Physical properties and classification of soils.
\r\n\t
",isbn:"978-1-83968-460-9",printIsbn:"978-1-83968-459-3",pdfIsbn:"978-1-83969-232-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"babca2dea1c80719111734cc57a21a4c",bookSignature:"Dr. Amin Talei",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10404.jpg",keywords:"Water Budget, Ground Measurement, Satellite Data, Empirical Models, Physical Models, Data-Driven Models, Artificial Neural Network, Neuro-Fuzzy Systems, Genetic Programming, Irrigation Management, Drought, Aquifer Management",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 29th 2020",dateEndSecondStepPublish:"November 26th 2020",dateEndThirdStepPublish:"January 25th 2021",dateEndFourthStepPublish:"April 15th 2021",dateEndFifthStepPublish:"June 14th 2021",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"A pioneering researcher in developing hydrological models using adaptive neuro-fuzzy systems, a pioneering researcher in tropical biofiltration systems, appointed head of the Civil Engineering Discipline in Monash University Malaysia.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"335732",title:"Dr.",name:"Amin",middleName:null,surname:"Talei",slug:"amin-talei",fullName:"Amin Talei",profilePictureURL:"https://mts.intechopen.com/storage/users/335732/images/system/335732.jpg",biography:"Associate Professor Amin Talei joined Monash University Malaysia in January 2013 and currently is the head of Civil Engineering discipline. His previous appointment was as researcher in School of Civil & Environmental Engineering of Nanyang Technological University of Singapore where he studied for his PhD during 2008-2011. His research is predominantly focused on hydrological modeling and flood forecasting using artificial intelligence techniques. Most recently, he has been also involved in research projects dealing with sustainable urban water management. To date, he has published over 50 articles in reputable journals and international conference proceedings. He has supervised several PhD and Master students and won the Supervisor of the Year Award in Monash University Malaysia in 2017. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"53281",title:"Soil Stabilization with Rice Husk Ash",doi:"10.5772/66311",slug:"soil-stabilization-with-rice-husk-ash",body:'\nRice husk is a by-product of the rice milling. About 100 millions of tons of husk per year are produced worldwide [1]. The husk is not suitable as animal feed because of its abrasive character and almost negligible digestible protein content [2], its high ash and lignin contents make it unsuitable as a raw material for paper manufacturing [3].
\nIn order to reduce such volume of waste, rice husk is burned either in open heaps or as a fuel in ovens for rice drying, power generation, etc. The burning volatilizes the organic compounds and water of the rice husk, and about 20% of the mass remains as rice husk ash (RHA) [2, 4–9]. If all rice husks had been burned, it would annually produce about 20 millions of tons of RHA worldwide. To value this residue is an alternative to its final disposition with environmental benefit.
\nPozzolanas are siliceous and/or aluminous materials, which in themselves possess little or no cementing properties, but chemically react with calcium hydroxide, such as lime, to form compounds possessing cementitious properties [10]. The RHA contains around 90% of silica [4, 5], which is the highest concentration of all plant residues [2]. Based upon this, RHA has been used to improve properties of soil either when added alone or when mixed with a hydraulic activator such as the cement and lime [1, 6–8, 11–16]. Soil stabilization by the addition of RHA and lime is particularly attractive for road pavements because it leads to cheaper construction and lesser disposal costs, reduces environmental damage and preserves the most highly qualified materials for priority uses [7, 8].
\nThe effect of the addition of RHA alone on the plasticity, unconfined compression strength (UCS) and California Bearing Ratio (CBR) of a lateritic soil with 45% passing the #200 sieve (75 μm), was studied by Rahman [11]. Results showed increases of UCS and CBR in 1 day with increase in RHA up to 20 and 18%, respectively, after which they started to decrease. Similarly, Alhassan [14] observed increasing of CBR with 6-day and 1-day soaking and without soaking when a clayey soil was stabilized with RHA up to 6 and 12%, respectively.
\nGenerally, RHA cannot be used alone in soil stabilization because of its lack of cementitious properties [7, 8]. Development of UCS has been observed when clayey, clayey sandy, silty clayey and silty sandy soils were treated with RHA and lime or cement [1, 7, 8, 12, 13]. In the case of cement, it was observed that little or insignificant increases of UCS in lateritic and clayey soils stabilized with RHA and cement with respect to its increase when they were treated with cement alone [6, 12]. For a given lime or cement content there is an optimum value of RHA content which corresponds to the maximum UCS, which varies depending on the type of soil, ash characteristics, hydraulic activator and curing time [1, 7, 8]. Alhassan [15] attributes the UCS decreasing after this optimum value to the excess RHA that could not be utilized for the alkaline reactions. Also, he shows that addition of RHA in clayey soil-lime specimens further increased the UCS at specified lime content. This increment was rapid between 0 and 4% RHA content but decreased in rate from 6 to 8% RHA content at specified curing period.
\nBasha et al. [8] found that a lesser amount of cement is required to achieve a given strength as compared to cement-stabilized silty sandy soil when RHA is added. Since cement is more costly than RHA, this results in lower construction cost. Ali et al. [7], evaluating the effectiveness in the improvement of a clayey sandy soil with RHA, showing that lime is a more effective stabilizing agent than cement.
\nThe aim of this chapter is to summarize experiences conducted in Uruguay to use soils improved with RHA and lime as pavement materials of low-volume roads [17–20]. First, a background of the state of the art of soil stabilization and, particularly, with RHA is performed. It is presented as results of mineralogical and reactivity characterizations of RHA with different burning processes, and unconfined compression strength improvement of different soils treated with mixtures of these ashes and lime. The results are analysed taking into account the accumulated worldwide experience, from which general conclusions are drawn.
Soils are the most widely used materials in civil engineering works, particularly in pavements. However, the properties of local soils are not suitable for the requirements of particular structures. In these cases, improving soil properties is an attractive alternative. There are essentially two forms of improvement: modification and stabilization [1, 21]. When physical properties of soil, such as plasticity, texture, volumetric stability, hydraulic conductivity and workability are improved, it is named modification, and stabilization when a significant level of long-term strength gain and durability are developed. Modification can produce important strength improvement.
\nDifferent criteria have been proposed to define whether the soil treated is modified or stabilized. Thompson [22, 23] established an optimum content of lime to stabilize the soil one which produces a UCS of 345 kPa with 28-day cured at room temperature or 48 h at 49.5°C. The criterion has been extended to soil stabilization with ashes and lime. The National Association of Australian State Road Authorities (NAASRA) divides lime-treated materials as modified and stabilized according to their fundamental behaviour under applied loadings [24]. Modified materials are used and evaluated in the same manner as conventional unbound flexible pavement while stabilized materials have a sufficiently enhanced elastic modulus and tensile strength to have a practical application in stiffening the pavement. Austroads suggests for lime modification of pavement layers 28-day UCS values between 0.5 MPa and 1.5 MPa, and for lime stabilization UCS greater than 1.5 MPa [24]. For lime stabilization, the use of pH testing together with 28-day UCS testing is recommended to establish the optimum lime content of a material, however, no mention is made on the strength to produce a lime-modified material.
\nThe strength requirements for using lime-stabilized materials as structural layers in pavement systems vary considerably from agency to agency [21]. Thompson [23] defined a lime-soil mixture as acceptable for a structural base if the UCS exceeded about 1050 kPa while some transport agencies of USA require minimal UCS values for sub-base and base layers between 700 kPa and 1400 kPa [21].
\nThe soil stabilization using ashes is explained by the pozzolanic reactions. When the lime (Ca(OH)2) is mixed with RHA, in the presence of water, it releases calcium ions (Ca++) and the pH of the medium increases above 12.4 [25]. In this high basic environment, the silicates and aluminates dissolve from the ash and react with the Ca++ to form calcium silicate hydrate (CSH) [2, 7, 8, 26]. In the case of mixture of cement and RHA, the silica reacts with the extra lime in the cement which in some cases can be as high as 60% [2]. Following James and Rao [27] the silicates formed are of the kind CSHI and CSHII, according to Eq. (1).
\nWhere
\nCSHI = CaO0.8-1.5SiO2.(H2O)1.0-2.5\x3c!-- Please check the equations given for “CSHI and CSHII”.
CSHII = CaO1.5-2.0SiO2.2(H2O)
These products of the pozzolanic reactions are primarily gels that cover and bond the soil grains causing the strength gain [7, 27, 28]. The gels slowly crystallize turning into well-defined CHS, which results in a further enhancement in strength. Pozzolanic reactions begin quickly, a few hours after adding the water to the mixture, and can continue for a very long period of time, even many years, as long as enough lime, silica and water are present and the pH remains high [21]. Ali et al. [7] show X-ray diffractograms (XRD) of mixtures of clayey sandy soil with RHA and lime cured for 7, 28 and 90 days. New peaks of calcium aluminate hydrate (CAH) and CSH appear after 7 days and continue to form after 28 and 90 days, while peaks of lime disappear at 28 days. These slow reactions cause a long-term strength gain of soils.
\nAli et al. [7] showed that addition of RHA-lime to a clayey sandy soil produces higher initial rate of UCS development. 6 and 9% RHA contents give an average increase in strength of 35 and 49% as the curing time increased from 7 to 28 days at 30°C. The rate of UCS development reduces at the later stages. The dependence of strength development on curing provides a considerable factor of safety for designs based on say 7-, 28- or 56-day strength [7]. UCS increases can be observed between 1 day and 7 day when both lime and cement were used to improve lateritic soil treated with RHA [11] and up to 28 days in a clayey soil stabilized with RHA and cement [12].
\nThe enhancement of UCS development by adding RHA is influenced by the temperature [7]. As the temperature increases, the rate of strength development is intensified, due to the crystallization of cementing minerals is accelerated. Ali et al. [7] observed a significantly higher rate of UCS development in specimens of clayey sandy soil stabilized with 612 and 18% RHA and 6 and 9% lime cured during 28 days at 60°C with respect to similar specimens cured with the same time but at 30°C.
The properties of RHA depend greatly on whether the husks have undergone complete destructive combustion or have only been partially burnt [4]. Houston [4] classified RHA into high-carbon char (black), low-carbon (grey) ash and (3) carbon-free (pink or white) ash. Colour changes are associated with the completeness of the combustion process as well as structural transformation of the silica in the ash [2]. XRD studies have shown that pink ash consists essentially of tridymite and cristobalite [4], the high-temperature crystalline forms of silica. There is little if any quartz, the low-temperature crystalline form of silica. At low-combustion temperatures considerable amorphous silica remains, giving black and grey ash. Also, white colour is an indication of complete oxidation of the carbon in the ash [2].
\nThe characteristic of the ash depends on temperature, burning time, cooling time and burning type [3, 8]. The type of ash suitable for pozzolanic activity is amorphous rather than crystallized [2]. The structural transformations of the silica affect the ash reactivity since the larger surface area of the silica the greater the extent of the chemical reactions with the Ca(OH)2 [2, 6]. Incineration of rice husk in the temperature range of 550–700°C is generally found to produce amorphous silica in the ash while temperatures in excess of 900°C produce unwanted crystallized forms [2]. However, Smith and Kamwanja [29] have reported that temperatures of about 800°C maintained for 12 h give small proportions of crystallized silica. Mehta [3] established that a highly reactive ash can be produced by maintaining the combustion temperature below 500°C under oxidizing conditions for relatively prolonged period or up to 680°C provided the high temperature exposure was less than one minute. Prolonged heating above this temperature may cause the material to convert (at least in part) to crystalline silica. Yeoh et al. [30] report that silica in RHA can remain in amorphous form at combustion temperatures of up to 900°C if the combustion time is less than 1 h, whereas crystalline silica is produced at 1000°C with combustion time more than 5 min. Other reports claim that crystallization of silica can take place at temperatures as low as 600, 500 or even at 350°C with 15 h of exposure [31].
\nTechnologies of ash production vary from open-heap burning to specially designed incinerators. When the rice husk is burned in open-heap or conventional oven, crystalline ash with low reactivity produced, while when it is incinerated in an oven with controlled temperatures, the residue is a highly reactive white ash [3]. The rice husk incinerated in oven at controlled temperature conditions between 800–900°C verified a high reactivity of the ash in comparison with the ash resulting of the open-heap burning. RHA from burning in heaps and oven-dried at 60°C showed a much scattered XRD with peaks of quartz and tridymite [7].
