Background/Purpose: Utilization
of total knee arthroplasty (TKA) is lower among blacks than whites in the
United States (U.S.), which may be due to blacks’ perception of increased TKA
risk.   Approximately 4% of TKA require revision within five years. The purpose
of this study was to determine whether U.S. blacks are at higher risk for TKA
revision than U.S. whites.

Methods: A systematic review
of English language articles, published during or after 2000, was performed on
March 31, 2015 using Medline via PubMed, the Cochrane register and EMBASE. In
addition, a hand search of unlisted journals that focus on racial disparities
was performed. Study inclusion criteria were (1) U.S. patient population, (2)
TKA as the primary procedure; (3) follow up period at least 2 years; (4)
reporting of revisions rates; (5) analysis of patient race as an independent
predictor of revision. Two reviewers screened titles, abstracts and full text
articles in a standardized manner. Meta-analysis was used to analyze the risk of
revision TKA in blacks compared to whites.

Results: 4286 studies were
identified and screened by title, 106 by abstract and 24 by full text. Six
studies met the inclusion criteria and were qualitatively reviewed (Table 1).
Only 4 of the 6 studies could be meta-analyzed because of overlapping study
populations in 3 of them. The meta-analysis represented 451,960 TKA patients,
of whom 31,568 (7.0%) underwent revision surgery and 28,772 (6.3%) were black.  The
risk of revision TKA was significantly higher among U.S. blacks than U.S. whites
(HR 1.38; 95% CI 1.20-1.59) (Figure 1). Analysis of the 3 studies with
overlapping study populations demonstrated discordant results as a result of
adjustment versus non-adjustment for insurance status (Figure 2).

Conclusion: Blacks in the U.S. are at higher risk for revision TKA
than whites, which may contribute to a perception of increased TKA risk among
blacks.  Socioeconomic status (as represented by insurance status) also
contributes to revision risk and is an important confounder in analyses of
race.