Disparities in Revision Arthroplasty: A Scoping Review of Racial, Sex-Based, and Geographic Domains

Abstract

Purpose of Review

Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) are high-cost procedures that disproportionately burden patients and healthcare systems. While disparities in primary total joint arthroplasty (TJA) are well documented, inequities specific to revision TJA remain less clearly characterized and are inconsistently interpreted. This scoping review synthesizes studies published from January 2019 onward to examine racial, sex-based, and geographic disparities in revision total hip or knee arthroplasty.

Recent Findings

Twenty-six studies met the inclusion criteria. Racial disparities were the most consistently documented, with multiple large database and registry studies demonstrating higher aseptic revision risk following primary TKA among Black patients compared with White patients. These disparities persisted after adjusting for patient, surgeon, and hospital characteristics. In contrast, racial disparities in revision THA were less consistent. Sex-based differences in revision TJA were smaller in magnitude and more heterogeneous, often reflecting biologic and biomechanical variation rather than access-related inequities. Geographic disparities highlighted substantial regional variation in revision TJA utilization and the influence of community-level social determinants of health on revision TJA risk and access.

Summary

Disparities in revision TJA are multifactorial and reflect the interaction of differential revision TJA risk, unequal access to revision TJA care, and cumulative exposure to social determinants of health across the arthroplasty care continuum. Advancing revision TJA equity will require integrating measures of revision TJA risk and revision TJA access, incorporating social vulnerability into risk stratification, and designing policy interventions that address structural determinants of surgical care.

Introduction

Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent high-cost procedures within musculoskeletal care and place a disproportionate burden on patients and healthcare systems. Compared with primary total joint arthroplasty (TJA), revision TJA is associated with higher postoperative complication rates, inferior patient-reported functional outcomes, and substantially greater healthcare expenditures [1–3]. From a systems perspective, revision TJA accounts for a disproportionate share of arthroplasty-related costs despite representing a smaller fraction of total procedures [4, 5]. As the volume of TJA continues to rise due to population aging and expanding indications, the absolute burden of revision surgery is expected to increase, amplifying the importance of understanding and addressing inequities in revision TJA [6, 7].

Disparities in TJA utilization and outcomes across race, sex, and geography have been widely reported in the context of primary TJA [8–11]. However, disparities specific to revision arthroplasty remain less clearly understood and are often interpreted inconsistently across studies, in part due to differences in study design, outcome definitions, and analytic frameworks [12]. Importantly, revision TJA is not a discrete or isolated event but rather the culmination of multiple upstream processes, including access to primary TJA, perioperative medical optimization, implant selection, postoperative rehabilitation, longitudinal surveillance, and timely access to revision surgery when failure occurs [13]. Each of these steps is susceptible to social, structural, and geographic inequities. As a result, observed differences in revision rates may reflect disparities in underlying revision risk, disparities in access to revision care, or a complex interplay of both, complicating the interpretation of revision utilization as a quality or equity metric.

The purpose of this review is to synthesize contemporary evidence since 2019 on disparities in revision TJA across the domains of race, sex, and geography to distinguish revision risk from revision access, identify patterns that are robust across study designs and populations, and highlight actionable targets for future research, policy, and clinical intervention aimed at reducing inequities in revision TJA care.

Materials and Methods

Information Sources and Search Strategy

The review protocol was developed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [14]. A structured literature search was conducted in PubMed, Scopus, Web of Science, and MEDLINE. The search strategy incorporated both Medical Subject Headings (MeSH) and free-text terms such as “total hip arthroplasty”, “total knee arthroplasty”, “revision”, “disparity”, and “inequity”. Boolean operators (AND/OR) were applied to optimize the retrieval of relevant literature. Searches were limited to peer-reviewed studies published from January 1, 2019 to present reflecting contemporary TJA practices, implant technology, and disparities frameworks. The search string used is outlined in the Appendix.

A supplemental manual search was performed with targeted keyword searches using terms such as “revision arthroplasty”, “revision total hip arthroplasty”, “revision total knee arthroplasty”, “sex differences”, “gender differences”, “geographic variation”, and “social determinants of health” to identify relevant studies not indexed under standard disparity-related keywords. Reference lists of included articles were also reviewed to identify additional eligible publications.

