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Summary
Groundwork
Articulatio genus replacements are the mainstay of handling for cease-stage osteoarthritis and are constructive. Given time, all knee replacements will fail and knowing when this failure might happen is important. We aimed to establish how long a knee replacement lasts.
Methods
In this systematic review and meta-analysis, we searched MEDLINE and Embase for example series and cohort studies published from database inception until July 21, 2018. Articles reporting xv year or greater survival of principal full genu replacement (TKR), unicondylar knee replacement (UKR), and patellofemoral replacements in patients with osteoarthritis were included. Manufactures that reviewed specifically complex chief surgeries or revisions were excluded. Survival and implant information were extracted, with all-cause survival of the knee replacement construct being the chief effect. We besides reviewed national joint replacement registry reports and extracted the information to be analysed separately. In the meta-analysis, we weighted each series and calculated a pooled survival estimate for each data source at xv years, xx years, and 25 years, using a fixed-effects model. This written report is registered with PROSPERO, number CRD42018105188.
Findings
From 4363 references institute by our initial search, we identified 33 example serial in xxx eligible articles, which reported all-cause survival for 6490 TKRs (26 case series) and 742 UKRs (seven example serial). No case serial reporting on patellofemoral replacements met our inclusion criteria, and no case serial reported 25 year survival for TKR. The estimated 25 year survival for UKR (based on i case series) was 72·0% (95% CI 58·0–95·0). Registries contributed 299 291 TKRs (47 series) and 7714 UKRs (5 series). The pooled registry 25 year survival of TKRs (14 registries) was 82·3% (95% CI 81·iii–83·2) and of UKRs (4 registries) was 69·8% (67·6–72·1).
Estimation
Our pooled registry data, which we believe to exist more accurate than the case series data, shows that approximately 82% of TKRs final 25 years and 70% of UKRs last 25 years. These findings volition be of utilise to patients and health-care providers; further information is required to predict exactly how long specific knee replacements will last.
Funding
The National Plant for Health Research, the National Articulation Registry for England, Wales, Northern Ireland, and Isle of Man, and the Royal College of Surgeons of England.
Introduction
Osteoarthritis of the knee is a common and potentially debilitating condition. The mainstay of treatment for terminate-stage affliction is knee replacement, and this procedure has been shown to be effective in most cases.
Depending upon the extent of disease, replacement surgery tin take the course of total knee replacement (TKR), unicondylar knee replacement (UKR), or patellofemoral replacement (PFR). In TKR, all the articular surfaces of the tibiofemoral joint are replaced (with or without the articulating surface of the patella). UKR and PFR are suitable for disease confined to ane compartment and but that compartment is replaced. TKR, UKR, and PFR are now some of the most common surgical procedures worldwide with a marked secular increase.
The aim of knee replacement surgery is the long-term relief of pain and restoration of part. Unfortunately, knee replacements neglect for a diversity of reasons, including loosening, infection, persistent hurting, and instability,
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and might require revision within the lifetime of the recipient. Knowing what the long-term failure rates are is important to facilitate resource planning, medicolegal assessment, benchmarking of different implants, and the provision of informed consent to patients. Given plenty time, all knee replacements volition fail and need to exist revised. Revision is expensive
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and results in worse outcomes than primary surgery.
The National Institute of Health and Care Excellence prepare a UK criterion in 2014, which stated that individual hip replacement components are only recommended if v% or fewer need revision at x years,
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National Institute for Health and Care Excellence
Total hip replacement and resurfacing arthroplasty for end phase arthritis of the hip. Technology appraisal guidance.
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just no equivalent benchmark exists for human knee replacement in either the medium (10 years) or long term.
In the U.k., in 2016, the typical patient requiring genu replacement was anile 69 years with a torso-mass index of 31 kg/chiliadii. Almost all (99%) knee replacements were done in patients with osteoarthritis and 56% of patients were women.
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An analysis of time and money spent on investigating painful total knee replacements.
