The Journal of Arthroplasty 28 (2013) 1329–1332

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The Journal of Arthroplasty

j ourna l homepage: www.arth rop lasty journa l .o rg

Revision Surgery After Total Joint Arthroplasty: A Complication-Based Analysis UsingWorldwide Arthroplasty Registers

Patrick Sadoghi, MD a, Michael Liebensteiner, MD b, Mark Agreiter, MD b, Andreas Leithner, MD a,Nikolaus Böhler, MD c, Gerold Labek, MD b

a Department of Orthopaedic Surgery, Medical University of Graz, Austriab Department of Orthopaedic Surgery, Medical University Innsbruck, Austriac Department of Orthopaedic Surgery, AKH Linz, Linz, Austria

The study was performed in cooperation with the EUCommission DG SANCO, Grant agreement 2003134). Futhe project is available at www.euphoric-project.eu.

Level of Evidence: Level III study— Retrospective anaregistry data.

The Conflict of Interest statement associated with thidx.doi.org/10.1016/j.arth.2013.01.012.

Reprint requests: Gerold Labek, MD, Medical UniverOrthopaedic Surgery, Anichstrasse 35, A-6020 Innsbruck

0883-5403/2808-0014$36.00/0 – see front matter © 20http://dx.doi.org/10.1016/j.arth.2013.01.012

a b s t r a c t

a r t i c l e i n f o

Article history:Received 15 October 2012Accepted 4 January 2013

Keywords:arthroplastyregister datacomplication

The authors performed a complication-based analysis of total knee (TKA), total hip (THA), and total anklearthroplasty (TAA) using worldwide arthroplasty registers. We extracted data with respect to reason forrevision surgery and pooled causes. The most common causes for revisions in THA were aseptic loosening(55.2%), dislocation (11.8 %), septic loosening (7.5%), periprosthetic fractures (6%), and others. The mostcommon causes in TKAwere aseptic loosening (29.8%), septic loosening (14.8%), pain (9.5%), wear (8.2%), andothers. The most common causes in TAA were aseptic loosening (38%), technical errors (15%), pain (12%),septic loosening (9.8%), and others. Revisions in TKA and THA differ with respect to type of complication.However, in case of TAA, higher rates of technically related complications are reported.

PHORIC project (funded by EUrther information concerning

lysis of prospectively collected

s article can be found at http://

sity Innsbruck, Department of, Austria.

13 Elsevier Inc. All rights reserved.

© 2013 Elsevier Inc. All rights reserved.

Revision rates and causes for revision surgery are mandatoryoutcome parameters for evaluation of the success of total jointarthroplasties [1–4]. It has been shown that published clinical studiesreveal discrepancies on these parameters, which might be affected byimplant design, surgical technique and skill, influence of the publichealth system, and the study design [5,6]. Therefore, due to theseinfluential factors and discrepancies in published material it is oftennot possible to draw definite conclusions of the published clinicalstudies or even perform an adequate systematic review or meta-analysis [7].

However, for the scientific community it is mandatory to drawdefinite conclusions to the whole patient population. One reason forthe structural flaws of clinical studies are the designs, as appropriateblinding is not possible and placebo-controlled studies do notconform with the Declaration of Helsinki in case of long-termfollow-up arthroplasty studies [8]. Revision surgery as definedendpoints of outcome studies is rare and often appears only manyyears after primary implantation. Cross-sectional studies after 5 to10 years of follow-up are on the one hand likely to underreport

complication analysis, or will, on the other hand, present thisinformation in a too late fashion [9]. Therefore, more suitablemethodsfor reporting complications and failure rates after total jointarthroplasties are arthroplasty registers such as initially started inSweden and now provided for various countries through the EFORT-portal [10].

Whilst revision rates and cumulative revisions of total jointarthroplasties reported by register data have already been affirmedin previous peer-reviewed work of the study group by Labek et al [11]an evaluation of the causes with respect to a comparison of totalknee and total hip with total ankle arthroplasty still lacks in thescientific literature.

