Journal of Racial and Ethnic Health Disparities

, Volume 6, Issue 1, pp 101–109 | Cite as

Racial Disparities in Revision Total Knee Arthroplasty: Analysis of 125,901 Patients in National US Private Payer Database

  • Martin Roche
  • Tsun yee Law
  • Assem A. Sultan
  • Erica Umpierrez
  • Anton Khlopas
  • Sam Rosas
  • Jennifer Kurowicki
  • Kevin Wang
  • Michael A. MontEmail author



There is a relative paucity of studies that characterized racial disparities in revision total knee arthroplasty (TKA). Therefore, this study was specifically conducted to evaluate the following: (1) incidence; (2) annual burden; (3) causes; and (4) age group distribution of revision TKA among different racial groups in the US sample population.


The PearlDiver database was utilized to identify patients with knee osteoarthritis (OA) who underwent primary then subsequent revision TKA from January 2007 to December 2014. Patients were stratified by race, and subset stratification by age was also performed. In each racial cohort, the overall incidence of revision TKA, annual revision burdens, and causes of revisions were calculated and compared. Additionally, a sub-analysis for the incidence of revision TKA stratified by age, in each cohort, was performed. Statistical analysis was performed to demonstrate revision incidence, burden, causes, and age distribution.


Revision incidence and burden were the highest in the African-American cohort (12.4%, 11.1%), (p < 0.001) and was lowest in the Asian cohort (3.4%, 3.3%) (p < 0.001). Across all cohorts, mechanical complications of the joint prosthesis were the most common cause of revision followed by periprosthetic joint infection, while contracture was the least common (p < 0.001). Subset analysis by age revealed that the highest incidence of revision TKA was in patients less than 40 years old in the Caucasian cohort (27.1%). The African-American (17.8%), other races (7.9%), and Hispanic (16.5%) cohorts had the highest incidence of revision in the 40 to 64 years age range. Among the Asian (4.1%) and Native American (9.7%) cohorts, revision incidence was highest in patients older than 65 years.


The present study demonstrated that racial disparities, highlighted by previous studies mainly in primary TKA, extend to influence revision TKA. Among the studied racial cohorts, race may affect outcomes and our results will help expand the current literature particularly on its role in revision TKA.


Race Ethnic Knee Total knee arthroplasty Replacement Revision 


Compliance with Ethical Standards

Conflicts of Interest

Martin Roche declares the following conflicts: Mako-stryker: paid consultant; Mako-stryker, Orthosensor: IP royalties; Mako-stryker, Orthosensor: paid presenter or speaker; Mako surgical-stryker: research support; Orthosensor: paid consultant; and Orthosensor, Cayenne: stock or stock options. Michael Mont declares the following conflicts: AAOS: board or committee member; Cymedica: paid consultant; DJ Orthopedics: paid consultant, research support; Johnson & Johnson: paid consultant, research support; Journal of Arthroplasty: editorial or governing board; Journal of Knee Surgery: editorial or governing board; Microport: IP royalties; National Institutes of Health (NIAMS & NICHD): research support; Ongoing Care Solutions: paid consultant, research support; Orthopedics: editorial or governing board; Orthosensor: paid consultant, research support; Pacira: paid consultant; Peerwell: stock or stock options; Performance Dynamics Inc.: paid consultant; Reflexion: paid consultant; Sage: paid consultant; Stryker: IP royalties, paid consultant, research support; Surgical Techniques International: editorial or governing board; and TissueGene: paid consultant, research support. All the rest of the authors declare that they have no conflict of interest.


