Does the indication for revision associate with the outcomes of revision total knee arthroplasty? A retrospective analysis with a minimum ten-year follow-up

doi:10.21203/rs.3.rs-2481128/v1

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Research Article

Does the indication for revision associate with the outcomes of revision total knee arthroplasty? A retrospective analysis with a minimum ten-year follow-up

https://doi.org/10.21203/rs.3.rs-2481128/v1

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Background

The long-term outcome of revision total knee arthroplasty (rTKA) remains variable. We aimed to determine whether the indication for revision affects rTKA outcomes and assess the risk factors for rTKA failure.

Methods

We reviewed all patients who underwent their first rTKA at our institution between January 2003 and December 2011. Patients were grouped based on the indication for revision. All patients with septic indications underwent staged exchange arthroplasty for periprosthetic joint infection (PJI). Demographic and perioperative variables were compared to analyze the survivorships and the risk factors for treatment failure and implant failure between septic and aseptic indications.

Results

Two-hundred-and-thirty patients (septic indication, 116 patients; aseptic indication, 114 patients) were included. The minimum follow-up duration was 10.3 years (mean: 12.3 years; range: 10.3–19.1 years). The overall treatment success rate of rTKA was 88.3% (203/230). The septic group had a significantly higher failure rate (18.10% vs. 5.26%, p < 0.05) and required earlier re-operation after index revision (14.6 vs. 23.0 months, p < 0.05) than the aseptic group. The identified risk factor in septic group for treatment failure and implant failure is “higher CRP level (> 100 mg/dl) during the first PJI episode before index revision” and “debridement, antibiotics, and implant retention procedure (DAIR) after index rTKA”, respectively. Severe osteoporosis with a history of periprosthetic fracture is the only independent risk factor for implant failure in aseptic group.

Conclusions

One-third of patients with septic indication for rTKA underwent re-operation, mostly for PJI. Identified risk factors for different indications could associate with unfavorable survivorships.

Revision total knee arthroplasty

survival rate

periprosthetic joint infection

Revision total knee arthroplasty (rTKA) has become a common procedure, increasing by 10% during the past decade[1].It is projected to increase to 268,000 cases by 2030 in America[2]. Previous studies focused on the mid-term survival of rTKA, demonstrating excellent results with a 13.3% re-operation rate[3]; however, limited information is available on the long-term durability and survival rate of rTKA[4, 5]. Furthermore, the reported survival rate varied from 71–89%, with different population and selection criteria[6].

Many factors affect rTKA outcomes, including complexity of host factors, amount of bone loss, diversity of bone grafting procedures, and condition of soft tissue[7–9]. However, studies have suggested that the preoperative condition (such as age and body mass index) and intraoperative findings (e.g., amount of bone loss or bone grafting) do not affect rTKA outcomes[10, 11]. A better understanding of the predictive factors for better survival of rTKA can help patients and surgeons adjust the modifiable risk to improve outcomes[12]. To our knowledge, limited studies have analyzed the factors affecting the survival rate of rTKA. However, the correlation between the modes of failure of rTKA and indication for index rTKA is unclear[13, 14], especially in periprosthetic joint infection (PJI), which is usually underestimated in registry databases[15]. Therefore, the long-term survival rate of rTKA for all indications for revision is vague in clinical practice.

This study aimed to evaluate and assess long-term survival, complications, modes of failure, and functional outcomes of rTKA with different indications for index revision, focusing on patients with septic (PJI) or aseptic indications (including aseptic loosening, wear, instability, malrotation or malalignment, periprosthetic fracture), in a single tertiary referral medical institution, with a minimum of 10-year follow-up.

Study design

We retrospectively reviewed the data on patients who underwent rTKA at our institution between January 2003 and December 2011. The inclusion criteria were patients who underwent rTKA using NexGen® Legacy® Constrained Condylar Knee with hybrid technique fixation, in which cement is used to fix the metaphysis combined with a cementless diaphyseal engaging stem[16].

The exclusion criteria were rTKA before index revision, primary total knee arthroplasty (TKA) involving use of revision knee prosthesis, and < 10-year follow-up.

Patients were grouped based on the indication for index revision surgery. Indications were further divided into aseptic (aseptic loosening, wear, instability, malrotation or malalignment, periprosthetic fracture) and septic indications (PJI). Variables were compared between groups to analyze the survivorships with the risk factors for treatment failure and implant failure.

