Revision knee arthroplasty is a complex procedure with the number and cost of knee revision procedures performed per year expected to rise. Few studies have examined adverse events following revision arthroplasty. The objective of this study was to determine rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications) and to compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the UK Hospital Episode Statistics. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes including infection (undergoing surgery), pulmonary embolism, myocardial infarction, stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications were included in the elective indications cohort. 939,021 primary knee arthroplasty cases were included of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75-2.35; odds ratio [OR] 3.54; 95% CI 2.81-4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. These findings highlight the burden of complications associated with revision knee arthroplasty. They will inform shared decision-making for patients considering revision knee arthroplasty for elective indications. Patients presenting with infection of a knee arthroplasty or a periprosthetic fracture are at very high risk of adverse events. It is important that acute hospital services and tertiary referral centres caring for these patients are appropriately supported to ensure appropriate urgency and an anticipation for increased care requirements

First-time revision acetabular components have a 36% re-revision rate at 10 years in Australia, with subsequent revisions known to have even worse results. Acetabular component migration >1mm at two years following revision THA is a surrogate for long term loosening. This study aimed to measure the migration of porous tantalum components used at revision surgery and investigate the effect of achieving press-fit and/or three-point fixation within acetabular bone. Between May 2011 and March 2018, 55 patients (56 hips; 30 female, 25 male) underwent acetabular revision THR with a porous tantalum component, with a post-operative CT scan to assess implant to host bone contact achieved and Radiostereometric Analysis (RSA) examinations on day 2, 3 months, 1 and 2 years. A porous tantalum component was used because the defects treated (Paprosky IIa:IIb:IIc:IIIa:IIIb; 2:6:8:22:18; 13 with pelvic discontinuity) were either deemed too large or in a position preventing screw fixation of an implant with low coefficient of friction. Press-fit and three-point fixation of the implant was assessed intra-operatively and on postoperative imaging. Three-point acetabular fixation was achieved in 51 hips (92%), 34 (62%) of which were press-fit. The mean implant to host bone contact achieved was 36% (range 9-71%). The majority (52/56, 93%) of components demonstrated acceptable early stability. Four components migrated >1mm proximally at two years (1.1, 3.2, 3.6 and 16.4mm). Three of these were in hips with Paprosky IIIB defects, including 2 with pelvic discontinuity. Neither press-fit nor three-point fixation was achieved for these three components and the cup to host bone contact achieved was low (30, 32 and 59%). The majority of porous tantalum components had acceptable stability at two years following revision surgery despite treating large acetabular defects and poor bone quality. Components without press-fit or three-point fixation were associated with unacceptable amounts of early migration

Introduction. As the demand for primary total knee arthroplasty (TKA) has been on the rise, so will be the demand for revision knee surgery. Nevertheless, our knowledge on the modes of failure and factors associated with failure of knee revision surgery is considerably lower to that known for primary TKA. To date, this has been mostly based on case series within the literature. Therefore, the aim of this study was to evaluate the survivorship of revision TKA and determine the reasons of failure. Methods. A retrospective study was conducted with prior approval of the institutional audit department. This involved evaluation of existing clinical records and radiographs of patients who underwent revision knee surgery at our institution between 2003 and 2015. Re-revision was identified as the third or further procedure on the knee in which at least one prosthetic component was inserted or changed. Results. 95 patients were identified who had re-revision knee replacement. Of these, there were 46 men (48%) and 49 women (52%) with an average age of 65 yrs. Infection was the main cause of failure (35.8%) followed by aseptic loosening (27.4%) and extensor mechanism problems leading to reduced range of motion (7.4%). Other causes included MCL Laxity (3.2%), oversized implants (3.2%) and fracture of the cement mantle (1.1%). The mean survivorship of revision knee replacements in our cohort was 31 months (Range between 1 – 119 months). Conclusion. The survival of knee re-revision implants is considerably different from primary TKA implants. The results of our study provide an improved understanding of the modes of failure of re-revision knee replacements, enabling orthopaedic surgeons the opportunity to better understand the current problems associated with revision knee surgery and the potential to improve our outcomes by tackling these issues

