the revision knee: issues that matter the ......the risk factors for revision surgery patient...

VOL. 98-B, No. 1, JANUARY 2016 105

THE REVISION KNEE: ISSUES THAT MATTER

The epidemiology of failure in total knee arthroplastyAVOIDING YOUR NEXT REVISION

M. Khan,K. Osman,G. Green,F. S. Haddad

From University College London Hospitals, London, United Kingdom

M. Khan, BSc MBBS MRCS, Clinical Research Fellow, Orthopaedic Department F. S. Haddad, BSc MD (Res), FRCS (Tr&Orth), Professor of Orthopaedic SurgeryUniversity College London Hospitals, Ground Floor, 250 Euston Road, London, NW1 2PG, UK.

K. Osman, Clinical Research Fellow, Orthopaedic Department G. Green, Clinical Research Fellow, Orthopaedic DepartmentUniversity College London Hospitals, Ground Floor, 250 Euston Road, London, NW1 2PG, UK.

Correspondence should be sent to Mr M Khan; e-mail: [email protected]

©2016 The British Editorial Society of Bone & Joint Surgerydoi:10.1302/0301-620X.98B1. 36293 $2.00

Bone Joint J 2016;98-B(1 Suppl A):105–12.

Total knee arthroplasty (TKA) is a cost effective and extremely successful operation. As longevity increases, the demand for primary TKA will continue to rise. The success and survivorship of TKAs are dependent on the demographics of the patient, surgical technique and implant-related factors.

Currently the risk of failure of a TKA requiring revision surgery ten years post-operatively is 5%.

The most common indications for revision include aseptic loosening (29.8%), infection (14.8%), and pain (9.5%). Revision surgery poses considerable clinical burdens on patients and financial burdens on healthcare systems.

We present a current concepts review on the epidemiology of failed TKAs using data from worldwide National Joint Registries.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):105–12.

Total knee arthroplasty (TKA) is a cost effec-tive and successful operation for patients withend-stage arthritis of the knee.1,2 In the UnitedStates, the demand for TKA is projected to riseby 673% to 3.48 million procedures by 2030,and revision TKA by 601%.3 Furthermore, thedemand for TKA among patients aged < 65years is predicted to be > 50% of the TKAswhich are performed by 2016.3 An ageing pop-ulation, a rising prevalence of risk factors suchas obesity, and the necessity to maintain activelifestyles will continue to feed this trend indeveloped countries.3,4 A consequential rise infailed TKAs is inevitable, and they present asignificant financial and health-related burdento patients and healthcare systems.5

We present a current concepts review on theepidemiology of failed TKAs using data fromworldwide National Joint Registries (NJRs).

Defining knee arthroplasty failureRevision surgery remains the benchmark out-come by which survival of orthopaedicimplants is assessed.6 However, using revisionsurgery as the sole endpoint underestimates thevolume of patients with pain or poor functionfollowing the primary procedure, and who donot qualify for revision surgery. Price et al6

highlighted this problem in a long-term reviewof 60 TKAs undertaken in 53 patients with pri-mary osteoarthritis, aged < 60 years at the timeof surgery, between 1987 and 1993. Theyreported a minimal 12-year cumulative survival

of 82.2% using revision as an end point. Thisdecreased dramatically to 59% if moderate orsevere pain was included as an end point.

The rate of poor outcome following primaryTKA ranges from 7% to 20% due to pain,stiffness, and poor function despite theabsence of a discernible objective reason forrevision.7-14 The use of different outcomemeasures substantially alters the proportionof TKAs which are deemed successful: 90-daymortality after TKA is 0.4%,15 3.8% ofpatients will undergo a non-revision re-oper-ation within four years,16 5.6% of patientshave worse Patient Reported Outcome Meas-ures (PROMs) six months post-operatively,17

or a Knee Society Score (KSS) of < 70.18 PROMs are becoming popular in the assess-

ment of satisfaction and health-gain post-operatively. Data from the Health and SocialCare Information Centre (HSCIC) Englandshow high post-operative PROM scores in theEQ-5D Index (82.1%), EQ-VAS (57.2%), andOxford Knee Score (94.4%) for 2014 to 2015following TKA, confirming the success of theoperation.19

