The Failed Total Knee Arthroplasty: Evaluation and Etiology

387

235

Background Revision THA and TKA are growing and important clinical and economic challenges. Healthcare systems tend to combine revision joint replacement procedures into a single service line, and differences between revision THA and revision TKA remain incompletely characterized. These differences carry implications for guiding care and resource allocation. We therefore evaluated epidemiologic trends associated with revision THAs and TKAs. Questions/purposes We sought to determine differences in (1) the number of patients undergoing revision TKA and THA and respective demographic trends; (2) differences in the indications for and types of revision TKA and THA; (3) differences in patient severity of illness scoring between THA and TKA; and (4) differences in resource utilization (including cost and length of stay [LOS]) between revision THA and TKA. Methods The Nationwide Inpatient Sample (NIS) was used to evaluate 235,857 revision THAs and 301,718 revision TKAs between October 1, 2005 and December 31, 2010. Patient characteristics, procedure information, and resource utilization were compared across revision THAs and TKAs. A revision burden (ratio of number of revisions to total number of revision and primary surgeries) was calculated for hip and knee procedures. Severity of illness scoring and cost calculations were derived from the NIS. As our study was principally descriptive, statistical analyses generally were not performed; however, owing to the large sample size available to us through this NIS analysis, even small observed differences presented are likely to be highly statistically significant.One or more of the authors (SMK, KO, EL) are employees of Exponent, Inc, Menlo Park, CA, USA, and Philadelphia, PA, USA. One of the authors certifies that he (DJB), or a member of his or her immediate family, has received or may receive payments or benefits, during the study period, an amount in excess of USD 100,001-USD 1,000,000, from DePuy Orthopaedics, Inc (Warsaw, IN, USA). One of the authors (TPV) certifies that he has received or may receive payments or benefits, during the study period, an amount in excess of USD 10,001-USD 100,000 from DePuy Orthopaedics, Inc (Warsaw, IN, USA). One of the authors (HER) certifies that he has received or may receive payments or benefits, during the study period, an amount in excess of USD 100,001-USD 1,000,000, from Zimmer, Inc (Warsaw, IN, USA Clin Orthop Relat Res (2015) 473:2131-2138 DOI 10.1007/s11999-014-4078-8 Clinical Orthopaedics and Related Research ® A Publication of The Association of Bone and Joint Surgeons®Results Revision TKAs increased by 39% (revision burden, 9.1%-9.6%) and THAs increased by 23% (revision burden, 15.4%-14.6%). Revision THAs were performed more often in older patients compared with revision TKAs. Periprosthetic joint infection (25%) and mechanical loosening (19%) were the most common reasons for revision TKA compared with dislocation (22%) and mechanical loosening (20%) for revision THA. Full (all-component) revision was more common i...

Section: Discussioncontrasting

confidence: 92%

Comparative Epidemiology of Revision Arthroplasty: Failed THA Poses Greater Clinical and Economic Burdens Than Failed TKA

Bozic

Kamath

Ong

et al. 2015

387

235

“…Possible explanations include higher pain tolerance in older patients or more peripheral neuropathy and less scar formation with less stiffness in older patients, leading to less pain. Recent reviews have summarized predictors/factors associated with persistent post-TKA pain in general [8] and for complex regional pain syndrome [1,19]. Residual confounding, adjustment for different sets of variables, different assessments of pain, and different age categorizations for analyses may explain differing study results.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Gender, Age, and Preoperative Pain Severity on Pain After TKA

Singh

Gabriel

Lewallen

2008

207

170

Do gender and age affect knee arthroplasty outcomes? In a cohort of patients who underwent primary or revision TKA between 1996 and 2004 and responded to a followup questionnaire 2 and 5 years after arthroplasty, we investigated the impact of gender and age on the prevalence of moderate or severe post-TKA knee pain (primary TKA: 2 years, 5290; 5 years, 2602; revision TKA: 2 years, 1109; 5 years, 505). Moderate-severe pain was higher in women than men after primary TKA at 2 and 5 years (9% versus 6.6% and 7.9% versus 6.5%) and postrevision TKA at 2 and 5 years (28.6% versus 22% and 28.9% versus 18.3%). More women compared to men and fewer patients between 61 and 70 years (versus patients B 60) had moderate-severe pain 2 years after primary TKA adjusting for gender, age, and preoperative pain severity. In the post-revision TKA group, the odds of moderate-severe pain were lower in patients older than 80 years (versus those B 60) at 2 years and higher in patients with moderate-severe preoperative pain at 2 and 5 years postoperatively, after adjustment for gender, age, and preoperative pain severity. We conclude female gender, younger age, and worse preoperative pain predict greater risk of moderate-severe pain postoperatively in patients with primary and revision TKA.

“…Inflammatory biomarkers play a pivotal role in this diagnostic process. In the case of aseptic inflammation, however, reliance on elevated laboratory infection biomarkers may lead to unnecessary and inappropriate surgery (implants unnecessarily removed or antibiotic cement spacers needlessly implanted) [12,16,35]. To optimize this diagnostic process, infection biomarkers with a fast response and high sensitivity and specificity for infection are needed [4,8,11,15].…”

Section: Introductionmentioning

confidence: 99%

Novel Biomarkers to Detect Infection in Revision Hip and Knee Arthroplasties

Glehr

Friesenbichler

Hofmann

et al. 2013

Background A periprosthetic joint infection is one of the most challenging complications associated with THA and TKA. In the diagnostic process for detecting a periprosthetic joint infection, one of the most important steps is analysis of laboratory infection biomarkers. Questions/purposes We investigated the sensitivity and specificity of the biomarkers procalcitonin, interleukin 6 (IL-6), and interferon a (IFN-a) as compared with conventional biomarkers (C-reactive protein [CRP], leukocyte level) for a periprosthetic joint infection associated with revision arthroplasties. Methods We prospectively included and analyzed 84 patients (124 revision arthroplasties). The blood parameters of interest were procalcitonin, IL-6, IFN-a, leukocyte level, and CRP. Samples were taken preoperatively and on the first, third, and seventh postoperative days. The sensitivity and specificity of these biomarkers then were calculated. Results Considering the preoperative values of 84 patients (124 operations), procalcitonin, IL-6, CRP, and leukocyte level correlated with periprosthetic joint infection, whereas IFN-a did not. A procalcitonin cut-off level of 0.35 ng/mL revealed a sensitivity of 80% and specificity of 37%. An IL-6 cut-off level of 2.55 pg/mL had a sensitivity of 92% and specificity of 59%. Conclusions In this study procalcitonin and IL-6 were helpful for detecting periprosthetic joint infections in revision arthroplasties, although CRP generally was superior. Procalcitonin and IL-6 may be considered adjuvant tests when the diagnosis of a periprosthetic joint infection is in doubt. This study showed, in addition to conventional biomarkers such as CRP and leukocyte level, procalcitonin and IL-6 were helpful for detecting infections associated with revision arthroplasties.