Abstract
Aims
The aim of this study was to perform a systematic review and bias evaluation of the current literature to create an overview of risk factors for re-revision following revision total knee arthroplasty (rTKA).
Methods
A systematic search of MEDLINE and Embase was completed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The studies were required to include a population of index rTKAs. Primary or secondary outcomes had to be re-revision. The association between preoperative factors and the effect on the risk for re-revision was also required to be reported by the studies.
Results
The search yielded 4,847 studies, of which 15 were included. A majority of the studies were retrospective cohorts or registry studies. In total, 26 significant risk factors for re-revision were identified. Of these, the following risk factors were consistent across multiple studies: age at the time of index revision, male sex, index revision being partial revision, and index revision due to infection. Modifiable risk factors were opioid use, BMI > 40 kg/m2, and anaemia. History of one-stage revision due to infection was associated with the highest risk of re-revision.
Conclusion
Overall, 26 risk factors have been associated with an increased risk of re-revision following rTKA. However, various levels of methodological bias were found in the studies. Future studies should ensure valid comparisons by including patients with identical indications and using clear definitions for accurate assessments.
Cite this article: Bone Jt Open 2024;5(8):644–651.
Take home message
Key risk factors for re-revision total knee arthroplasty were age, male sex, partial index revision, and infection as index revision indication.
Correctable risk factors were preoperative anaemia and BMI ≥ 40 kg/m2.
Preoperative opioid use and depression may also be correctable risk factors.
Introduction
Revision total knee arthroplasty (rTKA) is complicated and is associated with significant costs for both patients and healthcare systems compared to primary knee arthroplasty.1 Previous studies have projected that the incidence of revisions will be tripled, or maybe even six-folded, over the next decade.2,3 The incidence of re-revisions is also expected to rise because implant survival is expected to decrease for each revision.4 Revision for periprosthetic joint infection (PJI) is associated with particularly low prosthesis survival, and eradication of infection may require multiple revisions. Thus, PJI is the most significant cause of repeated revisions.5
Risk factors for PJI and other implant-related complications have been widely investigated in the case of primary knee arthroplasty, but limited research has focused on re-revision surgery.6 However, re-revised patients suffer the greatest functional disabilities and constitute some of the largest costs per patient for healthcare systems.7,8 Identifying preoperative risk factors for re-revision, and correcting them, if possible, may reduce re-revision rates. No systematic review has yet investigated risk factors associated with re-revision following rTKA. The aim of this study was to perform a systematic review and bias evaluation of the current literature to create an overview of risk factors for re-revision following rTKA.
Methods
This study is a systematic review of published scientific articles. No ethical approval was required at our institution because all data acquired are publicly available. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed throughout the study.9 The protocol for this study was submitted to PROSPERO (reg. number CRD42022380715) before the study began. Our research protocol was structured according to the Population, Intervention, Comparison, and Outcome (PICO) framework.10 Our research question was: “Which preoperative factors increase the risk of re-revision in patients with a previous rTKA?”.
Eligibility
All study designs were included except case reports. Our search was limited to English literature published from 1 January 1946 to 20 December 2022. There were three main criteria for inclusion: 1) studies had to include a population of index rTKA patients; 2) the reported primary or secondary outcomes of the study had to be re-revision; and 3) the study had to investigate any association between preoperative factors and risk of re-revision expressed as relative risk (RR), odds ratio (OR), or hazard ratio (HR). Significant results required a p-value < 0.05 or a 95% CI which did not include 1.
Search strategy
The databases MEDLINE and Embase were searched according to the PRISMA guidelines.9 The search string was based on a combination of Medical Subject Headings (MeSH) words and free-text words: knee arthroplasty, revision, reoperation, re-revision, multiple revisions, failed revision, and repeat revision. The complete search string is available in Supplementary file i.
Statistical analysis
The screening process was managed in Covidence systematic review software (Veritas Health Innovation, Australia).11 Two separate reviewers (JTH, UKK) screened titles and abstracts followed by full-text review. The final number of included studies was determined after full-text review. Results from multivariate analyses were prioritized over uni- or bivariate analyses. The bias evaluation was performed for articles passing the full-text review according to the principles of the Newcastle-Ottawa Scale (NOS). The NOS principles consist of selection, comparability, and outcome.12 The maximal score was 9. A score of ≥ 6 was considered high-quality.13 Two authors (JTH, UKK) scored each study separately before deciding on a final score. All disagreements were resolved by discussion and final decision by the author group.
