Clinicians › Knee

Revision knee replacement

135 citationsUpdated Sep 2026

Overview

Revision total knee arthroplasty is a technically demanding procedure associated with inferior outcomes and higher complication risks compared to primary arthroplasty [14]. Demand for these procedures is rising due to population longevity and obesity [14]. In Northern Illinois, revision total knee arthroplasties increased 59% [16], while estimates of revision rates after almost seven years ranged from 4.3 percent to 8.0 percent [9]. Despite the technical challenges, the overall complication rate for revision total knee arthroplasty declined from 9.3% during 1993-1996 to 7.3% during 1997-1999 in Northern Illinois [16]. Outpatient revision knee arthroplasty has been found to be safe in carefully selected patients and case scenarios [21].

Periprosthetic joint infection was the dominant reason for failure during the first 15 years after primary total knee arthroplasty in a cohort of 11,134 knees [18]. Single-stage revision total knee arthroplasty is an effective strategy with a high success rate comparable to the two-stage approach in appropriately selected patients for chronic periprosthetic joint infection [10]. In a series of 235 revisions of unicompartmental knee arthroplasty to total knee arthroplasty, the five-year survival of the total knee arthroplasties free of re-revision was good [64]. Patients and surgeons can expect clinically meaningful improvement in patient-reported outcome measures and low re-revision rates when undergoing revision total knee arthroplasty for flexion instability when using consistent and established diagnostic criteria and surgical correction techniques [33].

Prognostic factors significantly influence long-term survival. Patients less than 55 years undergoing revision total knee arthroplasty have a 5-year revision-free survival of 80% [7]. Conversely, patients specifically revised for instability or who had prior total knee arthroplasty revisions had the highest risk of re-revision at 10 years [4]. An age greater than seventy years, revision five years or more after the primary arthroplasty, and absence of patellar subluxation are positive indicators of survival of a revision total knee replacement [8]. High-volume revision surgeons have better outcomes following revision total knee arthroplasty [6].

Anatomy & Pathophysiology

Bony Anatomy

The knee joint comprises the distal femur, proximal tibia, and patella [41]. The medial femoral condyle is larger and projects farther posteriorly and distally than the lateral condyle [69]. Conversely, the lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction [69]. The tibial articular surface slopes 7° to 10° in the sagittal plane [69], with the posterior slope of the medial tibial plateau averaging 10.7° and the lateral plateau averaging 7.2° [84]. The medial tibial plateau is larger than the lateral plateau and is concave in both frontal and sagittal planes [69]. The lateral tibial plateau is smaller, more circular, concave in the frontal plane, and convex in the sagittal plane [69].

The patella is the largest sesamoid bone in the body, with a mean thickness of 2.5 cm [69, 84]. It possesses the thickest articular surface in the body, measuring approximately 5 mm in the midportion and 2 mm on the sides [69]. The patellar articular surface features a vertical central ridge separating the broader lateral facet from the medial facet, along with a smaller odd facet [69]. The tibial tuberosity, the attachment site for the patellar tendon, is typically located in the midline anteriorly but may be slightly lateral [69]. Gerdy’s tubercle, the insertion site of the iliotibial band, is located 2 to 3 cm lateral to the tibial tubercle on the proximal tibia [69]. The fibular head is located a mean of 1.5 cm distal to the joint line, with a range of 6 to 32 mm [84].

Ligaments

The anterior cruciate ligament (ACL) travels from the medial border of the lateral femoral condyle to its insertion site anterolateral to the medial tibial spine [41]. It prevents anterior translation and rotation of the tibia on the femur [41]. The posterior cruciate ligament (PCL) runs from the lateral aspect of the medial femoral condyle to the posterior aspect of the tibia, just below the joint line [41]. The PCL prevents posterior subluxation of the tibia on the femur [41]. The medial collateral ligament has superficial and deep portions which stabilize the knee to valgus stresses [41]. The lateral collateral ligament runs from the lateral femoral condyle to the head of the fibula and is the main stabilizer against varus stress [41]. The popliteofibular ligament is present in 90% of knees and runs from the tendon of the popliteus muscle to the styloid on the posterior fibular head [41].

The ACL is composed of 90% type I collagen and 10% type III collagen [69, 70]. Its mean length is 33 mm and mean midsubstance width is 11 mm [69, 84]. The femoral attachment is a semicircular area on the posteromedial aspect of the lateral femoral condyle [69, 70]. The tibial attachment is a broad, irregular, oval-shaped area slightly medial and anterior to the midline and between the medial and lateral tibial spinous processes [69]. The ACL has two bundles named according to their tibial insertions: the anteromedial bundle is tight in flexion and the posterolateral bundle is tight in extension [70, 73]. The PCL has a mean length of 38 mm and a mean width of 13 mm [84]. It has a broad, crescent-shaped femoral attachment on the anterolateral medial femoral condyle [84]. The tibial insertion onto the posterior central sulcus is 10 to 15 mm distal to the joint line of the knee [84]. The anterolateral bundle of the PCL is tight in knee flexion and the posteromedial bundle is tight in knee extension [84].

The ACL is typically subjected to peak loads of 170 N during walking and up to 500 N with running [85, 86]. The ultimate strength of the ACL in young patients is about 1750 N [85, 86]. Sectioning the PCL increases contact pressures in the medial compartment and the patellofemoral joint [85, 86].

Menisci

The menisci are C-shaped fibrocartilaginous disks that provide shock absorption, increase congruency between joint surfaces, enhance joint stability, and aid in distribution of synovial fluid [41]. The medial meniscus is firmly attached to the joint capsule along its entire peripheral edge [41]. The lateral meniscus is attached to the anterior and posterior capsule but has a region posterolaterally where it is not firmly attached [41]. The medial meniscus has less mobility than the lateral meniscus and is more susceptible to tearing when trapped between the femoral condyle and tibial plateau [41]. The lateral meniscus is larger than the medial meniscus and carries a greater share of the lateral compartment pressure than the medial meniscus carries for the medial compartment [41].

The medial meniscus has a semicircular shape covering approximately 50% to 60% of the medial tibial plateau in adulthood [79]. The posterior horn of the medial meniscus averages 11 mm in the anterior-posterior dimension [79]. The lateral meniscus has a more circular C-shape with symmetric sizes of the anterior and posterior horns [79]. The mean lateral meniscus excursion from knee extension to flexion is 11.2 mm, compared to a mean medial meniscus excursion of 5.1 mm [79]. Menisci have three zones based on vasculature and extracellular matrix composition: white-white (avascular), red-white (limited vasculature), and red-red (most vascularized) [79]. The menisci bear one-third to one-half body weight and help with load transmission [85, 86]. Removal of the menisci increases contact stresses by up to four times the load transfer to bone [85, 86].

Vascular and Nerve Anatomy

The blood supply to the knee is formed from an anastomosis around the knee derived from the descending geniculate artery, medial and lateral superior geniculate arteries, medial and lateral inferior geniculate arteries, middle geniculate artery, and anterior tibial recurrent arteries [69]. The middle geniculate artery supplies both the anterior and posterior cruciate ligaments [69]. The inferior geniculate arteries pass deep to their respective collateral ligaments [69]. The blood supply of the patella is derived from the geniculate artery complex with some contribution from the anterior tibial recurrent artery and primarily exists in the middle to inferior portions of the patella [69].

The knee is innervated by branches of the femoral nerve (L2, L3, L4), obturator nerve (L2, L3, L4), and sciatic nerve (L4, L5, S1, S2) [69]. The largest nerve providing innervation of the intra-articular knee is the posterior articular branch of the tibial nerve [69]. The infrapatellar branch of the saphenous nerve arises proximal to the knee joint medially and crosses distal to the patella to innervate the skin over the region of the anterior knee and proximal tibia [69]. The popliteal artery travels through the adductor hiatus, where it is relatively immobile, and distally through the fibrous arch deep to the soleus muscle [91]. The common peroneal nerve travels along the posterior edge of the biceps femoris and continues distally around the fibular neck [91]. The tibial nerve courses distally through the center of the popliteus fossa after branching from the sciatic nerve [91].

Pathophysiology and Failure Mechanisms

Infection followed by stiffness is the most common mechanism of failure in TKA revisions [39]. In a cohort of 499 revision TKAs, infection was the major cause of failure (44.1%), followed by stiffness (22.6%), patellar or extensor mechanism problems (12.8%), periprosthetic fracture (5.9%), loosening (4.9%), haematoma formation (3.9%), malalignment (2.9%), and instability (2.9%) [54]. 83% of failures in this cohort were early, defined as less than two years postoperatively [54].

The etiology of extensor mechanism disruption after total knee arthroplasty is complex and multifactorial, with risk factors including patient comorbidities, prior knee procedures, surgical technique, and prosthetic design [135]. The incidence of extensor mechanism disruption after total knee arthroplasty has been reported to range from 0.17 to 2.5% [135]. The tibial bone block in an extensor mechanism allograft creates a stress riser, increasing the risk of proximal tibial shaft fracture if a short tibial component is used [163]. The drift toward further varus alignment postoperatively in posterior-stabilized and constrained condylar knee arthroplasty is consistent with the knee adduction moment remaining high after surgery [129]. Restoration of femoral joint line was the significant factor that increased postoperative range of motion of the knee after revision total knee arthroplasty [182]. In contemporary revision total knee arthroplasty, recreating the joint line within 5 mm of preoperative improves knee-specific health outcomes [192].