All patients in the septic group were treated by staged exchange arthroplasty before rTKA. Staged exchange arthroplasty was performed as follows: at the first stage of revision arthroplasty, we obtained multiple intraoperative tissues for culture (three sets) and pathology specimens with radical debridement. Then, antibiotic-loaded bone cement implantation was performed following prosthesis removal. After the first stage surgery, routine 4-week systemic intravenous (IV) plus 2-week oral antimicrobial agents, according to the culture result, was followed with guidance from an infectious disease specialist. Following another 6-week drug holiday, we set an interim of 3 months and obtained joint arthrocentesis before the final stage revision arthroplasty after ensuring PJI eradication. The profiles of microorganism during all PJI episodes were analyzed.

Definition of terms

PJI was defined as the presence of one of the following: (1) a sinus tract communicating with the prosthesis; (2) isolated pathogen from two or more samples obtained from the infected prosthetic joint; and (3) presence of any four of the following—(a) elevated serum erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) concentration, (b) elevated synovial leukocyte count, (c) elevated synovial neutrophil percentage (PMN%), (d) presence of purulence in the affected joint, (e) isolation of a microorganism in one culture of periprosthetic tissue or fluid, and (f) more than five neutrophils per high-power field in five high-power fields observed from histological analysis of periprosthetic tissue at ×400 magnification[17].

“Treatment success” was defined as a well-functioning joint without second revision of rTKA, while “treatment failure” was defined as re-operation for any reason (including DAIR), removal of prosthesis, revision of rTKA, or mortality related to rTKA. The mode of treatment failure was compared with the previous indication for index revision. “Implant failure” was defined as implant removal for any reason (not including DAIR), for example, aseptic loosening or staged exchange arthroplasty.

Protocols for reinfection

After index revision, if PJI recurred, we treated the patients per the protocol for their clinical presentation. We performed debridement, antibiotics, and implant retention (DAIR) procedure for acute infections with polyethylene exchange based on the classification by Tsukayama[18], under the condition of stable prosthesis and intact skin or soft tissue, even for late acute PJI (> 3 months after index revision surgery). An acute PJI was defined as an acute onset of symptoms and signs of PJI existing for ≤ 4 weeks before DAIR. For late chronic infections (infection > 4 weeks after index surgery and symptom onset > 4 weeks), staged exchange arthroplasty was performed using the protocol earlier described.

Functional outcome

The Oxford knee score (OKS) and Short-Form 12 (SF-12) were used to evaluate the functional outcome after rTKA through telephonic consultation by the research assistant.

Statistics analysis

We evaluated the association between qualitative variables using the chi-square or Fisher’s exact test. A comparison of normally distributed continuous variables was performed using analysis of variance (ANOVA). We evaluated the survival of rTKA using Kaplan-Meier curves. To explore the variables that affect survival, univariable analysis was performed. Kaplan-Meier curves were compared using Cox models and adjusted Hazard ratios were determined. Finally, a Cox multivariable model was created using significant and clinically relevant factors (p < 0.05). For all tests, a 5% significance value was accepted. Processing and data analysis were performed using SPSS version 20.0 (IBM Corp. Armonk, NY, USA).

Study group

From January 2003 to December 2011, 230 patients were included. The septic and aseptic groups included 116 and 114 patients, respectively. The mean follow-up duration was 165.5 months (range, 124.5–207.5 months). The demographics of both groups are presented in Table 1.

Table 1

Demographic data of patients who underwent revision total knee arthroplasty (TKA) for septic and aseptic indications.
Variables	Septic group (n = 116)	Aseptic group (n = 114)	P-value
Male/Female	52/64	42/72	0.77
Age, years (range)	69.3 (32–86)	71.0 (37–86)	0.78
Body mass index, kg/m² (range)	27.7 (16.0–40.6)	28.1 (20.7–41.2)	0.70
American Society of Anesthesiologists Score (I/II/III)	0/50/66	1/54/59	0.88
Follow-up duration, months (range)	124.6 (124.5–203.8)	134.3 (126.3–207.5)	0.77
Charlson Comorbidity index (range)	2.3 (1–9)	2.0 (1–7)	0.98
Pertinent comorbidities, n (%)	100 (86.2)	103 (90.4)	0.56
Hypertension, n (%)	58 (50.0)	50 (43.9)
Diabetes, n (%)	30 (25.9)	41 (36.0)
Osteoporosis (T score < -2.5), n (%)	28 (24.1)	32 (28.1)
Acute myocardial infarction, n (%)	11 (9.5)	9 (7.9)
Renal diseases, n (%)	11 (9.5)	7 (6.1)
Congestive heart failure, n (%)	3 (2.6)	4 (3.5)
Peripheral vascular disease, n (%)	5 (4.3)	3 (2.6)
Deep vein thrombosis, n (%)	6 (5.2)	4 (3.5)
Cerebral vascular disease, n (%)	7 (6.0)	6 (5.3)
Steroid use, n (%)	5 (4.3)	6 (5.3)
Systemic lupus erythematosus, n (%)	3 (2.6)	5 (4.4)
Cancer, n (%)	7 (6.0)	5 (4.4)
Liver cirrhosis, n (%)	3 (2.6)	1 (0.9)
Cigarette Smoking, n (%) (> 1 pack/dayday)	7 (6.0)	4 (3.5)
Asthma, n (%)	3 (2.6)	1 (0.9)

