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/m. 2. , 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

Aims. This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data. Methods. This is an observational cohort study using data from the German Arthroplasty Registry (EPRD). A total of 17,842 rTHAs were included, and the rates and cumulative incidence of hip re-revision and mortality following septic and aseptic rTHA were analyzed with seven-year follow-up. The Kaplan-Meier estimates were used to determine the re-revision rate and cumulative probability of mortality following rTHA. Results. The re-revision rate within one year after septic rTHA was 30%, and after seven years was 34%. The cumulative mortality within the first year after septic rTHA was 14%, and within seven years was 40%. After multiple previous hip revisions, the re-revision rate rose to over 40% in septic rTHA. The first six months were identified as the most critical period for the re-revision for septic rTHA. Conclusion. The risk re-revision and reinfection after septic rTHA was almost four times higher, as recorded in the ERPD, when compared to previous meta-analysis. We conclude that it is currently not possible to assume the data from single studies and meta-analysis reflects the outcomes in the ‘real world’. Data presented in meta-analyses and from specialist single-centre studies do not reflect the generality of outcomes as recorded in the ERPD. The highest re-revision rates and mortality are seen in the first six months postoperatively. The optimization of perioperative care through the development of a network of high-volume specialist hospitals is likely to lead to improved outcomes for patients undergoing rTHA, especially if associated with infection. Cite this article: Bone Joint J 2024;106-B(6):565–572

Aims. We compared the risks of re-revision and mortality between two-stage and single-stage revision surgeries among patients with infected primary hip arthroplasty. Methods. Patients with a periprosthetic joint infection (PJI) of their primary arthroplasty revised with single-stage or two-stage procedure in England and Wales between 2003 and 2014 were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HRs) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. Results. In total, 535 primary hip arthroplasties were revised with single-stage procedure (1,525 person-years) and 1,605 with two-stage procedure (5,885 person-years). All-cause re-revision was higher following single-stage revision, especially in the first three months (HR at 3 months = 1.98 (95% confidence interval (CI) 1.14 to 3.43), p = 0.009). The risks were comparable thereafter. Re-revision for PJI was higher in the first three postoperative months for single-stage revision and waned with time (HR at 3 months = 1.81 (95% CI 1.22 to 2.68), p = 0.003; HR at 6 months = 1.25 (95% CI 0.71 to 2.21), p = 0.441; HR at 12 months = 0.94 (95% CI 0.54 to 1.63), p = 0.819). Patients initially managed with a single-stage revision received fewer revision operations (mean 1.3 (SD 0.7) vs 2.2 (SD 0.6), p < 0.001). Mortality rates were comparable between these two procedures (29/10,000 person-years vs 33/10,000). Conclusion. The risk of unplanned re-revision was lower following two-stage revision, but only in the early postoperative period. The lower overall number of revision procedures associated with a single-stage revision strategy and the equivalent mortality rates to two-stage revision are reassuring. With appropriate counselling, single-stage revision is a viable option for the treatment of hip PJI. Cite this article: Bone Joint Res 2023;12(5):321–330

Implant fracture of modular revision stems is a major complication after total hip arthroplasty revision (rTHA). Studies looking at specific modular designs report fracture rates of 0.3% to 0.66% whereas fractures of monobloc designs are only reported anecdotally. It is unclear whether the overall re-revision rate of modular designs is higher and if, whether stem fractures or other revision reasons are responsible for this elevation. All revisions within 5 years after implantation of a revision stems (n. 0. =13,900; n. 5. =2506) were analysed using Cox regression with design (modular: n=17, monobloc: n=27), BMI, Sex and Elixhauser Score as independent variables. One stage and two stage revisions were analysed separately (1-stage: modular n= 7,102; monobloc n= 4,542; 2-stage: 1,551 / 704). The revision volume of the hospitals was also considered (low: <20 revisions, medium: 21–50 revisions, high: >50 revisions). For the 1-stage revisions, the re-revision risk after 4 years was 14,3% [13.2%, 15.5%] for monobloc and 17.4% [16.40%, 18.40%] for modular stems (p< 0.001). Stem fracture was the reason for re-revision in 2.4% of the modular (fracture rate 0.42%) and 0.6% of the monobloc revisions. The difference in re-revision rates between the designs was mainly due to differences in dislocation and stem loosening. For the 2-stage revisions, the revision risks for either design were similar (21.7% [18,5%, 25.4%] vs. 23.0% [20.8%, 25.4%]; p=0.05). Patient characteristics influenced the comparison between the two designs in the 1-stage group but very little in the 2-stage group. Modular revision stem fractures only contribute very minor to re-revision risk. In 2-stage revisions, no difference in overall re-revision rates between designs was observed. This might indicate that the differences observed for 1-stage procedures are due to differences between the patient cohorts, not reflected by the parameters available or surgeon choice