  1. 1.
    Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The functional outcomes of total knee arthroplasty. J Bone Joint Surg. 2005;87(8):1719–24.Google Scholar
  2. 2.
    Ethgen O, Bruyère O, Richy F, Dardennes C, Reginster J-Y. Health-related quality of life in total hip and total knee arthroplasty. J Bone Joint Surg. 2004;86(5):963–74.CrossRefGoogle Scholar
  3. 3.
    Pulido L, Parvizi J, Macgibeny M, et al. In hospital complications after total joint arthroplasty. J Arthroplast. 2008;23(6 Suppl 1):139–45.CrossRefGoogle Scholar
  4. 4.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5.Google Scholar
  5. 5.
    Ong KL, Mowat FS, Chan N, Lau E, Halpern MT, Kurtz SM. Economic burden of revision hip and knee arthroplasty in Medicare enrollees. Clin Orthop Relat Res. 2006;446:22–8.CrossRefGoogle Scholar
  6. 6.
    Oduwole K, Molony D, Walls R, Bashir S, Mulhall K. Increasing financial burden of revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2010;18(7):945–8.CrossRefGoogle Scholar
  7. 7.
    Kremers HM, Visscher SL, Kremers WK, Naessens JM, Lewallen DG. The effect of obesity on direct medical costs in total knee arthroplasty. J Bone Joint Surg. 2014;96(9):718–24.CrossRefGoogle Scholar
  8. 8.
    Nwachukwu BU, Kenny AD, Losina E, Chibnik LB, Katz JN. Complications for racial and ethnic minority groups after total hip and knee replacement. J Bone Joint Surg. 2010;92(2):338–45.CrossRefGoogle Scholar
  9. 9.
    Mortazavi SMJ, Schwartzenberger J, Austin MS, Purtill JJ, Parvizi J. Revision total knee arthroplasty infection: incidence and predictors. Clin Orthop Relat Res. 2010;468(8):2052–9.CrossRefGoogle Scholar
  10. 10.
    Schairer WW, Vail TP, Bozic KJ. What are the rates and causes of hospital readmission after total knee arthroplasty? Clin Orthop Relat Res. 2014;472(1):181–7.CrossRefGoogle Scholar
  11. 11.
    Racial disparities in total knee replacement among Medicare enrollees—United States, 2000-2006. MMWR Morb Mortal Wkly Rep. 2009;58(6):133–38.Google Scholar
  12. 12.
    Figaro MK, Williams-Russo P, Allegrante JP. Expectation and outlook: the impact of patient preference on arthritis care among African Americans. J Ambul Care Manage. 2005;28(1):41–8.CrossRefGoogle Scholar
  13. 13.
    Lavernia CJ, Alcerro JC, Rossi MD. Fear in arthroplasty surgery: the role of race. Clin Orthop Relat Res. 2010;468(2):547–54.CrossRefGoogle Scholar
  14. 14.
    Skinner J, Zhou W, Weinstein J. The influence of income and race on total knee arthroplasty in the United States. J Bone Joint Surg. 2006;88(10):2159–66.Google Scholar
  15. 15.
    Hanchate DA, Zhang TY, Felson SD, Ash SA. Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets. Med Care. 2008;46(5):481–8.CrossRefGoogle Scholar
  16. 16.
    Irgit K, Nelson CL. Defining racial and ethnic disparities in THA and TKA. Clin Orthop Relat Res. 2011;469(7):1817–23.CrossRefGoogle Scholar
  17. 17.
    Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg. 2005;87(7):1487–97.Google Scholar
  18. 18.
    Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA. 2012;308(12):1227–36.CrossRefGoogle Scholar
  19. 19.
    Blum MA, Singh JA, Lee G-C, Richardson D, Chen W, Ibrahim SA. Patient race and surgical outcomes after total knee arthroplasty: an analysis of a large regional database. Arthritis Care Res. 2013;65(3):414–20.CrossRefGoogle Scholar
  20. 20.
    Dy CJ, Marx RG, Bozic KJ, Pan TJ, Padgett DE, Lyman S. Risk factors for revision within 10 years of total knee arthroplasty. Clin Orthop Relat Res. 2014;472(4):1198–207.CrossRefGoogle Scholar
  21. 21.
    Springer BD, Odum SM, Nagpal VS, et al. Is socioeconomic status a risk factor for stiffness after total knee arthroplasty? A multicenter case-control study. Orthop Clin N Am. 2012;43(5):e1–7.CrossRefGoogle Scholar
