Revision Knee Replacement Research Articles

Pearls: How to Administer an Intraosseous Injection of Antibiotics Before Primary and Revision Knee Replacement.

Pearls: How to Administer an Intraosseous Injection of Antibiotics Before Primary and Revision Knee Replacement.

No exponential rise in revision knee replacement surgery over the past 15 years: an analysis from the National Joint Registry

To investigate trends in the incidence rate and the main indication for revision knee replacement (rKR) over the past 15 years in the UK. Repeated national cross-sectional study from 2006 to 2020 using data from the National Joint Registry (NJR). Crude incidence rates were calculated using population statistics from the Office for National Statistics. Annual total counts of rKR increased from 2,743 procedures in 2006 to 6,819 procedures in 2019 (149% increase). The incidence rate of rKR increased from 6.3 per 100,000 adults in 2006 (95% CI 6.1 to 6.5) to 14 per 100,000 adults in 2019 (95% CI 14 to 14) (122% increase). Annual increases in the incidence rate of rKR became smaller over the study period. There was a 43.6% reduction in total rKR procedures in 2020 (during the Covid-19 pandemic) compared to 2019. Aseptic loosening was the most frequent indication for rKR overall (20.7% procedures). rKR for aseptic loosening peaked in 2012 and subsequently decreased. rKR for infection increased incrementally over the study period to become the most frequent indication in 2019 (2.7 per 100,000 adults [95% CI 2.6 to 2.9]). Infection accounted for 17.1% first linked rKR, 36.5% second linked rKR and 49.4% third or more linked rKR from 2014 to 2019. Recent trends suggest slowing of the rate of increase in the incidence of rKR. Infection is now the most common indication for rKR, following recent decreases in rKR for aseptic loosening. Infection was prevalent in re-revision KR procedures.

Regional economic burden of revision total knee replacement: A cost-complexity analysis

BackgroundGIRFT tasked regional networks with addressing case-load, complexity-spread and cost of revision knee replacement (KR), but the regional cost burden is not clear. The tariff for revision KR is currently not dependent on surgical complexity. 2 years of revision KR complexity data using the validated Revision Knee Complexity Classification (RKCC) checklist as a demonstration of complexity spread in the region has previously been published. The aims of this study were to estimate the annual regional cost of revision TKR using existing data, and estimate the cost/saving of complexity-clustering using existing data from 8 revision centres. MethodsFinancial data from the regional high-volume centre for one year (2019) of RKCC data collection was obtained. Mean cost, tariff and balance was calculated for R1, R2 and R3 (RKCC), and applied to data from each revision centre to provide local estimates. Complexity clustering was considered using 3 hypothetical scenarios of high-volume centre absorbing R2s and/or R3s in place of R1s. ResultsMean net loss was £2,290.08 for R1s, £6,471.42 for R2s and £6,454.26 for R3s. The estimated total annual loss for the region was £1,005,025. Complexity-clustering was associated with greater losses; £162,918 for high-volume centre taking R2s and R3s, £37,477.60 for taking just R3s and £125,440 for taking just R2s. ConclusionRevision TKR surgery is expensive and insufficiently remunerated with current measures. Restructuring of regional workload would create additional financial burden on specialist centres with current tariff awards structure. Managing reimbursement at a regional or central level may help to incentivise compliance with GIRFT ideals.

631 A Comparison of the Microbiology Profile for Two-Stage Revision Surgery in Periprosthetic Joint Infection (PJI) of Primary Knee Arthroplasty and Lower Limb Endoprostheses for Tumour Surgery