The stability of the knee joint is provided by bony articulations as well as dynamic and static soft-tissue stabilizers [91]. The four major ligamentous stabilizers of the knee are the anterior cruciate ligament, the posterior cruciate ligament, the medial collateral ligament, and the fibular collateral ligament [91]. The posterolateral corner and posteromedial corner as well as the medial and lateral menisci confer additional stability to the knee [91]. The posteromedial corner of the knee has five major components: the posterior oblique ligament, the semimembranosus tendon and its expansions, the oblique popliteal ligament, the posteromedial joint capsule, and the posterior horn of the medial meniscus [78]. The central arm of the posterior oblique ligament must be tightened in surgical repair or reconstruction, or passive stability cannot be attained regardless of any other surgical procedures [78]. The posteromedial capsule and posterior oblique ligament become progressively relaxed as the knee flexes, but with active contraction of the semimembranosus muscle, each of the three arms of the posterior oblique ligament is tense [78].

The joint capsule and the collateral ligaments are the principal extraarticular static stabilizing structures [72]. The medial capsule is more distinct and well defined than its lateral counterpart [72]. The anteromedial and anterolateral portions of the capsule are relatively thin structures but are reinforced by the medial and lateral patellar retinacular expansions, the iliotibial band laterally, and the medial patellofemoral ligament medially [72]. The medial patellofemoral ligament is more important for patellar stability and runs from the patella near the junction of the middle and superior thirds to the medial femoral epicondyle [72].

The knee joint surface loads are three times body weight during level walking and up to four times body weight with stair walking [85, 86]. The patella bears half the body weight with normal walking and seven times the body weight with squatting and jogging [85, 86]. In descending stairs, compressive force on the patellofemoral joint reaches two to three times body weight [85, 86]. Patellectomy decreases the length of the moment arm by the width of the patella and decreases the power of extension by 30% [85, 86]. The mechanical axis of the lower extremity normally passes just medial to the medial tibial spine [85, 86]. The mechanical axis of the lower extremity is in 3 degrees of valgus angulation from the vertical axis [85, 86]. The anatomic axis of the femur is in 6 degrees of valgus angulation from the mechanical axis [85, 86]. The anatomic axis of the tibia is in 2 to 3 degrees of varus angulation from the mechanical axis [85, 86].

Classification

Bone Defect Classifications

Anderson Orthopaedic Research Institute (AORI): The AORI classification is the most practical and widely used system for bone defects in revision total knee arthroplasty [20]. It defines three types of defects in the femur (F1, F2, F3) and tibia (T1, T2, T3) [20]. Type 1 defects involve intact cortical bone with small metaphyseal bone defects measuring less than 5 mm that do not jeopardize prosthetic component stability [20]. Type 2 defects involve loss of cortical bone and damage to the metaphyseal bone that requires filling to restore the joint line [20]. Type 3 defects involve deficient metaphyseal bone with severe bone loss affecting a significant portion of a femoral condyle or tibial plateau, producing knee instability due to collateral ligament injury [20]. A modified classification proposed by Rosso et al. in 2019 incorporates bone quality into the AORI framework [20].

Failed Stemmed Components: A specific classification system for bone loss with failed stemmed components grades the tibia and femur independently based on the location and degree of bone loss in the metaphysis and diaphysis [173]. Type 1 defects have no appreciable bone loss in the metaphysis and diaphysis [173]. Type 2 defects have cancellous bone loss in the metaphysis with intact cortices and intact diaphyseal bone [173]. Type 3A defects have extensive cancellous metaphyseal bone loss extending into the proximal diaphyseal canal with intact distal diaphyseal cortices [173]. Type 3B defects have extensive cancellous metaphyseal bone loss extending into the diaphysis along the entire length of the diaphyseal canal with cortical thinning [173]. Type 4 defects have extensive metaphyseal and diaphyseal bone loss with profound cortical thinning and pronounced expansion of endosteal bone [173].

Baldini: A novel Baldini classification for revision total knee arthroplasty has been developed and validated as a modified grading system [45].

Radiographic and Loosening Classifications

Total Knee Loosening: The total knee loosening classification divides the knee into geographic zones to allow systematic evaluation of prosthetic loosening [125]. Possible loosening is categorized when 25% to 49% of the interface displays radiolucency [125]. Probable loosening is categorized when more than 50% of the interface displays radiolucency [125]. Definite loosening is categorized by implant subsidence, debonding, or cement mantle fracture [125].

Krenn et al.: The Krenn et al. classification differentiates between four types of loosening: wear-induced (type I), infection-induced (type II), mixed-induced (type III), and indifferent-induced (type IV) [158].

Etiology and Failure Classifications

International Classification of Diseases (ICD-9-CM): The ICD-9-CM was updated in 2005 to include a more extensive method of documenting indications for revision total knee arthroplasty [37]. Infection and aseptic loosening were the most common indications for revision total knee arthroplasty in a national database analysis using the updated ICD-9-CM classification [37].

Clinical Presentation

Preoperative Evaluation and Diagnosis

Preoperative evaluation for revision total knee arthroplasty (TKA) requires a thorough history, clinical examination, laboratory assessment, and critical review of radiographs [43]. The history aims to confirm that symptomatology is consistent with a failed TKA and to exclude contraindications such as infection, Charcot arthropathy, neuromuscular disease, or adverse medical conditions [43]. Reviewing previous operative reports is necessary to assess the prior surgical approach, soft-tissue releases, and the size and type of existing prosthetic components [43]. No single investigation can reliably diagnose TKA failure preoperatively [100], and there is weak agreement between radiologist interpretation of preoperative bone scans and surgeon interpretation of clinical and radiographic data regarding component loosening [31].

Clinical examination includes assessment of range of motion, ligamentous stability, lower-limb alignment, and patellofemoral tracking [43]. The skin is inspected for previous incisions, anterior soft-tissue mobility, and preexisting ulcerations that require treatment before revision [43]. A neurologic examination ensures adequate motor control of the operative extremity [43]. If diminished pulses are present, noninvasive arterial studies are obtained and a preoperative vascular surgery consultation is considered [43]. Signs of venous insufficiency are evaluated with duplex color ultrasonography [43]. The examination must rule out referred pain from adjacent areas, such as a diseased hip joint, or radicular pain from spinal nerve root impingement, to confirm symptoms are secondary to the failed TKA [43].

For periprosthetic fractures, a history of prefracture pain, swelling, or instability may suggest implant loosening, infection, or polyethylene wear [29]. Physical examination assesses previous incisions, skin and soft-tissue quality, wound complication risks, and neurovascular status [29]. Assessment of the medial collateral ligament function is critical in determining the need for constrained implants [29]. Standard AP and lateral knee radiographs are obtained, and full-length femoral or tibial radiographs are required when stemmed implants are present to identify other preexisting devices [29]. Radiographs are assessed for evidence of loosening, osteolysis, implant wear, or malposition [29].

Etiology and Epidemiology

Infection (25.2%) and implant loosening (16.1%) are the most common causes of revision TKA [119]. Periprosthetic joint infection and aseptic loosening remain the leading indications for revision [15]. At one institution, infection was the most common reason for revision, with a higher rate of early revisions [55]. The most common type of revision procedure reported was all component revision (35.2%) [119]. Revision TKA volumes increased 59% between the periods 1993-1996 and 1997-1999 [16]. The estimated lifetime risk of revision depends on patient age and implant type, with fully constrained and unicondylar knee arthroplasty associated with higher lifetime revision risk [23]. Lifetime risk of revision may be a more meaningful outcome measure than implant survival at defined time periods when counselling patients prior to TKA [122].

Patient Factors and Prognostic Indicators

Patients specifically revised for instability or who had prior TKA revisions had the highest risk of re-revision at 10 years [4]. Patients less than 55 years undergoing revision TKA have a modest 5-year revision-free survival of 80% [7]. The results of revision TKA are affected by preoperative diagnosis but not gender [32]. Higher body mass index was not associated with moderate-severe knee pain at 2 and 5 years after primary or revision total knee arthroplasty [22]. Most patients did not recall being counseled about the complication leading to revision, and most expected their revision to last longer than the primary TKA regardless of how long the original implant lasted [34].

Clinical Outcomes and Complications

Revision TKA leads to a significant reduction in symptoms and improvement in function [27]. The overall complication rate for revision total knee arthroplasties declined from 9.3% during 1993-1996 to 7.3% during 1997-1999 [16]. Revision total knee arthroplasty performed for infection is associated with significantly higher long-term mortality at all time points compared with aseptic revision surgery [56]. Patients and surgeons can expect clinically meaningful improvement in PROMs and low re-revision rates when undergoing revision TKA for flexion instability when using consistent and established diagnostic criteria and surgical correction techniques [33]. Repeat revision TKA is a rare and complex procedure influenced by a number of confounding factors [28]. Outpatient revision TKA did not carry a higher risk of medical complications, hospital readmissions, or re-revision compared to inpatient revision TKA [52].

Investigations

Plain radiography: Plain radiographs serve as the appropriate initial imaging studies for most knee conditions, allowing assessment of surgical implants [89]. Weight-bearing AP and lateral views assess cartilage loss from the distal femur and tibial plateau [89]. The PA (Rosenberg) flexion view assesses cartilage loss from the posterior femur and tibial plateau [89]. Patellofemoral views assess patellofemoral alignment, patellar and trochlear morphology, and patellofemoral arthritis [89].

