This article reviews the recent updates in revision of total knee arthroplasty (RTKA). We reviewed the recent articles on RTKA in databases including PubMed, Google Scholar, and SCOPUS. Total knee arthroplasty (TKA) involves the replacement of all three compartments of the knee in surgery of the knee joint to restore capacity and function. TKA is one of the most common and reliable surgical treatment options for the treatment of knee diseases. However, some patients require revision of TKA (RTKA) after primary TKA for various reasons, including mechanical wear, implant loosening or breakage, malalignment, infection, instability, periprosthetic fracture, and persistent stiffness. Unfortunately, the overall outcome of RTKA is not as satisfactory as for primary TKA due to the uncertainty regarding the actual success rate and the risk factors for failure. Cementation, modular metal augmentation, bone grafting, autologous bone grafting, allogenic bone grafting, impactation bone grafting, structural bone allografting, metaphyseal fixation, using porous titanium coated press fit metaphyseal sleeves and porous tantalum structural cones, and megaprostheses or customized prostheses are the currently available management options for RTKA. However, most of the management systems possess specific complications. Novel approaches should be developed to improve functional capacity, implant survival rates, and quality of life in a cost-efficient manner.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/os.12425

Bone Defects in Revision Total Knee Arthroplasty and Management.

Total knee replacement (TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions (ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.

Perioperative blood management strategies for patients undergoing total knee replacement: Where do we stand now?

The effectiveness of cryotherapy on joint arthroplasty recovery remains controversial. This systematic review was conducted to assess the effectiveness of cryotherapy in patients after joint arthroplasty. Comprehensive literature searches of several databases including Cochrane Library (2013), MEDLINE (1950–2013), and Embase (1980–2013) were performed. We sought randomised controlled trials that compared the experimental group received any form of cryotherapy with any control group after joint arthroplasty. The main outcomes were postoperative blood loss, adverse events, and pain. Analyses were performed with Revman 5.0. Results were shown as mean differences (MD) and standard deviations or as risk difference and 95 % confidence intervals (CIs). Ten trials comprised 660 total knee arthroplastys and three trials comprised 122 total hip arthroplastys (THAs) met the inclusion criteria. Blood loss was significantly decreased by cryotherapy (MD = −109.68; 95 % CI −210.92 to −8.44; P = 0.03). Cryotherapy did not increase the risk of adverse effect (n.s.). Cryotherapy decreased pain at the second day of postoperative (MD = −1.32; 95 % CI −2.37 to −0.27; P = 0.0003), but did not decreased pain at the first and third day of postoperative (n.s.). Cryotherapy appears effective in these selected patients after joint arthroplasty. The benefits of cryotherapy on blood loss after joint arthroplasty were obvious. However, the subgroup analysis indicated that cryotherapy did not decreased blood loss after THA. Cryotherapy did not increase the risk of adverse effect. Cryotherapy decreased pain at the second day of postoperative, but did not decreased pain at the first and third day of postoperative. II.

Cryotherapy on postoperative rehabilitation of joint arthroplasty

Total knee arthroplasty (TKA) often causes a significant amount of blood loss with an accompanying decline in hemoglobin and may increase the frequency of allogeneic blood transfusion rates. Unfortunately, allogeneic blood transfusions have associated risks including postoperative confusion, infection, cardiac arrhythmia, fluid overload, increased length of hospital stay, and increased mortality. Other than reducing the need for blood transfusions, reducing perioperative blood loss in TKA may also minimize intra-articular hemorrhage, limb swelling, and postoperative pain, and increase the range of motion during the early postoperative period. These benefits improve rehabilitation success and increase patients' postoperative satisfaction. Preoperative anemia, coupled with intraoperative and postoperative blood loss, is a major factor associated with higher rates of blood transfusion in TKA. Thus, treatment of preoperative anemia and prevention of perioperative blood loss are the primary strategies for perioperative blood management in TKA. This review, combined with current evidence, analyzes various methods of blood conservation, including preoperative, intraoperative, and postoperative methods, in terms of their effectiveness, safety, and cost. Because many factors can be controlled to reduce blood loss and transfusion rates in TKA, a highly efficient, safe, and cost-effective blood management strategy can be constructed to eliminate the need for transfusions associated with TKA.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/os.12361

Perioperative Blood Management Strategies for Total Knee Arthroplasty.