Eligibility Criteria

Eligible studies included peer-reviewed publications examining disparities in revision THA or revision TKA across race, ethnicity, sex, or geographic context. Studies were included if they directly evaluated revision TJA as an outcome or provided mechanistic insight into revision risk, utilization, or access to revision care. Eligible study designs encompassed retrospective cohort studies, registry analyses, administrative or claims-based analyses, and systematic reviews.

Exclusion criteria included non-peer-reviewed publications, editorials, letters to the editor, studies not published in English, and studies that did not stratify outcomes by a disparity-related variable of interest. The full eligibility criteria, outlined in Table 1, are based on the Population, Intervention, Comparison, and Outcome (PICO) framework recommended by the Cochrane Library for systematic reviews [15].

Table 1.

Population, Intervention, Comparison, and Outcome (PICO) framework inclusion and exclusion criteria

	Term	Inclusion Criteria	Exclusion Criteria
P	Population	Adult patients undergoing primary or revision THA or TKA; studies stratifying populations by race, ethnicity, sex, or geographic context	Pediatric populations; non-arthroplasty populations; studies not stratifying outcomes by a disparity-related variable
I	Intervention	Exposure to disparity-related factors, including race, ethnicity, sex, geographic location, socioeconomic status, or social determinants of health, in relation to revision arthroplasty	Studies evaluating technical surgical interventions only (e.g., implant design, surgical approach) without analysis of disparity-related factors
C	Comparison	Comparisons between demographic or geographic groups	Studies lacking a comparison group or failing to contrast outcomes across demographic or geographic strata
O	Outcome	Revision arthroplasty outcomes, including revision risk, time to revision, or access to revision care	Studies reporting only primary arthroplasty utilization or short-term perioperative outcomes without revision-related endpoints

Abbreviations: THA total hip arthroplasty, TKA total knee arthroplasty

Study Selection and Data Extraction

Titles and abstracts of identified records were screened for relevance. Full-text review was performed for studies meeting initial screening criteria. From each included study, data were extracted into a Microsoft Excel spreadsheet, including publication year, study design, procedure type (revision or primary THA or TKA), population characteristics, disparity variables examined, analytic approach, and principal findings. Findings were synthesized thematically across disparity domains and organized according to race and ethnicity, sex, and geography.

Results

The literature search identified a total of 141 records across PubMed, Scopus, Web of Science, and MEDLINE. No duplicate records were removed, and 141 unique studies underwent title and abstract screening. Of these, 114 studies were excluded for failing to meet inclusion criteria, most commonly due to lack of revision-specific outcomes or absence of stratification by a disparity-related variable. Full-text review was performed for 27 articles, of which 26 met eligibility criteria and were included in the final synthesis. The study selection process and PRISMA-ScR flow diagram is outlined in Fig. 1.

Fig. 1.

PRISMA-ScR flow diagram outlining study selection process

The characteristics of the included studies are summarized in Table 2, outlining the study author, year, data source, procedure type analyzed, and key findings. The studies are classified into 3 thematic domains: race, sex, and geography.

Table 2.

