Abstract
SummaryBackgroundTotal joint replacements for end-stage osteoarthritis of the hip and knee are cost-effective and demonstrate significant clinical improvement. However, robust population based lifetime-risk data for implant revision are not available to aid patient decision making, which is a particular problem in young patient groups deciding on best-timing for surgery.MethodsWe did implant survival analysis on all patients within the Clinical Practice Research Datalink who had undergone total hip replacement or total knee replacement. These data were adjusted for all-cause mortality with data from the Office for National Statistics and used to generate lifetime risks of revision surgery based on increasing age at the time of primary surgery.FindingsWe identified 63 158 patients who had undergone total hip replacement and 54 276 who had total knee replacement between Jan 1, 1991, and Aug 10, 2011, and followed up these patients to a maximum of 20 years. For total hip replacement, 10-year implant survival rate was 95·6% (95% CI 95·3–95·9) and 20-year rate was 85·0% (83·2–86·6). For total knee replacement, 10-year implant survival rate was 96·1% (95·8–96·4), and 20-year implant survival rate was 89·7% (87·5–91·5). The lifetime risk of requiring revision surgery in patients who had total hip replacement or total knee replacement over the age of 70 years was about 5% with no difference between sexes. For those who had surgery younger than 70 years, however, the lifetime risk of revision increased for younger patients, up to 35% (95% CI 30·9–39·1) for men in their early 50s, with large differences seen between male and female patients (15% lower for women in same age group). The median time to revision for patients who had surgery younger than age 60 was 4·4 years.InterpretationOur study used novel methodology to investigate and offer new insight into the importance of young age and risk of revision after total hip or knee replacement. Our evidence challenges the increasing trend for more total hip replacements and total knee replacements to be done in the younger patient group, and these data should be offered to patients as part of the shared decision making process.FundingOxford Musculoskeletal Biomedical Research Unit, National Institute for Health Research.
Highlights
Hip and knee replacements have been routinely done for the treatment of end-stage arthritis over the past 40 years;[1,2 76 000] total hip replacements and 82 000 total knee replacements were done in 2014 in the UK alone,[3] with the greatest increase in the number of total knee replacements in recent years
Between Jan 1, 1991, and Dec 31, 2011, 117 434 patients were identified from the database as having undergone a total hip replacement (n=63 158) or total knee replacement (n=54 276) during the study period
For women between the ages of 50 and 60 years at primary surgery, the lifetime risk of revision (LTRR) does not change a great deal for total hip replacement and increases by a few percentage points for total knee replacement
Summary
Hip and knee replacements have been routinely done for the treatment of end-stage arthritis over the past 40 years;[1,2 76 000] total hip replacements and 82 000 total knee replacements were done in 2014 in the UK alone,[3] with the greatest increase in the number of total knee replacements in recent years. The outcomes of joint replacements are determined in several different ways, including mortality[4,5] and morbidity rates after surgery, functional outcome and satisfaction recorded as patient-reported outcome scores,[6] and by rates of failure of the implant leading to revision surgery.[3,7] Total hip replacement and total knee replacement have demonstrated improved function,[8] reduced pain, and improved quality of life[9] for patients, and are cost-effective.[9] Predictions are that in the 10–20 years primary joint replacement rates will substantially increase, as a consequence of an ageing population, and because of increasing use in patients younger than age 60 years,[10] who currently represent 15% of the entire population undergoing surgery, but might increase in the future.[11] This rise in the number of patients younger than 60 years undergoing surgery is a concern because joint registries reveal that 10-year revision rates in this group are higher than for older age groups.[3] For all patients, the decision to have surgery is largely based on the balance between potential risk and benefit. Robust population based lifetime-risk data for implant revision are not available to aid patient decision making, which is a particular problem in young patient groups deciding on besttiming for surgery
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