NJRs provide a wealth of community-basedcomparative data including patient character-istics, implant factors, and surgical techniques.They highlight trends in the variation of out-comes whilst remaining sensitive to the impactof changing practice and allowing the identifi-cation of best practice.20 There is mountingrecognition that registries are an excellent

106 M. KHAN, K. OSMAN, G. GREEN, F. S. HADDAD

CCJR SUPPLEMENT TO THE BONE & JOINT JOURNAL

adjunct to randomised controlled trials in determining thesafety and effectiveness of different interventions in a timelyand cost effective manner.21-23 The Swedish Knee replace-ment project was established in 1975 and was the first NJRof its kind.24,25 With surgical advancement, the focus of theregistry shifted from evaluating short-term complicationsof TKA to time to first revision. There are currently 11NJRs worldwide which all use time to first revision as theprimary endpoint.20 Presently, no other benchmark existsfor the assessment of clinical outcome. Furthermore, mon-itoring revision rates permits the identification of factorsinfluencing the outcome.

Indications for revision More than 76 000 TKAs are performed annually in theUnited Kingdom and risk of revision following primaryTKA for osteoarthritis (OA) ten years post-operatively is< 5%.26 This figure is consistent across a number of

registries including 4% in Sweden, 5% in New Zealand,and 6.8% in Australia.26-30 Pooled data from registriesworldwide identifies that the most common indication forrevision surgery is aseptic loosening (29.8%), followed byinfection (14.8%) and pain (9.5%) (Table I).31-34 Infectionand pain as indications for revision have increased com-pared with aseptic loosening which has fallen since theNJRs first began (Fig. 1).27 The American Joint Replace-ment Registry (AJRR) highlights the fact that 68% ofpatients who underwent revision TKA between 2012 and2013 did so within three months of the initial procedure.30

Patellofemoral pain, instability, and stiffness comprise theother main indications for revision surgery.

Large non-registry cohort studies echo similar findingswith aseptic loosening and infection being the most com-mon indication for revision TKA (Table II).35-46 Studiespublished from 2010 onwards clearly demonstrate thatinfection is the most common indication for revision withintwo years of the primary procedure, and aseptic looseningis the most common indication for late revision.36,38,40-43

This trend has also been observed in NJRs.26-30 Polyethyl-ene wear and its sequelae of osteolysis and late instabilityare now uncommon. However, this was the dominant indi-cation for revision in studies published prior to 2006,accounting for almost 25% of all revisions (Table II).35,44-47

Advancement in surgical techniques, tribology and poly-ethylene manufacturing (gamma sterilisation in inert envi-ronments and the use of highly cross-linked polyethylene)may have contributed to fewer polyethylene- and implant-related failures.37 Fehring et al46 concluded that the totalnumber of early revision TKAs and the overall rate of revi-sion could be reduced by 40% and 25%, respectively, if allTKAs were routinely cemented with careful balancing ofthe ligaments.

Pain, instability, and stiffness are more likely to bereported now as causes of failure after TKA in NJRs26-29

and retrospective studies undertaken in the US,36,37,40,41 incontrast to multicentre studies from Korea and Japan.38,39

This observation may be partially explained by the fact thatEuropean NJRs and data series from the United Stateswould include operations on a much younger cohort of

Table I. Variation trends for the indication of revision TKA for the most commonly referred to National Joint Registries (NJR)

NJR England, Wales, and Northern Ireland

Swedish knee arthroplasty register

Australian orthopaedic association NJR New Zealand NJR American NJR

1st annualreport 200432 (%)

11th annual report 201426(%)

1stannual report 199933(%)

13th annual report 201429 (%)

1st annual report 200034(%)

14thannual report 2014 (%)

1st annual report 199928(%)

15th annual report 201328(%)

1st annual report 201330

(< 3 monthsto revision)

Aseptic loosening

41.4 32.0 43.6 26.0 40.3 32.7 0 34.6 N/a

Deepinfection

18.4 22.0 11.2 22.0 9.1 17.4 50 27.4 45.7

Pain 23.0 15.0 n/a n/a 2.6 9.6 0 29.3 n/a

TKA, total knee arthroplasty

5%

4%

3%

2%

1%

0%

Cu

mu

lati

ve in

cid

ence

0 1 2 3 4 5 6 7 8 9 10 11 12 13Years since primary procedure

Loosening/lysisInfectionPatellofemoral painPainInstability

Fig. 1

Graph showing the cumulative incidence of the indication for revisionof primary total knee arthroplasty. (Reproduced from Australian Ortho-paedic Association NJR: Annual Report 2014).