Study demographics and key findings

Author	Year	Data Source	Procedure Type	Disparity Domain	Key Findings Related to Revision Arthroplasty
Aggarwal et al. [16]	2023	PearlDiver, 2014-2016	THA	Race	Revision rates did not differ by race overall and were significantly lower among Black patients after matching.
Aggarwal et al. [17]	2024	PearlDiver, 2014-2016	TKA	Race	Black patients had higher revision rates pre-matching, but no racial differences in revision arthroplasty persisted after matching.
Alvarez et al. [18]	2022	MEDLINE database, 2002-2022	THA, TKA	Race	Black patients had higher revision risk after THA/TKA, while Hispanic patients showed increased complications and readmissions compared to White patients.
Anil et al. [19]	2025	New York database	THA	Race	Black patients had slightly lower revision risk than White patients, with no long-term differences in cumulative revision rates.
Barry et al. [9]	2023	ACS-NSQIP, 2008-2020	THA, TKA	Race	Minority patients, particularly Black and Hispanic patients, had significantly lower adjusted revision rates.
Bass et al. [20]	2019	Institution database, 2008-2012	TKA	Race	Black patients had higher unadjusted revision risk, but only younger age, male sex, and constrained implants predicted risk after adjustment.
Bass et al. [21]	2021	Multistate database, 2004-2014	TKA	Race	Black patients had higher septic and aseptic revision risk, with greater disparities at high-volume centers.
Benes et al. [22]	2023	REACHnet database, 2014-2020	THA	Race	Nonelective THA, tobacco use, alcohol dependence, and public insurance increased revision or reoperation risk; no racial differences observed.
Bennett et al. [23]	2025	Veterans Affairs medical center, 2014-2020	TKA	Race	Revision TKA patients were more often Black and younger, with higher pain scores and lower total OME prescribed at discharge.
Chen et al. [24]	2021	Multistate database, 2015-2018	THA	Gender	Women had slightly higher revision risk than men, especially under age 55, though absolute differences were minimal.
Dhanjani et al. [25]	2023	National Inpatient Sample, 2006-2014	THA, TKA	Race	Race and income influenced revision type and indication, with minorities and lower-income patients showing distinct, widening revision arthroplasty patterns.
Ferucci et al. [26]	2024	Alaska database, 2015-2018	THA, TKA	Race	Alaska Native/American Indian patients underwent fewer procedures than Whites but were younger, rural, and had longer hospital stays.
Grant et al. [27]	2024	Ontario database, 2015-2020	THA	Gender	Women had higher surgical complications, including revision, within 1 year, while men had more early complications after surgery.
Gu et al. [28]	2020	ACS-NSQIP, 2007-2014	TKA	Gender	Male revision TKA patients had higher postoperative complication risk, while females had increased urinary tract infection risk.
Hilibrand et al. [29]	2020	National Inpatient Sample, 2001-2011	THA, TKA	Geography	Revision arthroplasty rates were nationally stable for TKA and declined for THA but varied over twofold by state.
Hinman et al. [30]	2020	Total Joint Replacement Registry, 2000-2016	TKA	Race	Black patients had higher aseptic revision risk, while Hispanic and Asian patients had lower septic and aseptic revision rates.
Klemt et al. [31]	2020	Institution database, 2010-2017	THA, TKA	Race	Black and Hispanic patients had higher BMI and infection risk, with Black patients showing greater comorbidity and longer stays.
Lewis et al. [32]	2022	International database, 2003-2019	TKA	Gender	Female sex increased fracture-related revision risk, while male sex increased infection-related revision risk.
Lizcano et al. [33]	2025	Institution database, 2017-2023	THA	Geography	Higher social vulnerability was associated with increased aseptic loosening revisions, reoperations, complications, and mortality.
Markel et al. [34]	2022	Michigan database, 2012-2018	THA	Gender	Women, especially younger patients, had the highest revision rates, with fractures early and aseptic loosening predominating later.
Mehta et al. [35]	2025	Pennsylvania database, 2012-2018	THA	Geography	One-year revision risk was modestly predictable, driven primarily by community factors, discharge location, and comorbidities.
Mirza et al. [36]	2023	New York database, 2006-2016	TKA	Race	Black patients had higher aseptic revision odds, with greatest disparities at high-volume surgeons and hospitals.
Paisner et al. [37]	2022	American Joint Replacement Registry, 2012-2020	TKA	Race	Black patients had the highest revision risk, while Asian, White, and Hispanic patients had lower revision rates.
Ramirez et al. [38]	2022	New York database, 2008-2016	THA, TKA	Geography	Centralizing care minimally increased travel overall but disproportionately burdened Hispanic, low-income, and rural patients.
Roche et al. [39]	2019	PearlDiver, 2007-2014	TKA	Race	Revision incidence was highest among Black patients and lowest among Asians, with mechanical complications the leading cause across groups.
Stronach et al. [40]	2022	Center for Medicare and Medicaid Service, 2019-2020	THA, TKA	Race	Arthroplasty utilization, including revisions, declined during COVID-19, with disproportionately larger reductions among Hispanic and non-White patients.