\nThe carbon content of RHA influences the stabilization process, retarding the reactions and producing low increases of strength. The avidity of carbon by calcium ions interfere the reactions between Ca++ and silica [32]. According to these authors, lime stabilization of soils with 6% of carbon is economically impracticable. Remaining carbon content less than 3% have been measured in a RHA obtained by burning in a simple combustion chamber at 800°C [11] and in heaps and oven-dried at 60°C [7].
Four RHA from no-controlled burning were studied (RHAU). Three RHA from rice husk burned in conventional ovens to rice drying were collected in the rice mills of Arrozur (RHAA) in Villa Sara, Arrozal 33 (RHA33) in Vergara, both in Eastern Uruguay, and Demelfor (RHAD) in Artigas, northern Uruguay. The remaining no-controlled RHA is a result of the incineration in the furnaces of the power-generation plant of Galofer (RHAG), situated in Villa Sara.
\nRHA produced in laboratory at controlled temperature and time (RHAC) was also studied. Rice husk taken from Arrozur was incinerated in an oven at 500, 650, 800 and 900°C (RHA500, RHA650, RHA800 and RHA900) for 4 h and cooled at room temperature.
Four different sandy soils were used in the researches. The soil, classified according to the Unified Soil Classification System (USCS) as well-graded silty sand (SW-SM), collected in the Perez Bustos quarry, near Montevideo (PBS). The silty sand (SM) from a quarry located in Vergara (VS) and a poorly graded sand (SP) taken from Villa Passano (VPS), both in eastern Uruguay. The reddish poorly graded silty sand (SW-SM) from the Sandstone quarry, near Artigas (SS), northern Uruguay. Table 1 shows the properties and classification of the soils. The fine content (grain-size passing the #200 sieve) is similar in PBS, VS and SS (less than 7%), while VPS has about 17% of fines. All the soils have plasticity index equal to zero (IP = 0), that is the soils are not plastic.
Property | Perez Bustos (PBS) | Vergara (VS) | Villa Passano (VPS) | Sandstone (SS) |
---|---|---|---|---|
Passing #4 (4.76 mm) | 98.6 | 100.0 | 99.8 | 99.8 |
Passing #10 (2 mm) | 89.6 | 99.9 | 91.6 | 99.6 |
Passing #40 (0.42 mm) | 26.1 | 41.0 | 13.8 | 77.6 |
Passing #200 (0.074 mm) | 6.5 | 16.9 | 3.6 | 6.2 |
USCS Classification | SW-SM | SM | SP | SP-SM |
Physical properties and classification of soils.
A commercial hydrated lime (L), mark Bulldog, produced by the Oriental de Minerales Company of Uruguay was used in the stabilization of PBS and SS. It is a calcium lime with 66% of calcium oxide (CaO), 5% of magnesium oxide (MgO) and other elements like silica and ferric oxide. The lime is fine with 100% passing the #10 sieve and 93% passing the #200 sieve, whereas 91% was greater than 2 mm.
\nThe VPS and VS were treated with a residual quicklime (RL) from Cementos del Plata Plant. This lime does not accomplish the requirements for its use as chimney filter and it is a calcium lime with CaO varying between 70 and 93%, a maximum MgO of 8% and ferric oxide (Fe2O3) between 0.5 and 4.5%.
X-ray diffraction analyses were performed on the residual RHA from the no-controlled burning in the Arrozur Mill (RHAA), RHA of controlled incineration (RHA500, RHA650, RHA800 and RHA900), PBS, mixtures of PBS with 15 and 20% RHAA and 5 and 10% lime cured for 28 days (PBS-15RHAA-5L, PBS-20RHAA-5L, PBS-20RHAA-10L), and mixtures of PBS with 15% RHA650 or RHA800 and 5% lime with 28 days (PBS-15RHA650-5L, PBS-15RHA800-5L). A dusty diffractometer with CuKα radiation and wavelength of 1.5418 Å was used. The samples were obtained from the specimens for the UCS tests once these were completed and they were milled in mortar before analysis to have a grain size less than 0.075 mm.
The organic matter content of all RHAU and RHAC was evaluated by loss on ignition tests, following the ASTM standard D7348. Samples of the RHAU were initially weighed and then subjected to a controlled temperature of 550°C during 3 h into a muffle. Because the RHAU were produced with temperatures similar or greater than 550°C, a temperature of 1000°C was adopted for tests. Thereafter, the samples were weighed after cooling at room temperature. The carbon content is the ratio between the final and initial weights of the samples.
Standard Proctor compaction tests according to AASHTO Standard T99 were carried out to determine the maximum dry unit weight (MDUW) and the optimum moisture content (OMC) of the PBS and materials of PBS treated with 20% of RHAA (PBS-20RHAA-10L) by dry weight of soil and 10% of lime by dry weight of soil. Modified Proctor compaction tests were conducted in accordance to AASHTO T180 on soils and soil-RHA-lime materials.
\nThe soils, RHA and lime were previously manually mixed in dry and thereafter various moisture contents were added and homogenized by manual mixing. The compaction was carried out immediately or 1 h after water mixing.
UCS tests of the soils and the soils stabilized with different RHA and lime contents and for different time periods were carried out following the AASHTO Standard T208. Cylindrical specimens, 3.72 cm in diameter and 7.65 cm in high were compacted into a metallic mould by kneading system at MDD and OMC of the corresponding standard or modified Proctor compaction test. The soil-RHA-lime specimens were compacted immediately or 1 h after water mixing and thereafter they were enveloped in polyvinyl film and stored in a moisture chamber at room temperature for the corresponding curing time. Finally, the specimens were tested in a triaxial load press up to failure.
XRD analyses of RHA from Arrozur (RHAA) and RHA from laboratory-controlled incineration (RHA500, RHA650, RHA800, RHA900) are given in Figure 1, where they have been dislocated in the intensity axle for better viewing. Peaks in the diffraction angles (2θ) of 21.96, 31.42, and 36.35° are observed in the XRD of the RHAA, which are characteristics of cristobalite, a high-temperature crystalline form of silica [4]. The rice husk is burned in conventional ovens in the Arrozur Mill producing a crystalline ash with low reactivity [3]. Peak of carbon is also identified in RHAA at 2θ of 26,62°, which is indication of crystallization of part of the organic of the husk during the burning.
X-ray diffractograms of residual RHA from Arrozur and laboratory-controlled incinerating RHA. Cr: cristobalite; C: carbon.
XRD of RHA500, RHA650, and RHA800 are similar and show amorphous shape, without well-defined peaks, indicating that the silica in these ashes is amorphous rather than crystalline. The XRD of RHA900 presents peaks of cristobalite similar to that of the no-controlled burning ash. An upper limit of controlled temperature to secure RHA with considerable amorphous silica would be about 800°C, if it is maintained for 4 h, beyond which they would lead to ashes with silica mostly crystallized.
\nDRX of materials of PBS treated with residual RHA from Arrozur (RHAU) and lime and with RHA burned at controlled temperatures of 650 and 800°C (RHAC) and lime are depicted in Figure 2. Peaks of quartz, corresponding to the sandy soil, remain in all the DRX because it is a crystalline mineral that cannot react with the ash and lime.
X-ray diffractograms of Perez Bustos soil treated with residual and controlled RHA and lime for 28 days. Qz: quartz; Il: illite; Cr: cristobalite; An: antigonite; L: lime; Al: albite.
The DRX of materials with RHAU (15 and 20%) and lime (5 and 10%) are similar. As was expected, peaks of cristobalite of the RHAU remain in those DRX. New peaks for 2θ of 24.37 and 35.75° of antigonite are present. This is a calcium aluminate silicate hydrate (CASH) which have been produced by the pozzolanic reactions between the Ca++ the lime and the silica of the ash. Despite the RHAU has mostly crystalline silica, it contains enough amorphous silica to react with the lime and form cementitious products. The peaks of lime mineral could be due to the exceeding lime that has not reacted before 28 days, because the alkaline reactions are slow.
\nNew peaks of albite, a calcium aluminate silicate hydrate (CAH), are observed in both DRX of materials with RHAC, which demonstrates that reactions between the amorphous silica of these ashes and the Ca++ of the lime have taken place before 28 days. The similarity among the XDR shows that the pozzolanic reactivity of the RHA is quite independent of controlled incineration temperatures within the range of 650–800°C.
\nIt is more difficult to identify the cementitious products in the DRX of the materials with RHAU than the DRX of the materials with RHAC. This would indicate that the reactivity of the RHAC is much greater than that of the RHAU, particularly within the controlled temperatures from 650 to 800°C. RHA percentages to obtain similar reactions are less in those produced at controlled temperature than in the residual ones. The use of RHA incinerated at controlled temperature within 650–800°C is a more efficient soil improving alternative.
The mean values of loss on ignition of the four RHAU studied and of the RHA produced in the laboratory at temperatures during 4 h are presented in Table 2. All the RHAU are resultant of the husk burning in conventional ovens and are black in colour and remained mainly with this colour with white veining or tended to a grey colour. The carbonized part of the organic during the no-controlled incineration cannot be volatilized when the ash is again incinerated at 550°C for 4 h. However, the RHAU have different organic contents maybe due to the type of oven, temperature gradients inside them and incineration times. The RHAU from the Galofer Power Generation Plant (RHAG) has the least organic content, which coincides with that it is the most fine and free of impurities ash. Slightly higher organic content has the RHAU from the Arrozur Mill (RHAA). This mill and Galofer Plant are located in the same place and the burning process are almost similar. RHA 33 and RHAD present a considerable amount of no burned husk, which influences the greater organic content determined. In any case, the organic content of the RHAU is greater than that considered as suitable for soil stabilization [32]
Material | Temperature (°C) | Time (h) | Loss on ignition (%) |
---|---|---|---|
RHAA | 550 | 3 | 18.6 |
RHAG | 550 | 3 | 15.0 |
RHA33 | 550 | 3 | 34.1 |
RHAD | 550 | 3 | 38.8 |
RHA500 | 1000 | 3 | 7.8 |
RHA650 | 1000 | 3 | 4.1 |
RHA800 | 1000 | 3 | 2.3 |
RHA900 | 1000 | 3 | 0.3 |
Loss on ignition of the RHA.
The organic content of the RHA noticeably decreases when the incineration is temperature-controlled. For a relatively low controlled temperature of 500°C (RHA500), the loss on ignition was 7.8% meanwhile that of RHAA was 18.6%. The organic content almost linearly decreases with the increasing of the controlled temperature. The control of temperature and the incineration method are fundamental when the objective is to produce RHA with high pozzolanic reactivity. The organic content of RHA500 and RHA650 are relatively high for soil stabilization purposes while it can be considered as allowable for RHA800 [32]. A lower limit of controlled temperature to secure a RHA with an allowable organic content would be about above 650°C, if it is maintained for 4 h.
The dry unit weight-moisture content relationship of PBS, PBS with 20% RHAA and 10% L (PBS-20RHAA-10L), SS, SS with 20% RHAD and 5% L (SS-20RHAD-5L), VPS, and VPS with 20% RHAG and 3% RL and 5% RL (VPS-20RHAG-3RL, VPS-20RHAG-5RL) are depicted in Figure 3. Figure 4 shows the compaction curves of VS and VS with 15and 20% RHA33 and 3 and 5% RL (VS-15RHA33-3RL, VS-20RHA33-3RL, VS-20RHA33-5RL).
\nDry unit weight-moisture content relationship of natural and stabilized Perez Bustos soil, Sandstone soil and Villa Passano soil.
Dry unit weight-moisture content relationship of natural and stabilized Vergara soil.
All the soils have oddly shaped compaction curves without MDD and OMC well defined. This kind of compaction curve is typically obtained in the Proctor tests of sandy soils because the impact effort used in these is not efficient to compact such soils. The most efficient compaction effort for these soils is the vibration. The compaction curves of all treated materials are similar in shape to the respective natural soils. Due to the compactions were performed immediately or 1 h after the mixing, without enough time to the development of the alkaline reactions. The addition of RHA and lime do not produce textural changes in the sandy soil, which results in a similar trend compaction curve for the stabilized material. The vibration is the most recommended compaction method for sandy soils stabilized with RHA and lime independent of the ash and lime characteristics and proportions.
\nThe dry unit weight (DUW) of all soil-RHA-lime materials are less than its corresponding natural soil for all compaction moistures. The RHA and lime have lower specific gravity and finer grain size distribution than those of the soil, so when added to a soil the specific gravity and the grain size distribution of the mixture are reduced resulting in the DUW decreasing [6, 7]. As a result the MDD of soil-RHA-lime materials are less than those of the soils (Table 3).
