Articles

How long does a knee replacement last? A systematic review

and meta-analysis of case series and national registry reports
with more than 15 years of follow-up
Jonathan T Evans, Robert W Walker, Jonathan P Evans, Ashley W Blom, Adrian Sayers*, Michael R Whitehouse*

Summary
Background Knee replacements are the mainstay of treatment for end-stage osteoarthritis and are effective. Given Lancet 2019; 393: 655–63
time, all knee replacements will fail and knowing when this failure might happen is important. We aimed to establish *Joint senior authors
how long a knee replacement lasts. Musculoskeletal Research Unit,
Translational Health Sciences,
Bristol Medical School,
Methods In this systematic review and meta-analysis, we searched MEDLINE and Embase for case series and cohort
University of Bristol,
studies published from database inception until July 21, 2018. Articles reporting 15 year or greater survival of primary Southmead Hospital, Bristol,
total knee replacement (TKR), unicondylar knee replacement (UKR), and patellofemoral replacements in patients UK (J T Evans MRCS,
with osteoarthritis were included. Articles that reviewed specifically complex primary surgeries or revisions were Prof A W Blom PhD,
A Sayers MSc,
excluded. Survival and implant data were extracted, with all-cause survival of the knee replacement construct being
M R Whitehouse PhD);
the primary outcome. We also reviewed national joint replacement registry reports and extracted the data to be Department of Trauma and
analysed separately. In the meta-analysis, we weighted each series and calculated a pooled survival estimate for each Orthopaedics, Torbay and
data source at 15 years, 20 years, and 25 years, using a fixed-effects model. This study is registered with PROSPERO, South Devon NHS Foundation
Trust, Torquay, UK
number CRD42018105188. (R W Walker MRCS); Health and
Policy Research Group,
Findings From 4363 references found by our initial search, we identified 33 case series in 30 eligible articles, which University of Exeter, Exeter, UK
reported all-cause survival for 6490 TKRs (26 case series) and 742 UKRs (seven case series). No case series reporting on (J P Evans MSc); and National
Institute for Health Research
patellofemoral replacements met our inclusion criteria, and no case series reported 25 year survival for TKR. The Bristol Biomedical Research
estimated 25 year survival for UKR (based on one case series) was 72·0% (95% CI 58·0–95·0). Registries contributed Centre, University Hospitals,
299 291 TKRs (47 series) and 7714 UKRs (five series). The pooled registry 25 year survival of TKRs (14 registries) was Bristol NHS Foundation Trust,
82·3% (95% CI 81·3–83·2) and of UKRs (four registries) was 69·8% (67·6–72·1). University of Bristol, Bristol,
UK (Prof A W Blom,
M R Whitehouse)
Interpretation Our pooled registry data, which we believe to be more accurate than the case series data, shows that
Correspondence to:
approximately 82% of TKRs last 25 years and 70% of UKRs last 25 years. These findings will be of use to patients and Mr Jonathan T Evans,
health-care providers; further information is required to predict exactly how long specific knee replacements will last. Musculoskeletal Research Unit,
Translational Health Sciences,
Bristol Medical School, University
Funding The National Joint Registry for England, Wales, Northern Ireland, and Isle of Man and the Royal College of of Bristol, Southmead Hospital,
Surgeons of England. Bristol BS10 5NB, UK
j.t.evans@bristol.ac.uk
Copyright © 2019 Elsevier Ltd. All rights reserved.

Introduction loosening, infection, persistent pain, and instability,2 and

Osteoarthritis of the knee is a common and potentially
debilitating condition. The mainstay of treatment for end-
stage disease is knee replacement, and this procedure has
been shown to be effective in most cases.1 Depending
upon the extent of disease, replacement surgery can take
the form 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 one compartment and only 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 function. Unfortunately,
knee replacements fail for a variety of reasons, including
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 enough time, all knee
replacements will fail and need to be revised. Revision is
expensive3,4 and results in worse outcomes than primary
surgery.
The National Institute of Health and Care Excellence
set a UK benchmark in 2014, which stated that individual
hip replacement components are only recommended if
5% or fewer need revision at 10 years,5 but no equivalent
benchmark exists for knee replacement in either the
medium (10 years) or long term.
In the UK, in 2016, the typical patient requiring knee
replacement was aged 69 years with a body-mass index
of 31 kg/m². Almost all (99%) knee replacements were