Abbreviations: ACS-NSQIP American College of Surgeons National Surgical Quality Improvement Program, BMI body mass index, OME oral morphine equivalents, THA total hip arthroplasty, TKA total knee arthroplasty

Racial Disparities in Revision Arthroplasty

Racial disparities represented the most consistently documented inequities in revision TJA, particularly following TKA. Across multiple large databases and registry studies, Black patients experienced higher revision risk after primary TKA compared with White patients, even after adjusting for age, medical comorbidities, and payer status [18, 21, 30, 36, 37, 39]. Analyses that distinguish septic from aseptic revision provide critical insight into the mechanisms underlying these disparities. In a multistate cohort encompassing more than 700,000 primary TKAs, Black patients had significantly higher risks of both septic (hazard ratio [HR] 1.11; 95% confidence interval [CI] 1.03-1.20) and aseptic revision TKA (HR 1.39; 95% CI 1.33-1.46) compared to White patients, with the strongest and most consistent association observed for aseptic failure at very-high-volume hospitals with ≥645 TKAs annually (HR 1.68; 95% CI 1.48-1.90) [21]. Similar findings were observed in matched cohort analyses demonstrating higher odds of early aseptic revision among Black patients regardless of surgeon experience or hospital volume (odds ratio [OR] 1.32; 95% CI 1.12-1.54) [36], as well as in national registry data showing the highest revision TKA rates among Black patients compared to White, Asian, and Hispanic-White patients (p< 0.001) [37].

Claims-based analyses further reinforce this pattern. In a large private-payer database, revision TJA incidence was highest among Black patients and lowest among Asian patients, with mechanical complications representing the most common cause of revision across racial groups (p< 0.001) [39]. These findings suggest that racial disparities in revision TJA extend beyond infection-related processes and imply mechanical, biologic, or care-delivery factors influencing the need for revision surgery.

Several studies have demonstrated that socioeconomic context modifies the relationship between race and revision risk. Institutional analyses showed that Black patients had higher revision rates after TKA than White patients (HR 1.69; 95% CI 1.01-2.81), but that low surgeon volume, younger age, male sex, and implant constraint were stronger predictors after multivariable adjustment [20]. National inpatient analyses similarly demonstrated that race and income jointly influence both revision risk and revision indication, with minority and lower-income patients more likely to undergo revision TKA and THA (p< 0.001) [25]. Additionally, matched cohort studies reported attenuation of racial disparities in revision risk after adjusting for comorbidities and access-related factors. In a retrospective matched analysis of TKA, unadjusted racial differences in revision risk were no longer significant after matching for patient characteristics and insurance status [17].

In contrast to TKA, racial disparities in revision following THA appear less consistent. Some cohort studies demonstrated higher short-term complications among Black patients after THA but no long-term difference in cumulative revision risk up to 10 years postoperatively [19], while others reported comparable or slightly lower adjusted revision rates among Black patients (OR 0.73; 95% CI 0.56-0.94) compared to White patients [9, 16]. Institutional and regional cohort studies showed no independent association between race and revision risk after primary THA, while factors such as alcohol dependence (OR 2.46; 95% CI 1.45-4.15), tobacco use (OR 1.36; 95% CI 1.04-1.78), and publicly insured patients (OR 2.08; 95% CI 1.18-3.70) increased the likelihood of revision THA [22]. An Alaskan database study showed that Alaska Native/American Indian patients were less likely to undergo primary and revision THA (rate ratio [RR] 0.69; 95% CI 0.55-0.85) compared to White patients [26]. A comprehensive systematic review demonstrated substantially lower utilization of primary THA among Black, Hispanic, and Asian patients (p< 0.05), with higher risks of postoperative complications, readmissions, and revision compared to White patients (p< 0.05), patterns largely attributed to differences in patient expectations, worse preoperative functional status, and unequal access to high-quality surgical care [18].

Beyond revision risk alone, race influences both the indications for revision and the clinical profile of patients presenting for revision TJA. In universally insured populations, Black patients continued to experience a higher aseptic revision risk after TKA compared to White patients (HR 1.61; 95% CI 1.42-1.83), indicating that disparities persisted even when insurance coverage was equalized [30]. Among patients undergoing revision TJA, minority race and ethnicity were associated with higher postoperative complication rates, greater comorbidity burden, and longer lengths of stay (p< 0.05), reflecting potentially increased clinical complexity prior to and at the time of revision [31]. Even within equal-access systems such as the Veterans Affairs healthcare system, patients undergoing revision TKA were more frequently Black (p= 0.05) and reported lower opioid prescribing (p< 0.01) despite higher postoperative pain scores (p< 0.01), highlighting persistent differences in perioperative care delivery [23]. Temporal analyses further demonstrated the fragility of racial equity in revision TJA, as arthroplasty utilization, including revision procedures, declined disproportionately among Black (-11.8%; p< 0.001) and Hispanic (-19.4%; p< 0.001) patients compared to White patients during the COVID-19 pandemic, widening preexisting disparities in access to surgical care [40].