Soil | RHA (%) | Lime (%) | MDUW (kN/m3) | OMC (%) |
---|---|---|---|---|
Perez Bustos | 0 | 0 | 17.4 | 5.7 |
20 | 10 | 13.6 | 8.6 | |
Sandstone | 0 | 0 | 18.0 | 5.7 |
20 | 5 | 11.8 | 12.4 | |
Villa Passano | 0 | 0 | 17.4 | 4.6 |
20 | 3 | 16.2 | 10.4 | |
20 | 5 | 13.5 | 12.4 | |
Vergara | 0 | 0 | 18.1 | 13.3 |
15 | 3 | 16.8 | 14.4 | |
20 | 3 | 15.9 | 14.9 | |
20 | 5 | 13.8 | 15 |
Maximum dry unit weight and optimum moisture content of soils and soil-RHA-lime materials.
It is observed from the treatment of VPS and VS (Figures 3 and 4) that the MDD decreases as the RHA and lime contents increase, which is in agreement with findings in [6, 7, 14, 16]. However, it can be seen from Figure 4 that the DUW decreases more with the increasing of lime content than that of the RHA.
\nThe OMC is greater with the adding of RHA and lime for all studied cases (Table 3). The results are in agreement with the findings given in [6–8, 14, 16]. One portion of the water added to the mixture is absorbed by the RHA due to its porous characteristic [7, 8]. Another part is consumed by the lime hydration, which is required for alkaline reactions. The soil improvement with RHA and lime is water consuming, so it is necessary to add a greater moisture content to reduce the suction effect in the pores and to reach the greatest efficiency of compaction. Following the results of the treatment of VPS and VS, the OMC increases with increase in RHA and lime content.
Figure 5 shows the 28-day UCS evolution as function of the RHA and lime contents. A general pattern of UCS gain is observed for all RHA and lime contents. The UCS of VS and SS with 5% lime increases with addition of RHA until an optimum is reached, beyond which the strength begins to decrease. The optimum RHA contents found were about 15% for VS-RHA33-5RL and SS-RHAG-5L and about 20% for VS-RHA33-3RL. The maximum UCS were not reached with the studied RHA contents in the other cases, however they were found fitted in parabolic curves, which demonstrates that they also would have an optimum RHA content greater than 20%.
28-day unconfined compression strength of soils with different RHA and lime contents.
The 28-day UCS of VS and SS treated with 5% lime are greater than those treated with 3% lime for RHA contents up to the optimum, beyond which the strength of soils with 3% lime tends to be greater than those with 5% lime. A similar trend can be observed in the treated VPS, however the difference of UCS for all given RHA contents are practically negligible. When commercial lime is used, the most economical solution would be to adopt the least possible amount of lime even it means using greater amount of RHA since this is a residue.
\nThe maximum 28-day UCS do not achieve the 345 kPa established to consider as optimum to stabilize a soil [22, 23]. From this and following the criteria suggested by different transport agencies [21, 24], all the studied improved soils can be defined as modified materials rather than stabilized. The shear strength of sandy soils mainly depends on the confining pressure so its UCS (confining pressure zero) is very low. In fact, the UCS of the studied soils is 8.2 kPa (PBS), 5.5 kPa (SS), 0 kPa (VPS) and 15.1 kPa (VS). If modified materials are those that behave as the corresponding untreated soil, the shear strength of studied materials would also depends on the confining pressure and therefore its UCS would be relatively low. The UCS method [22, 23] was developed for soil stabilization with lime and it should be adjusted to be adequately used for soil stabilization purpose using ashes.
\nThe time dependence of the UCS of sandy soils treated with different residual RHA and lime contents is observed in Figure 6. A gain of UCS over time is observed for all studied RHA and lime combinations with a variation rate that reduces with the time. For the same lime content, the initial variation rate is higher when it is added a greater RHA content, 5.6 and 7.6 in the first 7 days for specimens with 15 and 20% RHAA, respectively, and tend to be similar at the later stages, 1.2 and 1.3, respectively, for the same materials from 7 days to 14 days. The initial variation rate is greater when it is increased the lime content maintaining constant the RHA content, 7.6 and 10.8 at 7 days when the lime content varies from 5to 10%, and tend to be similar (1.3) at the later stages. The dependence of strength development on time provides a considerable factor of safety for designs based on say 7- or 28-day strength [7].
Unconfined compression strength of materials of Perez Bustos soil modified with RHAA and lime as a function of time.
A significant increase of UCS results when RHAC are used, as can be seen in Figure 6. The UCS of specimens with 15% of these controlled ashes and 5% lime is greater than that of the specimens with RHAU for all stabilizer contents and times. The UCS of PBS-15RHA650-5L and PBS-15RHA800-5L at 28 days are, respectively, 41 and 36 times greater than that of PBS. They are, respectively, 5.1 and 4.5 times the 28-day UCS of PBS-15RHAA-5L, and 1.8 and 1.6 times 56-day UCS of PBS-20RHAA-10L. The RHA from controlled incineration at temperatures from 650 to 800°C are more reactive than the RHA from incineration in conventional ovens, being needed less amounts of RHA and lime to reach greater UCS.
\nThe UCS of tested materials with RHAC is quite similar, which evidences a similar pozzolanic reactivity for both incineration temperatures. The 28-day UCS of soils modified with RHAC and lime cured for 28 days would be independent of the incineration temperature within the range of 650–800°C.
The improvement of soils through addition of rice husk ash (RHA) and lime was studied in several researches. Four sandy soils from different locations of Uruguay and four residual RHA (RHAU) produced in conventional ovens were used for this objective. RHA produced in laboratory with controlled temperature and time (RHAC) were also investigated. Results and analysis of these researches allow to draw the following conclusions:
\nAll the RHAU are black in colour, classifying as high-carbon char, with less or more presence of no burned husk. The RHAU from power-generation oven (RHAG) is the finest and has negligible rice husk content. The X-ray diffractogram (XRD) of the RHA resultant of rice husk incineration in conventional oven of the Arrozur Mill (RHAA) shows peaks of cristobalite, a high-temperature crystalline form of silica and carbon from the crystallization of part of the organic. The organic content of the four RHAU is high to very high, greater than the considered as suitable for soil stabilization. The RHAG has the least loss on ignition, followed by RHAA. The higher loss on ignition is due to the no burned husk presents in these ashes. As the type of ash suitable for pozzolanic activity is amorphous rather than crystallized and with low organic content, the studied RHAU can be defined as low to moderately low ashes.
\nThe RHAC show XRD without clear peaks for incineration temperatures from 500–800°C, indicating that the silica in these ashes is amorphous rather than crystalline. Peak of cristobalite is observed in the RHAC from husk incineration at 900°C. An upper limit of controlled temperature to secure RHA with considerable amorphous silica would be about 800°C, when it is maintained for 4 h. The loss on ignition reduces respect to the RHAU when the incineration is controlled at temperatures between 500 and 900°C, so that is less the greater the temperature. However, the organic content of ashes produced with temperatures until 650°C are still unwanted for soil stabilization purposes, while it is allowable for the ashes incinerated at temperatures equal or greater than 800°C. A lower limit of controlled temperature to secure a RHA with an allowable organic content would be about 650°C, when it is maintained for 4 h. Incineration of rice husk in the temperature range of 650–800°C is found to produce RHA of the highest pozzolanic reactivity.
\nThe DRX of soil treated with RHAU and lime with 28 days show new peaks of antigonite. This is a calcium aluminate silicate hydrate resultant of the reactions between the calcium ions of the lime and the silica of the ash. Despite the RHAU is low reactive, it is still capable to react with the lime to form cementitious products. New peaks of albite, a calcium aluminate silicate hydrate resultants of the reactions between the calcium ions of the lime and the silica of the ash, are observed in the DRX of materials with RHAC and 28 days. When the lime is mixed with RHA, in presence of water, pozzolanic reactions take place to produce cementitious products as calcium silicate hydrate (CSH) and calcium aluminate silicate hydrate (CASH).
\nThe unconfined compression strength (UCS) of soils is improved with adding all RHAU contents. Despite these ashes are low reactive, they can react with the lime to from cementitious products that bond the grains of sandy soils improving their strength. However, the 28-day UCS does not achieve the values established by different transport agencies to consider the soils as stabilized. The materials of soils improved with RHAU and lime can be defined as modified rather than stabilized. Although, modification can produce important strength gain.
\nThe UCS increases with the increase of the RHAU amount until to reach an optimum, beyond which the strength begins to decrease. The optimum RHAU is higher when the lime amount is less, however it is possible to reach higher UCS when is added the least amount of lime and RHAU contents higher than the optimum corresponding to higher lime contents. When commercial lime is used, it would be a more economical solution since the RHA is a residue.
\nA gain of UCS over time is observed for all studied RHA and lime combinations. Pozzolanic reactions begin quickly and continue for a very long period of time, even many years, as long as enough free calcium ions and silica are present and the pH remains high. The UCS increase rate is greater at starting and reduces at the later stages.
\nIn countries with high rice production, rice husk and RHA are residues whose final disposition is a big concern, the use of RHA for soil improvement is particularly attractive. It reduces the environmental impact, disposal costs and preserves non-renewable resources such as soils and rocks. It is an economic alternative, particularly in roads, by giving value to a waste material, enabling the use of low-quality materials with reducing transport costs, and improving the pavement performance with reducing maintenance and rehabilitation costs.
Please provide the volume number for Ref. [13].
Please provide the location details for Ref. [21].
Total knee arthroplasty is an effective treatment option which has been applied with increasing rates in recent years with its highly satisfactory results. Recently increased total knee arthroplasty (TKA) procedures increase the number of complications too. In addition to proper patient selection, an accurate surgical technique, early diagnosis, and proper management of complications are required. Complications of TKA have a wide range. Complications vary from small skin problems to mortality. The development of complications may be due to many factors. Some of these are listed below:
Error in surgical technique.
Medical error.
Nurse error.
Patient non-compliance.
Trauma.
Associated comorbid diseases.
Reviewing all the risk factors before surgery and being prepared for the complications that may occur may be lifesaving in TKA, which is currently applied frequently. It is important to recognize, identify, and classify the complications in a timely manner in the correct and effective management of complications. The ambiguity about the complications of TKA in the literature helped identify and classify the complications in a study conducted in 2013 by the knee community [1]. According to this study, 22 complications were described. These are [1]:
Bleeding
Wound problems
Thromboembolism
Neural deficit
Vascular issues
Medial collateral ligament injury
Instability
Malalignment
Stiffness-toughness-contracture
Deep wound infection
Fracture
Extensor mechanism injury
Patellofemoral dislocation
Tibiofemoral dislocation
Bearing surface wear
Osteolysis
Implant loosening
Implant breakage
Reoperation
Revision
Re-hospitalization and mortality [1]
When the complications are examined, it is seen that some of them are simple and easy to overcome with a short-term solution, while some of them can be serious and can go to revision arthroplasty. The number of complications such as implant fracture and polyethylene surface wear has been reduced due to the techniques and innovations in implant materials and designs. In a study, it was shown that the most common cause of revisions in the first 5 years postop was infection, and the reasons for revision in the next 5 years were polyethylene loosening [2]. Complications will be classified as intraoperative, early postoperative, and late postoperative complications (\nTable 1\n\n).\n
\nIntraoperative | \nEarly postoperative | \nLate postoperative | \n
---|---|---|
Vascular injuries | \nBleeding | \nInstability | \n
Neurological complications | \nSuperficial skin problems | \nJoint stiffness | \n
Extensor mechanism injury Patellar tendon injury Quadriceps tendon injury Patella fractures | \nDeep skin problems | \nPeriprosthetic joint infection | \n
Deep vein thrombosis | \nPeriprosthetic fractures | \n|
Pulmonary embolism | \nAseptic loosening | \n|
\n | Osteolysis | \n|
Medial collateral ligament injury | \n\n | Patellofemoral joint problems | \n
Intraoperative, early postoperative, and late postoperative complications.
Although arterial injury during knee replacement is rare, it may have serious results from limb loss to mortality. Arterial injuries can be seen as thromboembolism, direct vascular laceration, pseudoaneurysm, and arteriovenous fistula [3]. The incidence is reported to be 0.03–0.2% in the literature [4].