CT: Computed tomography provides enhanced bone detail through three-dimensional imaging in the axial, sagittal, and coronal planes [89]. CT imaging may help visualize osteolytic lesions around joint arthroplasty and cortical disruption in cases of infection or neoplasia [89]. Three-dimensional CT reconstructions may help with preoperative planning for reconstitution of bone loss in joint arthroplasty [89]. Axial plane CT imaging of the knee can help assess the rotational alignment of components of a total knee arthroplasty in cases of patellar maltracking [89].

MRI: Magnetic resonance imaging may identify the degree of articular cartilage injury, associated bone marrow edema, and lesion location [89]. MRI may be used to assess the continuity of the quadriceps or patellar tendon [89]. Additionally, MRI may be used to assess the margin of resection for a neoplasm and define the location of nerves or vessels relative to popliteal cysts [89].

Bone scan: Technetium-99 (Tc-99) radionuclide imaging may help identify infection, neoplasia, occult fracture, implant loosening, or failure of osseointegration [89]. Gallium-67 (Ga-67) radionuclide imaging may help differentiate between aseptic and septic prosthetic loosening [89]. Increased radionuclide activity in bone may be a normal postoperative finding for up to 6 to 12 months after an arthroplasty [89]. There is weak agreement regarding component loosening between a radiologist's opinion of a preoperatively obtained bone scan and the surgeon's preoperative interpretation of clinical and radiographic data [31].

Other Considerations: The AORI classification defines three types of bone defects each in the femur (F1, F2, F3) and tibia (T1, T2, T3) [20]. In the AORI classification, Type 1 defects involve intact cortical bone with small metaphyseal bone defects measuring less than 5 mm that do not jeopardize prosthetic stability [20]. Type 2 defects involve loss of cortical bone and damage to the metaphyseal bone that needs to be filled in to restore the joint line [20]. Type 3 defects involve deficient metaphyseal bone with severe bone loss affecting a significant portion of a femoral condyle or tibial plateau, producing knee instability [20]. A modified classification of bone loss proposed by Rosso et al. in 2019 takes into account bone quality in addition to the AORI classification [20]. Management of bone loss in revision total knee arthroplasty requires a systematic approach including careful preoperative evaluation, implant selection, and understanding of available reconstruction options [50]. Revision total knee arthroplasty presents numerous technical challenges requiring careful preoperative planning, meticulous surgical technique to preserve host bone, and attention to gap balancing [24].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacologic interventions for revision total knee arthroplasty. However, preoperative evaluation is mandatory to rule out contraindications such as infection, Charcot arthropathy, neuromuscular disease, or adverse medical conditions before proceeding with surgery [43].

Operative

Indications: Revision total knee arthroplasty is indicated for failed primary implants, with the most frequent causes of failure being infection, loosening, instability, arthrofibrosis, and osteolysis [37]. Infection and aseptic loosening were the most common indications for 60,355 revision TKAs undertaken between October 2005 and December 2006 [37]. Preoperative history must determine if symptomatology is consistent with a failed TKA and rule out referred pain from adjacent areas such as a diseased hip joint or radicular pain from spinal nerve root impingement [43]. Expectations for improvement should be tempered if a diagnostic anesthetic injection yields minimal subjective pain relief [156]. Central sensitization is a risk factor for persistent postoperative pain and dissatisfaction [180]. Morbidly obese patients have significantly higher rates of re-operation and re-revision at 10 years compared to non-morbidly obese patients [65].

Surgical Approach / Technique: Adequate exposure is the first step in successful revision TKA, requiring flexion well beyond 90 degrees, to about 110 degrees, to safely remove implants and insert components [151]. The standard medial parapatellar approach may be insufficient if passive flexion is less than 80 to 90 degrees under anesthesia [151]. The midline incision should start more proximally than the previous incision to establish normal tissue planes proximal to the extensor mechanism [151]. The medial parapatellar capsular incision begins at the proximal extent of the rectus tendon and ends distally one centimeter medial to the tibial tubercle [151]. A wide intra-articular synovectomy is required, removing all fibrous adhesions from the suprapatellar pouch, medial and lateral gutters, and any adherent fibrous tissue on the dorsal aspect of the quadriceps tendon proximal to the patella [174]. Release of adhesions in the suprapatellar pouch and gutters is performed after medial arthrotomy to increase flexion and ease patellar eversion [151]. A subperiosteal dissection of the medial retinaculum and deep medial collateral ligament to the semimembranosus insertion is completed with external rotation of the tibia, which reduces tension on the extensor mechanism by displacing the tubercle laterally [174]. Fibrous tissue between the patellar tendon and anterolateral tibia must be released to mobilize the distal extensor mechanism, and scar tissue on the lateral patella is gently released to allow subluxation [174]. A medial capsular approach combined with extensive synovectomy provides adequate exposure for the majority of cases with an acceptable complication rate [110]. Minimally invasive revision TKA is a reasonable approach for selected revisions, though it requires appropriate instrumentation and careful patient selection due to increased difficulty [115].

Implant Selection: Hybrid component fixation is a useful treatment option, with cemented and hybrid-fixation replacements showing equal stability at 24 months [51, 117]. Radiological outcomes and re-revision rates are largely similar between cemented and hybrid fixation techniques [141]. Current literature indicates no major superiority of a specific stem fixation method regarding postoperative outcomes [112]. Modular components with press-fit stems and metaphyseal cement fixation resulted in 83% survivorship at eight years, with infection being the most common cause of failure [124]. Hinged-design implants are most commonly indicated for infection, instability, and aseptic loosening [131]. New semi-constrained revision systems show favorable short-term outcomes with improved clinical scores and range of motion [53]. Young patients treated with specific study implants have a lower revision risk compared to those treated with established designs [40]. Revision of unicompartmental knee arthroplasty to TKA is more complex than primary TKA, with a higher incidence of constrained implants and thicker polyethylene inserts [36]. Patellar rebar augmentation allows for extended indications for patellar revision arthroplasty [127].

Bone Loss Management: Management of bone loss requires a systematic approach tailored to the size and location of the deficit, patient age, and life expectancy [11, 50]. The Anderson Orthopaedic Research Institute (AORI) classification defines three types of bone defects in the femur (F1, F2, F3) and tibia (T1, T2, T3) [20]. AORI type 1 involves intact cortical bone with small metaphyseal defects less than 5 mm that do not jeopardize component stability [20]. AORI type 2 involves loss of cortical bone and damage to metaphyseal bone requiring filling to restore the joint line [20]. AORI type 3 involves severe metaphyseal deficiency affecting a significant portion of a femoral condyle or tibial plateau, producing instability due to collateral ligament injury [20]. Impaction grafting is the preferred technique for substantial bone loss [12]. AORI type I minor deficits are commonly managed with cement or morselized allograft [63]. Trabecular metal cones are an efficient option for significant bone deficits and stable biological fixation [63]. Metaphyseal cones are an option for severe defects, though the best treatment for severe bone loss remains undetermined [30]. Combining diaphyseal impaction grafting with metaphyseal cones provides an excellent option for complex revisions [26]. Porous-coated metaphyseal sleeves achieve short-term stable fixation, which is helpful as more patients present with greater bone loss [123]. The use of cementless metaphyseal fixation increased from 14% to 19% over a study period, but overall utilization remains relatively low at 16% [133]. Appropriate metaphyseal fixation is crucial for stability and implant support [118].

Infection Management: Single-stage revision TKA is an effective strategy with a high success rate comparable to the two-stage approach in appropriately selected patients [10]. Arthrodesis is performed after failed infected TKA, involving removal of prosthetic components and all cement, wide accurate debridement with multiple lavages, and fixation with an external fixator or intramedullary nail [184]. Arthrodesis procedures are performed under tourniquet with a time limit of 2 hours, and immediate full weightbearing is allowed [184].

Soft Tissue and Wound Management: Adequate soft tissue coverage is essential to lower infection rates, with careful consideration given to the potential for reoperation, especially in two-stage reimplantation [166]. Adequate debridement of nonviable tissue is of utmost importance before closure [166]. The selection of closure and coverage methods should be based on wound assessment, associated risks, treatment morbidity, reoperation, recovery time, and long-term prognosis [166]. The reconstructive ladder serves as a general guide to stratify options, but the concept of a reconstructive “elevator” allows the surgeon to jump directly to the level of complexity with the highest chance for success if lower rung options have low success rates [166]. The operation with the highest probability of success must be the first choice in the reconstructive ladder [166]. Prophylactic flap coverage for high-risk patients resulted in successful subsequent TKA with no wound complications, despite a high rate of complications at the time of flap transfer [166].

Periprosthetic Fracture Management: After assessing for other serious injuries, the clinician should obtain a detailed history of the TKA and injury events [29]. Significant medical comorbidities such as syncope, cardiopulmonary compromise, head injury, or stroke must be identified and managed by specialists before addressing the fracture [29]. A history of prefracture pain, swelling, or instability may suggest loosening, infection, or polyethylene wear [29]. Previous surgical notes and radiographs provide information on the surgical approach, implant brand and type, collateral ligament status, and complications [29]. Physical examination should assess previous incisions, skin and soft-tissue quality, wound complication risks, and neurovascular status [29]. Assessment of medial collateral ligament function is critical in determining the need for constrained implants [29]. Standard AP and lateral radiographs should be obtained and assessed for loosening, osteolysis, implant wear, or malposition [29].