Sex Disparities in Revision Arthroplasty

Sex-based differences in revision TJA outcomes demonstrate distinct patterns that differ in magnitude and underlying mechanism from racial disparities. Large administrative and registry-based analyses indicate that women may experience a modestly higher early revision risk following THA. In a multistate cohort of more than 130,000 primary THAs, women had a slightly higher adjusted risk of revision within 2 years compared to men (HR 1.16; 95% CI 1.07-1.26), with the strongest association observed among patients younger than 55 years (HR 1.47; 95% CI 1.20-1.81) [24]. Although absolute differences in revision risk were small, these findings suggest that sex-specific factors, such as differences in bone quality, hip anatomy, or implant biomechanics, may influence early failure patterns after THA.

Registry analyses further support sex-based differences in the timing and causes of revision TJA. A Michigan statewide quality registry study demonstrated that women, particularly women younger than 65 years, had higher early revision rates after primary THA, most commonly for periprosthetic fracture and instability, whereas men were more frequently revised for infection and aseptic loosening (p< 0.001) [34]. Comparably, an international registry study spanning Australia, Sweden, and the United States found that women were more likely to undergo revision TKA for fracture-related indications (OR 3.2; 95% CI 2.2-4.8), while men exhibited higher rates of revision for infection (OR 1.9; 95% CI 1.7-2.0), highlighting sex-specific revision mechanisms rather than uniform differences in overall revision incidence [32].

Sex-based disparities appear more pronounced when examining complication profiles and perioperative trajectories rather than revision risk alone. In a population-based cohort study in Ontario, women undergoing primary THA experienced higher rates of major surgical complications, including revision, within 1 year postoperatively (2.9% versus 2.5%; p< 0.001), whereas men had higher rates of medical complications within 30 days (6.3% versus 2.7%, p< 0.001) [27]. In the revision TKA setting, a retrospective cohort study reported that men experienced higher rates of overall postoperative complications, whereas women demonstrated increased rates of urinary tract infection within 30 days of revision surgery [28].

Collectively, these findings indicate that sex-based variation in revision TJA is more likely driven by biologic and biomechanical differences than by inequities in access to care. While smaller in magnitude and less consistent than racial disparities, these differences remain clinically meaningful and most often manifest through variation in revision TJA indications, complication profiles, and perioperative risk pathways.

Geographic Disparities in Revision Arthroplasty

Geographic disparities in revision TJA reflect broader system-level and place-based influences, frequently operating through social determinants of health (SDOH), including healthcare resource distribution, referral networks, travel burden, and access to specialized surgical care. National analyses demonstrate substantial geographic variation in both primary and revision arthroplasty utilization across the United States [29, 33, 35]. A study utilizing the National Inpatient Sample reported more than twofold variation in revision THA and TKA rates across states (p< 0.001), with discordance between primary and revision volumes in some regions [29]. Thus, regional differences in referral patterns, practice norms, and healthcare infrastructure may influence utilization independent of underlying disease burden.

Beyond regional variation, neighborhood-level SDOH play a critical role in shaping revision TJA outcomes. In an institutional cohort study of aseptic revision THA, a higher Area Deprivation Index and Social Vulnerability Index were independently associated with increased rates of reoperation (p< 0.05), 90-day postoperative complications (OR 1.66; p< 0.05), and mortality (OR 2.13; p< 0.05) [33]. Similarly, a Pennsylvania-based retrospective cohort study found that community-level SDOH measures, including zip code neighborhood deprivation and discharge location, explained more variation in 1-year revision risk after primary THA than patient race alone [35]. Geographic context, therefore, captures structural factors not fully reflected by individual-level demographic variables.

Policy-oriented analyses further illustrate the equity implications of healthcare system design. Using statewide administrative data from New York, Ramirez et al. (2022) modeled the effects of hypothetical centralization of revision THA and TKA to higher-volume hospitals. While only around 1% of patients experienced meaningful increases in travel burden, the centralization disproportionately affected rural (OR 98; 95% CI 49.6-192.2), low-income (OR 69.5; 95% CI 17.0-283), and Hispanic populations (OR 12.3; 95% CI 5.04-30.2) [38]. Thus, efficiency-driven policies may inadvertently exacerbate geographic disparities in revision arthroplasty.

