No exponential rise in revision knee replacement surgery over the past 15 years: an analysis from the National Joint Registry

Macrophage response to fibrin structure mediated by Tgm2-dependent mitochondrial mechanosensing

Following an injury at the implantation position, blood-material interactions form a fibrin architecture, which serves as the initial activator of foreign body response (FBR). However, there is limited knowledge regarding how the topography of fibrin architectures regulates macrophage behavior in mitigating FBR. Mechanical cues of the microenvironment have been reported to shape immune cell functions. Here, we investigated macrophage mechanobiology at the organelle level by constructing heterogeneous fibrin networks. Based on findings in vivo, we demonstrated that adhesion-mediated differentiation of mitochondrial function modulated macrophage polarization. The finite activation of integrin signaling upregulated transglutaminase 2 (Tgm2) in a trans-manner, augments PGC1α-mediated mitochondrial biogenesis. Our study highlighted the previously overlooked spatial structures of host proteins adsorbed on material surfaces, advocating for a paradigm shift in material design strategies, from focusing solely on physical properties to considering the modification of host proteins.

Higher hospital volume reduces early failure rates in single-stage revision TKR for infection: An analysis of the United Kingdom National Joint Registry and National Administrative Databases

PURPOSE

Revision knee replacement (RevKR) for infection is rare but increasing. It is hypothesised that higher hospital volume reduces adverse outcomes. The aim was to estimate the association of surgical unit volume with outcomes following first, single-stage RevKR for infection.

METHODS

This population-based cohort study merged data from the United Kingdom National Joint Registry, Hospital Episode Statistics, National Patient Reported Outcome Measures and the Civil Registrations of Death. Patients undergoing procedures between 1 January 2009 and 30 June 2019 were included. Early outcomes were chosen to reflect the quality of the surgical provision and included re-revision at 2 years, mortality, serious medical complications, length of stay and patient-reported outcome measures (PROMs). Adjusted fixed effect multivariable regression models were used to examine the association between surgical unit mean annual caseload and the risk of adverse outcomes.

RESULTS

A total of 1477 patients underwent first-time single-stage RevKRs for infection across 267 surgical units and 716 surgeons. Following adjustment for age, gender, American Society of Anaesthesiologists grade, surgeon volume, year of surgery and operation funder and modelling surgical unit volume with restricted cubic spline, a greater mean annual volume was associated with a lower risk of re-revision at 2 years. The odds of re-revision in hospitals performing fewer than or equal to 12 cases per year was 2.53 (95% confidence interval = 1.50-4.31) times more likely than hospitals performing three to four cases per month. Annual variation in surgical unit volume was not associated with mortality and serious medical complications within 90 days. Only 99 out of 1477 (7%) of patients had linked PROMs which precluded subsequent analysis.

CONCLUSION

Overall, higher volume surgical units had lower rates of early re-revision following the first RevKR for infection. We were unable to provide recommended specific volume thresholds for units; however, the probability of re-revision appears to be lowest in the highest volume units.

LEVEL OF EVIDENCE

Level III, retrospective cohort study of prospectively collected data.

Higher surgeon volume reduces early failure in first time revision of non-infected total knee arthroplasty: An analysis using data from the United Kingdom National Joint Registry

PURPOSE

Revision total knee replacement (RevKR) is an increasingly common procedure. It is hypothesised that higher surgical volume is linked to lower levels of adverse outcomes. The aim was to estimate the association of surgical volume on patient outcomes following first single-stage RevKR for non-infected indications.

METHODS

This population-based cohort study used data from the United Kingdom National Joint Registry, Hospital Episode Statistics and National Patient Reported Outcome Measures. Patients undergoing procedures between 1 January 2009 and 30 June 2019 were included. The primary outcome measure was re-revision within 2 years; chosen to reflect the quality of the surgical provision. Fixed effect multivariable regression models were used to examine the association between surgeon and surgical unit annual caseload and the risk of adverse outcomes.

RESULTS

A total of 8695 patients underwent first time single stage revision for aseptic loosening, instability, or malalignment across 389 surgical units and 1204 surgeons. Following adjustment for age, gender, ASA grade, year of surgery and operation funder, higher surgeon volume was associated with a lower risk of re-revision at 2 years. The risk of re-revision decreased amongst surgeons performing ≥9 annual revisions (OR 0.77, 95% CI 0.62-0.95, p-value = 0.02) compared to those performing <9 annual revisions.

CONCLUSIONS

Annual surgeon case volume of ≥9 first single-stage RevKR for non-infected indications is independently associated with reductions in early re-revision. This evidence supports the setting of minimum volume targets to improve outcomes for patients.

