Sound management decisions are critical to outcomes in revision arthroplasty. Aiming to improve outcomes, revision networks facilitate speciality trained, high volume surgeons, share experience and best practice, contributing to decision making within and away from their base hospital. We have reported the early clinical experience of East Midlands Specialist Orthopaedic Network (EMSON). In this paper we report beneficial clinical effects, both demonstrable and unquantifiable supporting the process.

Using the UK HES database of revisions, performed before and after EMSON was established, (April 2011 – March 2018), data from EMSON hospitals were compared to all other hospitals in the same time-period. Primary outcome was re-revision surgery within 1 year. Secondary outcomes were re-revision, complications within first two years and median LOS.

57,621 RTHA and 33,828 RTKA procedures were involved with around 1,485 (2.6%) and 1,028 (3.0%) respectively performed within EMSON. Re-revision THA rates, within 1 year, in EMSON were 7.3% and 6.0% with re-revision knee rates 11.6% and 7.4%, pre- and post-intervention. Re-revision rates in the rest England in the same periods were 7.4% to 6.8% for hips and 11.7% to 9.7% for knees. This constituted a significant improvement in 1-year re-revision rates for EMSON knees. (β = −0.072 (−0.133 to −0.01), p = 0.024). The reduction in hip re-revision did not reach statistical significance. Secondary outcomes showed a significant improvement for 1 and 2-year RTHA complication rates.

Re-revision rates for RTKA and complication rates for RTHA improved significantly after the introduction of EMSON. Other outcomes studied also improved to a greater extent in the network hospitals. While anecdotal experience with networks is positive, the challenge in collating data to prove clinic benefit should not be underestimated. Beyond the formal process, additional communication, interaction, and support has immeasurable benefit in both elective and emergency scenarios.

The aim of this study is to examine the differences in long-term mortality rates between infected and aseptic revision total hip arthroplasty (rTHA) in a single specialist centre over an 18-year period.

Retrospective consecutive study of all patients who underwent rTHA at our tertiary centre between 2003 and 2020 was carried out. Revisions were classified as infected or aseptic. We identified patients’ age, gender, American Society of Anaesthesiologists grade (ASA) and body mass index (BMI). The primary outcome measure was all-cause mortality at 5 years, 10 years and over the whole study period at 18 years. Death was identified through both local hospital electronic databases and linked data for the National Joint Registry. Kaplan-Meier survival curves were used to estimate time to death. Where two-stage revision techniques were used of the management of infected cases, these were grouped as a single revision episode for the purpose of analysis.

In total, 1138 consecutive hip revisions were performed on 1063 patients (56 bilateral revisions – aseptic, 10 Excision arthroplasties – infection, 9 – Debridement, Antibiotics, Implant retention (DAIR) with 893 aseptic revisions in 837 patients (78.7%) and 245 infected revisions in 226 patients (21.3%). Average age of the entire study cohort was 71.0 (24–101) with 527 female (49.6%). Average age of the infection and aseptic cohorts was 68.8 and 71.5 respectively. Revisions for infection had higher mortality rates throughout the three time points of analysis. Patients’ survivorship for infected vs aseptic revisions was; 77.8% vs 87.7% at 5 years, 62.8% vs 76.5% at 10 years and 62.4% vs 72.0% at 18 years. The unadjusted 10-year risk ratio of death after infected revision was 1.58 (95% confidence interval 1.28–1.95) compared to aseptic revisions.

rTHA performed for infection is associated with significantly higher long-term mortality at all time points compared to aseptic revision surgery.

The clinical success of THA is accepted, however wide variation in implant usage and outcomes is reported across the world. The Getting It Right First Time initiative in the UK has recommended increased use of cemented constructs in patients over 70. A clear clinical directive has been proposed aiming to reduce revision rates, improve outcomes and increase cost effectiveness.

This study compares the outcomes of cemented, hybrid and cementless THA from a high-volume single center at long-term follow-up.

A prospective database identified 1,699 cemented, 5,782 hybrid and 2,631 cementless THAs. Mean follow-up was 8.1 years, 5.3 years and 6.3 years respectively. Primary endpoint was revision for any reason.

47 (1.79%) cemented, 93 (1.60%) hybrid and 39 (1.48%) cementless THAs underwent revision. The difference in overall revision rate was statistically significant (P=0.002). Mean time to revision was 4.5 years in the cemented group, 2.1 years in the hybrid group and 2.6 years in the cementless group.

1 year survivorship was 99.2% in the cemented group, 99.0% in the hybrid group and 98.9% in the cementless group. 3 year survivorship was 98.6% in the cemented group, 98.8% in the hybrid group and 98.9% in the cementless group. At 10 years it was 97.0%, 97.6% and 97.9% respectively. (Difference not statistically significant (p=0.09). Of relevance cemented fixation showed the lowest 10-year survivorship in patients over 70, over 75 and over 80. (not statistically significant P=0.5, 0.6 and 0.47 respectively).

In a high-volume center, excellent outcomes were achieved at 10 years with all three constructs. Cemented THA had the lowest survivorship compared to hybrid, then cementless fixation. Cemented fixation did not outperform cementless fixation in any age group. Surgeons should monitor their outcomes. Use of a philosophy that works best in their own hands should be supported.

Hip and knee revisions continue to increase in number and complexity. With an understanding that revisions have a high re-revision rate, the importance of correct decisions made at the index procedure, is paramount for patients and surrounding health care economy.

Since January 2015, East Midlands Specialist Orthopaedic Network, (set up on a ‘hub-and-spoke’ model), has allowed all revisions performed within our region, (5 hospitals with a 4 million population), to be discussed at a weekly ‘web’ conference. Integrated radiology allows clinical information to be reviewed remotely at each hospital. Chaired by specialist revision surgeons, with other surgeons, a microbiologist and radiology, vascular, plastics opinions available as required, a formal management plan is ‘signed off’ by the chair and returned to referring institution. We present prospective data of Network activities.

To January 2018, 1007 cases have been referred by 18 consultants from 5 hospitals. A change in proposed plan was seen in 48% cases. (40% involved technique and exposure advice; 18% involved surgical inventory; 22% further investigation; 11% microbiological input; 9% other miscellaneous advice) Few (5%) patients were transferred directly. We also identified 20% increase in outpatient referrals to the ‘hub’.

The network is an excellent tool for discussing complex cases, supporting surgeons in smaller units. A significant number of alterations in plan are made with a few patients transferred directly. We feel the network can only enhance care and are working now to identify exactly how it has affected clinical outcomes. We encourage others to adopt this approach.

Introduction

Between 2005 and 2010, the number of revision hip arthroplasties rose by 49.1%, and revision knee arthroplasties by 92.1%. This number is predicted to rise by 31% and 332% respectively by 2030.

In March 2014, NHS England invited bids to run a pilot revision network. Nottingham Elective Orthopaedic Service (NEOS) was successful and the East Midlands Specialist Orthopaedic Network (EMSON) runs on a ‘hub-and-spoke’ model.