Survivorship analysis of total knee arthroplasty. Cumulative rates of survival of 9200 total knee arthroplasties

From 1971 through 1987, 9200 total knee arthroplasties were performed at the Mayo Clinic. Actuarial analysis was used to estimate cumulative rates of survival. Use of a proportional-hazard, general linear model led to the identification of four independent variables that were associated with a significantly lower risk of failure: primary total knee arthroplasty, a diagnosis of rheumatoid arthritis, an age of sixty years or more, and use of a condylar prosthesis with a metal-backed tibial component. When all four of these favorable variables were present (without regard for radiographic changes and non-disabling symptoms), the probability of an implant being in situ was 97 per cent at both five and ten years.     

Survivorship analysis in total condylar knee arthroplasty. A statistical review.

Survivorship analysis, which is often encountered in the medical literature, is used to calculate the probability of a certain event, such as failure of a prosthesis, as a function of the time elapsed since an operation. Possible pitfalls in the use of this method are related to the size of the population of patients and the definition of how the outcome is measured. We studied the outcomes of 204 total knee arthroplasties in 165 patients, using six different end-points, in order to illustrate these problems. Survivorship estimates that are cited without confidence intervals have little clinical value.     

Revision total knee arthroplasty. A survival analysis.

The results of revision total knee arthroplasty (TKA) have been documented reasonably well in the literature. It is notable, however, that none of these reports have used the technique known as survival analysis to compare virgin and revision arthroplasties. This technique has an advantage over conventional analyses because it does not exclude patient data for inadequate follow-up study or patient death. In this study, survival analysis was applied to 37 revision TKAs performed exclusively by the senior author. With failure defined as removal of the prosthesis, revision surgeries experienced a 97.0% survival rate at 6 years. The secondary arthroplasty demonstrated a significantly lower survival rate than the index procedure over a period of approximately 6 years.     

Survivorship analysis of 1,041 Charnley total hip arthroplasties

Survivorship analysis of 1,041 cemented Charnley total hip arthroplasties performed as a primary procedure revealed a probability of component survival at 10 years of 92%; the probability of acetabular cup survival was 99% and of femoral component survival was 96%. Three-zone acetabular demarcation was present in 16% of cases, as was migration of the cup greater than 5 mm. However, the acetabular revision rate was 1.65%, confirming the long-term clinical durability of the 22-mm internal diameter cup. Radiographic evidence of definite femoral component loosening was present in 9.6% and high-grade femoral bone-cement demarcation was present in 3.5%. The isolated femoral revision rate was 1.8%. Based on detailed survivorship analysis, a high-risk group of patients was identified for component failure and for femoral component loosening (radiographic). These patients were male, young (less than 50 years), heavy (greater than 170 pounds), and active (not Charnley class C). Given these findings, it is difficult to justify the widespread use of noncemented total hip systems, except in identifiable high-risk patients.     

The cruciate ligaments in total knee arthroplasty: a kinematic analysis of 2 total knee arthroplasties

In vivo weight-bearing fluoroscopic kinematic analysis using an interactive model fitting technique with 3-dimensional computer-aided design solid models was done using 16 anterior and posterior (bicruciate)-sparing and 6 posterior cruciate-sparing total knee arthroplasties (TKAs). All patients had a satisfactory clinical result with a minimum of 12 months' follow-up. The femorotibial contact position of TKAs started posterior to the midline in extension. Bicruciate TKAs revealed gradual posterior femoral rollback and limited anterior-posterior translation but remained posterior to the sagittal plane midline in all positions. Posterior cruciate-sparing TKAs began significantly posterior in extension, demonstrated progressive anterior translation with flexion, and had exaggerated medial condyle translation on deep knee bend. The posterior cruciate-retaining TKAs of this study had the most abnormal kinematic performance.     

