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What Can Be Learned From Minimum 20-year Followup Studies of Knee Arthroplasty?

  • Symposium: 2014 Knee Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Long-term evaluation of knee arthroplasty should provide relevant information concerning the durability and performance of the implant and the procedure. Because most arthroplasties are performed in older patients, most long-term followup studies have been performed in elderly cohorts and have had low patient survivorship to final followup; the degree to which attrition from patient deaths over time in these studies might influence their results has been poorly characterized.

Questions/purposes

The purpose of this study was to examine the results at 20-year followup of two prospectively followed knee arthroplasty cohorts to determine the following: (1) Are there relevant differences among the two implant cohorts in terms of revision for aseptic causes (osteolysis, or loosening)? (2) How does patient death over the long followup interval influence the comparison, and do the comparisons remain valid despite the high attrition rates?

Methods

Two knee arthroplasty cohorts from a single orthopaedic practice were evaluated: a modular tibial tray (101 knees) and a rotating platform (119 knees) design. All patients were followed for a minimum of 20 years or until death (mean, 14.1 years; SD 5.0 years). Average age at surgery for both cohorts was > 70 years. The indications for the two cohorts were identical (functionally limiting knee pain) and was surgeon-specific (each surgeon performed all surgeries in that cohort). Revision rates through a competing risks analysis for implants and survivorship curves for patients were evaluated.

Results

Both of these elderly cohorts showed excellent implant survivorship at 20 years followup with only small differences in revision rates (6% revision versus 0% revision for the modular tibial tray and rotating platform, respectively). However, attrition from patient deaths was substantial and overall patient survivorship to 20-year followup was only 26%. Patient survivorship was significantly higher in patients < 65 years of age in both cohorts (54% versus 15%, p < 0.001 modular tray cohort, and 52% versus 26%, p = 0.002 rotating platform cohort). Furthermore, in the modular tray cohort, patients < 65 years had significantly higher revision rates (15% versus 3%, p = 0.0019).

Conclusions

These two cohorts demonstrate the durability of knee arthroplasty in older patients (the vast majority older than 65 years). Unfortunately, few patients lived to 20-year followup, thus introducing bias into the analysis. These data may be useful as a reference for the design of future prospective studies, and consideration should be given to enrolling younger patients to have robust numbers of living patients at long-term followup.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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Acknowledgments

We thank the following for their review of radiographs at each of the previous followup intervals: Gary Fetzer MD, David Hennessy MD, Michael Iossi MD, Andrew Malin MD, and Matthew Squire MD.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01029 JPP, Iowa City, IA, 52242, USA

    John J. Callaghan MD & Steve S. Liu MD

  2. Department of Orthopaedic Surgery, VA Medical Center, Iowa City, IA, USA

    John J. Callaghan MD & Richard C. Johnston MD

  3. Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01051 JPP, Iowa City, IA, 52242, USA

    Christopher T. Martin MD & Andrew J. Pugely MD

  4. Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01066 JPP, Iowa City, IA, 52242, USA

    Yubo Gao PhD & Richard C. Johnston MD

  5. Des Moines Orthopaedic Surgeons, West Des Moines, IA, USA

    Devon D. Goetz MD

  6. North Carolina Orthopaedic Clinic, Durham, NC, USA

    Scott S. Kelley MD

Authors
  1. John J. Callaghan MD
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  2. Christopher T. Martin MD
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  3. Yubo Gao PhD
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  4. Andrew J. Pugely MD
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  5. Steve S. Liu MD
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  6. Devon D. Goetz MD
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  7. Scott S. Kelley MD
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  8. Richard C. Johnston MD
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Corresponding author

Correspondence to John J. Callaghan MD.

Additional information

One of the authors certifies that he (JJC), or a member of his immediate family, has or may receive payments or benefits, during the study period, an amount more than USD 1,000,001 from DePuy (Warsaw, IN, USA) and less than USD 10,000 from Lippincott Williams & Wilkins (Baltimore, MD, USA). We (CTM, AJP) acknowledge use of the Bierbaum Research Fund (an institutional resident research fund).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at the University of Iowa, Iowa City, IA, USA, and Des Moines Orthopaedic Surgeons, West Des Moines, IA, USA.

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Callaghan, J.J., Martin, C.T., Gao, Y. et al. What Can Be Learned From Minimum 20-year Followup Studies of Knee Arthroplasty?. Clin Orthop Relat Res 473, 94–100 (2015). https://doi.org/10.1007/s11999-014-3744-1

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  • DOI: https://doi.org/10.1007/s11999-014-3744-1

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