Aims. The aim of this study was to measure the effect of hospital case volume on the survival of revision total knee arthroplasty (RTKA). Methods. This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTKA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTKA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTKA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant. Results. From 1998 to 2019, 8,301 patients (8,894 knees) underwent RTKA surgery in Scotland (median age at RTKA 70 years (interquartile range (IQR) 63 to 76); median follow-up 6.2 years (IQR 3.0 to 10.2). In all, 4,764 (53.6%) were female, and 781 (8.8%) were treated for infection. Of these 8,894 knees, 957 (10.8%) underwent a second revision procedure. Male sex, younger age at index revision, and positive infection status were associated with need for re-revision. The ten-year survival estimate for RTKA was 87.3% (95% CI 86.5 to 88.1). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was significantly associated with lower risk of re-revision (HR 0.78 (95% CI 0.64 to 0.94, p < 0.001)). The risk of re-revision steadily declined in centres performing > 20 cases per year; risk reduction was 16% with > 20 cases; 22% with > 30 cases; and 28% with > 40 cases. The lowest level of risk was associated with the highest volume centres. Conclusion. The majority of RTKA in Scotland survive up to ten years. Increasing yearly hospital case volume above 20 cases is independently associated with a significant risk reduction of re-revision. Development of high-volume tertiary centres may lead to an improvement in the overall survival of RTKA. Cite this article: Bone Joint J 2021;103-B(4):602–609

Aims. We compared the risks of re-revision and mortality between two-stage revision surgery and single-stage revision surgery among patients with infected primary knee arthroplasty. Methods. Patients with a periprosthetic joint infection (PJI) of their primary knee arthroplasty, initially revised with a single-stage or a two-stage procedure in England and Wales between 2003 and 2014, were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HR) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. Results. A total of 489 primary knee arthroplasties were revised with single-stage procedure (1,390 person-years) and 2,377 with two-stage procedure (8,349 person-years). The adjusted incidence rates of all-cause re-revision and for infection were comparable between these strategies (HR overall five years, 1.15 (95% confidence interval (CI) 0.87 to 1.52), p = 0.308; HR overall five years, 0.99 (95% CI 0.70 to 1.39), p = 0.949, respectively). Patients initially managed with single-stage revision received fewer revision procedures overall than after two-stage revision (1.2 vs 2.2, p < 0.001). Mortality was lower for single-stage revision between six and 18 months postoperative (HR at six months, 0.51 (95% CI 0.25 to 1.00), p = 0.049 HR at 18 months, 0.33 (95% CI 0.12 to 0.99), p = 0.048) and comparable at other timepoints. Conclusion. The risk of re-revision was similar between single- and two-stage revision for infected primary knee arthroplasty. Single-stage group required fewer revisions overall, with lower or comparable mortality at specific postoperative periods. The single-stage revision is a safe and effective strategy to treat infected knee arthroplasties. There is potential for increased use to reduce the burden of knee PJI for patients, and for the healthcare system. Cite this article: Bone Joint Res 2022;11(10):690–699

