Rotating-hinge prosthesis for aseptic revision knee arthroplasty: A multicentre retrospective study of 127 cases with a mean follow-up of five years

High Rates of Early Septic Failure, but Low Rates of Aseptic Loosening After Revision Total Knee Arthroplasty With Contemporary Rotating-Hinge Prostheses

BACKGROUND

The purpose of this study was to determine implant survivorship and functional outcomes for revision total knee arthroplasty (rTKA) with contemporary rotating-hinge knee implants.

METHODS

A retrospective review identified 115 rTKAs using contemporary rotating-hinge implants from 2014 to 2018 for the treatment of instability (34, 30%), reimplantation after periprosthetic joint infection (PJI) (33, 29%), aseptic loosening (25, 22%), arthrofibrosis (14, 12%), periprosthetic fracture (4, 3%), osteolysis (4, 3%), and femoral component fracture (1, 1%). There were 70 women (61%), and the mean age was 67 years (range, 27 to 94). The mean follow-up was 3 years (range, 2 to 6). Kaplan-Meier analysis and Cox proportional hazard models estimated survivorship.

RESULTS

The re-revision rate was 20% (23 of 115) at an average of 18 months postoperatively. Re-revision indications included PJI (n = 14), aseptic loosening (n = 4), arthrofibrosis (n = 2), instability/malalignment (n = 1), femoral stem fracture (n = 1), and hinge mechanism disruption (n = 1). At 2 and 5 years, survivorship free from all-cause re-revision was 86 and 64%, and survivorship free from re-revision for aseptic loosening was 100 and 87%, respectively. Use of a rotating-hinge implant in reimplantation after PJI was a risk factor for subsequent re-revision (hazard ratio = 2.4, P = 0.046). On a radiographic review of unrevised rotating-hinges, there were major radiolucent lines around 2 femoral and 5 tibial components. The mean Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement increased from 43 preoperatively to 60 at 1 year (P < 0.001).

CONCLUSIONS

In patients treated with a rotating-hinge implant for rTKA, there were relatively poor 2-year (86%) and 5-year (64%) survivorship free from all-cause re-revision, most commonly due to PJI. Midterm survivorship free from re-revision for aseptic loosening was modest (87%). There should be a goal to mitigate complications in complex rTKAs with rotating-hinge implants, namely PJI.

Constraint degree in revision total knee replacement: a registry study on 1432 patients

PURPOSE

Total knee replacement (TKR) failure represents a hard challenge for knee surgeons. TKR failure can be managed in revision with different constraint, related with soft and bone knee damages. The choice of the right constraint for every failure cause represents a not summarized entity. The purpose of this study is identifying distribution of different constraints in revision TKR (rTKR) for failure cause and the overall survival.

METHODS

A registry study based on the Emilia Romagna Register of the Orthopaedic Prosthetic Implants (called RIPO) was performed with a selection of 1432 implants, in the period between 2000 and 2019. Selection implants including primary surgery constraint, failure cause and constraint revision for every patient, and divided for constraint degrees used during procedures (Cruciate Retaining-CR, Posterior Stabilized-PS, Condylar Constrained Knee-CCK, Hinged).

RESULTS

The most common cause of primary TKR failure was aseptic loosening (51,45%), followed by septic loosening (29,12%). Each type of failure was managed with different constraint, the most used was CCK in the most of failure causes, such as to manage aseptic and septic loosening in CR and PS failure. Overall survival of TKA revisions has been calculated at 5 and 10 years for each constraint, with a range of 75.1-90.0% at 5 years and 75.1-87.5% at 10 years.

CONCLUSION

Constraint degree in rTKR is typically higher than primary, CCK is the most used constraint in revision surgery with an overall survival of 87.5% at 10 years.

Etiology of Total Knee Arthroplasty Revisions: A Two-Decade Institutional Perspective

Total knee arthroplasty (TKA) implant survival time is determined by various patient and implant-related factors and varies significantly in recent worldwide reports. In our study, we have included 247 TKA revisions in 203 patients performed in our hospital over the last 20 years. Multiple etiologies of revisions were identified and classified into 10 categories. Time to failure was analyzed with regard to etiology, patient demographics, and other relevant data. The overall average time to revision was 44.08 months (95% confidence interval (CI) between 33.34 and 49.82 months). Age at primary implant was negatively correlated with time to revision (hazard ratio (HR) = 1.0521 and 95% CI of HR = 1.0359 to 1.0685) and female patients showed a 1.59 times higher risk of implant failure than males. Periprosthetic joint infection was the cause of 46.56% (n=115) of revisions (out of which 12.55% (n=31) were early infections, diagnosed within the first three months), while aseptic loosening was found in 31.98% (n=79) of cases. Infection correlated with a shorter time to revision compared to aseptic loosening (p<0.05). These findings emphasize the need to intensify efforts to deliver the best patient care, select the best antibiotic regimen, and improve surgical techniques to decrease the incidence of infectious complications.

Midterm results of modular hinge total knee arthroplasty using cementless osseointegrating stems: low fixation associated complications and good functional outcome in primary and revision knee arthroplasty

PURPOSE

This study aimed to investigate functional outcome and complications after primary and revision modular H-TKA using hybrid fixation with cementless stems.