Abstract Aim To compare the microbiology organisms responsible for PJI in patients who underwent two-stage revision of infected primary knee replacement with two-stage revision of infected oncological endoprostheses of the lower limb in a single institution. Method 118 patients were treated with 2-stage revision surgery for infected knee arthroplasty and lower limb endoprostheses between 1999 and 2019. 74 patients had two-stage revision for PJI of knee arthroplasty and 44 had two-stage revision to eradicate infection of lower limb endoprostheses for tumour resection. All microbiological data from the first stage sampling was collected and analysed retrospectively. Patient host and extremity criteria were categorised according to the MSIS Host and Extremity Staging System. Results According to the MSIS Staging System, the host and extremity grade of the knee arthroplasty PJI cohort were significantly better than endoprostheses PJI(p<0.05). The incidence of multi-drug resistance (MDR) was higher, 36% in the endoprosthetic group compared to 17% in the infected primary knee replacement group (p=0.001). MDR was most common in coagulase-negative staphylococcus. Gram-positive organisms were isolated in more than 80% of cultures from both cohorts. Coagulase-negative staphylococcus (CoNs) was the commonest gram-positive organism and E Coli was the commonest Gram-negative organism in both groups. Conclusion Patients presenting with PJI after lower limb endoprostheses have a higher incidence of MDR organisms compared to an arthroplasty cohort. Pre-operative microbiological sampling and meticulous sampling methods intra-operatively are extremely important in these patients.

Repeat revision TKR for failed management of peri-prosthetic infection has long-term success but often require multiple operations: a case control study.

Prosthetic joint infection (PJI) is associated with poor outcomes and catastrophic complications. The aim of this study was to present the outcomes of re-revision surgery for PJI of the knee following previous failed two-stage exchange arthroplasty. A retrospective analysis was performed of 32 patients who underwent re-revision knee arthroplasty, having already undergone at least one previous two-stage exchange for PJI with a minimum follow-up of two-years for alive patients. Outcomes were compared to a matched control of two-stage revisions for PJI of a primary knee replacement also containing 32 patients. Outcomes investigated were eradication of infection, re-operation, mortality and limb-salvage rate. Successful eradication of infection was achieved in 50% of patients following re-revision surgery, compared with 91% following two-stage exchange of primary knee replacement for PJI (p < 0.001). Fourteen (44%) patients required further re-operation compared with three (9%) patients in the primary group (p = 0.006). Amputation was performed in one case (3%) with thirteen patients (92%) who had infection controlled by debridement, antibiotics and implant retention (DAIR), further revision surgery or arthrodesis. Two patients died with infection (6%) and the long-term rate for infection control was 91%. The mean number of procedures following surgery for the re-revision group was 2.8 (0-9) compared with 0.13 (0-1) for the primary two-stage group (p < 0.001). Five-year patient survival was 90.6% (95% CI 77.1-100). The limb-salvage rate for the re-revision cohort was 97%. Outcomes for re-revision knee arthroplasty for PJI have higher re-operation and failure rates, but no worse mortality than in revisions of primary knee replacements. Failures can successfully be managed by further operation.

Impact of patient and prosthesis characteristics on common reasons for total knee replacement revision: a registry study of 36,626 revision cases from Australia, Sweden, and USA.

Background and purposeTotal knee replacement (TKR) studies usually analyze all-cause revision when considering relationships with patient and prosthesis factors. We studied how these factors impact different revision diagnoses.Patients and methodsWe used data from 2003 to 2019 of TKR for osteoarthritis from the arthroplasty registries of Sweden, Australia, and Kaiser Permanente, USA to study patient and prosthesis characteristics for specific revision diagnoses. There were 1,072,924 primary TKR included and 36,626 were revised. Factors studied included age, sex, prosthesis constraint, fixation method, bearing mobility, polyethylene type, and patellar component use. Revision diagnoses were arthrofibrosis, fracture, infection, instability, loosening, pain, patellar reasons, and wear. Odds ratios (ORs) for revision were estimated and summary effects were calculated using a meta-analytic approach.ResultsWe found between-registry consistency in 15 factor/reason analyses. Risk factors for revision for arthrofibrosis were age < 65 years (OR 2.0; 95% CI 1.4–2.7) and mobile bearing designs (MB) (OR 1.7; CI 1.1–2.5), for fracture were female sex (OR 3.2; CI 2.2–4.8), age ≥ 65 years (OR 2.8; CI 1.9–4) and posterior stabilized prostheses (PS) (OR 2.1; CI 1.3–3.5), for infection were male sex (OR 1.9; CI 1.7–2.0) and PS (OR 1.5; CI 1.2–1.8), for instability were age < 65 years (OR 1.5; CI 1.3–1.8) and MB (OR 1.5; CI 1.1–2.2), for loosening were PS (OR 1.5; CI 1.4–1.6), MB (OR 2.2; CI 1.6–3.0) and use of ultra-high molecular weight polyethylene (OR 2.3; CI 1.8–2.9), for patellar reasons were not resurfacing the patella (OR 13.6; CI 2.1–87.2) and MB (OR 2.0; CI 1.2–3.3) and for wear was cementless fixation (OR 4.9; CI 4.3–5.5).InterpretationPatients could be counselled regarding specific age and sex risks. Use of minimally stabilized, fixed bearing, cemented prostheses, and patellar components is encouraged to minimize revision risk.

