The Journal of Arthroplasty Vol. 11 No.

1 1996

Survivorship Analysis of Cemented Total

Condylar Knee Arthroplasty
A Long-term Follow-up Report on 348 Cases
Adel Nafei, MD, Ole Kristensen,

MD, Harald Moustgaard

Ivan Hvid, MD, PhD, and Jorn Jensen,

Knudsen,

MD,

MD

Abstract: Survivorship analysis was used in the evaluation of 348 consecutive primary total condylar knee arthroplasties (total knee arthroplasties) performed on
253 patients in a 27-month period, with a maximum follow-up period of 12 years.
The diagnosis was osteoarthrosis in 184 cases and rheumatoid arthritis in 164 cases.
Ten patients (10 total knee arthroplasties) were lost to follow-up evaluation. The
endpoint was defined as prosthesis not in situ. The variables considered were age,
sex, body 1Tlassindex, and diagnosis. The overall cumulative survival rate was 92%.
The survival rate of the osteoarthrosis group was significantly higher (97%) than
that of the rheumatoid arthritis group (87%). None of the other variables affected
survival rate significantly. Key words: knee arthroplasty, knee prosthesis, longterm results, survivorship analysis, total condylar knee.

The prosthesis used in this study is a modification

(5 posterior slope of the tibial component) of the
original Insall-Burstein prosthesis, which is of the
semiconstrained, crudate ligamem-sacrificing, cem e n t e d type without metal backing. Since 1979 the
prosthesis has b e e n used in our department w h e n
total knee resurfacing arthroplasty was indicated.
Several authors have reported long-term survival
analysis of total knee arthroplasty with different prosthetic designs. 14 Few authors have reported longterm survival analysis of this design, and then only as
smaller subgroups of larger heterogenous series. 4-6
This study a i m e d to evaluate the survival rate of
a fairly large consecutive series of the a b o v e - m e n tioned prosthetic design, p e r f o r m e d as a p r i m a r y
i n t e r v e n t i o n in a single center, and to evaluate
some of the factors that m i g h t influence the longt e r m survival rate of the prostheses.

From the Department of Orthopedic Surgery, Aarhus University

Hospitals, Aarhus, Denmark.
Reprint requests: Adel Nafei, MD, Heriuf Trollesgade 7C, st.,
DK-8200 Aarhus N, Denmark.

Materials and Methods

During the period October 1979 through December 1982, 348 consecutive primary total condylar
knee arthroplasties (TKAs) were performed on 253
patients. The diagnosis was osteoarthrosis (OA) in
184 cases and r h e u m a t o i d arthritis (RA) in 164
cases. In the OA group, there were 32 m e n (36
TICAs) and 115 w o m e n (148 TKAs). In the RA
group, there were 21 m e n (33 TICAs) and 85 w o m e n
(131 TICAs). Median age at surgery was 70 years
(quartiles, 64 and 73 years) in the OA group and 61
years (quartiles, 50 and 68 years) in the RA group.
Ten patients (10 TICAs) were lost to follow-up evaluation (5 TICAs in each group). The indication for
knee arthroplasty in our d e p a r t m e n t is chronic joint
pain, due to advanced degenerative changes involving m o r e t h a n one joint compartment.
The operating theater was equipped with laminar airflow. First-generation i n s t r u m e n t a t i o n was
used for prosthesis implantation. 9 All sizes of the
implant w e r e available for utilization in the period
in question. We resurfaced the patella in all cases.

