Reasons for revision are associated with rerevised total knee arthroplasties: an analysis of 8,978 index revisions in the Dutch Arthroplasty Register

Background and purpose — From previous studies, we know that clinical outcomes of revision total knee arthroplasty (rTKA) differ among reasons for revision. Whether the prevalence of repeat rTKAs is different depending on the reason for index rTKA is unclear. Therefore, we (1) compared the repeat revision rates between the different reasons for index rTKA, and (2) evaluated whether the reason for repeat rTKA was the same as the reason for the index revision.Patients and methods — Patients (n = 8,978) who underwent an index rTKA between 2010 and 2018 as registered in the Dutch Arthroplasty Register were included. Reasons for revision, as reported by the surgeon, were categorized as: infection, loosening, malposition, instability, stiffness, patellar problems, and other. Competing risk analyses were performed to determine the cumulative repeat revision rates after an index rTKA for each reason for revision.Results — Overall, the cumulative repeat revision rate was 19% within 8 years after index rTKA. Patients revised for infection had the highest cumulative repeat revision rate (28%, 95% CI 25–32) within 8 years after index rTKA. The recurrence of the reason was more common than other reasons after index rTKA for infection (18%), instability (8%), stiffness (7%), and loosening (5%).Interpretation — Poorest outcomes were found for rTKA for infection: over 1 out of 4 infection rTKAs required another surgical intervention, mostly due to infection. Recurrence of other reasons for revision (instability, stiffness, and loosening) was also considerable. Our findings also emphasize the importance of a clear diagnosis before doing rTKA to avert second revision surgeries.

The number of revision total knee arthroplasties (rTKA) has increased over the past years, and projections predict further increases in the coming decades (Kurtz et al. 2007, Patel et al. 2015, LROI 2019). The outcome of these rTKAs is in general inferior compared with the outcome of the primary total knee arthroplasty (Greidanus et al. 2011, Baker et al. 2012, Nichols and Vose 2016). Evidence suggests that one of the determinants for outcome of rTKA is the indication for the revision. To illustrate, several studies have shown a poor prognosis when the rTKA is performed for infection or stiffness compared with revisions for aseptic loosening (Sheng et al. 2006, Pun and Ries 2008, Baker et al. 2012, Van Kempen et al. 2013, Leta et al. 2015). Poor results were reported in terms of complication rates, patient satisfaction, and survival of the prosthesis. However, the majority of these studies based their findings on small samples, and single-center cohorts.A repeat revision indicates that either the initial problem was not resolved despite the index revision, or that another problem occurred. Several reasons for a failed index rTKA can be: inaccurate diagnosis, the decision to choose operative versus nonoperative treatment, surgical failure, the occurrence of complications, or insufficient rehabilitation protocols. Insight into whether the reason for index rTKA is related to the same reason for the repeat rTKA might provide a base for improvement of treatment choices in these revision surgeries.Therefore, we (1) compared the repeat revision rates among the different reasons for index rTKA, and (2) evaluated how often the reason for repeat rTKA was the same as the reason for the index revision.