Results
The search string identified 4,847 articles. Following the removal of duplications, 3,636 titles and abstracts were screened. A total of 3,551 studies were subsequently excluded; 85 studies remained for full-text review, of which 15 met the inclusion criteria and were included (Figure 1).
Fig. 1
Overview of the selection process.
Study characteristics
In total, the studies reported 21,476 rTKA procedures (Table I). Two studies did not give the number of procedures but only reported on patients, which amounted to 25,759 undergoing rTKA. The included articles were either single-centre retrospective cohort studies or multicentre register studies. The mean or median age of patients in the studies ranged from 41 to 72 years. The proportion of females in the studies ranged from 41% to 68%. Only index revisions with aseptic indications were investigated in eight studies. Index revisions with septic indications were investigated in three studies, and index revisions with all indications were investigated in four studies. Length of observation periods varied from nine to 30 years. Follow-ups were not described for all studies, and some included follow-up periods as short as one year.
Table I.
Characteristics of included studies.
| Study | Size | Patients’ mean or median age, yrs, at index revision | Females in the study, n (%) | Design | Includes definition of revision | Indication for index revision | Indication for primary arthroplasty | Observation period, yrs |
|---|---|---|---|---|---|---|---|---|
| Chalmers et al 201914 | 135 rTKAs | 43 (18 to 50) | 80/135 (49) | Single centre, retrospective cohort | Yes | Aseptic indications | N/A | 18 |
| Geary et al 202015 | 1,560 rTKAs | 65 (28 to 94) | 936/1,560 (60) | Single centre, retrospective cohort | Yes | All indications | N/A | 30 |
| Aggarwal et al 201416 | 84 rTKAs | 41 (16 to 48) | 46/84 (55) | Single centre, retrospective cohort | Yes | All indications | All indications | 11 |
| Klasan et al 202117 | 1,720 rTKAs | 66 (SD 9.6) | 839/1,720 (49) | Multiple centres, retrospective register | Yes | Aseptic indications | All indications | 17 |
| Leta et al 201518 | 1,016 rTKAs | 69 (25 to 94) | 693/1,016 (68) | Multiple centres, retrospective register | Yes | Aseptic indications | All indications | 18 |
| Arndt et al 202219 | 4,299 rTKAs | 65 (22 to 96) | 2,670/4299 (62) | Multiple centres, retrospective register | No | Aseptic loosening and pain without loosening | N/A | 22 |
| Wilke et al 201520 | 78 rTKAs | 69 (40 to 86) | 41/78 (52) | Single centre, retrospective cohort | Yes | Septic Indications | N/A | 9 |
| Ong et al 201021 | 1,599 rTKAs | 72 (SD 5.3) | 999/1,599 (63) | Multiple centres, retrospective register | Yes | All indications | Osteoarthritis | 10 |
| Cochrane et al 202222 | 157 rTKAs | 63 (SD 8.2) | 21/157 (13) | Single centre, retrospective cohort | Yes | Aseptic indications | N/A | 11 |
| Wilson et al 202023 | 11,786 patients | N/A | 7,111/11,786 (60) | Multiple centres, retrospective register | No | Aseptic indications | N/A | 9 |
| Wilson et al 202024 | 13,973 patients | N/A | 8,436/13,973 (60) | Multiple centres, retrospective register | No | Aseptic indications | N/A | 9 |
| Ross et al 202225 | 1,448 rTKAs | 59 (SD 7.5) | 741/1,448 (51) | Multiple centres, retrospective register | Yes | All indications | N/A | 11 |
| Citak et al 201926 | 91 rTKAs | 67 (SD 11) | 37/91 (41) | Case-control study | No | Septic indications | N/A | 10 |
| Lewis et al 202227 | 2,605 rTKAs | 67 (SD 9.8) | 1,565/2,605 (60) | Multiple centres, retrospective register | Yes | Only instability | Osteoarthritis | 21 |
| Leta et al 201928 | 644 rTKAs | 69 (SD 10.5) | 321/644 (50) | Multiple centres, retrospective register | Yes | Septic indications | All indications | 23 |
-
N/A, not available; rTKA, revision total knee arthroplasty.
Risk factors
In total, the 15 studies reported 26 statistically significant risk factors for re-revision following rTKA (Table II).
Table II.