Survivorship analysis at 15 years of cemented press-fit condylar total knee arthroplasty

We performed a survival analysis on 354 cemented primary press-fit condylar total knee arthroplasties in 277 patients with prospective follow-up (mean, 8.8 years; range, 0.3-16.9 years). The number of patients alive reaching 15 years at follow-up for survival analysis was 15. The cumulative survival rate at 15 years was 81.7% (95% confidence interval, 72.1%-88.5%), using revision for all causes as our end point. Indications for revision in our patient group were aseptic loosening 4.5%, infection 2.3%, and exchange of polyethylene insert 1.1%. Our results indicate that the cemented press-fit condylar total knee arthroplasty has a good long-term survival, at 15 years, based on revision as the end point.     

Lateral release rates after total knee arthroplasty.

For a total knee replacement to function well, the patella must track centrally in the trochlear groove. A lateral release may be required to ensure such central tracking. During surgery, an evaluation was made of patellar tracking in 178 patients undergoing total knee replacement. The Genesis II prosthesis with a deep-dish tibial insert was used for all the patients. The evaluation was made using the nontouch technique and the axial traction (modified no-touch) technique before and after release of the tourniquet. With the tourniquet still inflated, there were 29 knees in which the patella tilted laterally and 11 additional knees in which the patella subluxed laterally. Using the modified no-touch technique, there were only 12 knees in which the patella tilted laterally and five in which it subluxed laterally. With the tourniquet deflated, only nine of the patellas tilted laterally and three subluxed laterally. It was only in this final group that a lateral release was done for an overall lateral release rate of 6%. Eleven of these 12 knees had a preoperative fixed valgus deformity greater than 10 degrees. Only one lateral release was required for a patient with a preoperative varus deformity. Four patients with a preoperative fixed valgus deformity and a laterally subluxed patella did not require a lateral release. Axial realignment and reconstitution of an anterior trochlear surface by the implant were sufficient to centralize the patella. Had only the no-touch test been used, there would have been 18 unnecessary lateral releases done. When the knees were evaluated radiographically, there was no statistical difference in patellar position between that group and the knees that required a lateral release. Overall in the entire group at 6 weeks after surgery, 105 knees (59%) had no patellar tilt. At 3 months, as quadriceps tone returned to normal, 138 knees (79%) had no patellar tilt. Thirty-three of the remaining 35 knees had a patellar tilt less than 10 degrees. None of the patients had lateral patellar subluxation at any time after surgery.     

Survivorship analysis and results of total condylar knee arthroplasty. Eight- to 11-year follow-up period

This study deals with survivorship of total condylar knee arthroplasties in 87 consecutive patients (112 knees) with follow-up periods of up to 11 years. The end point of the survivorship was defined as: (1) the need for revision due to septic or aseptic loosening; (2) roentgenographic loosening evidenced by a shift of component position; or (3) radiolucency extending under the condyle of the tibial component and partially along the peg, when associated with clinical symptoms. Life table calculations predict 88.7% survivorship of total condylar knee arthroplasty. Using revision for septic or aseptic loosening and recommendation for surgery as an end point, the survivorship was 94.1% 11 years after operation in this series. Seventy-two patients (90 knees) of 87 were available for clinical and roentgenographic study at eight to 11 years. Eight patients (12 knees) had died and seven patients (ten knees) were lost to follow-up study. The results were excellent to good in 93%, fair in 3%, and poor in 4%. Roentgenographic evaluation revealed well-fixed components in 36 knees (40%). Radiolucencies of varying degrees were present in 54 knees (60%). Of the 54 knees, seven had radiolucency under the tibial condyle in Zones I-IV and partially along the peg in Zones V and VI. Two knees had component loosening, one with a loose patella and the other a loose tibial component; both of these patients were symptomatic. Variables such as the patient's age, sex, diagnosis, alignment and position of the prosthesis, and level of bone cut did not correlate with the development of radiolucencies at the cement-bone interface.(ABSTRACT TRUNCATED AT 250 WORDS)     

Survivorship of cementless total knee arthroplasty without tibial plateau screw fixation