THE EPIDEMIOLOGY OF FAILURE IN TOTAL KNEE ARTHROPLASTY 107

VOL. 98-B, No. 1, JANUARY 2016

patients. Such patients are more physically active withhigher demands and expectations, therefore placing greaterstrain through the prostheses leading to earlier failure.Operating on younger patients highlights the importance ofmeticulous ligament balancing.

The risk factors for revision surgeryPatient factors. The age and gender of the patient are majorfactors affecting the outcome of primary TKA. All registriesconcur that the rate of revision increases with decreasingage.26-29,48 In Sweden, patients aged < 65 years have twicethe risk of revision compared with those aged > 75 years,regardless of diagnosis or the type of implant.29 In Aus-tralia, four years post-operatively, patients with osteo-arthritis aged < 55 years have > 4.5 times the risk of revision

than do those aged > 75 years.27 Men have higher rates ofrevision than women (Fig. 2).26-29,38 In England, Wales, andNorthern Ireland, the Cumulative Risk of Revision (CRR)in men aged > 75 years is 2% ten years post-operatively,whereas in those aged < 55 years it is 12%.26 A large multi-centre study reported similar findings: for every ten years ofincreasing age, the overall risk of failure of TKA decreasedby 60% (OR 0.41; 95% confidence interval (CI) 0.37 to0.49).38 It is therefore imperative that younger patients arefully informed of the increased risk of revision by referenc-ing registry data, especially as the demand for TKA inyounger patients rises (Fig. 3). The reasons for this demandinclude higher patient expectations and an increased inci-dence of degenerative joint disease resulting from the obe-sity pandemic.49,50

Table II. Indications for revision surgery over the last decade from retrospective cohort studies

StudyStudy Design

No. of revisionTKAs

Male / female (No. of patients)

Mean age at RKA(yrs)

Years of operations

Meanfollow-up times

Mean time to revision

Ratio of early*/ late† revision

Causes of revision knee procedure

Sharkey et al, 201435

USSinglecentre RR

781 291 / 453 Male: 65.4 (37 to 96): Female: 65.1 (34 to 96)

2003 to 2012 NA 0.84* (1day to 1.97 yrs) 6.9†

(2 to 30.36)

37.6% / 62.4% Aseptic loosening 39.9% Infection 27.4% Instability 7.5% Fracture 4.7% Arthrofi-brosis 4.5% PE wear: 3.5%

Le et al, 201437 US

Singlecentre RR

253 103 / 143 64 2001 to 2011 N/a 35 mths (9 to 51) 46% / 54% Infection 24%*, 25%† Insta-bility 26%*, 18%† Stiffness 18%*, 14%† PE wear 2%*, 9%†

Koh et al, 201438 Korea

Multicentre RR

634 NA NA 2008 to 2012 5 yrs 76.5 mths (1 to 312) 27% / 73% Infection 38% Aseptic Loos-ening 33% Wear 13% Insta-bility 7% Stiffness 3%

Kasahara et al, 201339 Japan

Multicentre RR

140 27 / 113 72.9 (71.5 to 74.3)

2006 to 2011 35 months(12 to 132)

73 mth (2 to 420) NA Aseptic loosening 40% Infection 24% Wear 9% Instability 9% Implantfailure: 6% Fracture: 4%

Dalury et al, 201340 US

Multi centre RR

820 283 / 410 69 (24 to 94) 2000 to 2011 NA 6 yrs (0.1 to 26) 49% / 51%‡ Aseptic loosening 23.1% Infection 18.4% PE wear 18.1% Instability 17.7% Pain/stiffness 9.3% Osteolysis 4.5%

