and Versions) (1946–January 20, 2021), and Embase (1980–January 20, 2021). We limited our search to English language literature. We excluded nonrandomized trials, trials on neck of femur fractures or revision surgery, systematic reviews, and meta-analyses. Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to the intervention groups. A total of 72 RCTs met the inclusion criteria. The total number of patients in those trials was 6,728. Only five RCTs (5.9%) reported significant differences between the intervention and the control groups. The largest subgroup of trials was minimally invasive versus standard techniques (18 RCTs) with no significant differences. Standard (lateral, posterior) approaches were compared in 23 RCTs with only 1 RCT reporting significant differences. Thirteen RCTs evaluated mini-incisions, with only 1 RCT reporting significant differences, and the remaining 18 RCTs evaluated variations of surgical approaches and interventions, with 3 RCTs reporting significant differences. The evidence reviewed indicates that for the vast majority of patients, a standard THA approach familiar to the surgeon leads to comparable outcomes. Level of evidence is II.

Aims Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost. Methods In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA. Results Cemented fixation had the lowest implant survival in all age groups, with a total ten-year survivorship of 97.0% (95% confidence interval (CI) 95.8 to 97.8) in the cemented group, 97.6% (95% CI 96.9 to 98.1) in the hybrid group, and 97.9% (95% CI 96.9 to 98.6) in the cementless group. This was not statistically significant (p = 0.092). There was no age group where cemented fixation outperformed hybrid or cementless fixation. Conclusion While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. We recommend that surgeons should carefully monitor their own outcomes and use fixation techniques that they are familiar with, and deliver the best outcomes in their own hands. Cite this article: Bone Joint J 2022;104-B(2):206–211.

The use of metaphyseal sleeves in revision total knee arthroplasty has gained popularity with numerous clinical series demonstrating excellent osseointegration and survivorship at medium- to long-term follow up. Once osseointegrated, sleeves provide excellent biological fixation and are difficult to remove. Here, we describe our surgical technique and sequence in removing metaphyseal sleeves in contemporary revision knee systems with case demonstrations.

Aims Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA). Methods Studies were identified by searching electronic databases: Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and Embase, from their inception to November 2020, for studies evaluating TKA patients with metal hypersensitivity/allergy. All studies reporting on diagnosing or managing metal hypersensitivity in TKA were included. Data were extracted and summarized based on study design, study population, interventions and outcomes. A practical guide is then formulated based on the available evidence. Results We included 38 heterogeneous studies (two randomized controlled trials, six comparative studies, 19 case series, and 11 case reports). The evidence indicates that metal hypersensitivity is a rare complication with some histopathological features leading to pain and dissatisfaction with no reliable screening tests preoperatively. Hypoallergenic implants are viable alternatives for patients with self-reported/confirmed metal hypersensitivity if declared preoperatively; however, concerns remain over their long-term outcomes with ceramic implants outperforming titanium nitride-coated implants and informed consent is paramount. For patients presenting with painful TKA, metal hypersensitivity is a diagnosis of exclusion where patch skin testing, lymphocyte transformation test, and synovial biopsies are useful adjuncts before revision surgery is undertaken to hypoallergenic implants with shared decision-making and informed consent. Conclusion Using the limited available evidence in the literature, we provide a practical approach to metal hypersensitivity in TKA patients. Future national/registry-based studies are needed to identify the scale of metal hypersensitivity, agreed diagnostic criteria, and management strategies. Cite this article: Bone Jt Open 2021;2(10):785–795.