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Research in context
Evidence before this study
We 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 estimate with more than 15 years follow-up,
and although many reviews compared subgroups (eg,
cemented vs cementless), we believe these studies to be prone
to selection bias. Before the advent of national joint
replacement registers, case series were the only sources of
survival estimates for knee replacements. A previous analysis
of the Finnish Arthroplasty Registry provided an estimate of
the survival of total knee replacement at 15 years of 88·7%
(95% CI 88·5–88·9) for total knee replacement (TKR) and
69·6% (68·2–70·9) for unicondylar knee 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 89·7% (95% CI 87·5–91·5) at 20 years.
Added value of this study
To our knowledge, we have provided the first simple and
generalisable estimate of the survival of knee replacements at
25 years, providing an answer to the question—how long does a
knee replacement last? Our findings showed that approximately
82% of TKRs and 70% of UKRs last for 25 years.
Implications of all the available evidence
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-care services, and those needing an estimate of knee
replacement survival for medicolegal purposes.

replacement pro­cedures; 18 different UKR implants and

4363 potentially eligible case series or cohort studies nine different PFR implants were used.6
identified by search of database
In this study, we wish to answer a simple question that
is posed to us by our patients, multiple times per day—
1481 duplicates identified how long does a knee replacement last?

2882 non-duplicate citations

Methods
Search strategy and selection criteria
This systematic review and meta-analysis followed
2670 excluded after screening a predefined protocol registered with PROSPERO
1072 insufficient follow-up
787 not primary TKRs (CRD42018105188) and adhered to PRISMA guidelines.7
471 no survival analysis We did one systematic review and meta-analysis of case
316 disease-specific indication other than osteoarthritis
24 duplicates that were not identified previously series and cohort studies reporting survival outcomes of
knee replacements and a second meta-analysis of
national joint replacement registries with more than
212 full-text articles reviewed
15 years of follow-up.
We systematically searched MEDLINE and Embase for
184 excluded case series and cohort studies that reported survival
83 insufficient follow-up or no survival analysis outcomes of knee replacements, published between com­
34 systematic reviews
11 articles based on registry data mencement of each database and July 21, 2018.
2 additional articles identified from 10 no CIs provided The search was done through the Ovid SilverPlatter
manual search of references 46 other
platform and contained keywords relating to knee
replacement, survival, and medical subject heading terms
30 articles included (33 unique case series) (see appendix for details of exact search terms used).
Bibliographies of all included articles, as well as review
articles, were manually screened for additional citations
(JTE). Nine studies were excluded because they were
26 series reporting TKR survival 7 series reporting UKR survival 0 series reporting PFR survival
included in quantitative included in quantitative included in quantitative not written in English. Studies were included if they
synthesis (meta-analysis) synthesis (meta-analysis) synthesis (meta-analysis) involved patients undergoing any type of knee replacement
(TKR, UKR, or PFR) for osteoarthritis or a predominantly
Figure 1: Flow chart of case series and cohort study selection unselected patient group (eg, studies that investigated
TKR=total knee replacement. UKR=unicondylar knee replacement. PKR=patellofemoral replacement. only one or two indications, such as rheumatoid arthritis,
were excluded). Survival reports of specific implants with
See Online for appendix done in patients with osteoarthritis and 56% of patients a mean or median follow-up of more than 15 years were
were women.3 In 2016, 108 713 knee replacement required. Articles that reviewed specifically complex
procedures were done in England, Wales, Northern primary surgeries or revisions were excluded, because
Ireland, and the Isle of Man.3 60 different implants were these types of procedures have different survivorship of
used for primary TKR, comprising 90·1% of all knee the implants. Some articles reported sur­vivorship from