METHODS

Between 2015 and 2018, 48 patients with 50 implants were included after hybrid implantation of a single design H-TKA system using cementless osseointegrating stems and modular components. Complications and clinical outcome were analysed using Knee Society Score (KSS), the Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) and the Short-Form Health Survey 12 (SF-12) score.

RESULTS

Indications for implantation were aseptic revision (n = 29, 58%), primary TKA (n = 19, 38%) and two-stage septic revisions (n = 2, 4%). Complications were reported in 26% (n = 12), whereas complications associated with hybrid fixation occurred in 5 (10%) cases, with 2 (4%) requiring revision surgery for aseptic loosening and 3 (6%) treated with an adapted postoperative protocol for perioperative fractures. Implant survivorship was 84% after a mean follow-up of 54 months. Postoperative KSS significantly improved from 51.50 (12-100) to 78.36 (41-99; p < 0.001). The mean WOMAC score was 19.26 (0-55), SF-12 PCS was 41.56 points (22.67-57.66) and SF-12 MCS was 49.21 points (23.87-63.21).

CONCLUSION

Hybrid modular implantation in H-TKA provides satisfactory clinical and functional results in primary and revision TKA. Clinical outcomes significantly improve with reduced pain, increased mobility, and good-to-excellent functional scores after implantation. Whilst implant survival is comparable to previous studies and complications associated with hybrid fixation are low, general complication rates are comparably high.

A Low Rate of Periprosthetic Infections after Aseptic Knee Prosthesis Revision Using Dual-Antibiotic-Impregnated Bone Cement

AIM

The incidence of periprosthetic joint infections (PJI) following aseptic knee revision arthroplasty lies between 3% and 7.5%. The aim of this study was to verify the hypothesis that the use of dual-antibiotic-impregnated cement in knee revision arthroplasty leads to a lower rate of periprosthetic joint infections.

METHODS

We retrospectively reviewed 403 aseptic revision knee arthroplasties performed between January 2013 and March 2021 (148 revisions of a unicompartmental prosthesis, 188 revisions of a bicondylar total knee arthroplasty (TKA), 41 revisions of an axis-guided prosthesis, and 26 revisions of only one component of a surface replacement prosthesis). The bone cement Copal G+C (Heraeus Medical, Wertheim, Germany) with two antibiotics-gentamycin and clindamycin-was used for the fixation of the new implant. The follow-up period was 53.4 ± 27.9 (4.0-115.0) months.

RESULTS

Five patients suffered from PJI within follow-up (1.2%). The revision rate for any reason was 8.7%. Survival for any reason was significantly different between the types of revision (p = 0.026, Log-Rank-test), with lower survival rates after more complex surgical procedures. The 5-year survival rate with regard to revision for any reason was 91.3% [88.2-94.4%] and with regard to revision for PJI 98.2% [98.7-99.9%], respectively.

CONCLUSION

The use of the dual-antibiotic-impregnated bone cement Copal G+C results in a lower rate of periprosthetic infections after aseptic knee prosthesis replacement than that reported in published prosthesis revisions using only one antibiotic in the bone cement.

Physical activity after revision knee arthroplasty including return to sport and work: a systematic review and meta-analysis including GRADE

BACKGROUND

The number of primary knee arthroplasties (KAs) performed annually is rising, especially among active, working age patients. Consequently, revision KA is also increasingly performed. Our aim was to systematically review the extent to which patients were physically active following revision KA, and the rate and timing of return to sport and work.

METHODS

A search was conducted in the databases Medline and Embase until February 24th, 2023. Studies describing patients with revision total knee arthroplasty (rTKA) or revision unicondylar knee arthroplasty (rUKA), with outcomes regarding physical activity or return to sport (RTS) or work (RTW) were included. Quality of studies was assessed using the Newcastle-Ottawa scale, meta-analyses were performed using RevMan 5.4 and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

RESULTS

Of the 4,314 articles screened, 22 studies were included describing 2,462 rTKA patients (no rUKA), 42% were male with a mean age of 67 years (range 24 - 95). No studies reported objective physical activity measurements. Twenty-two studies reported patient reported outcome measures (PROMs). The PROMs that were pooled on a scale from zero to ten were the UCLA Activity Score, the Tegner Activity Level Scale, the Lower-Extremity Activity Scale, Devane Activity Score, and physical activity related subscales of the Knee injury and Osteoarthritis Outcome Score. The retrospective studies of moderate quality showed a statistically significant postoperative improvement of 1.7 points (MD = 1.71, 95% CI 1.48 - 1.94 (p < 0.0001); 14 studies, n = 1,211). For the prospective moderate-quality studies, a statistically significant postoperative increase of 0.9 points was found (MD = 0.89, 95% CI 0.48 - 1.30 (p < 0.0001); 6 studies, n = 1,027). Regarding RTS, 12% of patients participated in so-called 'non-recommended' activities (i.e., hockey, soccer, football, gymnastics, jogging, singles tennis, and basketball) after rTKA (1 study, n = 206). The pooled RTW was 86% (2 studies, range 18-95%, n = 234).