\nVascular injuries may develop due to the thermal effect of cement polymerization, joint manipulations, dislocations, and excessive manipulation [5]. Considering the issue as specific to the total knee arthroplasty, care should be taken against vascular injury during posterior cruciate ligament and posterior capsular release during femoral condylar cutting. Atypical localization of vascular structures due to changes in adhesions and normal anatomy in revision cases increases the risk of vascular injury twice as compared to primary cases [6]. Nowadays, increasing procedures of TKA bring about the possibility of vascular injuries although they are rare. Therefore, it is necessary to take precautions against vascular injuries that may develop, to identify risky patients and to make an early diagnosis. For this, a good anamnesis and physical examination are essential. It is important to examine the presence of hypertension, diabetes, smoking, and vascular claudication. Coldness of the extremities to be operated during physical examination, skin atrophy and thinning, prominent vascular structures, ulcerative wound, and distal arterial pulse weakness are the findings that need attention. In addition to these findings, the presence of vascular calcifications in radiological scanning, a history of bypass, and an ankle-brachial index below 0.9 are other findings that should be considered. No tourniquet should be used in patients with the abovementioned conditions [7]. Embolism and arterial insufficiency may develop due to tourniquet effect in patients with vascular disease and atheroma plaque in the superficial artery [8]. It has been shown that during the manipulation of the superficial femoral artery fixed during tourniquet effect, intimal damage may occur [9]. Improper placement of retractors can also cause damage by direct mechanical trauma [10]. Particularly during insertion of the posterior retractor, a 1 cm area in the lateral portion of the midline was identified as a risky area [11]. In a cadaver study, neurovascular structures on the tibial side were mapped on a clock diagram. Accordingly, the popliteal vein at 12 o’clock, the popliteal artery at 1 o’clock, and the anterior tibial artery at 2 o’clock for the left knee were shown as in place [12]. Cautious use of the saw between 11 and 3 o’clock defined in the tibial cutting is important in protecting vascular structures [12].
\nIf vascular injury is suspected the tourniquet should be deflated, and bleeding control should be performed before the incision is closed. The possibility of arterial injury should be taken into consideration in the presence of excessive and pulsatile bleeding and in the absence of peripheral pulses. Although recent studies suggest bleeding control after routine tourniquet deflation prior to incision, its benefit is controversial [13]. The surgeon should perform a postoperative peripheral pulse examination routinely, suspect acute ischemia in the presence of cold and delayed distal capillary filling, and request cardiovascular consultation [14]. Acute ischemia cases with delayed diagnosis of 4–6 hours cause irreversible damage. Prophylactic fasciotomy is performed after revascularization [14].
\nPseudoaneurysm may present with pulsatile swelling in the popliteal fossa due to direct damage to the popliteal artery during surgery. Doppler ultrasonography is useful in the diagnosis. In the treatment, excision of the lesion and repair with vascular graft is applied after embolization [15]. Arteriovenous fistula is less common. It usually occurs due to injury to the medial and lateral geniculate arteries and its branches. It may present with pulsatile swelling in the popliteal region that gives “trill.” Hemarthrosis or pseudoaneurysm may develop. Ultrasound and angiography are used for diagnosis [16]. The detected lesions should be evaluated together with cardiovascular surgery, and treatment should be planned. Embolization, lesion excision, and graft repair are treatment options [15].
\nNerve injuries are rare during TKA. Peroneal nerve injury is the most common of these [17]. Sacral plexopathy and sciatica neuropathy are also seen, although rarely [18]. Risk factors for neurological injury are [19]:
Flexion deformity
Advanced valgus deformity
Presence of an intra-articular hematoma
It has been shown that the risk of nerve injury is increased in patients with rheumatoid arthritis [20]. However, none of these risk factors is directly related to nerve injury [18]. Nerve injury is associated not only with the surgical procedure but also with the anesthesiologist-induced regional anesthesia [21]. Hypertension, diabetes, nerve compression history, presence of tethered cord, and rheumatoid arthritis in the patients increase the risk of neural complications secondary to regional anesthesia [22]. The duration of tourniquet use was associated with nerve injuries. According to this, in the tourniquet applications exceeding 2 hours, the risk of peroneal and tibial nerve injuries including 89% peroneal nerve was determined as 7%. All of these have been shown to get recovery. In procedures exceeding 2 hours, the 10–30-minute break and deflation of the tourniquet reduces the complication rate [19]. Although there is a minimal effect on the functional results of the patients effect on the functional results of the patients during the follow-up, paresthesia and numbness are seen in the distal and lateral site of incision due to the injury of the infrapatellar branch of the saphenous nerve. It is seen in the literature at a rate of 25–76%, and most of these recover spontaneously [23]. Nerve injuries are difficult to detect intraoperatively. In the presence of postoperative nerve injury, physical therapy should be planned immediately. EMG examination is recommended after 3 months [20]. If no improvement is observed, nerve exploration may be planned in the future.
\nThe extensor mechanism in the knee joint consists of quadriceps muscle group, quadriceps tendon, patella, patellar retinaculum, patellar tendon, and tuberositas tibia. Extensor mechanism integrity may be impaired during surgery [20]. Although extensor mechanism injuries occur more frequently postoperatively, they may also occur intraoperative. The incidence is reported to be between 1 and 12% [24]. The treatment of extensor mechanism injuries is quite difficult and the results are not satisfactory.
\nRupture usually occurs at the site of insertion to the tuberositas tibia. The risk of development is less than 1% [25]. Less frequently, intratendinous and infrapatellar tendon rupture may also occur [25]. The risk of injury increases when patellar tendon mobility decreases. These are [26]:
Patella baja
Previous surgery
Severe limitation of movement in the knee
The risk of tendon injury especially on stiffness knees due to forced manipulations and during the tibial bone cutting increases during surgery. The most common injury mechanism after surgery is falling onto the knee while knee is flexed [27]. Patellar tendon injury without trauma is seen by weakening the tendon after repeated contact of the polyethylene insert [27].
\nIn patients with patellar tendon rupture, pain, swelling, loss of extension, and a palpable defect at the infrapatellar side are detected.
\nAge, functional status, tendon rupture localization, and soft tissue status are the determinants of the treatment. Splitting and bracing are considered in patients who do not have functional expectations and are unsuitable for surgery [28]. Treatment of acute patellar tendon rupture intraoperative is primary repair [26]. Several techniques have been described using staple and suture anchors for this purpose [28]. Reconstruction techniques are used in patients with poor soft tissue quality. For this purpose, biological materials (hamstring tendon autograft, achilles, peroneal tendon autograft, and extensor mechanism allograft) and synthetic materials can be used [28, 29, 30].
\nIt is very rare. It is especially seen as a rupture from the intersion side to the patella. Excessive patella cutting, previous quadriceps snip, or V-Y tipping are risk factors [28]. The clinical finding is similar to patellar tendon rupture.
\nGood results have been reported with plaster cast in partial tears [31]. Extensor loss greater than 20° is considered a complete tear and should be treated surgically. It has unsatisfactory results due to high complication rates and tendency to re-rupture depending on tendon quality and soft tissue condition.
\nPatellar fractures are the most common injury among the extensor mechanism injuries [24, 32]. In general, the risk increases with excessive bone cutting while preparing for patellar component. Patellar fracture may occur by direct trauma to the anterior knee or as an avulsion due to the pull of the quadriceps muscle [32].
\nFor diagnosis, pain, swelling, and extensor insufficiency are detected in front of the knee. Lateral knee radiography and tomography in case of clinical suspicion are helpful imaging methods for the diagnosis.
\nA classification has been developed to assess implant stability and extensor mechanism continuity for periprosthetic patella fractures [33]. Type 1, a stable implant and continuous extensor mechanism; Type 2, a stable implant but a discontinuous extensor mechanism; and Type 3, which indicates instable implant and discontinuous extensor mechanism. Patellar bone stock is classified as 3A if good and 3B if poor. Treatment is also determined according to this classification. Conservative treatment methods are preferred for type 1 cases, while surgical treatments are preferred for types 2 and 3 [33]. In recent studies, it is reported that 40–50% of complications occur and more than half strength loss of extensor mechanism is observed [34].
\nDuring total knee replacement, medial collateral ligament (MCL) is important for soft tissue stabilization and coronal plan stability. The incidence of iatrogenic MCL injury is 2.2–2.7% [35]. In the case of surgical injuries, direct repair, constrained prosthesis use, and even revision at the same session are among the options [36]. Unrecognized MCL injuries during surgery cause early instability. This leads to early implant wear and consequently the need for early revision. Therefore, it is important to diagnose and repair the injury during surgery [37]. Sudden instability in the valgus stress test during knee stabilization indicates MCL injury. Injury may occur from femoral insertion, within the tendon or tibial insertion [38]. Primary repair technique varies according to injury level. Fixation with screw is recommended if MCL injury occurs from its femoral insertion site. Otherwise, if it is through tendon, repairing with insoluble suture technique is recommended. Finally, if MCL injury occurs from its tibial insertion site, both insoluble suture anchor technique and fixation with staple technic are recommended [39, 40]. Factors that increase the risk of medial collateral ligament injury during surgery are as follows [39]:
Using a larger saw blade than femoral condyle
Delayed excision of medial side osteophytes
Performing challenging manipulations of varus-valgus
Patients with flexion contractures [39]
Patient-related risk factors include obesity and severe deformities [41, 42].
\nA certain algorithm has not yet been established for the treatment of iatrogenic MCL injuries that occur intraoperative. Many treatment methods with disadvantages and advantages have been used [39, 43, 44]. The traditional method is using constrained prosthesis. However, in this method, it was shown that the stress load on the implant increased and direct repair and treatment with non-constrained prosthesis were recommended instead. In addition, augmentation or increase in polyethylene thickness has been proposed [45]. In one study, it was shown that the risk of instability was 57% in the use of non-constrained prostheses independent of the repair technique after MCL injury [37]. In a 2016 study, four treatment modalities were compared after MCL injury. These are the use of non-constrained prosthesis only, the use of non-constrained prosthesis with primary repair, the use of non-constrained prosthesis only, and the use of constrained prosthesis with primary repair. In 23 patients, the most appropriate treatment method according to the knee community scoring was found to be the use of constrained prosthesis only [46]. However, due to the small number of patients, larger series of studies are needed to determine which treatment is most appropriate.
\nBleeding is seen in varying rates between 0 and 39% after TKA [47]. This naturally increases the need for blood transfusion. Intraoperatively, care should be taken about bleeding and good bleeding control is established. Thus, the amount of bleeding is reduced to a minimum. As a result, the risks of immunological reaction due to transfusion are reduced.
\nBleeding tolerance is low in patients with comorbid disease and in patients with insufficient cardiac capacity, and the risk of complications increases even in small amounts of bleeding. Preoperative blood preparation before surgery and limitation of the use of anticoagulants are among the measures that can be taken. Precautions during and after TKA surgery can reduce the amount of bleeding. These methods are as follows:
Use of femoral intramedullary plugs [48]
Hypotensive anesthesia [49]
Cryotherapy and Jones bandage [50]
Application of tranexamic acid [55]
Fibrinolysis is activated by surgical trauma and tourniquet use [56]. Increased fibrinolytic activity causes increased bleeding during TKA. Tranexamic acid shows an anti-fibrinolytic effect by inhibiting the conversion of plasmin to plasminogen [57]. Tranexamic acid can be administered in four different ways: intravenous, oral, intramuscular, and intra-articular [55]. Transition to maximum plasma levels is 30 minutes for intramuscular use, 5–15 minutes for intravenous use, and 2 hours after oral use [58]. Patients with total knee arthroplasty may be treated with a fast-acting intravenous route. Many studies have shown that administration of tranexamic acid after tourniquet deflation and postoperative dose repeat reduces the amount of bleeding and the need for transfusion [59, 60, 61]. However, many different protocols for the use of tranexamic acid have been implemented. Preoperative single dose and repeated dose every 8 hours for 3 days have been described in the literature and shown to be effective [62]. In a study conducted in 2011, tranexamic acid was administered at a dose of 10 mg/kg 10 minutes before the tourniquet was opened, and the same dose was repeated 3 hours postoperatively. Five hundred mg tranexamic acid was administered orally 3 times a day for 5 days. At the end of this study, it was shown that the amount of hemorrhage and the rate of transfusion decreased effectively [55].
\nThe incidence of wound problems after TKA is 1–25% [63]. The skin problems may be delayed wound healing, skin necrosis, traumatic or atraumatic separation of the lips of the wound, prolonged serous discharge at the wound site, formation of superficial or deep hematoma, allergic reaction to patch, suture material or dressing materials, bullae formation, fat necrosis, bleeding, keloid formation, and superficial or deep infection [64].