The Journal of Arthroplasty Vol. 11 No. 1 January 1996

T h e p r o s t h e t i c c o m p o n e n t s w e r e c e m e n t e d in all
cases. All p a t i e n t s w e r e o p e r a t e d b y or u n d e r
s u p e r v i s i o n of t h e s a m e s e n i o r s u r g e o n . T h r e e
other surgeons were involved. Operative technical
goals w e r e to a c h i e v e a t i b i o f e m o r a l a l i g n m e n t
b e t w e e n 3 a n d 10 of valgus, a n e u t r a l p o s i t i o n of
t h e p r o s t h e t i c c o m p o n e n t s (tilt < 5), a r a n g e of
m o t i o n g r e a t e r t h a n 95 , a n d a stable k n e e (a m a x i m u m of 5 i n s t a b i l i t y o n full e x t e n s i o n ) .
Patients w e r e e x a m i n e d clinically a n d r a d i o g r a p h i cally p r i o r to surgery, i m m e d i a t e l y after surgel T, 12
w e e k s after surgery, a n d at o n e - y e a r intervals. The
k n e e rating score f r o m t h e Hospital for Special
Surgery~0 w a s u s e d in t h e e v a l u a t i o n s . T i b i o f e m o r a l
a l i g n m e n t b e f o r e a n d after s u r g e r y a n d p o s i t i o n i n g
of t h e p r o s t h e t i c tibial c o m p o n e n t s after s u r g e r y
w e r e a n a l y z e d in b o t h diagnostic g r o u p s (Table i ) .
F a i l u r e w a s d e f i n e d as a p r o s t h e s i s w e r e a r e v i sion operation was performed or recommended.
The factors c o n s i d e r e d w e r e d i a g n o s i s , age, sex,
a n d obesity. As for age, t h e p a t i e n t s w e r e s u b g r o u p e d i n t o t w o g r o u p s : a n e l d e r l y g r o u p (> 60
y e a r s ) a n d a y o u n g e r g r o u p (< 60 y e a r s ) . W e
d e f i n e d o b e s i t y as a b o d y m a s s i n d e x (BMI) g r e a t e r
t h a n 27 u n i t s . B o d y m a s s i n d e x w a s c a l c u l a t e d
f r o m t h e p a t i e n t s ' b o d y w e i g h t in k i l o g r a m s (W)
a n d h e i g h t in m e t e r s (H), w h e r e B M I = W / H 2, w i t h
a n o r m a l r a n g e b e t w e e n 2 I a n d 26 u n i t s . ~ T h e
m e d i a n B M I in t h e O A g r o u p w a s 28 u n i t s ( q u a r tiles, 25 a n d 30), a n d in t h e R A g r o u p it w a s 24
units (quartiles, 20 a n d 26).
T h e p a t i e n t s i n t h e O A a n d R A g r o u p s w e r e sign i f i c a n t l y d i f f e r e n t f r o m e a c h o t h e r in f o u r a s p e c t s
( M a n n - W h i t n e y U test):

A g e at t i m e of s u r g e r y ( m e d i a n age of O A / R A
g r o u p s , 7 0 / 6 I years, P < .0001)
B o d y m a s s i n d e x ( m e d i a n B M I of O A / R A
g r o u p s , 2 8 / 2 4 U, P < .0001)
P r e o p e r a t i v e H o s p i t a l for Special S u r g e r y score
( m e d i a n score of O A / R A g r o u p s , 5 6 / 4 8 p o i n t s ,
P < .0001).
Preoperative deviations from the acceptable knee
axis b e t w e e n 3 a n d 10 of v a l g u s ( m e d i a n of
d e v i a t i o n of O A / R A g r o u p s , ] 0 o / 4 , P <

.0001).
T h e r e f o r e , it w a s n e c e s s a r y to e x a m i n e t h e s u r v i v a l
r a t e s a n d t h e factors t h a t m a y i n f l u e n c e t h e s e r a t e s
within each group separately.
The method
d e s c r i b e d b y A r m i t a g e 12 w a s
e m p l o y e d to c o n s t r u c t s u r v i v o r s h i p tables. P a t i e n t s
w h o h a d d i e d o r w e r e lost to f o l l o w - u p e v a l u a t i o n
w e r e c e n s o r e d a c c o r d i n g to t h e l a t e s t a v a i l a b l e
a s s e s s m e n t . T h e l o g - r a n k t e s t w a s u s e d to c o m p a r e
t h e c u m u l a t i v e s u r v i v a l r a t e s of t h e d i f f e r e n t
g r o u p s a n d s u b g r o u p s . O t h e r statistical tests a r e
o t h e r w i s e specified. A P v a l u e less t h a n .05 w a s
c o n s i d e r e d significant.