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In 2016, 108 713 knee replacement procedures were done in England, Wales, Northern Republic of ireland, and the Isle of Human being.
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- Kassam AM
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An analysis of time and money spent on investigating painful total knee joint replacements.
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threescore different implants were used for main TKR, comprising 90·1% of all knee replacement procedures; xviii different UKR implants and nine different PFR implants were used.
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National Articulation Registry
Prostheses used in hip, knee, talocrural joint, elbow and shoulder replacement procedures 2016. 14th annual report 2017.
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Enquiry in context
Evidence before this study
Nosotros searched MEDLINE and Embase for systematic reviews and meta-analyses published in English. Our search identified 34 systematic reviews, but none of these articles produced a combined survival gauge with more than 15 years follow-upward, and although many reviews compared subgroups (eg, cemented vs cementless), nosotros believe these studies to be decumbent to selection bias. Before the advent of national articulation replacement registers, case series were the only sources of survival estimates for knee replacements. A previous analysis of the Finnish Arthroplasty Registry provided an guess of the survival of total genu replacement at xv years of 88·seven% (95% CI 88·v–88·9) for total knee replacement (TKR) and 69·6% (68·2–seventy·9) for unicondylar articulatio genus replacement (UKR). An analysis that used the UK Clinical Practice Research Datalink (CPRD) database was published in 2017, and estimated survival of TKR to be 89·vii% (95% CI 87·5–91·five) at twenty years.
Added value of this study
To our knowledge, we have provided the start elementary and generalisable estimate of the survival of knee replacements at 25 years, providing an answer to the question—how long does a genu replacement last? Our findings showed that approximately 82% of TKRs and 70% of UKRs concluding for 25 years.
Implications of all the available prove
Our findings, combined with those of previous registry analyses and the analysis of the CPRD data by Bayliss and colleagues, are of use to patients, people providing and commissioning health-intendance services, and those needing an estimate of genu replacement survival for medicolegal purposes.
In this study, we wish to answer a simple question that is posed to us by our patients, multiple times per twenty-four hour period—how long does a human knee replacement last?
Methods
Search strategy and selection criteria
This systematic review and meta-analysis followed a predefined protocol registered with PROSPERO (CRD42018105188) and adhered to PRISMA guidelines.
Nosotros did one systematic review and meta-analysis of example serial and cohort studies reporting survival outcomes of knee replacements and a second meta-analysis of national joint replacement registries with more than fifteen years of follow-upwardly.
We systematically searched MEDLINE and Embase for instance series and cohort studies that reported survival outcomes of knee replacements, published between beginning of each database and July 21, 2018. The search was washed through the Ovid SilverPlatter platform and contained keywords relating to knee replacement, survival, and medical discipline heading terms (see appendix for details of exact search terms used). Bibliographies of all included articles, as well as review articles, were manually screened for boosted citations (JTE). Nine studies were excluded because they were non written in English. Studies were included if they involved patients undergoing any type of knee replacement (TKR, UKR, or PFR) for osteoarthritis or a predominantly unselected patient grouping (eg, studies that investigated only one or two indications, such as rheumatoid arthritis, were excluded). Survival reports of specific implants with a mean or median follow-upwards of more than than 15 years were required. Articles that reviewed specifically circuitous chief surgeries or revisions were excluded, considering these types of procedures have different survivorship of the implants. Some articles reported survivorship from registry data; nosotros excluded these studies considering their inclusion would lead to duplication of data identified from the second data source. Systematic reviews were retrieved, and citations searched, but pooled data from the reviews themselves were not included because their inclusion would result in duplication.
The showtime national joint replacement registry was founded in Sweden in 1975; at the fourth dimension of writing, six registries have more than than 15 years of potential follow-up for knee replacement (those in Australia, Denmark, Republic of finland, New Zealand, Kingdom of norway, and Sweden). For the analysis of information from national joint replacement registries, we reviewed websites and the most recent annual reports of national joint replacement registries with fifteen years of follow-up at the time of data collection (July 21, 2018) for fifteen year or longer survival data on TKR, UKR, or PFR constructs. These national registries collect data on all patients undergoing knee replacements in both public and private hospitals and aim to include all joint replacements in their cohort.