Aims Single-stage revision total knee arthroplasty (rTKA) is gaining popularity in treating chronic periprosthetic joint infections (PJIs). We have introduced this approach to our clinical practice and sought to evaluate rates of reinfection and re-revision, along with predictors of failure of both single- and two-stage rTKA for chronic PJI. Methods A retrospective comparative cohort study of all rTKAs for chronic PJI between 1 April 2003 and 31 December 2018 was undertaken using prospective databases. Patients with acute infections were excluded; rTKAs were classified as single-stage, stage 1, or stage 2 of two-stage revision. The primary outcome measure was failure to eradicate or recurrent infection. Variables evaluated for failure by regression analysis included age, BMI, American Society of Anesthesiologists grade, infecting organisms, and the presence of a sinus. Patient survivorship was also compared between the groups. Results A total of 292 consecutive first-time rTKAs for chronic PJI were included: 82 single-stage (28.1%); and 210 two-stage (71.9%) revisions. The mean age was 71 years (27 to 90), with 165 females (57.4%), and a mean BMI of 30.9 kg/m2 (20 to 53). Significantly more patients with a known infecting organism were in the single-stage group (93.9% vs 80.47%; p = 0.004). The infecting organism was identified preoperatively in 246 cases (84.2%). At a mean follow-up of 6.3 years (2.0 to 17.6), the failure rate was 6.1% in the single-stage, and 12% in the two-stage groups. All failures occurred within four years of treatment. The presence of a sinus was an independent risk factor for failure (odds ratio (OR) 4.97; 95% confidence interval (CI) 1.593 to 15.505; p = 0.006), as well as age > 80 years (OR 5.962; 95% CI 1.156 to 30.73; p = 0.033). The ten-year patient survivorship rate was 72% in the single-stage group compared with 70.5% in the two-stage group. This difference was not significant (p = 0.517). Conclusion Single-stage rTKA is an effective strategy with a high success rate comparable to two-stage approach in appropriately selected patients. Cite this article: Bone Joint J 2021;103-B(8):1373–1379.

Background The aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients. Methods Retrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications. Results 15 patients included; 3 males and 12 females with median age 72 years (range 60–93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7–7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5–8), complete incorporation with cortical round-off was seen at median 12 months (range 8–48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection. Conclusions Use of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.

Aim to evaluate the role of preoperative magnetic resonance imaging (MRI) in assessing patients with a history of quiescent hip septic arthritis undergoing total hip arthroplasty. Materials and methods retrospective consecutive study of patients with previous history of septic arthritis who underwent MRI scans of their hips prior to primary hip arthroplasty surgery and who also had minimum 2 years follow up postoperatively. Detailed radiographic examinations were obtained, demographic and microbiological data collected. The primary outcome measure was whether a preoperative MRI scan had influenced the surgical decision-making and planning. Rate of recurrence of infection and complications was also collected at final follow up. Results sixteen patients with quiescent hip septic arthritis were included. There were 4 males and 12 females with average age at time of primary hip arthroplasty 51.7 years (range 22–75). Five patients had childhood septic arthritis with no documented microbiology data. Eleven patients had adult onset septic arthritis. In patients with childhood septic arthritis the MRI findings were similar to those with degenerative joint disease and had no added value to the routine surgical work up. MRIs of patients with adult onset septic arthritis showed persistent findings of effusion, marrow oedema and soft tissue oedema and had no added value to the surgical planning. All but one underwent single stage total hip arthroplasty. At final follow up, with average 4.6 years (range 2–8), none had a recurrence of infection. Conclusion In our experience, preoperative MRI scans did not influence the surgical decision making and are not recommended for routine practice in the surgical work up of quiescent septic arthritis prior to total hip arthroplasty.

Background Fracture fixation techniques of comminuted periprosthetic distal femoral fractures have high risk of complications. The aim of this study was to evaluate short- to medium-term outcomes of comminuted periprosthetic distal femoral fractures treated with distal femoral replacements (DFR) at a tertiary arthroplasty unit. Methods Retrospective consecutive study of all patients who underwent DFR for periprosthetic fractures with minimum 2-year follow-up between 2010 and 2018. Clinical outcomes, surgical complications, revision for any cause, loosening, Knee Society Score and mortality data were collected at final follow-up. Results Thirty patients with average age 81 years (range, 65-90; 6 males and 24 females) were included. All had comminuted fractures (Rorabeck type-2/3). All patients had cemented DFRs. Three patients (10%) with multiple comorbidities died postoperatively. Average time from admission to being fit for discharge was 9 days (range, 3-14). Clinical outcomes and follow-up were available for 27 patients with a median follow-up duration of 4 years (2-13 years). Complication rate was 7.4% with one reoperation, change of polyethylene insert. None of the components have been revised to date. Average Knee Society Score at final follow-up was 78 (range, 57-92) with median arc of motion flexion-extension being 100° (range, 60°-125°). Conclusions In our experience, DFRs for comminuted periprosthetic fractures allow immediate mobilization and rehabilitation leading to satisfactory clinical outcomes with low complication rate for this challenging group of patients. Level of evidence level IV.