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registry data; we excluded these studies because 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 first national joint replacement registry was
founded in Sweden in 1975; at the time of writing,
six registries have more than 15 years of potential follow-
up for knee replacement (those in Australia, Denmark,
Finland, New Zealand, Norway, and Sweden). For the
analysis of data from national joint replacement registries,
we reviewed websites and the most recent annual reports
of national joint replacement registries with 15 years of
follow-up at the time of data collection (July 21, 2018) for
15 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 articles were screened by three
reviewers (JTE, RWW, and JPE) using the web application
Rayyan,8 and in cases of disagreement were included for
full review. Data were extracted twice on publication
date, implant type, fixation technique, number of knee
replacements, age and sex of recipient, indication for
knee replacement, loss to follow-up, and summary
survivorship estimates (including CIs), when available.
Data were not extracted from figures to prevent potential
inaccuracy, particularly in the case of older, low-reso­
lution figures. Any discrepancy between the twice-
extracted data was rectified by review of the full text by
all reviewers, after which there were no cases of
disagreement.
Data analysis
Our primary exposure was the make and model of the
knee replacement construct and our primary 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 fundamental to the outcome of surgery. Aggre­
gated data from multiple constructs would not allow this
level of detail and would thus hide the variability in
performance between constructs. Statistical analysis
was done with Stata 15 (release 15). Knee replacement
construct survival estimates at 15 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 data.
Data from registries were analysed in the same way
as data from the case series to produce equivalent
forest plots. The contribution each implant series made
was weighted according to the standard error of that
individual estimate.
Study quality was assessed using the non-summative
four-point system (consecutive cases, multicentre, under
20% loss to follow-up, and using multivariable analysis)
developed by Wylde and co-workers.9 This system was
preferred over the summative MINORS score because of
the high loss to follow-up in joint replacement case series
and because some of the scoring criteria were not
relevant to joint replacement.10

Individual case series articles Australian Orthopaedic Finnish Arthroplasty Report,

Association National Joint November, 2017
Replacement Registry annual
report, 2017
TKR UKR TKR UKR TKR UKR
Study-level characteristics
Location 26 articles in Seven articles in Australia Australia Finland Finland
ten countries four countries
Number of unique implant series included 26 7 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
Mean age (years) 67·3* 68·7* 68·5† NA 65–74‡§ 65–74‡§
Proportion of female patients 55·4%¶ 65·0%¶ 56·8%† NA 68·4%†§ 68·4%†§
Proportion of arthroplasties implanted for 87·5%|| 93·7%|| 97·6%† NA 88·9%†§ 88·9%†§
osteoarthritis

TKR=total knee replacement. UKR=unicondylar knee replacement. NA=not applicable. *Weighted mean for age by number of arthroplasties in series. †All primary knee
operations in the report (not just those included in study). ‡Exact value not 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. ¶Weighted proportion of female patients by number in study if the
proportion of women was reported. ||Weighted proportion by number of arthroplasties in series if reported.

Table 1: Study-level and participant-level characteristics of contributing data sources