LEVEL OF EVIDENCE

Level III, retrospective cohort study of prospectively collected data.

What is the impact of longer patient travel distances and times on perioperative outcomes following revision knee replacement: a retrospective observational study using data for England from Hospital Episode Statistics

OBJECTIVES

Patients undergoing revision total knee replacement (RevKR) surgery often have difficulties mobilising and increasingly rely on family support. Evolving practice in England aims to manage these patients in specialised centres with the intention of improving outcomes. This practice will result in longer travel distances and times in this frailer group of patients. We want to examine the types of distances and travel times patients can be expected to travel for this complex orthopaedic surgery and to explore concerns of how these impact patient outcomes.

DESIGN

Retrospective observational study from the Hospital Episode Statistics. Multivariable adjusted logistic regression models were used to investigate the relationship between patient travel distances and times with perioperative outcomes.

SETTING

Patients presenting to tertiary referral centres between 1 January 2016 and 31 December 2019. A tertiary referral centre was defined as a trust performing >49 revisions in the year prior.

PARTICIPANTS

Adult patients undergoing RevKR procedures for any reason between 1 January 2016 ando 31 December 2019.

EXPOSURE

The shortest patient level travel distance and time was calculated using the Department of Health Journey Time Statistics using Transport Accessibility and Connectivity Calculator software and Dijkstra's algorithm.

MAIN OUTCOME MEASURES

The primary outcome is emergency readmission within 30 days. Secondary outcomes are mortality within 90 days and length of inpatient stay.

RESULTS

6880 patients underwent RevKR at 36 tertiary referral centres. There was a weak correlation between social deprivation and travel distance, with patients from the most deprived areas travelling longer distances. Overall, 30-day readmission was not statistically associated with longer driving distance (OR 1.00 95% CI 0.99 to 1.02) or peak driving times (OR 1.00 95% CI 0.99 to 1.01).

CONCLUSIONS

There was no association between increasing travel distance and time on perioperative outcomes for RevKR patients.

The projected economic burden and complications of revision hip and knee arthroplasties: Insights from national registry studies

The rising volume of primary hip and knee arthroplasties has led to a parallel increase in revision surgeries, creating significant clinical and economic challenges for healthcare systems worldwide. This study synthesizes national arthroplasty registry data to evaluate trends in revision aetiology, associated costs and regional disparities. While advancements in prosthetic design have reduced aseptic loosening rates (declining to 35.1% for hips and 18.3% for knees), septic complications now account for a growing proportion of revision cases, rising to 18.2% for hips and 21.6% for knees. Additionally, instability and malalignment persist at 15.9% and 14.1%, respectively. Revision procedures are 76% more costly than primary surgeries, with two-stage septic revisions incurring costs of up to $37,297 per case. Beyond direct surgical costs, prolonged recovery and productivity loss contribute to a broader economic impact. Regional variations, such as higher periprosthetic fracture rates in England and Wales, highlight inconsistencies in data reporting and healthcare practices. Addressing these challenges requires standardized infection definitions, enhanced registry collaboration and investment in infection prevention strategies. The role of referral centres in improving outcomes and reducing costs through multidisciplinary care is increasingly recognized. By integrating evidence-based infection management protocols and leveraging emerging technologies, the orthopaedic community can optimize patient outcomes and reduce the financial burden of revising arthroplasties. LEVEL OF EVIDENCE: Level IV.

Is Wear Still a Concern in Total Knee Arthroplasty With Contemporary Conventional and Highly Crosslinked Polyethylene Tibial Inserts in the mid- to Long-Term?

Background

Modern literature has brought into question if wear of tibial inserts made from conventional or highly crosslinked polyethylene (HXL PE) is still a factor limiting longevity of total knee arthroplasty (TKA) in the mid- to long-term. It is the objective of this study to determine: 1) most common causes of mid- to long-term TKA failure, 2) the prevalence of delamination, and 3) the medial/lateral linear wear rates of conventional and HXL PE tibial inserts retrieved in the mid- to long-term.

Methods

A tibial insert retrieval cohort of 107 inserts (79 conventional, 28 HXL PE) with a minimum time in situ of 6.5 years (mean 11.7 ± 4) was studied. Failure causes were determined from chart-review, delamination presence was assessed microscopically, and medial/lateral linear wear was determined by minimal thickness changes measured with a dial-indicator.

