Higher mid-term revision rates of posterior stabilized compared with cruciate retaining total knee arthroplasties: 133,841 cemented arthroplasties for osteoarthritis in the Netherlands in 2007–2016

Figures & data

Table 1. Patient characteristics of patients who received a cemented fixed-bearing primary total knee arthroplasty for osteoarthritis with cruciate retaining (CR) or posterior stabilized (PS) knee system in the Netherlands in 2007–2016

	CR TKA	PS TKA	Total
	(n = 60,546)	(n = 73,295)	(n = 133,841)
Mean age (SD)	69 (9.3)	69 (9.4)	69 (9.3)
Age (%)
< 50	2	2	2
50–59	14	15	15
60–69	36	36	36
70–79	35	35	35
≥ 80	13	12	12
Sex (%)
Male	34	34	34
Female	66	66	66
ASA score (%)
I	19	18	19
II	67	68	67
III–IV	14	14	14
Previous surgery^a (%)
Yes	32	34	33
No	67	65	66
Unknown	1	1	1

a Includes meniscectomy, arthroscopy, osteotomy, osteosynthesis, ligament reconstruction, synovectomy, and other previous surgery.

TKA: total knee arthroplasty.

Figure 1. Cumulative revision rates of cemented cruciate retaining or posterior stabilized fixed bearing total knee arthroplasties for osteoarthritis by type of knee system in the Netherlands in 2007–2016 (n = 133,841). Dotted lines represent the 95% confidence interval.

Table 2. Multivariate survival analyses of cemented cruciate retaining (CR) or posterior stabilized (PS) fixed bearing total knee arthroplasties for osteoarthritis in the Netherlands in 2007–2016

		Crude model		Adjusted model^a
	n	HRcrude	CI	HRadj	CI
TKA system
CR (ref)	60,546	1.0		1.0
PS	73,295	1.4^b	1.4–1.5	1.5^b	1.4–1.6
Age
< 50	2,851	2.5^b	2.2–2.9	2.4^b	2.1–2.8
50–59	19,552	1.6^b	1.4–1.7	1.4^b	1.4–1.7
60–69 (ref)	47,982	1.0		1.0
70–79	46,864	0.8^b	0.7–0.9	0.8^b	0.8–0.9
≥ 80	16,368	0.5^b	0.4–0.6	0.5^b	0.5–0.6
Sex
Female (ref)	87,660	1.0		1.0
Male	45,905	1.1^c	1.0–1.1	1.0	0.9–1.1
ASA score
I (ref)	24,298	1.0		1.0
II	89,657	0.9^d	0.9–1.0	1.1^c	1.0–1.2
III–IV	18,164	1.0	0.9–1.1	1.3^b	1.2–1.4
Previous operations^e
No (ref)	84,447	1.0		1.0
Yes	42,503	1.4^b	1.3–1.5	1.2^b	1.1–1.3

TKA: total knee arthroplasty;

HR_crude: crude hazard ratio; HR_adj: adjusted hazard ratio.

a Adjusted for age at surgery, sex, ASA score, and previous operations.

b p < 0.001;

c p = 0.02;

d p = 0.04.

e Includes meniscectomy, arthroscopy, osteotomy, osteosynthesis, ligament reconstruction, synovectomy, and other previous surgery.

Figure 2. Cumulative revision rates of cemented cruciate retaining or posterior stabilized fixed bearing total knee arthroplasties for osteoarthritis by type of knee system per age category, stratified for sex, in the Netherlands in 2007–2016 (n = 133,841). CR: cruciate retaining TKA system; PS: posterior stabilized TKA system.

Table 3. Multivariate survival analyses of cemented fixed bearing primary cruciate retaining (CR) or posterior stabilized (PS) total knee arthroplasty for osteoarthritis in the Netherlands in 2007–2016

	TKA	Primary	Revisions	Crude model		Adjusted model^a
	system	TKAs (n)	(n)	HRcrude	CI	HRadj	CI
Any type of revision
CR (ref)	60,546	1,718	1.0		1.0
PS	73,295	2,659	1.4^b	1.4–1.5	1.5^b	1.4–1.6
Minor revisions^c
CR (ref)	60,546	333	1.0		1.0
PS	73,295	713	2.0^b	1.7–2.2	2.0^b	1.7–2.3
Patella addition^d
CR (ref)	60,546	402	1.0		1.0
PS	73,295	555	1.3^b	1.1–1.5	1.3^b	1.1–1.5
Major revisions^e
CR (ref)	60,546	911	1.0		1.0
PS	73,295	1,238	1.3^b	1.2–1.4	1.3^b	1.2–1.4

For abbreviations, see Table 2

a Adjusted for age at surgery, sex, ASA score, and previous operations.

b p < 0.001.

c Only insert and/or patella exchange (excluding patella addition).

d Only patella addition. A patellar component was placed during the primary procedure of 17.7% (n = 10,668) of cruciate retaining TKAs and of 28.5% (n = 20,831) of posterior stabilized TKAs.

e Revision of at least femur or tibia.