Overview of studies investigating and finding significance of risk factors for re-revision.
| Variable | Risk factor | Reference* | Risk, 95% CI | Studies investigating risk factor |
|---|---|---|---|---|
| Indication for index revision | Instability as an indication for index revision | Arthrofibrosis as an indication for index revision | HR 8.1 (1.6 to 15) | Chalmers et al 201914 |
| Aseptic loosening as an indication of index revision | Arthrofibrosis as an indication for index revision | HR 6.9 (1.3 to 12.7) | Chalmers et al 201914 | |
| Infection as an indication for index revision | Aseptic indication for index revision | OR 1.9 (1.5 to 2.5) RR 2.7 (1.3 to 4.6) |
Geary et al 202015 Aggarwal et al 201416 |
|
| History of a one-stage revision due to infection | No history of a one-stage revision due to infection History of a two two-stage revision due to infection |
OR 26.7 (5.8 to 123.6) RR 4.3 (1.3 to 14.8) |
Citak et al 201926 Leta et al 201928 |
|
| History of a two-stage revision due to infection | No history of a two-stage revision due to infection | OR 3.9 (1.9 to 8.3) | Citak et al 201926 | |
| Isolation of Enterococcus from knee joint | No isolation of Enterococcus | OR 16.9 (2.0 to 140.9) | Citak et al 201926 | |
| Patient factors (non-modifiable) | Age at the time of index revision | Per year increase | HR 1 (0.9 to 1.1) HR 0.97 (0.96 to 0.99) HR 1 (0.9 to 1.0) p = 0.197 |
Chalmers et al 201914 Klasan et al 202117 Wilke et al 201520 Ong et al 201021 |
| Age below 65 years | Age above 65 years | OR 1.6 (1.2 to 2) | Geary et al 202015 | |
| Age below 60 years | Age above 70 years | RR 1.6 (1.1 to 2.5) | Leta et al 201518 | |
| Age between 50 to 59 years | Age between 60 and 69 years | HR 1.3 (1.1 to 1.6) | Arndt et al 202219 | |
| Age below 50 years | Age between 60 and 69 years | HR 1.9 (1.5 to 2.4) | Arndt et al 202219 | |
| Male sex | Female sex | HR 1.4 (0.7 to 2.7) HR for females 0.6 (0.5 to 0.9) OR 1.4 (1.1 to 1.8) HR 1.2 (1.1 to 1.4) HR 1 (0.4 to 2.2) HR 1.5 (1.1 to 2.1) RR 2 (1.4 to 2.8) |
Chalmers et al 201914 Klasan et al 202117 Geary et al 2020 15 Arndt et al 202219 Wilke et al 201520 Ong et al 201021 Leta et al 201518 |
|
| Diagnosed hepatitis C | No present diagnosis of hepatitis C | OR 1.29 (1.1 to 1.6) | Ross et al 202225 | |
| Patient factors - modifiable | BMI, kg/m2 BMI, kg/m2 ≥ 40 |
Per unit increase Per unit increase Per unit increase BMI < 30 |
HR 1.0 (1 to 1.1) HR 1.1 (1 to 1.1) OR 1.2 (0.9 to 1.5) RR 2.9 (1.3 to 6.6) |
Chalmers et al 201914 Wilke et al 201520 Cochrane et al 202222 Aggarwal et al 201416 |
| Patients with > 2 opioid prescriptions before surgery | Opioid-naïve patients | OR 1.4 (1.1 to 1.9) | Wilson et al 202023 | |
| Patients stopped use of opioids before surgery | Opioid-naïve patients | OR 1.4 (1.1 to 1.9) | Wilson et al 202023 | |
| Patients with continuous use of opioids | Opioid-naïve patients | OR 1.8 (1.5 to 2.2) | Wilson et al 202023 | |
| Depression diagnosis within 1 year of revision TKA | No present diagnosis of depression | OR 1.2 (1.0 to 1.4) | Wilson et al 202024 | |
| Preoperative anaemia (haemoglobin ≤ 12 g/dl) | No anaemia (haemoglobin ≥ 12 g/dl) | OR 3.5 (1.5 to 4.5) | Cochrane et al 202222 | |
| Implant-related factors | Prior revision | No prior revision | HR 2.6 (1.3 to 5.3) HR 1.1 (0.9 to 1.3) |
Chalmers et al 201914 Wilke et al 201520 |
| Index revision: isolated posterior stabilized implant | Fully stabilized | HR 4.3 (1.5 to 12.4) | Lewis et al 202227 | |
| Index revision: minor revision† | All-component exchange | HR 1.3 (1.0 to 1.6) | Lewis et al 202227 | |
| Index revision: partial revision‡ | All-component exchange | HR 1.6 (1.1 to 2.2) HR 2.0 (1.2 to 3.4) HR 1.5 (1.3 to 1.8) HR 1.7 (1.1 to 2.6) HR 1.7 (1.0 to 2.8) |
Lewis et al 202227 Lewis et al 202227 Arndt et al 202219 Leta et al 201518 Klasan et al 202117 |
-
*
Reference is defined as the comparative factor against which the statistical analyses were conducted.