Abstract screening and data extraction
The abstracts of journal manufactures were screened by three reviewers (JTE, RWW, and JPE) using the web application Rayyan,
and in cases of disagreement were included for full review. Information were extracted twice on publication appointment, implant blazon, fixation technique, number of knee replacements, age and sex of recipient, indication for articulatio genus replacement, loss to follow-upwardly, and summary survivorship estimates (including CIs), when bachelor. Data were non extracted from figures to prevent potential inaccuracy, particularly in the instance of older, depression-resolution figures. Whatsoever discrepancy between the twice-extracted data was rectified past review of the full text by all reviewers, later on which there were no cases of disagreement.
Data analysis
Our master exposure was the brand and model of the genu replacement construct and our principal outcome was all-cause revision of any part of this construct. We required estimates of survival for specific constructs because we believe that this make and model of the construct central to the upshot of surgery. Aggregated information from multiple constructs would non allow this level of particular and would thus hide the variability in functioning betwixt constructs. Statistical analysis was washed with Stata 15 (release 15). Articulatio genus replacement construct survival estimates at fifteen years, 20 years, and 25 years, assuming survivorship approximated risk, were pooled with meta-analysis. Each series was weighted according to its standard error (calculated from published CIs). A fixed-effects model was used. Variability between studies and publication bias were assessed using visual representation of the information.
Data from registries were analysed in the same style equally information from the case series to produce equivalent woods plots. The contribution each implant serial made was weighted according to the standard error of that private guess.
Written report quality was assessed using the not-summative iv-point arrangement (sequent cases, multicentre, under 20% loss to follow-upwards, and using multivariable analysis) adult by Wylde and co-workers.
9
- Wylde V
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This system was preferred over the summative MINORS score because of the high loss to follow-upwards in articulation replacement instance series and because some of the scoring criteria were not relevant to joint replacement.
10
- Slim K
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- Kwiatkowski F
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Methodological index for non-randomized studies (minors): evolution and validation of a new musical instrument.
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This report is registered with PROSPERO, number CRD42018105188.
Part of the funding source
The funder of the study had no role in study design, information collection, data assay, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had concluding responsibility for the conclusion to submit for publication.
Results
The search of published case series produced 4363 manufactures. 1481 duplicates were removed, leaving 2882 articles for screening (figure 1). After screening, 212 full-text articles remained for review, with 2 additional citations identified through manual search of references and reviews (appendix). Nine manufactures that were non written in English language were excluded. Post-obit review of full-text articles, 30 journal articles reporting 33 unique example serial were included; these articles reported 7232 human knee replacements (range 50–1000). 26 instance series reported survival of TKRs and 7 reported survival of UKRs; no case series reporting on PFR met our inclusion criteria. A full listing of included articles and survival estimates can be found in the appendix. A summary of study-level and patient-level characteristics of each data source is provided (table 1).