Schroer et al, 201341

USMulti centre RR

844 313 / 531 65 2010 to 2011 NA 5.9 yrs (10 days to31 yrs)

35.3% / 64.7% Aseptic Loosening 31.2% Instability 18.7% Infection 16.2% PE Wear 10% Arthrofibrosis 7%

Haasper et al47 Germany

SingleCentre RR

150 NA NA 2009 NA 55 mths (0.5 to 125 mths)

NA Aseptic loosening 30.7% Instability 24.7% Stiffness 17.3% Component malposition 6%

Bozic et al, 201042 US

Nationwide Inpatient Sample RR

60 355 25 711 / 34 644

65.8 2005 to 2006 NA NA NA Infection 25.2% Aseptic loosening 16.1% Implant failure 9.7%

Hossain et al, 201043

UKSingle centre RR

349 204 / 139 67.8 (32 to94)

1999 to 2008 57.7 mths 84.3 mths (1 to 167) 32% / 68% Infection 35.7% Aseptic loosening 14.9% PE wear 12.3% Conversion from UKA 8.3%

Mulhall et al, 200644 US

Multicentre PCS 318

318 NA 68.7 (34 to 85) NA 1 yr 7.9 yrs (0.5 to 27 yrs) 69% / 31% Osteolysis: 59.4% Aseptic loosening: 41.3% Instability 28.9% PE Wear: 24.9% Failed PE insert 18.1% Infec-tion 10.4%

Sheng et al 200445 MA on 33 studies & 1356 patients

NA 429 / 611 67 (45 to 90) 1990 to 2002 57 mths(6 to 108)

N/A N/A Aseptic loosening 55%PE wear 11% Instability 10% Disease progression 4%

Sharkey et al, 200235

USSingle centre RR

212 75 / 128 Male: 68.7 (31.6 to 88.7) Female: 68.4 (36.1 to 96.9)

1997 to 2000 NA 1.1* (9 days to 2 yrs)7† (2.2 to 28)

55.6% / 42.4% PE wear: 25% Loosening: 24.1% Instability: 21.2% Infection: 17.5% Arthrofibrosis: 14.6%Malposition: 11.8%

Fehring et al, 200146 US

Singlecentre RR

440 1986 to 1999 5 years 19 months 63% within 5 years of index procedure

Infection: 38% Instability: 27% Failure of ingrowth (cementless fixation) 13% Patellofemoral problems 8% PE wear 7%

* Early revision (< 2 years post primary total knee arthroplasty)† Late revision (> 2 years post primary total knee arthroplasty) ‡ Defined early revision < 5 years post index procedureRR, Retrospective review, PCS: prospective cohort study, MA: meta-analysis, NA: not available; US, United States, UK, United Kingdom



Patients with rheumatoid arthritis who undergo TKAhave the highest rate of revision secondary to infection,especially in men.29,51,52 However, with improved medicalmanagement the number of rheumatoid patients requiringTKA has fallen dramatically.29 Surgical technique. The year of primary operation affectsthe likelihood of revision. The cumulative percentage prob-ability of a revision being undertaken increases slightly foreach operative year between 2003 and 2007.26 Thus, therisk of revision five years post-operatively for patients whounderwent TKA in 2008 was 3% compared with 1.7% forthose whose operation was undertaken in 2003 (Fig. 4).26

This variation may reflect incomplete data in the NJR until

about 2007/8. The Swedish Knee Arthroplasty Register(SKAR) has captured a large range of data over a muchgreater period and illustrates the reducing risk for revisionover time (Fig. 5).

When considering all knee procedures, partial arthro-plasties account for between 7% and 9%, primary TKAsfor between 83% and 88%, and revision TKAs for between5% and 8%.26-29 Partial arthroplasty including unicom-partmental, patellofemoral, bicompartmental, unispacer,and partial resurfacing, has a higher rate of revision thanTKA.26-29 Unicompartmental arthroplasty (UKA) com-prises > 90% of all partial procedures.26-28 Proponents ofUKA cite as advantages the preservation of normal

Fig. 2

Kaplan–Meier estimates of the cumulative percentage probability of afirst revision of primary knee arthroplasty broken down by age groupand gender at increasing years after primary surgery. (Reproducedwith permission from NJR England Wales Northern Ireland, AnnualReport 2014).

