Purpose The relationship between remoteness of patient residence and post-surgical outcomes, such as early implant revision, has yet to be examined. The aim of this study was to assess whether the incidence of all-cause revision at up to 2 years following primary hip or knee total joint arthroplasty varies with the remoteness of a person’s place of residence at the time of the primary procedure.

Methods An analysis was performed of data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 1 Sept 1999 to 31 Dec 2022. The Modified Monash Model (2015) of remoteness classification was used to categorise patient residence and hospital location into metro-regional (MM 1-2) and rural-remote (MM 3-7). All-cause revision within the two-year period after surgery for primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) for osteoarthritis as the primary diagnosis was selected as the primary outcome. A directed-acyclic graph approach was used to prioritise covariates for inclusion in a Cox proportional hazards regression model. Cumulative percent revision (CPR) rates with 95% confidence intervals was reported with hazard ratios between subgroups of residential and hospital remoteness.

Results The two-year CPR for primary TKA ranged from 1.8% (95% CI 1.7 - 1.9) to 2.2% (95% CI 1.8 - 2.7). Patients residing in rural-remote areas who travelled to a metro-regional hospital displayed a significantly higher rate of revision following TKA compared to patients that were treated at a rural-remote hospital (HR: 1.11, 95% CI 1.05 - 1.18, P = 0.001) within two-year follow-up of the primary procedure. Patients residing in rural-remote areas that stayed in these areas for their operation displayed a significantly reduced revision rate compared to metro-regional patients that stayed in-area for their joint replacement (HR=0.90, 95%CI 0.85 - 0.95, P <0.001). Infection was the dominant reason for TKA revision for patients in the follow-up period. No discernible differences in revision risk were observed between patient and hospital combinations for primary total hip replacement.

Conclusions Travel distance, but not remoteness of a patient’s place of residence may be associated with cumulative risk of early revision (within 2 years) of primary TKA, particularly in regional/remote patients travelling out of area, but not for patients undergoing THA. Further work linking service utilisation prior to a revision procedure is required to clarify whether differences in revision between remoteness and travel distances are due to variability in the clinical threshold for offering revision arthroplasty between regional and metropolitan surgeons or improved outcomes of the primary procedure.

The authors have declared no competing interest.

CS was engaged by MB to contribute to the project. No external funding was received for the preparation of the analysis or the manuscript.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Data for this study was requested from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The AOANJRR is funded by the Commonwealth Government of Australia and provides non-identifying data on request to surgeons and academic institutions to be used for research and the preparation of publications and conference presentations. The AOANJRR uses the 'opt off' approach to patient consent i.e. patients are automatically enrolled in the national registry unless they choose to 'opt off'. This method is employed by the AOANJRR for two reasons: 1) No direct patient contact is required, and 2) The large number of joint replacements undertaken in Australia.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

All data produced in the present study are available upon reasonable request to the authors.