Metaphyseal sleeves have become an integral part of surgeons’ armamentarium in dealing with complex revision knee arthroplasty. They offer the advantages of addressing bone defects with biological fixation techniques, efficient surgical preparation providing a stable tibial platform which optimises joint line positioning and gap balancing leading to excellent long-term survivorship and clinical outcomes. Here, we review the concept of metaphyseal fixation, indications of metaphyseal sleeves and their limitations with our surgical tips on how to remove well-fixed sleeves. We also present our tertiary experience and review clinical outcome studies of metaphyseal sleeves in revision knee arthroplasty literature.

Patella dislocation after primary or revision total knee arthroplasty (TKA) is a major challenge in revision surgery. In practice, the main reason for patella maltracking and instability following TKA is malrotation of the femoral and/or tibial components. A number of soft tissue procedures, once component malrotation is corrected, have been described including proximal realignment, quadricepsplasty and distal realignment of patellar tendon with tibial tubercle osteotomy. Here, we describe our modified surgical technique in managing chronically dislocated patellae in knee arthroplasty which comprises of extensive lateral releases, vastus medialis obliquus (VMO) advancement and soft tissue reconstruction of the extensor mechanism with accompanying three case presentations achieving satisfactory clinical outcomes.

Aims We report our early experience in acetabular reconstruction for significant bone loss and pelvic discontinuity using custom triflange acetabular components. Patients and methods Retrospective consecutive review of all patients treated at our specialist tertiary unit with significant acetabular defects (Paprosky 3A/3B) and pelvic discontinuity who were reconstructed with custom triflange implants. The primary outcomes were radiographic failure and complications. Results 17 patients (17 hips) were included; 3 males/14 females with a mean age of 72 years (range 61–83). The average follow-up was 3.6 years (2–7 years). Bony defects were Paprosky 3B in 13/17 hips (76%) with pelvic discontinuity encountered in the majority of cases 15/17 hips (88%) and intra-pelvic failed components in 11/17 (64%). At final follow up, no radiographic failures were observed although three patients developed complications (17.6%); haematoma requiring washout out; intra-operative ilium fracture; and recurrent dislocation in one patient. Conclusions Our experience suggest that acceptable outcomes can be achieved with custom implants for this group of challenging patients, although longer follow up is needed to monitor future implants’ failure.

AIM: to investigate the relationship between pain catastrophising and patient-reported clinical outcomes following primary total hip arthroplasty. MATERIALS AND METHODS: prospective consecutive study of 103 patients who completed preoperative Pain Catastrophisation Score (PCS), preoperative and 12-month postoperative Oxford Hip Score (OHS). Correlation analysis was carried out between the improvement in OHS (mean difference between pre- and postoperative scores) and the mean preoperative PCS score using the Pearson's r rank test. Multiple linear regression was then performed using the postoperative OHS as the outcome variable against a number of predictor variables. RESULTS: there were 37 males and 66 females with average age of 60.5 years (range 22–84). Mean preoperative PCS score was 16.3 (±13.6; range 0–49). Mean preoperative OHS was 16.5 (±3.5) which had improved at 12-months postoperatively to a mean 38.1 (±11.1). The difference was statistically significant (P

