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1.  Results of 32 Allograft-prosthesis Composite Reconstructions of the Proximal Femur 
The use of allograft-prosthesis composites for reconstruction after bone tumor resection at the proximal femur has generated considerable interest since the mid1980s on the basis that their use would improve function and survival, and restore bone stock. Although functional improvement has been documented, it is unknown whether these composites survive long periods and whether they restore bone stock. We therefore determined long-term allograft-prosthesis composite survival, identified major complications that led to revision, and determined whether allograft bone stock could be spared at the time of revision. We also compared the radiographic appearance of allografts sterilized by gamma radiation and fresh-frozen allografts. We retrospectively reviewed 32 patients with bone malignancy in the proximal femur who underwent reconstruction with a cemented allograft-prosthesis composite. The allograft-prosthesis composite was a primary reconstruction for 23 patients and a revision procedure for nine. The minimum followup was 2 months (median, 68 months; range, 2–232 months). The cumulative incidence of revision for any reason was 14% at 5 years (95% confidence interval, 1%–28%) and 19% at 10 years (95% confidence interval, 3%–34%). Nine patients (28%) had revision of the reconstruction during followup; four of these patients had revision surgery for infection. Allografts sterilized by gamma radiation showed worse resorption than fresh-frozen allografts. Based on reported results, allograft-composite prostheses do not appear to improve survival compared with megaprostheses.
Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-1132-z
PMCID: PMC2816772  PMID: 19851817
2.  10-year results following impaction bone grafting of major bone defects in 29 rotational and hinged knee revision arthroplasties 
Acta Orthopaedica  2013;84(4):387-391.
Background and purpose
— Substantial bone loss in revision total knee arthroplasty (TKA) is a challenging problem. We studied whether impaction bone grafting provides long-term restoration of bone stock in the treatment of major bone defects in revision surgery of rotational and hinged knee arthroplasties (LINK Endo-Model).
Patients and methods
— Between 1996 and 2006, 29 knees in 29 patients underwent revision procedures of rotational and hinged knee arthroplasties using impaction bone grafting (IBG) to reconstruct major bone defects. At the latest follow-up, the clinical examination included the Knee Society score (KSS), standardized radiographs, and a questionnaire for the WOMAC score.
Results
— After a mean follow-up of 10 (6–13) years, 14 knees with 19 IBG reconstructions (5 total, 9 partial revisions) had failed. 12 knees were treated with re-revision surgery mean 5 (1–12) years after the first revision, due to mechanical failure and aseptic loosening of the components. In all these failed cases, the surgeon observed a lack of incorporation with bone graft resorption in the femur or tibia during the re-revision procedure. In all 15 knees that were not re-revised, with 21 reconstructions (6 total, 9 partial revisions), an improvement in the combined KSS score (knee score + function score) of 60 points (p < 0.001) was found at the latest follow-up. In 12 of these knees, a clear incorporation with no visible radiolucent lines around the component and no sign of substantial graft resorption was noted, while unclear radiographic graft incorporation was seen in 3 knees.
Interpretation
— Our results clearly indicate that IBG alone is not a methodologically sound technique in the revision of rotational and hinged knee arthroplasties.
doi:10.3109/17453674.2013.814012
PMCID: PMC3768039  PMID: 23799350
3.  Total Knee Arthroplasty for Post-Traumatic Proximal Tibial Bone Defect: Three Cases Report 
Bone stock deficiency in primary as well as in revision total knee arthroplasty (TKA) represents a difficult problem to surgeon with regard to maintaining proper alignment of the implant components and in establishing a stable bone-implant interface. Different surgical procedures are available in these situations, for instances the use of bone cement, prosthetic augments, custom implant, and wire mesh with morsellized bone grafting and structural bone allograft. Structural allograft offers a numerous advantages as easy remodeling and felling cavitary or segmental defects, excellent biocompatibility, bone stock restoration and potential for ligamentous reattachment. In this article we report a short term result of three cases affected by severe segmental medial post/traumatic tibial plateau defect in arthritic knee, for which massive structural allograft reconstruction and primary total knee replacement were carried. The heights of the bone defect were between 27-33 mm and with moderate medio-lateral knee instability. Pre-operative AKS score in three cases was 30, 34 and 51 points consecutively and improved at the last follow-up to 83, 78 and 85 consecutively. No acute or chronic complication was observed. Last radiological exam referred no signs of prosthetic loosening, no secondary resorption of bone graft and well integrated graft to host bone. These results achieved in our similar three cases have confirmed that the structural bone allograft is a successful biological material to restore hemi-condylar segmental tibial bone defect when total knee replacement is indicated.
doi:10.2174/1874325001105010143
PMCID: PMC3093746  PMID: 21584202
Tibial bone defect; structural allograft; total knee arthroplasty.
4.  Revision Surgery for Patellofemoral Problems: Should We Always Resurface? 
Background
Routine patellar resurfacing performed at the time of knee arthroplasty is controversial, with some evidence of utility in both TKA (tricompartmental) and bicompartmental knee arthroplasty. However, whether one approach results in better implant survival remains unclear.
Questions/purposes
We asked whether (1) routine patellar resurfacing in TKAs resulted in lower cumulative revision rates compared to bicompartmental knee arthroplasties, (2) patella-friendly implants resulted in lower cumulative revision rates than earlier designs, and (3) bicompartmental knee arthroplasties revised to TKAs had higher cumulative revision rates than primary TKAs.
Patients and Methods
From a community-based joint registry, we identified 8135 patients treated with 9530 cemented, all-polyethylene patella TKAs and 627 bicompartmental knee arthroplasties without patellar resurfacing. We compared age, gender, year of index procedure, diagnosis, cruciate status, revision, and revision reason.
Results
TKAs had a lower cumulative revision rate for patella-only revision than bicompartmental knee arthroplasties (0.8% versus 4.8%). Adjusting for age, bicompartmental knee arthroplasties were 6.9 times more likely to undergo patellar revision than TKAs. There was no difference in the cumulative revision rate for patella-only revisions between patella-friendly and earlier designs. The cumulative revision rate for any second revision after a patella-only revision was 12.7% for bicompartmental knee arthroplasties while that for primary TKAs was 6.3%.