Summary Statement. We analysed impaction bone grafting used together with cemented or uncemented fixation in acetabular revision surgery. The overall risk for re-revision did not differ between the cemented and uncemented group. However, aseptic loosening was more common in the cemented group. Background. Several surgical techniques address bone defects in cup revision surgery. Bone impaction grafting, introduced more than thirty years ago, is a biologically and mechanically appealing method. The primary aim of this study was to evaluate the effect of bone impaction grafting when used with uncemented and cemented fixation in cup revision surgery. Uncemented cups resting on more than 50% host bone were used as controls. Patient and Methods. Cup fixation was studied in ninety hips (eighty-two patients), revised due to loosening between 1993 and 1997. There were fifty-three isolated cup and thirty-seven total revisions. Patients were followed for thirteen years using conventional radiography, radiostereometry (RSA), Harris Hip score and a pain questionnaire. Peroperatively the surgeon assessed the acetabular bone bed vitality. In hips where the cup was judged to rest on > 50% vital bone (group I, n=43), an uncemented cup was used. If the cup was resting on ≤ 50% living bone, uncemented (group IIa, n=21,) or cemented (group IIb, n=26) technique was chosen, according to the surgeon's preference. The mean age of patients at index revision was 61±12 years, 56% were females. The most common index diagnosis was primary osteoarthritis (n=45) followed by rheumatoid arthritis (n=10). Results. At thirteen years, acetabular component failure had necessitated a second revision in 6/7/8 hips in Groups I/IIa/IIb respectively. These re-revisions were performed 1–10 (mean 7.1) years after index revision. Moreover four cup / liner revisions were performed in hips with femoral loosening, not allowing further RSA measurements. These twenty-five hips were followed until re-revision. Deceased patients (n=21) and patients with deteriorating medical condition, not able to attend the follow-up (n=7), were censored in the survival statistics. Aseptic loosening was the most common reason of re-revision. However, in the uncemented groups (I/IIa), four cups were re-revised due to liner wear, osteolysis or instability. In the total study population, and up to two years, the median proximal migration was lowest in Group I followed by Group IIa and Group IIb (p≤0,006). At thirteen years the mean proximal migration was highest in Group IIb 1.29 mm (SD 1.23) followed by Group I 0.30 mm (SD 0.40) and Group IIa 0.22 mm (SD 0.22), p = 0.05. In cases subsequently re-revised because of loosening or with radiographically loose cups at the last follow-up, a higher proximal migration was observed compared to the non-revised and radiographically well-fixed group (up to seven years: p < 0.001; thirteen years: p=0.04). Discussion/Conclusion. We found an increased risk for rerevision in cases with less than 50% host bone-implant contact. These cups showed high early proximal migration, measured by RSA, indicating poor initial fixation. Rate of re-revision due to any reason did not differ between cemented and uncemented cups. The cemented group (IIb) had a higher risk of being re-revised due to aseptic loosening. Poor bone stock, use of small bone chips, inferior impaction technique, and no or restricted contact with living bone are probable reasons for failures when extensive bone grafting is needed

Recent projections expect the number of revision knee replacements performed to grow from 38,000 in 2005 to 270,000 by the year 2030. 1. Although the results of primary total knee arthroplasty are well documented, with overall implant survivorship at 15 years greater than 95%. 2. the results of revision procedures are not as well known. What if the revision TKR fails and what is the prevalence of failure of revision TKRs, the complications and re-operation rates? There are various studies which has either exclusively dealt with the causes or outcomes of revision with a particular prosthesis and survivorship analysis. The effectiveness of revision total knee replacement must be considered in the light of complications rates which could be either medical, orthopaedic surgery related complications or combination of both. The purpose of this study was to evaluate the prevalence of complications, reoperation rates and outcomes in a single surgeon's series between 1984 and 2008. Ninety nine index revision cases were studied. Incidences of surgical complications were 52.5%. The total reoperation rate was 34.3% whilst single re revision accounted for 19.9% whereas multiple re-revision incidences were 4%. The mean outcome in terms of Knee Society Score, Knee Society Function, and Knee society range of motion was statistically and clinically significant between pre operative and posts operative score at one year and remained consistent with time. These results suggest that modern revision total knee replacement are satisfactory operations and the outcomes perhaps can be improved if relatively simple strategies are followed by focusing these operations to specialized that accumulate enough experience from these demanding surgeries. Overall the results asserts that even in the hands of an experienced surgeon the complications do occur which is usually multi factorial, whilst in the light of complications and reoperation incidence the patients can be counselled thoroughly before the procedure

The use of impaction bone grafting during revision arthroplasty of the hip in the presence of cortical defects has a high risk of post-operative fracture. Our laboratory study addressed the effect of extramedullary augmentation and length of femoral stem on the initial stability of the prosthesis and the risk of fracture.

Cortical defects in plastic femora were repaired using either surgical mesh without extramedullary augmentation, mesh with a strut graft or mesh with a plate. After bone impaction, standard or long-stem Exeter prostheses were inserted, which were tested by cyclical loading while measuring defect strain and migration of the stem.

Compared with standard stems without extramedullary augmentation, defect strains were 31% lower with longer stems, 43% lower with a plate and 50% lower with a strut graft. Combining extramedullary augmentation with a long stem showed little additional benefit (p = 0.67). The type of repair did not affect the initial stability. Our results support the use of impaction bone grafting and extramedullary augmentation of diaphyseal defects after mesh containment.