The survival rate and clinical outcome following primary total knee arthroplasty is reportedly similar in patients with osteoarthritis and rheumatoid arthritis [7, 9, 11-14, 16, 17, 21, 22, 24, 25, 27]. Outcomes of revision surgery for osteoarthritis have been extensively reviewed but less has been reported on the outcomes following revision for selected patients with rheumatoid arthritis [26, 28-30]. The purpose of this study was to confirm the findings reported by Rööser et al.  and Sheng et al.  regarding the high failure rate (19-28%) following revision total knee arthroplasty in a selected series of patients with rheumatoid arthritis treated for either mechanical reasons or infection. Additionally, we aimed to expand the literature by reporting (1) the clinical function of the revision procedure based on the Knee Society knee score and function score; (2) our radiographic findings at the time of followup including bone-cement radiolucencies, osteolytic lesions, and component subsidence or migration; and (3) the overall survival rate of the revision procedure with a second revision procedure as the endpoint.
We recognize some limitations in this study. First, ours was a select patient population and selection bias may have influenced the outcomes. Second, the size of our cohort is also relatively small particularly when evaluating patients undergoing revision for mechanical failure separately from those who underwent revision for infection. However, the small number of patients reviewed reflects the rarity of these procedures in patients with rheumatoid arthritis but may nonetheless lead to small-sample bias. Despite the small number of patients reported, only two patients were lost to followup of less than 2 years. Third, we did not perform a blinded radiographic analysis. Fourth, our analysis of patients treated for infection was limited owing to the number of deaths (29%) that occurred within 6 months of the revision procedure. Fifth, the primary and revision total knee arthroplasty components were of a heterogeneous population. Finally, the revision procedures performed and the level of surgical complexity were also heterogeneous and comparison to a control population was not possible.
In the cohort of 24 patients (26 knees) treated for mechanical failure of one or more of the prosthetic components, five failures occurred (19%) at a mean of 46 months following revision. The failure rate in our selected series is similar to previously published reports (Table 8) [26, 29]. With regard to patients treated for infection, our failure rate of 25% is also comparable to the results of others (Table 8) [1, 3]. Bongartz et al. questioned whether this high rate of reinfection was actually due to persistent undetectable bacteria , whereas, Berbari et al. demonstrated that a two-staged infection protocol may yield the best survival for patients with rheumatoid arthritis . The high rate of failure observed in patients with rheumatoid arthritis is likely multifactorial as this autoimmune disease can directly affect a patient's bone quality , ligament integrity , and reactivation of joint synovitis can lead to further implant loosening .
When excluding the failures that occurred, the Knee Society knee score and the Knee Society knee function score improved in patients treated for mechanical failure and infection. Improvements in knee scores were overall higher than improvements in knee function scores that may reflect multiple joint involvement associated with rheumatoid arthritis. For patients undergoing revision for mechanical failure, the overall improvement in the Knee Society knee score and the Knee Society knee function score is comparable to the findings of Sheng et al. (Table 8) . Further comparison of our results to other authors was not possible as either a comparable clinical evaluation system was not used or patients with rheumatoid arthritis were not analyzed independently from patients with osteoarthritis [8, 26].
After excluding the patients who either died or failed, nonprogressive tibial radiolucencies were noted in only two patients (two knees). Both patients have been asymptomatic at 76 months and 44 months postoperatively. These patients are closely followed and no further revision procedure has been indicated. Similarly, Sheng et al. also noted radiolucent lines in five of 16 knees; all were less than 1 mm in width and none required subsequent revision . No additional radiographic osteolytic lesions have been identified in the remainder of patients and no component has subsided or migrated.
The overall survival rate following revision total knee arthroplasty in this series of rheumatoid arthritis patients was 77% at 59 months. The survival rate at our institution is comparable to the reports of others (Table 8) [26, 29], but is substantially lower than the reported survival rate of 94% to 97% following revisions performed in patients with osteoarthritis [10, 23, 33].
In conclusion, revision total knee arthroplasty can be a challenging and complex endeavor in patients with advanced rheumatoid arthritis. Revision total knee arthroplasty in these patients carries a substantial risk of morbidity and mortality that is higher than patients with osteoarthritis [2, 31]. One contributing factor may be the use of disease-modifying antirheumatic medications and high-dose corticosteroids leading to an increased risk of adverse long-term outcomes [4, 31]. Our high failure rate following revision total knee arthroplasty for both mechanical issues and infection in patients with rheumatoid arthritis is similar to other studies and emphasizes the potential difficulties in treating these patients.
We thank Rebecca Moore and Patricia Conroy-Smith for their help in maintaining the total joint registry and database at our institution.
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