We compared the risks of re-revision and mortality between two-stage and single-stage revision surgeries among patients with infected primary hip arthroplasty. Patients with a periprosthetic joint infection (PJI) of their primary arthroplasty revised with single-stage or two-stage procedure in England and Wales between 2003 and 2014 were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HRs) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. In total, 535 primary hip arthroplasties were revised with single-stage procedure (1,525 person-years) and 1,605 with two-stage procedure (5,885 person-years). All-cause re-revision was higher following single-stage revision, especially in the first three months (HR at 3 months = 1.98 (95% confidence interval (CI) 1.14 to 3.43), p = 0.009). The risks were comparable thereafter. Re-revision for PJI was higher in the first three postoperative months for single-stage revision and waned with time (HR at 3 months = 1.81 (95% CI 1.22 to 2.68), p = 0.003; HR at 6 months = 1.25 (95% CI 0.71 to 2.21), p = 0.441; HR at 12 months = 0.94 (95% CI 0.54 to 1.63), p = 0.819). Patients initially managed with a single-stage revision received fewer revision operations (mean 1.3 (SD 0.7) vs 2.2 (SD 0.6), p < 0.001). Mortality rates were comparable between these two procedures (29/10,000 person-years vs 33/10,000). The risk of unplanned re-revision was lower following two-stage revision, but only in the early postoperative period. The lower overall number of revision procedures associated with a single-stage revision strategy and the equivalent mortality rates to two-stage revision are reassuring. With appropriate counselling, single-stage revision is a viable option for the treatment of hip PJI