Table 1 Study-level and participant-level characteristics of contributing information sources
| Individual case series articles | Australian Orthopaedic Association National Joint Replacement Registry annual written report, 2017 | Finnish Arthroplasty Report, November, 2017 | ||||
|---|---|---|---|---|---|---|
| TKR | UKR | TKR | UKR | TKR | UKR | |
| Report-level characteristics | ||||||
| Location | 26 articles in ten countries | Vii manufactures in four countries | Australia | Commonwealth of australia | Finland | Republic of finland |
| Number of unique implant serial included | 26 | vii | 24 | 0 | 23 | 5 |
| Year of publication | 1999–2018 | 1999–2013 | 2017 | NA | 2017 | 2017 |
| Participant-level characteristics | ||||||
| Total joint replacements included | 6490 | 742 | 209 435 | 0 | 89 856 | 7714 |
| Hateful age (years) | 67·3 * Weighted mean for age by number of arthroplasties in serial. | 68·7 * Weighted hateful for historic period by number of arthroplasties in series. | 68·5 † All primary knee operations in the report (not just those included in written report). | NA | 65–74 ‡ Exact value non reported, median within this age range. § Note that these values are the same in the TKR and UKR columns because the Finnish Arthroplasty Registry does not differentiate between TKR and UKR. | 65–74 ‡ Verbal value non reported, median within this age range. § Note that these values are the same in the TKR and UKR columns because the Finnish Arthroplasty Registry does non differentiate betwixt TKR and UKR. |
| Proportion of female patients | 55·4% ¶ Weighted proportion of female patients by number in report if the proportion of women was reported. | 65·0% ¶ Weighted proportion of female patients past number in study if the proportion of women was reported. | 56·viii% † All primary knee operations in the study (not simply those included in study). | NA | 68·four% † All primary articulatio genus operations in the report (not just those included in study). § Annotation that these values are the aforementioned in the TKR and UKR columns because the Finnish Arthroplasty Registry does not differentiate between TKR and UKR. | 68·four% † All primary human knee operations in the written report (not just those included in study). § Note that these values are the aforementioned in the TKR and UKR columns because the Finnish Arthroplasty Registry does not differentiate between TKR and UKR. |
| Proportion of arthroplasties implanted for osteoarthritis | 87·five% ‖ Weighted proportion by number of arthroplasties in series if reported. | 93·7% ‖ Weighted proportion by number of arthroplasties in series if reported. | 97·6% † All master articulatio genus operations in the report (not simply those included in study). | NA | 88·ix% † All principal knee operations in the study (not just those included in study). § Note that these values are the aforementioned in the TKR and UKR columns because the Finnish Arthroplasty Registry does not differentiate between TKR and UKR. | 88·ix% † All master knee joint operations in the report (not merely those included in study). § Note that these values are the same in the TKR and UKR columns considering the Finnish Arthroplasty Registry does not differentiate betwixt TKR and UKR. |
TKR=full human knee replacement. UKR=unicondylar knee replacement. NA=not applicable.
* Weighted mean for historic period past number of arthroplasties in series.
† All primary knee operations in the written report (not just those included in written report).
‡ Exact value non reported, median within this age range.
§ Annotation that these values are the aforementioned in the TKR and UKR columns because the Finnish Arthroplasty Registry does not differentiate between TKR and UKR.
¶ Weighted proportion of female patients by number in study if the proportion of women was reported.
‖ Weighted proportion by number of arthroplasties in serial if reported.
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Quality assessment of the case series revealed that 22 (67%) of 33 were consecutive, 1 (three%) of 33 were multicentre, all 33 (100%) had less than 20% loss to follow-upwardly, and only four (12%) of 33 included multivariable analyses. These proportions reflect the fact that, in full general, the quality of published case serial is low.
26 unique example series reported survival for 6490 TKRs, with follow-up ranging from fifteen years to 23 years. 14 series reported survival at 15 years (4137 TKRs) and five at twenty years (763 TKRs). Non all series reported survival at exactly fifteen years or 20 years and some series reported survival at more one timepoint. Pooled assay of data derived from case series reported at exactly fifteen years or 20 years showed an all-cause construct survivorship of 96·iii% (95% CI 95·7–96·nine) at xv years and 94·8% (92·v–97·1) at xx years. Figure 2A shows a wood plot for the meta-analysis of data on TKRs derived from case serial at 15 years and 20 years.