The biomechanics of metaphyseal cone augmentation in revision knee replacement

The demand for revision knee replacement (RKR) has increased dramatically with rising patient life expectancy and younger recipients for primary TKR. However, significant challenges to RKR arise from osseous defects, reduced bone quality, potential bone volume loss from implant removal and the need to achieve implant stability. This study utilizes the outcomes of an ongoing RKR clinical trial using porous metaphyseal cones 3D-printed of titanium, to investigate 1) bone mineral density (BMD) changes in three fixation zones (epiphysis, metaphysis, and diaphysis) over a year and 2) the biomechanical effects of the cones at 6 months post-surgery. It combines dual-energy x-ray absorptiometry (DXA), computed tomography (CT) with patient-specific based finite element (FE) modelling. Bone loss (−0.086 ± 0.05 g/cm2) was found in most patients over the first year. The biomechanical assessment considered four different loading scenarios from standing, walking on a flat surface, and walking downstairs, to a simulated impact of the knee. The patient-specific FE models showed that the cones marginally improved the strain distribution in the bone and shared the induced load but played a limited role in reducing the risks of bone fracture or cement debonding. This technique of obtaining real live data from a randomized clinical trial and inserting it into an in-silico FE model is unique and innovative in RKR research. The tibia RKR biomechanics examined open up further possibilities, allowing the in-silico testing of prototypes and implant combinations without putting patients at risk as per the recommended IDEAL framework standards. This process with further improvements could allow rapid innovation, optimization of implant design, and improve surgical planning.

Randomised comparative effectiveness trial of Pulmonary Embolism Prevention after hiP and kneE Replacement (PEPPER): the PEPPER trial protocol

IntroductionMore than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%–0.5% fatal PE, and over 1000...

UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): what does analysis of linked, routinely collected national datasets tell us about mid–late term revision risk after knee replacement?

ObjectiveTo identify patients at risk of mid-late term revision of knee replacement (KR) to inform targeted follow-up.DesignAnalysis of linked national datasets from primary and secondary care (Clinical Practice Research Datalink...

Readability and quality of online information for patients pertaining to revision knee arthroplasty: An objective analysis

BackgroundModern patients use the internet more frequently for their health information. Our aim was to assess the quality and readability of online patient education materials relating to revision knee arthroplasty. We hypothesised that this information would be too difficult to read for the average patient and of a lesser quality than desired. MethodA search of the top 50 results on 3 search engines (Google, Bing, Yahoo) was completed (MeSH “revision knee arthroplasty”, “revision knee replacement”). Readability of these websites was calculated using a specialised website, www.readable.com to produce 3 scores (Gunning-Fog (GF), Flesch Reading Ease (FRE), Flesch-Kincaid Grade (FKG). Quality was assessed using the Journal of American Medical Association (JAMA) benchmark criteria and the Health On the Net (HON) code toolbar extension. Results89 unique websites were identified. Mean FRE was 44.01 ± 11.05. The mean GF was 12.01 ± 2.94. The mean FKG level was 10.06 ± 1.95. As per the FRE score, no webpage was pitched at or below a sixth grade reading level. The GF index identified only 3 websites (3.4%) at 6th grade reading level. As per FKG score, most webpages (n = 58, 65.2%) found themselves in the 10th grade reading level and above. Four websites (4.5%) displayed a HONcode certificate. However, all had expired. Most websites (n = 34, 38.2%) didn't meet any of the JAMA criteria. ConclusionThe reading level of these materials is too high for the average patient and of a low quality. Given what we know about levels of health literacy and their relationship with patient outcomes, it is vital that we address these deficiencies promptly.