Fig. 3

The relative distribution of primary arthroplasties among different agegroups (%) (all types of implants) since 1975. (Reproduced from SwedishKnee Arthroplasty Register, Annual Report 2014).

Fig. 4

Changes in cumulative percentage chance of implant failure by year ofprimary operation using Kaplan–Meier estimates. (Reproduced withpermission from NJR England Wales Northern Ireland, Annual Report2014).

Fig. 5

Cumulative rate of revision after total knee arthroplasty (%). (Repro-duced with permission from Swedish Knee Arthroplasty Register,Annual Report 2014).



kinematics, lower peri-operative morbidity, blood loss andrisk of infection compared with TKA, and an acceleratedrehabilitation and recovery.53-55 However, the volume ofUKAs which are undertaken has diminished over time andcontinues to decline (Fig. 6).26,27,29 The Australian registryreports that the number of UKAs undertaken in 2013 haddecreased by 2.7% compared with the previous year and by49.5% compared with 2003.27 One reason for this declineis that UKA performed for osteoarthritis has a substantiallyhigher risk of revision26,27,29 and for re-operation.55 The rateof revision for UKA has been reported to be twice as high asthe equivalent group of TKAs at each period of review post-operatively, and three times higher at ten years post-opera-tively.26 The CRR for primary UKA ranges from 12.7% atten years26 to 19.1% at 13 years27 post-operatively. Onereason for the higher failure rates is offering UKA toyounger patients.26,29 This delays the need for a TKA inyounger patients with mild disease but often such patientsare more active and put a greater amount of strain on theirimplants. This explains the high CRR ten years post-oper-atively in patients aged < 55 years who undergo UKA(21%) compared with that of patients aged > 75 years whoundergo UKA (6%). It has been estimated that if 100patients undergoing TKA received a UKA instead thiswould result in one fewer death and three more re-opera-tions during the first four post-operative years.55

Finally, the risk of subsequent revision is twice as high inpatients who have undergone conversion from a UKA to aTKA than for primary TKA.29 Revision of a failed UKA toanother UKA is rare and reflects the higher risk of re-revisionassociated with this than if the UKA is revised to a TKA.27,29

Information from the New Zealand Joint Registry showsno difference in the rate of revision in relation to the oper-ative approach (i.e. medial or lateral parapatellar

approach).28 This registry also showed that patients werestatistically twice as likely to develop periprosthetic infec-tion requiring revision surgery within six months of the ini-tial procedure if it had been performed in a laminar flowtheatre (revision risk (RR) 0.24%) rather than a conven-tional operating theatre (RR 0.11%). On further analysis,the rates of revision for deep infection within six monthswere 2.9 times higher if the operation was undertaken in aconventional theatre using space suits (RR 0.26%) and2.8 times higher if it was undertaken in a laminar flow the-atre using space suits (RR 0.25%), compared with operat-ing in a conventional theatre without space suits (RR0.09%). Furthermore, the rate of revision rate doubledwith the use of spacesuits in either conventional or laminarflow theatres.28 Such findings pose an interesting predica-ment and warrant further research and validation.

Historically, there has not been overwhelming evidenceto support the use of bone cement or resurfacing of thepatella during primary TKA; the choice lying with the sur-geon. Data from NJRs show that the risk of revision is sub-stantially increased with the use of uncemented comparedwith cemented implants.26-29 They also confirm that > 80%of TKAs are performed with cement. Cox regression anal-ysis, adjusting for age, gender, year of operation, and use ofpatellar component, showed that the risk of revision forTKA with an uncemented tibial component was 1.7 (1.4 to1.9) times higher than for that if a cemented componentwas used.29