-
†
Minor revision was defined as revision without tibial or femoral component exchange.
-
‡
Partial revision was defined as revision with either tibial or femoral component exchange, but not both.
-
HR, hazard ratio; OR, odds ratio; TKA, total knee arthroplasty.
Indication for index revision
The indication for index revision was associated with an increased risk of re-revision in three studies. Instability compared to arthrofibrosis increased the risk of re-revision by a HR of 8.1 (95% CI 1.6 to 14.9).14 Aseptic loosening compared to arthrofibrosis increased the risk of re-revision by a HR of 6.9 (95% CI 1.3 to 12.7).14 Infection compared to aseptic indications increased the risk of re-revision by an OR of 1.9 (95% CI 1.5 to 2.5),15 and by a RR of 2.7 (95% CI 1.3 to 4.6).16
Patient factors
Across 11 studies, 14 patient-specific factors were associated with an increased risk of re-revision. Increasing age at the time of index revision was found to be a weak but statistically significant protective factor for re-revision in one out of four studies, with a HR of 0.97 (95% CI 0.96 to 0.99).17 Three studies used cut-off values for age at the time of index revision.15,18,19 They found that age patients aged below 65 years (OR 1.6 (95% CI 1.2 to 2)), aged below 60 years (RR 1.6 (95% CI 1.1 to 2.5)), aged between 50 and 59 years (HR 1.3 (95% CI 1.1 to 1.6)), and aged below 50 years (HR 1.9 (95% CI 1.5 to 2.4)) significantly increased the risk of re-revision when compared with patients aged above 60, 65, or 70 years, respectively. Male sex was associated with an increased risk of re-revision in five out of seven studies.14,15,17-21 Two studies reported HRs of 1.2 (95% CI 1.1 to 1.4) and 1.5 (95% CI 1.1 to 2.1). One study reported an OR of 1.4 (95% CI 1.1 to 1.8) and another reported a RR of 2 (95% CI 1.4 to 2.8). Female sex was a protective factor for re-revision in one study (HR for women 0.6 (95% CI 0.5 to 0.9)).17 BMI ≥ 40 kg/m2 increased the risk of re-revision by a RR of 2.9 (95% CI 1.3 to 6.6) compared with patients who had BMI < 30 kg/m2.16 However, when analyzing BMI as per unit increase, three studies found no association between BMI and an increased risk of re-revision.14,20,22 Patients with opioid prescriptions leading up to rTKA had an increased risk of re-revision in one study.23 The study found that patients who collected ≥ two opioid prescriptions, six months preceding rTKA, had an increased risk of re-revision by an OR of 1.4 (95% CI 1.1 to 1.9) compared to opioid-naïve patients. The same risk was found even though patients stopped their use of opioids in the year before rTKA (OR 1.4 (95% CI 1.1 to 1.9)). Patients with continuous use of opioids throughout the year preceding rTKA had an increased risk of re-revision by an OR of 1.8 (95% CI 1.5 to 2.2). However, the study did not specify whether patients were recorded more than once in the analysis. Patients diagnosed with depression, preoperative anaemia defined as haemoglobin ≤ 12 g/dL, and hepatitis C had an increased risk of re-revision by ORs of 1.2 (95% CI 1.0 to 1.4), 3.5 (95% CI 1.5 to 4.5), and 1.3 (95% CI 1.1 to 1.6), respectively.22,24,25
Implant-related factors
Implant-related factors associated with an increased risk of re-revision were found in eight studies. Prior revision was found to increase the risk of re-revision in one study (HR 2.6 (95% CI 1.3 to 5.3),14 but was not a statistically significant factor in another study.20 One study found that an isolated posterior-stabilized implant, which was inserted during the index revision, increased the risk of re-revision by a HR of 4.3 (95% CI 1.5 to 12.4) compared with higher-constraint implants.27 The same study found that a minor index revision, defined as revision without tibial or femoral component exchange, increased the risk of re-revision by a HR of 1.3 (95% CI 1.0 to 1.6). A partial revision, defined as isolated tibial or femoral component exchange, was found to increase the risk of re-revision in four studies when compared to all-component exchange revision.17-19,27 The studies found HRs of 1.6 (95% CI 1.1 to 2.2), 2.0 (95% CI 1.2 to 3.4), 1.5 (95% CI 1.3 to 1.8), 1.7 (95% CI 1.1 to 2.6), and 1.7 (95% CI 1.0 to 2.8), respectively. The largest risk of re-revision was found to be a history of a one-stage revision due to infection (OR 26.7 (95% CI 5.8 to 123.6)) when compared to no history of a one-stage revision due to infection.26 Another study found a RR of 4.3 (95% CI 1.3 to 14.8).28 However, this was only found for patients aged > 70 years, and the comparison was made against patients with a history of a two-stage revision due to infection. In addition, the sample sizes of the two studies were small. History of a two-stage revision due to infection was found to increase the risk of re-revision by an OR of 3.9 (95% CI 1.9 to 8.3) compared to patients with no history of a two-stage revision due to infection.26 Finally, isolation of Enterococcus from the knee joint before index revision was found to increase the risk of re-revision by an OR of 16.9 (95% CI 2.0 to 140.9) compared to no isolation of Enterococcus.26