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This study is registered with PROSPERO, number
CRD42018105188.
Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
A Survival Weight
(%; 95% CI) (%)
15 years
Abdeen et al (2010)11 88·7 (71·8–91·8) 0·32
Callaghan et al (2005)12 97·0 (89·0–100·0) 1·07
Dixon et al (2005)13 92·6 (86·0–98·0) 0·90
Gill et al (1999)14 98·6 (90·5–99·8) 1·49
Hernigou et al (2009)15 91·0 (85·0–97·0) 0·90
Hernigou et al (2009)15 92·0 (90·0–94·0) 8·08
Kim et al (2018)16 99·0 (93·0–100·0) 2·64
99·0 (93·0–100·0) 2·64
Kim et al (2018)16
Macheras et al (2017)17 98·8 (97·6–100·0) 22·45
McCalden et al (2017)18 96·4 (95·5–97·3) 39·91
Nakamura et al (2017)19 96·2 (94·1–98·3) 7·33
78·7 (56·2–100·0) 0·07
Newman et al (2009)20
92·3 (84·9–96·2) 1·01
Oliver et al (2018)21
94·7 (90·9–98·5) 2·24
Schiavone Panni et al (2017)22
Vessely et al (2006)23 93·7 (91·8–95·6) 8·95
Subtotal 96·3 (95·7–96·9) 100·00
20 years
Callaghan et al (2013)24 90·8 (83·0–97·0) 10·54
Callaghan et al (2010)25 96·5 (92·6–100·0) 37·74
Epinette et al (2014)26 91·4 (87·2–96·3) 24·95
84·4 (70·8–97·6) 2·88
Eriksen et al (2009)27
Gill et al (1999)14 98·6 (90·5–99·8) 23·89
Subtotal 94·8 (92·5–97·1) 100·00
B or 20 years showed an all-cause construct survivorship
15 years
Argenson et al (2013)28 83·0 (79·0–87·0) 66·37
Foran et al (2013)29 93·0 (83·0–98·0) 18·88
Newman et al (2009)20 89·8 (74·3–100·0) 6·43
Yang et al (2003)30 84·6 (73·3–95·9) 8·32
Subtotal 85·5 (82·2–88·7) 100·00
20 years
Argenson et al (2013)28 74·0 (67·0–81·0) 32·80
Foran et al (2013)29 90·0 (79·0–96·0) 22·25
O’Rourke et al (2005) 31
84·0 (76·0–92·0) 25·11
Parratte et al (2012)32 83·0 (74·0–92·0) 19·84
Subtotal 81·9 (77·9–85·9) 100·00
25 years
O’Rourke et al (2005)31 72·0 (58·0–95·0) 100·00
0 10 20 30 40 50 60 70 80 90 100
Figure 2: Forest plot of estimates for reported survival of knee replacements from case series
(A) Total knee replacements at 15 years and 20 years. (B) Unicondylar knee replacements at 15 years, 20 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 estimate, weighted by the standard error of that
individual series.
658 www.thelancet.com Vol 393 February 16, 2019
the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication.
Results
The search of published case series produced 4363 articles.
1481 duplicates were removed, leaving 2882 articles
for screening (figure 1). After screening, 212 full-text
articles remained for review, with two additional citations
identified through manual search of references and
reviews (appendix). Nine articles that were not written
in English were excluded. Following review of full-text
articles, 30 journal articles reporting 33 unique case
series were included; these articles reported 7232 knee
replacements (range 50–1000). 26 case series reported
survival of TKRs and seven reported survival of UKRs; no
case series reporting on PFR met our inclusion criteria.
A full list 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).
Quality assessment of the case series revealed that
22 (67%) of 33 were consecutive, 1 (3%) of 33 were
multicentre, all 33 (100%) had less than 20% loss to
follow-up, and only 4 (12%) of 33 included multivariable
analyses. These proportions reflect the fact that, in
general, the quality of published case series is low.
26 unique case series reported survival for 6490 TKRs,
with follow-up ranging from 15 years to 23 years. 14 series
reported survival at 15 years (4137 TKRs) and five at
20 years (763 TKRs). Not all series reported survival at
exactly 15 years or 20 years and some series reported
survival at more than one timepoint. Pooled analysis of
data derived from case series reported at exactly 15 years
of 96·3% (95% CI 95·7–96·9) at 15 years and 94·8%
Number Total number of Pooled survival
of series arthroplasties at the estimate (95% CI)
start of the series
Total knee replacement
15 years 15 4137 96·3% (95·7–96·9)
16·8 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% (92·8–99·4)
20 years 5 763 94·8% (92·5–97·1)
20·8 years 1 160 86·9% (80·4–91·5)
22 years 1 163 82·1% (76·2–88·0)
23 years 1 489 89·0% (82·0–93·0)
Unicondylar knee replacement
15 years 4 387 85·5% (82·2–88·7)
16 years 1 113 81·3% (67·7–94·8)
20 years 4 437 81·9% (77·8–85·9)
22 years 1 140 84·0% (75·0–93·0)
25 years 1 136 72·0% (58·0–95·0)
Table 2: Pooled estimates of survival for each available timepoint
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(92·5–97·1) at 20 years. Figure 2A shows a forest plot for