Introduction. The epidemiology of re-revision total hip arthroplasty (THA) is not well understood. The purpose of this study is to investigate the epidemiology of re-revision THA, and identify risk factors that are associated with failure of re-revision THA. Methods. A retrospective analysis was performed on 288 patients who underwent revision THA at a single institution between 1/2012 and 12/2013. Patients who underwent revision hip arthroplasty two or more times were included. Patients were excluded if their indication for their first revision was due to periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected through the electronic medical record. Re-revision failure was defined as the need for any additional return to the operating room, regardless of indication. A logistic regression analysis was performed to assess for significant predictors of re-revision failure. Results. A total of 51 re-revision patients were included in this study. Mean age at re-revision was 59.6 (±14.2 years). There were 32 (67%) females. Mean BMI was 28.8 (±5.4). Median ASA level was 2 (23; 55%). The median number of revisions was 3 (range 2–11). The most common indication for re-revision was acetabular component loosening (15; 29%), followed by PJI (13; 25%) and instability (9; 18%). Among re-revision patients, the most common indication of the first revision was acetabular component loosening (11; 27%), followed by polyethylene wear (8; 19%) and instability (8; 19%) (Figure 1). There was a significantly increased risk of re-revision failure if the re-revision procedure involved exchanging only the head and polyethylene liner (RR=1.792; p=0.017), if instability was the indication for the first revision (RR=3.000; p<0.001), as well as if instability was the indication for the re-revision (RR=1.867; p=0.038). If only the femoral component was exchanged during the re-revision, there was a decreased risk of failure (RR=0.268, p=0.046). 1-year re-revision survival was 54% (23/43). Discussion. Acetabular component loosening and PJI were the most common indications for re-revision. There was an increased risk of re-revision failure if instability was a cause for reoperation at any point during the revision history, or if only an isolated head and polyethylene liner exchange was indicated during the re-revision procedure. There was a decreased risk of re-revision failure if only an isolated femoral stem revision was performed. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction. Revision Total Knee Arthroplasty (TKA) is becoming increasingly prevalent as the number of TKA procedures grow in a younger, higher-demand population. Factors associated with patients requiring multiple revision TKAs are not yet well understood. The purpose of this study is to investigate the epidemiology of re-revision TKA, and identify risk factors that are associated with failure of re-revision TKA. Methods. A retrospective analysis was performed on 358 patients who underwent revision TKA at a single institution between 1/2012 and 12/2013. Patients who underwent revision knee arthroplasty two or more times were included. Patients were excluded if their indication for the first revision was periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected. Re-revision failure was defined as the need for any additional operative intervention. A logistic regression analysis was performed to assess for significant predictors of re-revision failure. Results. A total of 66 re-revision TKA patients were included in this study. Mean age at re-revision was 60 (±11 years). There were 48 (73%) females. Mean BMI was 31.8 (±6.9). Median ASA level was 2 (40/59; 68%). Average follow up was 2.1 (±1.0) years, with 68% (45/66) of patients having greater than 2 year follow up (Table 1). The median number of revisions was 2 (range 2–11). The most common indication for re-revision was arthrofibrosis (15; 23%), followed by PJI (14; 21%) and aseptic component loosening (13; 20%). Among re-revision patients, the most common indication of the first revision was aseptic component loosening (17; 30%), followed by arthrofibrosis (16; 28%) and instability (9; 16%) (Table 2). Among the top four indications for re-revision, both the re-revision and initial revision indication were the same. Additionally, 42% of patients possessed the same indication for re-revision as the initial revision. The proportion of patients that had a lateral release performed in either the index procedure or initial revision was higher in re-revisions performed for patellar maltracking (p=0.013). There was a significantly increased risk of re-revision failure if the patient had a higher BMI (OR=1.22; p=0.006). Re-revision survival at 30 days was 92% (60/65), at 1 year was 81% (52/64), and at 2 years 73% (33/45). The indication history of re-revision failure is shown on Table 3. Discussion. Arthrofibrosis and PJI were the most common indications for re-revision. There was an increased risk of re-revision failure in patients with a higher BMI. It was common to have a re-revision TKA for the same indication as the initial revision. A better understanding of the indications and patient factors that are associated with re-revision failures can help align surgeon and patient expectations in this challenging population. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Revision Total Knee Arthroplasty (rTKA) is predicted to increase by more than 600% between 2005 and 2030. The survivorship of primary TKA has been extensively investigated, however more granular information on the risks of rTKA is needed. The aim of the study was to investigate the incidence of re-revision TKA, with explanatory variables of time from primary to revision, and indication (aseptic vs septic). Secondary aim was to investigate mortality. This is an analysis of the Scottish Arthroplasty Project data set, a national audit prospectively recording data on all joint replacements performed in Scotland. The period from 2000 to 2019 was studied. 4723 patients underwent revision TKA. The relationship between time from primary to revision TKA and 2nd revision was significant (p<0.001), with increasing time lowering probability of re-revision (OR 0.99 95% CI 0.987 to 0.993). There was no significant association in time to first revision on time from 1st revision to re-revision (p>0.05). Overall mortality for all patients was 32% at 10 years (95% CI 31-34), Time from primary TKA to revision TKA had a significant effect on mortality: p=0.004 OR 1.03 (1.01-1.05). Septic revisions had a reduced mortality compared to aseptic, OR 0.95 (0.71-1.25) however this was not significant (p=0.69). This is the first study to demonstrate time from primary TKA to revision TKA having a significant effect on probability of re-revision TKA. Furthermore the study suggests mortality is increased with increasing time from primary procedure to revision, however decreased if the indication is septic rather than aseptic

The aim of this study was to measure the effect of hospital case volume on the survival of revision total hip arthroplasty (RTHA). This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTHA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTHA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTHA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant. From 1999 to 2019, 13,020 patients underwent RTHA surgery in Scotland (median age at RTHA 70 years (interquartile range (IQR) 62 to 77)). In all, 5,721 (43.9%) were female, and 1065 (8.2%) were treated for infection. 714 (5.5%) underwent a second revision procedure. Co-morbidity, younger age at index revision, and positive infection status were associated with need for re-revision (p<0.001). The ten-year survival estimate for RTHA was 93.3% (95% CI 92.8 to 93.8). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was not significantly associated with lower risk of re-revision (HR1, 95% CI 1.00 to 1.00, p 0.073)). The majority of RTHA in Scotland survive up to ten years. Increasing yearly hospital case volume cases is not independently associated with a significant risk reduction of re-revision