Background The aim of this study is to present our experience in managing fractured femoral stems over the last 10 years for both primary and revision stems at our tertiary unit focusing on modes of failure and operative techniques. Methods This is a retrospective consecutive study of all patients with fractured femoral stems that were operatively managed in our unit between 2008 and 2018. Detailed radiographic evaluation (Paprosky classification) was undertaken and data collected on operative techniques used to extract distal fractured stem fragments. Results Thirty-five patients (35 hips) were included (25 men/10 women) with average age at time of presentation of 68 years (range, 29-93). Average body mass index was 30 (standard deviation, 3.8; range, 22.5-39). There were variety of stems both contemporary and historical, primary and revision cases (15 hips polished tapered cemented stems, 10 hips composite beam and miscellaneous stems, and 10 revision hip stems). The predominant mechanism of failure was fatigue due to cantilever bending in distally fixed stems. Surgical techniques used to extract distal fragment were drilling technique in 2 hips, cortical window in 13 hips, extended trochanteric osteotomy (ETO) in 5 hips, and proximal extraction in 15 hips. Conclusion When faced with a contemporary fractured stem, drilling techniques into the distal fragment are unlikely to succeed. If a trochanteric osteotomy had been used at time of index surgery, this could be used again to aid proximal extraction with conventional revision instrumentations. The cortical window technique is useful but surgically demanding technique that is most successful in extracting polished tapered fractured stems particularly when an ETO is not planned for femoral reconstruction. Use of trephines can be useful for removal of longer, uncemented stems. Finally, an ETO might be necessary when other techniques have failed.

Femoroacetabular impingement is a cause of hip pain in young adults as a result of premature dynamic contact between the femur and acetabulum that occurs within the physiological range of hip motion. Diagnosis is made by patient history, clinical examination and radiographic findings. Cross-sectional imaging with computed tomography and magnetic resonance arthrography may be necessary in selected patients. Femoroacetabular impingement can be treated non-operatively with physiotherapist-led conservative care including analgesia and intra-articular steroid injections. Arthroscopic hip surgery aiming to restore pain-free functional range of movement and repair damaged labrum can help in selected patients with no pre-existing osteoarthritis. This review outlines the clinical assessment, investigations and management of femoroacetabular impingement in young adults.

To describe a surgical technique in correcting valgus deformity during total knee replacement and evaluate medium-term clinical outcomes. This was a retrospective consecutive series of total knee replacement for severe valgus deformity of patients who underwent a lateral ligament complex release with a sliver osteotomy of the lateral femoral condyle with a minimum 1-year follow-up and recording objective and patient-reported outcome measures. Twenty-three patients (25 knees) were included with median follow-up of 5 years (range 1–15 years) and average age 67.7 years (range 43–87). The primary diagnosis was osteoarthritis in 14 patients (61%) and inflammatory arthritis in 9 patients (39%). At final follow-up, the median mechanical tibiofemoral angle was restored to 4° (range 2–7) compared with a median valgus of 20° (range 13–30) preoperatively. This was statistically significant (P