Crohn’s disease in total knee arthroplasty patients correlates with increased rates of 90-day and overall postoperative complications and readmissions

BackgroundJoint involvement is a common extraintestinal manifestation of Crohn’s Disease (CD) that may require total knee arthroplasty (TKA). There is a paucity of evidence regarding the relationship between CD and postoperative outcomes after TKA surgery. This study seeks to evaluate the impact of CD on 90-day and ≥2-year follow-up postoperative outcomes of TKA patients. MethodsWe retrospectively analyzed the Statewide Planning and Research Cooperative System database (2009–2013) and isolated ICD-9 codes for TKA patients (8154), while excluding those with any revision of knee replacements (0080–0084) and split into 2 groups with or without CD (5550–5559). Patient demographics and postoperative outcomes were compared. Logistic regression analyses with covariates (sex, race, Deyo score, age, and insurance) were utilized to evaluate the association of CD with 90-day and overall postoperative outcomes. ResultsA total of 89,134 TKA patients were identified, 244 of whom had CD. Significant differences in age, race distribution, insurance, and Deyo score (all, p < 0.05) were found. Multivariable analysis demonstrated CD was an independent risk factor for 90-day and overall medical complications, surgical complications, and readmission. Univariate and multivariable analyses report CD had significant increased rates and was a predictor, respectively, of overall blood transfusions (OR 1.5 [95% CI 1.1–2.0] p < 0.01), acute renal failure (OR 1.7 [95% CI 1.1–2.6] p = 0.03), and pulmonary embolism (OR 2.5 [95% CI 1.3–4.6] p = 0.01). ConclusionPatients with CD undergoing TKA have increased risk both 90-day and overall surgical and medication complications, as well as readmissions compared to patients without CD.

Minimal important changes and differences were estimated for Oxford hip and knee scores following primary and revision arthroplasty

ObjectivesTo create estimates for clinically meaningful changes and differences in pain and joint function for the Oxford Hip and Knee Scores (OHS/OKS) in primary and revision joint replacement. Study Design and Setting694,487 primary and revision joint replacement procedures were analyzed from the NHS PROMs dataset between 2012-2020. Minimal important changes (MIC) and differences (MID) were calculated using distribution and anchor-based methods (including receiver-operating characteristic (ROC) curve and predictive-modelling techniques). ResultsFor comparison of two or more groups (such as in a clinic trial), MID estimates were ∼5 points. For cohort studies investigating changes over time in a single group of patients, MICgroup estimates were 12.4 points (primary hip replacement), 8.6 points (revision hip replacement), 10.5 points (primary knee replacement) and 9.4 points (revision knee replacement). For studies investigating changes over time at the individual patient level, MICadjusted estimates were ∼8 points, ∼6 points, ∼7 points and ∼6 points respectively. ConclusionThis study has calculated contemporary estimates of clinically important changes and differences for the OHS/OKS for primary and revision hip and knee replacement. These estimates can be used to inform sample size calculations and to interpret changes in joint function over time and differences between groups.

Results of revision knee replacement for patients with isolated fixed flexion deformity after primary or revision knee replacement

BackgroundPostoperative fixed flexion deformity is a known complication of knee replacement surgery. We present our results of revision surgery for treatment of isolated fixed flexion deformity after knee replacement. Methods32 patients had revision knee replacement for fixed flexion deformity and were included in this retrospective study. Minimum follow up period was 28 months. ResultsTwo different surgical interventions had been done in these patients.Group 1 (15 patients) had revision of the femoral component, posterior capsular release and tibial component was not revised. Group 2 (18 Patients) had revision of both femoral and tibial components. One patient was included in both groups as she had both interventions.The extent of preoperative flexion deformity in group 1 was from 15 to 40 deg (mean 20.6 deg). Postoperative range of extension was 0 to 20 deg (mean 8.2 deg). In group 2, preoperative flexion deformity was 10 to 25 deg (mean 16.9 deg) and postoperative flexion deformity was 0 to 20 deg (mean 4.2 deg). The difference in improvement between the two groups was not statistically significant on Mann Whitney U test (two tailed p value 0.181) for non normal distribution. Improvement in Oxford knee score following surgery was only 1 point in both groups. ConclusionRevision for isolated fixed flexion deformity leads to improvement in range of extension, but improvement in clinical score is marginal. The choice of preservation or revision of the tibial component did not make a significant difference to the outcome.