Aims. The aim of this study was to explore the relationship between reason for revision total hip arthroplasty (rTHA) and outcomes in terms of patient-reported outcome measures (PROMs). Methods. We reviewed a prospective cohort of 647 patients undergoing full or partial rTHA at a single high-volume centre with a minimum of two years’ follow-up. The reasons for revision were classified as: infection; aseptic loosening; dislocation; structural failure; and painful THA for other reasons. PROMs (modified Oxford Hip Score (mOHS), EuroQol five-dimension three-level health questionnaire (EQ-5D-3L) score, and visual analogue scales for pain during rest and activity), complication rates, and failure rates were compared among the groups. Results. The indication for revision influenced PROMs improvement over time. This finding mainly reflected preoperative differences between the groups, but diminished between the first and second postoperative years. Preoperatively, patients revised due to infection and aseptic loosening had a lower mOHS than patients with other indications for revision. Pain scores at baseline were highest in patients being revised for dislocation. Infection and aseptic loosening groups showed marked changes over time in both mOHS and EQ-5D-3L. Overall complications and re-revision rates were 35.4% and 9.7% respectively, with no differences between the groups (p = 0.351 and p = 0.470, respectively). Conclusion. Good outcomes were generally obtained regardless of the reason for revision, with patients having the poorest preoperative scores exhibiting the greatest improvement in PROMs. Furthermore, overall complication and reoperation rates were in line with previous reports and did not differ between different indications for rTHA. Cite this article: Bone Joint J 2022;104-B(7):859–866

Aims. Isolated acetabular liner exchange with a highly crosslinked polyethylene (HXLPE) component is an option to address polyethylene wear and osteolysis following total hip arthroplasty (THA) in the presence of a well-fixed acetabular shell. The liner can be fixed either with the original locking mechanism or by being cemented within the acetabular component. Whether the method used for fixation of the HXLPE liner has any bearing on the long-term outcomes is still unclear. Methods. Data were retrieved for all patients who underwent isolated acetabular component liner exchange surgery with a HXLPE component in our institute between August 2000 and January 2015. Patients were classified according to the fixation method used (original locking mechanism (n = 36) or cemented (n = 50)). Survival and revision rates were compared. A total of 86 revisions were performed and the mean duration of follow-up was 13 years. Results. A total of 20 patients (23.3%) had complications, with dislocation alone being the most common (8.1%; 7/86). Ten patients (11.6%) required re-revision surgery. Cementing the HXLPE liner (8.0%; 4/50) had a higher incidence of re-revision due to acetabular component liner-related complications than using the original locking mechanism (0%; 0/36; p = 0.082). Fixation using the original locking mechanism was associated with re-revision due to acetabular component loosening (8.3%; 3/36), compared to cementing (0%; 0/50; p = 0.038). Overall estimated mean survival was 19.2 years. There was no significant difference in the re-revision rate between the original locking mechanism (11.1%; 4/36) and cementing (12.0%; 6/50; p = 0.899). Using Kaplan-Meier survival analysis, the revision-free survival of HXLPE fixed with the original locking mechanism and cementing was 94.1% and 93.2%, respectively, at ten years, and 84.7% and 81.3%, respectively, at 20 years (p = 0.840). Conclusion. The re-revision rate and the revision-free survival following acetabular component liner exchange revision surgery using the HXLPE liner were not influenced by the fixation technique used. Both techniques were associated with good survival at a mean follow-up of 13 years. Careful patient selection is necessary for isolated acetabular component liner exchange revision surgery in order to achieve the best outcomes. Cite this article: Bone Joint J 2024;106-B(5 Supple B):59–65