In this review, we assess the effects of negative-pressure wound therapy (NPWT) following primary hip and knee replacement surgery with a systematic review of randomized controlled trials (RCTs). We searched the Cochrane Bone, Joint, and Muscle Trauma Group's Specialized Registry on June 12, 2018; the Cochrane Central Register of Controlled Trials (CENTRAL, 2018, Issue 1); Ovid MEDLINE (1946-2018); and Embase (1980-2018). To identify RCTs, we combined a subject-specific search strategy with a sensitivity-maximizing version of the Cochrane highly sensitive search strategy. Included were RCTs and quasi-RCTs that compare NPWT with other treatments or no treatment following primary hip and knee replacements. We excluded trials that were focused on patients undergoing revision hip or knee replacements or who had pathological bone disease or periprosthetic fractures. Five RCTs met the inclusion criteria and are included in this review, making a total of 382 patients with primary total hip/knee replacements. Included trials were of varying quality, with little consistency in control groups or outcome measures; therefore, a meta-analysis could not be performed. Overall, three RCTs reported no significant differences in primary outcomes after NPWT, in comparison to standard or conventional wound care. One trial reported significant reduction in wound seroma size in patients undergoing primary hip replacements after NPWT, compared to standard dressings (NPWT, 1.97 vs. 5.08 mL [p = 0.021]; n = 19). Finally, one trial that compared NPWT with standard dressings following primary hip/knee replacements (n = 209) reported statistically significant differences that favored NPWT for overall reduction in length of hospital stay (mean difference, 0.9 d, 95% confidence interval [CI], -0.2-2.5; p = 0.07), number of dressing changes (mean difference, 1.7; 95% CI, 0.8-2.5; p = 0.002), and a fourfold reduction in reported postoperative surgical wound complications (8.4% vs. 2.0%; p = 0.06). Cost-effectiveness quality adjusted life years showed greater savings for higher-risk patients (body mass index ≥ 35; ASA ≥ 3). We find no justification for applying NPWT to all postoperative wounds after routine total hip and knee replacement; however, NPWT may benefit selected patients who are at high risk for wound complications.

Background We aimed to evaluate the outcomes of hybrid fixation technique in condylar revision total knee arthroplasty (rTKA) using cementless metaphyseal tibial sleeves and short-cemented femoral stems with a rotating platform articulation. Methods Retrospective consecutive study of all condylar rTKAs with a cemented femoral stem between 2009 and 2016 was conducted. Patients were identified using a local prospective database and linkable data obtained from the National Joint Registry for rTKA. Demographic, clinical, and surgical data were collected from patients’ electronic health records. The primary outcome measure was mechanical failure and implant survivorship using a nationally collected data, complications, re-operations, and “any-cause revision” were also recorded. Results There were 72 consecutive patients (72 knees) with minimum 5-year follow-up: 33 (45.8%) females and 39 (54.2%) males with a median age of 70 years (range 47-88). The indication for revision surgery was aseptic loosening (n = 34, 47.2%), instability (n = 17, 23.6%), infection (n = 14, 19.5%) with 10 patients having 2-stage approach and 4 patients with single-stage approach, stiffness (n = 4, 5.6%), and malalignment (n = 3, 4.1%). At mean follow-up of 6.87 years (median 6.7; range 5-11.8), only 2 patients required revision for infection. Using “any-cause implant revision” as an end point, implant survivorship for this construct was 97.2% at median 6.7 years. To date, none of the femoral stems have been revised for mechanical failure. Conclusion In rTKA with good femoral condylar bone stock, we have shown excellent survivorship with a short-cemented femoral stem, in conjunction with a mobile-bearing and a tibial sleeve. This has the advantage of reducing the length of the revision construct of this complex surgery. Level of Evidence Level IV.

Background S-ROM hip is a well-established and versatile prosthesis that offers extensive metaphyseal and diaphyseal geometries providing solutions for a variety of surgical scenarios. The aim of this study is to report on long-term survivorship and radiographic outcomes of complex primary total hip arthroplasty (THA) using a modular cementless stem (S-ROM). Methods Retrospective consecutive study was conducted of 167 patients (167 hips): 97 males and 70 females with average age at the time of surgery of 55 years (range 22-76). All patients underwent complex THA by the senior author from 1987 to 1999. Patients were identified using a prospective database. Demographic, clinical, and surgical data were collected from health records. All patients received a cementless acetabular component with a standard polyethylene liner. The primary outcome measure was survivorship beyond 15 years using stem revision for any cause as an end point. Secondary outcome measure was rate of radiographic loosening using Engh classification. Results Only 3 patients required stem revision for aseptic loosening and 1 for periprosthetic fracture. Isolated acetabular revision was undertaken in 23 of 167 patients (13.8%) due to polythene wear, osteolysis, and aseptic loosening. Proximal femoral stress shielding (zone 1, 7) was noted in 34 of 167 hips (20.4%). Stable bony ingrowth was noted in 144 hips (86.2%) and the remaining 23 hips had stable fibrous ingrowth (13.8%). Using stem “any-cause revision” as an endpoint, the mean stem survivorship was 31.5 years (95% confidence interval 31.007-31.985) with 30-year estimated survivorship of 97.6%. Conclusion In a single designer surgeon series, S-ROM stem has stood the test of time with long-term, 30-year survivorship of 97.6% and continues to play an important role in modern hip surgery providing longevity and versatility. However, further comparative long-term studies from independent centers are needed for a definitive conclusion. Level of Evidence IV.