Patient-reported outcome measures following revision knee replacement: a review of PROM instrument utilisation and measurement properties using the COSMIN checklist

ObjectivesTo identify: (1) patient-reported outcome measures (PROMs) used to evaluate symptoms, health status or quality of life following discretionary revision (or re-revision) knee joint replacement, and (2) validated joint-specific PROMs,...

Orthopaedic surgeons' perceptions of the changing burden of revision joint replacement surgery in Australia: A qualitative study.

Studies examining trends in revision joint replacement surgery have been quantitative in their design. A qualitative research approach could provide detailed insights into the changing burden of revision surgery from an important stakeholder perspective. This study aimed to investigate orthopaedic surgeons' perceptions around the burden of revision hip and knee replacement surgery in Australia. A descriptive qualitative study design was used. Highly experienced Australian orthopaedic surgeons specialising in primary and/or revision hip and knee replacement surgery were purposely sampled. Interviews covered the perceived burden of revision joint replacement, factors contributing to revision burden and anticipated future burden. Deductive and inductive coding techniques were used to identify themes. Semi-structured interviews were conducted with 14 orthopaedic surgeons, who had substantial consultant experience (range 15-30years) and largely high-volume practices. Five key themes were identified: (1) Revision burden has decreased over time; (2) Changes in clinical indications; (3) Perceived lack of policies focused on minimising revision surgery; (4) Role of the national registry and (5) Future trends and opportunities. The main indications for revision joint replacement surgery were perceived to have changed over time, moving away from implant failure-related causes towards infection and periprosthetic fracture. Most participants considered that formal policies designed to reduce revision rates did not exist but acknowledged the positive role of the national registry, particularly within an international context. The improving evidence base and provision of registry feedback on surgeon and implant performance was expected to reduce the proportion of revision procedures.

How long do revised and multiply revised knee replacements last? An analysis of the National Joint Registry.

Knee replacements are common and effective operations but patients that undergo this intervention are at risk of needing subsequent costly and often complex revision surgery with poorer outcomes than primary surgery. The treatment pathway over the life of the patient in terms of risk of revision and re-revision(s) is poorly described. We aim to provide detailed information on the longevity of revision surgery. This was a retrospective observational registry-based study of the National Joint Registry. Kaplan-Meier estimates were used to determine the cumulative probability of revision and subsequent re-revision(s) following primary knee replacement. Analyses were stratified by age and gender and the influence of time from first to second revision on the risk of further revision was explored. There were 33,292 revision knee replacements with a linked primary episode. Revision rates of revision knee replacements were higher in males and younger patients. 19·9% of revisions were revised again within 13 years, 20·7% of second revisions were revised again within 5 years and 20·7% of third revisions were revised again within 3 years. A shorter time between revision episodes was associated with earlier subsequent revision. Males and younger patients are at higher risk of multiple revisions. Patients who undergo a revision have steadily increasing risk of further revision the more procedures they undergo, and each subsequent revision lasts for approximately half the time of the previous one. This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston National Health Service Foundation Trust and the University of Bristol. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. This study was also supported by funding from Healthcare Quality Improvement Partnership and the National Joint Registry. Posts of authors of this work are part funded by a grant from the National Joint Registry to conduct statistical analysis for the National Joint Registry. AS was funded by a Medical Research Council Strategic Skills Fellowship MR/L01226X/1.

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline

BackgroundRevision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making. AimTo provide guidelines for surgeons and units delivering revision KR services. MethodsA formal consensus process was followed by BASK’s Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data. ResultsThere are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR.This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model. ConclusionsRevision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.