Results
A t 12 y e a r s , t h e o v e r a l l c u m u l a t i v e s u r v i v a l rate
w a s 9 2 . 3 % ( 9 5 % c o n f i d e n c e limits, 8 9 . 6 - 9 5 . 0 ) ,
w i t h a n a v e r a g e a n n u a l f a i l u r e r a t e of 0 . 7 % . The
s u r v i v a l c u r v e w i t h 9 5 % c o n f i d e n c e limits for t h e
t o t a l m a t e r i a l is s h o w n in F i g u r e 1. I n t h e O A
g r o u p t h e r e w e r e t h r e e f a i l u r e s (2 cases of late
d e e p i n f e c t i o n a n d 1 case of m e c h a n i c a l l o o s e n -

T a b l e 1. A Short Statistical Report on the Pre- a n d

Postoperative Knee Axis a n d Positioning of the
P r o s t h e t i c Tibial C o m p o n e n t i n the

1oo.
99

Two Diagnostic Groups

99

Preoperative Postoperative
OA

Knee axis
Median
Lower quartile
Upper quartile
Tibial tilt, anteroposterior view
Median
Lower quartile
Upper quartile
Tibial tilt, side view
Median
Lower quartile
Upper quartile

RA

0A

RA

97

9s

~ 99
~
J

94

so

~ 93

_3
_6
6

6
2
l0 o

5
3
7

5
4
7

_2
0o
_4

_2
0o
_3

_1 o
3

0o
3

OA, osteoarthrosis; RA, rheumatoid arthritis; -, varus/posterior tilt.

i.

89

'2

'o

'6

'9

,'0

1',

;2 '

YEARS AFTER OPERATION

Fig. 1. Cumulative survival rate of the total material.

Hatched area represents 95 % confidence limits.

Survivorship Analysis of TKA

Nafei et al.

ing). T h e c u m u l a t i v e success r a t e of t h e O A g r o u p
w a s 9 7 % ( 9 5 % c o n f i d e n c e limits, 9 4 . 7 - 9 9 . 5 ) , w i t h
a n a v e r a g e a n n u a l f a i l u r e r a t e of 0 . 3 % .
I n t h e R A g r o u p , t h e r e w e r e 13 failures (5 cases
of late d e e p i n f e c t i o n , 6 cases of m e c h a n i c a l l o o s e n i n g , a n d 2 cases of t r a u m a t i c l o o s e n i n g ) . T h e
c u m u l a t i v e success r a t e in t h e R A g r o u p w a s 8 7 %
( 9 5 % c o n f i d e n c e limits, 8 2 . 2 - 9 1 . 8 ) , w i t h a n a v e r age a n n u a l f a i l u r e r a t e of 1 . 2 % .
T h e c u m u l a t i v e s u r v i v a l r a t e of t h e O A g r o u p
w a s s i g n i f i c a n t l y h i g h e r t h a n t h a t of t h e R A g r o u p
(Fig. 2, P = .005). N o n e of t h e o t h e r v a r i a b l e s (age,
sex, BMI) h a d a statistically s i g n i f i c a n t effect o n
s u r v i v a l rate. A s u m m a r y of t h e c u m u l a t i v e surv i v a l r a t e s i n r e l a t i o n to t h e o t h e r factors c o n s i d e r e d i n b o t h d i a g n o s t i c g r o u p s is g i v e n in Table 2.

100
99
98
97
9e959493-

w 92.
~ 91~ 90"
~ 89.
~ 88"
87.
i 86
~ 85.
~

B,
83

81
8O

OA

RA

Discussion

12

Fig. 2. Cumulative survival rates of the osteoarthrosis

(OA) and the rheumatoid arthritis (RA) groups. Hatched
areas represen t 95% confidence limits. P = .005.

T h e o v e r a l l c u m u l a t i v e r a t e s of s u r v i v a l in this
series ( 9 8 % at 5 y e a r s , 9 2 % at 12 y e a r s ) c o i n c i d e
w i t h t h o s e r e p o r t e d b y o t h e r authors.4, 6 T h e c o m p a r i s o n w i t h o t h e r m a t e r i a l is o f t e n w e a k e n e d b y
t h e fact t h a t o n l y f e w a u t h o r s r e p o r t t h e i r s u r v i v a l
rates a c c o m p a n i e d b y c o n f i d e n c e limits.
T h e m o s t p r o m i n e n t f e a t u r e of this s t u d y ' s
results is t h e s i g n i f i c a n t d i f f e r e n c e b e t w e e n t h e
s u r v i v a l r a t e s of t h e t w o d i a g n o s t i c g r o u p s , w h i c h
conflicts w i t h e a r l i e r r e p o r t s . R a n d a n d I l s t r u p
f o u n d t h a t t h e d i a g n o s i s of R A w a s a v a r i a b l e
f a v o r i n g a h i g h o v e r a l l success r a t e w h e n t h e
w h o l e g r o u p w a s c o n s i d e r e d ( d i f f e r e n t t y p e s of