Conclusions
Bicompartmental knee arthroplasties had higher revision rates than TKAs. Femoral component design did not influence the cumulative revision rate. Secondary patella resurfacing in a bicompartmental knee arthroplasty carried an increased revision risk compared to resurfacing at the time of index TKA. To reduce the probability of reoperation for patellofemoral problems, our data suggest the patella should be resurfaced at the time of index surgery.
Level of Evidence
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-011-2036-2
PMCID: PMC3237992  PMID: 21858641
5.  Revision Rates after Primary Hip and Knee Replacement in England between 2003 and 2006 
PLoS Medicine  2008;5(9):e179.
Background
Hip and knee replacement are some of the most frequently performed surgical procedures in the world. Resurfacing of the hip and unicondylar knee replacement are increasingly being used. There is relatively little evidence on their performance. To study performance of joint replacement in England, we investigated revision rates in the first 3 y after hip or knee replacement according to prosthesis type.
Methods and Findings
We linked records of the National Joint Registry for England and Wales and the Hospital Episode Statistics for patients with a primary hip or knee replacement in the National Health Service in England between April 2003 and September 2006. Hospital Episode Statistics records of succeeding admissions were used to identify revisions for any reason. 76,576 patients with a primary hip replacement and 80,697 with a primary knee replacement were included (51% of all primary hip and knee replacements done in the English National Health Service). In hip patients, 3-y revision rates were 0.9% (95% confidence interval [CI] 0.8%–1.1%) with cemented, 2.0% (1.7%–2.3%) with cementless, 1.5% (1.1%–2.0% CI) with “hybrid” prostheses, and 2.6% (2.1%–3.1%) with hip resurfacing (p < 0.0001). Revision rates after hip resurfacing were increased especially in women. In knee patients, 3-y revision rates were 1.4% (1.2%–1.5% CI) with cemented, 1.5% (1.1%–2.1% CI) with cementless, and 2.8% (1.8%–4.5% CI) with unicondylar prostheses (p < 0.0001). Revision rates after knee replacement strongly decreased with age.
Interpretation
Overall, about one in 75 patients needed a revision of their prosthesis within 3 y. On the basis of our data, consideration should be given to using hip resurfacing only in male patients and unicondylar knee replacement only in elderly patients.
Jan van der Meulen and colleagues show that about one in 75 patients with a primary hip or knee replacement needed a revision of their prosthesis within 3 years.
Editors' Summary
Background.
Though records show attempts to replace a hip date back to 1891, it was not till the 1960s before total hip replacements were successfully performed, and the 1970s before total knee replacements were carried out. These procedures are some of the most frequently performed surgical operations, with a total of 160,00 total hip and knee replacement procedures carried out in England and Wales and about half a million in the US in 2006. Hip and knee replacements are most commonly used as a treatment for severe arthritis once other approaches, such as pain relief medications, have failed. A total hip replacement involves replacing the head of the femur (the thigh bone) with an artificial component, typically metal; the socket into which the new femur head will insert is also replaced with artificial components. In an alternative procedure, resurfacing, rather than replacing the entire joint, the diseased surfaces are replaced with metal components. This procedure may be better suited to patients with less severe disease, and is also thought to result in quicker recovery. The techniques for hip and knee replacement can also be divided into those where a cement is used to position the metal implant into the bone (cemented) versus those where cement is not used (cementless).
Why Was This Study Done?
To date, little evidence has been available to compare patient outcomes following hip or knee replacement with the many different types of techniques and prostheses available. National registries have been established in a number of countries to try to collect data in order to build the evidence base for evaluating different types of prosthesis. Specifically, it is important to find out if there are any important differences in revision rates (how often the hip replacement has to be re-done) following surgery using the different techniques. In England and Wales, the National Joint Registry (NJR) has collected data on patient characteristics, types of prostheses implanted, and the type of surgical procedures used, since its initiation in April 2003.
What Did the Researchers Do and Find?
The researchers linked the records of the NJR and the Hospital Episode Statistics (HES) for patients treated by the NHS in England who had undergone a primary hip and knee replacement between April 2003 and September 2006. The HES database contains records of all admissions to NHS hospitals in England, and allowed the researchers to more accurately identify revisions of procedures that were done on patients in the NJR database.
They identified 327,557 primary hip or knee replacement procedures performed during that time period, but only 167,076 could be linked between the two databases.
76,576 patients in the linked database had undergone a primary hip replacement. The overall revision rate was 1.4% (95% confidence interval [CI] 1.2%–1.5%) at 3 years, with the lowest revision rates experienced by patients who had cemented prostheses. Women were found to have higher revision rates after hip resurfacing, and the revision rate was about twice as high in patients who had had a hip replacement for other indications than osteoarthritis. A patient's age did not appear to affect revision rates after hip surgery.
80,697 patients in the linked database had undergone a primary knee replacement. The overall revision rate was 1.4% (95% CI 1.3%–1.6%) at three years, again with the lowest rates of replacement experienced by patients who had cemented prostheses. Revision rates after knee replacement strongly decreased with age.
What Do These Findings Mean?
Overall, about one in 75 patients required a revision of their joint replacement, which is considered low, and cemented hip or knee prosthesis had the lowest revision rates. Post hip replacement, the highest revision rate was in patients who had undergone hip resurfacing, especially women. Following knee replacement, the highest revision rate was in patients who had undergone unicondylar prosthesis. However, in this study patients were only followed up for three years after the initial knee replacement, and it's possible that different patterns regarding the success of these differing techniques may emerge after longer follow-up. Importantly, this study was entirely observational, and data were collected from patients who had been managed according to routine clinical practice (rather than being randomly assigned to different procedures). Substantial differences in the age and clinical characteristics of patients receiving the different procedures were seen. As a result, it's not possible to directly draw conclusions on the relative benefits or harms of the different procedures, but this study provides important benchmark data with which to evaluate future performance of different procedures and types of implant.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050179.