In surgical practice, hemostasis is used to minimize postoperative bleeding in total knee arthroplasty. We performed a prospective randomized study to determine the influence of tourniquet use and the timing of its release on amount of bleeding. Eighty four patients (96 knees) were scheduled for total knee arthroplasty and randomly divided into three groups. Posterior cruciate retaining bicompartmental total knee prostheses were used in all. In group I, no tourniquet was used. In group II, a tourniquet was used and was deflated for hemostasis once all components had been inserted. In group III, the tourniquet was deflated after wound closure and application of a compressive dressing. Mean blood drainage, mean volume of blood transfusion, hemoglobin (Hb) and hematocrit (Hct) values and operative time were compared between the three groups. Mean blood drainage was 810 mL (300-1300) in groups I 720 mL (240-1200) in group II and 705 mL (250-1150) in group III (p = 0.062). The Hb and Hct values, tourniquet time (for groups II and III) and volume of blood transfusion were similar. The operative time was significantly longer for first group (p = 0.012). Using tourniquet and its intraoperative release with hemostasis, does not reduce blood loss in total knee arthroplasty, but using tourniquet reduces operation time significantly.

The influence of tourniquet use and timing of its release on blood loss in total knee arthroplasty.

Effect of fibrin sealant on blood loss following total knee arthroplasty: A systematic review and meta-analysis

Drainage is a routine practice used to reduce hematoma and blood loss following total hip arthroplasty. The aim of this study was to assess the effect of clamped drainage on blood loss and wound healing after total hip arthroplasty. A prospective cohort of 44 patients with hip osteoarthritis or femur head necrosis undergoing total hip arthroplasty was randomized equally into two groups: 6-h postoperative clamped or non-clamped suction tube drainage. Body mass index, gender distribution, preoperative hemoglobin, hip pathology, and affected side were comparable between the two groups. Blood loss, hemoglobin levels, and wound healing complications were recorded and compared between groups. The drainage blood loss and calculated blood loss volumes were higher for the non-clamped group. About 100 mL more blood loss was noticed in the non-clamped group. There was no significant difference in adverse events or need for transfusion. The present study showed a statistically significant reduction in postoperative drainage amount between clamped and unclamped drainage groups, but this difference was not large enough to warrant increased blood transfusion requirements in patients with unclamped drainage. Further studies are essential to define the critical period of clamping that is compatible with the dual objectives of reduced blood loss and lack of wound complications from hematoma.

/pdf/the-use-of-clamped-drainage-to-reduce-blood-loss-in-total-4swgl9cud7.pdf

The use of clamped drainage to reduce blood loss in total hip arthroplasty.

Objective
Blood loss following total knee arthroplasty is a serious side-effect of surgery and impacts on patient recovery and quality of life. The aim of this study was to assess the effect of postoperative knee position during recovery on blood loss and range of motion.

/pdf/effects-of-knee-position-on-blood-loss-following-total-knee-5fbulph9z2.pdf

Effects of knee position on blood loss following total knee arthroplasty: a randomized, controlled study