Table 2. Twelve-year Cumulative Survival Rates of the Two Diagnostic Groups

as a Function
Osteoarthrosis

Age (years)
> 60
_<60
Sex
Men
Women
Body mass index
> 27
_<27

1'o

YEARS AFTER OPERATION

In prosthetic knee reconstruction, where the

m a i n i n d i c a t i o n is d e g e n e r a t i v e c h r o n i c p a i n , t h e
logical c h o i c e of t h e e n d p o i n t m u s t b e w h e n a
p a t i e n t h a s p a i n ; t h a t is, a p r o s t h e t i c life s p a n
w o u l d b e a p a i n - t o - p a i n cycle.
S o m e a u t h o r s c h o o s e p r o s t h e t i c r e v i s i o n as t h e
endpointl,2,5,6; o t h e r s a d d s e v e r e p a i n ( w i t h o u t
r e v i s i o n ) to t h e r e v i s i o n criteria as a n e n d p o i n t definition. 8 Other authors analyze their materials
a c c o r d i n g to a v a r i e t y of endpoints.4, 7,13 W e p r e f e r
to a p p l y r e v i s i o n as t h e e n d p o i n t , as it is a c l e a r - c u t
a n d a c o m p a r a b l e c r i t e r i o n , w h i c h is i n d e p e n d e n t
of subjectivity, a n d it is b a s e d p r e d o m i n a n t l y o n a
p a t i e n t ' s i n t r a c t a b l e r e s i d u a l p a i n . R a d i o g r a p h s at
t h e t i m e of d e c i s i o n m a k i n g for r e v i s i o n will s u p p o r t t h e s u r g e o n ' s d e c i s i o n , as r a d i o l u c e n t z o n e s
c o r r e l a t e w i t h r e s i d u a l p a i n i n t e n s i t y , as w e
s h o w e d earlier.14,15

Variable

of Different

Group
CL

Variables

Rheumatoid Arthritis Group

CSR
CL

CSR

157
27

97.3
100

94.6-100
--

84
80

91.6
90.5

85.8-97.4
83.1-97.9

36
148

100
96.5

-93.6-99.4

33
131

81.0
90.4

68.2-93.8
85.6-95.2

94
90

98.9
95.2

96.8-100
90.9-99.5

30
134

96.7
85.6

90.4-100
80.0-91.2

n, number of cases in the subgroup; CSR, cumulative survival rate (%) at 12 years; CL, 95% confidence
limits.

10 The Journal of Arthroplasty Vol. 11 No. 1 January 1996

prostheses). 5 Nevertheless, w h e n they considered
the 5-year survival probability of a prosthetic
design similar to the one used in our series, they
f o u n d no significant difference. Several other studies concluded that the diagnosis did not affect survival rates. 2,6A6 In our earlier reports on the same
prosthesis using the traditional case follow-up
m e t h o d of assessment, we f o u n d no significant difference in o u t c o m e b e t w e e n the OA and RA
groups, only tendencies toward a better o u t c o m e
in the OA group.15,17-21 Nevertheless, w h e n the
survivorship m e t h o d of analysis was applied, the
OA group proved to have a significantly better outcome t h a n the RA group. This controversy concerning the significance of the diagnosis on the
prosthetic survival rate and our finding of significant differences b e t w e e n the two diagnostic groups
(age, BMI, preoperative Hospital for Special
Surgery score, and preoperative alignment)
strongly suggest that investigators must stratify
their material according to the diagnosis.
In the present series no significant difference was
f o u n d b e t w e e n the survival rates of y o u n g e r and
elderly patients within the diagnostic groups. The
findings reported by Ritter et a1.13 and Rand and
Ilstrup 5 concerning the effect of age on prosthesis
survival must be cautiously interpreted, as their
material was analyzed irrespective of the diagnosis.
For the purpose of comparability, we emphasize
the importance of stratified analysis and presentation of confidence limits and data about implant
positioning. Revision operation is the most suitable
endpoint to apply.

Acknowledgment
The authors t h a n k Soren M. Bentzen, DMSc,
PhD, Institute of Cancer Research, Aarhus University, for his participation in the statistical analysis of
this work.

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