Revision total knee arthroplasty in the young patient: is there trouble on the horizon?
BACKGROUND
The volume of total knee arthroplasties, including revisions, in young patients is expected to rise. The objective of this study was to compare the reasons for revision and re-revision total knee arthroplasties between younger and older patients, to determine the survivorship of revision total knee arthroplasties, and to identify risk factors associated with failure of revision in patients fifty years of age or younger.


METHODS
Perioperative data were collected for all total knee arthroplasty revisions performed from August 1999 to December 2009. A cohort of eighty-four patients who were fifty years of age or younger and a cohort of eighty-four patients who were sixty to seventy years of age were matched for the date of surgery, sex, and body mass index (BMI). The etiology of failure of the index total knee arthroplasty and all subsequent revision total knee arthroplasties was determined. Kaplan-Meier survival curves were used to evaluate the timing of the primary failure and the survivorship of revision knee procedures. Finally, multivariate Cox regression was used to calculate risk ratios for the influence of age, sex, BMI, and the reason for the initial revision on survival of the revision total knee arthroplasty.


RESULTS
The most common reason for the initial revision was aseptic loosening (27%; 95% confidence interval [CI] = 19% to 38%) in the younger cohort and infection (30%; 95% CI = 21% to 40%) in the older cohort. Of the twenty-five second revisions in younger patients, 32% (95% CI = 17% to 52%) were for infection, whereas 50% (95% CI = 32% to 68%) of the twenty-six second revisions in the older cohort were for infection. Cumulative six-year survival rates were 71.0% (95% CI = 60.7% to 83.0%) and 66.1% (95% CI = 54.5% to 80.2%) for revisions in the younger and older cohorts, respectively. Infection and a BMI of ≥ 40 kg/m(2) posed the greatest risk of failure of revision procedures, with risk ratios of 2.731 (p = 0.006) and 2.934 (p = 0.009), respectively.


CONCLUSIONS
The survivorship of knee revisions in younger patients is a cause of concern, and the higher rates of aseptic failure in these patients may be related to unique demands that they place on the reconstruction. Improvement in implant fixation and treatment of infection when these patients undergo revision total knee arthroplasty is needed.
Rothman Institute of Orthopaedics at Thomas Jefferson University, Sheridan Building, 10th Floor, 125 South 9th Street, Philadelphia, PA 19107. E-mail address for V.K. Aggarwal: vinayagg1@gmail.com.
Vinay K
VK
Aggarwal
Rothman Institute of Orthopaedics at Thomas Jefferson University, Sheridan Building, 10th Floor, 125 South 9th Street, Philadelphia, PA 19107. E-mail address for V.K. Aggarwal: vinayagg1@gmail.com.
Nitin
N
Goyal
Rothman Institute of Orthopaedics at Thomas Jefferson University, Sheridan Building, 10th Floor, 125 South 9th Street, Philadelphia, PA 19107. E-mail address for V.K. Aggarwal: vinayagg1@gmail.com.
Gregory
G
Deirmengian
Rothman Institute of Orthopaedics at Thomas Jefferson University, Sheridan Building, 10th Floor, 125 South 9th Street, Philadelphia, PA 19107. E-mail address for V.K. Aggarwal: vinayagg1@gmail.com.
Ashwin
A
Rangavajulla
Rothman Institute of Orthopaedics at Thomas Jefferson University, Sheridan Building, 10th Floor, 125 South 9th Street, Philadelphia, PA 19107. E-mail address for V.K. Aggarwal: vinayagg1@gmail.com.
Javad
J
Parvizi
Rothman Institute of Orthopaedics at Thomas Jefferson University, Sheridan Building, 10th Floor, 125 South 9th Street, Philadelphia, PA 19107. E-mail address for V.K. Aggarwal: vinayagg1@gmail.com.
Matthew S
MS
Austin
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D019645:Arthroplasty, Replacement, Knee; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D007720:Knee Prosthesis / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D011475:Prosthesis Failure / Q000209:etiology; D016459:Prosthesis-Related Infections / Q000209:etiology / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D017211:Treatment Failure; D055815:Young Adult