The aim of this study was therefore to perform a complication-based analysis in case of revision surgery of total knee (TKA), total hip(THA), and total ankle arthroplasty (TAA) using worldwide Arthro-plasty Registers by summarizing relative likelihood of different causesfor revision surgery, and to describe differences between thearthroplasties and registers, if applicable.

The study hypothesis was that revision rates and causes forrevision surgery after total ankle arthroplasty (TAA) differ incomparison to total knee (TKA) and total hip arthroplasty (THA).

Material and Methods

The authors performed a systematic review of published nationalarthroplasty registers as well as clinically relevant literature.Therefore, national arthroplasty registers were identified using theEFORT-portal and its link-solving mechanism [10]. In addition,

Table 1Reasons for Revision Surgery After Total Knee Arthroplasty (TKA), Total HipArthroplasty (THA), and Total Ankle Arthroplasty (TAA) UsingWorldwide ArthroplastyRegisters.

Cause for RevisionTotal Hip

ArthroplastyTotal KneeArthroplasty

Total AnkleArthroplasty

Data collection 1979 to 2009 1979 to 2009 1993 to 2007Aseptic loosening 55.2a 29.8 38Luxation/Instability 11.8 6.2 8.5Septic loosening 7.5 14.8 9.8Periprosthetic fracture 6 3 2Wear 4.2 8.2 8Pain without other cause 3.7 9.5 12Implant breakage 2.5 4.7 5.3Technical error 3.8 4.6 15

We Observed More Technically Related Complications in Case of TAA.a Values represent percentage of cause of revisionwith respect to the total number of

revision surgeries within one year.

1330 P. Sadoghi et al. / The Journal of Arthroplasty 28 (2013) 1329–1332

publications in journal articles were searched according to theregistries reference lists [9].

Inclusion criteria compromised data sets of national jointarthroplasty registers with at least 90% of attrition with respect tothe whole country or a representative clinical study for datavalidation. In order to avoid double reporting only the most actualand biggest data sets of each country were included. Datasets ofannual reports included the number of all primary implantations andall revision surgeries within the period of one year. Therefore, theannual report from Sweden from 2010 included all implantedarthroplasties and all revised cases from the 1st of January to the31st of December 2010, respectively. In addition, we reported thetime periods, in which the reported revision cases had beenimplanted, if applicable. We excluded datasets if not reporting thenumber of primary arthroplasties, and the number of revisionsurgeries. Reporting primaries serves as an overview of implantusage to the reader.

With respect to these criteria, we included the data from nationalarthroplasty registers from Sweden, Norway, Finland, Denmark,Australia, and New Zealand in order to describe revisions afterprimary total hip and knee arthroplasty and in case of total anklearthroplasty we used the register data from Norway and New Zealand[10], which have, equal to the Swedish register, published parts oftheir data in clinical journals.

Arthroplasty of the shoulder and elbow or small fingers or handjoints, or small joints of the foot was only reported in theNorwegian register and therefore not included in this study.Unicompartmental knee arthroplasties (UKA), which were mainlyreported from Australia and Swedish registers, were also excludedfrom this analysis.

We extracted the following parameters in the includeddatasets: Country, period of the report, number of primaryimplantations, number of revision surgeries, number of asepticloosenings and/or osteolysis, dislocations, septic loosening, peri-prosthetic fractures, technical errors or failures, implant breakage(fracture), wear, or pain without other reason. These primarydata were entered by the revision surgeons to the best of theirpersonal judgement.

All data were extracted in duplicate by at least two independentreviewers and entered into a predefined datasheet. Data consistencywas checked after extraction by a third, independent investigator.Disagreement was resolved by consensus or with help of the seniorauthor in accordance to the PRISMA (Preferred Reporting Items forSystematic reviews and Meta-Analyses) statement, an evidence-based, established guideline for systematic reviews published by theCONSORT group [12].