\nEtiologic reasons that may develop the problem before TKA should be determined in advance, and appropriate measures should be taken [65]. Presence of systemic diseases such as diabetes, hypertension, rheumatoid arthritis, and vascular insufficiency, which may adversely affect wound healing before TKA, should be questioned. Since the soft tissues around the knee are thinner than the other parts of the body, even the smallest problem that may occur at the wound site can cause serious complications. Incision planning should be made carefully in the case of a history of operation from the same place and scarring beforehand, and if necessary, plastic surgery assistance should be taken.
\nFactors adversely affecting wound healing are obesity, hypertension, diabetes, smoking, chronic drug use, steroid use, previous radiotherapy, scarring, inflammatory disease, malnutrition, albumin levels below 3.5 g/dl, and hemoglobin levels below 10 g/dl. Transferrin and lymphocyte levels may also contribute to wound healing problems [66]. Therefore, a detailed anamnesis and physical examination and laboratory examination before surgery give an idea about possible skin problems. Accordingly, measures are taken, replacement therapies are given, and surgery may be postponed until the current pathology is corrected, if necessary. Adjustment of fasting blood sugar levels below 200 g/dl and keeping HbA1C below 6.5 in patients with diabetes will reduce the risk of possible wound problems [67].
\nPatients with a body mass index above 30 kg/m2 are 6 times more likely to have infection and wound problems [66]. In obese patients, dietician support should be given before surgery; unnecessary exclusion should be avoided during surgery, and soft tissue surgery should be applied carefully.
\nA study of smoking patients showed that there were 2 times more wound problems [65]. Because of the vasoconstrictor effect of nicotine in the cigarette, it is recommended to quit smoking 60 days before surgery due to decreased blood supply at the wound site.
\nIncision planning should be performed in the presence of scar after previous surgery. In the presence of a single longitudinal incision without problems, the same incision should be used. If the old incision cannot be used, a distance of at least 7–8 cm should be left. If there is more than one old incision scar in the anterior part of the knee, the most lateral scar is used considering that the anterior knee feeding is from the medial perforating artery. In addition, the lateral soft tissue flap should not be dissected too much [65]. Unnecessary retractors and additional soft tissue damage should be avoided during surgery. The wound lips should be exactly opposite to each other. Overstretched closing should be avoided. This should be checked with capillary filling time.
\nEspecially in patients with risk factors, it should be performed without tourniquet or at low pressures [65]. Difficult rehabilitation in the early postoperative period should be postponed if possible until it is ensured that there are no wound problems.
\nHematoma formation increases the risk of infection [65]. Therefore, measures should be taken to prevent the formation of hematoma. These include no dead space during wound closure, good bleeding control, use of a Jones bandage, and avoidance of overdose of the prophylactic anticoagulants used [65, 68]. Once the hematoma has developed, a needle aspiration can be performed. However, if the hematoma is organized and the drainage cannot be achieved, discharge and debridement can be achieved by arthrotomy under operating room conditions.
\nThe presence of necrosis in the wound leads to catastrophic consequences. Respect to soft tissue is the most important step to prevent necrosis development. The depth of necrosis is important. Superficial necrosis can be treated by local intervention. If larger, debridement and full-thickness skin grafts or fasciocutaneous flaps are required [69]. If necrosis includes full-thickness soft tissue, closure with fascial skin or muscular skin graft should be performed after urgent aggressive debridement [70].
\nDespite all current precautions, surgical site infections remain the most serious and feared complications of TKA. After TKA, patients should be followed up with daily dressings, and wound discharge should be evaluated carefully. Prolonged wound discharge is defined as a discharge that lasts more than 48 hours regardless of the amount of drainage [64]. Wet wounds greater than 2×2 cm are considered abnormal after 72 hours and are associated with fat necrosis, hematoma, necrosis, or poor closure of the fascia. They are reported as 1–10% after primary knee replacement [65]. In the early stage of treatment, usually dressing and immobilization for 3–5 days is recommended [71]. Continuous discharge for 72 hours is dangerous. If it exceeds 5 days, debridement should be applied in operating room conditions as it will increase the risk of superficial or deep infection [64].
\nSuperficial infection: It is defined as infection of the soft tissue above the skin—subcutaneous and deep fascia that has not passed under the deep fascia, not opened into the joint cavity. It occurs most frequently in the first 30 days after surgery. The incidence of superficial infection after TKA has been reported as 10% [72]. It may occur through direct contamination or blood. Improper preparation of direct contamination sterilization environment, inadequate surgical field preparation, presence of sloppy surgical team, non-sterile dressing materials, and application may occur as a result of the presence of infected patients in the same environment [73]. The risk of direct contamination can be minimized by precautions. Hematogen contamination can occur if there is any other focus of infection in the body. Therefore, in the presence of a possible infection focus with detailed anamnesis and examination before the operation, the current focus treatment can be planned through detailed examination.
\nInfection after TKA can be evaluated as patient-related risk factors, surgical intervention-related factors, and postoperative factors [66, 68, 74, 75, 76, 77].
\nPatient-related risk factors include advanced age, previous knee surgery, previous knee infection, steroid use, presence of inflammatory disease, obesity, diabetes, smoking, intravenous drug use, hematologic diseases, oncologic diseases, above ASA score 2, immunosuppressive use, regional skin problems, old incision scars, previous radiotherapy procedures, malnutrition, vascular insufficiency, albumin level below 3.5 g/dl, transferrin level below 200 mg/dl, hemoglobin level below 10 g/dl [78, 79].
\nSurgical intervention related risk factors include prolonged surgical time of more than 2 hours, absence of laminar flow in the operating room, transfusion, use of hinged knee prosthesis, failure of surgical team to comply with asepsis, and sterility rules [80].
\nOperative period related risk factors include prolonged hospital stay pre- and postoperative, lack of appropriate antibiotic prophylaxis, hematoma formation, and prolonged wound drainage for more than 5 days [81].
Superficial wound infection is considered with the presence of at least one of the following: discharge from the wound incision, culture of the wound from aseptic conditions, suspicion of infection in clinical evaluation, disproportionate pain, increased temperature, erythema, and localized swelling [79].
\nIn superficial wound infection, unlike deep infection, there is no progressive change in erythrocyte sedimentation rate, C-reactive protein level, and peripheral leukocyte count; the increase is below 25% [82]. In addition, leukocytes in synovial fluid are detected less than 2000/ml, and polymorphonuclear leukocytes are detected under 50%. Alpha defensin and leukocyte esterase tests are negative [71].
\nWhen superficial wound infection is detected, the development of deep infection can be prevented by early intervention. Otherwise, it may develop into periprosthetic infection and cause catastrophic results. In the presence of superficial infection, local wound care due to the underlying cause and debridement should be performed if appropriate anti-therapy is required [80]. In the selection of antibiotics, consultation with infectious diseases should be requested. Antibiotherapy is continued after reproduction. If deep infection is excluded in surgical debridement, the joint should not be opened, and the implant should not be touched [83]. Hyperbaric oxygen therapy has a positive effect on appropriate patient selection [84].
\nDeep vein thrombosis is the general name of thrombosis in the venous circulatory system. It occurs most commonly in the deep veins of the lower extremity [85]. From asymptomatic deep vein thrombosis to pulmonary embolism, which can be fatal, it can be confused with clinical manifestations of varying degrees [85]. It is one of the important complications that increase morbidity and mortality after TKA [86]. Even with mechanical or pharmacological methods, the incidence of asymptomatic DVT is 5.1%, and the incidence of symptomatic DVT is 0.4% [87]. The mortality rate due to pulmonary embolism after TKA is 0.08% [88].
\nIt is important to understand the Virchow triad in the pathogenesis of DVT development. There is a slowdown in blood flow (stasis), endothelial damage, and hypercoagulability [89]. The admixture of fat and bone marrow particles into the venous system after engraving of the femoral canal during TKA explains the hypercoagulability branch of the Virchow triad. Hyperflexion of the leg during surgery and anterior manipulation of the tibia with retractors explain endothelial damage. In addition, this manipulation causes obstruction of the popliteal veins and prolonged immobilization of the leg, leading to venous pooling and stasis [89].
\n\n
VTE risk increases after age of 40 and doubles every 10 years after that age [90]. Age increases the risk of VTE regardless of other risk factors.
Genetic factors are also an important parameter that increases the risk of DVT. Factor V Leiden mutation that causes thrombophilia, as well as protein C, protein S, and antithrombin III deficiency are among the factors that increase the risk of DVT.
Although tourniquet use has been reported to cause venous stasis, it has been shown that it does not significantly increase the risk of DVT because of its fibrinolytic effect [91, 92].
The type of anesthesia also affects the risk of developing DVT. General anesthesia has been shown to increase the risk of DVT compared to neuraxial anesthesia (spinal or epidural). Neuroaxial blockade causes vasodilatation in the lower extremities and reduces venous pooling; therefore it explains the mechanism of action [93].
Other risk factors that increase the risk of DVT are immobilization, smoking, oral contraceptive and hormone use, history of VTE, obesity, malignancy, and difficult knee manipulations.
A painful, swollen, and reddened leg after TKA should suggest the possibility of DVT. Incomplete DVTs usually do not show signs. Incomplete DVTs are seen especially after arthroplasty. Clinical findings are seen in 1% of all DVT cases. Physical examination findings include redness, swelling, and Homan’s sign test and Pratt test positivity. Clinical Wells risk score was established for the diagnosis of deep vein thrombosis [94]. Clinical Wells Scoring criteria are malignancy, paralysis (paresthesia or splinting lower extremity), immobilization for more than 3 days, localized tenderness in the deep venous system, swelling of the lower extremity, 3-cm-diameter differentiation from the other leg, pretibial gode positive edema, history of deep vein thrombosis, and collateral superficial veins. The presence of each risk factor was evaluated as 1 point, and clinical scoring of 3 and above was found to be a high risk for the development of deep vein thrombosis.
\nClinical data are not sufficient for the diagnosis of DVT. Therefore, further examination with clinical risk scoring, D-dimer level, Doppler ultrasonography, contrast-enhanced venography, CT, and MRI should be performed. Venography is the best method for the diagnosis of DVT in the lower extremities. The accuracy rate was 97% in the lower extremity veins and 70% in the iliac veins [95]. Venography is not preferred as first-line imaging because it has a 3% risk of DVT and is an invasive method, and also it requires contrast matter that can be toxic to the kidneys. Doppler USG is the most commonly used first-line imaging method because of its cheapness, reproducibility, and patient comfort in the suspicion of DVT. Proximal DVT sensitivity was 96%, distal DVT sensitivity was 44%, and DVT specificity was 93% [96].
\nPulmonary embolism should be suspected in the case of sudden shortness of breath, tachypnea, tachycardia, and chest pain after TKA. However, since there are many other diseases with these findings, risk factor assessment and effective differential diagnosis should be made. Wells pulmonary embolism clinical probability scoring was established [97]. Pulmonary angiography is the gold standard for the diagnosis of pulmonary embolism [85].
\nPrimary treatment of DVT and related pulmonary embolism is very difficult and cost-effective. Therefore, it is more plausible to establish protocols that prevent the development of DVT and to give ideal prophylaxis. Many pharmacological and mechanical prophylaxis methods are available. The aim is to prevent the development of DVT and not to increase bleeding. Therefore the drug or method of choice should be patient-specific:
\nMechanical prophylaxis: The aim is to reduce venous stasis by compressing the lower extremity and to increase fibrinolysis. The risk of hemorrhage is very low, and, if applied correctly, there are almost no complications. Patient compliance is important in mechanical prophylaxis and is the only negative aspect of the method. Mechanical prophylaxis methods include early mobilization, in-bed exercise, use of antithromboembolic socks, and pneumatic compression devices. It has ben shown that intermittent pneumatic compression devices provide as effective prophylaxis as chemical prophylactic agents, and the American College of Chest Physicians (ACCP) recommends the use of mechanical prophylaxis [98].
\nChemical prophylaxis: Many agents are used. They all have their own advantages and disadvantages. Risk factors are determined by patient-based evaluation and the most appropriate agent should be preferred:
\nK vitamin antagonist warfarin: It prevents the formation of fibrin by inactivating 2, 7, 9, and 10 of the clotting factors. It also inhibits the activation of fibrinolysis-causing protein C and S. Since this effect occurs earlier, it creates a temporary clotting condition. Patients with warfarin should therefore be heparinized until the effect on coagulation factors begins. The anticoagulant effects of warfarin are reversible and monitored by the international normalization rate (INR) measurement. Interaction with other drugs, narrow confidence interval, and dual effect have recently reduced the usage of post-TKA [99, 100].
