The Journal of Arthroplasty 29 (2014) 17741778

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Why Are Total Knee Arthroplasties Failing TodayHas Anything

Changed After 10 Years?
Peter F. Sharkey, MD, Paul M. Lichstein, MD, MS, Chao Shen, MD, Anthony T. Tokarski, BS,
Javad Parvizi, MD, FRCS
The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this study was to determine the frequency and cause of failure after total knee arthroplasty
Received 19 April 2013 and compare the results with those reported by our similar investigation conducted 10 years ago. A total of
Accepted 21 July 2013 781 revision TKAs performed at our institution over the past 10 years were identied. The most common
failure mechanisms were: loosening (39.9%), infection (27.4%), instability (7.5%), periprosthetic fracture
Keywords:
(4.7%), and arthrobrosis (4.5%). Infection was the most common failure mechanism for early revision
knee arthroplasty
failure
(b 2 years from primary) and aseptic loosening was the most common reason for late revision. Polyethylene
revision (PE) wear was no longer the major cause of failure. Compared to our previous report, the percentage of
revisions performed for polyethylene wear, instability, arthrobrosis, malalignment and extensor mechanism
deciency has decreased.
2014 Published by Elsevier Inc.

Since its introduction, total knee arthroplasty (TKA) has evolved into
one of the most successful and thoroughly investigated surgical in-
terventions, especially over the past two decades [1]. Survival rates greater
than 90% after 10 years follow-up highlight the durability of primary TKA
[2]. With expectations for successful outcomes, the number of primary
TKA performed annually is projected to increase exponentially in the next
few years [3,4]. In 2003 there were approximately 402,100 primary TKA
performed and demand is anticipated to increase by 673% to over three
million procedures by the year 2030 [5]. Despite long survivorship and
improved outcomes, the increasing number of primary TKA has been
associated with increased rates of revision TKA procedures [1].
An aging population and the acceptance of TKA in young active
patients have contributed to the increasing number of both primary
and revision TKA procedures performed annually. The Australian
national registry reported revision TKA accounted for 8.3% of all knee
replacement surgeries conducted in 2011 and this number trends
higher yearly [6]. The most frequently reported mechanisms of failure
in primary TKA have varied but consistently include periprosthetic
joint infection (PJI), loosening, and instability [7]. Recent studies have
further analyzed failure mechanisms of primary TKA highlighting
not only the role of PJI and aseptic loosening in failure, but also how
such failure mechanisms may affect revision surgery outcomes [7,8].
Knowledge of the etiology of failure mechanisms is of paramount
importance for delivery of appropriate care.
The Conict of Interest statement associated with this article can be found at http://
dx.doi.org/10.1016/j.arth.2013.07.024.
Reprint requests: Peter F Sharkey MD, The Rothman Institute Research, The
Sheridan Building, 125th South 9th & Samson Street, Ste 1000, Philadelphia PA 19107.
A previous study performed 10 years ago at our institution deter-
mined the mechanisms of TKA failure between 1997 and 2000 [9].
However, surgical technique, prosthetic design, perioperative care,
and surgical experience have evolved over the past 10 years. Addi-
tionally, it has been suggested that advancements in prosthetic com-
ponent design and surgical instrumentation have generated a
paradigm shift in the etiology of common failure mechanisms [8].
The purpose of the current study was to elucidate if the etiology of
failure of TKA has changed over the past decade at our institution.
Methods and Materials
Following Institutional Review Board approval, we performed a
systematic retrospective review of all revision TKA performed at our
institution between July 1, 2003 and July 1, 2012. During this time
period, 10,003 total knee arthroplasty surgeries were performed, with
781 (7.8%) revision surgeries. Important information pertinent to
demographics such as age, gender, weight, and race was recorded. The
interval from primary TKA to revision procedures was obtained in
addition to whether the primary TKA had been performed at our
institution or was referred from elsewhere. Failure mechanisms were
determined by review of our institutional prospective revision data-
base and corroborated by review of operative records. At our insti-
tution, data on revision cases are collected prospectively which
includes collection of intraoperative data by a research fellow who is
present during each revision arthroplasty. With the assistance of the
primary surgeon, the research fellow completes questionnaires
related to the cause of failure and nature of intraoperative ndings.
All revision TKA patients were subdivided into early and late
failure groups depending upon the time interval between primary