As the questionnaires of the different registers differed, wereunited these in more general groups in order to better compareresults. This was possible by logical explanation and applied in case ofthe term “incorrect axis” which was handled as “technical error”.

In many cases, multiple choices of causes for revision werepossible, which could not always be acknowledged by choosing themost fitting reason for revision only.

All investigations were performed independent of the implanteddevices and therefore, the countries’ individual performances,surgical procedures, and influence of the public health systemcould be evaluated.

Statistical Analysis

We report in a descriptive fashion without significance values asthis work is set to define benchmarks and not compare outcomeparameters between individual implant designs. In addition, registerdata are meant to represent the whole patient population with thesingle limitation of attrition of individual registers. We report relativerevision rates in relation to all revisions of the reported year.

Results

We were able to identify reasons for revision surgery in case oftotal knee and total hip arthroplasty using the register data fromSweden, Norway, Finland, Denmark, Australia, and New Zealandincluding 391,913 primary and 36,307 (9%) cases of revised TKAs and485,790 primary and 77,036 (15%) cases of revised THAs. Revisionsurgeries were reported from prosthesis, which had been implantedfrom 1979 to 2009 in THAs and TKAs. In case of total anklearthroplasty we were able to include data from the registers fromNorway and New Zealand including 1113 primary cases and 189(17%) cases of revision surgery in total. These prostheses had beenimplanted from 1993 to 2007. The most common causes for revisionsurgery in THA in relative values were aseptic loosening (55.2%),followed by dislocation (11.8 %), septic loosening (7.5%), peripros-thetic fractures (6%), wear (4.2%), pain without other reason (3.7%),and implant breakage (2.5%). The most common causes for revisionsurgery in TKA in relative values were aseptic loosening (29.8%),septic loosening (14.8%), pain without other reason (9.5%), wear(8.3%), instability (6.2%), implant breakage (4.7%), and periprostheticfracture (3%). The most common causes for revision surgery in TAAwere aseptic loosening (38%), followed by technical errors (15%), painwithout other cause (12%), septic loosening (9.8%), instability (8.5%),implant breakage (5.3%), and periprosthetic fracture (2%). Thisinformation is further illustrated in Table 1 and Figs. 1, 2, and 3.

Discussion

The aim of this study was therefore to perform a complication-based analysis in case of revision surgery of total knee (TKA), total hip(THA), and total ankle arthroplasty (TAA) using worldwide Arthro-plasty Registers by summarizing relative likelihood of different causesfor revision surgery, and to describe differences between thearthroplasties and registers, if applicable.

The study hypothesis was that revision rates and causes forrevision surgery after total ankle arthroplasty (TAA) differ incomparison to total knee (TKA) and total hip arthroplasty (THA).

We found that revision surgery in total knee arthroplasty is mostcommonly due to aseptic loosening, septic complications, painwithout other cause, and wear compared to total hip arthroplastywith revision most commonly due to aseptic loosening, luxation, andseptic loosening. Whilst the different value with respect to luxation isobviously dependent on the biomechanical setting of THA, thedifferences of aseptic loosening are rather unclear. After total hiparthroplasty one out of 13 patients has to be revised due to asepticloosening, one out of 59 patients due to dislocation, and one out of 93has to undergo revision with at least exchange of parts of the implantdue to septic complications. In contrast to that, only 29.8% of revisions

Fig. 1. Diagram illustrating the causes for revision surgery after Total Hip Arthroplasty(THA) using worldwide Arthroplasty Registers in relative percentages with respect tothe total number of revisions reported.

Fig. 3. Diagram illustrating the causes for revision surgery after Total AnkleArthroplasty (TAA) using worldwide Arthroplasty Registers in relative percentageswith respect to the total number of revisions reported.

1331P. Sadoghi et al. / The Journal of Arthroplasty 28 (2013) 1329–1332

after TKA are performed due to aseptic loosening and the hazard forseptic complications is almost twice as high.