\nHeparin: It acts by inactivating circulating antithrombin III. Antithrombin III also inactivates circulating factors 2, 9, 10, 11, and 12. The use of standard heparin has recently been restricted due to the low risk of bleeding due to low-molecular-weight heparin.
\nAcetylsalicylic acid: It acts as an anticoagulant by blocking thromboxane A2, which is necessary for platelet aggression. Recent studies have shown that VTE can be used prophylactically [101].
Other oral anticoagulants that may be used: rivaroxaban (direct factor Xa inhibitor), apixaban (direct factor Xa inhibitor), and dabigatran (direct thrombin inhibitor).
The development of instability after TKA is the third most common cause of revision (17%) after aseptic loosening and infection [102]. Patients present with signs of pain and swelling with movement and weight loss. There may also be pain, emptiness, or abnormal friction and rattling noise in some range of motion. On the knee during walking, varus or valgus orientation and recurvatum can be seen. Anterior knee pain during sitting up is typical in flexion instabilities. The heaviest table is knee dislocation. The treatment of instability is revision surgery. However, the rate of recurrent instability after revision was 18–60% [103]. This high rate is usually due to the lack of correct identification of the cause of instability.
\nA clinical classification of knee instability was established. Components of this classification are flexion-extension gap mismatch, component alignment problem, isolated ligament failure, extensor mechanism failure, component loosening, and global instability [103].
\nThe success of total knee replacement depends on the correct alignment of the lower limb mechanical axis. It is recommended that the postoperative lower limb mechanical axis should be in neutral alignment. The tibial cut surface in the coronal plane should be made perpendicular to the mechanical axis of the tibia. Similarly the femoral cut in the coronal plane should be made perpendicular to the mechanical axis of the femur. It is necessary for a stable knee to obtain a rectangular gap in both flexion and extension after bone incisions and soft tissue release in TKA. Balancing the gaps is important to ensure stability and for full range of motion. Flexion gap controlled by posterior femoral condylar cut and tibial cut. Extansion gap controlled by distal femoral condylar cut and the tibial cut. If there is a symmetric gap problem, tibial bone cut is adjusted first; otherwise if there is asymmetric gap problem, adjust femoral bone cut first. For example, if the knee is tight both in extension and flexion, it is called symmetrical gap problem, and its solution is to cut more proximal tibia. The asymmetric gap is one of the most common causes of instability. In some patients, the underlying cause increases the risk of instability. These reasons can be listed as follows:
Knee with advanced deformity.
Regional muscle weakness.
Neuromuscular disease.
Internal side ligament or posterior cruciate ligament failure.
Obesity and rheumatoid arthritis.
Charcot arthropathy
It is necessary for a stable knee to obtain a rectangular gap in both flexion and extension after bone incisions and soft tissue release in TKA. If the cavity is larger than the prosthesis, the term symmetrical discrepancy is used. The reason for this instability is that the distal femoral incision or the tibial incision is more than necessary [85].
\nIf the tibial incision is excessive, both extension and flexion will be loose. If this condition is noticed intraoperatively, it is thought that the problem is solved with a thicker insert, but in fact, both the patellofemoral joint problems can arise as the joint line will go down more inferiorly and the early relaxation and fixation problems can arise because the tibial component will sit on the narrower surface.
\nIf the distal femoral incision is excessive, there will be looseness in the extension range. The use of a thick insert during surgery will improve the looseness of the extension, but there will be tightness in flexion [104]. In addition, as the joint line will increase, both the effective distance of collateral ligament will decrease, and patellofemoral joint problems will occur. Therefore, if the distal femoral incision is excessive, the use of distal femoral augment should be preferred instead of the use of a thick insert [105].
\nAsymmetric mismatches occur when the joint space is trapezoidal rather than rectangular. It occurs mostly during surgery after excessive loosening of the soft tissue and is most commonly seen in extension. In this case, the transition to the restrictive prosthesis should be considered [106].
\nOne of the reasons that greatly affect patient satisfaction after TKA operations is the amount of joint range of motion. To achieve good results, a flexion range of at least 90° is required. Sixty-five degrees of flexion is required during walking; 106° of flexion is required when sitting on a chair and tying shoes. Postoperative limited and painful joint movements significantly reduce patient comfort. A flexion range of less than 90° for 6 weeks after TKA surgery is defined as a rigid knee [107].
\nHip osteoarthritis, heterotropic ossification, and reflex symptomatic dystrophy can be considered as independent factors. Inadequate posterior femoral incision and inadequate medial collateral ligament releasing of the knee with severe varus deformity may be among the causes for a rigid knee due to surgical technique [108, 109]. In one study, it was observed that joint stiffness occurred more frequently than unilateral knee arthroplasty in patients who underwent bilateral total knee arthroplasty in the same session, and manipulation was required under anesthesia [110].
\nExcessive tight extension and flexion gap, tight PCL, malrotation of components, and inadequate tibial slop angle may lead to joint stiffness [108].
\nOne of the most important indicators of joint stiffness is the extremely limited range of motion in the knee before surgery [109]. The range of motion obtained within the surgery should be considered in the determination of joint stiffness. A sudden loss of motion should suggest a mechanical problem, loosening, and infection.
\nArthrofibrosis is the most treatment-resistant cause of joint stiffness. It develops due to excessive increase of fibrous tissue in the joint [108].
\nThe strongest determinant of postoperative flexion movements is the degree of preoperative flexion. Other than that, age, preoperative diagnosis, and severity of deformity are other factors [111].
\nThe efficacy of conservative treatment is limited in joint stiffness after TKA. Aggressive range of motion improvement of 3.1° was observed with aggressive physical therapy for almost 1 year [112]. It has been shown that the use of continuous passive motion device (CPM) in the early postoperative period reduces bleeding and is beneficial in preventing joint stiffness by reducing the formation of fibrosis [113].
\nAlthough there is no consensus in the literature, manipulation under anesthesia should be performed in cases where knee flexion is below 90° between 2 weeks and 3 months. Revision rates are lower in patients with early manipulation [114]. Manipulation is performed under general anesthesia using a muscle relaxant until the knee and hip reach at least 90°. After this procedure, an average gain of 30–47° was reported [115].
\nIf the joint movement limitation continues despite these methods, surgical procedures are performed. These are arthroscopic release, open release and limited revision knee arthroplasty, and total revision knee arthroplasty [116].
\nDeep infection after TKA is the most common cause of revision. Systemic complications such as septicemia and cardiopulmonary insufficiency may also occur in patients with periprosthetic infection [117]. As a result, it increased mortality rates. Nowadays, the incidence of deep infection after TKA varies between 0.4 and 2% [74]. Factors that pave the way for infection in the postoperative period include the presence of rheumatoid arthritis, diabetes, hemophilia, malignancy, HIV, obesity, smoking, intravenous drug addiction, knee septic arthritis and osteomyelitis, prolonged surgical time, malnutrition, steroid use, and prolonged skin problems.
\nAntibiotic prophylaxis is the most effective method to prevent infection [118]. Prophylaxis should be administered 30–60 minutes. Before skin incision [119]. It has been shown that short postoperative antibiotherapy is more beneficial than the longer one [120].
\nFewer people entering the operating room, using drapes to prevent superficial contamination, providing laminar air flow, effective sterilization of surgical instruments, and keeping the surgical time 150 minutes below are also necessary to prevent infection [121].
\nRisk groups of patients should be identified before the operation, and a separate planning should be made for each patient according to comorbid diseases. Antibiotic cement has been shown to reduce the infection rate in patients at risk [122]. However, it has been reported that the use of antibiotic cement in the patient group with no risk may cause premature loosening [123].
\nThe most common organisms produced after infected knee arthroplasties are Staphylococcus aureus, coagulase negative Staphylococcus, and Streptococcus bacteria [124]. However, many microorganisms can also be active. Variations have occurred in microorganisms due to the unnecessary antibiotics used recently, and this has led to the development of resistance. Of these microorganisms, the most common isolates are methicillin-resistant Staphylococcus aureus (MRSA) and many antibiotics [125]. Fungal infections are not common, but the most common causative agents in these isolated are Candida species [126].
\nBacteria that cause prosthetic infection form a biofilm layer on the implant. This biofilm layer increases the virulence of the agent. In addition, it forms resistance to treatment because of its limitation on antibiotic permeability. The best antibiotic to cross the biofilm layer is rifampicin [127]. There are studies suggesting the addition of rifampicin to antibiotic treatment specific for the reproductive bacteria [127, 128].
\nDetailed anamnesis and detailed physical examination should be performed in the diagnosis of periprosthetic infection. In addition, the presence of a progressive radiolucent area around the prosthesis with direct radiographs, osteopenia, or osteolysis extending to the subchondral bone and the formation of new bone in the periosteal area can be evaluated in favor of infection [129]. The pain caused by rest is unique. However, increasing severity of pain and prolonged drainage at the wound site can also be evaluated in favor of infection. Arthrocentesis is then performed. In the case of active isolation, the necessary treatment is started. Empirical antibiotic therapy should be avoided. Wait until the agent is isolated. Because empirical antibiotherapy will suppress a possible infection and may cause deep infection due to delayed diagnosis of prosthesis infection that may be saved by debridement and may require removal of the prosthesis [130].
\nCRP and sedimentation values should be evaluated in diagnosis. However, it should be remembered that CRP returns to its previous level after 14–21 days postoperatively [131]. Alpha defensin, lactoferrin, ELA-2, BPI, procalcitonin, and synovial CRP values are other parameters that can be used in diagnosis [132].
\nCurrent consensus has been reached in the diagnosis of periprosthetic infection [133]. Accordingly:
Major criteria
Generation of the same agent in two positive cultures.
Presence of sinus mouth associated with prosthesis. In the presence of one of them, the diagnosis is established [133].
Minor criteria
Calculated weights of high serum CRP (>1 mg/dL), D-dimer (>860 ng/mL), and erythrocyte sedimentation rate (>30 mm/h) are also 2, 2, and 1 points, respectively.
High synovial fluid white cell count (>3000 cells/μL), alpha defensin (signal cutoff ratio > 1), leukocyte esterase (++), polymorphonuclear percentage (>80%), and synovial CRP (>6.9 mg/L) were arranged as 3, 3, 3, 2, and 1 points, respectively.
Patients with a total score equal to or greater than 6 were considered infected.
\nThe goal of infection treatment in total knee arthroplasty is eradication of the infection, pain relief, and maintenance of limb function. Treatment options are antibiotic pressure, debridement, single- or double-stage revision, arthrodesis, resection arthroplasty, and amputation. Revision surgery also has single-stage or double-stage revision options [134, 135, 136].
\nPeriprosthetic fractures around the knee are fractures that occur during or after surgery within 15 cm of the knee joint or within 5 cm of the intramedullary part of the prosthesis, if any [137]. The incidence of these fractures after TKA is 0.3–2.5% for femur and 0.4 01% for tibia [138, 139].
\nThe main risk factor related to the patient is the age of the patient. This risk is due to an increased risk of falling due to the patient’s age and osteoporosis associated with age [140]. Corticosteroid use, diseases that may increase the risk of falling with rheumatoid arthritis (epilepsy, Parkinson’s, cerebellar ataxia, myasthenia gravis) can be counted as other patient-related risk factors [141].
\nIntraoperative diaphyseal femoral fractures may occur due to incorrect placement of the intramedullary guide and osteopenia [142]. Unsuitable bone incisions, aggressive impaction of the ligamentous posterior stabilized femoral component, and eccentric placement of trial components are also risk factors for femoral fracture. It has been shown to increase the frequency of periprosthetic fractures due to increased resistance in flexion and rotation movements in anterior femoral notching [143]. The possibility of periprosthetic fracture is increased in revision TKA cases [144]. Periprosthetic fractures are more common due to the rotational forces of restrictive prosthesis using shear forces in the prosthesis [141].
\nDue to the stronger structure of the tibia, fracture development is rare.
\nFor femoral periprosthetic fractures, there is a classification that questions fracture displacement and component fixation.
Type 1 describes fractures with non-displaced and stable components.
Type 2 refers to component stable fractures with displacement of more than 5 mm or angulation of more than 5°.
Type 3 indicates loose fractures [145].
The femur fractures vertically more than the metaphyseal region. A stable periosteum prevents displacement. It is followed conservatively without any additional intervention. For fractures penetrating the femoral cortex, whether or not a bone graft is used, the penetration level should be treated with a stem prosthesis that is at least twice the diameter of the femoral canal [146].