Complications and Technical Issues: Disengagement of a locking screw can cause acute joint locking and requires urgent arthroscopic removal [138]. Osteotomy of the tibial tubercle provides satisfactory exposure to extract broken tibial metal trays with rigidly fixed stems easily and safely [159]. All tibial tubercle osteotomies healed within 6 months postoperatively with no complications related to the surgical technique [159]. In a series of tibial tubercle osteotomies with absorbable suture fixation, the mean preoperative range of motion increased from 87.9° to 95.26° postoperatively at latest follow-up [49]. The mean total knee score after revision was 99.5 at latest follow-up in this series [49]. The mean SF-36 score was 88 at follow-up evaluation in this series [49].

Other Considerations: Preoperative evaluation involves a thorough history, clinical examination, laboratory assessment, and critical review of radiographs [43]. Analysis of previous surgical procedures and operative reports is necessary to assess the previous surgical approach, soft-tissue releases, and the size and type of present prosthetic components [43]. The skin is inspected to determine previous incisions, mobility of anterior soft tissues, and presence of preexisting ulcerations that would require treatment before proceeding [43]. A neurologic examination is performed to ensure adequate motor control of the operative lower extremity [43]. These findings support the development of revision teams within arthroplasty centres of excellence to offer patients the best possible outcomes [6]. Despite improvements in implant design and surgical technique, revision TKA continues to impose a major economic and clinical burden on the health care system [15]. Revision TKA is approximately 65% as cost effective as primary TKA but remains an excellent cost-effective means of improving function, pain relief, and quality of life [44]. The number of revision TKAs performed annually has been projected to increase by 601% between 2005 and 2030 [37]. Even with longer operating times, a patient undergoing revision TKA did not utilize more postanesthesia care unit time, nor more perioperative narcotics, than a patient undergoing primary TKA [57]. General anesthesia is associated with increased risk of numerous postoperative complications in patients undergoing revision TKA [143]. The preferred use of neuraxial anaesthesia and coordinated discharge planning in patients with a history of transient ischaemic attack/cerebrovascular accident may reduce the risk of readmission following discharge after revision TKA [205].

Complications

General Outcomes and Burden: The overall complication rate for revision total knee arthroplasties declined from 9.3% during 1993-1996 to 7.3% during 1997-1999 in a Northern Illinois cohort [16]. The incidence of early post-operative morbidity after aseptic knee revisions is similar to that reported after primary procedures [149]. Revision TKA can be safely performed on an outpatient basis in appropriately selected patients who do not have an increased risk of adverse events relative to inpatient revision TKA [210].

Infection (PJI): Periprosthetic joint infection (PJI) and aseptic loosening remain the most common causes of revision total knee arthroplasty [15]. In a large cohort of 11,134 knees, PJI was the dominant reason for failure during the first 15 years after primary TKA [18]. Infection was the most common reason for revision total knee arthroplasty at one institution, with a higher rate of early revisions [55]. In a specialized arthroplasty center, PJI was the most common reason for revision and re-revision TKA [196]. In a cohort of 499 revision TKAs, infection was the major cause of failure (44.1%), followed by stiffness (22.6%) and patellar or extensor mechanism problems (12.8%) [54]. PJI and periprosthetic fracture are the leading causes of re-revision surgery following aseptic revision TKA [99]. Patients with revision for PJI had a 33% greater-than-expected mortality [207]. A PJI following TKA was associated with a significantly higher mortality risk compared to major aseptic revisions [212]. Mortality is elevated soon after revision TKA for infection and fracture [221]. Registry data revealed nearly twice the re-revision rates for septic revision TKA compared to single-centre studies in Germany [183]. Both 5-year mortality and PJI re-revision rates following PJI were relatively high [186]. Revision TKA for aseptic failure following two-stage exchange for PJI is associated with a high reoperation rate (43%) and high reinfection rate (20%) at five years [165]. In the rare event of an ipsilateral infection after PJI, all occurred greater than one year from the index PJI and 2 of 3 were with the same organism when source infection control failed [213].

Aseptic Loosening: Repeat revision total knee arthroplasty has significantly lower survivorship compared to first-time revisions [140]. The most common reason for re-revision in patients with varus-valgus constrained implants was PJI, and progressive radiographic findings, young age, and severe bone loss were associated with increased risk of revision for aseptic loosening [67]. Midterm survivorship free from re-revision for aseptic loosening was modest (87%) in patients with contemporary rotating-hinge prostheses [164]. Survivorship free from revision for aseptic loosening was 100% at one and two years, and survivorship free from any re-revision was 85.1% at one and two years in patients with massive distal femoral bone loss treated with bicondylar femoral cones and a hinge TKA [168].

Stiffness / Arthrofibrosis: Stiffness following total knee arthroplasty is among the more common complications, with a reported prevalence of 1.3% to 6.9% [146]. In a study of 35 patients undergoing revision TKA for stiffness, 17 (49%) required a further intervention for stiffness or sustained a complication [146]. Stiffness was defined as a total range of motion less than 90° more than 3 months after the revision surgery or if a physician had to perform an additional procedure under anesthesia within the 3 months due to lack of sufficient progress in ROM [142].

Other Considerations: Re-revision of a failed unicompartmental knee arthroplasty (UKA) is equivalent to revision rates of primary TKA and substantially better than re-revision rates of revision TKA [171]. The five-year survival of TKAs free of re-revision was good in a large series of 235 revisions of UKA to TKA [64]. Revision free survivorship and arthroplasty related complications at two years following revision UKA are lower than that for primary TKA, but higher than that for aseptic revision TKA [147]. Cementless TKRs had a higher revision rate (absolute difference, 0.5%) and reoperation rate (absolute difference, 1.3%) compared to cemented TKRs [220]. The use of metal-backed modular tibial components was associated with an increased risk of reoperation compared to all-polyethylene tibial components [101]. Similar to investigations from international registries, an increased risk of all-cause revision and revision for infection was found when using posterior-stabilized bearings in TKA in the United States [60]. A decreased associated risk for both all-cause revision and revision for infection was found with the use of all-polyethylene designs for primary TKA [224]. Morbid obesity significantly increased the risk of subsequent revision, reoperation, and reinfection following two-stage revision total knee arthroplasty for infection [218]. The results regarding the impact of smoking on complications are even more magnified for revision procedures compared to published effects of smoking on primary total knee arthroplasty [58]. Younger patients (<60 years) undergoing aseptic revision TKA have similar implant survivorship, complication rates, and patient-reported outcomes compared to older patients, despite a higher rate of re-revision [104]. Preoperative estimated glomerular filtration rate is a marker for postoperative complications following revision total knee arthroplasty [102]. Postoperative blood products are associated with markedly increased rates of PE and VTE and infectious complications following revision TKA [208]. Revision total knee arthroplasty patients diagnosed with COVID-19 postoperatively had increased rates of thromboembolic events, pneumonia, and 90-day readmissions [172]. There is evidence of higher risk for re-revision surgery in hospitals with fewer than 25 R-TKA per year [47]. Higher volume surgical units had lower rates of early re-revision following the first revision knee replacement for infection [194]. Extended oral antibiotic prophylaxis after aseptic revision total knee arthroplasty resulted in a periprosthetic joint infection rate equivalent to primary TKA, representing a 2- to 4-fold decrease compared with published aseptic revision infection rates [177]. Intraosseous vancomycin administration at the time of reimplantation during two-stage revision TKA was associated with significantly reduced rates of recurrent PJI compared to IV antibiotic prophylaxis alone [217]. There is a trend toward a higher PJI rate in the postoperative period of total revision surgery when preoperative prophylaxis is withheld [222]. Patients undergoing 2-stage revision for PJI are more likely to be older and have greater comorbidities and therefore, are at increased risk for intraoperative and postoperative complications [103]. The additional burden of a subsequent second stage can be associated with major morbidity and mortality [103]. Further high-quality long-term studies would better clarify complications, clinical and radiological results of metaphyseal sleeves in total knee arthroplasty revision [17].

Recovery

Functional Outcomes and Activity: Patients and surgeons can expect clinically meaningful improvement in patient-reported outcome measures and low re-revision rates when undergoing revision total knee arthroplasty for flexion instability using consistent diagnostic criteria and surgical correction techniques [33]. Return to physical activity is achievable after revision total knee arthroplasty in the same proportion as after primary total knee arthroplasty, but it occurs later [109]. Activity levels by UCLA score remain relatively high after revision total knee arthroplasty, despite lower Knee Society pain and function scores when compared with those after primary total knee arthroplasty [225]. Age under 70 and male sex are associated with higher activity levels after revision total knee arthroplasty [68]. Twelve percent of patients participate in activities deemed not recommended by Knee Society guidelines after revision total knee arthroplasty [68]. Higher body mass index was not associated with moderate-severe knee pain at 2 and 5 years after revision total knee arthroplasty [22]. Revision total knee arthroplasty for arthrofibrosis can be expected to result in modest gains in range of motion, but pain may not improve [137].

Perioperative Care and Resource Utilization: A patient undergoing revision total knee arthroplasty did not utilize more postanesthesia care unit time than a patient undergoing primary total knee arthroplasty [57]. A patient undergoing revision total knee arthroplasty did not utilize more perioperative narcotics than a patient undergoing primary total knee arthroplasty [57]. Outpatient revision total knee arthroplasty can be feasible and safe, though additional studies are needed to define the appropriateness and drivers of successful discharge [130]. There was a substantial increase in surgeon work effort for revision total knee arthroplasty not commensurate with current Medicare reimbursement [126].