the meta-analysis of data on TKRs derived from case Registry Survival Weight
series at 15 years and 20 years. (%; 95% CI) (%)
Pooled survival at each timepoint is shown in table 2. 15 years
AGC/AGC Australian
When we rounded survival at timepoints that were Advance/Advance II Australian
92·6 (91·4–93·6) 1·77
92·2 (90·3–93·8) 0·70
not exactly 15 years or 20 years down to the closest Advantim/Advantim Australian 93·6 (91·2–95·3) 0·51
Duracon/Duracon Australian 92·9 (92·4–93·4) 8·58
time­point (to include as many case series as possible in Genesis II CR/Genesis II Australian 94·2 (93·6–94·8) 5·96
Genesis II CR/Profix Mobile Australian
our analyses), pooled survival was 96·3% (95% CI Genesis II Oxinium CR/Genesis II Australian
88·8 (86·2–90·9)
89·0 (85·7–91·5)
0·39
0·26
95·7–96·8) at 15 years and 92·0% (90·1–93·8) at Genesis II PS/Genesis II
Kinemax Plus/Kinemax Plus
Australian
Australian
93·4 (92·3–94·3) 2·15
91·5 (89·6–93·0) 0·74
20 years (appendix). LCS CR/LCS Australian 92·2 (91·5–92·8) 5·08
LCS CR/MBT Australian 93·9 (93·2–94·6) 4·38
Seven unique case series reported survival for 742 UKRs, LCS CR/MBT Duofix Australian 92·8 (91·8–93·7) 2·38
MBK (Zimmer)/Nexgen Australian
with follow-up ranging from 15 years to 25 years. Maxim/Maxim Australian
92·0 (88·5–94·5) 0·24
88·9 (86·1–91·1) 0·34
Four series reported survival at 15 years (387 UKRs), Natural Knee II/Natural Knee II Australian 89·4 (87·8–90·9) 0·89
Nexgen CR/Nexgen Australian 95·6 (95·0–96·1) 7·09
four at 20 years (437 UKRs), and one at 25 years Nexgen LPS/Nexgen Australian 93·7 (92·7–94·5) 2·65
PFC Sigma CR/MBT Australian
(136 UKRs). Not all series reported survival at exactly PFC Sigma CR/PFC Sigma Australian
93·9 (92·8–94·8)
94·9 (94·1–95·5)
2·15
4·38
15 years, 20 years, or 25 years, and some series reported PFC Sigma PS/PFC Sigma
Profix/Profix
Australian
Australian
92·7 (91·1–94·1) 0·95
94·5 (93·8–95·2) 4·38
survival at more than one time­point. Pooled analysis of Scorpio CR/Series 7000 Australian 93·3 (92·6–93·9) 5·08
Scorpio PS/Scorpio+ Australian 91·5 (89·5–93·1) 0·66
data derived from case series reported at exactly 15 years, Scorpio PS/Series 7000 Australian 88·5 (85·9–90·6) 0·39
Anametric Finnish
20 years, and 25 years showed an all-cause construct Guepar hinged Finnish
83·2 (79·4–87·1) 0·14
0·02
78·4 (69·6–88·4)
survivorship of 85·5% (95% CI 82·2–88·7) at 15 years, Kinematic stab
Duracon
Finnish 90·9 (86·6–95·4) 0·11
Finnish 92·2 (91·8–92·6) 13·41
81·9% (77·9–85·9) at 20 years, and 72·0% (58·0–95·0) PCA Interax DI Finnish 73·9 (69·4–78·8) 0·10
AGC V2 Finnish 7·09
at 25 years. Figure 2B shows a forest plot for the meta- AGCV2/Maxim Finnish
90·6 (90·1–91·2)
89·9 (87·5–94·6) 0·17
AGC Dual articular
analysis of the data on UKRs derived from case series Duracon Rotating Hinge
Finnish
Finnish
90·2 (86·2–94·4) 0·13
91·7 (88·7–94·7) 0·24
at 15 years, 20 years, and 25 years. Duracon TS Finnish 82·8 (76·8–89·3) 0·05
Kinematic Rotating Hinge Finnish 79·7 (70·7–89·8) 0·02
Pooled survival at each timepoint can be seen in table 2. PFC Sigma Finnish 92·9 (92·3–93·4) 7·09
PFC Sigma RP Finnish
When we rounded survival at timepoints that were not NexGen Finnish
93·8 (89·9–97·8)
96·1 (95·5–96·8)
0·14
5·08
exactly 15 years, 20 years, or 25 years down to the closest Maxim
Link Endo-Model
Finnish
Finnish
90·3 (88·8–91·9) 0·89