The website of the British Orthopaedic Association contains information for patients and surgeons
The website of the National Institute for Health and Clinical Excellence contains guidance on hip prostheses
Information is available from the US National Institutes of Health (Medline) on hip replacement, including interactive tutorials and information about rehabilitation and recovery
Medline also provides similar resources for knee replacement
The NHS provides information for patients on hip and knee replacement, including questions patients might ask, real stories, and useful links
The National Joint Registry provides general information about joint replacement, as well as allowing users to download statistics on the data it has collected on the numbers of procedures carried out in the UK
doi:10.1371/journal.pmed.0050179
PMCID: PMC2528048  PMID: 18767900
6.  Causes, Risk Factors, and Trends in Failures After TKA in Korea Over the Past 5 Years: A Multicenter Study 
Background
Failure after total knee arthroplasty (TKA) may be related to emerging technologies, surgical techniques, and changing patient demographics. Over the past decade, TKA use in Korea has increased substantially, and demographic trends have diverged from those of Western countries, but failure mechanisms in Korea have not been well studied.
Questions/purposes
We determined the causes of failure after TKA, the risk factors for failure, and the trends in revision TKAs in Korea over the last 5 years.
Methods
We retrospectively reviewed 634 revision TKAs and 20,234 primary TKAs performed at 19 institutes affiliated with the Kleos Korea Research Group from 2008 to 2012. We recorded the causes of failure after TKA using 11 complications from the standardized complication list of The Knee Society, patient demographics, information on index and revision of TKAs, and indications for index TKA. The influences of patient demographics and indications for index TKA on the risk of TKA failure were evaluated using multivariate regression analysis. The trends in revision procedures and demographic features of the patients undergoing revision TKA over the last 5 years were assessed.
Results
The most common cumulative cause of TKA failure was infection (38%) followed by loosening (33%), wear (13%), instability (7%), and stiffness (3%). However, the incidence of infections has declined over the past 5 years, whereas that of loosening has increased and exceeds that of infection in the more recent 3 years. Young age (odds ratio [OR] per 10 years of age increase, 0.41; 95% confidence interval [CI], 0.37–0.49) and male sex (OR, 1.88; 95% CI, 1.42–2.49) were associated with an increased risk of failure. The percentage of revision TKAs in all primary and revision TKAs remained at approximately 3%, but the annual numbers of revision TKAs in the more recent 3 years increased from that of 2008 by more than 23%.
Conclusions
Despite a recent remarkable increase in TKA use and differences in demographic features, the causes and risk factors for failures in Korea were similar to those of Western countries. Infection was the most common cause of failure, but loosening has emerged as the most common cause in more recent years, which would prompt us to scrutinize the cause and solution to reduce it.
Level of Evidence
Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-013-3252-8
PMCID: PMC3889422  PMID: 23982406
7.  Revision Total Knee Arthroplasty with a Cemented Posterior Stabilized, Condylar Constrained or Fully Constrained Prosthesis: A Minimum 2-year Follow-up Analysis 
Clinics in Orthopedic Surgery  2010;2(2):112-120.
Background
The clinical and radiological outcomes of revision total knee arthroplasty with a cemented posterior stabilized (PS), condylar constrained knee (CCK) or a fully constrained rotating hinge knee (RHK) prosthesis were evaluated.
Methods
This study reviewed the clinical and radiological results of 36 revision total knee arthroplasties with a cemented PS, CCK, and RHK prosthesis in 8, 25, and 13 cases, respectively, performed between 1998 and 2006. The mean follow-up period was 30 months (range, 24 to 100 months). The reason for the revision was aseptic loosening of one or both components in 15, an infected total knee in 18 and a periprosthetic fracture in 3 knees. The average age of the patients at the time of the revision was 65 years (range, 58 to 83 years). The original diagnosis for all primary total knee arthroplasties was osteoarthritis except for one case of a Charcot joint. All revision prostheses were fixed with cement. The bone deficiencies were grafted with a cancellous allograft in the contained defect and cortical allograft fixed with a plate and screws in the noncontained defect. A medial gastrocnemius flap was needed to cover the wound dehiscence in 6 of the 18 infected cases.
Results
The mean Knee Society knee score improved from 28 (range, 5 to 43) to 83 (range, 55 to 94), (p < 0.001) and the mean Knee Society function score improved from 42 (range, 10 to 66) to 82 (range, 60 to 95), (p < 0.001) at the final follow-up. Good or excellent outcomes were obtained in 82% of knees. There were 5 complications (an extensor mechanism rupture in 3 and recurrence of infection in 2 cases). Three cases of an extensor mechanism defect (two ruptures of ligamentum patellae and one patellectomy) were managed by the RHK prosthesis to provide locking stability in the heel strike and push off phases, and two cases of recurrent infection used an antibiotic impregnated cement spacer. The radiological tibiofemoral alignment improved from 1.7° varus to 3.0° valgus in average. Radiolucent lines were observed in 18% of the knees without progressive osteolysis.
Conclusions
Revision total knee requires a more constrained prosthesis than primary total knee arthroplasty because of the ligamentous instability and bony defect. This short to midterm follow-up analysis demonstrated that a well planned and precisely executed revision can reduce pain and improve the knee function significantly. Infected cases showed as good a result as those with aseptic loosening through the use of antibiotics-impregnated cement beads and proper soft tissue coverage with a medial gastrocnemius flap.
doi:10.4055/cios.2010.2.2.112
PMCID: PMC2867196  PMID: 20514269
Total knee replacement; Revision; Prosthesis design; Treatment outcome
8.  Cementless Revision TKA with Bone Grafting of Osseous Defects Restores Bone Stock with a Low Revision Rate at 4 to 10 years 
Background
Addressing bone loss in revision TKA is challenging despite the array of options to reconstruct the deficient bone. Biologic reconstruction using morselized loosely-packed bone graft potentially allows for augmentation of residual bone stock while offering physiologic load transfer. However it is unclear whether the reconstructions are durable.