Risk of bias
The studies scored between four and eight points according to NOS (Table III). Ten studies scored ≥ six points. The largest differences in the bias score were found in the comparability and outcome categories. The major reasons for the differences were caused by studies comparing patients who did not have the same indication for the index revision and by studies not accounting for loss to follow-up.
Table III.
Newcastle-Ottawa Scale (NOS) bias evaluation of included studies.
| NOS | Study | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Chalmers et al 201914 | Geary et al 202015 | Aggarwal et al 201416 | Klasan et al 202117 | Leta et al 201518 | Arndt et al 202219 | Wilke et al 201520 | Ong et al 201021 | Cochrane et al 202222 | Wilson et al 202023 | Wilson et al 202024 | Ross et al 202225 | Lewis et al 202227 | Citak et al 201926 | Leta et al 201928 | ||
| Selection | Was the cohort truly representative?* | No | No | No | Yes | Yes | Yes | No | No | No | Yes | Yes | Yes | Yes | Yes | Yes |
| Did patients originate from the same population? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |
| Did the study attain exposure for re-revisions? | Yes | No | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | |
| Was no interest of the outcome present at the start of the study? | No | Yes | Yes | Yes | Yes | Yes | No | Yes | No | No | No | No | Yes | No | Yes | |
| Comparability | Did the compared populations have the same implant? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Did the compared populations have the same indication for index revision? | No | No | No | No | No | No | Yes | No | No | No | No | No | Yes | Yes | Yes | |
| Outcome | Were assessments of outcome made from medical records or database records? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Was the follow-up period a minimum of 2 years? | Yes | Yes | Yes | Yes | Yes | Yes | No | Yes | No | No | No | Yes | Yes | No | Yes | |
| Did the study account for loss to follow-up? | Yes | No | Yes | No | Yes | No | No | Yes | No | No | No | No | No | No | No | |
| Total number of points | 6 | 5 | 7 | 7 | 8 | 6 | 5 | 7 | 4 | 5 | 5 | 6 | 8 | 6 | 8 | |
-
*
A truly representative cohort was defined as representative of an average population of revision knee arthroplasty patients without selection of specific socioeconomic groups or implants.
Discussion
The aim of this study was to perform a systematic review and bias evaluation of the current literature to create an overview of risk factors for re-revision following rTKA. We identified 15 studies spanning a wide range of patient populations and study designs. In total, 26 significant risk factors for re-revision were found. To our knowledge, no prior study has systematically reviewed risk factors for re-revision following rTKA. Our study identified a subgroup of risk factors that remained statistically significant across several different studies: age, male sex, index revision being a partial revision, and infection as an indication for index revision. These findings emphasize the importance of the patient’s revision history when assessing the risk of subsequent re-revisions. One study found several indications for the index revisions to be risk factors for re-revision.14 However, the relevance of these findings is debatable, as the reference was index revisions with an indication of arthrofibrosis. The case-control study by Citak et al26 highlighted the particularly high risk associated with a history of one-stage revision due to infection. The study was a retrospective case control; patients with a history of one-stage revision due to infection who underwent subsequent re-revision were compared to patients with a history of one-stage revision due to infection who did not undergo re-revision. Despite the methodological limitations inherent in the study, this finding underscores the importance of careful consideration and management of infections in rTKA.