The effect of age on the outcomes of cementless mobile bearing unicompartmental knee replacements

PurposeUnicompartmental Knee Replacements (UKR) are being performed in patients with increasing demands and life expectancies with surgical concerns that cemented fixation will not last. Cementless fixation may offer a solution, but the results in different age groups have not been assessed. The effect of age at surgery on the outcomes of cementless UKRs was investigated. MethodsA prospective cohort of 1000 medial cementless mobile bearing UKR were analysed. Patients were categorised into four age groups (< 55, 55 to < 65, 65 to < 75 and ≥ 75 years). Implant survival was assessed using endpoints reoperation, revision and major revision requiring revision knee replacement components. Functional outcomes were assessed.Results10 year cumulative revision rate for the < 55, 55 to < 65, 65 to < 75 and ≥ 75 groups were 2.1% (CI 0.6–6.1), 1.8% (CI 0.6–5.3), 3.2% (CI 1.5–6.5) and 4.1% (1.7–9.6) with no differences between groups (p = 0.52). Two of the 22 revisions were considered major. The 10 year cumulative reoperation rates were 4.5% (CI 2.0–10.0), 3.0% (CI 1.3–6.5), 3.8% (CI 2.0–7.1) and 4.1% (CI 1.7–9.6) with no differences between groups (p = 0.81). The 10 year median Oxford Knee Scores were 42.5, 46.5, 45 and 42.5, respectively. The 10 year median Objective American Knee Society Scores were 95 for all age groups.ConclusionThe cementless mobile bearing UKR has low reoperation and revision rates and similar functional outcomes in all age groups. Cementless UKR should be used in all age groups and age should not be considered a contraindication.Level of evidenceIII.

Revision Total Knee Arthroplasty Using an Uncemented Metaphyseal Sleeve, Rotating Hinge Prosthesis: A Case Series of 99 Patients

BackgroundHinge knee replacement is a salvage procedure with historically high failure and complication rates. We aim to analyze the use of an uncemented metaphyseal sleeve revision knee replacement in our unit—a third-generation rotating hinge knee prosthesis. This is the largest reported series of this implant with longest follow up. MethodsWe retrospectively identified 99 revision cases performed (2002-2018). In total, 67 of 99 (68%) cases were performed for aseptic etiology, whereas 32 of 99 (32%) cases were performed for infection. Clinical outcomes were assessed using the Oxford Knee Score, survivorship analysis, and incidence of revision/reoperations. Mean follow-up was 7 years (range 1.5-18). ResultsAt follow-up, the mean Oxford Knee Score had improved from 10 points to 25 points. At mean 7 years of follow up, 18 of 99 cases had undergone revision giving a survivorship of 81% (90% aseptic). In total, 10 of 18 cases were performed for infection (10%) and 9 of 18 cases were performed for aseptic reasons (9%), of which 5 were for patella resurfacing (2 revision), 2 for failure of bony ingrowth, and 1 for fracture. Twenty-six patients (26%) had complications postoperatively, with patella disorders and reduced range of movement the most common. Patients who did not undergo patella resurfacing were significantly more likely to need revision of any cause (P = .01). ConclusionThis is the largest study of this prosthesis with longest follow-up. It demonstrates good survivorship and improvement in knee pain. Those with infection are at greatest risk of revision. Significant numbers have patella dysfunction/anterior knee symptoms therefore patella resurfacing should be considered when using this implant. Level of EvidenceIV.

Revision knee replacement for prosthetic joint infection: Epidemiology, clinical outcomes and health-economic considerations

Prosthetic joint infection (PJI) is a devastating complication of knee replacement surgery. Recent evidence has shown that the burden of disease is increasing as more and more knee replacement procedures are performed. The current incidence of revision total knee replacement (TKR) for PJI is estimated at 7.5 cases per 1000 primary joint replacement procedures at 10 years. Revision TKR for PJI is complex surgery, and is associated to a high rate of post-operative complications. The 5-year patient mortality is comparable to some common cancer diagnoses, and more than 15% of patients require re-revision by 10 years. Patient-reported outcome measures (PROMs) including joint function may be worse following revision TKR for PJI than for aseptic indications. The complexity and extended length of the treatment pathway for PJI places a significant burden on the healthcare system, highlighting it as an area for future research to identify the most clinically and cost-effective interventions.