Questions/purposes
We therefore sought to determine (1) survivorship and complications, (2) function, and (3) radiographic findings of cementless revision TKA in combination with loosely-packed morselized bone graft to reconstruct osseous defects at revision TKA.
Patients and Methods
We retrospectively reviewed 56 patients who had undergone revision TKAs using cementless long-stemmed components in combination with morselized loose bone graft at our institution. There were 26 men and 30 women with a mean age of 68.3 years (range, 56–89 years). Patients were followed to assess symptoms and function and to detect radiographic loosening, component migration, and graft incorporation. The minimum followup was 4 years (mean, 7.3 years; range, 4–10 years).
Results
Cumulative prosthesis survival, with revision as an end point, was 98% at 10 years. The mean Oxford Knee Scores improved from 21 (36%) preoperatively to 41 (68%) at final followup. Five patients (9%) had reoperations for complications.
Conclusions
Our observations suggest this technique is reproducible and obviates the need for excessive bone resection, use of large metal augments, mass allografts, or custom prostheses. It allows for bone stock to be reconstructed reliably with durable midterm component fixation.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-011-1938-3
PMCID: PMC3183215  PMID: 21678098
9.  Ipsilateral lower extremity joint involvement increases the risk of poor pain and function outcomes after hip or knee arthroplasty 
BMC Medicine  2013;11:144.
Background
Poor pain and function outcomes are undesirable after an elective surgery such as total hip or knee arthroplasty (THA/TKA). Recent studies have indicated that the presence of contralateral joint influences outcomes of THA/TKA, however the impact of ipsilateral knee/hip involvement on THA/TKA outcomes has not been explored. The objective of this study was to assess the association of ipsilateral knee/hip joint involvement on short-term and medium-term pain and function outcomes after THA/TKA.
Methods
In this retrospective study of prospectively collected data, we used the data from the Mayo Clinic Total Joint Registry to assess the association of ipsilateral knee or hip joint involvement with moderate to severe pain and moderate to severe activity limitation at 2-year and 5-year follow-up after primary and revision THA and TKA using multivariable-adjusted logistic regression analyses.
Results
At 2 years, 3,823 primary THA, 4,701 primary TKA, 1,218 revision THA and 725 revision TKA procedures were studied. After adjusting for multiple covariates, ipsilateral knee pain was significantly associated with outcomes after primary THA (all P values <0.01): (1) moderate to severe pain: at 2 years, odds ratio (OR), 2.3 (95% confidence interval (CI) 1.5 to 3.6); at 5 years, OR 1.8 (95% CI 1.1 to 2.7); (2) moderate to severe activity limitation: at 2 years, OR 3.1 (95% CI 2.3 to 4.3); at 5 years, OR 3.6 (95% CI 2.6 to 5.0). Ipsilateral hip pain was significantly associated with outcomes after primary TKA (all P values <0.01): (1) moderate to severe pain: at 2 years, OR 3.3 (95% CI 2.3 to 4.7); at 5 years, OR 1.8 (95% CI 1.1 to 2.7); (2) moderate to severe activity limitation: at 2 years, OR 3.6 (95% CI 2.6 to 4.9); at 5 years, OR 2.2 (95% CI 1.6 to 3.2). Similar associations were noted for revision THA and TKA patients.
Conclusions
To the best of our knowledge, this is the first study showing that the presence of ipsilateral joint involvement after THA or TKA is strongly associated with poor pain and function outcomes. A potential way to improve outcomes is to address ipsilateral lower extremity joint involvement.
doi:10.1186/1741-7015-11-144
PMCID: PMC3681648  PMID: 23738845
Arthroplasty; Ipsilateral; Joint replacement; Outcomes; Risk factors; Total hip replacement; Total knee replacement
10.  Does a Cemented Cage Improve Revision THA for Severe Acetabular Defects? 
Background
Evidence suggests a growing incidence of revision total hip arthroplasty (THA) including a subset with large acetabular defects. Revision THA for severe acetabular bone loss is associated with a relatively high rate of mechanical failure.
Questions/purposes
We questioned whether cementing a cage to the reconstructed acetabular defect and pelvis would improve the rate of mechanical failure for patients with Type 3 defects (Paprosky et al.) with and without pelvic discontinuity in comparison to historical controls.
Methods
We retrospectively collected data on 33 patients who underwent 35 revision THAs using an acetabular reconstruction cage cemented to morselized allograft and either structural allograft or trabecular metal augmentation for Type 3 defects in the presence (n = 13) and absence (n = 22) of pelvic discontinuity at a mean followup of 59 months (range, 24–92 months). The primary outcome was mechanical failure, defined as revision of the acetabular reconstruction for aseptic loosening.
Results
Revision surgery for mechanical failure occurred in four of the 13 patients with pelvic discontinuity and two of the 22 patients without discontinuity. Radiographic loosening occurred in one patient with and one patient without pelvic discontinuity. Seven of the 35 revisions were subsequently revised for deep infection all in patients who were immunocompromised.
Conclusions
Cementing the cage to the pelvis can offer an advantage for treating severe acetabular defects. Trabecular metal augmentation appears to provide better initial mechanical stability than a structural allograft, but successful allograft reconstruction may restore bone stock.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1546-7
PMCID: PMC3018232  PMID: 20857251
11.  Does a Cemented Cage Improve Revision THA for Severe Acetabular Defects? 
Background
Evidence suggests a growing incidence of revision total hip arthroplasty (THA) including a subset with large acetabular defects. Revision THA for severe acetabular bone loss is associated with a relatively high rate of mechanical failure.
Questions/purposes
We questioned whether cementing a cage to the reconstructed acetabular defect and pelvis would improve the rate of mechanical failure for patients with Type 3 defects (Paprosky et al.) with and without pelvic discontinuity in comparison to historical controls.