The overall treatment success rate was 88.3% (203/230). Twenty-seven patients experienced treatment failure and underwent revision of rTKA (re-rTKA). The indication for re-rTKA included PJI (21/27, 77.8%), aseptic loosening (4/27, 14.8%), insert wear and broken stem (1/27, 3.7%), and periprosthetic fracture (1/27, 3.7%). Two patients underwent amputation after re-rTKA (2/27, 7.4%) at the final follow-up due to uncontrolled PJI.

Mechanism of treatment failure

We carefully examined the mechanism of failure among patients with treatment failure. Eighteen patients in the septic group (18/21, 85.7%) had recurrent PJI. The other three patients in the septic group (3/21, 14.3%) underwent revision for aseptic causes (aseptic loosening of femoral component). The persistence of recurrent failure mechanism (PJI) rate in the septic group was 15.5% (18/116). In contrast, three patients in the aseptic group (3/6, 50.00%) had treatment failure caused by PJI. One patient underwent revision for recurrent aseptic loosening. The persistence of recurrent failure mechanism (aseptic loosening) rate in the aseptic group was 0.88% (1/114).

Treatment failure rate, frequency, and time to the second surgery between groups

Based on the indication for the index revision, the treatment failure rate was significantly higher in the septic group than in the aseptic group (18.10% vs. 5.26%, p < 0.001*).

Regarding re-operation rate after index revision, there was a significantly higher possibility of second surgery (21/116 vs. 6/114; 18.10% vs. 5.26%, p < 0.001*) after a shorter interval (14.62 vs. 23.02 months, p < 0.001*) in the septic group than in the aseptic group. Furthermore, most second surgeries in both groups were performed using DAIR for acute PJI (12/21 vs. 2/6; 57.14% vs. 33.33%), which was more likely to be performed in the septic group than in the aseptic group (Table 2). The risk factors for treatment failure in each group with Cox multivariable analysis revealed “higher CRP level (> 100 mg/dl) during the first PJI episode before index revision” in the septic group, whereas no specific predictor for treatment failure was identified in the aseptic group (Table 3).

Table 2

Comparison of second surgery for revision total knee arthroplasty between the septic and aseptic groups.
Variables	Septic group (n = 116)		Aseptic group (n = 114)		p-value
*Any reason for second surgery, n (%)**	21	(18.10)	6	(5.26)	0.018*
*Time to second surgery, months (mean)**	14.62	(10.42)	23.02	(20.04)	0.032*
Type of second surgery
*DAIR, n (%)**	12		2		0.021*
*2-stage resection arthroplasty, n (%)**	6		1		0.032*
Aseptic loosening, n (%)	3		1		0.231
Periprosthetic fracture, n (%)	0		1
Insert wear with broken stem, n (%)	0		1
Recurrence of failure mechanism
PJI, n (%)	18	(15.52)
Aseptic loosening, n (%)			1	(0.88)
Key: *Significant differences between groups; DAIR: debridement, antibiotics, and implant retention; PJI: periprosthetic joint infection