Effigy two Forest plot of estimates for reported survival of knee replacements from case series, 12 Cemented rotating-platform total knee replacement. a concise follow-upwardly, at a minimum of fifteen years, of a previous report. 13 Modular fixed-bearing total genu arthroplasty with memory of the posterior cruciate ligament. A written report of patients followed for a minimum of fifteen years. 15 Fifteen yr outcome of the ceraver hermes posterior-stabilized full knee arthroplasty: safety of the procedure with experienced and inexperienced surgeons. 16 2017 Chitranjan S. Ranawat Award: does reckoner navigation in genu arthroplasty improve functional outcomes in young patients? A randomized study. 22 Long-term follow-up of a non-randomised prospective cohort of one hundred and ninety 2 total knee arthroplasties using the NexGen implant. 23 The Chitranjan Ranawat Honour: long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties. 25 Cemented rotating-platform full knee replacement: a concise follow-upwardly, at a minimum of twenty years, of a previous report. 26 Long lasting issue of hydroxyapatite-coated implants in primary knee arthroplasty: a continuous series of two hundred and seventy total knee joint arthroplasties at fifteen to twenty two years of clinical follow-up. 27 The cementless AGC 2000 knee prosthesis: 20-year results in a consecutive series. 28 Mod unicompartmental genu arthroplasty with cement: a curtailed follow-up, at a mean of xx years, of a previous report.
Evidence full explanation
(A) Total knee replacements at xv years and xx years. (B) Unicondylar genu replacements at fifteen years, twenty years, and 25 years. The CIs for individual point estimates are shown with horizontal lines. The surrounding box shows the contribution made by that individual estimate to the overall pooled guess, weighted by the standard error of that private serial.
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Pooled survival at each timepoint is shown in tabular array ii. When we rounded survival at timepoints that were not exactly xv years or 20 years down to the closest timepoint (to include as many example serial as possible in our analyses), pooled survival was 96·iii% (95% CI 95·7–96·8) at xv years and 92·0% (90·one–93·8) at 20 years (appendix).
Table 2 Pooled estimates of survival for each available timepoint
| Number of serial | Full number of arthroplasties at the showtime of the serial | Pooled survival estimate (95% CI) | |
|---|---|---|---|
| Total knee replacement | |||
| 15 years | 15 | 4137 | 96·three% (95·seven–96·9) |
| sixteen·8 years | 2 | 228 | 96·3% (93·5–99·0) |
| 18 years | 2 | 572 | 93·8% (81·0–96·0) |
| 19 years | 2 | 356 | 96·1% (92·eight–99·4) |
| 20 years | five | 763 | 94·8% (92·5–97·i) |
| 20·viii years | i | 160 | 86·9% (80·4–91·five) |
| 22 years | ane | 163 | 82·1% (76·ii–88·0) |
| 23 years | one | 489 | 89·0% (82·0–93·0) |
| Unicondylar knee replacement | |||
| 15 years | 4 | 387 | 85·five% (82·two–88·7) |
| 16 years | 1 | 113 | 81·3% (67·7–94·viii) |
| 20 years | 4 | 437 | 81·ix% (77·8–85·9) |
| 22 years | 1 | 140 | 84·0% (75·0–93·0) |
| 25 years | one | 136 | 72·0% (58·0–95·0) |
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Vii unique instance serial reported survival for 742 UKRs, with follow-up ranging from fifteen years to 25 years. Four series reported survival at xv years (387 UKRs), four at twenty years (437 UKRs), and ane at 25 years (136 UKRs). Not all series reported survival at exactly 15 years, xx years, or 25 years, and some serial reported survival at more than one timepoint. Pooled analysis of information derived from instance series reported at exactly fifteen years, 20 years, and 25 years showed an all-crusade construct survivorship of 85·5% (95% CI 82·2–88·seven) at fifteen years, 81·9% (77·9–85·nine) at 20 years, and 72·0% (58·0–95·0) at 25 years. Figure 2B shows a forest plot for the meta-assay of the data on UKRs derived from case serial at xv years, 20 years, and 25 years.
Pooled survival at each timepoint tin can be seen in table ii. When we rounded survival at timepoints that were non exactly 15 years, twenty years, or 25 years down to the closest timepoint (to include as many series as possible in our analyses), pooled survival was 85·three% (95% CI 82·0–88·six) at 15 years, 82·2% (78·6–85·9) at xx years, and 72·0% (58·0–95·0) at 25 years (appendix).