Methods
We retrospectively collected data on 33 patients who underwent 35 revision THAs using an acetabular reconstruction cage cemented to morselized allograft and either structural allograft or trabecular metal augmentation for Type 3 defects in the presence (n = 13) and absence (n = 22) of pelvic discontinuity at a mean followup of 59 months (range, 24–92 months). The primary outcome was mechanical failure, defined as revision of the acetabular reconstruction for aseptic loosening.
Results
Revision surgery for mechanical failure occurred in four of the 13 patients with pelvic discontinuity and two of the 22 patients without discontinuity. Radiographic loosening occurred in one patient with and one patient without pelvic discontinuity. Seven of the 35 revisions were subsequently revised for deep infection all in patients who were immunocompromised.
Conclusions
Cementing the cage to the pelvis can offer an advantage for treating severe acetabular defects. Trabecular metal augmentation appears to provide better initial mechanical stability than a structural allograft, but successful allograft reconstruction may restore bone stock.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1546-7
PMCID: PMC3018232  PMID: 20857251
12.  Do Fresh Osteochondral Allografts Successfully Treat Femoral Condyle Lesions? 
Background
Fresh osteochondral allograft transplantation is an increasingly common treatment option for chondral and osteochondral lesions in the knee, but the long-term outcome is unknown.
Questions/purposes
We determined (1) pain and function, (2) frequency and types of reoperations, (3) survivorship at a median of 13.5 years, and (4) predictors of osteochondral allograft failure in the distal femur.
Methods
We evaluated 122 patients (129 knees) who underwent osteochondral allograft transplantation of the femoral condyle. Mean age was 33 years and 53% were male. Clinical evaluation included the modified Merle d’Aubigné-Postel (18-point), IKDC, and Knee Society function (KS-F) scores. We defined graft failure as revision osteochondral allografting or conversion to arthroplasty. We determined whether patient characteristics or attributes of the graft influenced failure. Minimum followup was 2.4 years (median, 13.5 years); 91% had more than 10 years of followup.
Results
Mean modified Merle d’Aubigné-Postel score improved from 12.1 to 16, mean IKDC pain score from 7.0 to 3.8, mean IKDC function score from 3.4 to 7.2, and mean KS-F score from 65.6 to 82.5. Sixty-one knees (47%) underwent reoperations. Thirty-one knees (24%) failed at a mean of 7.2 years. Survivorship was 82% at 10 years, 74% at 15 years, and 66% at 20 years. Age of more than 30 years at time of surgery and having two or more previous surgeries for the operated knee were associated with allograft failure.
Conclusions
Followup of femoral condyle osteochondral allografting demonstrated durable improvement in pain and function, with graft survivorship of 82% at 10 years.
Level of Evidence
Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2556-4
PMCID: PMC3528935  PMID: 22961315
13.  Revision of Infected Total Knee Arthroplasty: Two-Stage Reimplantation Using an Antibiotic-Impregnated Static Spacer 
Clinics in Orthopedic Surgery  2013;5(3):180-187.
Background
A two-stage revision remains as the "gold standard" treatment for chronically infected total knee arthroplasties.
Methods
Forty-five septic knee prostheses were revised with a minimum follow-up of 5 years. Static antibiotic-impregnated cement spacers were used in all cases. Intravenous antibiotics according to sensitivity test of the culture were applied during patients' hospital stay. Oral antibiotics were given for another 5 weeks. Second-stage surgery was undertaken after control of infection with normal erythrocyte sedimentation rate and C-reactive protein values. Extensile techniques were used if needed and metallic augments were employed for bone loss in 32 femoral and 29 tibial revisions.
Results
The average interval between the first-stage resection and reimplantation was 4.4 months. Significant improvement was obtained with respect to visual analog scale pain and clinical and functional scores, and infection was eradicated in 95.6% of cases following a two-stage revision total knee arthroplasty. Radiographic evaluation showed suitable alignment without signs of mechanical loosening.
Conclusions
This technique is a reasonable procedure to eradicate chronic infection in knee arthroplasty and provides proper functional and clinical results. However, it sometimes requires extensile surgical approaches that could imply arduous surgeries. Metallic augments with cementless stems available in most of the knee revision systems are a suitable alternative to handle bone deficiencies, avoiding the use of bone allografts with its complications.
doi:10.4055/cios.2013.5.3.180
PMCID: PMC3758987  PMID: 24009903
Two-stage revision; Chronically infected knee arthroplasty; Extensile approach; Metallic augments
14.  CT Lesion Model-Based Structural Allografts: Custom Fabrication and Clinical Experience 
Summary
Background
Patients requiring knee and hip revision arthroplasty often present with difficult anatomical situations that limit options for surgery. Customised mega-implants may be one of few remaining treatment options. However, extensive damage to residual bone stock may also be present, and in such cases even customised prosthetics may be difficult to implant. Small quantities of lost bone can be replaced with standard allografts or autologous bone. Larger defects may require structural macro-allografts, sometimes in combination with implants (allograft-prosthesis composites).
Methods
Herein, we describe a process for manufacturing lesion-specific large structural allografts according to a 3D, full-scale, lithographically generated defect model. These macro-allografts deliver the volume and the mechanical stability necessary for certain complex revisions. They are patient-and implant-matched, negate some requirements for additional implants and biomaterials and save time in the operating theatre by eliminating the requirement for intra-operative sizing and shaping of standard allografts.