82·6 (78·3–87·3) 0·11
timepoint (to include as many series as possible in our Arge Finnish 93·1 (91·9–94·3) 1·49
Genesis II CR Finnish 96·2 (94·2–98·2) 0·54
analyses), pooled survival was 85·3% (95% CI 82·0–88·6) TCIV Finnish 87·0 (83·9–90·2) 0·22
Performance Finnish
at 15 years, 82·2% (78·6–85·9) at 20 years, and 72·0% PCA Finnish
85·0 (82·2–87·8) 0·27
70·0 (67·3–72·8) 0·28
(58·0–95·0) at 25 years (appendix). Freeman-Swanss Finnish 88·2 (84·6–91·9) 0·16
Synatomic Townley Finnish 68·7 (64·7–72·9) 0·13
The search of joint replacement registry reports Subtotal 93·0 (92·8–93·1) 100·00
yielded 47 series reporting TKRs and five reporting 20 years
UKRs. The estimates from these series all originated Anametric
Guepar hinged
Finnish
Finnish
76·5 (71·5–82·0) 0·43
78·4 (69·6–88·4) 0·13
from the Australian and Finnish registries. The other Kinematic stab Finnish 85·7 (79·4–92·5) 0·28
Duracon Finnish 89·7 (89·1–90·3) 32·92
four arthroplasty registries with 15 years of potential PCA Interax DI Finnish 69·8 (64·6–75·4) 0·41
AGC V2 Finnish
follow-up did not provide survival estimates that were AGCV2/Maxim Finnish
87·4 (86·6–88·2) 18·52
85·6 (77·5–94·6) 0·16
broken down by implant type, and therefore we could AGC Dual articular Finnish 80·7 (71·4–91·3) 0·12
Duracon TS Finnish 82·8 (76·8–89·3) 0·30
not use them in our analyses. Kinematic Rotating Hinge Finnish 72·2 (60·2–86·6) 0·07
PFC Sigma Finnish
All 47 TKR series reported survival analyses at 15 years NexGen Finnish
89·8 (88·8–90·9)
95·9 (95·2–96·6)
10·75
24·19
(299 291 TKRs), 20 series reported survival at 20 years Maxim
Link Endo-Model
Finnish
Finnish
88·6 (86·3–90·9) 2·24
77·3 (70·9–84·3) 0·26
(88 532 TKRs), and 14 series at 25 years (76 651 TKRs). The Arge Finnish 92·1 (90·6–93·7) 4·93
TCIV Finnish 84·5 (80·8–88·5) 0·80
pooled survival data derived from registry data showed Performance Finnish 82·2 (79·0–85·5) 1·12
PCA Finnish
an all-cause construct survivorship of 93·0% (95% CI Freeman-Swanss Finnish
63·7 (60·5–67·1)
87·4 (83·6–91·4)
1·09
0·78
92·8–93·1) at 15 years, 90·1% (89·7–90·4) at 20 years, and Synatomic Townley Finnish 61·9 (57·2–67·0) 0·49
Subtotal 90·1 (89·7–90·4) 100·00
82·3% (81·3–83·2) at 25 years. We obtained 15 year
25 years
estimates from both the Australian and the Finnish Anametric Finnish 76·5 (71·5–82·0) 3·29
registries and the 20 year and 25 year estimates were Guepar hinged
Kinematic stab
Finnish
Finnish
78·4 (69·6–88·4) 1·03
80·3 (71·3–90·5) 0·98
exclusively from the Finnish registry. Duracon Finnish 87·1 (85·5–88·8) 33·31
AGC V2 Finnish 84·1 (82·4–85·8) 31·37
We obtained all data on UKRs exclusively from the AGC Dual articular Finnish 80·7 (71·4–91·3) 0·92
Kinematic Rotating Hinge Finnish
Finnish registry. All five UKR series reported survival PFC Sigma Finnish
72·2 (60·2–86·6)
86·2 (83·2–95·6)
0·52
2·36
analyses at 15 years (7714 UKRs), four series reported Link Endo-Model Finnish 77·3 (70·9–84·3) 2·02
TCIV Finnish 84·5 (80·8–88·5) 6·12
Performance Finnish 80·3 (76·5–84·2) 6·12
PCA Finnish 61·0 (57·4–64·8) 6·62
Freeman-Swanss Finnish 85·5 (80·3–91·0) 3·17
Synatomic Townley Finnish 55·9 (49·8–62·7) 2·18
Subtotal 82·3 (81·3–83·2) 100·00
Figure 3: Forest plot of estimates for reported survival of total knee 0 10 20 30 40 50 60 70 80 90 100
replacements from registry reports at 15 years, 20 years, and 25 years