Failure of the extensor mechanism is a debilitating complication with significant limitation on patients’ function and quality of life. Allograft reconstruction in selected patients restores function with good outcomes. This chapter discusses the challenges of managing extensor mechanism failure in revision knee surgery and we describe our surgical technique in allograft extensor mechanism reconstruction with case demonstrations.

The principles and concepts of managing periprosthetic joint infection rTKA are well-established. Early intervention in acute infections with thorough debridement and modular exchange is preferred. Patient selection, meticulous surgical debridement, and targeted antibiotic treatment in conjunction with a specialist microbiologist are the most important factors to ensure success in managing chronic PJI in either a single- or two-stage strategy. This chapter focuses on the practical aspects of managing infection in revision knee surgery and present our recent tertiary experience.

Chronic patella dislocation after primary or revision TKA is a major challenge in revision surgery. This chapter describes a surgical technique which had been developed based on the biomechanical principles of changing the vector force to centralise the patella and further reinforced by a viable dynamic vastus medialis obliquus (VMO) stabiliser to ensure durability and a sustained outcome with practical tips and case demonstration.

Periprosthetic distal femoral fractures are the most common around the knee and are expected to increase with the exponential growth of TKA. For acute comminuted fractures, the use of distal femoral replacements leads to satisfactory clinical outcomes with an acceptable complication rate for this challenging group of patients. Meticulous preoperative planning is crucial with appropriate surgical skills in using endoprostheses. This strategy offers patients immediate mobilisation with the ability to fully weight-bear which helps to reduce perioperative medical complications. This chapter discusses the management of periprosthetic knee fractures from an arthroplasty perspective using massive endoprostheses.

Primary total knee arthroplasty is an effective and successful operation that has helped millions of patients worldwide. Over the last few decades, significant advances in our understanding of knee kinematics, implant designs and manufacturing processes have helped to ensure improved outcomes and longevity of knee arthroplasty. Despite its proven success, a significant proportion of patients remain dissatisfied with their knees. In this chapter, we will discuss our surgical philosophy in primary TKA, reverting to first principles and discussing some contentious contemporary variations in practice.

One of the main pillars of a durable revision knee construct is implant fixation. Stemmed components are used in most revision cases. Adjunctive fixation is also needed in cases of bone loss and a compromised epiphysis where surface cementation is not enough to support the implants. In this chapter, we focus on the philosophies of different fixation techniques and our preferred approach to not only achieve durable fixation but also to help in joint reconstruction by the use of tibial metaphyseal sleeves to reliably establish a stable tibial platform with the frame principle.

The common indications for rotating-hinge implants in revision knee practice are soft tissue failure; posterior capsule, MCL and significant complex bone loss. They are also part of segmental bone replacing prostheses, either as a distal femoral replacement or using massive augments to fill in major bone defects. They also play a role in complex primary cases. Contemporary hinge implants have seen improved outcomes and survivorship since the introduction of the rotating-hinge mechanism. However, common complications with hinges remain high with early loosening and patellofemoral issues. This chapter focuses on the practical aspects of hinge implants and their kinematics to avoid common hinge-related complications.

Despite its success and durability, about 20% of patients report unfavourable outcomes following their TKA. This is multifactorial with ongoing knee pain, limited function, and failure to meet preoperative expectations being the issues most likely to result in dissatisfaction. A systematic approach to evaluating problematic knees is essential to ascertain whether a revision surgery, a major undertaking, would solve the patient’s problems. In this chapter, we try to shed light on some practical aspects of evaluating patients presenting to revision knee clinics.