Table 4. Cumulative 8-year revision rates of cemented fixed bearing total knee arthroplasties for osteoarthritis with cruciate retaining (CR) or posterior stabilized (PS) knee system, stratified for sex, age, and ASA score, in the Netherlands in 2007–2016 (n = 133,841)

	CR TKA system		PS TKA system
Sex, age	8-year revision		8-year revision
ASA-score	n	rate (%) (CI)	n	rate (%) (CI)
Male, < 60 years
ASA I	1,561	7.2 (5.6–9.2)^a	1,753	12.1 (9.8–15.0)^a
ASA II	2,105	7.8 (6.0–10.3)^a	2,605	14.4 (11.4–18.1)^a
ASA III–IV	236	6.1 (3.3–11.3)	347	13.0 (7.7–22.2)
Total	4,015	7.2 (6.1–8.5)^a	4,842	12.7 (11.1–14.5)^a
Male, 60–69 years
ASA I	1,975	2.7 (2.0–3.7)^a	2,161	5.6 (4.4–7.2)^a
ASA II	5,127	4.3 (3.5–5.2)^a	6,408	6.5 (5.6–7.7)^a
ASA III–IV	890	4.9 (3.3–7.5)	1,057	7.6 (5.5–10.6)
Total	8,193	4.0 (3.4–4.7)^a	9,835	6.3 (5.6–7.1)^a
Male, ≥ 70 years
ASA I	1,091	3.4 (2.0–5.6)	1,310	5.5 (4.1–7.5)
ASA II	5,766	2.3 (1.9–2.9)	6,765	3.4 (2.8–4.2)
ASA III–IV	1,546	2.2 (1.5–3.4)	2,034	4.0 (2.9–5.5)
Total	8,621	2.6 (2.2–3.2)^a	10,365	4.0 (3.4–4.6)^a
Female, < 60 years
ASA I	1,717	8.3 (6.7–10.4)	2,124	8.7 (7.1–10.7)
ASA II	3,444	7.5 (6.3–8.9)	4,579	9.6 (8.3–11.0)
ASA III–IV	533	8.9 (4.4–18.1)	728	11.9 (8.7–16.4)
Total	5,876	8.2 (7.2–9.3)	7,648	9.4 (8.5–10.5)
Female, 60–69 years
ASA I	2,690	5.7 (4.6–7.2)	3,070	5.4 (4.2–7.0)
ASA II	9,030	4.0 (3.5–4.7)^a	11,011	7.2 (6.2–8.3)^a
ASA III–IV	1,410	5.9 (4.3–8.1)	1,916	7.9 (6.0–10.5)
Total	13,499	4.7 (4.2–5.3)	16,400	6.6 (6.0–7.3)
Female, ≥ 70 years
ASA I	2,259	2.0 (1.4–2.8)^a	2,524	4.4 (3.5–5.6)^a
ASA II	14,016	3.0 (2.7–3.5)^a	16,562	4.0 (3.6–4.5)^a
ASA III–IV	3,280	3.1 (2.4–4.0)	4,120	3.8 (3.0–4.7)
Total	20,187	2.9 (2.6–3.3)^a	23,984	4.0 (3.6–4.3)^a

TKA: total knee arthroplasty.

a p < 0.05 for PS compared with CR TKAs.

Figure 3. Cumulative major revision rates of cemented cruciate retaining or posterior stabilized fixed bearing total knee arthroplasties for osteoarthritis by type of knee system per age category, stratified for sex, in the Netherlands in 2007–2016 (n = 133,841). CR: cruciate retaining TKA system; PS: posterior stabilized TKA system

Table 5. Cumulative minor and major 8-year revision rates of cemented fixed bearing total knee arthroplasties for osteoarthritis by type of TKA system, stratified for sex and age, in the Netherlands in 2007–2016 (n = 133,841)