CONCLUSIONS

The majority of patients self-reported an improved postoperative activity level after rTKA. Patients could maintain an active lifestyle in daily life, including sports and work. For reliable physical activity, RTS and RTW estimations, more studies are required. In terms of GRADE, the quality of evidence for the five prospective studies was rated as low.

LEVEL OF EVIDENCE

Level 3.

The anatomical shape of the distal femur is an independent risk factor for aseptic loosening following one-stage septic knee revision using rotating hinge knee prosthesis

PURPOSE

Aseptic loosening (AL) is the second most common reason for failure after one-stage septic knee revision. In this context, the goal of the study is to identify risk factors for AL following one-stage septic knee revision using rotating hinge implants. We aimed to answer the following research question: How does the anatomical shape of the distal femur represent an independent risk factor for AL following one-stage septic knee revision arthroplasty?

METHODS

Patients, who had undergone re-revision surgery due to AL of the rotating hinge knee prosthesis after one-stage septic knee revision arthroplasty between January 2008 and December 2018, were included. For this purpose, 41 patients with AL after one-stage septic knee revision using rotating hinge implants and 37 controls without any revision surgery at latest follow-up were included in this study. Using standardized anteroposterior (AP) views of the knee in all patients, we measured the inner diameter of the femur 20 cm proximally from the joint line and at a point 2 cm proximally from the adductor tubercle.

RESULTS

Among the vast majority of AL cases, we identified an isolated loosening of the femoral component. The AL group showd a high distribution of the Type C according to the Citak classification with 75.7%. Contrary to this, with 24.3% (p < 0.001) the amount of Type C cases was relatively low in the control group. Consequently, Type C configurations of the distal femur represent an independent risk factor for AL with an approximately sevenfold higher risk for AL compareed to Type A and Type B.

CONCLUSIONS

The novel radiological classification system of the distal femur shows that the Type C subtype is an independent and main risk factor for AL after one-stage septic knee revision using rotating hinge knee implants.

Similar outcomes of constrained condylar knee and rotating hinge prosthesis in revision surgery for extension instability after primary total knee arthroplasty

BACKGROUND

Instability is one of the most common reasons for total knee arthroplasty (TKA) failure. Constrained prosthesis can be used for significant ligamentous laxity, but there is not much evidence on the appropriate level of restriction for unstable varus-valgus TKA. The objective of this study was to compare the outcome and survival at a minimum follow-up of five years between rotating hinge knee prosthesis (RHK) and constrained condylar knee prosthesis (CCK) for extension instability following primary TKA.

HYPOTHESIS

For symptomatic extension instability after primary TKA, good functional outcomes and survival can be achieved with both designs.

MATERIAL AND METHODS

Consecutive patients with unstable primary TKA who underwent revision with either RHK (n=34) or CCK (n=30) were retrospectively compared. Assessments were performed by the Knee Society Scores (KSS), and visual analogue scales (VAS) for pain and patient satisfaction. Radiological evaluation was made. Complications and re-operations were analyzed.

RESULTS

Mean post-operative follow-up was 10.3 (range 5-16) years for both groups. At the final follow-up, there was no significant difference between groups in the KSS-knee (p=0.228) or KSS-function (p=0.324) score, VAS-pain (p=0.563), VAS-satisfaction (p=0.780), major complication rate (p=0.194), or TKA survival at 10 years (p=0.091).

CONCLUSION

The present study showed comparable good functional outcomes and survival at long-term between RHK and CCK arthroplasties. Both designs can be recommended for revision of total knee arthroplasty with symptomatic extension instability.

LEVEL OF EVIDENCE

Level III.

Beneficial effect of a zirconium-nitride-coated implant in total knee arthroplasty revision for suspected metal hypersensitivity

INTRODUCTION

Revision of total knee arthroplasty (rTKA) for suspicion of metal hypersensitivity (MHS) may require hypoallergenic implants. Results for coated implants have not been reported. The aim of the present study was to assess short-term results and survival of rTKA for MHS using a multilayer implant coating.

HYPOTHESIS

Multilayer implant coating improves functional results in rTKA, with survival comparable to primary coated implants.

MATERIAL AND METHODS

A single-center retrospective observational study included 28 patients (30 knees) undergoing rTKA for MHS using a coated implant between May 2011 and November 2016. Exclusion criteria comprised implant malpositioning and history of infection in the affected knee. Clinical and radiological results were assessed on the International Knee Society (IKS) and SF-36 functional scores and Ewald radiological score. Survival was calculated on Kaplan-Meier estimation.

RESULTS

Mean follow-up was 3.8 years. Mean IKS score increased by 40.2 points (40%) [range, 28.1-52.3] (p<0.05). Mean range of motion increased by 17° [range, 9.5-24.5°] (p<0.05). Mean physical and mental SF-36 components were respectively 44.7 and 46.1. Survivorship was 93%.

DISCUSSION

There was significant functional improvement after rTKA for MHS. There were no short-term complications related to the zirconium nitrate coating. However, studies with longer follow-up will be needed for confirmation.

LEVEL OF EVIDENCE

IV; retrospective study.