\nWhen non-displaced fractures and stable prosthesis occur after TKA, conservative treatment may be preferred. Four to six weeks of non-weight procedure, long leg plaster, or hinged orthosis is followed.
\nDisplaced and unreducible supracondylar fractures are almost always treated surgically in the presence of adequate bone stock (\nFigure 1\n) [147].
\nLocked compression plates are preferred for knee periprosthetic fractures [144]. Prosthetic revision should be performed in fractures that cause prosthesis loosening and malposition. In these cases, stented prosthesis of sufficient length should be placed to obtain a stable fixation of the intact bone [138]. Knee replacement revision after periprosthetic fractures is often associated with the loss of range of motion (ROM) [148].
\nSupracondylar periprosthetic femur fracture treated with open reduction and internal fixation.
The majority of tibial periprosthetic fractures during surgery involve the plateau region and are generally non-displaced [146, 149]. If prosthetic loosening is present, revision surgery using a stem component long enough to cross the fracture line is required [150].
\nPostoperative tibial fractures can be examined in four groups. In type 1 fracture, revision is recommended because tibial component will be in varus alignment. The medial defect should be closed with bone graft or metal support [150]. Type 2 fractures are treated with nonsurgical treatment if the component is stable and there is minimal displacement [149]. Displaced type 2 fractures are treated with internal fixation. If the component is unstable, it must be revised using a long tibial stem to cross the fracture line [149]. Internal fixation should be performed for type 3 and 4 fractures [145].
\nThe deterioration of the relationship between prosthesis and bone is defined as loosening. The loosening may be between the prosthetic cement and the cement bone. Loosening is inevitable in long-term prostheses. It is useful to distinguish the concepts of osteolysis and loosening. Without prosthesis osteolysis, loosening of the cement may occur. The mechanisms that cause loosening are micromotion, component collapse, and periprosthetic osteolysis [151].
\nOveruse and osteopenia are the causes of patient-related loosening. Implant design may also be the cause of loosening. According to this, loosening is more likely in cementless prosthesis and constrained prosthesis. One of the most important causes of aseptic loosening is malalignment. It has been shown that a 4 mm medial collapse of the tibial component and varus deformity of more than 2° increases the likelihood of loosening [152]. In the early period, a radiolucent line is seen between the component and bone on radiography, and a collapse occurs as the loosening progresses. Loosening is more common around the tibial component [152]. In the presence of loosening around the whole component, septic loosening should be considered, and differential diagnosis should be performed.
\nIn the case of loosening, the treatment is decided according to symptoms and progress. If pain is associated with instability and there are X-ray findings, early revision surgery is recommended for bone stock preservation.
\nOsteolysis usually occurs due to inflammatory reactions caused by worn polyethylene particles or in the presence of infection. Metal particles can also cause osteolysis. Titanium causes more osteolysis than cobalt and chromium. Giant cells that develop against abrasive particles act by forming a membrane [153]. Particle size is important for this mechanism. The particle sizes range from 1 to 100 micrometers under the electron microscope. Large parts do not cause osteolysis [153]. There is no osteolysis if the parts are not spread to the cancellous bone, so osteolysis is not seen when the cancellous bone is properly covered with cement [154]. On the other hand, the incidence of osteolysis increases when pres-fit prosthesis is applied; screw fixation without cement is used or cement breaks [155]. Osteolysis is closely related to prosthetic design. Osteolysis usually occurs after 2 years of TKA. Occurrence is rare before 2 years [156]. Osteolysis is mostly seen in the tibia [157]. Diagnosis includes pain, joint effusion, and synovitis due to joint instability. Focal bone destruction may be seen on radiolucent line and X-ray. It can be seen that there is no continuity of trabeculae and bone cortex in cancellous bone. Therefore, control X-rays are very important in patient follow-up and must be compared with old radiographs in controls. CT and MRI can be used for osteolysis that cannot be detected on direct radiography [158].
\nIf the lesion is small in treatment and the prosthesis is stable, observation is sufficient. Bisphosphonate and calcium supplementation can be initiated [159]. If the prosthesis is instable, two options can be applied. The first one is debridement, polyethylene replacement, and curettage, followed by impaction of the defect with bone graft. The second is revision [159].
\nPatellofemoral joint problems after TKA generally cause anterior knee pain. Patients’ ability to tolerate this pain rarely causes patellofemoral joint problems to be revised [160]. It should be kept in mind that not only patellar component-related procedures but also procedures involving the tibiofemoral joint may cause this problem. Even in revision surgery due to a problem of patellofemoral origin, it is often caused by a component in the tibia and femur [161]. In a study, patella and malrotation were among the eight most common causes of failed TKA [162].
\nAdvanced valgus alignment, previous high tibial osteotomy, or tuberositas tibia osteotomy increases the rate of patellofemoral joint problems in TKA [160].
\nThere are many points to be considered in the surgical technique to prevent patellofemoral joint problems. These are [163]:
\nComponent placement: If the femoral component is placed medially, anteriorly, or flexed, or if there is internal rotation and if the component is excessive in size, patellofemoral problems may occur finally. Likewise, the medialization and internal rotation of the tibial component increases the risk.
\nSurgical approach type: Midvastus and subvastus interventions that protect the extensor mechanism more can reduce PF joint problems.
\nLateral release: The need for lateral retinacular release increases PF joint problems.
\nPatella resection amount: When patellar component is used, resection of the patella with anterior–posterior reduction of 12 mm increases the risk of PF joint problems [164, 165].
Patellar surface replacement is controversial today. However, in a recent study, it was found that anterior knee pain was less common in patients who underwent patellar surface change than those who did not. In the same study, the causes of PF joint revision were more common in patients without patella surface changes [166].
\nThe results in patients with patellar articular surface alteration due to persistent anterior knee pain after TKA are not as successful as those with surface replacement during primary TKA [167]. In the treatment of anterior knee pain after TKA, mechanical causes should be investigated after the exclusion of an underlying infection.
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\\n\\nThe Author, on his or her own behalf and on behalf of any of the Co-Authors, reserves the following rights in the Work but agrees not to exercise them in such a way as to adversely affect IntechOpen's ability to utilize the full benefit of this Publication Agreement: (i) reprographic rights worldwide, other than those which subsist in the typographical arrangement of the Work as published by IntechOpen; and (ii) public lending rights arising under the Public Lending Right Act 1979, as amended from time to time, and any similar rights arising in any part of the world.
\\n\\nThe Author, and any Co-Author, confirms that they are, and will remain, a member of any applicable licensing and collecting society and any successor to that body responsible for administering royalties for the reprographic reproduction of copyright works.
\\n\\nSubject to the license granted above, copyright in the Work and all versions of it created during IntechOpen's editing process, including all published versions, is retained by the Author and any Co-Authors.
\\n\\nSubject to the license granted above, the Author and Co-Authors retain patent, trademark and other intellectual property rights to the Work.
\\n\\nAll rights granted to IntechOpen in this Article are assignable, sublicensable or otherwise transferrable to third parties without the specific approval of the Author or Co-Authors.
\\n\\nThe Author, on his/her own behalf and on behalf of the Co-Authors, will not assert any rights under the Copyright, Designs and Patents Act 1988 to object to derogatory treatment of the Work as a consequence of IntechOpen's changes to the Work arising from the translation of it, corrections and edits for house style, removal of problematic material and other reasonable edits as determined by IntechOpen.
\\n\\nAUTHOR'S DUTIES
\\n\\nWhen distributing or re-publishing the Work, the Author agrees to credit the Monograph/Compacts as the source of first publication, as well as IntechOpen. The Author guarantees that Co-Authors will also credit the Monograph/Compacts as the source of first publication, as well as IntechOpen, when they are distributing or re-publishing the Work.
\\n\\nThe Author agrees to:
\\n\\nThe Author will be held responsible for the payment of the agreed Open Access Publishing Fee before the completion of the project (Monograph/Compacts publication).
\\n\\nAll payments shall be due 30 days from the date of issue of the invoice. The Author or whoever is paying on behalf of the Author and Co-Authors will bear all banking and similar charges incurred.
\\n\\nThe Author shall obtain in writing all consents necessary for the reproduction of any material in which a third-party right exists, including quotations, photographs and illustrations, in all editions of the Work worldwide for the full term of the above licenses, and shall provide to IntechOpen, at its request, the original copies of such consents for inspection or the photocopies of such consents.
\\n\\nThe Author shall obtain written informed consent for publication from those who might recognize themselves or be identified by others, for example from case reports or photographs.
\\n\\nThe Author shall respect confidentiality during and after the termination of this Agreement. The information contained in all correspondence and documents as part of the publishing activity between IntechOpen and the Author and Co-Authors are confidential and are intended only for the recipients. The contents of any communication may not be disclosed publicly and are not intended for unauthorized use or distribution. Any use, disclosure, copying, or distribution is prohibited and may be unlawful.
\\n\\nAUTHOR'S WARRANTY
\\n\\nThe Author and Co-Authors confirm and warrant that the Work does not and will not breach any applicable law or the rights of any third party and, specifically, that the Work contains no matter that is defamatory or that infringes any literary or proprietary rights, intellectual property rights, or any rights of privacy.
\\n\\nThe Author and Co-Authors confirm that: (i) the Work is their original work and is not copied wholly or substantially from any other work or material or any other source; (ii) the Work has not been formally published in any other peer-reviewed journal or in a book or edited collection, and is not under consideration for any such publication; (iii) Authors and any applicable Co-Authors are qualifying persons under section 154 of the Copyright, Designs and Patents Act 1988; (iv) Authors and any applicable Co-Authors have not assigned, and will not during the term of this Publication Agreement purport to assign, any of the rights granted to IntechOpen under this Publication Agreement; and (v) the rights granted by this Publication Agreement are free from any security interest, option, mortgage, charge or lien.
\\n\\nThe Author and Co-Authors also confirm and warrant that: (i) he/she has the power to enter into this Publication Agreement on his or her own behalf and on behalf of each Co-Author; and (ii) has the necessary rights and/or title in and to the Work to grant IntechOpen, on behalf of themselves and any Co-Author, the rights and licences in this Publication Agreement. If the Work was prepared jointly by the Author and Co-Authors, the Author confirms that: (i) all Co-Authors agree to the submission, license and publication of the Work on the terms of this Publication Agreement; and (ii) the Author has the authority to enter into this biding Publication Agreement on behalf of each Co-Author. The Author shall: (i) ensure each Co-Author complies with all relevant provisions of this Publication Agreement, including those relating to confidentiality, performance and standards, as if a party to this Publication Agreement; and (ii) remain primarily liable for all acts and/or omissions of each Co-Author.
\\n\\nThe Author agrees to indemnify IntechOpen harmless against all liabilities, costs, expenses, damages and losses, as well as all reasonable legal costs and expenses suffered or incurred by IntechOpen arising out of, or in connection with, any breach of the agreed confirmations and warranties. This indemnity shall not apply in a situation in which a claim results from IntechOpen's negligence or willful misconduct.
\\n\\nNothing in this Publication Agreement shall have the effect of excluding or limiting any liability for death or personal injury caused by negligence or any other liability that cannot be excluded or limited by applicable law.
\\n\\nTERMINATION
\\n\\nIntechOpen has the right to terminate this Publication Agreement for quality, program, technical or other reasons with immediate effect, including without limitation (i) if the Author and/or any Co-Author commits a material breach of this Publication Agreement; (ii) if the Author and/or any Co-Author (being a private individual) is the subject of a bankruptcy petition, application or order; or (iii) if the Author and/or any Co-Author (as a corporate entity) commences negotiations with all or any class of its creditors with a view to rescheduling any of its debts, or makes a proposal for, or enters into, any compromise or arrangement with any of its creditors.
\\n\\nIn the event of termination, IntechOpen will notify the Author of the decision in writing.
\\n\\nIntechOpen’s DUTIES AND RIGHTS
\\n\\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen, at its discretion, agrees to publish the Work attributing it to the Author and Co-Authors.
\\n\\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen agrees to provide publishing services which include: managing editing (editorial and publishing process coordination, Author assistance); publishing software technology; language copyediting; typesetting; online publishing; hosting and web management; and abstracting and indexing services.
\\n\\nIntechOpen agrees to offer free online access to readers and use reasonable efforts to promote the Publication to relevant audiences.