www.thelancet.com Vol 393 February 16, 2019 659

 Articles

Registry Survival Weight A

(%; 95% CI) (%) 4137 TKRs at start 763 TKRs at start
100 (15 series) (five series)
15 years
Oxford Phase II Finnish 74·8 (67·5–82·8) 2·57
Oxford Phase III Finnish 74·1 (72·2–76·0) 41·67
90
Milller-Galante Unicondylar Finnish 67·1 (61·8–73·0) 4·80 299 291 TKRs at start
88 532 TKRs at start
85·8 (83·8–87·9) 35·80 (47 series)
Milller-Galante II Finnish (20 series)
Miller-Galante I Finnish 64·1 (61·0–67·3) 15·16 80

Survival (%)
76 651 TKRs
Subtotal 76·5 (75·2–77·7) 100·00 at start
(14 series)
70
20 years
Oxford Phase II Finnish 58·3 (45·4–75·0) 1·80
Milller-Galante Unicondylar Finnish 62·2 (56·3–68·7) 10·26 60
Milller-Galante II Finnish 81·6 (79·0–84·2) 58·34
Miller-Galante I Finnish 56·0 (52·4–59·7) 29·60 Case series pooled estimate
71·6 (69·6–73·6) 100·00 50 Registry reports pooled estimate
Subtotal

0
25 years
Oxford Phase II Finnish 53·4 (39·5–72·4) 1·88
B
Milller-Galante Unicondylar Finnish 60·0 (53·6–67·0) 11·33 136 UKRs
100 at start
Milller-Galante II Finnish 80·0 (77·2–83·0) 60·50
(one series)
Miller-Galante I Finnish 51·8 (47·6–56·4) 26·28 387 UKRs at start
Subtotal 69·8 (67·6–72·1) 100·00 (four series) 437 UKRs at start
90
(four series)
0 10 20 30 40 50 60 70 80 90 100

Figure 4: Forest plot of estimates for reported survival of unicondylar knee replacements from registry 80
Survival (%)

reports at 15 years, 20 years, and 25 years

survival at 20 years (3935 UKRs), and four series at 70 7714 UKRs at start
(five series) 3935 UKRs at start
25 years (3935 UKRs). The pooled survival data derived (four series)
from registry data showed an all-cause construct 60
survivorship of 76·5% (95% CI 75·2–77·7) at 15 years, 3935 UKRs
71·6% (69·6–73·6) at 20 years, and 69·8% (67·6–72·1) at start
(four series)
at 25 years. 50
Forest plots for the meta-analysis of data derived from
0
joint replacement registry reports for TKR and UKR are 15 20 25
provided in figures 3 and 4. Time since surgery (years)

A comparison of the point estimates at each timepoint

for the two sources is shown for TKR and UKR (figure 5).
Discussion
The question of how long does a knee replacement last is
frequently asked by patients, and to date, we have not had
a generalisable answer. The implant itself is fundamental
to the survival outcome of surgery and each individual
series should be considered as a different patient
cohort. We have used individual estimates for each implant
to synthesise a single pooled estimate, weighting the
estimates according to standard error. This type of analysis,
which derives an overall estimate according to how
frequently each implant has been used, is unique to our
study. The pooled registry data presented here show that
82·3% of TKRs and 69·8% of UKRs last 25 years. Only
one case series 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 suggest
better 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. One in
Figure 5: Comparison of pooled survival estimates for knee replacements
from case series and registry reports at 15 years, 20 years, and 25 years
(A) Total knee replacements. (B) Unicondylar knee replacements. The size of the
circle representing each point estimate is proportional to the total number of
hip replacements at the start of all the series contributing to that pooled
estimate. Bars indicate 95% CIs. TKR=total knee replacement. UKR=unicondylar
knee replacements.
five patients who undergo TKR for osteoarthritis reports
an unfavourable pain outcome after surgery,33 and given
our results, not all these patients seem to undergo revision
surgery. The age of the patients in our study is similar to
that reported by the largest national registries, such as
the National Joint 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 high proportion might affect the
generalisability of the results. Given the secular changes in
the sex distribution of patients receiving knee replacements
seen in the SKAR, we expect this effect to be small.34 In