Seventy-two cementless tricompartmental total knee arthroplasties were performed in 47 patients using a porous-coated prosthesis without screw fixation for the tibial components between 1984 and 1986. These individuals were observed at regular intervals for a minimum of three years. Their Hospital for Special Surgery pain and function scores as well as roentgenographic signs of anatomic alignment and subsidence were evaluated at six months, one year, and three years postoperatively. The roentgenographic evaluation for subsidence looked at a measurable difference in the anteroposterior roentgenograph on the medial and lateral plateaus and on the lateral roentgenograph anteriorly and posteriorly. Early postoperative interpretations have suggested pain and knee scores to be much lower than scores in the cemented prosthesis. Reassessment after three years, however, revealed no further deterioration of the noncemented prosthesis in respect to knee scores and survival analysis. Roentgenographic analysis showed no correlation between subsidence and alignment alterations, subsidence and time, or subsidence and pain. It appears that after an initial period of discomfort, the noncemented knee can achieve a functional, clinical, and roentgenographic result much better than previously anticipated. The consequences beyond this time period still remain unknown.     

Infected total knee arthroplasties

Thirty infected total knee arthroplasties were investigated in 29 patients over an average interval of 42 months. Eleven infections began in the immediate perioperative period. Six developed from postoperative wound-healing problems. The remainder were late infections. Staphylococcus was found in 16 infections, gram-negative agents in five, mixed organisms in five, and other gram-positives in four. Sixteen knees were arthrodesed, six knees were treated by retention of the components, and two above-knee amputations and one resection arthroplasty were performed. Five patients had two-stage revisions to new components. Evidence of persistent infection was present in three arthrodeses, two retained arthroplasties, and one knee that was revised. Perioperative infections were associated with staphylococcal organisms and responded less favorably to conservative treatment. The failure of primary wound healing demands immediate measures to obtain skin coverage. Retention of the arthroplasty components is possible only in selected patients.     

Cemented total knee arthroplasties

INTRODUCTION: The aseptic loosening of cemented total knee arthroplasties is still an unsolved problem. In this regard, the hydrolysis resistance in the metal-to-bone cement interface is of major importance. MATERIAL AND METHODS: Cemented pre-treated tibia components coated by means of a silica/silane interlayer system of the model "Columbus PS" were dynamically loaded with the help of a knee-simulator similar to DIN ISO 14243. After loading, the components were microscopically analysed concerning debonding in the metal-to-bone cement interface as well as with regard to cement mantle defects. These data were matched with uncoated "Columbus PS" components. Unloaded coated and uncoated tibia components acted as a control. RESULTS: In comparison with uncoated tibia components, the pre-treated and coated ones yielded a highly significant reduction of cement defects (p < 0.01) as well as a significant reduction of debonding in the metal-to-bone cement interface (p < 0.05). CONCLUSION: By means of the silica/silane interlayer system for cemented tibia components, a hydrolytic debonding in the metal-to-bone cement interface with subsequent mechanical loosening and consecutive early cement mantle failure can be significantly reduced. This could lead to an increased long-term stability of the metal-to-bone cement compound with decreased aseptic loosening in clinical use.     

The Attenborough and Gallannaugh knee prostheses for total knee arthroplasty. A comparison and survival analysis.

The characteristic feature of the Attenborough knee prosthesis was a stabilizing link rod, designed to act in place of the cruciate ligaments and to supplement the function of the collateral ligaments when damaged by disease. However, the reported long-term results obtained with this prosthesis have not been satisfactory, and survival analysis of 505 arthroplasties in which this prosthesis was used demonstrates a cumulative 14-year success rate of only 44.9%. In 1982, a new design incorporating the link rod was developed and the results of 149 knees in which this prosthesis was used show a cumulative seven-year success rate of 98.4%, compared with 70.1% in the Attenborough series. The clinical results of the Gallannaugh series are presented in this study. Knee function has been separated from patient activity, the patients being categorized in groups according to their physical state. Thus, the result of the knee operation can be assessed even in those disabled by age and infirmity. The Gallannaugh prosthesis is of particular value in circumstances where the use of an unconstrained prosthesis would be impractical.     