http://dx.doi.org/10.1016/j.arth.2013.07.024
0883-5403/ 2014 Published by Elsevier Inc.
 P.F. Sharkey et al. / The Journal of Arthroplasty 29 (2014) 17741778
TKA and revision procedure with two years being considered as the
cut-off between early and late failures. The cause of overall failure,
as well as a comparison in the cause of failure of TKA in 2002
(previously reported) and 2012 was conducted. Statistical analysis
was performed using SPSS Version 15.0 (SPSS Inc., Chicago, Illinois)
software and signicance was determined using Chi Squared analy-
sis for dichotomous comparisons of early, late, and overall failure
mechanisms. Patients were further categorized by the number of
components involved in the revision procedure and grouped ac-
cordingly as complete (three-component revision or resection arthro-
plasty), two components, single component, PE exchange, or isolated
patellar resurfacing.
Results
There were 781 total knee arthroplasty revisions included in the
present study. Revision surgeries were performed in 318 (41%)
patients referred from outside institutions. 453 patients were female
and 291 were male. The average age of male patients was 65.4 years
(range, 3796 years) and the average age of female patients was
65.1 years (range, 3486 years) at time of revision TKA. The average
body mass index was 33.06 (kg/m 2) (range, 17.760.7) in female
patients and 31.9 (range, 18.662.8) in male patients. Revision sur-
gery was conducted for 667 posterior stabilized, 62 cruciate retaining,
49 unicondylar, and 3 constrained primary TKAs.
The average time before revision TKA in the early failure group
was 0.84 years (range, 1 day to 1.97 years). In the late failure group,
the average time to revision was 6.9 years (range, 2.01 years to
30.36 years). Fig. 1 displays the mechanism of the failure and the
corresponding percentage of patients with each failure mode. Fig. 2
displays the percentage of patients with each failure mechanism
stratied into early, late, and overall failure subgroups. The results of
our prior investigation are provided for comparison. Patients under-
going early revision comprised 37.6% of our cohort and 62.4% of the
revisions were performed more than 2 years after the initial surgery.
Of the revision surgeries, 299 (38%) involved exchange of all TKA
components. Two components were exchanged in 273 (35%) cases. A
PE exchanged was performed in 119 (15%) cases. One component was
Fig. 1. The percentage of patients with each failure mechanism stratied into early and late subgroups is shown.
1775
exchanged in 81 (10%) cases. Isolated patella resurfacing was per-
formed in 9 (1%), (Table).
Aseptic loosening of the prosthesis was the most common etiology
of failure overall, with component loosening observed in 39.9% of all
revision procedures. Loosening of the prosthesis was more common in
the late revision group, accounting for 51.4% of patients undergoing
revision more than two years following index arthroplasty. By con-
trast, loosening accounted for 22.8% of early revision cases. Instability
was observed in 6.1% of early and 10.3% of late revision surgeries.
The most common failure mechanism in the early revision group
was infection, which was responsible for 37.6% of revisions performed
less than 2 years after the primary procedure. Infection also
accounted for 21.9% of revision TKA in the late failure group and for
27.4% of overall revision TKA procedures at our institution.
Complications related to the extensor mechanism were an
important cause of revision TKA. The etiology of failure for exten-
sor mechanism related complications in all revision TKA included
loosening of the patellar component (3%), isolated patellar resurfacing
(4%), and extensor mechanism deciency (0.3%).
Cumulatively, the incidence of PE wear, with or without osteolysis,
was 3.5% for overall revision TKA procedures and accounted for 4.3%
of the patients in the late failure group and 2% of the patients in the
early failure group. The overall incidence of other causes for revision
TKA was similar in both the early and late revision groups. The over-
all incidence of arthrobrosis and peri-prosthetic fracture was 4.5%
and 4.7%, respectively.
Compared with our results of 10 years ago, the current data sug-
gest polyethylene (PE) wear is no longer the primary cause of TKA
failure. Figs. 3 and 4 display a comparison of the percentage of patients
in 2002 and 2012 with TKA failure stratied by mechanism and
segregated by early and late presentation. The most common indi-
cations in our present cohort for revision TKA in all the patients were
loosening (39.9%), infection (27.4%), instability (7.5%) and peripros-
thetic fractures (4.7%). 62.4% of the revision TKA procedures were
performed more than 2 years after primary surgery. Additionally,
as depicted in Fig. 5, the overall incidence of loosening and infec-
tion was seen to have increased since 2002 and predominate in our
recent cohort. However, signicant reductions were seen in the
1776 P.F. Sharkey et al. / The Journal of Arthroplasty 29 (2014) 17741778