Discussion

This review demonstrates that disparities in revision TJA are not uniform across procedures or populations, but instead reflect the interaction of differential revision TJA risk, unequal access to revision TJA care, and broader SDOH. Rather than representing isolated surgical events, revision disparities appear to arise from inequities that accumulate across the TJA care continuum.

Among the domains examined, racial disparities in aseptic revision following TKA emerged as the most consistent and clinically salient finding [21, 25, 36, 37, 39]. The reproducibility of this association across diverse datasets suggests that it is unlikely to be explained by residual confounding alone. Importantly, the predominance of aseptic rather than septic revision shifts attention away from infection-related mechanisms and toward factors influencing implant survivorship, biomechanics, long-term functional loading, and postoperative care [21, 36]. The consistent racial disparities in revision TKA are not observed in revision THA, underscoring the procedure-specific nature of revision inequities and suggesting that mechanisms driving disparity differ between joints [16, 19].

Recent studies further demonstrate that surgeon- and hospital-level characteristics do not fully account for observed racial disparities. Even after controlling for surgeon experience, volume, and training, Black patients remained at elevated risk for early aseptic revision following TKA [36]. Registry-based analyses similarly showed persistent disparities after adjusting for hospital characteristics and implant features [21, 37]. These findings challenge explanations that attribute inequities to individual surgeon technical skill and instead point toward downstream factors, such as implant selection, postoperative rehabilitation, and longitudinal surveillance, operating within care environments shaped by structural inequities.

Importantly, disparities in revision TJA cannot be interpreted through revision risk alone. Observed revision rates reflect both the likelihood of implant failure and the probability that a patient undergoes revision surgery once failure occurs. In populations with reduced access to surgery, constrained referral pathways, or substantial travel and resource barriers, lower revision utilization may mask higher underlying failure risk [16, 29, 38]. This distinction between revision risk and revision access helps reconcile apparent inconsistencies in the literature and is particularly evident in studies demonstrating lower utilization of both primary and revision TJA among minority populations during periods of system stress, such as the COVID-19 pandemic [40].

An increasingly consistent theme across studies is the central role of SDOH in shaping revision outcomes. Community-level measures of social vulnerability and neighborhood deprivation independently predicted adverse revision outcomes and, in some analyses, explained more variation than patient race alone [33, 35]. This does not diminish the relevance of race. Rather, it reinforces race as a marker of cumulative structural exposure that intersects with socioeconomic and environmental disadvantage [25, 35].

Sex-based patterns in revision TJA differ from racial disparities. Compared to race, sex-based variation in revision TJA risk and outcomes is smaller in magnitude and less consistent, and more often reflects biologic and biomechanical differences rather than inequities in access to care [24, 32, 34]. Differences in revision indication and complication profiles, particularly among younger patients, highlight the importance of incorporating sex-specific factors into risk stratification without overinterpreting these differences as access-related disparities [27, 28].

From a policy perspective, system redesign efforts must be evaluated through an equity lens. Although centralization of revision TJA care to high-volume centers may improve outcomes overall, modeling studies suggest that such policies may disproportionately burden rural, low-income, and Hispanic populations through increased travel distance and time [38]. Similarly, the COVID-19 pandemic disproportionately reduced utilization of TJA care among minority populations, underscoring the fragility of equity in access-dependent surgical services [40].

Several limitations of the existing literature warrant acknowledgment. First, many included studies rely on administrative claims or registry data, which lack granularity regarding implant positioning, alignment, fixation technique, bone quality, and rehabilitation intensity, which are all factors directly relevant to aseptic revision risk. Second, important social and contextual variables, including patient expectations, health literacy, transportation access, and informal caregiving support, are inconsistently captured, limiting the ability to fully disentangle biologic risk from structural determinants of health. Third, definitions of revision vary across datasets, with some studies capturing only inpatient or early revisions, while others include longer-term or outpatient revisions, complicating direct comparison across cohorts. Follow-up duration is similarly heterogeneous, which may differentially affect the detection of early versus late failure mechanisms. Finally, residual confounding remains possible despite multivariable adjustment, particularly for unmeasured socioeconomic and care-delivery factors. Nevertheless, the convergence of findings across diverse data sources, study designs, and populations strengthens confidence in the central conclusions of this review.