660 www.thelancet.com Vol 393 February 16, 2019


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 age of patients
having knee replacements in 2016 to be 69 years and
57% of patients to be women.2,34
The higher survival estimates at 20 years reported by
case series are notable, but not surprising. Similar find­
ings were seen by Pabinger and colleagues,35 who reported
the mean proportion of TKRs needing revision to be
50% higher in registries than in case series. We also saw
the same effect in our analysis of the survival of hip
replacements.36 Differences in reported survival between
registries and case series could be due to bias inherent to
the reporting of case series, including selection and
reporting bias. Our results support this theory by showing
publication bias in case series. Several registry TKR
construct series report survival that is well below our
pooled estimate (figure 3); however, this effect is not
present in case series (figure 2A). These findings suggest
that the most poorly performing constructs are not
reported and published in case series.
We identified 34 systematic reviews in our search, many
of which attempted to report pooled survival of knee
replacement. However, almost all these reviews focus on
the comparison 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
one pooled result for each type of knee replacement. In
2017, van der List and colleagues37 published a review that
gave a 15 year survival estimate extrapolated from shorter-
term data and only included cementless implants, and so
is susceptible to selection bias. Only 15·1% of all primary
knee operations in the 2016 NJR were reported to use
cementless implants, and so their results are not
generalisable.3 A study in 2014 by Niinimaki and co-
workers38 analysed Finnish registry data to estimate the age
and sex-adjusted survival of TKR and UKR at 15 years. The
authors provide 15 year survival estimates of 88·7%
(95% CI 88·5–88·9) for TKR and 69·6% (68·2–70·9) for
UKR, figures that are lower than the estimates produced
by our pooled analyses. These findings might be because
Niinimaki and co-workers38 only used data from 1985 to
2011, and did not include results from the Australian
registry. The authors noted the varying survival between
different implants, further supporting our differentiation
by the implant used. Analysis of the UK Clinical Practice
Research Datalink database by Bayliss and colleagues39
estimated survival of total knee re­placement to be 89·7%
(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 by 50%, which further
highlights the heterogeneity and low-quality reporting
of case series. The methods of survival analysis varied
www.thelancet.com Vol 393 February 16, 2019 661
Articles
among identified articles, with many using Kaplan-
Meier;40 however, life-table methods, such as those
described by Armitage,41 were also used.11 Some articles
reported 15 year survival of implants before 15 years
mean follow-up had been reached, and therefore did
not meet our inclusion criteria. We noted a trend
towards the use of a competing risks method, believed
by some to be a more accurate estimate of survival,
given the high mortality seen in arthroplasty cohorts.42–45
As we discuss in another paper,46 competing risks and
Kaplan-Meier methods are not more or less accurate
than each other, but simply report different phenomena.
The heterogeneity observed in case series reinforces
the importance of results from arthroplasty registries
that are more consistent in their use of analysis
techniques.
Our study did have some limitations. Our pooled
data were not adjusted or stratified by patient factors
that might have a role in determining survivorship,
such as age, sex, or indication for the primary procedure.
This detail is not provided in the data available to us
and would require collaboration between registries
with individual patient data. We provide an aggregated
estimate for survival in all patients and, to our
knowledge, this report is the first of its type with this
length of follow-up. As with all survival reports, we
cannot account for a surgeon’s willingness to revise a
knee replacement based upon individual patient factors.
This revision threshold might change between countries
and affect the generalisability of results between
nations. Our pooled registry results are drawn only
from Australia and Finland, with 20 year and 25 year
TKR data and all UKR data coming exclusively from
Finland. Although this small number of countries
provides limited geographical capture, the number of
knee replacements included from registries is still far
greater than that from case series; for TKR this number
is 299 291 compared with 6490 knees, and in UKR this
number is 7714 compared with 742 knees. We excluded
papers that were not written in English, which removed
nine further series. If all these case series had met the
inclusion criteria, they might have altered our pooled
results, but we expect 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 aggregation in
the absence of individual patient-level data. The number
of UKRs at risk in the 25 year follow-up group was less
than 25 constructs in two of our included registry series.
Although the accuracy of Kaplan-Meier estimates
should be questioned when the number at risk 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 interpretation
 Articles
of survivorship accounting for all revision operations
and not a limited or biased subset of a particular
indication for revision. From the patient perspective,
any subsequent re-operation carries risks, and therefore
all revisions should be counted.
In conclusion, pooled survival derived from case series
appears to show a more optimistic estimate than pooled
registry data. Given this finding and the bias inherent in
published case series, we believe registry data to be the
more accurate estimate. Not enough information is yet
available to tell us exactly how long a TKR or UKR lasts;
however, using available arthroplasty registry data,
82% of TKRs and 70% of UKRs last 25 years in patients
See Online for video with osteoarthritis (video).
Contributors
JTE was responsible for study concept, design, screening, data extraction,
data analysis, and writing of this manuscript. RWW and JPE completed
the second screening of abstracts, second extraction of data, and review
of the manuscript. AWB and MRW were responsible for study concept,
design, and writing of the manuscript. AS was responsible for study
concept, design, data analysis, and writing of the manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
This study was supported by the UK National Institute for Health
Research (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 by a joint National Joint
Registry of England, Wales, Northern Ireland, and the Isle of Man and
Royal College of Surgeons of England fellowship. AS was supported by a
Medical Research Council (MRC) strategic skills fellowship
(MR/L01226X/1). We thank the library and information service at
Southmead Hospital, North Bristol NHS Trust for their help in
recovering full-text articles.
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