Resurfacing the patella is extremely variably undertakenacross countries and remains an area of controversy(Table III).56,57 A patellar button was used in > 70% of TKAcases in Sweden during the 1980s, but its use fell to 2.3% in2013 (Fig. 7).29 TKA performed without patellar resurfacingin Sweden between 1991 and 2000, however, had a signifi-cantly higher rate of revision than those performed with patel-lar resurfacing (RR × 1.3, 95% CI 1.1 to 1.4). Conversely,TKA performed with patellar resurfacing between 1999 and2008 had a higher risk of revision (RR × 1.2, 95% CI 1.1 to1.4). In contrast, the Australian registry reports an increasein patellar resurfacing from 41% of all TKAs in 2005 to56.8% in 2013.27 Estimating the impact of patellar resur-facing on the risk of revision is extremely complex and can-not explain the variations in the findings worldwide.Furthermore, registry data cannot accurately interpret theimpact of patellar resurfacing on the success of TKA, espe-cially if a secondary operation was required to resurface thepatella to manage subsequent patellofemoral symptoms.

Almost one quarter of TKAs undertaken in Australia arecomputer navigated.27 At ten years post-operatively, thereis no overall difference in CRR between navigated and non-navigated TKAs. However, navigated TKAs performed inpatients aged < 65 years are less likely to require revisionfor loosening or osteolysis.27 Finally, the outcome is betterif the operation is undertaken by a surgeon who performs ahigh volume of operations. This has been reported severaltimes.58,59

Fig. 6

The relative yearly distribution of types of implant used for primarysurgery. (Reproduced with permission from Swedish Knee Arthro-plasty Register, Annual Report 2014).



Implant design. In Australia an unconstrained (cruciateretaining) prosthesis is most commonly used (79.2%)followed by a posterior stabilised (cruciate sacrificing) TKA(28%).27 This is similar in England where an unconstrainedprosthesis is the most popular (65.6%) followed by a pos-terior stabilised TKA (22.8%). Overall, the most com-monly used TKA in England is a cemented unconstrainedfixed bearing design, comprising 55.9%.26 This design hasthe lowest rate of revision with a CRR ten years post-operatively of 3%. Posterior stabilised designs have thehighest rates of revision.26,28 For cemented TKA, themobile-bearing posterior stabilised prosthesis has CRR tenyears post-operatively of 5%; and for uncemented TKA,the fixed-bearing posterior stabilised prosthesis has a CRRat ten years post-operatively of 9%.26 In contrast, theAJRR’s first annual report (2013) clearly shows that themost popular design of TKA is posterior stabilised (59.1%)followed by unconstrained (40.1%).30 The impact of thison revision has not been estimated, perhaps as the registryis in its infancy.

The Australian Registry showed that fixed tibial bearingshad a lower rate of revision compared with rotating orslide-rotating mobile tibial bearings.27 There were no dif-ferences in the rates of revision between the modular fixedtibial component and the non-modular all-polyethylene tib-ial component.27 However, the all-polyethylene tibial com-ponents have higher rates of revision compared with the

polyethylene moulded tibial components.27 A large singlecentre retrospective study recently reported that all-polyethylene tibial components had a significantly lowerrisk of revision compared with metal-backed modularimplants, (hazard ratio, 0.3; 95% CI 0.2 to 0.5; p < 0.0001)and therefore were associated with a better outcome.60 Theauthors also reported that in metal-backed modular tibialdesigns, unconstrained TKA performed better than theposterior-stabilised TKA (p = 0.002), which is consistentwith registry findings.

Bearing surfaces have an important but undeterminedrole in TKA. Prostheses using high cross-linked poly-ethylene (XLPE) have a lower rate of revision comparedwith those using non cross-linked polyethylene.27 The Aus-tralian Registry has shown a cumulative incidence of loos-ening or lysis of 0.8%, ten years post-operatively, for TKAusing XLPE and 1.7% for TKA using non-XLPE. The over-all use of XLPE in Australia, however, is much less thannon-XLPE.27 In the United States, XLPE is used in 75% ofTKAs and non-XLPE in 25%.30

