PMID- 34846307
OWN - NLM
STAT- MEDLINE
DCOM- 20220309
LR  - 20230814
IS  - 1528-1132 (Electronic)
IS  - 0009-921X (Print)
IS  - 0009-921X (Linking)
VI  - 480
IP  - 3
DP  - 2022 Mar 1
TI  - What Are the All-Cause Survivorship Rates and Functional Outcomes in Patients 
      Younger Than 55 Years Undergoing Primary Knee Arthroplasty? A Systematic Review.
PG  - 507-522
LID - 10.1097/CORR.0000000000002023 [doi]
AB  - BACKGROUND: Approximately one-fourth of TKAs will be performed in patients 55 
      years or younger within the next decade. Postoperative outcomes for younger 
      patients who had a knee arthroplasty were systematically reviewed in 2011; 
      however, numerous studies evaluating young patients who had both a TKA and 
      unicompartmental knee arthroplasty (UKA) have been reported in the past decade. 
      Therefore, to better counsel this growing population of young patients undergoing 
      knee arthroplasty, an updated understanding of their expected postoperative 
      outcomes is warranted. QUESTIONS/PURPOSES: In this systematic review, we 
      evaluated (1) all-cause survivorship, (2) reasons for revision, (3) 
      patient-reported outcomes, and (4) return to physical activity and sport in 
      patients 55 years or younger undergoing primary TKA or UKA. METHODS: A 
      comprehensive search of PubMed, Medline, SportDiscus, and CINAHL was performed to 
      identify all original studies evaluating outcomes after primary knee arthroplasty 
      for young patients (55 years of age or younger) from inception until March 2021. 
      The following keywords were used: knee, arthroplasty, replacement, pain, 
      function, revision, survivorship, sport, physical activity, and return to play. 
      Only original research studies that were related to knee arthroplasty and 
      reported postoperative outcomes with a minimum 1-year follow-up for patients 55 
      years or younger were included. Unpublished materials, publications not available 
      in English, and studies with a primary diagnosis of rheumatoid arthritis were 
      excluded. The Methodological Index for Non-Randomized Studies (MINORS) score was 
      used to evaluate the study quality of case series and comparative studies, while 
      the Cochrane Risk of Bias tool and the Jadad scale were used for randomized 
      studies. The primary outcomes of interest for this study were all-cause 
      survivorship rate, reasons for all-cause revision, Knee Society and Knee Society 
      Function scores (minimum clinically important difference [MCID] 7.2 and 9.7, 
      respectively), WOMAC scores (MCID 10), Tegner scores (no reported MCID for knee 
      arthroplasty), and return to physical activity or sport. Knee Society and Knee 
      Society Function scores range from 0 to 100, with scores from 85 to 100 
      considered excellent and below 60 representing poor outcomes. All-cause 
      survivorship rate and reasons for revision were both reported in 17 total 
      studies. Knee Society scores were presented in 19 and Knee Society Function 
      scores were reported in 18 included studies. WOMAC scores and Tegner scores were 
      each found in four included studies, and return to physical activity and return 
      to sport analyses were performed in seven studies. Overall, 21 TKA studies and 
      five UKA studies were included in this analysis, featuring 3095 TKA knees and 482 
      UKA knees. RESULTS: Kaplan-Meier estimates of all-cause survivorship ranged from 
      90% to 98% at 5 to 10 years of follow-up after TKA and from 84% to 99% (95% CI 
      93% to 98%) at 10 years to 20 years post-TKA. All-cause UKA survivorship was 90% 
      at 10 years and 75% at 19 years in the largest Kaplan-Meier estimate of 
      survivorship for patients younger than 55 who underwent UKA. Common reasons for 
      revision in TKA patients were polyethylene wear/loosening, aseptic tibial 
      loosening, and infection, and in UKA patients the common reasons for revision 
      were knee pain, aseptic loosening, progression of knee osteoarthritis, and 
      polyethylene wear/loosening. Knee Society scores ranged from 85 to 98 for 5-year 
      to 10-year follow-up and ranged from 86 to 97 at 10-year to 20-year follow-up in 
      TKA patients. Knee Society Function scores ranged from 70 to 95 for 5-year to 
      10-year follow-up and ranged from 79 to 86 at 10-year to 20-year follow-up. 