Table 3

Results of multivariate logistic regression analysis of variables associated with failure (treatment or implant failure) of rTKA with group stratification.
	Multivariate model results
Treatment failure (any reason for reoperation)	Adjusted odds ratio (95% CI)	p-value
Septic group
CRP level > 100 mg/dl during the first PJI episode before index revision	4.11 (1.11–15.3)	0.031*
Use of immunosuppressive drugs	9.46 (0.56–8.36)	0.191
Same pathogen between PJI before index revision	0.12 (0.10–3.62)	0.321
3-stage resection arthroplasty or more before the index revision	0.19 (0.03–3.89)	0.323
Aseptic group
Bone defect requires structural allo-bone grafting in index revision	1.78 (0.29–9.34)	0.222
Osteoporosis (T score < -2.5) with periprosthetic fracture before index revision	0.18 (0.33–7.32)	0.876
Loosening of femoral component for the index revision	0.91 (0.21–9.32)	0.921
Loosening of tibial component for the index revision	0.13 (0.19–4.32)	0.342
Implant failure (with removal of prosthesis)
Septic group
DAIR after index revision	2.67 (1.19–10.31)	0.033*
CRP level > 100 mg/dl during the first PJI episode before index revision	3.22 (0.16–13.3)	0.331
Use of immunosuppressive drugs	5.46 (0.56–7.76)	0.391
Same pathogen between PJI before index revision	0.22 (0.13–4.32)	0.433
3-stage resection arthroplasty or more before the index revision	0.65 (0.23–6.39)	0.348
Aseptic group
Bone defect requires structural allo-bone grafting in index revision	2.58 (0.19–9.32)	0.122
Osteoporosis (T score < -2.5) with periprosthetic fracture before index revision	3.78 (1.65–13.32)	0.021*
Loosening of femoral component for the index revision	0.54 (0.12–3.31)	0.763
Loosening of tibial component for the index revision	0.87 (0.98–2.56)	0.234
PJI: periprosthetic joint infection; CRP: C-reactive protein; DAIR: surgical debridement, antibiotics, and implant retention; CI: confidence interval; *p value < 0.05.

Implant survival

Regarding implant survival after rTKA, any reason for prosthesis removal—including re-rTKA or staged exchange arthroplasty—was considered the prosthesis survival end point. No patients underwent amputation before re-rTKA. The aseptic group exhibited a significantly better survival than the septic group (99.4% vs. 87.1% at 30 months, 93.2% vs. 80.3% at 60 months, and 90.4% vs. 71.6 at 120 months, Fig. 1A)

We further analyzed the independent factors that contributed to “implant failure” in each group. For the septic group, patients who had undergone DAIR after index revision had inferior implant survival (p < 0.05) (Fig. 1B) and higher risk for implant failure (adjusted odds ratio: 2.67, p < 0.05) (Table 3). Moreover, the greater amount of times the patient had undergone DAIR, the worse the survival (p < 0.05) (Fig. 1C). For the aseptic group, severe osteoporosis with periprosthetic fracture (adjusted odds ratio: 3.78, p < 0.05) before index revision contributed to higher possibility for implant failure (Table 3).

Bacteria strain in PJI

Bacteria strain for patients diagnosed with PJI during follow-up in the septic group was analyzed. The culture of samples taken intraoperatively revealed negative culture (21%), Gram-positive pathogen (37%, especially Staphylococcus aureus [30%]), fungus culture (2%), and polymicrobial culture (6%). The same strain of bacteria as that previously cultured (staged exchange arthroplasty before index revision) was identified only in five patients (27.8%, 5/18; especially methicillin-resistant Staphylococcus aureus [13.3%]).

Functional outcome

The OKS improved by 12.4 (95% CI, 11.6–13.3) points and the SF-12 physical component score improved by 9.1 (95% CI, 8.1–10.2) points in our study. The level of patient satisfaction with pain relief and function correlated with improvement. There were lower improvement scores in the OKS and SF-12 in the septic than in the aseptic group, but this was not significant.

In this study, patients who underwent rTKA for septic indications after staged exchange arthroplasty had less favorable outcomes, with lower prosthesis retention rates (90.4% vs. 71.6 at 120 months), and earlier and higher incidence of second surgery (14.62 vs. 23.02 months and 18.10% vs. 5.26%, respectively) than those with aseptic indications.

