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      The Epidemiology of Revision Total Knee Arthroplasty in the United States

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          Abstract

          Understanding the cause of failure and type of revision total knee arthroplasty (TKA) procedures performed in the United States is essential in guiding research, implant design, and clinical decision making in TKA. We assessed the causes of failure and specific types of revision TKA procedures performed in the United States using newly implemented ICD-9-CM diagnosis and procedure codes related to revision TKA data from the Nationwide Inpatient Sample (NIS) database. Clinical, demographic, and economic data were reviewed and analyzed from 60,355 revision TKA procedures performed in the United States between October 1, 2005 and December 31, 2006. The most common causes of revision TKA were infection (25.2%) and implant loosening (16.1%), and the most common type of revision TKA procedure reported was all component revision (35.2%). Revision TKA procedures were most commonly performed in large, urban, nonteaching hospitals in Medicare patients ages 65 to 74. The average length of hospital stay (LOS) for all revision TKA procedures was 5.1 days, and the average total charges were $49,360. However, average LOS, average charges, and procedure frequencies varied considerably by census region, hospital type, and procedure performed.

          Level of Evidence: Level II, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.

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          Most cited references23

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          Prevalence of knee and hip osteoarthritis and the appropriateness of joint replacement in an older population.

          Relatively little is known about the prevalence of knee and hip osteoarthritis in the general population. To estimate the prevalence of knee and hip osteoarthritis and the appropriateness of joint replacement in a general population of older individuals, the validated Knee and Hip OsteoArthritis Screening Questionnaire (KHOA-SQ) was sent to a random sample of individuals aged 60 to 90 years, stratified by age and sex, living in a single province in Spain. Respondents positive for knee or hip osteoarthritis on the KHOA-SQ were invited to be examined by an orthopedic surgeon. Diagnosis of knee or hip osteoarthritis was based on clinical and radiographic data. For respondents judged as having osteoarthritis, the appropriateness of knee or hip replacement was evaluated using published explicit criteria. Of 11 002 individuals contacted, 7577 completed the KHOA-SQ. The derived prevalence of hip osteoarthritis was approximately 7.4%. It was slightly higher in women (8.0%) than in men (6.7%) and tended to increase with age. The estimated appropriateness rate for hip replacement was 37.7% in men and 52.7% in women with osteoarthritis. The derived prevalence of knee osteoarthritis was 12.2%; it was significantly higher in women (14.9%) than in men (8.7%) and tended to increase with age. The estimated appropriateness rate for knee replacement was 11.8% in men and 17.9% in women with osteoarthritis. Knee and hip osteoarthritis are highly prevalent diseases in the older population. The estimation of appropriateness for hip replacement seems to be significantly higher than that for knee replacement.
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            The Chitranjan Ranawat Award: Long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties.

            We examined factors affecting survivorship, and reasons for reoperation and revision of a cemented modular condylar total knee arthroplasty (TKA). One thousand and eight consecutive primary cemented cruciate-retaining TKAs performed at one institution were studied. At the time of review, 411 patients (562 knees) had died, 43 patients (45 knees) had their knee components revised or removed, and 47 patients (62 knees) were lost to followup. Mean followup of living patients with their TKA components in situ (244 patients, 331 knees) was 15.7 years. Survivorship at 15 years for revision for any reason, revision for mechanical failure, and revision for aseptic loosening were 95.9%, 97.0%, and 98.8% respectively. Survivorship was poorer among patients aged less than 60. Forty-five knees had components removed or revised; approximately one-third were removed for infection, one-third for aseptic loosening or tibial polyethylene wear, and one-third for other causes. Mechanical implant failures accounted for less than one-half of the reoperations and revisions, while infection and periprosthetic fractures accounted for a substantial portion of revisions and reoperations. Because mechanical arthroplasty failures have become less common, other complications related to arthroplasty have become proportionately more frequent.
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              Current etiologies and modes of failure in total knee arthroplasty revision.

              Although total knee arthroplasty is a very effective intervention and increasing in prevalence, failures do occur. We studied patients presenting for total knee arthroplasty revision to determine any modifiable causes of failure, both short and long term, and where future efforts should be directed to reduce the incidence of failure. A multicenter prospective observational cohort study of 318 consecutive patients, with minimum 1 year follow-up, undergoing total knee arthroplasty revision was performed. Associations between modes of failure were also assessed. The mean time from primary procedure to total knee arthroplasty revision was 7.9 years. Many patients (64.4%) had more than one cause of failure. Thirty-one percent of patients were early (< 2 years) failures at a mean of 11 months. These had a higher prevalence of infection, perioperative factors and comorbidities. Late failures occurred at a mean of 119.2 months. Other major causes of failure included instability (28.9%), wear (24.5%) and component loosening suggesting the importance of modifications in technique, implants and other areas. Application of these findings will ultimately reduce revision numbers through continued refinement of total knee arthroplasty practice and through further specific investigation of these modes of failure. Therapeutic study, level II-2 (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.
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                Author and article information

                Contributors
                bozick@orthosurg.ucsf.edu
                Journal
                Clin Orthop Relat Res
                Clinical Orthopaedics and Related Research
                Springer-Verlag (New York )
                0009-921X
                1528-1132
                25 June 2009
                25 June 2009
                January 2010
                : 468
                : 1
                : 45-51
                Affiliations
                [1 ]Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 500 Parnassus Ave., MU320W, San Francisco, CA 94143-0728 USA
                [2 ]Exponent, Inc., Philadelphia, PA USA
                [3 ]Exponent, Inc., Menlo Park, CA USA
                [4 ]Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave., MU320W, San Francisco, CA 94143-0728 USA
                [5 ]Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA USA
                [6 ]Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN USA
                Article
                945
                10.1007/s11999-009-0945-0
                2795838
                19554385
                638b91fc-c5bc-4e80-bc65-19f632d8a66d
                © The Author(s) 2009
                History
                : 21 October 2008
                : 5 June 2009
                Categories
                Symposium: Papers Presented at the Annual Meetings of the Knee Society
                Custom metadata
                © The Association of Bone and Joint Surgeons® 2010

                Orthopedics
                Orthopedics

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