      Return to physical activity and sport was reported variably; however, most 
      patients younger than 55 have improved physical activity levels after knee 
      arthroplasty relative to preoperative levels. CONCLUSION: Although all-cause 
      survivorship rates were frequently above 90% and patient-reported outcome scores 
      were generally in the good to excellent range, several studies reported long-term 
      survivorship rates from 70% to 85% and fair patient-reported outcome scores, 
      which must be factored into any preoperative counseling with patients. We could 
      not control for surgeon volume in this report, and prior research suggests that 
      increasing volume is associated with less frequent complications; in addition, 
      the studies we included were variably affected by selection bias, transfer bias, 
      and assessment bias, which makes it likely that the findings of our review 
      represent best-case estimates. To limit the frequency of revision in patients 
      younger than 55 years undergoing TKA, clinicians should be cautious of 
      polyethylene wear/loosening, aseptic tibial loosening, and infection, while knee 
      pain and progression of knee osteoarthritis are also common reasons for revision 
      in patients younger than 55 undergoing UKA. Further research should isolate 
      younger knee arthroplasty patients and evaluate postoperative activity levels 
      while accounting for preoperative physical activity and sport participation. 
      LEVEL OF EVIDENCE: Level IV, therapeutic study.
CI  - Copyright (c) 2021 by the Association of Bone and Joint Surgeons.
FAU - Paul, Ryan W
AU  - Paul RW
AUID- ORCID: 0000-0002-6846-3349
AD  - Rothman Orthopaedic Institute, Philadelphia, PA, USA.
FAU - Osman, Alim
AU  - Osman A
AD  - Eastern Virginia Medical School, Norfolk, VA, USA.
FAU - Clements, Ari
AU  - Clements A
AUID- ORCID: 0000-0001-9771-7160
AD  - Sidney Kimmel Medical College, Philadelphia, PA, USA.
FAU - Tjoumakaris, Fotios P
AU  - Tjoumakaris FP
AD  - Rothman Orthopaedic Institute, Philadelphia, PA, USA.
FAU - Lonner, Jess H
AU  - Lonner JH
AD  - Rothman Orthopaedic Institute, Philadelphia, PA, USA.
FAU - Freedman, Kevin B
AU  - Freedman KB
AD  - Rothman Orthopaedic Institute, Philadelphia, PA, USA.
LA  - eng
PT  - Journal Article
PT  - Systematic Review
PL  - United States
TA  - Clin Orthop Relat Res
JT  - Clinical orthopaedics and related research
JID - 0075674
SB  - IM
MH  - Age Factors
MH  - Arthroplasty, Replacement, Knee/*methods
MH  - *Patient Reported Outcome Measures
MH  - *Prosthesis Failure
MH  - *Recovery of Function
MH  - Reoperation/*methods
MH  - Return to Sport
PMC - PMC8846274
COIS- All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and 
      Related Research(R) editors and board members are on file with the publication and 
      can be viewed on request.
EDAT- 2021/12/01 06:00
MHDA- 2022/03/11 06:00
PMCR- 2023/03/01
CRDT- 2021/11/30 12:20
PHST- 2021/07/12 00:00 [received]
PHST- 2021/10/04 00:00 [accepted]
PHST- 2021/12/01 06:00 [pubmed]
PHST- 2022/03/11 06:00 [medline]
PHST- 2021/11/30 12:20 [entrez]
PHST- 2023/03/01 00:00 [pmc-release]
AID - 00003086-202203000-00014 [pii]
AID - CORR-D-21-01012 [pii]
AID - 10.1097/CORR.0000000000002023 [doi]
PST - ppublish
SO  - Clin Orthop Relat Res. 2022 Mar 1;480(3):507-522. doi: 
      10.1097/CORR.0000000000002023.