Fig. 2. Percentage of patients with each failure mechanism stratied into early, late, and overall failure subgroups is shown.

incidence of instability, arthrobrosis, malalignment, and extensor methodology. There is debate concerning optimal xation which
mechanism deciency. include cement technique and use of cementless components.
Although cemented xation has been reported to be less technically
challenging and provides initial secure prosthesis stability, cementless
Discussion
xation offers potential advantages such as less fat embolization and
reliable long-term xation. Recently, Nakama et al demonstrated that
Although the incidence of revision TKA is relatively low in general,
cementless xation had a higher rate of early loosening but low risk
the percentage continues to steadily increase annually [1]. Therefore,
for late aseptic loosening [12]. In contrast, other studies have demon-
we undertook the present investigation to determine the incidence
strated that there was no signicant difference in the incidence of
of various failure modes in contemporary TKA requiring revision
aseptic loosening in primary TKA between cemented and cementless
surgery. An updated study into the evolution of the mechanisms of
prostheses [12,13]. In a meta-analysis conducted by Gandhi et al [13]
failure over the past decade is intended to assist investigators in
randomized controlled trials of cemented and cementless methods
identifying and avoiding common failure modes. Our results indicate
were reviewed and it was concluded that implant survival and func-
aseptic prosthetic loosening, infection and post-operative instability
tional scores were similar in both groups [11]. Regardless of prosthesis
were the three most common reasons for all contemporary revision
type, another study showed revision TKA for aseptic loosening gene-
TKA procedures. In further subgroup analysis, PJI was the most
rated superior patient satisfaction and functional outcomes when
common cause of revision in patients who underwent revision within
compared to revision TKA for all other indications [14].
two years of their primary TKA and loosening of the prosthesis was
According to our study, infection has now become the most
the most common reason for revision in patients undergoing the
common mode of early failed TKA. Although perioperative prophy-
procedure greater than two years from their primary TKA. Less than
lactic antibiotics and other anti-infection modalities have been widely
50% of the revision TKA procedures were done within 2 years
utilized in primary TKA, infection is still one of the most common
following primary TKA compared with 55.6% in our previous report.
major complications related to joint replacement surgery. Not only
PE wear was no longer the most common cause of revision TKA in this
was infection the most likely cause of early failure, it was the second
contemporary cohort of patients, a signicant difference from our
most common cause in the late revision group as well. These results
conclusions of 10 years ago [7], likely highlighting the successful
have also been reported by others. After reviewing 349 failed TKA
development of more wear resistant biomaterials or better locking
cases, Hossain et al [8] demonstrated that infection accounted for 30%
mechanism for the polyethylene into the tibial tray [10].
of all revision procedures and in fact was the most common cause
In the present study, aseptic prosthetic loosening was the most
of failure in both primary and revision TKA. Bozic et al [7] reviewed
common indication for revision TKA in the past ten years. Similar
and analyzed 60,357 revision TKAs in the United States and found a
results have been noted from national joint registry annual reports.
similar incidence of infection. According to the 2012 annual report of
According to the Australian and Swedish 2011 annual reports of knee
the England and Wales national joint registry, infection accounts for
arthroplasty, the most common reason for revision TKA was aseptic
23% of revision TKA procedures. Other annual reports from national
loosening, accounting for more than 20% of all the revision TKA [6,11].
joint registries found similar trends [11]. Two stage revision pro-
Loosening of the prosthesis is related to TKA component xation
cedures for the treatment of infected TKA are considered the gold
standard. Sadly, the outcomes of revision TKA for infection have been
Table shown to be suboptimal. Vanhegan et al [15] suggested that revision
Number of Components Exchanged. TKA is more likely to be successful when the causative organism was
Components Exchanged Number of Cases known. Therefore, research for early and accurate diagnosis of in-
fecting organisms could increase the rate of successful septic revision
1 81 (10%)
2 273 (35%) surgery in the future.
Total 299 (38%) Instability was a consistent mechanism of failure comparing our
PE exchange 119 (15%) current and prior investigations. Although it was again demonstrated
Resurfacing 9 (1%) to be the third most common failure mode in primary TKA, the over-
PE = polyethylene. all incidence has decreased dramatically since our last report. There
 P.F. Sharkey et al. / The Journal of Arthroplasty 29 (2014) 17741778 1777