Revision knee arthroplasty is a major undertaking for most patients, particularly septic revisions which carry a high morbidity and mortality. In a large cohort of rTKA cases at our tertiary centre, the 10-year survivorship of septic revisions was 68.7 and 80.2% for aseptic revisions. These findings have important practical implications as these outcomes are comparable to those that we see in some cancer patients; the risk of mortality following septic rTKA is higher than that of some of the most common cancers. This reality should be highlighted in candid discussions when counselling patients not only at time of revision surgery, when patients have little choice when infection has already developed, but more importantly at time of primary TKA, particularly for those patients who are at higher risk for developing periprosthetic joint infection. This chapter focuses on long-term mortality in revision knee patients, particularly focusing on septic versus aseptic revisions.

Orthoplastic rTKA cases are challenging and should be managed closely with plastic reconstructive surgeons within a multidisciplinary team approach. Infrapatellar soft tissue defects are the most commonly encountered ones in rTKA practice. These defects are amenable to a pedicled medial gastrocnemius flap. This is commonly done by transposing the flap, as a muscle-only flap, necessitating a combined split-thickness skin graft. This chapter focuses on managing soft tissue defects in rTKA practice particularly in the presence of infection.

Complex primary total knee arthroplasty includes a variety of clinical scenarios with either compromised surrounding soft tissues, deformity, or lack of suitable bone for fixation. In this chapter, we will provide some tips and lessons that we have learnt over years of practice dealing with complex and unusual cases with some common themes and basic principles that would apply to most complex cases including deformities, previous fractures, previous patellectomy, revising unicompartmental knees and the use of patient-specific instrumentation and primary hinge implants, among others.

There are varying indications to revise a poorly performing TKA. Understanding why a knee is not functioning well and being able to fix the problem is an essential prerequisite before embarking on revision surgery. This chapter focuses on some of the contemporary indications for revision providing a summary of our practical experience and views on the current challenges in rTKA.

The aim of revision surgery is to deliver near-normal knee kinematics in the presence of a compromised bone stock and a compromised soft tissue envelope as a result of the original failure or repeated operations. Constrained implants are often used to provide the stability needed. In this chapter focuses on the practical implications of constraint in rTKA in the context of instability, particularly the kinematics of condylar revision implants, the role of varus valgus constraint and its impact on fixation interfaces as we as the role of mobile bearings.

The demand for salvage surgery is increasing, with more and more patients coming to their third or fourth revision in a situation with increasing bone loss. Traditionally, salvage options rely on allograft-prosthetic composite techniques, the use of massive endoprostheses which are currently the most commonly used option, implant-arthrodesis techniques and amputation. This chapter focuses on the practical aspects of salvage revision surgery, particularly the use of massive endoprostheses, and presents our tertiary experience with case demonstrations.

In revision knee surgery, adequate exposure to the knee joint is crucial for the safe removal of components, scar tissue, protecting important structures, and minimising iatrogenic complications of bone loss or extensor mechanism injury. In this chapter, we describe our approach to surgical exposure in revision knees particularly focusing on our technique of getting extensile exposure through a tibial crest osteotomy.

The principles of joint reconstruction in condylar revision knee arthroplasty are similar to that of a primary arthroplasty, with a balanced approach relying on a stable tibial platform and intact collaterals with the frame principle. In this chapter, we discuss the principles of surgical reconstruction and discuss the use of a balanced approach for an efficient and reproducible workflow in revision knee practice.

The safe removal of implants with minimal bone loss is a crucial step in revision knee surgery and it paves the way for an efficient and successful reconstruction. While most revised primary knees are cemented implants that require certain techniques for removal, cementless knees, revision components and metaphyseal sleeves or cones for adjunctive fixation are used more commonly and certain techniques are needed to extract those implants safely. In this chapter we describe our practical approach and tips to successful implant removals in revision surgery with the overarching principle that patience is indeed a virtue.