Aim. It still remains unclear whether postoperative antibiotic treatment is advantageous in presumed aseptic revision-arthroplasties of the hip (rTHA) and knee (rTKA) with unexpected-positive-intraoperative-cultures (UPIC). The aim of this study was to evaluate if there is a difference in the septic and/or aseptic re-revision rate in patients with or without postoperative antibiotics. Method. In this retrospective propensity-score (PS) matched cohort-study we compared the re-revision rate and the microbiological spectrum in rTHA and rTKA treated with (AB-Group; n=70) and without (non-AB-Group; n=70) antibiotic treatment in patients with UPIC. Baseline covariates for PS-matching were type of revision, sex, Body-Mass-Index, age, Surgical-Site-Infection-Score, American-Society-of-Anesthesiologists-Classification, serum C-reactive-protein. All patients received routine antibiotic prophylaxis, but empiric AB treatment was started only in patients in the AB-Group. Post-operative treatment was decided on an individual basis according to the preference of the surgeon and the infectious disease specialist for a minimum duration of two weeks. In total, 90 rTHA (45 AB-Group, 45 in non-AB-Group) patients with UPICs and 50 rTKA (25 AB-Group, 25 in non-AB-Group) were included in the study. There was no significant variation in patient demographics. Results. After a median follow-up of 4.1 (IQR: 2.9-5.5) years after rTHA and rTKA, there was no higher re-revision rate (p=0.813) between the AB-group 10/70 (14.3%), and the non-AB-group 11/70 (15.7%). In the AB group, 4.3% (3/70) of patients underwent revision due to septic complications compared to 5.7% (4/70) in the non-AB group (survival log-rank: p=0.691). In total, 30/70 (42.9%) of patients in the AB-group and 23/70 (32.9%) of patients in the non-AB group were diagnosed as having an “infection likely” according to the PJI diagnostic criteria of EBJIS (p=0.223). All UPICs comprised low virulent microorganisms and were considered as a contaminant. In total, 68/70 (97.1%) of the patients in the AB-group received a dual antibiotic treatment for a mean duration of 41 (IQR: 23.5-56.5) days. Conclusion. Postoperative antibiotic treatment did not result in a decreased re-revision rate compared to non-antibiotic treatment in patients with UPIC in presumed aseptic rTHA and rTKA. UPICs with pathogens are likely to be a containment and therefore the classification of “infection likely” according to the EBJIS definition can be safely ignored

Infection after total hip arthroplasty (THA) is a devastating complication. With an ageing population and increased demands for THA, prosthetic joint infection (PJI) is expected to become an even greater problem in the future. In late PJI a one- or two-stage revision procedure is most often used. Factors determining the outcomes are not fully understood and there is controversy in the choice between the two methods. The, two-stage method in infected THA is regarded as more resource demanding and is associated with a high distress in the patients. The aim of this study was to compare the risk for second revision (re-revision) between one- and two-stage revision. During 1979–2015, 1659 first-time revisions performed due to infection were reported to the Swedish Hip Arthroplasty Register. Two-stage revision was the most common procedure (n=1255). Risk for a re-revision was compared between one- and two-stage revision using Cox-regression analysis adjusted for age, sex, diagnosis and method of fixation. The primary end-point was a re-revision regardless of cause. Aseptic loosening, infection, and dislocation necessitating re-revision were used as secondary outcomes. There was no difference in risk of re-revision regardless of cause (HR (one-stage/two-stage)=0.9, 95% C.I.=0.7–1.1, p=0.3), re-revision due to aseptic loosening (HR=1.1, 95% C.I.=0.7–1.6, p=0.7) or re-revision due to infection (HR=0.7, 95% C.I.=0.5–1.1, p=0.2). Dislocation necessitating a re-revision was less common in the one-stage group (HR=0.4, 95% C.I.=0.2–0.9, p=0.03). In this analysis re-revision rates were similar in the two groups. When analysed specifically for infection, risk of re-revision did not differ between one and two stage revision. Our findings confirm recent systematic reviews on the matter. This observational study supports increased utilisation of the one-stage approach. However prospective randomized studies are needed to validate these findings