Reports on rTKA survival vary widely and differ according to the indications for rTKA[5, 11, 19–23]. Marby et al. focused on the aseptic loosening of primary TKA from 1989 to 1994 with a minimum follow-up of 2 years, and they included 72 patients who underwent rTKA with fully cemented femoral and tibial stems; they reported a 92% survival rate at 10 years in this series[11]. Shannon et al reviewed 60 patients who underwent rTKA with cemented component and un-cemented stem for failed primary total knee arthroplasty with a variety of etiologies in 2003, with a 19% re-revision rate[20]. Sierra et al reviewed the indication for reoperation after rTKA for the past three decades in 2004[19]. There were a total of 1814 index revisions in 1627 patients with a variety of indications. The cumulative risk for first reoperation was 16.1%, 26%, and 31.4% at 5, 10, and 15 years, respectively. Wood et al reported the method of press-fit uncemented stem and metaphyseal cemented fixation in a selected series of patients undergoing rTKA with aseptic etiologies in 2009[21]. The survival rate of revision was 98% at 12 years. Garcia et al. reported the average survival rate of rTKA for aseptic and septic causes among patients with rheumatoid arthritis in 2010, which was 76% at 5 years[22]. Michael et al. revealed several indications for 1632 rTKAs performed for 1560 patients, and the overall failure rate was 22.8%[5]. Obviously, the indication seems to be a critical factor in determining the survival rate in rTKA; however, this remained obscure with the lack of long-term follow-up. Several studies have reported poor clinical results after rTKA for PJI [24, 25]. Therefore, the first methodology provided by Bae et al.[26] was designed to compare the outcomes of rTKA based on indications for the index revision (for example, polyethylene wear, loosening, infection), although there were no significant differences between these indications.

Our study classified the study group based on septic and aseptic indications for the index revision. We consistently followed the treatment protocol and used the same kind of prosthesis with hybrid fixation technique with a long-term follow-up. Our series revealed significantly inferior survival in the septic group.

Age could be a significant factor influencing the survival rate of rTKA. Rand et al.[27] and Bae et al.[26] found a significantly higher failure rate below the age of 70 and 65, respectively. This might be due to faster polyethylene wear in younger patients [26]. However, in our study, age was not a significant factor affecting the outcome.

Severe osteoporosis (T score <-2.5) with periprosthetic fracture contributed to higher implant failure in our study’s aseptic group. The incidence of osteoporosis could be up to 36.7% in TKA populations, and osteoporosis has become a risk factor for surgery related complications, including aseptic loosening or periprosthetic fractures[28]. The major reason for implant failure in the aseptic group was still PJI—especially with this identified risk factor—which agrees with a previous report[29]. However, in our study, there was no significant risk factor for treatment failure in aseptic group. This might be due to the higher rate for septic loosening in patients with severe osteoporosis in aseptic group, in this situation, only staged exchange arthroplasty could be performed instead of DAIR.

Regarding poor outcome in the septic group in our series, we mainly focused on the survival rate after staged exchange arthroplasty. The average success rate of staged exchange arthroplasty of the knee is approximately 80% with widespread heterogeneity due to the variety in its definition[30–33]. Due to the varied treatment protocols and different kind of prostheses used, the authors could not perform multivariate analysis on survival to identify the independent risk factors in these studies[30–33]. In our series, the septic group included 116 patients treated using consistent protocols with the same prosthesis, with an average follow-up of 124.6 months (124.5–203.8). Our results showed that 81.9% of patients successfully retained the prosthesis during the follow-up; furthermore, we were able to determine the factors contributing to treatment and implant failure.

For risk factors contributing to treatment failure in the septic group, Shohat, N. et al. proposed higher pre-operative CRP level as a poor prognostic factor with a machine learning model[34]. In a recent review article, lower CRP levels were associated with a better DAIR outcome[35]. Our study found similar trends: patients with pre-operative CRP levels above 100 mg/dl had 4.1 times higher odds of reinfection.

The key factor affecting survival rate in the cohort who underwent staged exchange arthroplasty was DAIR. Our protocol for DAIR emphasized the duration of the onset of symptoms and signs (< 4 weeks), under the condition of stable prosthesis and intact skin or soft tissue, regardless of interval from index revision, which was coherent to some studies with acceptable outcomes[36–37]. In our series, the survival rates in patients who underwent DAIR reduced significantly to 60% at the 20th month (average survival duration 48.2 ± 7.99 months). Conversely, the survival in patients who did not undergo DAIR procedure was 86.7% at the 84th month (average survival duration, 130.9 ± 3.45 months). Furthermore, the fates of patients in the septic group differed significantly based on the frequency of DAIR. The average survival duration was 49.3 ± 9.48, 44.8 ± 13.84, and 29.6 ± 19.02 months for those who underwent DAIR one, two, or three times, respectively. The rate of successful implant retention from the first DAIR was 9/27 (33.3%); however, the survival in the second DAIR decreased to 2/27 (7.4%). Only 1 patient successfully preserved the implant after the third DAIR procedure during the 95-month-follow-up.

