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Arthroplasty Register Data:
Outcomes ofKnee Arthroplasty
inYounger Patients
NilsP.Hailer andAnnetteW-Dahl
Contents
40.1 Introduction – 464
40.2 Trends intheDemography ofKnee Arthroplasty
Patients – 464
40.3 What Is “Outcome”? – 465
40
40.4 Implant Survival – 466
40.4.1 TKA andUKA intheYoung Patient – 466
40.4.2 Cemented Compared withCementless Fixation – 467
40.5 Patient-Reported Outcomes – 468
References – 470
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_40
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N. P. Hailer and A. W-Dahl
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40.1 Introduction
The number of knee arthroplasties performed in
younger patients is increasing in most countries that
report arthroplasty register data, and the proportion
of younger age groups among all knee arthroplasty
patients is also on the rise. Within the context of knee
arthroplasty surgery, “young” is mostly dened as an
age below 55years, but the denition sometimes includes
persons of working age, i.e., up to 65years.
> Compared to the mostly good or even excellent results
obtained in the elderly, patients who receive a unicompartmental (UKA) or total knee arthroplasty
(TKA) before the age of 55 are at higher risk of
implant revision.
As in the elderly, revision rates in younger patients are
considerably higher after UKA than after TKA, a nding that is consistent over all established registers. However, the threshold to revise a UKA may be lower than
to revise a TKA, and this has to be considered when
comparing revision rates between these two fundamentally different principles. There is no register- based
evidence that uncemented knee arthroplasty gives better outcomes than cemented TKA, neither in terms of
implant survival nor with respect to patient-reported
outcomes. Younger patients have higher expectations on
their articial joint.
> After knee arthroplasty younger patients gain func-
tion just as the elderly do after this procedure.
However, young patients are – at least in some
aspects– more often dissatised with the outcome of
their procedure.
In conclusion, the young patient is at increased risk
of inferior outcome after both total and partial knee
arthroplasty, and the cemented knee arthroplasty can
still be considered a gold standard that other methods
have to be measured against.
plasty (Swedish Knee Arthroplasty Register 2019). The
average age of patients treated with a total knee arthroplasty in Sweden was 71years in 1994, and it has only
slightly declined to 69years in 2018.
> However, the proportion of patients younger than 55
at the time of index surgery has grown from 1.8% to
7% (W-Dahl etal. 2010).
In absolute numbers, the increase in the proportion of
younger patients is more easily visible, and in Sweden
the number of patients operated with TKA has risen
almost 8-fold from 1994 to 2018 (Swedish Knee Arthroplasty Register 2019). This observation of an increasing incidence of knee arthroplasty in younger patients is
consistent over the Nordic countries, where the increase
in the incidence of knee arthroplasty is highest in the
younger patients (Niemelainen etal. 2017).
> Generally speaking, UKA is an implant that is more
frequently chosen in younger patients, such that the
average age of patients at the time of insertion of this
type of implant is about 5years below that of patients
receiving TKA.
The National Joint Registry of England and Wales
(NJR) does not reach quite as far back in time as the
Nordic arthroplasty registers, but it supports Nordic
data on the demographics of patients who received
total vs. unicompartmental knee arthroplasty. According to NJR data, patients receiving UKA were typically
around the age of 64, whereas those operated with TKA
were aged 70years at the time of the index procedure.
Moreover, females dominate in the group of patients
operated with TKA, whereas 53% of all patients in the
NJR who receive UKA are males (National Joint Registry 2019).
The “young knee arthroplasty patient” differs from
the average knee arthroplasty patient not only in terms
of age, but also in terms of the indications underlying
surgery.
40.2 Trends intheDemography ofKnee
Arthroplasty Patients
Historically, the use of total knee arthroplasty was
established in the group of elderly patients, and due to
excellent or at least good results in many patients the
method rapidly gained wide acceptance (. Fig.40.1).
However, since the 1990s, epidemiological studies and
arthroplasty register data indicate a robust increase in
the number and proportion of younger patients treated
with either a total or a unicompartmental knee arthro-
> While osteoarthritis of the knee dominates as the
underlying diagnosis in both older and younger knee
arthroplasty patients, the proportion of patients
operated due to rheumatoid arthritis or previous frac-
ture is higher in knee arthroplasty patients under the
age of 55.
