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    REGISTRY REVIEW: Revision Total Hip Arthroplasty in the US

    Given the projected increase in primary total hip arthroplasty (THA) – particularly among young and active patients – it’s not surprising that the demand for revision procedures is also expected to rise. [1,2]

    Knowing which postoperative diagnoses most commonly lead to revision THA could help surgeons take steps to prevent the underlying complications, such as infection and instability, during the index procedure, as well as assist them in preparing for future demand.

    RELATED: Register for ICJR’s 8th Annual Revision Hip & Knee Course, June 17-19

    That’s a role the American Joint Replacement Registry (AJRR) can fill. Surgeons who participate in the AJRR have contributed the details on nearly 58,000 revision THAs performed in the US between 2012 and 2019, providing insight into revision issues. It’s important to note that the AJRR team spent a great deal of time ensuring the accuracy of the submitted data. Thanks to this concerted effort, we have a clearer picture of why these revisions were performed.

    For example, the 2020 Annual Report from AJRR shows that overall, infection was the top reason for revision THA between 2012 and 2019, followed by instability and aseptic loosening (Figure 1).

    Figure 1. Diagnoses Leading to Revision THA

    Based on data from the 2020 Annual Report from the American Joint Replacement Registry

    The AJRR explains the “Other” category this way: “If none of the submitted codes matched a defined category, the primary reason for revision was placed in an ‘other’ category. This category was then examined and all procedures with a non-relevant or obviously erroneous diagnosis were removed.” So, although 57,970 revisions were reported, the reason for the procedure was clear for 49,024.

    Revisions are most likely to occur within the first 3 months after the primary procedure, based on AJRR data on “linked” revisions – meaning, the primary and revision procedures were performed at the same institution. However, linked data are rare: The AJRR database includes only 8065 linked primary and revision procedures.

    Besides information on diagnoses leading to revision THA, data in AJRR’s 2020 Annual Report show that between 2012 and 2019:

    Dual-mobility constructs gained ground on 36-mm femoral heads. Around 2015, usage of conventional 36-mm femoral heads began a steady decline as usage of dual-mobility articulations began to rise. This increase was statistically significant not only for revisions overall, but also for revisions performed specifically in patients with instability/dislocations (P<0.0001 for both). Use of constrained liners also became more common.

    The Restoration Modular stem was the most commonly implanted stem. However, it has been losing ground since 2012, dropping from about 25% of revision procedures in 2012 to just under 15% in 2019. The Arcos Modular stem and the Summit stem both experienced increases in usage between 2012 and 2019.

    A variety of acetabular cups have been used. The AJRR data show no single “winner” among the cups available for revision THA. However, the G7 has experienced significant growth since 2014 and was the most implanted cup in 2019.

    As with primary THA, highly cross-linked polyethylene liners were preferred for revision procedures. Interest in antioxidant polyethylene grew from 2012 to 2019, but highly cross-linked polyethylene remained the liner material of choice by an overwhelming margin: 10.79% versus 83.88%, respectively, in 2019.

    Most patients were discharged home after revision THA, as was seen with discharge after primary THA. However, the percentage who were discharged home with or without home healthcare was much lower for a revision procedure than for a primary procedure: 61.3% versus 85.8%, respectively, in 2019. Nearly one third – 30.7% – of revision THA patients were discharged to a skilled nursing facility, reflecting the more complex care that may be needed by post-revision patients. The remainder of patients were discharged to a combination of inpatient care facilities, inpatient rehabilitation facilities, and other types of facilities.

    The 2020 Annual Report from AJRR can be found here.

    References

    1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr;89(4):780-5. doi: 10.2106/JBJS.F.00222.
    2. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am. 2014 Apr 16;96(8):624-30. doi: 10.2106/JBJS.M.00285.