Conclusion
While a robust data set from long-term follow-up of patients receiving customised macro-allografts is not yet available, initial clinical experience and results suggest that lesion-matched macro-allografts can be an important component of revision joint surgery.
doi:10.1159/000345269
PMCID: PMC3678296  PMID: 23800856
X-ray computed tomography; X-ray CT; Individualised medicine; Customised transplant; Bone transplantation; Allograft
15.  Revision Total Knee Arthroplasty for Aseptic and Septic Causes in Patients with Rheumatoid Arthritis 
Revision total knee arthroplasty in patients with rheumatoid arthritis can be challenging. We asked whether we could confirm previously reported high failure rates following revision total knee arthroplasty in patients with rheumatoid arthritis. We therefore determined the Knee Society knee score and function scores, radiographic evidence of failure, and overall survival of the revision procedure in these patients. We retrospectively reviewed 39 patients with rheumatoid arthritis who underwent 45 TKA revisions from 1994 to 2006. Twenty-seven of the 45 TKA revisions were for mechanical failure of the prosthetic components and 18 for infection. Five of the 27 knees (19%) revised for mechanical failure subsequently failed a second time. Five of the 18 patients who underwent revision for infection died within 6 months and three of the remaining knees failed secondary to reinfection. Excluding the knees that failed, the average Knee Society knee score and function score improved in both subgroups. Two knees had radiographic evidence of nonprogressive tibial radiolucencies. The probability of survival for all knees (revision as the end point) was 76% ± 9% at 5 years. We confirmed the previously reported high mortality and subsequent failure rates following revision total knee arthroplasty for both mechanical issues and infection in patients with rheumatoid arthritis and emphasize the potential difficulties in treating these patients.
Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-1061-x
PMCID: PMC2795816  PMID: 19727993
16.  Dual massive skeletal allograft in revision total knee arthroplasty 
Indian Journal of Orthopaedics  2011;45(4):368-371.
The reconstruction of large uncontained defects represents a major challenge to the revision total knee surgeon, and the outcome of the revision often depends on the management of these bone deficiencies. We report the first successful use of both complete distal femoral and proximal tibia massive allografts in the reconstruction of large femoral and tibial uncontained defects during revision total knee arthroplasty. At the five-year follow up, we did not find any infection, graft failure or loosening of implant, in spite of using two massive structural allografts in a single revision total knee arthroplasty.
doi:10.4103/0019-5413.82345
PMCID: PMC3134025  PMID: 21772633
Massive allograft; revision total knee arthroplasty; uncontained bone defect
17.  Depression in primary TKA and higher medical comorbidities in revision TKA are associated with suboptimal subjective improvement in knee function 
Background
To characterize whether medical comorbidities, depression and anxiety predict patient-reported functional improvement after total knee arthroplasty (TKA).
Methods
We analyzed the prospectively collected data from the Mayo Clinic Total Joint Registry for patients who underwent primary or revision TKA between 1993–2005. Using multivariable-adjusted logistic regression analyses, we examined whether medical comorbidities, depression and anxiety were associated with patient-reported subjective improvement in knee function 2- or 5-years after primary or revision TKA. Odds ratios (OR), along with 95% confidence intervals (CI) and p-value are presented.
Results
We studied 7,139 primary TKAs at 2- and 4,234 at 5-years; and, 1,533 revision TKAs at 2-years and 881 at 5-years. In multivariable-adjusted analyses, we found that depression was associated with significantly lower odds of 0.5 (95% confidence interval [CI]: 0.3 to 0.9; p = 0.02) of ‘much better’ knee functional status (relative to same or worse status) 2 years after primary TKA. Higher Deyo-Charlson index was significantly associated with lower odds of 0.5 (95% CI: 0.2 to 1.0; p = 0.05) of ‘much better’ knee functional status after revision TKA for every 5-point increase in score.
Conclusions
Depression in primary TKA and higher medical comorbidity in revision TKA cohorts were associated with suboptimal improvement in index knee function. It remains to be seen whether strategies focused at optimization of medical comorbidities and depression pre- and peri-operatively may help to improve TKA outcomes. Study limitations include non-response bias and the use of diagnostic codes, which may be associated with under-diagnosis of conditions.
doi:10.1186/1471-2474-15-127
PMCID: PMC3990241  PMID: 24725511
Total knee arthroplasty; Knee function; Functional limitation; Primary; Arthroplasty; Joint replacement; Outcomes; Patient-reported outcomes
18.  ACL reconstruction with BPTB autograft and irradiated fresh frozen allograft*  
Objective: To analyze the clinical outcomes of arthroscopic anterior cruciate ligament (ACL) reconstruction with irradiated bone-patellar tendon-bone (BPTB) allograft compared with non-irradiated allograft and autograft. Methods: All BPTB allografts were obtained from a single tissue bank and the irradiated allografts were sterilized with 2.5 mrad of irradiation prior to distribution. A total of 68 patients undergoing arthroscopic ACL reconstruction were prospectively randomized consecutively into one of the two groups (autograft and irradiated allograft groups). The same surgical technique was used in all operations done by the same senior surgeon. Before surgery and at the average of 31 months of follow-up (ranging from 24 to 47 months), patients were evaluated by the same observer according to objective and subjective clinical evaluations. Results: Of these patients, 65 (autograft 33, irradiated allograft 32) were available for full evaluation. When the irradiated allograft group was compared to the autograft group at the 31-month follow-up by the Lachman test, the anterior drawer test (ADT), the pivot shift test, and KT-2000 arthrometer test, statistically significant differences were found. Most importantly, 87.8% of patients in the autograft group and just only 31.3% in the irradiated allograft group had a side-to-side difference of less than 3 mm according to KT-2000. The failure rate of the ACL reconstruction with irradiated allograft (34.4%) was higher than that with autograft (6.1%). The anterior and rotational stabilities decreased significantly in the irradiated allograft group. According to the overall International Knee Documentation Committee (IKDC), functional and subjective evaluations, and activity level testing, no statistically significant differences were found between the two groups. Besides, patients in the irradiated allograft group had a shorter operation time and a longer duration of postoperative fever. When the patients had a fever, the laboratory examinations of all patients were almost normal. Blood routine was normal, the values of erythrocyte sedimentation rate (ESR) were 5~16 mm/h and the contents of C reactive protein (CRP) were 3~10 mg/L. Conclusion: We conclude that the short term clinical outcomes of the ACL reconstruction with irradiated BPTB allograft were adversely affected. The less than satisfactory results led the senior authors to discontinue the use of irradiated BPTB allograft in ACL surgery and not to advocate using the gamma irradiation as a secondary sterilizing method.
doi:10.1631/jzus.B0820335
PMCID: PMC2666208  PMID: 19353750
Anterior cruciate ligament (ACL) reconstruction; Patellar tendon; Autograft; Allograft; Irradiation; Prospective randomized study
19.  Liner Exchange and Bone Grafting: Rare Option to Treat Wear & Lysis of Stable TKAs 
Background
Liner exchange and bone grafting are commonly performed for wear and osteolysis around well-fixed modular acetabular components that otherwise would require structural allografting and revision THA. However, liner exchange in the face of substantial lysis around TKA has been performed rarely with reports of failure rates of up to 25% at 3 year followup.