Fig. 3. Comparison of the percentage of patients in 2002 and 2012 with early TKA failure stratied by mechanism. *P b 0.05, **P b 0.01.

were 62 cruciate retaining primary TKAs that underwent revision,
of those, 11 (17.7%) underwent revision for instability. Of the 667
posterior stabilized primary TKAs that underwent revision, instability
was the failure mode in 56 knees (8.4%). Such improvements in
stability following TKA may be attributable to advancements in
operative technique, but the development and increased utilization of
posterior stabilized prostheses may also be responsible. The success of
CR TKA is more sensitive than PS TKA to optimal anatomic ligament
tensioning. This issue may prove more challenging for surgeons
performing low volumes of TKA. Of the 11 CR knees that underwent
revision, all (100%) cases were performed at an outside institution.
Establishing stability with a PS design may be more reliable and less
challenging. Of the 56 knees undergoing revision for instability, 32
(57.1%) were originally performed outside of our institution.
The incidence of patients developing arthrobrosis following pri-
mary TKA has decreased in recent years. Several authors have
reported that the incidence of arthrobrosis was less than 5% in all
primary TKA patients [14,16]. It is well accepted that multiple factors
are involved in the development of arthrobrosis following TKA
[17,18]. Preoperative knee range of motion, surgical technique, post-
operative rehabilitation, and patient specic biologic factors all play
a role in stiffness after primary TKA. Most authors agree that limited
pre-operative range of motion is the strongest predictor of post-
operative stiffness [1921].
Revision TKA is one method used to treat severe stiffness following
primary TKA [22]. Kim et al [19] reviewed 54 patients who had stiffness
after primary TKA and demonstrated that although revision TKA was
expected to improve both functional outcome and range of motion, this
improvement was modest. Furthermore, in a systematic review of the
treatment of arthrobrosis after primary TKA, revision resulted in the
least improvement compared to other methods reviewed (manipula-
tion under anesthesia, arthroscopic release and open release) [23]. After
reviewing 25 revision TKA patients who exhibited postoperative
stiffness, Keeney et al [24] suggested that the results of revision TKA
for stiffness were less predictable than revisions for other reasons. In our
study, we found a relationship between arthrobrosis and chronic

Fig. 4. Comparison of the percentage of patients in 2002 and 2012 with late TKA failure stratied by mechanism. **P b 0.01.
1778 P.F. Sharkey et al. / The Journal of Arthroplasty 29 (2014) 17741778
Fig. 5. Comparison of overall incidence of failure between 2002 and 2012 stratied by mechanism. *P b 0.05, *P b 0.01.
infection. This nding has also been reported by others [19,25]. If
patients exhibit stiffness after primary TKA, a work-up to rule out deep
infection should be performed.
Our study has limitations. First, we only included patients under-
going revision TKA at a single institution where referral for chal-
lenging revision is common. The results from a large population or a
national registry database might yield different ndings. Another
limitation is the follow-up interval for each patient varied and
therefore limits some conclusions. The third limitation is that not all of
the primary TKA procedures were performed at our institute. Despite
these limitations, we were able to illustrate the etiological changes of
revision TKA with a large cohort of patients. The strength of our study
compared to registry data is that the cause of failure is much more
likely to be accurate as a dedicated research fellow was present during
these revision arthroplasties to collect the necessary data related to
revision surgery.
Our results showed that aseptic loosening, infection, instability,
periprosthetic fracture, and arthrobrosis are the most common
etiologies of failure in TKA over the last ten years for patients revised
at our institution. Infection is the most common mechanism of failure
in patients revised in less than two years and second only to aseptic
loosening in late failures. Ruling out PJI should be prioritized in
patients with primary TKA failure. In contrast, aseptic loosening is the
most common overall reason for failure in TKA patients. Given the
majority of TKA patients revised for loosening were more than two
years from primary surgery; stable long term xation is a critical
concern. Instability remains a common failure etiology; however the
incidence has decreased dramatically possibly secondary to advance-
ments in surgical technique and more common use of prosthetic
designs utilizing a posterior stabilized construct. Arthrobrosis
continues to be encountered frequently and although further
investigation into its relationship with infection is necessary, the
clinician is well advised to screen for PJI in cases of failure secondary
to arthrobrosis. PE wear, which had been shown to be the most
common etiology in our past investigation, has decreased remarkably
with the development of more resilient biomaterials and is no longer
the most common indication for revision TKA at our institution.
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