The search of articulation replacement registry reports yielded 47 series reporting TKRs and five reporting UKRs. The estimates from these series all originated from the Australian and Finnish registries. The other four arthroplasty registries with 15 years of potential follow-up did not provide survival estimates that were broken down by implant type, and therefore we could not use them in our analyses.
All 47 TKR series reported survival analyses at 15 years (299 291 TKRs), 20 series reported survival at 20 years (88 532 TKRs), and xiv series at 25 years (76 651 TKRs). The pooled survival data derived from registry information showed an all-cause construct survivorship of 93·0% (95% CI 92·8–93·i) at 15 years, 90·1% (89·7–xc·iv) at 20 years, and 82·3% (81·3–83·2) at 25 years. We obtained 15 year estimates from both the Australian and the Finnish registries and the 20 twelvemonth and 25 year estimates were exclusively from the Finnish registry.
We obtained all data on UKRs exclusively from the Finnish registry. All five UKR series reported survival analyses at 15 years (7714 UKRs), four serial reported survival at 20 years (3935 UKRs), and four series at 25 years (3935 UKRs). The pooled survival data derived from registry information showed an all-cause construct survivorship of 76·5% (95% CI 75·2–77·seven) at 15 years, 71·6% (69·six–73·6) at 20 years, and 69·eight% (67·half dozen–72·1) at 25 years.
Forest plots for the meta-analysis of data derived from articulation replacement registry reports for TKR and UKR are provided in Figure 3, Effigy four.
A comparison of the bespeak estimates at each timepoint for the ii sources is shown for TKR and UKR (effigy v).
Effigy 5 Comparison of pooled survival estimates for knee replacements from case serial and registry reports at 15 years, 20 years, and 25 years
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(A) Total knee replacements. (B) Unicondylar articulatio genus replacements. The size of the circle representing each bespeak approximate is proportional to the full number of hip replacements at the start of all the series contributing to that pooled approximate. Bars indicate 95% CIs. TKR=total articulatio genus replacement. UKR=unicondylar articulatio genus replacements.
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Discussion
The question of how long does a knee replacement last is frequently asked past patients, and to date, we have not had a generalisable answer. The implant itself is fundamental to the survival effect of surgery and each private series should be considered as a different patient accomplice. We have used individual estimates for each implant to synthesise a single pooled estimate, weighting the estimates according to standard fault. This type of assay, which derives an overall estimate according to how frequently each implant has been used, is unique to our written report. The pooled registry information presented here show that 82·3% of TKRs and 69·8% of UKRs last 25 years. Just one example serial reported the 25 year survival of UKRs (72·0%, 95% CI 58·0–95·0) and no TKR series provided 25 year results. Case series at 20 years of follow-up propose amend survival of TKR and UKR than comparable registry data. Although survival of a knee replacement prosthesis is important, it is not the only measure of success. 1 in 5 patients who undergo TKR for osteoarthritis reports an unfavourable pain outcome later surgery,
33
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and given our results, not all these patients seem to undergo revision surgery. The age of the patients in our report is similar to that reported past the largest national registries, such as the National Articulation Registry for England, Wales, Northern Ireland, and the Isle of man (NJR) and the Swedish Knee Arthroplasty Register (SKAR), suggesting that our data are likely to be generalisable. The proportion of female patients appears to be higher in the Finnish Arthroplasty Register than in the Australian registry or the pooled results of the case series, and this loftier proportion might impact the generalisability of the results. Given the secular changes in the sex distribution of patients receiving genu replacements seen in the SKAR, nosotros wait this effect to be minor.
In the NJR, the median age of patients undergoing knee replacement surgery is 70 years and 57% are women, and similarly the SKAR reports the mean historic period of patients having human knee replacements in 2016 to be 69 years and 57% of patients to be women.