The aim of this study was to measure the effect of hospital case-volume on the survival of revision total knee arthroplasty (RTKA). A retrospective analysis of Scottish Arthroplasty Project data was performed. The primary outcome was RTKA survival at ten years. The primary explanatory variable was annual hospital case-volume. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CI) to determine the lifespan of RTKA. Multivariable Cox proportional hazards were used to estimate relative revision risks over time. From 1998 to 2019, 8894 patients underwent RTKA surgery in Scotland (median age 70 years, median follow-up 6.2 years, 4789 (53.5%) females; 718 (8.8%) for infection). Of these patients, 957 (10.8%) underwent a second revision procedure on their knee. Male sex, younger age at index revision, and positive infection status were associated with need for re-revision. The ten-year survival estimate for RTKA was 87.3% (95%CI 86.5–88.1). Adjusting for gender, age, surgeon volume and infection status, increasing hospital case-volume was significantly associated with lower risk of re-revision (Hazard Ratio 0.78 (0.64–0.94, p<0.001)). The risk of re-revision steadily declined in centres performing >20 cases per year: relative risk reduction 16% with >20 cases; 22% with >30 cases; and 28% with >40 cases. The majority of RTKA in Scotland survive up to ten years. Increasing yearly hospital case-volume above 20 cases is independently associated with a significant risk reduction of re-revision. Development of high-volume tertiary centres may lead to an improvement in the overall survival of RTKA

Abstract. Introduction. Revision total knee arthroplasty (RTKA) is a complex procedure with higher rates of re-revision, complications and mortality compared to primary TKA. We report the effects of the establishment of a Revision Arthroplasty Network (The East Midlands Specialist Orthopaedic Network; EMSON). Methodology. The Revision Arthroplasty Network was established in January 2015 and covered the Nottinghamshire and Lincolnshire areas of England. This comprises a collaborative weekly multidisciplinary meeting where upcoming RTKA procedures are discussed, and a plan agreed. Using the Hospital Episode Statistics database, RTKA procedures carried out between 2011 and 2018 from the five EMSON hospitals were compared to all other hospitals in England. Age, sex, and Hospital Frailty Risk scores were used as covariates. The primary outcome was re-revision surgery within 1 year of the index revision. Secondary outcomes were re-revision surgery within two years, any complication within one and two years and median length of stay. Results. 33,828 RTKA procedures were performed across England; 1,028 (3.0%) were conducted within EMSON. Re-revision rates within 1 year were 11.6% and 7.4% pre- and post-intervention respectively within the network. This compares to a pre-post change from 11.7% to 9.7% for the rest of England. In comparative interrupted time-series analysis, there was a significant immediate improvement in re-revision rates for EMSON hospitals compared to the rest of England at 1 year (p = 0.024) and 2 years (p=0.032). Conclusion. Re-revision rates for RTKA improved significantly at one and two years with the introduction of EMSON, when compared to the rest of England

Aim. Debridement Antibiotics and Implant Retention(DAIR) is a procedure to treat a periprosthetic joint infection(PJI) after Total Hip Arthroplasty(THA) or Total Knee Arthroplasty(TKA). The timing between the primary procedure and the DAIR is likely a determinant for its successful outcome. There are few retrospective studies correlating timing of a DAIR with success (1,2). However, the optimal timing of a DAIR and the chance of success still remains unclear. We aimed to assess the risk of re-revision within one year after a DAIR procedure and to evaluate the timing of the DAIR in primary THA and TKA. An estimation of the chance of a successful DAIR will help clinicians and patients in their decision-making process in case of an acute postoperative PJI. Method. We used data from the Dutch Arthroplasty Register(LROI) and selected all primary THA and TKA in the period 2007–2016 who underwent a DAIR within 12 weeks after primary procedure. A DAIR was defined as a revision for infection in which only modular parts were exchanged. A DAIR was successful if not followed by a re-revision within 1 year after DAIR. The analyses were separated for THA and TKA procedures. Results. 207 DAIRs were performed <4 weeks after THA of which 41(20%) received a re-revision within 1 year; 87 DAIRs were performed between 4–8 weeks of which 15(17%) were re-revised and 11 DAIRs were performed >8 weeks and 2(18%) received a re-revision. 126 DAIRs were performed <4 weeks after TKA of which 27(21%) received a re-revision within 1 year; 68 DAIRs were performed between 4–8 weeks of which 14(21%) were re-revised and 15 DAIRs were performed >8 weeks and 3(20%) received a re-revision. Conclusions. There was no difference in 1-year re-revision rate after a DAIR procedure by timing of DAIR procedure for total hip and knee arthroplasty based on Dutch registry data