\\n\\nIntechOpen is granted the authority to enforce the rights from this Publication Agreement on behalf of the Author and Co-Authors against third parties, for example in cases of plagiarism or copyright infringements. In respect of any such infringement or suspected infringement of the copyright in the Work, IntechOpen shall have absolute discretion in addressing any such infringement that is likely to affect IntechOpen's rights under this Publication Agreement, including issuing and conducting proceedings against the suspected infringer.
\\n\\nIntechOpen has the right to include/use the Author and Co-Authors names and likeness in connection with scientific dissemination, retrieval, archiving, web hosting and promotion and marketing of the Work and has the right to contact the Author and Co-Authors until the Work is publicly available on any platform owned and/or operated by IntechOpen.
\\n\\nMISCELLANEOUS
\\n\\nFurther Assurance: The Author shall ensure that any relevant third party, including any Co-Author, shall execute and deliver whatever further documents or deeds and perform such acts as IntechOpen reasonably requires from time to time for the purpose of giving IntechOpen the full benefit of the provisions of this Publication Agreement.
\\n\\nThird Party Rights: A person who is not a party to this Publication Agreement may not enforce any of its provisions under the Contracts (Rights of Third Parties) Act 1999.
\\n\\nEntire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by, or on behalf of, the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (known as the "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of any fraudulent pre-contract misrepresentation or concealment.
\\n\\nWaiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
\\n\\nVariation: No variation of this Publication Agreement shall have effect unless it is in writing and signed by the parties, or their duly authorized representatives.
\\n\\nSeverance: If any provision, or part-provision, of this Publication Agreement is, or becomes invalid, illegal or unenforceable, it shall be deemed modified to the minimum extent necessary to make it valid, legal and enforceable. If such modification is not possible, the relevant provision or part-provision shall be deemed deleted. Any modification to, or deletion of, a provision or part-provision under this clause shall not affect the validity and enforceability of the rest of this Publication Agreement.
\\n\\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\\n\\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
\\n\\nPolicy last updated: 2018-09-11
\\n"}]'},components:[{type:"htmlEditorComponent",content:'When submitting a manuscript, the Author is required to accept the Terms and Conditions set out in our Publication Agreement – Monographs/Compacts as follows:
\n\nCORRESPONDING AUTHOR'S GRANT OF RIGHTS
\n\nSubject to the following Article, the Author grants to IntechOpen, during the full term of copyright, and any extensions or renewals of that term, the following:
\n\nThe foregoing licenses shall survive the expiry or termination of this Publication Agreement for any reason.
\n\nThe Author, on his or her own behalf and on behalf of any of the Co-Authors, reserves the following rights in the Work but agrees not to exercise them in such a way as to adversely affect IntechOpen's ability to utilize the full benefit of this Publication Agreement: (i) reprographic rights worldwide, other than those which subsist in the typographical arrangement of the Work as published by IntechOpen; and (ii) public lending rights arising under the Public Lending Right Act 1979, as amended from time to time, and any similar rights arising in any part of the world.
\n\nThe Author, and any Co-Author, confirms that they are, and will remain, a member of any applicable licensing and collecting society and any successor to that body responsible for administering royalties for the reprographic reproduction of copyright works.
\n\nSubject to the license granted above, copyright in the Work and all versions of it created during IntechOpen's editing process, including all published versions, is retained by the Author and any Co-Authors.
\n\nSubject to the license granted above, the Author and Co-Authors retain patent, trademark and other intellectual property rights to the Work.
\n\nAll rights granted to IntechOpen in this Article are assignable, sublicensable or otherwise transferrable to third parties without the specific approval of the Author or Co-Authors.
\n\nThe Author, on his/her own behalf and on behalf of the Co-Authors, will not assert any rights under the Copyright, Designs and Patents Act 1988 to object to derogatory treatment of the Work as a consequence of IntechOpen's changes to the Work arising from the translation of it, corrections and edits for house style, removal of problematic material and other reasonable edits as determined by IntechOpen.
\n\nAUTHOR'S DUTIES
\n\nWhen distributing or re-publishing the Work, the Author agrees to credit the Monograph/Compacts as the source of first publication, as well as IntechOpen. The Author guarantees that Co-Authors will also credit the Monograph/Compacts as the source of first publication, as well as IntechOpen, when they are distributing or re-publishing the Work.
\n\nThe Author agrees to:
\n\nThe Author will be held responsible for the payment of the agreed Open Access Publishing Fee before the completion of the project (Monograph/Compacts publication).
\n\nAll payments shall be due 30 days from the date of issue of the invoice. The Author or whoever is paying on behalf of the Author and Co-Authors will bear all banking and similar charges incurred.
\n\nThe Author shall obtain in writing all consents necessary for the reproduction of any material in which a third-party right exists, including quotations, photographs and illustrations, in all editions of the Work worldwide for the full term of the above licenses, and shall provide to IntechOpen, at its request, the original copies of such consents for inspection or the photocopies of such consents.
\n\nThe Author shall obtain written informed consent for publication from those who might recognize themselves or be identified by others, for example from case reports or photographs.
\n\nThe Author shall respect confidentiality during and after the termination of this Agreement. The information contained in all correspondence and documents as part of the publishing activity between IntechOpen and the Author and Co-Authors are confidential and are intended only for the recipients. The contents of any communication may not be disclosed publicly and are not intended for unauthorized use or distribution. Any use, disclosure, copying, or distribution is prohibited and may be unlawful.
\n\nAUTHOR'S WARRANTY
\n\nThe Author and Co-Authors confirm and warrant that the Work does not and will not breach any applicable law or the rights of any third party and, specifically, that the Work contains no matter that is defamatory or that infringes any literary or proprietary rights, intellectual property rights, or any rights of privacy.
\n\nThe Author and Co-Authors confirm that: (i) the Work is their original work and is not copied wholly or substantially from any other work or material or any other source; (ii) the Work has not been formally published in any other peer-reviewed journal or in a book or edited collection, and is not under consideration for any such publication; (iii) Authors and any applicable Co-Authors are qualifying persons under section 154 of the Copyright, Designs and Patents Act 1988; (iv) Authors and any applicable Co-Authors have not assigned, and will not during the term of this Publication Agreement purport to assign, any of the rights granted to IntechOpen under this Publication Agreement; and (v) the rights granted by this Publication Agreement are free from any security interest, option, mortgage, charge or lien.
\n\nThe Author and Co-Authors also confirm and warrant that: (i) he/she has the power to enter into this Publication Agreement on his or her own behalf and on behalf of each Co-Author; and (ii) has the necessary rights and/or title in and to the Work to grant IntechOpen, on behalf of themselves and any Co-Author, the rights and licences in this Publication Agreement. If the Work was prepared jointly by the Author and Co-Authors, the Author confirms that: (i) all Co-Authors agree to the submission, license and publication of the Work on the terms of this Publication Agreement; and (ii) the Author has the authority to enter into this biding Publication Agreement on behalf of each Co-Author. The Author shall: (i) ensure each Co-Author complies with all relevant provisions of this Publication Agreement, including those relating to confidentiality, performance and standards, as if a party to this Publication Agreement; and (ii) remain primarily liable for all acts and/or omissions of each Co-Author.
\n\nThe Author agrees to indemnify IntechOpen harmless against all liabilities, costs, expenses, damages and losses, as well as all reasonable legal costs and expenses suffered or incurred by IntechOpen arising out of, or in connection with, any breach of the agreed confirmations and warranties. This indemnity shall not apply in a situation in which a claim results from IntechOpen's negligence or willful misconduct.
\n\nNothing in this Publication Agreement shall have the effect of excluding or limiting any liability for death or personal injury caused by negligence or any other liability that cannot be excluded or limited by applicable law.
\n\nTERMINATION
\n\nIntechOpen has the right to terminate this Publication Agreement for quality, program, technical or other reasons with immediate effect, including without limitation (i) if the Author and/or any Co-Author commits a material breach of this Publication Agreement; (ii) if the Author and/or any Co-Author (being a private individual) is the subject of a bankruptcy petition, application or order; or (iii) if the Author and/or any Co-Author (as a corporate entity) commences negotiations with all or any class of its creditors with a view to rescheduling any of its debts, or makes a proposal for, or enters into, any compromise or arrangement with any of its creditors.
\n\nIn the event of termination, IntechOpen will notify the Author of the decision in writing.
\n\nIntechOpen’s DUTIES AND RIGHTS
\n\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen, at its discretion, agrees to publish the Work attributing it to the Author and Co-Authors.
\n\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen agrees to provide publishing services which include: managing editing (editorial and publishing process coordination, Author assistance); publishing software technology; language copyediting; typesetting; online publishing; hosting and web management; and abstracting and indexing services.
\n\nIntechOpen agrees to offer free online access to readers and use reasonable efforts to promote the Publication to relevant audiences.
\n\nIntechOpen is granted the authority to enforce the rights from this Publication Agreement on behalf of the Author and Co-Authors against third parties, for example in cases of plagiarism or copyright infringements. In respect of any such infringement or suspected infringement of the copyright in the Work, IntechOpen shall have absolute discretion in addressing any such infringement that is likely to affect IntechOpen's rights under this Publication Agreement, including issuing and conducting proceedings against the suspected infringer.
\n\nIntechOpen has the right to include/use the Author and Co-Authors names and likeness in connection with scientific dissemination, retrieval, archiving, web hosting and promotion and marketing of the Work and has the right to contact the Author and Co-Authors until the Work is publicly available on any platform owned and/or operated by IntechOpen.
\n\nMISCELLANEOUS
\n\nFurther Assurance: The Author shall ensure that any relevant third party, including any Co-Author, shall execute and deliver whatever further documents or deeds and perform such acts as IntechOpen reasonably requires from time to time for the purpose of giving IntechOpen the full benefit of the provisions of this Publication Agreement.
\n\nThird Party Rights: A person who is not a party to this Publication Agreement may not enforce any of its provisions under the Contracts (Rights of Third Parties) Act 1999.
\n\nEntire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by, or on behalf of, the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (known as the "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of any fraudulent pre-contract misrepresentation or concealment.
\n\nWaiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
\n\nVariation: No variation of this Publication Agreement shall have effect unless it is in writing and signed by the parties, or their duly authorized representatives.
\n\nSeverance: If any provision, or part-provision, of this Publication Agreement is, or becomes invalid, illegal or unenforceable, it shall be deemed modified to the minimum extent necessary to make it valid, legal and enforceable. If such modification is not possible, the relevant provision or part-provision shall be deemed deleted. Any modification to, or deletion of, a provision or part-provision under this clause shall not affect the validity and enforceability of the rest of this Publication Agreement.
\n\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\n\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
\n\nPolicy last updated: 2018-09-11
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I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. I have served as the editor for many books, been a member of the editorial board in science journals, have published many papers and hold many patents.",institutionString:null,institution:{name:"Sheffield Hallam University",country:{name:"United Kingdom"}}},{id:"54525",title:"Prof.",name:"Abdul Latif",middleName:null,surname:"Ahmad",slug:"abdul-latif-ahmad",fullName:"Abdul Latif Ahmad",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"20567",title:"Prof.",name:"Ado",middleName:null,surname:"Jorio",slug:"ado-jorio",fullName:"Ado Jorio",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidade Federal de Minas Gerais",country:{name:"Brazil"}}},{id:"47940",title:"Dr.",name:"Alberto",middleName:null,surname:"Mantovani",slug:"alberto-mantovani",fullName:"Alberto Mantovani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"12392",title:"Mr.",name:"Alex",middleName:null,surname:"Lazinica",slug:"alex-lazinica",fullName:"Alex Lazinica",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/12392/images/7282_n.png",biography:"Alex Lazinica is the founder and CEO of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). He is the member of many Pharmaceutical Associations and acts as a reviewer of scientific journals and European projects under different research areas such as: drug delivery systems, nanotechnology and pharmaceutical biotechnology. Dr. Sezer is the author of many scientific publications in peer-reviewed journals and poster communications. Focus of his research activity is drug delivery, physico-chemical characterization and biological evaluation of biopolymers micro and nanoparticles as modified drug delivery system, and colloidal drug carriers (liposomes, nanoparticles etc.).",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"61051",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"100762",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"St David's Medical Center",country:{name:"United States of America"}}},{id:"107416",title:"Dr.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Texas Cardiac Arrhythmia",country:{name:"United States of America"}}},{id:"64434",title:"Dr.",name:"Angkoon",middleName:null,surname:"Phinyomark",slug:"angkoon-phinyomark",fullName:"Angkoon Phinyomark",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/64434/images/2619_n.jpg",biography:"My name is Angkoon Phinyomark. I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). 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