Results

The most common mid-to long-term etiologies for failure were instability (44.9%), PE wear 15%), aseptic loosening (14%), and infection (13.1%). Delamination occurred in 70% of inserts (72.1% conventional, 64.3% HXLPE). Gross material loss due to delamination appeared to be the underlying reason for at least 33.3% of cases exhibiting instability. Of the cases removed for infection, 75% exhibited no histopathological hallmarks of acute infection. The medial/lateral wear rates were 0.054/0.051 (conventional) and 0.014/0.011 (HXL) mm/y, respectively.

Conclusions

Polyethylene wear still appears to be a major primary and secondary cause for TKA revision in the mid- to long-term. Wear may manifest as destabilizing delamination or as continuous release of fine wear particles potentially resulting in inflammatory responses and subsequent failure.

Septic complications are on the rise and aseptic loosening has decreased in total joint arthroplasty: an updated complication based analysis using worldwide arthroplasty registers

INTRODUCTION

A decade ago, a comprehensive study was conducted to investigate the reasons for revision surgeries and their respective frequencies in cases of total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on a complication-based analysis of joint replacement registries. The aim of the present study was to determine whether the causes and risks of their occurrence have changed over the last ten years and to present an updated analysis.

MATERIALS AND METHODS

A systematic review of national arthroplasty registries from seven countries examined the causes and rates of revisions of THA and TKA. The study focused on a descriptive analysis that provided an updated overview without statistical significance values.

RESULTS

The most common causes for revisions of THA were aseptic loosening (35.1%), deep infection (18.2%), dislocation/instability (15.9%), and periprosthetic fractures (11.4%). The most common causes for revisions of TKA were deep infection (21.6%), aseptic loosening (18.3%), instability (14.1%), and pain (10.9%).

CONCLUSION

The findings of this study revealed significant shifts in the underlying causes of revision surgeries in the last decade. Notably, septic complications emerged as the predominant reason for revision of primary TKA, while they also gained prominence as a cause of failure of THA. Although aseptic loosening remains the primary cause for re-operation of THA, the relative risk has decreased for both THA and TKA.

Prevention and treatment of peri-implant fibrosis by functionally inhibiting skeletal cells expressing the leptin receptor

The cellular and molecular mediators of peri-implant fibrosis-a most common reason for implant failure and for surgical revision after the replacement of a prosthetic joint-remain unclear. Here we show that peri-implant fibrotic tissue in mice and humans is largely composed of a specific population of skeletal cells expressing the leptin receptor (LEPR) and that these cells are necessary and sufficient to generate and maintain peri-implant fibrotic tissue. In a mouse model of tibial implantation and osseointegration that mimics partial knee arthroplasty, genetic ablation of LEPR+ cells prevented peri-implant fibrosis and the implantation of LEPR+ cells from peri-implant fibrotic tissue was sufficient to induce fibrosis in secondary hosts. Conditional deletion of the adhesion G-protein-coupled receptor F5 (ADGRF5) in LEPR+ cells attenuated peri-implant fibrosis while augmenting peri-implant bone formation, and ADGRF5 inhibition by the intra-articular or systemic administration of neutralizing anti-ADGRF5 in the mice prevented and reversed peri-implant fibrosis. Pharmaceutical agents that inhibit the ADGRF5 pathway in LEPR+ cells may be used to prevent and treat peri-implant fibrosis.

The experience of patients undergoing aseptic, elective revision knee joint replacement surgery: a qualitative study

BACKGROUND

Around 6,000 revision knee replacement procedures are performed in the United Kingdom each year. Three-quarters of procedures are for aseptic, elective reasons, such as progressive osteoarthritis, prosthesis loosening/wear, or instability. Our understanding of how we can best support these patients undergoing revision knee replacement procedures is limited. This study aimed to explore patients' experiences of having a problematic knee replacement and the impact of undergoing knee revision surgery for aseptic, elective reasons.

METHODS

Qualitative semi structured interviews with 15 patients (8 women, 7 men; mean age 70 years: range 54-81) who had undergone revision knee surgery for a range of aseptic, elective indications in the last 12 months at an NHS Major Revision Knee Centre. Interviews were audio-recorded, transcribed, de-identified and analysed using reflexive thematic analysis.

RESULTS

We developed six themes: Soldiering on; The challenge of navigating the health system; I am the expert in my own knee; Shift in what I expected from surgery; I am not the person I used to be; Lingering uncertainty.

CONCLUSIONS

Living with a problematic knee replacement and undergoing knee revision surgery has significant impact on all aspects of patients' lives. Our findings highlight the need for patients with problematic knee replacements to be supported to access care and assessment, and for long-term psychological and rehabilitation support before and after revision surgery.

