The literature is constantly growing on the association between patient, surgical, and healthcare factors in relation to hip and knee revisions. Since most of these studies have been conducted utilizing joint registry data, they are restricted to variables recorded in registries. These registries rarely track patient characteristics, while other studies have limited patient-focused variables in favour of surgical and prosthetic variables. Our study evaluated seventy-two variables, most of which focused on patient lifestyle and healthcare factors. This allowed for a broad analysis of the influence of patient characteristics on early TJR revisions, representing an important addition to the existing literature.
In this study, we found that the primary reason for revision surgery was prosthetic joint infection. This finding was consistent with national reports that showed over 30% of total joint revisions were due to infection(1). The demographics of our study also matched closely to what was observed in national reports. Where females represented 53.7% and 60.2% of hip and knee replacements respectively, and the median age ranged from 67–68 years(1). Surprisingly, we found BMI was not associated with revision in our study, whereas other studies have reported a relationship between elevated BMI and early revisions(2, 12, 13). One explanation for this could be that our sample population had an higher mean BMI (over 30 kg/m2) with less variability compared to other studies(2, 12, 13). Furthermore, our study found that age was not associated with increased odds of a patient having to undergo revision surgery. Current literature is inconsistent on the impact of age on revisions status. In one Canadian report, age was found not to differ between early revisions and non-revision groups for hip and knee(1). However, two large registry studies in the UK found that younger patients were more likely to require a revision due to infection(12, 13). This may suggest a population specific association. The fact that our study population was younger than the UK studies(12, 13) might be another explanation.
Our data indicated that both the number of live births and hysterectomy were associated with reducing risk of undergoing revision surgery. Interestingly, our data also showed that the likelihood of a hysterectomy increased with more live births. This is not surprising given that emergency hysterectomies are performed to manage life-threatening hemorrhage after a caesarean or vaginal delivery. One systematic review found that multiparity accounted for 87% of emergency peripartum hysterectomies worldwide (14). Thus, our observation in the current study might represent the same potential mechanism. However, the negative association with TJR revision surgery necessitates further investigation.
Our study found that patients having hypertension, back pain that radiates to either leg, or more than five co-morbidities were less likely to undergo revision surgery. This represented an interesting finding given the overwhelming evidence that co-morbidities are a risk factor for revision surgery(1, 15). Patients with co-morbidities are complex and high-risk surgical candidates, having longer lengths of stay in hospital, higher risk of readmission, and increased risk of mortality(16). Combined with the advanced age of our study population, this may have represented a relative contraindication for revision surgery in our study and explain the reduced revision rate. However, we recognized that this is a complex variable to interpret and highly dependent on the co-morbidities incorporated into the analysis.
Back pain that radiates to either leg represents a non-specific variable for sciatica and chronic pain. Therefore, it could be postulated that these patients were managed with pharmacologic therapy for their chronic pain and were unlikely to report pain after TJR. Given pain is a clinical indication of a failed prosthetic, this may explain its association with non-revisions. Furthermore, a large meta-analysis discovered hypertension was not associated with the risk of periprosthetic joint infection(2). While our study and others report infection as the leading cause of revisions, it does not account for over 60% of indications for revision(1). Our study included all indications for revision surgery which may explain the difference.
While patient activity level was not collected in this study, lateral epicondylitis can be interpreted as a surrogate variable for activity. Patients that reported lateral epicondylitis are likely to have manually intensive occupations or increased athletic activity(17). Therefore, this finding could suggest a link between activity level and revision rates. We found that one surgeon coded E5 had a high volume (16.5%) of TJR and a statistically higher proportion of revisions compared to other surgeons. This is in contrast to previous reports that higher surgery volume contributes to lower or no difference of revision rates (3, 12, 14). This finding can likely be attributed to the individual surgeon’s practice and not a generalizable association.
Observational cohort studies such as this come with inherent bias and limitations. However, when analysing cases of TJR revisions that occur infrequently; these studies provide important insight for further research. One limitation of this study is the low power due to a limited number of revisions. Given the low rate of revision surgery, large recruitment of TJR patients is needed to obtain more revision cases. However, due to logistical reasons this typically means fewer variables are collected on patients. Additionally, hip and knee replacements were combined in our analysis to boast the quantity of revisions and while they are similar, they also have differences. For example the second common reason for hip revision is periprosthetic fracture, while for knee it is prosthetic instability(1). However, on subsequent analysis we did not find a difference in the demographics of revisions when comparing hip to knee.
In summary, to our knowledge, this is the most extensive study examining patient factors associated with revision surgery for knee or hip arthroplasty. For which we found seven out of seventy-two factors to be associated with revision status. Additionally, our case group was found to be homogenous with no distinct differences found within revision patients. It is key to note that the variables found to be non-significant also provide value to existing literature. While some of these variables may have been underpowered in our analysis, indicated by their significance reported in other studies. They still provide evidence of factors that are unlikely to be associated with early TJR revisions.