Questions/purposes
We therefore evaluated the technique of liner exchange and bone grafting for cases of wear and extensive osteolysis around TKAs in which the components were well-fixed and well-aligned to determine (1) rerevision rates; (2) fate of the bone graft; (3) radiographic loosening rates; and (4) functional scores.
Methods
We retrospectively reviewed 22 patients (25 knees) who underwent revision TKA with exchange of the modular polyethylene insert and bone grafting in cases with well-fixed components and large areas of osteolysis (up to 54 cm2 on a single projection) at the time of revision. The average area of osteolysis was 21 cm2 and 10 cm2 on the AP projection of the femur and tibia, respectively. On the lateral projection, the average area of osteolysis for the femur and tibia was 22 cm2 and 9.3 cm2. Minimum clinical and radiographic followup was 22 and 22 months (average, 61 and 59; range, 22–142 and 22–130, respectively).
Results
One of the 25 knees was revised for aseptic loosening or recurrence of osteolysis. On radiographs, 84.6% and 70% of femoral and tibial osteolytic lesions, respectively, showed evidence of complete or near complete graft incorporation. The remaining lesions showed evidence of partial graft incorporation with the exception of one tibial lesion, which was in the revised case. All other components were well fixed with no evidence of radiographic loosening.
Conclusions
In this selected series of cases with extensive osteolysis around well-fixed and well-aligned TKAs, liner exchange and bone grafting provided durable midterm results with extensive graft incorporation.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1521-3
PMCID: PMC3008882  PMID: 20809171
20.  Monoblock all-polyethylene tibial components have a lower risk of early revision than metal-backed modular components 
Acta Orthopaedica  2013;84(6):530-536.
Background and purpose
With younger patients seeking reconstructions and the activity-based demands placed on the arthroplasty construct, consideration of the role that implant characteristics play in arthroplasty longevity is warranted. We therefore evaluated the risk of early revision for a monoblock all-polyethylene tibial component compared to a metal-backed modular tibial construct with the same articular geometry in a sample of total knee arthroplasties (TKAs). We evaluated risk of revision in younger patients (< 65 years old) and in older patients (≥ 65 years old).
Method
Fixed primary TKAs with implants from a single manufacturer, performed between April 2001 and December 2010, were analyzed retrospectively. Patient characteristics, surgeon, hospital, procedure, and implant characteristics were compared according to tibial component type (monoblock all-polyethylene vs. metal-backed modular). All-cause revisions and aseptic revisions were evaluated. We used descriptive statistics and Cox regression models.
Results
27,657 TKAs were identified, 2,306 (8%) with monoblock and 25,351 (92%) with modular components. In adjusted models, the risk of early all-cause revision (hazard ratio (HR) = 0.5, 95% confidence interval (CI): 0.3–0.8) and aseptic revision (HR = 0.6, CI: 0.3–1.2) was lower for the monoblock cohort than for the modular cohort. In older patients, the early risk of all-cause revision was 0.6 (CI: 0.4–1.0) for the monoblock cohort compared to the modular cohort. In younger patients, the adjusted risk of all-cause revision (HR = 0.3, CI: 0.1–0.7) and of aseptic revision (HR = 0.3, CI: 0.1–0.7) were lower for the monoblock cohort than for the modular cohort.
Interpretation
Overall, monoblock tibial constructs had a 49% lower early risk of all-cause revision and a 41% lower risk of aseptic revision than modular constructs. In younger patients with monoblock components, the early risk of revision for any cause was even lower.
doi:10.3109/17453674.2013.862459
PMCID: PMC3851665  PMID: 24237424
21.  Poorer survival after a primary implant during revision total knee arthroplasty 
International Orthopaedics  2012;37(3):415-419.
Purpose
Revision total knee arthroplasty (rTKA) is a complex procedure. Depending on the degree of ligament and bone damage, either primary or revision implants are used. The purpose of this study was to compare survival rates of primary implants with revision implants when used during rTKA.
Methods
A retrospective comparative study was conducted between 1998 and 2009 during which 69 rTKAs were performed on 65 patients. Most common indications for revision were infection (30 %), aseptic loosening (25 %) and wear/osteolysis (25 %). During rTKA, a primary implant was used in nine knees and a revision implant in 60.
Results
Survival of primary implants was 100 % at one year, 73 % [95 % confidence interval (CI) 41–100] at two years and 44 % (95 % CI 7–81) at five years. Survival of revision implants was 95 % (95 % CI 89–100) at one year, 92 % (95 % CI 84–99) at two years and 92 % (95 % CI 84–99) at five years. Primary implants had a significantly worse survival rate than revision implants when implanted during rTKA [P = 0.039 (hazard ratio = 4.56, 95 % CI 1.08–19.27)].
Conclusions
Based on these results, it has to be considered whether primary implants are even an option during rTKA.
doi:10.1007/s00264-012-1739-7
PMCID: PMC3580082  PMID: 23263508
22.  Causes of Failure after Total Knee Arthroplasty in Osteoarthritis Patients 55 Years of Age or Younger 
Purpose
To identify the modes of failure after total knee arthroplasty (TKA) in patients >55 years of age and to compare with those >55 years of age in patients who underwent revision TKA.
Materials and Methods
We retrospectively reviewed 256 revision TKAs among patients who underwent TKA for knee osteoarthritis between January 1992 and December 2012. The causes of TKA failure were analyzed and compared between the groups.