Patient-Relevant Outcomes Following First Revision Total Knee Arthroplasty, by Diagnosis: An Analysis of Implant Survivorship, Mortality, Serious Medical Complications, and Patient-Reported Outcome Measures Utilizing the National Joint Registry Data Set

BACKGROUND

The purpose of this study was to investigate patient-relevant outcomes following first revision total knee arthroplasties (rTKAs) performed for different indications.

METHODS

This population-based cohort study utilized data from the United Kingdom National Joint Registry, Hospital Episode Statistics Admitted Patient Care, National Health Service Patient-Reported Outcome Measures, and the Civil Registrations of Death. Patients undergoing a first rTKA between January 1, 2009, and June 30, 2019, were included in our data set. Patient-relevant outcomes included implant survivorship (up to 11 years postoperatively), mortality and serious medical complications (up to 90 days postoperatively), and patient-reported outcome measures (at 6 months postoperatively).

RESULTS

A total of 24,540 first rTKAs were analyzed. The patient population was 54% female and 62% White, with a mean age at the first rTKA of 69 years. At 2 years postoperatively, the cumulative incidence of re-revision surgery ranged from 2.7% (95% confidence interval [CI], 1.9% to 3.4%) following rTKA for progressive arthritis to 16.3% (95% CI, 15.2% to 17.4%) following rTKA for infection. The mortality rate at 90 days was highest following rTKA for fracture (3.6% [95% CI, 2.5% to 5.1%]) and for infection (1.8% [95% CI, 1.5% to 2.2%]) but was <0.5% for other indications. The rate of serious medical complications requiring hospital admission within 90 days was highest for patients treated for fracture (21.8% [95% CI, 17.9% to 26.3%]) or infection (12.5% [95% CI, 11.2% to 13.9%]) and was lowest for those treated for progressive arthritis (4.3% [95% CI, 3.3% to 5.5%]). Patients who underwent rTKA for stiffness or unexplained pain had some of the poorest postoperative joint function (mean Oxford Knee Score, 24 and 25 points, respectively) and had the lowest proportion of responders (48% and 55%, respectively).

CONCLUSIONS

This study found large differences in patient-relevant outcomes among different indications for first rTKA. The rate of complications was highest following rTKA for fracture or infection. Although rTKA resulted in large improvements in joint function for most patients, those who underwent surgery for stiffness and unexplained pain had worse outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Epidemiology of revision hip replacement surgery in the UK over the past 15 years-an analysis from the National Joint Registry

OBJECTIVES

To investigate trends in the incidence rate and main indication for revision hip replacement (rHR) over the past 15 years in the UK.

DESIGN

Repeated national cross-sectional study from 2006 to 2020.

SETTING/PARTICIPANTS

rHR procedures were identified from the National Joint Registry for England, Wales, Northern Ireland, the Isle of Man and the States of Guernsey. Population statistics were obtained from the Office for National Statistics.

MAIN OUTCOME MEASURES

Crude incidence rates of rHR.

RESULTS

The incidence rate of rHR doubled from 11 per 100 000 adults in 2006 (95% CI 10.7 to 11.3) to a peak of 22 per 100 000 adults (95% CI 22 to 23) in 2012, before falling to 17 per 100 000 adults in 2019 (95% CI 16 to 17) (24.5% decrease from peak). The incidence rate of rHR reduced by 39% in 2020 compared with 2019 (during the COVID-19 pandemic). The most frequent indications for rHR between 2006 and 2019 were loosening/lysis (27.8%), unexplained pain (15.1%) and dislocation/instability (14.7%). There were incremental increases in the annual number and incidence rates of rHR for fracture, infection, dislocation/instability and a decrease in rHR for aseptic loosening/lysis.

CONCLUSIONS

The incidence rate of rHR doubled from 2006 to 2012, likely due to high early failure rates of metal-on-metal hip replacements. The incidence of rHR then decreased by approximately 25% from 2012 to 2019, followed by a large decrease during the COVID-19 pandemic. The decrease in the number of rHR performed for aseptic loosening/lysis may reflect improved wear and implant longevity. Increased healthcare resource will be required to care for the increasing numbers of patients undergoing rHR for fracture and infection.

Patient-relevant outcomes following elective, aseptic revision knee arthroplasty: a systematic review

BACKGROUND

The aim of this systematic review was to summarise the evidence for the clinical effectiveness of revision knee arthroplasty (rKA) compared to non-operative treatment for the management of patients with elective, aseptic causes for a failed knee arthroplasty.

METHODS

MEDLINE, Embase, AMED and PsychINFO were searched from inception to 1st December 2020 for studies on patients considering elective, aseptic rKA. Patient-relevant outcomes (PROs) were defined as implant survivorship, joint function, quality of life (QoL), complications and hospital admission impact.