The proportion of patients who have undergone prior
surgery in the index knee is also much higher in younger
than in elderly patients. This observation reects the
fact that both soft-tissue injuries to the knee and tibial
condylar fractures frequently occur in patients in their
Arthroplasty Register Data: Outcomes ofKnee Arthroplasty inYounger Patients
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a
b
465
40
. Fig. 40.1 Cemented total knee arthroplasty in a 49-year-old male with primary osteoarthritis. (a) Preoperative frontal and lateral views,
and (b) postoperative frontal and lateral views
20s or 30s, and that early-onset rheumatoid arthritis can
lead to severe joint destruction at a relatively young age
(Wennergren etal. 2018; Innala etal. 2014). This difference in the indications underlying knee arthroplasty
surgery is important to remember, since most registers
consistently report that results after TKA performed for
other reasons than osteoarthritis are inferior to those
found after surgery due to osteoarthritis, and thus, the
group of younger patients is at higher risk of implant
failure than the average elderly patient.
> However, even if only patients with osteoarthritis are
analyzed, younger patients who receive TKA remain
at higher risk of revision than older patients, indicating that not only the underlying indication but
younger age per se is a risk factor for earlier failure
(Harrysson etal. 2004).
40.3 What Is “Outcome”?
The issue of implant revision leads to the next important question: What parameters contribute to the
term “outcome after knee arthroplasty”? Obviously,
the occurrence of revision surgery, performed due to
implant loosening or for other reasons such as infection
or instability, is an important measure of outcome, and
it is the main outcome reported by all national arthroplasty registers. However, since the turn of the millennium, much well-deserved focus has been directed
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N. P. Hailer and A. W-Dahl
40
toward patient- reported outcomes. These are produced
by patients directly reporting on their own health status
without interpretation by a surgeon or other medical
professionals, and a patient-reported outcome measure
(PROM) is a specic tool, often a questionnaire, that
measures different aspects of patient-reported outcomes (Wilson etal. 2019). PROMs have been used for
more than 20years and are increasing in studies as well
as national arthroplasty register analyses as an integral
part of the evaluation after knee arthroplasty surgery.
PROMs evaluating knee arthroplasty surgery include
both generic general health instruments such as the
well-established EQ-5D and SF-36 as well as diseasespecic instruments such as the Oxford Knee Score
(OKS), Knee Injury and Osteoarthritis Outcome Score
(KOOS), and The Western Ontario and McMaster
Universities Arthritis Index (WOMAC). Expectations
before and satisfaction after surgery are other measures
that are commonly used in the evaluation of subjective
outcomes.
And, as for the outcome revision surgery, we shall see
that young patients differ from the average elderly patients
in several facets that PROMs attempt to capture, be it
pain, function, or the ability to return to work or sports.
> An important factor that affects PROMs is the preop-
erative level of expectation, and this also differs
between young and elderly patients.
Thus, in the following we will analyze both implant
survival and PROMs with a focus on younger patients
operated with a knee arthroplasty. We will compare
outcomes after total with those after unicompartmental
arthroplasty, and evaluate whether cemented or cementless xation gives better results.
40.4 Implant Survival
40.4.1 TKA andUKA intheYoung Patient
> As a rule of thumb, most established arthroplasty
registers report overall 10-year implant survival rates
of more than 95% after cemented TKA.
When implant survival is stratied by age groups, the
unadjusted survival is lower in the youngest age groups,
with 10-year survival rates dropping to just above 90%
in Swedish patients younger than 55years at the time
of primary arthroplasty surgery (Swedish Knee Arthroplasty Register 2019), a result that at rst glance may
appear quite satisfactory (. Fig.40.2a).
> However, when transformed into a relative risk of
revision, it becomes apparent that younger patients
have an approximately 2.1-fold higher adjusted risk
of implant revision when compared to patients aged
65 to 74, the dominating age group in the Swedish
Knee Arthroplasty Register.
Again, this observation is fairly consistent throughout
the Nordic arthroplasty registers, including Norway,
Denmark, and Finland. In the Danish Knee Arthroplasty Register, the risk of revision after TKA in
patients younger than 40years is about 4.6-fold higher
compared to those aged 70–79years (Dansk Knaealloplastikregister 2019). The notion that younger
patients are at much higher risk of revision is also
conrmed by numbers from the NJR where the group
of patients under the age of 55 runs by far the highest risk of revision after total knee arthroplasty, both
in females and in males. Average 10-year implant survival in the NJR is estimated at around 89% in this
age group.