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National Joint Registry
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,
The higher survival estimates at 20 years reported past case series are notable, just not surprising. Like findings were seen by Pabinger and colleagues,
who reported the mean proportion of TKRs needing revision to exist fifty% higher in registries than in case series. Nosotros also saw the aforementioned upshot in our analysis of the survival of hip replacements.
Differences in reported survival betwixt registries and example series could exist due to bias inherent to the reporting of case series, including selection and reporting bias. Our results back up this theory by showing publication bias in case serial. Several registry TKR construct series report survival that is well below our pooled estimate (figure iii); notwithstanding, this effect is non present in case series (figure 2A). These findings suggest that the about poorly performing constructs are non reported and published in example series.
We identified 34 systematic reviews in our search, many of which attempted to report pooled survival of knee replacement. Even so, nigh all these reviews focus on the comparing of different types of knee replacement (cemented vs cementless, mobile vs fixed bearing, or UKR vs TKR); we believe that, methodologically, these reviews are susceptible to selection bias, and we therefore created 1 pooled consequence for each blazon of genu replacement. In 2017, van der List and colleagues
published a review that gave a xv year survival estimate extrapolated from shorter-term information and only included cementless implants, and and then is susceptible to pick bias. Just 15·i% of all primary knee operations in the 2016 NJR were reported to apply cementless implants, then their results are not generalisable.
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A study in 2014 by Niinimaki and co-workers
38
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analysed Finnish registry data to judge the age and sex activity-adjusted survival of TKR and UKR at 15 years. The authors provide 15 twelvemonth survival estimates of 88·7% (95% CI 88·5–88·nine) for TKR and 69·6% (68·2–seventy·9) for UKR, figures that are lower than the estimates produced past our pooled analyses. These findings might exist because Niinimaki and co-workers
38
- Niinimaki T
- Eskelinen A
- Makela Yard
- Ohtonen P
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Unicompartmental knee arthroplasty survivorship is lower than TKA survivorship: a 27-year Finnish registry study.
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only used data from 1985 to 2011, and did not include results from the Australian registry. The authors noted the varying survival betwixt dissimilar implants, further supporting our differentiation past the implant used. Assay of the UK Clinical Practice Enquiry Datalink database by Bayliss and colleagues
estimated survival of full knee replacement to be 89·vii% (95% CI 87·5–91·5) at 20 years, which is consistent with our analysis.
We excluded ten articles that did not report CIs and seven that did not report all-cause construct survival. These articles could have increased the number of series included in our study past fifty%, which further highlights the heterogeneity and low-quality reporting of case series. The methods of survival analysis varied among identified articles, with many using Kaplan-Meier;
still, life-tabular array methods, such equally those described past Armitage,
were besides used.
Some manufactures reported xv twelvemonth survival of implants earlier 15 years hateful follow-upward had been reached, and therefore did not run across our inclusion criteria. We noted a trend towards the use of a competing risks method, believed past some to be a more accurate estimate of survival, given the high mortality seen in arthroplasty cohorts.
,
43
- Melton JTK
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,
,
Every bit we discuss in another paper,
competing risks and Kaplan-Meier methods are not more or less accurate than each other, but simply report unlike phenomena. The heterogeneity observed in example series reinforces the importance of results from arthroplasty registries that are more consistent in their use of assay techniques.