RESULTS

No studies compared elective, aseptic rKA to non-operative management. Forty uncontrolled studies reported on PROs following elective, aseptic rKA (434434 rKA). Pooled estimates for implant survivorship were: 95.5% (95% CI 93.2-97.7%) at 1 year [seven studies (5524 rKA)], 90.8% (95% CI 87.6-94.0%) at 5 years [13 studies (5754 rKA)], 87.4% (95% CI 81.7-93.1%) at 10 years [nine studies (2188 rKA)], and 83.2% (95% CI 76.7-89.7%) at 15 years [two studies (452 rKA)]. Twelve studies (2382 rKA) reported joint function and/or QoL: all found large improvements from baseline to follow-up. Mortality rates were low (0.16% to 2% within 1 year) [four studies (353064 rKA)]. Post-operative complications were common (9.1 to 37.2% at 90 days).

CONCLUSION

Higher-quality evidence is needed to support patients with decision-making in elective, aseptic rKA. This should include studies comparing operative and non-operative management. Implant survivorship following elective, aseptic rKA was ~ 96% at 1 year, ~ 91% at 5 years and ~ 87% at 10 years. Early complications were common after elective, aseptic rKA and the rates summarised here can be shared with patients during informed consent.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020196922.

The Role of Single Positive Cultures in Presumed Aseptic Total Hip and Knee Revision Surgery-A Systematic Review of the Literature

(1) Background: Prior to revision hip (THA) or knee arthroplasty (TKA), periprosthetic low-grade infection (PJI) should be ruled out. Despite advances in preoperative diagnosis, unsuspected positive cultures (UPCs) may occur in initially planned aseptic revisions. Particularly, single UPCs pose a diagnostic and therapeutic dilemma, as their impact on outcome is unclear and recommendations are heterogeneous. This review investigates the frequency of single UPCs and their impact on implant survivorship. (2) Methods: In July 2022, a comprehensive literature search was performed using PubMed and Cochrane Library search. In total, 197 articles were screened. Seven retrospective studies with a total of 5821 cases were able to be included in this review. (3) Results: Based on the cases included, UPCs were found in 794/5821 cases (14%). In 530/794 cases (67%), the majority of the UPCs were single positive. The most commonly isolated pathogens were coagulase negative Staphylococci and Cutibacterium acnes. Five of seven studies reported no influence on revision- or infection-free survival following a single positive culture. In two studies, single UPCs following THA revision were correlated with subsequent re-revision for PJI. (4) Conclusions: Single UPCs of a non-virulent pathogen following presumed aseptic TKA revision may be interpreted as contaminants. A single UPC following THA revision may be a risk factor for subsequent PJI. The role of systemic antibiotic treatment remains unclear, but it should be considered if other risk factors for PJI are present.

Re-revision Knee Arthroplasty in a Tertiary Center: Infection and Multiple Previous Surgeries Were Associated With Poor Early Clinical and Functional Outcomes

BACKGROUND

The incidence of re-revision knee arthroplasty (re-revision KA) is increasing and associated with high complication and failure rates. The aim of this study was to investigate re-revision rates, complications, and patient-reported outcomes following re-revision KA and factors associated with poor outcome.

METHODS

This was a retrospective cohort study of 206 patients (250 knees) undergoing re-revision KA at a major revision center from 2015 to 2018. The mean follow-up was 26 months (range, 0 to 61) and mean age at re-revision KA was 69 years (range, 31 to 91 years). The main indications for surgery were prosthetic joint infection (PJI) (n = 171/250, 68.4%) and aseptic loosening (n = 25/250, 10.0%). We compared re-revision rates, joint function, and complications for aseptic and infective indications. Logistic regressions were performed to identify risk factors for further reoperation.

RESULTS

The estimated re-revision rates at 2 years were 28.7% (95% confidence interval [CI]: 22.7-35.9) and at 4 years were 42.0% (95% CI: 32.8-52.6). Mean Oxford Knee Score was 26 points (range, 1 to 48). Mean EuroQoL-5D-5L utility was 0.539 (range, -0.511 to 1.000). Multivariable analyses demonstrated that PJI (Odds Ratio [OR] 2.39, 95% CI 1.06-5.40, P = .036), greater number of previous surgeries (OR 1.18, 95% CI 1.04-1.33, P = .008), and higher Elixhauser score (OR 1.06, 95% CI 1.01-1.13, P = .045) were independently associated to further surgery.

CONCLUSION

Re-revision KA carried a high risk of early failure. Multiple revised joints and patients with more comorbidities had worse function. Patients undergoing re-revision KA for PJI should be counseled to expect higher failure rates and complications than patients who have aseptic indications.