  22. 22.
    Kasahara Y, Majima T, Kimura S, Nishiike O, Uchida J. What are the causes of revision total knee arthroplasty in Japan? Clin Orthop Relat Res. 2013;471(5):1533–8.CrossRefGoogle Scholar
  23. 23.
    Koh IJ, Kim TK, Chang CB, Cho HJ, In Y. Trends in use of total knee arthroplasty in Korea from 2001 to 2010. Clin Orthop Relat Res. 2013;471(5):1441–50.CrossRefGoogle Scholar
  24. 24.
    Koh IJ, Cho WS, Choi NY, Kim TK. Causes, risk factors, and trends in failures after TKA in Korea over the past 5 years: a multicenter study. Clin Orthop Relat Res. 2014;472(1):316–26.CrossRefGoogle Scholar
  25. 25.
    Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468(1):45–51.CrossRefGoogle Scholar
  26. 26.
    Namba RS, Cafri G, Khatod M, Inacio MCS, Brox TW, Paxton EW. Risk factors for total knee arthroplasty aseptic revision. J Arthroplast. 2013;28(8, Supplement):122–7.CrossRefGoogle Scholar
  27. 27.
    Hosaka K, Saito S, Ishii T, Mori S, Sumino T, Tokuhashi Y. Asian-specific total knee system: 5−14 year follow-up study. BMC Musculoskelet Disord. 2011;12:251.CrossRefGoogle Scholar
  28. 28.
    Chaichankul C, Tanavalee A, Itiravivong P. Anthropometric measurements of knee joints in Thai population: correlation to the sizing of current knee prostheses. Knee. 2011;18(1):5–10.CrossRefGoogle Scholar
  29. 29.
    Cheng FB, Ji XF, Lai Y, Feng JC, Zheng WX, Sun YF, et al. Three dimensional morphometry of the knee to design the total knee arthroplasty for Chinese population. Knee. 2009;16(5):341–7.CrossRefGoogle Scholar
  30. 30.
    Urabe K, Miura H, Kuwano T, Matsuda S, Nagamine R, Sakai S, et al. Comparison between the shape of resected femoral sections and femoral prostheses used in total knee arthroplasty in Japanese patients: simulation using three-dimensional computed tomography. J Knee Surg. 2003;16(1):27–33.Google Scholar
  31. 31.
    Tang Q, Zhou Y, Yang D, Xu H, Liu Q. The offset of the tibial shaft from the tibial plateau in Chinese people. J Bone Joint Surg. 2010;92(10):1981–7.CrossRefGoogle Scholar
  32. 32.
    Perfetti DC, Boylan MR, Naziri Q, Khanuja HS, Urban WP. Does sickle cell disease increase risk of adverse outcomes following total hip and knee arthroplasty? A Nationwide Database Study. J Arthroplast. 2015;30(4):547–51.CrossRefGoogle Scholar
  33. 33.
    Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis. 2014;73(12):2107–15.CrossRefGoogle Scholar
  34. 34.
    Kurtz S, Lau E, Ong K, Zhao K, Kelly M, Bozic K. Future young patient demand for primary and revision joint replacement: National Projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467(10):2606–12.CrossRefGoogle Scholar
  35. 35.
    Kim KT, Lee S, Ko DO, Seo BS, Jung WS, Chang BK. Causes of failure after total knee arthroplasty in osteoarthritis patients 55 years of age or younger. Knee Surg Relat Res. 2014;26(1):13–9.CrossRefGoogle Scholar
  36. 36.
    W-Dahl A, Robertsson O, Lidgren L. Surgery for knee osteoarthritis in younger patients. Acta Orthop. 2010;81(2):161–4.CrossRefGoogle Scholar
  37. 37.
    Rand JA, Trousdale RT, Ilstrup DM, Harmsen WS. Factors affecting the durability of primary total knee prostheses. J Bone Joint Surg Am. 2003;85-a(2):259–65.CrossRefGoogle Scholar

Copyright information

© W. Montague Cobb-NMA Health Institute 2018

Authors and Affiliations

  • Martin Roche
    • 1
  • Tsun yee Law
    • 1
  • Assem A. Sultan
    • 2
  • Erica Umpierrez
    • 2
  • Anton Khlopas
    • 2
  • Sam Rosas
    • 1
  • Jennifer Kurowicki
    • 1
  • Kevin Wang
    • 1
  • Michael A. Mont
    • 2
    Email author
  1. 1.Holy Cross Orthopedic InstituteFort LauderdaleUSA
  2. 2.Department of Orthopaedic SurgeryCleveland ClinicClevelandUSA

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