Retrospective analysis of total knee arthroplasty cases for visual, histological, and clinical eligibility of unicompartmental knee arthroplasties

We retrospectively analyzed 97 total knee arthroplasty cases with medial osteoarthritis from seven participating surgeons in our teaching hospital to determine the percentage of patients who met the following eligibility criteria for unicompartmental knee arthroplasty (UKA): healthy cartilage in the lateral compartment based on (1) visual analysis, (2) histological analysis and (3) absence of UKA contraindications based on clinical analysis. The cases with healthy lateral cartilage, intact anterior cruciate ligament and posterior cruciate ligament, lack of patello-femoral arthritis, preoperative range of motion (ROM) greater than 90, and genu varum less than 10° represented 21% of the 97 cases studied. This percentage would likely have been higher had the cases been assessed earlier in the disease process. It was concluded that there is the potential to utilize UKA more frequently in the future.     

Twenty-year survival analysis in total knee arthroplasty by a single surgeon

Between January 1988 and December 2006, a total of 3014 primary total knee arthroplasties (TKAs) in 2042 patients were performed, and survivorship analysis was performed. Survivorship analysis showed a 10-year survival of 93.8% and a 20-year survival of 70.9%. There was no significant difference in the survival rate according to sex and diagnosis (P = .142 and .443, respectively). The survival rate was higher in the patients older than 60 years (P < .001). The survival rate of Total Condylar IV (TC-IV) was higher than that of Ortholoc (Dow Corning Wright Medical, Arlington, Tenn) (P < .001). Total knee arthroplasty results in satisfactory long-term survival rates. However, the survival rate decreases over time. The risk of requiring revision TKA was related to age and type of implants. Careful consideration is necessary to decide the time for TKA and select type of implants.     

Survivorship analysis of total knee arthroplasty with the kinematic prosthesis in patients who have rheumatoid arthritis

Eighty-eight primary total knee arthroplasty procedures in 61 patients with rheumatoid arthritis were performed using the Kinematic total knee prosthesis (Howmedica, Rutherford, NJ) with cement between 1980 and 1985. No patients were lost to follow-up evaluation. Thirty-one of 61 patients died during the study period. Survivorship for all patients by life-table method was estimated as 56% at 10 years. This was shorter than the expected survival rate of a sex- and age-matched control group. Fifty procedure outcomes in 34 patients (27 women, 7 men) who were followed for more than 10 years were available for clinical evaluation. Complications occurred in 11 cases; in 4 of these, revision surgery was required. With revision as the endpoint, the survival rate of the prostheses was estimated as 93% at 10 years.     

Survivorship analysis of cemented total condylar knee arthroplasty: A long-term follow-up report on 348 cases

Survivorship analysis was used in the evaluation of 348 consecutive primary total condylar knee arthroplasties (total knee arthroplasties) performed on 253 patients in a 27-month period, with a maximum follow-up period of 12 years. The diagnosis was osteoarthrosis in 184 cases and rheumatoid arthritis in 164 cases. Ten patients (10 total knee arthroplasties) were lost to follow-up evaluation. The endpoint was defined as prosthesis not in situ. The variables considered were age, sex, body mass index, and diagnosis. The overall cumulative survival rate was 92%. The survival rate of the osteoarthrosis group was significantly higher (97%) than that of the rheumatoid arthritis group (87%). None of the other variables affected survival rate significantly.     

Survivorship of unconstrained total shoulder arthroplasty

The results of fifty-three unconstrained (Neer-II or Gristina) total shoulder arthroplasties were reviewed with the use of survivorship analysis. Failure was defined as the need for revision or the onset of the patient's dissatisfaction. The method of survivorship analysis is presented in detail. Fifty-one total shoulder arthroplasties were followed for a minimum of two years (average, sixty-seven months). The results are reported with the use of the American Shoulder and Elbow Surgeons' rating form. After eleven years, the survivorship was 73 per cent for all prostheses, 71 per cent for the Neer prostheses, and 92 per cent for all prostheses in patients who had rheumatoid arthritis. Data on survivorship of the Gristina prosthesis were available after four years only, at which time it was 100 per cent. The relief of pain, which was the primary reason for the operation, was good or excellent in 82 per cent, improved in 6 per cent, and poor in 12 per cent of the shoulders in these patients.