Abstract. Introduction. Re-revision knee replacement (RR-KR) is complex surgery, with a significant impact on individual patients and health resource use. The aim of this study was to investigate early patient-relevant outcomes following RR-KR. Methodology:. 206 patients (250 knees) undergoing RR-KR were recruited from a major revision centre between 2015–2018. Patient-relevant outcomes assessed were: implant survivorship, complications (90-days), joint function and quality of life (final follow-up). Risk factors for further revision surgery at 1 year were investigated using multiple logistic regression. Results. Mean age at RR-KR was 69.0 years. Indications for RR-KR included: infection (n=171, 68.4%), aseptic loosening (n=25, 10.0%), and instability (n=24, 9.6%). Mean follow-up was 25.5 months. Kaplan Meier survivorship at 1 year was 71.3% (95% CI 64.1-77.3%). RR-KR for PJI had lower reoperation-free survival at 2 years compared to aseptic indications (55.7% versus 78.1%, p<0.05). 35 knees (14.0%) were readmitted within 90 days, the main indication being surgical site infection (54.3%, 4 superficial, 15 deep). At final follow-up, 44% of patients were dissatisfied with the outcome from RR-KR. Mean Oxford Knee Score was 25.1 (range 1–48). Median EQ-5D index was 0.648 (IQR 0.343-0.735). Risk factors for further revision surgery at 1 year were: PJI (OR 2.4;p<0.05) greater number of previous surgeries (OR 1.18;p<0.05) and higher Elixhauser score (OR 1.06;p<0.05). Conclusion. RR-KR was associated with high rates of early failure and post-operative complications. Infective indication for surgery, multiple previous surgeries and worse baseline patient comorbidity were associated to lower implant survivorship

Introduction: In a previous study (ARCO, 2002), we reported that the clinical results of revision total hip arthroplasty for osteonecrosis patients were less satisfactory than those found for a matched group of osteoarthritis patients. The aim of this study was to evaluate the potential factors that may have contributed to these findings. Materials and Methods: This study included 34 hips in 30 osteonecrosis patients who had undergone revision of a femoral total hip arthroplasty component. There were 19 men (22 hips) and 11 women (12 hips) who had a mean age of 46.1 years (range, 28 to 69 years). The surgeries were performed between March 1984 and January 2001. Most femoral stems (91%) were implanted without cement. Prostheses were of different stem lengths, but most (97%) were proximally porous-coated. The mean follow-up was 8.2 years [range, 0.1 (a re-revision) to 19.8 years]. A physical examination as well as patient and physician outcome forms were collected at each visit. Preoperative x-rays were categorized according to the technique of Della Valle and Paprosky. A Kaplan-Meier survival analysis was performed (PEPI statistical software package). Results: Risk factors for osteonecrosis included 15 corticosteroid, 8 alcohol, 7 trauma, and 4 unknown. This was the first revision in 27 cases, second revision in 5 cases, and third revision in 2 cases. Preoperatively, the defects included 4 Type I, 9 Type II, 15 Type IIIA, 2 Type IIIB, 1 Type IV, and 3 unknown types. Of the 34 hips, the femoral component was re-revised in 12 cases. One of the failures was the only fully porous coated stem that was implanted. One of the 3 cemented implants failed, as compared to 11 of the 31 implanted without cement. Survival rates were 90.9% (74.4%–97.1%) at 5 years, 54.8% (24.9%–81.6%) at 10 years, 54.8% (19.9%–85.6%) at 15 years, and 27.4% (1.7%–88.9%) at 20 years. There was no relationship between frequency of re-revision and defect category, risk factors, or age. Discussion: Although there was a high failure rate (12/34; 34%) in this patient cohort, over 50% survived at least 10–15 years. The lack of a relationship between the patient age or the extent of defect and re-revision suggest that other factors concerning this disease need to be examined