Type of revision, sex	CR TKA system 8-year revision		PS TKA system 8-year revision
Age, years	n	rate (%) (CI)	n	rate (%) (CI)
Minor (only insert and/or patella exchange^a)
Male
< 60	4,015	1.8 (1.4–2.5)^b	4,842	3.7 (3.0–4.7)^b
60–69	8,193	1.1 (0.8–1.5)	9,835	1.8 (1.4–2.2)
≥ 70	8,624	0.7 (0.4–1.2)	10,365	1.3 (1.0–1.7)
Total	20,844	1.1 (0.9–1.3)^b	25,061	2.0 (1.7–2.3)^b
Female
< 60	5,876	1.2 (0.9–1.6)^b	7,648	2.7 (2.1–3.4)^b
60–69	13,499	0.8 (0.6–1.1)	16,400	1.2 (0.9–1.5)
≥ 70	20,187	0.4 (0.3–0.6)^b	23,984	0.8 (0.7–1.0)^b
Total	39,596	0.7 (0.6–0.8)^b	48,064	1.3 (1.1–1.4)^b
Major (including femur or tibia)
Male
< 60	4,015	4.2 (3.3–5.3)^b	4,842	7.0 (5.6–8.7)^b
60–69	8,193	2.0 (1.6–2.5)^b	9,835	3.3 (2.7–3.9)^b
≥ 70	8,624	1.1 (0.9–1.5)	10,365	1.5 (1.2–2.0)
Total	20,844	2.1 (1.8–2.4)^b	25,061	3.4 (3.0–3.8)^b
Female
< 60	5,876	5.2 (4.4–6.2)	7,648	4.7 (4.0–5.5)
60–69	13,499	2.6 (2.2–3.1)^b	16,400	3.8 (3.3–4.4)^b
≥ 70	20,187	1.7 (1.5–2.0)	23,984	2.0 (1.8–2.3)
Total	39,596	2.5 (2.3–2.7)^b	48,064	3.0 (2.8–3.3)^b

a Excluding patella addition.

b p < 0.05 for PS compared with CR TKAs.

Table 6. Reasons for minor or major revisions of cruciate retaining and posterior stabilized cemented fixed bearing TKA systems for osteoarthritis in the Netherlands in 2007–2016

	Minor revision^a (n = 1,046)		Major revision^b (n = 2,149)		Any revision^c (n = 4,377)
	CR (n = 333) PS (n = 713)		CR (n = 911) PS (n = 1,238)		CR (n = 1,718) PS (n = 2,659)
Reason for revision	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
Patellar pain	102 (30.6)	18 (26.2)	84 (9.2)	145 (11.7)	549 (32.0)	842 (31.7)
Instability	138 (41.4)	263 (36.9)	327 (35.9)	284 (22.9)^g, ^h	477 (27.8)	567 (21.3)^g, ^h
Loosening tibial component	0 (0.0)	3 (0.4)	242 (26.6)	505 (40.8)^g, ^h	243 (14.1)	513 (19.3)^g, ^h
Infection	67 (20.1)	207 (29.0)^f	161 (17.7)	252 (20.4)	244 (14.2)	499 (18.8)^g, ^h
Malalignment	6 (1.8)	11 (1.5)	254 (27.9)	371 (30.0)	265 (15.4)	387 (14.6)
Loosening femoral component	1 (0.3)	1 (0.1)	78 (8.6)	117 (9.5)	80 (4.7)	119 (4.5)
Arthrofibrosis	20 (6.0)	30 (4.2)	32 (3.5)	55 (4.4)	61 (3.6)	93 (3.5)
Revision after removal	0 (0.0)	1 (0.1)	48 (5.3)	97 (7.8)^e	48 (2.8)	98 (3.7)
Patellar dislocation	10 (3.0)	15 (2.1)	37 (4.1)	30 (2.4)^e	74 (4.3)	71 (2.7)^e
Wear of inlay	18 (5.4)	33 (4.6)	18 (2.0)	25 (2.0)	37 (2.2)	61 (2.3)
Periprosthetic fracture	0 (0.0)	6 (0.8)	21 (2.3)	69 (5.6)^f	21 (1.2)	75 (2.8)^f
Loosening patellar component	10 (3.0)	14 (2.0)	6 (0.7)	9 (0.7)	20 (1.2)	31 (1.2)
Other reason for revision	53 (15.6)	118 (15.3)	112 (12.3)	122 (9.9)^d	219 (12.7)	315 (11.8)

a Only insert and/or patella exchange (excluding patella addition).

b Revision of at least femur or tibia.

c Any type of revision, including patella addition (CR n = 402; PS n = 555). A patellar component was placed during the primary proce-dure of 17.7% (n = 10,668) of cruciate retaining TKAs and of 28.5% (n = 20.831) of posterior stabilized TKAs.

d p = 0.03

e p = 0.01

f p = 0.001

g p < 0.001

h Categories differ significantly for PS compared with CR TKAs after applying a Bonferroni correction (p = 0.05/39 = 0.001).