Our report did accept some limitations. Our pooled data were non adapted or stratified past patient factors that might have a role in determining survivorship, such as age, sex, or indication for the principal process. This detail is not provided in the data available to united states of america and would require collaboration betwixt registries with private patient data. We provide an aggregated estimate for survival in all patients and, to our knowledge, this report is the beginning of its blazon with this length of follow-upwardly. Every bit with all survival reports, we cannot account for a surgeon'south willingness to revise a knee joint replacement based upon private patient factors. This revision threshold might change between countries and bear upon the generalisability of results betwixt nations. Our pooled registry results are drawn only from Australia and Finland, with twenty yr and 25 year TKR data and all UKR information coming exclusively from Republic of finland. Although this pocket-size number of countries provides express geographical capture, the number of knee replacements included from registries is notwithstanding far greater than that from example serial; for TKR this number is 299 291 compared with 6490 knees, and in UKR this number is 7714 compared with 742 knees. Nosotros excluded papers that were not written in English, which removed 9 further series. If all these case series had met the inclusion criteria, they might have altered our pooled results, merely nosotros look this effect would have been small. We assume that survival estimates are equivalent to risks, for generating pooled estimates, and although the assumption that no censoring occurs (patients dying with a knee replacement in situ) is clearly violated, this assumption provides a useful method of assemblage in the absenteeism of private patient-level data. The number of UKRs at risk in the 25 twelvemonth follow-up group was less than 25 constructs in ii of our included registry series. Although the accuracy of Kaplan-Meier estimates should be questioned when the number at take chances is this small, this sample size is reflected in the weighting of estimates for our pooled results. The strengths of our study include an inclusive and comprehensive design, a-priori inclusion criteria, and a realistic estimation of survivorship accounting for all revision operations and not a limited or biased subset of a detail indication for revision. From the patient perspective, any subsequent re-performance carries risks, and therefore all revisions should exist counted.
In determination, pooled survival derived from case series appears to testify a more optimistic estimate than pooled registry information. Given this finding and the bias inherent in published case serial, we believe registry data to exist the more than accurate estimate. Non enough information is yet available to tell u.s.a. exactly how long a TKR or UKR lasts; however, using available arthroplasty registry information, 82% of TKRs and lxx% of UKRs last 25 years in patients with osteoarthritis (video).
This online publication has been corrected. The corrected version commencement appeared at thelancet.com on Feb 20, 2019
Contributors
JTE was responsible for report concept, design, screening, data extraction, data analysis, and writing of this manuscript. RWW and JPE completed the second screening of abstracts, 2nd extraction of data, and review of the manuscript. AWB and MRW were responsible for report concept, design, and writing of the manuscript. Every bit was responsible for written report concept, design, data analysis, and writing of the manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
This study was supported past the UK National Establish for Health Inquiry (NIHR) Biomedical Research Centre at the University Hospitals Bristol National Health Service (NHS) Foundation Trust and the University of Bristol, UK. The views expressed in this publication are our own and not necessarily those of the NHS, the NIHR, or the Uk Department of Health. JTE was supported past a articulation National Joint Registry of England, Wales, Northern Ireland, and the Isle of man and Purple College of Surgeons of England fellowship. AS was supported by a Medical Research Council (MRC) strategic skills fellowship ( MR/L01226X/1 ). Nosotros thank the library and information service at Southmead Hospital, Due north Bristol NHS Trust for their help in recovering full-text articles.
Supplementary Materials
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Article Info
Publication History
Published: 16 February 2019
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DOI: https://doi.org/ten.1016/S0140-6736(xviii)32531-5
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© 2019 The Authors. Published by Elsevier Ltd.
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Evans JT, Walker RW, Evans JP, Blom AW, Sayers A, Whitehouse MR. How long does a knee replacement concluding? A systematic review and meta-analysis of case series and national registry reports with more than than fifteen years of follow-up. Lancet 2019; 393: 655–63—In this Article, the Summary has been corrected to include the National Plant for Health Research as a funder. This is an Open Admission article under the CC By four.0 licence, and the copyright statement in the Summary has been updated accordingly. These corrections have been made to the online version as of Feb 20, 2019.
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- Knee and hip replacements and the adventure of revision
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We read with interest the Articles by Jonathan Evans and colleaguesane,2 on implant survival after knee and hip replacements. Based on an exhaustive literature review and meta-analysis, the authors found long-term implant survival to exist improve than was generally thought.
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- Human knee and hip replacements and the risk of revision – Authors' reply
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We thank Edward Burn and colleagues, Michael Tanzer, and Ze-Yu Luo and colleagues for their comments on our Manufactures.one,ii
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