Risk Factors and Complications: Patients less than 55 years undergoing revision total knee arthroplasty have a modest 5-year revision-free survival of 80% [7]. There is evidence of higher risk for re-revision surgery in hospitals with fewer than 25 revision total knee arthroplasty cases per year [47].

Key Evidence

• [L5] Understanding the basic principles of exposure of the knee is essential for optimal performance of revision knee replacement. [2] (10.5435/00124635-199801000-00006)
• [L2] An approach to revision total knee arthroplasty that maintains bone and soft tissue about the knee establishes an effective and durable construct. [3] (10.1097/01.blo.0000218724.29344.89)
• [L4] Patients specifically revised for instability or who had prior TKA revisions had the highest risk of re-revision at 10 years. [4] (10.1016/j.arth.2019.02.001)
• [L3] These findings support the development of revision teams within arthroplasty centres of excellence to offer patients the best possible outcomes following revision total knee arthroplasty. [6] (10.1302/0301-620x.103b6.bjj-2020-2287.r1)
• [L3] Patients less than 55 years undergoing revision TKA have a modest 5-year revision-free survival of 80%. [7] (10.1016/j.arth.2020.12.008)
• [L2] An age greater than seventy years, revision five years or more after the primary arthroplasty, and absence of patellar subluxation are positive indicators of survival of a revision total knee replacement. [8] (10.2106/jbjs.e.00737)
• [L3] Estimates of the rates of revision knee replacement after almost seven years ranged from a low of 4.3 percent to a high of 8.0 percent. [9] (10.2106/00004623-199906000-00004)
• [L3] Single-stage revision total knee arthroplasty is an effective strategy with a high success rate comparable to the two-stage approach in appropriately selected patients. [10] (10.1302/0301-620x.103b8.bjj-2021-0224.r1)
• [L5] Management of bone loss in revision total knee arthroplasty requires proficiency in multiple techniques tailored to the size and location of the deficit, patient age, and life expectancy. [11] (10.1097/01.blo.0000229360.04620.93)
• [L4] It has become the preferred technique for the management of substantial bone loss in revision total knee arthroplasty. [12] (10.1097/01.blo.0000214414.06464.00)
• [L4] Revision total knee arthroplasty is a demanding procedure where adequate treatment of bone losses is mandatory to achieve good results, and bone quality should also be taken into consideration when approaching bone losses. [13] (10.1186/s13018-019-1328-1)
• [L4] Revision total knee arthroplasty is a technically demanding procedure with inferior outcomes and higher complication risks compared to primary arthroplasty, yet demand is rising due to population longevity and obesity; healthcare systems must address capacity and maximize patient outcomes. [14] (10.1302/0301-620x.97b6.35185)
• [L5] Despite improvements in implant design and surgical technique, revision total knee arthroplasty continues to impose a major economic and clinical burden on the health care system, with periprosthetic joint infection and aseptic loosening remaining the most common causes of revision. [15] (10.1016/j.arth.2025.07.038)
• [L3] Revision total knee arthroplasties increased 59%, and the overall complication rate declined from 9.3% during 1993-1996 to 7.3% during 1997-1999. [16] (10.1097/01.blo.0000137563.27841.e9)
• [L4] Further high-quality log-term studies would better clarify complications, clinical and radiological results of this promising technique in total knee arthroplasty revision. [17] (10.1007/s00402-018-2967-0)
• [L3] In this large cohort of patients with comprehensive followup of revision procedures, PJI was the dominant reason for failure during the first 15 years after primary TKA. [18] (10.1007/s11999-017-5396-4)
• [L5] Revision total knee arthroplasty presents complex challenges including bone loss and ligamentous insufficiency. [19] (10.1016/j.arth.2007.05.022)
• [L4] [20] (10.1302/2058-5241.6.210007)
• [L4] Outpatient revision knee arthroplasty was found to be safe in carefully selected patients and case scenarios. [21] (10.1016/j.arth.2020.02.021)
• [L3] Higher body mass index was not associated with moderate-severe knee pain at 2 and 5 years after primary or revision total knee arthroplasty. [22] (10.1016/j.arth.2010.02.006)
• [L3] The estimated lifetime risk of revision following knee arthroplasty was dependent on patient age and implant type, with fully constrained and unicondylar knee arthroplasty being associated with a higher lifetime revision risk. [23] (10.1016/j.arth.2024.11.054)
• [L5] Revision total knee arthroplasty presents numerous technical challenges requiring careful preoperative planning, meticulous surgical technique to preserve host bone, and attention to gap balancing. [24] (10.5435/00124635-201106000-00001)
• [L4] While long-term follow-up will be important, this technique provides an excellent option for the management of complex revision TKAs. [26] (10.1302/0301-620x.102b6.bjj-2019-1511.r1)
• [L4] Revision TKA leads to a significant reduction in symptoms and improvement in function. [27] (10.1007/s00167-011-1624-8)
• [L3] Repeat revision TKA is a rare and complex procedure influenced by a number of confounding factors. [28] (10.1007/s00167-020-05985-8)
• [L5] [29] (10.5435/jaaos-d-15-00680)
• [Paper] Revision total knee arthroplasty can pose challenges due to complex bone defects, and metaphyseal cones are an option for severe defects, though the best treatment option for severe bone loss is yet to be determined. [30] (10.1055/s-0036-1593343)
• [L3] In revision total knee arthroplasty, there is weak agreement regarding component loosening between a radiologist's opinion of a preoperatively obtained bone scan and the surgeon's preoperative interpretation of clinical and radiographic data. [31] (10.1016/j.arth.2019.02.065)
• [L3] Our data suggest the results of revision TKA are affected by preoperative diagnosis but not gender. [32] (10.1007/s11999-008-0451-9)
• [L3] Patients and surgeons can expect clinically meaningful improvement in PROMs and low re-revision rates when undergoing revision TKA for flexion instability when using consistent and established diagnostic criteria and surgical correction techniques. [33] (10.1016/j.arth.2025.03.086)
• [L2] Most patients did not recall being counseled about the complication leading to revision, and most expected their revision to last longer than the primary TKA regardless of how long the original implant lasted. [34] (10.1097/blo.0b013e3181492955)
• [L3] The revision of UKA to TKA is a more complex procedure compared to primary TKA, with a higher incidence of using constrained implants and thicker PE inserts. [36] (10.1016/j.arth.2013.02.003)
• [L3] [37] (10.1302/0301-620x.99b5.bjj-2016-0617.r3)
• [L3] Infection followed by stiffness is the most common mechanism of failure in TKA revisions. [39] (10.1016/j.arth.2008.11.062)
• [L4] Young patients treated with the study implant have a lower revision risk compared to young patients treated with established knee implant designs. [40] (10.1016/j.arth.2019.02.011)
• [L5] [43] (10.1016/j.arth.2007.01.001)
• [L2] Revision TKA is approximately 65% as cost effective as primary TKA but remains an excellent cost-effective means of improving function, pain relief, and quality of life. [44] (10.1097/01.blo.0000214420.14088.76)
• [L4] [45] (10.1016/j.arth.2026.06.061)
• [L3] We found evidence of higher risk for re-revision surgery in hospitals with fewer than 25 R-TKA per year. [47] (10.1016/j.arth.2019.11.045)
• [L4] [49] (10.1007/s00402-014-1950-7)
• [L5] Management of bone loss associated with revision TKA is challenging and requires a systematic approach including careful preoperative evaluation, implant selection, and understanding of available reconstruction options to achieve reproducible clinical outcomes. [50] (10.5435/jaaos-d-15-00660)
• [L4] Hybrid component fixation is a useful treatment option in revision total knee arthroplasty. [51] (10.1097/01.blo.0000214418.36959.c5)
• [L3] Outpatient revision TKA did not carry a higher risk of medical complications, hospital readmissions, or re-revision compared to inpatient revision TKA. [52] (10.1016/j.arth.2025.04.025)
• [L4] Revision TKAs using a new semi-constrained revision system showed favorable short-term follow-up outcomes, with improvement in clinical scores and ROM. [53] (10.1186/s13018-023-03503-3)
• [L3] [54] (10.1007/s00264-010-1134-1)
• [L4] At this institution, infection was the most common reason for revision total knee arthroplasty, with a higher rate of early revisions. [55] (10.1186/s42836-022-00134-7)
• [L4] Revision total knee arthroplasty performed for infection is associated with significantly higher long-term mortality at all time points compared with aseptic revision surgery. [56] (10.1016/j.arth.2021.01.068)
• [L3] Even with longer operating times, a patient undergoing revision total knee arthroplasty did not utilize more postanesthesia care unit time, nor more perioperative narcotics, than a patient undergoing primary total knee arthroplasty. [57] (10.1097/01.blo.0000214428.34280.c2)
• [L3] The results are even more magnified for revision procedures compared to published effects of smoking on primary total knee arthroplasty complications. [58] (10.1016/j.arth.2018.03.024)
• [L3] Similar to investigations from international registries, we found an increased risk of all-cause revision and revision for infection when using posterior-stabilized bearings in TKA in the United States. [60] (10.2106/jbjs.21.01251)
• [L3] [63] (10.1016/j.arth.2013.04.033)
• [L3] In this large series of 235 revisions of UKA to TKA, the five-year survival of the TKAs free of re-revision was good. [64] (10.1302/0301-620x.107b12.bjj-2025-0184.r2)
• [L3] Morbidly obese patients undergoing revision TKA had significantly higher rates of re-operation and re-revision at 10 years compared to non-morbidly obese patients. [65] (10.1016/j.arth.2019.01.010)
• [L3] The most common reason for re-revision was PJI, and progressive radiographic findings, young age, and severe bone loss were associated with increased risk of revision for aseptic loosening. [67] (10.1016/j.arth.2020.12.017)
• [L4] Age under 70 and male sex are associated with higher activity levels, while 12% participate in activities deemed not recommended by Knee Society guidelines. [68] (10.1016/j.arth.2007.03.030)
• [L3] PJI and periprosthetic fracture are the leading causes of re-revision surgery following aseptic revision TKA. [99] (10.1007/s00402-020-03698-8)
