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Influence of Hospital Volume on Revision Rate After Total Knee Arthroplasty with Cement
Mona Badawy, MD1; Birgitte Espehaug, PhD2; Kari Indrekvam, MD, PhD1; Lars B. Engesæter, MD, PhD3; Leif I. Havelin, MD, PhD2; Ove Furnes, MD, PhD2
1 Kysthospital in Hagavik, Hagaviksbakken 25, 5217 Hagavik, Norway. E-mail address for M. Badawy: mona.badawy@helse-bergen.no. E-mail address for K. Indrekvam: kari.indrekvam@helse-bergen.no
2 The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, 5021 Bergen, Norway. E-mail address for B. Espehaug: birgitte.espehaug@helse-bergen.no. E-mail address for L.I. Havelin: leif.havelin@helse-bergen.no. E-mail address for O. Furnes: ove.furnes@helse-bergen.no
3 Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway. E-mail address: lars.engeseter@UiB.no
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Investigation performed at Kysthospital in Hagavik, Hagavik, and Norwegian Arthroplasty Register, Bergen, Norway

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Sep 18;95(18):e131 1-6. doi: 10.2106/JBJS.L.00943
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The number of total knee replacements has substantially increased worldwide over the past ten years. Several studies have indicated a correlation between high hospital procedure volume and decreased morbidity and mortality following total knee arthroplasty. The purpose of the present study was to evaluate whether there is a correlation between procedure volume and the risk of revision following total knee arthroplasty with use of hospital volume data from the Norwegian Arthroplasty Register.


Thirty-seven thousand, three hundred and eighty-one total knee arthroplasties that were reported to the Norwegian Arthroplasty Register from 1994 to 2010 were used to examine the annual procedure volume per hospital. Hospital volume was divided into five categories according to the number of procedures performed annually: one to twenty-four (low volume), twenty-five to forty-nine (medium volume), fifty to ninety-nine (medium volume), 100 to 149 (high volume), and ≥150 (high volume). Cox regression (adjusted for age, sex, and diagnosis) was used to estimate the proportion of procedures without revision and the risk ratio (RR) of revision. Analyses were also performed for two commonly used prosthesis brands combined.


The rate of prosthetic survival at ten years was 92.5% (95% confidence interval, 91.5 to 93.4) for hospitals with an annual volume of one to twenty-four procedures and 95.5% (95% confidence interval, 94.1 to 97.0) for hospitals with an annual volume of ≥150 procedures. We found a significantly lower risk of revision for hospitals with an annual volume of 100 to 149 procedures (relative risk = 0.73 [95% confidence interval, 0.56 to 0.96], p = 0.03) and ≥150 procedures (relative risk = 0.73 [95% confidence interval, 0.54 to 1.00], p = 0.05) compared with hospitals with an annual volume of one to twenty-four procedures. Similar results were found when we analyzed two commonly used prosthesis brands.


In the present study, there was a significantly higher rate of revision knee arthroplasties at low-volume hospitals as compared with high-volume hospitals.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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