About 10% of all revisions after total knee arthroplasty aredocumented due to “pain without any other reason”, which mightbe considered as an indicator for potential improvement of diagnosticpathways prior to revision. This factor is lower in THA, with only 3.7%of revisions within the period of one year.

Implant fracture was found to be relatively frequent with 2.5% ofall reasons for revision after THA and about 5% after TKA and TAAcompared to subjective estimations among orthopaedic surgeons.

In general, revision rates after total ankle arthroplasty aresignificantly higher than after hip- or knee arthroplasty and aproportion of 15% of all revisions due to technical errors could berated as an indicator for potential improvement in surgical techniquesand instruments. However, the classification of technically reportedcomplications is dependent on the subjective evaluation of therevision surgeon who might be biased due to the relatively newankle arthroplasty in comparison to knee or hip arthroplasty. Inaddition, we observed significantly higher numbers of primaryimplantations in case of THA and TKA in contrast to TAA per year. Itis obvious, that surgeons are not that familiar with TAA in contrast toTHA and TKA and might therefore either make more technicalmistakes for real or judge other reasons for revision as technicallyrelated due to uncertainty.

Fig. 2. Diagram illustrating the causes for revision surgery after Total Knee Arthroplasty(TKA) using worldwide Arthroplasty Registers in relative percentages with respect tothe total number of revisions reported.

The last years showed developments of projects rising to build upnational arthroplasty registers with high quality data and a sufficientlong-term follow-up in Europe and the Pacific region for furthercalculations [10,13]. In order to report adequate revision rates andcauses for revision surgery, arthroplasty registers are stated to besuperior in contrast to clinical studies [1,14].

Havelin LI [15] has stated in his PhD thesis that a prospective studywith a defined endpoint difference of 1% between two differentarthroplasty designs after 10 years of follow-up with a confidenceinterval of 95% and a statistical power of over 80% would lead to asample size estimation of 13,474 cases. A defined endpoint differenceof 2% between two arthroplasty designs would therefore still remain3008 cases included in a prospective setting. This calculation statesthe obvious, that most study designs might be underpowered and, onthe other hand, a prospectively planned study including sufficientcases is very difficult or almost impossible to organize.

Arthroplasty registers differ from clinical studies with respect toorganizational factors as they are planned to include all cases of acountry and therefore lead to more representative overall data onrevision rates and causes without further extrapolation [10]. Howev-er, the high number of actual cases pays off by a lower number ofvariables, which is further recorded in arthroplasty datasets. Variouspublications out of the Scandinavian region showed the positiveeffects and possibilities of huge datasets using arthroplasty registerdata [16–20]. However, national register data always representinformation confounders by the way of collection of these data,which might differ between the various countries and thereforemislead to wrong interpretation without adequate detailed knowl-edge in the field [1].

Implantation of total ankle arthroplasty on a regular basis hasstarted many years after the first total knee and total hiparthroplasty [21,22]. Therefore, complications, which are inherentto the relatively new system in its early years might still be present,and are no longer reported in failure rates of TKAs and THAs [23–25]. Such inbuilt complications might be presented as technicallyrelated errors leading to revision surgery after total ankle arthro-plasty. Technical errors might be misplacement of the implants axis,loosening due to inadequate preparation with a poorly preparedbone stock, a steep learning curve or wrong indication for surgery.The present investigation showed that total ankle arthroplasty stilldoes have a higher value of technically related complications incontrast to TKA or THA.

