Revision knee arthroplasty: Can good outcomes be achieved at lower volumes?

Background: The National Joint Registry (NJR) demonstrates a re-revision rate for primary knee arthroplasty of 14.2% at 7 years. The 2015 Getting it Right First Time (GIRFT) report highlighted that 58% of surgeons undertaking revision knee arthroplasty (RKA) performed fewer than five cases per year. It has been suggested that revision cases be centralised in specialist centres with a multidisciplinary team (MDT) approach. Such a hub and spoke or cluster models may still require revision surgery to be performed at relatively low volume units.

Methods: An analysis of RKA surgery performed in a four surgeon, lower volume revision knee unit over 10 years to December 2016 was undertaken. The effect of the introduction of a MDT was reviewed. The minimum follow up was two years. The primary outcome measure was re-revision. Hospital data as well as individual surgeon NJR reports were used to ensure all re-revisions were accounted for. Outcome scores were available for 68% of cases.

Results: There were 192 RKAs performed in 187 patients at a mean (stdev) of 6.3 (5.4) years from the index procedure. The mean age at surgery was 68.2 (10.9) years. Twenty nine (15.5%) patients had died at the time of final review. Twelve (6.3%) cases required a further revision procedure. The commonest complication was stiffness requiring MUA. The overall 7 year survivorship was 94.9% (95% CI 90.2-97.3). The mean Oxford score at 5.4 years was 30.4 (10.4).

Conclusions: RKA can be reliably performed at lower volume centres with appropriate MDT systems in place.