CORR Insights®: Reason for Revision TKA Predicts Clinical Outcome: Prospective Evaluation of 150 Consecutive Patients With 2-years Followup

Abstract

More than 650,000 total knee replacements are performed annually in the United States [2]. This number is expected to rise in the next 20 years, as the population of the world ages and medical interventions continue to increase average life expectancy [4]. The rapid increase in the use of this health technology brings with it the growing specter of the failed knee replacement. Revision knee arthroplasty is a complex and demanding procedure requiring meticulous planning, a skilled surgical team, and familiarity with an adequate inventory of surgical implants. It does not achieve the same outcome in terms of quality of life or restoration of function compared with primary knee arthroplasty [3].The use of primary knee arthroplasty has evolved alongside its associated evidence base. Prospective clinical trials supplemented by data from large national registry cohorts remain an invaluable tool in the assimilation of evidence and continue to guide surgical decision making. Although questions remain regarding primary knee replacement, strides have been made to determine what the best practices are for the patient, surgeon and the wider healthcare infrastructure. The same cannot be said for revision knee arthroplasty.Revision knee replacement encompasses a heterogeneous case mix of pathology and indication. We find it frustrating that revision knee replacement continues to be handled by the occasional surgeon, limiting ready acquisition of the necessary skill level for the surgeon, surgical team and rehabilitation service. The logistical difficulties found in attempting to design meaningful studies are magnified. While most arthroplasty registries are designed to identify revision as their ultimate endpoint, the information gathered is extremely limited. Mode of failure data is inconsistently collected and the majority of registries offer no insight into functional performance. We are left basing surgical decisions on a restricted pool of observational, often retrospective, case series data. These papers often lack the power and design to ask questions pertinent to clinical practice. We have limited information regarding who needs an operation. Which operation should be done? How will it be performed? Who will perform it? What implant should we use? How should it be fixed and what level of constraint is required? How are functional outcomes influenced by the indication for revision, the type of surgery performed (one versus two stage), and the number of previous revisions (law of diminishing returns)?The current article from van Kempen and colleagues substantially adds to our current knowledge base by emphasizing the behavior of the revision knee population and secondarily, the role of research in revision knee surgery. It emphasizes the growing appreciation that patient