Implant model. Registry analysis of TKAs by brand hasshown a risk of revision ten years post-operatively of < 5%with overlapping CIs indicating similar performances interms of the risk of revision.26 In England, the highest ratesof revision related to the Rotaglide + mobile knee TKAwhich had a revision rate of 7.14% at ten years, and thePreservation UKA which had a revision rate of 20.14% atten years.26 Using Cox regression analysis and adjustmentsfor differences in gender, age and year of operation, theSKAR also found that the Preservation UKA had the high-est risk ratio for revision (RR 1.57, p = 0.04; 95% CI 1.02to 2.40).29 The TKAs performed in Sweden with the highestrisk of revision are the F/S MIII (RR 1.45, p < 0.01; 95% CI1.21 to 1.74) and the PFC RP (RR 1.67, p < 0.01; 95% CI1.27 to 2.19).29 The New Zealand Registry report that theInsall/Burstein (1.8 per 100 observed component-years;ocys) and Optetrak (0.93 ocys) prostheses have a signifi-cantly higher rate of revision than the overall rate of 0.5 per100 ocys at the 95% CI.28

The Australian Registry reports that the Nexgen CR/NExgenTKA has the overall lowest CRR ten years post-operativelyof 3.2% (2.9% if uncemented and 2.7% if cemented).27

Using a standardised approach, they identified six types ofTKA as outliers with respect to CRR. These include theGenesis II CR (cementless) / Profix Mobile (cemented) com-bination (ten year CRR, 13%); Genesis II Oxinium PS(cemented) / Genesis II (Cementless) combination (five yearCRR, 31%); GMK Primary (cementless)/ GMK Primary(Cementless) combination (one year CRR, 3%); Optetrak

Table III. The percentage of patients that had their patella resurfaced as part of their total knee arthroplasties performed in various countries

Swedish Knee Arthroplasty Register annual report 201429

Norwegian Arthroplasty Register annual report 201056

Danish Knee Arthroplasty Register annual report 201357

Australia Orthopaedic Association NJR annual report 201427

New Zealand joint Registry 15-year report27

2.3 10.4 77 56.8 32

NJR, National Joint Registry

Fig. 7

The yearly distribution (%) of the use of patella button in total kneearthroplasty (TKA). (Reproduced with permission from SKAR Annualreport 2014).



CR (cemented) / Optetrak (cemented) combination (tenyear CRR, 11.9%); Scorpio NRG PS (cementless) / series7000 (cementless) combination (five year CRR, 8.4%);Vanguard PS / Maxim combination (five year CRR, 5.8%);and the LCS PS femoral component (three year CRR,7.5%). The comparator group includes all other typeswithin the same class, regardless of their rate of revision.

In conclusion, registries are an indispensable tool in pro-viding comparative data from large populations on the out-comes of individual TKAs in a community. Such data arecritical to an evidence-based approach to the choice ofprosthesis. Registries also serve as a system of quality-assurance surveillance to monitor the outcomes of newdevices, generate observational evidence, and cost savings.However, there remains an important role for well con-ducted large-scale randomised controlled trials to assessindividual types of prostheses to a depth which cannot beachieved by registries.20 This will also minimise the intro-duction of new technologies directly from industry intohealth care. The National Institute for Health and ClinicalExcellence (NICE) in the United Kingdom has set thebenchmark for approving new prostheses at 10% revisionten years post-operatively.

The overall percentage of patients requiring revision TKAis low. However, with the large number of TKAs performedannually, this translates into a significant absolute numberwith considerable financial and healthcare implications forpatients and healthcare systems. The survivorship of TKAs isdetermined by the changing demographics of patients, surgi-cal technique and implant-related factors. The most com-mon modes of failure include aseptic loosening, infection,pain and instability. Future research, education, and trainingshould consider regenerative techniques that halt or reversedegenerative joint disease in younger patients, improving theselection of patients for surgery and the appropriate earlyevaluation and long-term monitoring of outcomes throughprospective studies and NJRs.

Author contributions:M. Khan: Writing paper, research, data analysis.K. Osman: Writing paper, research.G. Green: Writing paper.F. S. Haddad: Writing paper.

This research / study / project was supported by The National Institute for HealthResearch University College London Hospitals Biomedical Research Centre.

No benefits in any form have been received or will be received from a commer-cial party related directly or indirectly to the subject of this article.

This article was primary edited by J. Scott.

This paper is based on a study which was presented at the 2014 CurrentConcepts in Joint Replacement® - The Journey Continues meeting held inIguassu Falls, Brazil, 17th-20th September.

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