title: Antibiotic cement was associated with half the risk of re-revision in 1,154 aseptic revision total knee arthroplasties.
abstract: OBJECTIVE
  Aseptic revisions comprise 80% of revision total knee arthroplasties (TKAs). We determined the incidence of re-revision TKA, the reasons for re-revision, and risk factors associated with these procedures.
  
  
  METHODS
  We conducted a retrospective cohort study of 1,154 patients who underwent aseptic revision TKA between 2002 and 2013 and were followed prospectively by a total joint replacement registry in the USA. Revision was defined as any operation in which an implanted component was replaced. Patient-, surgeon-, and procedure-related risk factors were evaluated. Survival analyses were conducted.
  
  
  RESULTS
  There were 114 re-revisions (10%) with a median time to reoperation of 3.6 years (interquartile range (IQR): 2.6-5.2). The infection rate was 2.9% (34/1,154) and accounted for 30% of re-revisions (34 of 114). In adjusted models, use of antibiotic-loaded cement was associated with a 50% lower risk of all-cause re-revision surgery (hazard ratio (HR) = 0.5, 95% CI: 0.3-0.9), age with a 20% lower risk for every 10-year increase (HR = 0.8, CI: 0.7-1.0), body mass index (BMI) with a 20% lower risk for every 5-unit increase (HR = 0.8, CI: 0.7-1.0), and a surgeon's greater cumulative experience (≥ 20 cases vs. < 20 cases) with a 3 times higher risk of re-revision (HR = 2.8, CI: 1.5-5).
  
  
  CONCLUSIONS
  Revised TKAs were at high risk of subsequent failure. The use of antibiotic-loaded cement, higher age, and higher BMI were associated with lower risk of further revision whereas a higher degree of surgeon experience was associated with higher risk.
authors.affiliation: a Department of Orthopaedic Surgery , The Permanente Medical Group , Oakland , CA.
authors.forename: Stefano A
authors.initials: SA
authors.lastname: Bini
authors.affiliation: b Surgical Outcomes and Analysis , Kaiser Permanente , San Diego , CA , USA.
authors.forename: Priscilla H
authors.initials: PH
authors.lastname: Chan
authors.affiliation: b Surgical Outcomes and Analysis , Kaiser Permanente , San Diego , CA , USA.|c Medicine and Devices Surveillance Centre of Research Excellence, School of Pharmacy and Medical Sciences, University of South Australia , Adelaide , SA , Australia.
authors.forename: Maria C S
authors.initials: MC
authors.lastname: Inacio
authors.affiliation: b Surgical Outcomes and Analysis , Kaiser Permanente , San Diego , CA , USA.
authors.forename: Elizabeth W
authors.initials: EW
authors.lastname: Paxton
authors.affiliation: d Department of Orthopaedic Surgery , Southern California Permanente Medical Group , Los Angeles , CA , USA.
authors.forename: Monti
authors.initials: M
authors.lastname: Khatod
mesh_terms: D017677:Age Distribution; D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D019072:Antibiotic Prophylaxis / Q000379:methods*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects* / Q000379:methods; D001843:Bone Cements; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011475:Prosthesis Failure / Q000187:drug effects*; D016459:Prosthesis-Related Infections / Q000453:epidemiology* / Q000601:surgery; D012042:Registries; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D017678:Sex Distribution; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents; D001843:Bone Cements