Low confidence in the cumulative evidence for the existence of a volume-outcome relationship after revision total knee replacement: A systematic review and meta-analysis.
Matthews AH., Stringfellow T., Redman H., Gray WK., Evans JP., Evans JT., Lamb SE., Briggs T., Price A., Toms AD.
PURPOSE: This systematic review and meta-analysis aimed to establish the relationship between the number of procedures a hospital or surgeon performs with outcomes following revision knee replacement (RevKR). METHODS: MEDLINE and Embase were searched using Ovid silver platter up to December 2024 for randomised controlled trials and cohort studies that reported RevKR volumes, in at least two categories, performed by hospitals and surgeons and their relationship to patient and provider level outcomes. The primary outcome was re-revision rate. Secondary outcomes included mortality, post-operative complications, patient-reported outcomes measures (PROMs), emergency readmissions and hospital length of stay. The effect estimates were pooled and plotted using a random-effects, non-linear dose-response meta-analysis (DRMA). Where limitations in the data prohibited DRMA, a narrative approach was utilised. ROBINS-I and the GRADE approach were used to assess the risk of bias and the confidence in the cumulative evidence, respectively. RESULTS: A total of 10 cohort studies with data from 1993 to 2021 were included. The confidence in the cumulative evidence exploring the relationship between surgeon/hospital volume and all outcomes after RevKR was very low. An inconsistent relationship was seen between hospital and surgeon volume and re-revision at any point. There was a non-linear dose-response relationship between higher hospital volume and lower odds of adverse post-operative events (p