• [L2] No single investigation can be relied on to diagnose TKA failure preoperatively. [100] (10.1097/01.blo.0000218727.14097.d5)
• [L3] [101] (10.1016/j.arth.2016.09.036)
• [L3] [102] (10.1016/j.arth.2018.12.005)
• [L3] [103] (10.1016/j.arth.2023.03.061)
• [L3] Younger patients (<60 years) undergoing aseptic revision TKA have similar implant survivorship, complication rates, and patient-reported outcomes compared to older patients, despite a higher rate of re-revision. [104] (10.1016/j.arth.2023.05.014)
• [L3] Return to physical activity is achievable after revision TKA in the same proportion as after primary TKA, but it occurs later. [109] (10.1002/ksa.12638)
• [L4] A medial capsular approach combined with an extensive intraarticular synovectomy provides adequate exposure for the majority of revision total knee arthroplasty cases with an acceptable rate of complications. [110] (10.1097/01.blo.0000214434.64774.d5)
• [L2] The current literature indicates no major superiority of using a specific stem fixation method for revision total knee arthroplasty regarding various postoperative outcomes. [112] (10.1016/j.arth.2024.10.030)
• [L4] Preliminary results are encouraging, and the authors believe this is a reasonable approach for selected total knee arthroplasty revisions, though it requires appropriate instrumentation and careful patient selection due to increased difficulty. [115] (10.1097/01.blo.0000218728.52214.ac)
• [L1] At 24 months after revision TKAs, cemented and hybrid-fixation replacements were equally stable. [117] (10.2106/jbjs.15.00909)
• [L4] Appropriate metaphyseal fixation is crucial for stability and implant support in revision total knee arthroplasty. [118] (10.2106/jbjs.24.01094)
• [L2] The most common causes of revision TKA were infection (25.2%) and implant loosening (16.1%), and the most common type of revision TKA procedure reported was all component revision (35.2%). [119] (10.1007/s11999-009-0945-0)
• [L3] Lifetime risk of revision may be a more meaningful measure of outcome than implant survival at defined time periods when counselling patients prior to TKA. [122] (10.1302/0301-620x.104b2.bjj-2021-0890.r1)
• [L4] Short-term stable fixation can be achieved with sleeves, which is helpful as more patients undergo revision total knee arthroplasty with greater bone loss. [123] (10.1007/s00167-017-4493-y)
• [L3] Revision total knee replacement using modular components with press-fit stems and metaphyseal cement fixation resulted in an 83 per cent survivorship at eight years, with infection being the most common cause of failure. [124] (10.2106/00004623-199511000-00009)
• [L4] [125] (10.1016/j.arth.2012.06.008)
• [L3] There was a substantial increase in work effort not commensurate with current Medicare reimbursement, which may limit patient access to revision TKA. [126] (10.1016/j.arth.2016.05.003)
• [L4] This technique allows the surgeon to extend indications for patellar revision arthroplasty. [127] (10.1016/j.arth.2020.08.057)
• [L3] The drift toward further varus alignment postoperatively is consistent with the knee adduction moment remaining high after surgery. [129] (10.1007/s11999-017-5477-4)
• [L3] While outpatient revision TKA can be feasible and safe, additional studies are needed to define the appropriateness and drivers of successful discharge following revision TKA. [130] (10.1016/j.arth.2025.08.007)
• [L4] The three most commonly reported indications for using hinged-design implants in revision total knee arthroplasty are infection, instability, and aseptic loosening. [131] (10.1016/j.arth.2024.10.126)
• [L4] The use of any cementless metaphyseal fixation increased over the study period from 14% to 19%, but overall utilization rates in revision total knee arthroplasty remain relatively low at 16%. [133] (10.1016/j.arth.2021.11.027)
• [Case_report] [135] (10.1007/s00167-008-0533-y)
• [L4] Disengagement of a locking screw in a revision total knee arthroplasty can cause acute joint locking and requires urgent arthroscopic removal. [138] (10.1007/s00167-004-0552-2)
• [L3] [140] (10.1016/j.arth.2025.04.085)
• [L1] Despite a trend favouring hybrid stems in revision TKA, current evidence revealed that radiological outcomes and re-revision rates are largely similar between cemented and hybrid fixation techniques. [141] (10.1186/s12891-024-07389-y)
• [L3] [142] (10.1016/j.arth.2010.04.001)
• [L3] General anesthesia is associated with increased risk of numerous postoperative complications in patients undergoing revision TKA. [143] (10.1016/j.arth.2019.03.048)
• [L3] [146] (10.1016/j.arth.2010.04.013)
• [L3] Revision free survivorship and arthroplasty related complications at two years following revision UKA are lower than that for primary TKA, but higher than that for aseptic revision TKA, whereas medical complications are similar to those following primary TKA. [147] (10.1016/j.arth.2024.12.026)
• [L3] The incidence of early post-operative morbidity after aseptic knee revisions is similar to that reported after primary procedures. [149] (10.1302/0301-620x.96b12.33621)
• [L5] [151] (10.2106/00004623-199901000-00017)
• [L3] Expectations for improvement after revision TKA should be tempered if diagnostic anesthetic injection yields minimal subjective pain relief. [156] (10.1016/j.arth.2020.12.056)
• [L4] [158] (10.1016/j.arth.2019.04.024)
• [L4] [159] (10.1007/bf00433999)
• [L4] [163] (10.1016/j.arth.2012.04.021)
• [L3] Midterm survivorship free from re-revision for aseptic loosening was modest (87%). [164] (10.1016/j.arth.2024.08.013)
• [L4] Revision TKA for aseptic failure following two-stage exchange for PJI is associated with a high reoperation rate (43%) and high reinfection rate (20%) at five years. [165] (10.1016/j.arth.2026.04.013)
• [L5] [166] (10.1016/j.arth.2015.12.054)
• [L4] Survivorship free from revision for aseptic loosening was 100% at one and two years, and survivorship free from any re-revision was 85.1% at one and two years. [168] (10.1016/j.arth.2026.05.076)
• [L3] Compared to published data, re-revision of a failed UKA is equivalent to revision rates of primary TKA and substantially better than re-revision rates of revision TKA. [171] (10.1016/j.arth.2013.02.040)
• [L3] Revision total knee arthroplasty patients diagnosed with COVID-19 postoperatively had increased rates of thromboembolic events, pneumonia, and 90-day readmissions. [172] (10.1016/j.arth.2023.09.028)
• [L4] [173] (10.1016/j.arth.2021.12.015)
• [L5] [174] (10.1302/0301-620x.98b1.36315)
• [L3] Extended oral antibiotic prophylaxis after aseptic revision total knee arthroplasty resulted in a periprosthetic joint infection rate equivalent to primary TKA, representing a 2- to 4-fold decrease compared with published aseptic revision infection rates. [177] (10.1016/j.arth.2022.01.040)
• [L3] Central sensitization is a risk factor for persistent postoperative pain and dissatisfaction in patients undergoing revision total knee arthroplasties. [180] (10.1016/j.arth.2019.03.042)
• [L4] Restoration of femoral joint line was the significant factor that increased postoperative ROM of the knee after RTKA. [182] (10.1007/s00167-019-05361-1)
• [L3] Registry data revealed nearly twice the re-revision rates for septic revision TKA compared to single-centre studies, reflecting real-world outcomes in Germany. [183] (10.1302/0301-620x.107b9.bjj-2024-1440.r1)
• [L4] [184] (10.1007/s00167-005-0664-3)
• [L3] Both 5-year mortality and PJI re-revision rates following PJI were relatively high. [186] (10.1016/j.arth.2024.07.019)
• [L3] In contemporary rTKA, recreating the joint line within 5 mm of preoperative improves knee-specific health outcomes. [192] (10.1016/j.arth.2022.02.062)
• [L3] Overall, higher volume surgical units had lower rates of early re-revision following the first revision knee replacement for infection. [194] (10.1002/ksa.12578)
• [L3] In a specialized arthroplasty center periprosthetic joint infection (PJI) was the most common reason for revision and re-revision TKA. [196] (10.1186/s12891-018-1977-y)
• [L3] The preferred use of neuraxial anaesthesia and coordinated discharge planning in patients with a history of transient ischaemic attack/cerebrovascular accident may reduce the risk of readmission following discharge after revision total knee arthroplasty. [205] (10.1007/s00167-015-3782-6)
• [L2] Patients with revision for PJI had a 33% greater-than-expected mortality. [207] (10.2106/jbjs.24.01630)
• [L3] Postoperative blood products are associated with markedly increased rates of PE and VTE and infectious complications following revision TKA. [208] (10.1016/j.arth.2026.06.051)
• [L3] Our findings suggest that revision TKA can be safely performed on an outpatient basis in appropriately selected patients who do not have an increased risk of adverse events relative to inpatient revision TKA. [210] (10.1016/j.arth.2024.06.020)
• [L3] A PJI following TKA was associated with a significantly higher mortality risk compared to major aseptic revisions. [212] (10.1016/j.arth.2025.05.117)
• [L3] In the rare event of an ipsilateral infection, all occurred greater than one year from the index PJI and 2 of 3 were with the same organism when source infection control failed. [213] (10.1016/j.arth.2024.03.034)
• [L3] Intraosseous vancomycin administration at the time of reimplantation during two-stage revision TKA was associated with significantly reduced rates of recurrent PJI compared to IV antibiotic prophylaxis alone. [217] (10.1016/j.arth.2026.03.013)
• [L3] Morbid obesity significantly increased the risk of subsequent revision, reoperation, and reinfection following two-stage revision total knee arthroplasty for infection. [218] (10.2106/jbjs.m.01289)
• [L3] Cementless TKRs had a higher revision rate (absolute difference, 0.5%) and reoperation rate (absolute difference, 1.3%). [220] (10.2106/jbjs.21.00179)
• [L3] Mortality is elevated soon after revision TKA for infection and fracture. [221] (10.1016/j.arth.2018.11.031)
• [L3] Our data show a trend toward a higher PJI rate in the postoperative period of total revision surgery when preoperative prophylaxis is withheld. [222] (10.1016/j.arth.2017.03.064)
• [L3] In this analysis of the AJRR with linkage of CMS data for supplementary outcomes capture, we found a decreased associated risk for both all-cause revision and revision for infection with the use of all-polyethylene designs for primary TKA. [224] (10.1016/j.arth.2024.06.060)
• [L3] Activity levels by UCLA score remain relatively high after revision TKA, despite lower Knee Society pain and function scores when compared with those after primary TKA. [225] (10.1016/j.arth.2006.12.059)