Concerning the mode of failure of rTKA (Table 2), PJI was the most common mode of recurrent failure in our series, accounting for 15.5% (18/116) in the septic group, which is compatible with the findings in previous studies[26, 38]. Most PJI were caused by different organisms. Only 27.8% (5/18) of cases were caused by the same type of bacteria, mainly in cases of methicillin-resistant Staphylococcus aureus (MRSA) infection. These PJIs might be attributed to the poorly vascularized scarred soft tissue commonly encountered after staged exchange arthroplasty in the septic group[26]. Moreover, only one patient in the aseptic group experienced recurrent aseptic loosening.

The functional outcome was lower in the septic than in the aseptic group, but this was not significantly different. This might be due to several factors. Firstly, all patients in our series underwent staged exchange arthroplasty using the same treatment protocols, mobile spacers, and implants. The mobile spacer allowed patients to keep moving, thereby reducing the incidence of soft tissue stiffness or quadriceps muscle atrophy[39, 40]. Secondly, due to repeated debridement with poorly vascularized tissue scarring, some limitation in the range of motion might be encountered in this group.

This study had some limitations. First, this was a retrospective study, which may have selection biases. We tried to minimize the bias by using the same treatment protocols, prostheses, and rehabilitation programs. The second limitation is lack of a detailed dataset on the second and third DAIR. Some of the patients in our cohort might have undergone staged exchange arthroplasty instead of a second DAIR based on the last International Consensus Meeting in 2018. It stated that staged exchange arthroplasty should be strongly considered to avoid additional procedure after initial DAIR because a second DAIR will not have a better success rate than the first DAIR[41]. The role of second DAIR has also been debated at length, with variable success rates[37, 42–44]. Thirdly, we did not compare the treatment failure rate of a second DAIR with that of staged exchange arthroplasty after a failed first DAIR. The outcome of these patients remains controversial in the literature[45–49]. Fourth, undetected PJI could be an issue during the long-term follow-up due to not filling the criteria in our protocol[16]. Nevertheless, we have included cultures for slow growing organisms such as Propionibacterium or Mycobacterium to minimize the risk for undetected PJI.

Patients who underwent rTKA for septic indications have less favorable outcomes than those who underwent rTKA for aseptic indications. The most common cause of rTKA failure in both groups is PJI. The fate of these patients might be less favorable due to DAIR in the septic group; however, rTKA survival in the aseptic group might be worse in patients who suffered from periprosthetic fracture with severe osteoporosis.

rTKA: revision total knee arthroplasty

PJI: periprosthetic joint infection

DAIR: debridement, antibiotics, and implant retention

TKA: total knee arthroplasty

ASA: American Society of Anesthesiologists

ESR: erythrocyte sedimentation rate

CRP: C-reactive protein

PMN%: neutrophil percentage

OKS: Oxford knee score

SF-12: Short-Form 12

ANOVA: analysis of variance

re-rTKA: revision rTKA

Ethics approval and consent to participate

Our study involved the comparison and analysis of de-identified, population-level data. Our study was approved by the Institutional Review Board (IRB: 201601034B0) at Chang Gung Memorial Hospital (CGMH) and the consent to participate was waived. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and material

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors have no relevant financial or non-financial interests to disclose.

Funding

One of the authors (Sheng‐Hsuan Lin) was supported by the Ministry of Science and Technology, Taiwan (MOST 108-2636-B-009 -001) for statistical analysis. One of the authors (Yu-Chih Lin) was supported by Chang Gung Memorial Hospital (CORPG5J0021, CORPG5G0021) for study design, monitoring, and interpretation.

Authors’ contributions

Yu-Chih Lin participated in the sequence alignment. Yu-Chih Lin participated in the study design and writing of the final manuscript. Yuhan Chang performed the statistical analyses. Chih-Hsiang Chang and Chi-Chien Hu contributed to the design of the article. Sheng-Hsun Lee and Sheng-Hsuan Lin conceived the study, participated in its design and coordination, and helped assemble the manuscript draft. All authors have read and approved the final manuscript.

Acknowledgements

We thank to Chun-Chieh Chen and Hsin-Nung Shih for their contributions of patients, and Uni-edit for editing and proofreading this manuscript.

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No competing interests reported.

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Does the indication for revision associate with the outcomes of revision total knee arthroplasty? A retrospective analysis with a minimum ten-year follow-up

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Abstract

Background

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Introduction

Materials And Methods

Study design

Definition of terms

Protocols for reinfection

Functional outcome

Statistics analysis

Results

Study group

Mechanism of treatment failure

Treatment failure rate, frequency, and time to the second surgery between groups

Implant survival

Bacteria strain in PJI

Functional outcome

Discussion

Conclusion

Abbreviations

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