It was observed that factors related to the nature of the index revision were often investigated, and often related to the risk of subsequent re-revision. This review finds a general trend of increased risk of re-revision if the index revision is performed on single components of a knee arthroplasty, suggesting that total revision of all components may result in a lower risk of re-revision. However, it is possible that all-component exchange simply lowers the surgeon’s willingness to offer a re-revision, among other reasons. Correctable risk factors, after index rTKA, included preoperative anaemia and BMI ≥ 40 kg/m2. Anaemia and increased BMI have already been identified as modifiable risk factors for revision in primary knee arthroplasties, suggesting that risk factors for first-time revision also apply to re-revisions.29 Patient use of opioids may also be a correctable risk factor. Opioids have been shown to increase the risk of postoperative infection by indirectly causing immunosuppression.23,30 A study by Wilson et al23 found an increased risk of re-revision for patients with opioid prescriptions described that this association seemed dose dependent. The study found that patients with only one opioid prescription had a near-baseline risk of re-revision. The risk for re-revision was found to increase for every increase in opioid prescription. Hypothetically, reducing opioid consumption may thus reduce the risk of re-revision, but many confounders can explain this relationship. Depression was also found to be a risk factor for re-revision.24 While this relationship is complex, as patients with chronic pain may alter their perception of pain,31 there is evidence that psychological stress induces changes in immunological functions.32 However, it is not possible to ascertain the causal relationship between opioid consumption, depression, and re-revision from the investigations presented in this study. Further investigations are warranted, as correcting these risk factors may reduce the risk of re-revision.
The NOS bias evaluation indicated varying degrees of methodological rigour across studies. While most studies scored well in terms of selection criteria, discrepancies in comparability and outcome assessment were identified as potential sources of bias. Ensuring that comparable study groups have the same implants and indications is important for drawing accurate conclusions. Future studies should focus on large sample sizes, study designs that include clear definitions of revision, identical indications for procedures across comparisons, and accurate descriptions of follow-up. This approach would minimize bias and allow for more precise risk assessments.
It is important to note that the most accurate comparisons and risk factor calculations should involve studies considering the same implant, indication for index revisions, indication for primary knee arthroplasty, and a well-defined concept of revision. Few studies considered the indication for primary knee arthroplasty, and some studies lack a clear definition of revision in their work. Consequently, certain implants or certain primary indications for knee arthroplasty may be over-represented in re-revision cohorts, potentially affecting outcomes and complications across population comparisons. Variations in study designs, populations, and definitions introduce bias when summarizing findings, particularly in studies with small sub-populations. These limitations were present in most of the included studies. Conflicting results have been observed, especially regarding the impact of BMI and to some extent age and male sex, as not all studies found significant results. Future studies would benefit from adopting a unified data dictionary that can be agreed upon by the orthopaedic community. In this manner, meta-analyses would be feasible, thus strengthening the evidence for risk factors.
In conclusion, this systematic review presents an overview of risk factors for re-revision following rTKA and assesses the level of bias in the available studies. Key risk factors for re-revision were age, male sex, partial index revision, and infection as indication for the first revision. Correctable risk factors were preoperative anaemia and BMI ≥ 40 kg/m2. Preoperative opioid use and depression may also be correctable risk factors. Future studies are needed with larger populations and clear definitions. Basic epidemiological research into patients undergoing re-revision is also needed, as limited research has been conducted.