See Also

• Total Knee Replacement

References

[2] Surgical Exposures in Revision Total Knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199801000-00006

[3] Cementless Fixation in Revision Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000218724.29344.89

[4] Contemporary Revision Total Knee Arthroplasty in Patients Younger Than 50 Years: 1 in 3 Risk of Re-Revision by 10 Years. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.02.001

[6] High-volume revision surgeons have better outcomes following revision total knee arthroplasty. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b6.bjj-2020-2287.r1

[7] High Rate of Re-Revision in Patients Less Than 55 Years of Age Undergoing Aseptic Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.12.008

[8] Revision Total Knee Arthroplasty. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00737

[9] Rates of Revision Knee Replacement in Ontario, Canada. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199906000-00004

[10] Outcomes of single- and two-stage revision total knee arthroplasty for chronic periprosthetic joint infection. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b8.bjj-2021-0224.r1

[11] Management of Bone Loss in Revision Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000229360.04620.93

[12] Impaction Grafting for Bone Defects in Revision Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000214414.06464.00

[13] Revision total knee arthroplasty (TKA): mid-term outcomes and bone loss/quality evaluation and treatment. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1328-1

[14] Dealing with the predicted increase in demand for revision total knee arthroplasty. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b6.35185

[15] Despite Improvements in Implant Design and Surgical Technique, Revision Total Knee Arthroplasty Continues to Be a Burden to Health Care. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.07.038

[16] Revision Total Knee Arthroplasty Complication Rates in Northern Illinois. Clinical Orthopaedics and Related Research. 2004. DOI: 10.1097/01.blo.0000137563.27841.e9

[17] Metaphyseal sleeves in total knee arthroplasty revision: complications, clinical and radiological results. A systematic review of the literature. Archives of Orthopaedic and Trauma Surgery. 2018. DOI: 10.1007/s00402-018-2967-0

[18] Periprosthetic Joint Infection Is the Main Cause of Failure for Modern Knee Arthroplasty: An Analysis of 11,134 Knees. Clinical Orthopaedics & Related Research. 2017. DOI: 10.1007/s11999-017-5396-4

[19] Management of Bone Loss in Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2007.05.022

[20] Management of bone loss in revision total knee arthroplasty: therapeutic options and results. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.210007

[21] The Feasibility of Outpatient Revision Total Knee Arthroplasty in Selected Case Scenarios. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2020.02.021

[22] Higher Body Mass Index Is Not Associated With Worse Pain Outcomes After Primary or Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.02.006

[23] The Estimated Lifetime Risk of Revision After Primary Knee Arthroplasty Is Influenced by Implant Design and Patient Age: Data From the National Joint Registries. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.11.054

[24] Metaphyseal Fixation in Revision Total Knee Arthroplasty: Indications and Techniques. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201106000-00001

[26] Outcomes of a technique combining diaphyseal impaction grafting and metaphyseal cones for severe bone loss in revision total knee arthroplasty. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b6.bjj-2019-1511.r1

[27] Predisposing factors which are relevant for the clinical outcome after revision total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1624-8

[28] Factors predicting repeat revision and outcome after aseptic revision total knee arthroplasty: results from the New Zealand Joint Registry. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-05985-8

[29] Revision Total Knee Arthroplasty for the Management of Periprosthetic Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00680

[30] The Use of Metaphyseal Cones for Bone Defects in Revision Total Knee Arthroplasty. The Journal of Knee Surgery. 2016. DOI: 10.1055/s-0036-1593343

[31] What Is the Value of Component Loosening Assessment of a Preoperatively Obtained Bone Scan Prior to Revision Total Knee Arthroplasty?. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.02.065

[32] Effect of Gender and Preoperative Diagnosis on Results of Revision Total Knee Arthroplasty. Clinical Orthopaedics & Related Research. 2008. DOI: 10.1007/s11999-008-0451-9

[33] Clinical Outcomes in Revision Total Knee Arthroplasty for Flexion Instability at a Mean of 3.2 Years. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.03.086

[34] Revision Total Knee Arthroplasty. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e3181492955

[36] Bone Loss During Revision of Unicompartmental to Total Knee Arthroplasty. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2013.02.003

[37] Contemporary failure aetiologies of the primary, posterior-stabilised total knee arthroplasty. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b5.bjj-2016-0617.r3

[39] Why Revision Total Knee Arthroplasty Fails?. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.11.062

[40] Midterm Performance of a Guided-Motion Bicruciate-Stabilized Total Knee System: Results From the International Study of Over 2000 Consecutive Primary Total Knee Arthroplasties. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.02.011

[41] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 3Sports Medicine > Image KNEE INJURIES.

[43] A Stepwise Approach to Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2007.01.001

[44] Cost Effectiveness of Revision Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000214420.14088.76

[45] Improving the Reliability of a Novel Baldini Classification for Revision Total Knee Arthroplasty: The Development and Validation of the Modified Grading System. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.06.061

[47] Low Hospital Volume Increases Re-Revision Rate Following Aseptic Revision Total Knee Arthroplasty: An Analysis of 23,644 Cases. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2019.11.045

[49] Tibial tubercle osteotomy with absorbable suture fixation in revision total knee arthroplasty: a report of 23 cases. Archives of Orthopaedic and Trauma Surgery. 2014. DOI: 10.1007/s00402-014-1950-7

[50] Bone Loss in Revision Total Knee Arthroplasty: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00660

[51] Hybrid Component Fixation in Revision Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000214418.36959.c5

[52] Inpatient Revision Total Knee Arthroplasty Has a Higher Risk of Early Complications: A Propensity Score-Matched Analysis with Outpatient Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.04.025

[53] Preliminary outcomes following revision total knee arthroplasty using a new fixed-bearing revision knee system in Asians: a mean of 3-year follow-up. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03503-3

[54] Failure following revision total knee arthroplasty: infection is the major cause. International Orthopaedics. 2010. DOI: 10.1007/s00264-010-1134-1

[55] Evolving etiologies and rates of revision total knee arthroplasty: a 10-year institutional report. Arthroplasty. 2022. DOI: 10.1186/s42836-022-00134-7

[56] Septic Revision Total Knee Arthroplasty Is Associated With Significantly Higher Mortality Than Aseptic Revisions: Long-Term Single-Center Study (1254 Patients). The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2021.01.068

[57] Revision Total Knee Arthroplasty Does Not Increase PACU Utilization. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000214428.34280.c2

[58] What Is the Impact of Smoking on Revision Total Knee Arthroplasty?. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.03.024

[60] Revision Risk for Total Knee Arthroplasty Polyethylene Designs in Patients 65 Years of Age or Older. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.21.01251

[63] Treatment of Large Bone Defects With Trabecular Metal Cones in Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2013.04.033

[64] Unicompartmental knee arthroplasty revisions to total knee arthroplasty. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b12.bjj-2025-0184.r2

[65] Morbid Obesity in Revision Total Knee Arthroplasty: A Significant Risk Factor for Re-Operation. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.01.010

[67] Varus-Valgus Constrained Implants in Revision Total Knee Arthroplasty: Mean Clinical Follow-Up of Six Years. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.12.017

[68] Patient Reported Activity After Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2007.03.030

[69] Aaos Comprehensive Orthopaedic Review 3. Anatomy and Biomechanics of the Knee > I. Anatomy.

[70] Miller S Review Of Orthopaedics. SECTION 1 KNEE > ANATOMY (FIG. 4.1).

[72] Campbell S Operative Orthopaedics 4 Volume Set. EXTRAARTICULAR LIGAMENTOUS STRUCTURES.

[73] Orthopaedic Knowledge Update Sports Medicine 6. Cruciate Ligament Injuries > Anterior Cruciate Ligament Injury > Anatomy and Biomechanics.