Objective To investigate the efficacy of autologous bone grafting plus screw fixation to reconstruct the medial tibial defects in total knee arthroplasty (TKA). Methods From November 2001 to November 2004, 46 patients (50 knees) with medial tibial bone defects underwent TKA at our hospital.There were 16 males (16 knees) and 30 females (34 knees). They included osteoarthritis (OA) (n = 35,38 knees) and rheumatoid arthritis (RA) (n = 11, 12 knees). A total of 46 patients underwent three-dimensional CT (computed tomography) reconstruction to evaluate the tibial plateau defects after osteotomy.Single or double distal femoral osteotomic bone was used to reconstruct the bone defects with the hollow nail internal fixation. Another 80 TKA patients (86 knees) were randomly selected as the control group. The surgical outcome, lateral migration of tibial component and joint line elevation, etc. were analyzed and the follow-up knee society scores recorded. Results The patients were followed up for 6 to 9 years. Two patients were lost to follow-up and 1 died of myocardial infarction at 5 years post-TKA in the test group. In the last follow-up, 1 case suffered deep infections and all others had no prosthetic loosening. One case ( 1 knee) had resorption of wedge-shaped bone graft after 8 years. The remaining graft healed and there was no screw displacement. Medial platform split fracture occurred in 3 patients (3 knees) in the OA group. The quantity of distal femoral osteotomy, thickness of polyethylene insert, tibial implant size, joint line elevation and lateral migration of tibial base were greater than the other two groups (q test, P ＜0. 05). The pre- and post-operative KSS scores had significant differences in each group ( F test, P ＜ 0. 05). But the same group showed no significant difference at 6, 9 years ( q test, P ＞ 0. 05). Conclusion As an easy and effective way of reconstructing the medial tibial bone defects, autologous bone grafting plus screw fixation can restore knee mechanical axis and stability. But in OA patients with tibial sclerosis, the complications of tibial component lateral migration, joint line elevation and splitting tibia fractures should be avoided during the reconstruction

Key words: 
Arthroplasty, repiacement,knee;  Bone remoding;  Fracture fixation

Autologous bone grafting plus screw fixation for medial tibial defects in total knee arthroplasty

【】Objective: To study whether the range
of knee flexion (ROF) is affected by geometrical mismatch of
the femoral component and the resultant change in the pos-terior condylar offset (PCO) after high-flexion posterior-sta-bilized total knee arthroplasty (TKA).
Methods: One hundred osteoarthritic patients (50 males
and 50 females) underwent femoral osteotomy by the ante-rior referencing technique. The PCO for each patient was
measured from lateral radiographs before, during and 2 years
after TKA. The thickness of the joint cartilage was mea-sured by magnetic resonance imaging before TKA and added
onto the radiographic measurement. The relationship be-tween changes in the PCO and improvements in the ROF
before, during and 2 years after TKA were statistically
analyzed.
Results: Compared with the preoperative value, the
PCO was reduced by (3.45±3.28) mm after TKA, with a sig-nificantly larger reduction observed in female patients than
male patients (P<0.05). When examining the subject popu-lation as a whole, there was a significant positive correla-tion between PCO and ROF improvement during TKA (P<
0.05), but this improvement was not maintained 2 years after
TKA (P>0.05). However, when male and female patients were
analyzed separately, there was a significant positive corre-lation between PCO change and ROF improvement for both
sexes at both time points (all P<0.05).
Conclusions: Restoration of PCO plays an important
role in the optimization of knee flexion even after posterior-stabilized TKA. Femoral components based on Caucasian
anatomic characteristics could not match the native anatomy
of distal femurs in Chinese population especially female
Chinese. Rotated resection of distal femur with anterior re-ferencing technique usually leads to a decreased PCO and
therefore reduces maximal obtainable flexion.
Key words: Arthroplasty, replacement, knee; Pros-thesis design; Range of motion, articular; Femur

Lei Wang

Papers

Effect of fibrin sealant on blood loss following total knee arthroplasty: A systematic review and meta-analysis

The use of clamped drainage to reduce blood loss in total hip arthroplasty.

Effects of knee position on blood loss following total knee arthroplasty: a randomized, controlled study

Autologous bone grafting plus screw fixation for medial tibial defects in total knee arthroplasty

Does mismatch of the femoral component aspect ratio influence the range of knee flexion after posterior-stabilized total knee arthroplasty?