References
1. Okafor C , Hodgkinson B , Nghiem S , Vertullo C , Byrnes J . Cost of septic and aseptic revision total knee arthroplasty: a systematic review . BMC Musculoskelet Disord . 2021 ; 22 ( 1 ): 706 . Crossref PubMed Google Scholar
2. Patel A , Pavlou G , Mújica-Mota RE , Toms AD . The epidemiology of revision total knee and hip arthroplasty in England and Wales: A comparative analysis with projections for the United States. A study using the National Joint Registry dataset . Bone Joint J . 2015 ; 97-B ( 8 ): 1076 – 1081 . Crossref PubMed Google Scholar
3. Kurtz S , Ong K , Lau E , Mowat F , Halpern M . Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030 . J Bone Joint Surg Am . 2007 ; 89-A ( 4 ): 780 – 785 . Crossref PubMed Google Scholar
4. Deere K , Whitehouse MR , Kunutsor SK , et al. How long do revised and multiply revised knee replacements last? An analysis of the National Joint Registry . Lancet Rheumatol . 2021 ; 3 ( 6 ): e438 – e446 . Crossref PubMed Google Scholar
5. Baek JH , Lee SC , Jin H , Kim JW , Ahn HS , Nam CH . Poor outcomes of revision total knee arthroplasty in patients with septic loosening compared to patients with aseptic loosening . J Orthop Surg Res . 2021 ; 16 ( 1 ): 624 . Crossref PubMed Google Scholar
6. Santaguida PL , Hawker GA , Hudak PL , et al. Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review . Can J Surg . 2008 ; 51 ( 6 ): 428 – 436 . PubMed Google Scholar
7. Kallala RF , Vanhegan IS , Ibrahim MS , Sarmah S , Haddad FS . Financial analysis of revision knee surgery based on NHS tariffs and hospital costs: does it pay to provide a revision service? Bone Joint J . 2015 ; 97-B ( 2 ): 197 – 201 . Crossref PubMed Google Scholar
8. Quinn J , Jones P , Randle R . Clinical outcomes following revision total knee arthroplasty: minimum 2-year follow-up . Clin Orthop Surg . 2022 ; 14 ( 1 ): 69 – 75 . Crossref PubMed Google Scholar
9. Page MJ , McKenzie JE , Bossuyt PM , et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews . BMJ . 2021 ; 372 : n71 . Crossref PubMed Google Scholar
10. Brown D . A review of the PubMed PICO Tool: using evidence-based practice in health education . Health Promot Pract . 2020 ; 21 ( 4 ): 496 – 498 . Crossref PubMed Google Scholar
11. No authors listed . Systematic review tool . Covidence . https://www.covidence.org/ ( date last accessed 19 July 2024 ). Google Scholar
12. Cook DA , Reed DA . Appraising the quality of medical education research methods: the Medical Education Research Study Quality Instrument and the Newcastle-Ottawa Scale-Education . Acad Med . 2015 ; 90 ( 8 ): 1067 – 1076 . Crossref PubMed Google Scholar
13. Shao J , Zhang H , Yin B , Li J , Zhu Y , Zhang Y . Risk factors for surgical site infection following operative treatment of ankle fractures: A systematic review and meta-analysis . Int J Surg . 2018 ; 56 : 124 – 132 . Crossref PubMed Google Scholar
14. Chalmers BP , Pallante GD , Sierra RJ , Lewallen DG , Pagnano MW , Trousdale RT . Contemporary revision total knee arthroplasty in patients younger than 50 years: 1 in 3 risk of re-revision by 10 years . J Arthroplasty . 2019 ; 34 ( 7S ): S266 – S270 . Crossref PubMed Google Scholar
15. Geary MB , Macknet DM , Ransone MP , Odum SD , Springer BD . Why do revision total knee arthroplasties fail? a single-center review of 1632 revision total knees comparing historic and modern cohorts . J Arthroplasty . 2020 ; 35 ( 10 ): 2938 – 2943 . Crossref PubMed Google Scholar
16. Aggarwal VK , Goyal N , Deirmengian G , Rangavajulla A , Parvizi J , Austin MS . Revision total knee arthroplasty in the young patient: is there trouble on the horizon? J Bone Joint Surg Am . 2014 ; 96-A ( 7 ): 536 – 542 . Crossref PubMed Google Scholar
17. Klasan A , Magill P , Frampton C , Zhu M , Young SW . Factors predicting repeat revision and outcome after aseptic revision total knee arthroplasty: results from the New Zealand Joint Registry . Knee Surg Sports Traumatol Arthrosc . 2021 ; 29 ( 2 ): 579 – 585 . Crossref PubMed Google Scholar
18. Leta TH , Lygre SHL , Skredderstuen A , Hallan G , Furnes O . Failure of aseptic revision total knee arthroplasties . Acta Orthop . 2015 ; 86 ( 1 ): 48 – 57 . Crossref PubMed Google Scholar
19. Arndt KB , Schrøder HM , Troelsen A , Lindberg-Larsen M . Prosthesis survival after revision knee arthroplasty for “pain without loosening” versus “aseptic loosening”: a Danish nationwide study . Acta Orthop . 2022 ; 93 : 103 – 110 . Crossref PubMed Google Scholar