This study has several shortcomings. One limitation of a nation-wide evaluation of register data is the different statistical approachand report forms used by the individual registers. It is known that

1332 P. Sadoghi et al. / The Journal of Arthroplasty 28 (2013) 1329–1332

calculation of pooled cumulative survival rates or Kaplan–Meiercurves is not reasonable using register datasets [26]. In addition,follow-up periods or questionnaires might not be standardizedbetween different register datasets. In order to overcome thesediscrepancies we evaluated datasets and simplified the information,whenever possible, in order to achieve comparable results (e.g. theterm “incorrect axis” was included in the group “technical error” foradequate comparison). However, the primary data of an arthroplastyregister were entered by the revision surgeons to the best of theirpersonal judgement and the quality of this meta-analysis stronglyrelies on the quality of this original data and on the completeness ofinformation in the individual arthroplasty registers. In addition, themain finding of technical errors is dependent on the subjectiveevaluation of the revision surgeon. In order to overcome thislimitation, we excluded cases with attrition rates, less than 90%with respect to thewhole country or a representative clinical study fordata validation, and in order to avoid double reporting only the mostactual and biggest data sets of each country were included. The highrate of implant fracture or breakage with 2.5% to 5.3% respectively, isnot typical for clinical studies and might indicate a systematic bias ofthe included register datasets. Next, the causes for revision surgeryare not reported with respect to the length of survival time on aregular basis in register data and therefore, cumulative survival curvescannot be synthesized out of the primary data.

We want to underline the significant benefit that this meta-analysis summarizes a very large dataset containing data ofarthroplasty registers, which are appropriately interpreted underexpert testimony of the senior author.

Conclusion

Causes for revision surgery in total knee and total hip arthroplastydiffer with respect to type of complication and likelihood. Sixty-sixpercent of all revisions after total hip arthroplasty are due to asepticloosening and dislocation whereas septic complications, wear, painwithout other reasons for revision, and implant fracture are morecommon after total knee arthroplasty. In case of total anklearthroplasty (TAA), higher rates of technically related complicationsare reported. This factor might pay off due to TAA as a technicallydemanding procedure with shorter experience regarding implanthistory and design.

References

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2. Migliore A, Perrini MR, Romanini E, et al. Comparison of the performance of hipimplants with data from different arthroplasty registers. J Bone Joint Surg Br2009;91B:1545.

3. Herberts P, Malchau H. Long-term registration has improved the quality of hipreplacement — a review of the Swedish THR Register comparing 160,000 cases.Acta Orthop Scand 2000;71:111.

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5. Schuh R, Neumann D, Rauf R, et al. Revision rate of Birmingham Hip Resurfacingarthroplasty: comparison of published literature and arthroplasty register data. IntOrthop 2012;36(7):1349.

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18. Robertsson O, Borquist L, Knutson K, et al. Use of unicompartmental instead oftricompartmental prostheses for unicompartmental arthrosis in the knee is a cost-effective alternative. Acta Orthop Scand 1999;70(2):170.

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21. Henricson A, Nilsson JA, Carlsson A. 10-year survival of total ankle arthroplasties: areport on 780 cases from the Swedish Ankle Register. Acta Orthop 2011;82(6):655.

22. Skyttä ET, Koivu H, Eskelin A, et al. Total ankle replacement: a population-basedstudy of 515 cases from the Finnish Arthroplasty Register. Acta Orthop 2010;81(1):114.

23. HenricsonA,SkoogA,CarlssonA.TheSwedishAnkleArthroplastyRegister: ananalysisof 531 arthroplasties between 1993 and 2005. Acta Orthop 2007;78(5):569.

24. Krause FG, Windolf M, Bora B, et al. Impact of complications in total anklereplacement and ankle arthrodesis analyzed with a validated outcome measure-ment. J Bone Joint Surg Am 2001;93(9):830.

25. Söderman P, Malchau H, Herberts P, et al. Are the findings in the Swedish NationalTotal Hip Arthroplasty Register valid? A comparison between the Swedish NationalTotal Hip Arthroplasty Register, the National Discharge Register, and the NationalDeath Register. J Arthroplasty 2000;15(7):884.

26. Migliore A, Perrini MR, Romanini E, et al. Comparison of the performance of hipimplants with data from different arthroplasty registers. J Bone Joint Surg Br2009;91:1545.

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