Future research should distinguish septic from aseptic TJA revision pathways, incorporate measures of revision TJA access alongside revision risk, and prioritize longitudinal designs linking primary TJA to revision TJA outcomes.

Conclusions

Disparities in revision TJA reflect the cumulative effects of differential revision risk, unequal access to care, and broader SDOH rather than isolated differences at the time of revision TJA surgery. Racial disparities in aseptic revision following TKA emerge as the most consistent and clinically meaningful finding, while sex-based differences largely reflect biologic and biomechanical variation. Geographic disparities highlight the importance of access and neighborhood context. Together, these findings underscore the need to reframe revision TJA as a longitudinal equity issue spanning the full continuum of care. Addressing disparities will require integrated strategies that extend beyond surgical technique to include equitable access to primary TJA, rehabilitation, follow-up, and revision TJA care, supported by policy and research approaches that prioritize SDOH.

Key References

• Bass AR, Do HT, Mehta B, Lyman S, Mirza SZ, Parks M, et al. Assessment of Racial Disparities in the Risks of Septic and Aseptic Revision Total Knee Replacements. JAMA Netw Open. 2021;4(7):e2117581. doi: 10.1001/jamanetworkopen.2021.17581.

  • ○ This large multistate cohort study demonstrated a significantly higher aseptic revision TKA risk among Black patients after primary TKA, providing foundational evidence of persistent racial disparities in revision TKA.
• Chen A, Paxton L, Zheng X, Peat R, Mao J, Liebeskind A, et al. Association of Sex With Risk of 2-Year Revision Among Patients Undergoing Total Hip Arthroplasty. JAMA Netw Open. 2021;4(6):e2110687. doi: 10.1001/jamanetworkopen.2021.10687.

  • ○ This multistate cohort analysis identified significantly increased revision THA risk following primary THA for women compared to men, suggesting biologic and biomechanical contributors to revision THA outcomes.
• Ramirez G, Myers TG, Thirukumaran CP, Ricciardi BF. Does Hypothetical Centralization of Revision THA and TKA Exacerbate Existing Geographic or Demographic Disparities in Access to Care by Increased Patient Travel Distances or Times? A Large-database Study. Clin Orthop Relat Res. 2022;480(6):1033-45. doi: 10.1097/CORR.0000000000002072.

  • ○ This modeling study demonstrated that centralization of revision TJA care may disproportionately increase travel burden for rural, socioeconomically disadvantaged, and Hispanic populations, underscoring structural geographic disparities.

Abbreviations

ACS-NSQIP

American College of Surgeons National Surgical Quality Improvement Program

BMI

Body mass index

CI

Confidence interval

HR

Hazard ratio

MeSH

Medical Subject Headings

OME

Oral morphine equivalents

OR

Odds ratio

PICO

Population, Intervention, Comparison, and Outcome

PRISMA-ScR

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

SDOH

Social determinants of health

THA

Total hip arthroplasty

TJA

Total joint arthroplasty

TKA

Total knee arthroplasty

Appendix

Search String.

((“Arthroplasty, Replacement, Hip“[MeSH] OR “Arthroplasty, Replacement, Knee“[MeSH] OR “total hip arthroplasty” OR “total knee arthroplasty” OR THA OR TKA OR “revision arthroplasty” OR “revision hip” OR “revision knee”) AND (revision OR reoperation OR rerevision) AND (disparity OR disparities OR inequity OR inequities OR inequalities OR inequality OR “Healthcare Disparities“[MeSH])) AND (“2019/01/01“[Date - Publication] : “3000“[Date - Publication])

Author contributions

J.H. conceptualized and designed the study framework, conducted the literature review, synthesized the data, wrote the manuscript text, and prepared all figures and tables. A.F.C. conceived the original project idea, provided critical revisions to the manuscript text, and supervised the project. All authors reviewed the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors. Informed consent was not required for this study because it involved only analysis of previously published de-identified data.

Institutional review board statement

This study was a scoping review of publicly available, published literature and did not involve human subjects or identifiable patient data. Therefore, institutional review board approval was not required.

Competing interests

The authors declare no competing interests.