Results
Thirty-one revision TKAs were performed in patients ≤55 years of age at the time of primary TKA, whereas 225 cases were in those >55 years of age at primary TKA. In the ≤55 years of age group, the most common cause of TKA failure was polyethylene wear (45%) followed by infection (26%) and loosening (17%). The interval from primary TKA to revision was 8.6 years (range, 1 to 17 years). There were relatively lower infection rate and higher loosening rate in patients ≤55 years of age, but the difference was not statistically significant.
Conclusions
The main causes of failure after TKA in patients ≤55 years of age were polyethylene wear, infection and loosening, and there was no significant difference in the modes of failure after TKA between the two groups.
doi:10.5792/ksrr.2014.26.1.13
PMCID: PMC3953520  PMID: 24639942
Knee; Arthroplasty; Failure; Revision; Younger age
23.  Failure following revision total knee arthroplasty: infection is the major cause 
International Orthopaedics  2010;35(8):1157-1164.
The objective of this study was to evaluate the survivorship of revision TKA and determine the reasons and predictors for failure. Between January 1999 to December 2005, 499 total knee arthroplasty revisions were performed on 474 patients. There were 292 (61.6%) women and 182 (38.4%) men. The average age at the time of index revision was 63.9 years. Revision was defined as surgery in which at least one component (tibial, patellar, femoral, or polyethylene) required exchange. At an average follow-up of 64.8 months (range, 24.1–111.6), and considering reoperation or re-revision as failure, there were 102 failures (18.3%). Infection was the major cause of failure (44.1%) followed by stiffness (22.6%), patellar or extensor mechanism problems (12.8%), periprosthetic fracture (5.9%), loosening (4.9%), haematoma formation (3.9%), malalignment (2.9%), and instability (2.9%). A total of 83% of failures were early (less than two years). Infection was the most common mechanism of failure of revision TKA. The majority of TKA revision failures tend to occur in the first two years after revision. The mode of failure of revision TKA appears to differ from the failure of primary TKA to some extent. Better understanding of current modes by which TKA revisions fail may enable surgeons to prevent these problems and improve outcomes for revision TKA.
doi:10.1007/s00264-010-1134-1
PMCID: PMC3167421  PMID: 20959981
24.  The influence of computer-assisted surgery on rotational, coronal and sagittal alignment in revision total knee arthroplasty 
Background
Despite good results of primary total knee arthroplasty (TKA), the number of revision total knee arthroplasties (rTKAs) is rising. Proper implant position is essential, since malposition leads to worse clinical outcome. In rTKA most anatomical landmarks have disappeared because of extensive bone loss, making it more difficult to adequately implant the knee prosthesis. In primary TKA, computer-assisted surgery (CAS) leads to better prosthetic alignment than mechanical navigation guides. Literature about the use of CAS in rTKA is scarce though, and the effect on rotational prosthetic alignment has not been investigated yet. Hence the primary objective of this study is to compare rotational prosthetic alignment when using CAS in rTKA compared to a mechanical navigation guide. Secondary objectives are to compare prosthetic alignment in the coronal and sagittal planes. It is hypothesized that CAS leads to better rotational, coronal and sagittal prosthetic alignment when used during rTKA.
Methods/Design
A prospective clinical intervention study with use of a historical control group will be conducted. Forty-four patients with a minimum age of 18 to be admitted for CAS-rTKA between September 2012 and September 2015 will be included in the intervention group. Forty-four patients with a minimum age of 18 who underwent rTKA with the use of a mechanical navigation guide between January 2002 and April 2012 will form the historical control group. Both groups will be matched according to gender and type of revision prosthesis. Rotational prosthesis alignment will be evaluated using a CT-scan of the knee joint.
Discussion
Proper implant position is essential, since malposition leads to worse clinical outcome. Several studies show a significantly positive influence of CAS on prosthetic alignment in primary TKA, but literature about the use of CAS in rTKA is limited. The purpose of this study is thus to investigate the influence of CAS during rTKA on postoperative prosthetic alignment, compared to mechanical navigation guides.
Trial registration
Netherlands National Trial Register NTR3512
doi:10.1186/1471-2474-15-94
PMCID: PMC3995112  PMID: 24646028
25.  Cemented fixed-bearing PFC total knee arthroplasty: survival and failure analysis at 12–17 years 
Background
Total knee arthroplasty (TKA) is the appropriate treatment for degenerative pathology of the knee. Implant surveillance is mandatory to improve clinical results. We present the long-term results of a series of consecutive TKA Press Fit Condylar (J&J), cemented fixed bearing with selective patellar resurfacing in nonselected patients.
Materials and methods
In this prospective case series, 223 TKA were clinically and radiographically evaluated using the Hospital for Special Surgery (HSS) knee score and the Knee Society Roentgenographic Evaluation and Scoring System.
Results
There were 197 patients, with an average age of 68.4 years [95% confidence interval (CI) 52.7–84.1 years]; 49 arthroplasties were implanted in men (21.1%) and 184 (78.9%) in women. The average follow-up was approximately 13.5 years (162.1 months; 95% CI 132.3–191.9), and it was possible to evaluate 179 implants (76.8% of the implanted prosthesis) in 176 patients. The average HSS score increased from 61.5 (95% CI 60.4–62.7) to 89.4 (95% CI 87.7–.93.5) points. The cumulative average survival rate at 15 years (the endpoint being failure with revision) was 90.6%  ± 2% standard deviation. Resurfacing the patella did not make a difference in terms of implant survival. Progressive radiolucent lines were observed around 20 implants (14.3%); all were revised.
Conclusions
The PFC system is an excellent prosthetic solution. Early clinical complications, mechanical axis and patellar resurfacing do not correlate with implant failure, whereas progressive radiolucent lines do.
doi:10.1007/s10195-011-0142-2
PMCID: PMC3163768  PMID: 21698373
Total knee arthroplasty; Long-term survival; Failure analysis

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