[78] Campbell S Operative Orthopaedics 4 Volume Set. POSTEROMEDIAL CORNER.

[79] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > Gross Anatomy.

[84] Aaos Comprehensive Orthopaedic Review 3. Radiographic Evaluation and Surgical Anatomy of the Knee > II. Surgical Anatomy of the Knee.

[85] Miller S Review Of Orthopaedics. ARTHRODESIS PERSON > Kinetics.

[86] Miller S Review Of Orthopaedics. Genetics of musculoskeletal conditions and abnormalities are summarized in Table 1.27 > ARTHRODESIS PERSON > Kinetics.

[89] Aaos Comprehensive Orthopaedic Review 3. Radiographic Evaluation and Surgical Anatomy of the Knee > I. Radiographic Evaluation.

[91] Aaos Comprehensive Orthopaedic Review 3. Knee Dislocations and Patellar Fractures* > I. Knee Dislocations.

[99] Infection and periprosthetic fracture are the leading causes of failure after aseptic revision total knee arthroplasty. Archives of Orthopaedic and Trauma Surgery. 2021. DOI: 10.1007/s00402-020-03698-8

[100] Preoperative Evaluations in Revision Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000218727.14097.d5

[101] Metal or Modularity: Why Do Metal-Backed Tibias Have Inferior Outcomes to All-Polyethylene Tibial Components in Patients With Osteoarthritis. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2016.09.036

[102] Preoperative Estimated Glomerular Filtration Rate Is a Marker for Postoperative Complications Following Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2018.12.005

[103] Modern Description of Antibiotic Spacer Options for PJI in Revision Total Knee Arthroplasty: Clinical Outcomes and Infection Eradication Rates. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.03.061

[104] Why and What Happens to Patients Younger Than 60 Years Who Need Revision Total Knee Arthroplasty?. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.05.014

[109] Return to physical activity after revision total knee arthroplasty: Comparative insights with primary procedure. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12638

[110] Surgical Exposures in Revision Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000214434.64774.d5

[112] What Is the Preferred Fixation Method for Stems Used in Revision Total Knee Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.030

[115] Minimally Invasive Revision Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000218728.52214.ac

[117] No Difference in Implant Micromotion Between Hybrid Fixation and Fully Cemented Revision Total Knee Arthroplasty. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.00909

[118] Metaphyseal Fixation in Revision Total Knee Arthroplasty. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.01094

[119] The Epidemiology of Revision Total Knee Arthroplasty in the United States. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-009-0945-0

[122] The lifetime risk of revision following total knee arthroplasty. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b2.bjj-2021-0890.r1

[123] Revision total knee arthroplasty with porous-coated metaphyseal sleeves provides radiographic ingrowth and stable fixation. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4493-y

[124] Revision total knee arthroplasty with use of modular components with stems inserted without cement.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199511000-00009

[125] Incidence of Osteolysis in Total Knee Arthroplasty. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.06.008

[126] Quantifying and Predicting Surgeon Work Effort for Primary and Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.05.003

[127] Patellar Rebar Augmentation in Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.08.057

[129] Polyethylene Damage Increases With Varus Implant Alignment in Posterior-stabilized and Constrained Condylar Knee Arthroplasty. Clinical Orthopaedics & Related Research. 2017. DOI: 10.1007/s11999-017-5477-4

[130] Not so Fast! Feasibility and Safety of Outpatient Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.007

[131] What Are the Indications for Hinged Implants in Revision Total Knee Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.126

[133] Use of Cementless Metaphyseal Fixation in Revision Total Knee Arthroplasty in the United States. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2021.11.027

[135] A “biologic technique” for the treatment of a disruption of the extensor mechanism after revision total knee arthroplasty: a case report. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0533-y

[137] Chapter 50 Revision Total Knee Arthroplasty. 2019.

[138] Acute locking in revision total knee arthroplasty due to disengagement of the locking screw. Knee Surgery, Sports Traumatology, Arthroscopy. 2004. DOI: 10.1007/s00167-004-0552-2

[140] Repeat Revision Total Knee Arthroplasty Has Significantly Lower Survivorship Compared to First-Time Revisions. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.04.085

[141] A systematic review and meta-analysis of hybrid vs. cemented stems – which method is more optimal for revision total knee arthroplasty?. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07389-y

[142] Stiffness After Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2010.04.001

[143] General vs Spinal Anesthesia for Revision Total Knee Arthroplasty: Do Complication Rates Differ?. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.03.048

[146] Revision Total Knee Arthroplasty for Stiffness. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2010.04.013

[147] Revision Unicompartmental Knee Arthroplasty: Worse than a Primary, but Better than a Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.12.026

[149] Re-admissions, re-operations and length of stay in hospital after aseptic revision knee replacement in Denmark. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b12.33621

[151] Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Specialized Exposure for Revision Total Knee Arthroplasty. The Journal of Bone & Joint Surgery. 1999. DOI: 10.2106/00004623-199901000-00017

[156] Utility and Prognostic Ability of a Diagnostic Injection Before Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.12.056

[158] Osteointegrative Sleeves for Metaphyseal Defect Augmentation in Revision Total Knee Arthroplasty: Clinical and Radiological 5-Year Follow-Up. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.04.024

[159] Tibial tubercle osteotomy in revision total knee arthroplasty. Archives of Orthopaedic and Trauma Surgery. 1997. DOI: 10.1007/bf00433999

[163] Fracture of the Proximal Tibia After Revision Total Knee Arthroplasty With an Extensor Mechanism Allograft. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.04.021

[164] High Rates of Early Septic Failure, but Low Rates of Aseptic Loosening After Revision Total Knee Arthroplasty With Contemporary Rotating-Hinge Prostheses. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.08.013

[165] Revision Total Knee Arthroplasty for Aseptic Failure After Staged Exchange for Periprosthetic Joint Infection: High Rates of Reoperation and Reinfection. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.04.013

[166] Soft Tissue Reconstruction and Flap Coverage for Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2015.12.054

[168] The “Distal Femoral Replacement Downgrade”: Technique of Using Bicondylar Femoral Cones with a Hinge Total Knee Arthroplasty Revision in Patients Who Have Massive Distal Femoral Bone Loss as an Alternative. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.05.076

[171] Revision of Unicompartmental Arthroplasty to Total Knee Arthroplasty: Not Always a Slam Dunk!. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2013.02.040

[172] Complications Rates Among Revision Total Knee Arthroplasty Patients Diagnosed With COVID-19 Postoperatively. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2023.09.028

[173] Classification of Bone Loss With Failed Stemmed Components in Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2021.12.015

[174] The surgical approach for revision total knee arthroplasty. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b1.36315

[177] Reduced Infection Rate After Aseptic Revision Total Knee Arthroplasty With Extended Oral Antibiotic Protocol. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.01.040

[180] Central Sensitization Is a Risk Factor for Persistent Postoperative Pain and Dissatisfaction in Patients Undergoing Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.03.042

[182] Femoral joint line restoration is a major determinant of postoperative range of motion in revision total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05361-1

[183] Much higher re-revision rates and mortality following septic revision total knee arthroplasty compared to meta-analyses. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b9.bjj-2024-1440.r1

[184] Arthrodesis of the knee after failed infected total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2005. DOI: 10.1007/s00167-005-0664-3

[186] Early Periprosthetic Joint Infections in Total Hip and Knee Arthroplasty: Microorganisms, Mortality, and Implant Survival Using a Combined Dataset From the Dutch Arthroplasty Register and the Dutch National Nosocomial Surveillance Network. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.07.019

[192] The Effect of Joint Line Elevation on Patient-Reported Outcomes After Contemporary Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.02.062

[194] Higher hospital volume reduces early failure rates in single‐stage revision TKR for infection: An analysis of the United Kingdom National Joint Registry and National Administrative Databases. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12578

[196] Analysis of Total Knee Arthroplasty revision causes. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-1977-y

[205] Predictors of hospital readmission following revision total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3782-6

[207] Fifteen-Year Mortality Following Periprosthetic Joint Infection in Total Knee Arthroplasty. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.01630

[208] Transfusions are Associated with an Elevated Risk of Venous Thromboembolism and Periprosthetic Joint Infection following Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.06.051

[210] Is Hospital-Based Outpatient Revision Total Knee Arthroplasty Safe? An Analysis of 2,171 Outpatient Aseptic Revision Procedures. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.06.020

[212] Increased Mortality Following Periprosthetic Joint Infection After Total Knee Arthroplasty: A Microbiologically Verified Nationwide Cohort of 916 Cases. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.05.117

[213] Periprosthetic Hip and Knee Infection: Is an Ipsilateral Uninfected Total Joint Arthroplasty at Risk?. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.03.034

[217] The John N. Insall Award: Reduced Reinfection Rate With Intraosseous Vancomycin Administration at Reimplantation in Two-Stage Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.013

[218] Morbid Obesity: A Significant Risk Factor for Failure of Two-Stage Revision Total Knee Arthroplasty for Infection. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01289

[220] A Matched Comparison of the Long-Term Outcomes of Cemented and Cementless Total Knee Replacements. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.21.00179

[221] Long-Term Mortality Trends After Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2018.11.031

[222] Withholding Preoperative Antibiotic Prophylaxis in Knee Prosthesis Revision: A Retrospective Analysis on Culture Results and Risk of Infection. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.03.064

[224] Lower Associated Risk of Revision With All-Polyethylene Tibial Components in Total Knee Arthroplasty: An Analysis of the American Joint Replacement Registry. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.06.060

[225] Patient Reported Activity After Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2006.12.059