20. Wilke B , Wagner E , Trousdale R . Long-term survival of a semi-constrained implant following revision for infection . J Arthroplasty . 2015 ; 30 ( 5 ): 808 – 812 . Crossref PubMed Google Scholar
21. Ong KL , Lau E , Suggs J , Kurtz SM , Manley MT . Risk of subsequent revision after primary and revision total joint arthroplasty . Clin Orthop Relat Res . 2010 ; 468 ( 11 ): 3070 – 3076 . Crossref PubMed Google Scholar
22. Cochrane NH , Wellman SS , Lachiewicz PF . Early infection after aseptic revision knee arthroplasty: prevalence and predisposing risk factors . J Arthroplasty . 2022 ; 37 ( 6S ): S281 – S285 . Crossref PubMed Google Scholar
23. Wilson JM , Farley KX , Bradbury TL , Erens GA , Guild GN . Preoperative opioid use is a risk factor for complication and increased healthcare utilization following revision total knee arthroplasty . Knee . 2020 ; 27 ( 4 ): 1121 – 1127 . Crossref PubMed Google Scholar
24. Wilson JM , Farley KX , Erens GA , Bradbury TL , Guild GN . Preoperative depression is associated with increased risk following revision total joint arthroplasty . J Arthroplasty . 2020 ; 35 ( 4 ): 1048 – 1053 . Crossref PubMed Google Scholar
25. Ross BJ , Ross AJ , Cole MW , Guild GN , Lee OC , Sherman WF . The impact of hepatitis C on complication rates after revision total knee arthroplasty: a matched cohort study . Arthroplast Today . 2022 ; 18 : 212 – 218 . Crossref PubMed Google Scholar
26. Citak M , Friedenstab J , Abdelaziz H , et al. Risk factors for failure after 1-stage exchange total knee arthroplasty in the management of periprosthetic joint infection . J Bone Joint Surg Am . 2019 ; 101-A ( 12 ): 1061 – 1069 . Crossref PubMed Google Scholar
27. Lewis PL , Campbell DG , Lorimer MF , Requicha F , W-Dahl A , Robertsson O . Primary total knee arthroplasty revised for instability: a detailed registry analysis . J Arthroplasty . 2022 ; 37 ( 2 ): 286 – 297 . Crossref PubMed Google Scholar
28. Leta TH , Lygre SHL , Schrama JC , et al. Outcome of revision surgery for infection after total knee arthroplasty: results of 3 surgical strategies . JBJS Rev . 2019 ; 7 ( 6 ): e4 . Crossref PubMed Google Scholar
29. Abram SGF , Judge A , Beard DJ , Price AJ . Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England . Lancet . 2018 ; 392 ( 10160 ): 2194 – 2202 . Crossref PubMed Google Scholar
30. Sacerdote P , Franchi S , Panerai AE . Non-analgesic effects of opioids: mechanisms and potential clinical relevance of opioid-induced immunodepression . Curr Pharm Des . 2012 ; 18 ( 37 ): 6034 – 6042 . Crossref PubMed Google Scholar
31. Gorczyca R , Filip R , Walczak E . Psychological aspects of pain . Ann Agric Environ Med . 2013 ; Spec no. 1 : 23 – 27 . PubMed Crossref Google Scholar
32. Ghoneim MM , O’Hara MW . Depression and postoperative complications: an overview . BMC Surg . 2016 ; 16 : 5 . Crossref PubMed Google Scholar
Author contributions
J. T. Hald: Conceptualization, Data curation, Formal analysis, Project administration, Validation, Writing – original draft, Writing – review & editing, Investigation, Visualization
U. K. Knudsen: Conceptualization, Data curation, Formal analysis, Investigation, Resources, Visualization, Writing – review & editing
M. M. Petersen: Conceptualization, Investigation, Methodology, Supervision, Validation, Writing – original draft
M. Lindberg-Larsen: Methodology, Supervision, Writing – review & editing
A. B. El-Galaly: Methodology, Supervision, Writing – review & editing
A. Odgaard: Conceptualization, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing
Funding statement
The authors received no financial or material support for the research, authorship, and/or publication of this article.
ICMJE COI statement
The authors have no conflicts of interest to disclose.
Data sharing
The data for this study are publicly available at nlm.nih.gov and elsevier.com/products/embase.
Acknowledgements
The authors would like to thank the library of Copenhagen University Hospital (Rigshospitalet), Denmark, which assisted in the formulation of the search string.
Ethical review statement
As this study is a systematic review of publicly available papers, no ethical dilemmas are present.
Open access funding
The authors confirm that the open access funding for this manuscript was self-funded.
© 2024 Hald et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