Reasons for revision after TKA differ between
younger and elderly patients. In a Finnish register
study, younger patients with TKA were at higher risk
of revision than older patients, and the risk increase was
pronounced for revisions for other reasons than infection (Julin etal. 2010). Mobilization under anesthesia
is not registered as a revision procedure in most joint
registries, and since the procedure can be performed on
an out-patient basis, reliable numbers on this topic are
often lacking. However, an analysis of the incidence of
this procedure in Swedish patients after primary knee
arthroplasty indicates that younger, female patients are
at considerably higher risk of developing postoperative
knee stiffness that requires treatment (Thorsteinsson
etal. 2019).
When compared with TKA, results after UKA are
inferior in terms of implant survival, an observation that
we will discuss in more detail. The 10-year survival rate
of all UKAs in the Swedish Knee Arthroplasty Register
is around 86% (Swedish Knee Arthroplasty Register
2019), and the NJR reports 10-year survival rates of
around 89% after UKA, compared to above 96% after
cemented TKA (National Joint Registry 2019). This is
consistent with ndings from Norway and Denmark,
with the Danish register reporting that UKA has
about double the risk of revision than TKA (Dansk
Knaealloplastikregister 2019).
When we take a closer look at Swedish patients
younger than 55years at the time of insertion of a
unicompartmental knee arthroplasty (.
Fig. 40.2b),
these are at 1.6-fold higher risk of conversion to a
Cummulative risk of revision
hm
ab
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age groups
467
40
mont
< 55 year
65–74 year
TKA UKA
. Fig. 40.2 Cumulative revision rates after total knee arthroplasty (a) and unicompartmental knee arthroplasty (b), divided by age
groups
total knee arthroplasty than those in the age group
between 65 and 74 (Swedish Knee Arthroplasty
Register 2019).
> The NJR conrms that younger patients receiving
UKA suffer from higher implant failure rates than
elderly patients.
The 10-year-survival rate of the UKA inserted into
patients <55years at the time of primary surgery is 84%,
compared with 91% after cemented TKA in the same
age group (National Joint Registry 2019).
The discussion about revision rates after UKA vs.
TKA has sometimes been heated. It has been suggested
that the dissatised patient with UKA may more readily be considered for revision surgery. In patients with
UKA and progression of disease in the contralateral
compartment, insertion of a contralateral UKA or conversion to a TKA may seem an appealing solution. In
contrast, the surgical option for patients who are dissatised after a TKA is more complex revision surgery,
a decision that may be less easily taken. In addition, the
average patient with UKA is younger and potentially
less comorbid.
> Therefore, the threshold to revise a patient with UKA
may be lower, thus giving rise to higher cumulative
revision rates and lower implant survival when
compared to patients with TKA.
40.4.2 Cemented Compared
withCementless Fixation
Historically, both components in TKA were xed using
bone cement, but cementless xation of the tibial component in TKA was popularized in the late 1980s, a concept later termed “inverse hybrid” xation (Rosenberg
etal. 1989). Long-term follow-up of such cohorts in the
Swedish Knee Arthroplasty Register indicates inferior
results after cementless tibial xation, with a relative
risk of revision of 1.6 when compared with cemented
implants. However, during the latest 10-year period,
implant survival does not differ statistically signicantly
between cemented and cementless xation of tibial
components in Sweden, but the proportion of cementless xation remains well below 10% of all Swedish knee
arthroplasty procedures (Swedish Knee Arthroplasty
Register 2019).
55-64 year
≥ 75 year
onth
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N. P. Hailer and A. W-Dahl
40
In Denmark, the risk of revision after cementless TKA is about 1.4 times higher when compared
to cemented TKA (Dansk Knaealloplastikregister
2019), and in Norway, cementless xation is also asso-
ciated with slightly higher failure rates after more
than 10 years, although not statistically signicantly
(Nasjonalt Register For Leddproteser 2019). In contrast
to the “inverse hybrid” xation described above, the
combination of cementless femoral components with a
cemented tibial tray in TKA has been termed “hybrid”
xation. According to a Norwegian register analysis, some hybrid designs are associated with slightly
improved implant survival when compared with totally
cemented TKA (Petursson etal. 2015).
> A recent Nordic register collaboration study indicates
that both hybrid and inverse hybrid xation techniques
can offer 10-year survival rates of 93% or above in
patients younger than 65years.
However, the entirely cementless xation of both femoral and tibial components is associated with a higher
revision risk (Niemelainen etal. 2020). Nonetheless, in
the Nordic countries cemented xation of both components dominates by far.
In accordance with praxis in the Nordic countries,
the NJR reports that entirely cementless or hybrid xation is used in less than 4% of all knee arthroplasties, and
the mean age of patients receiving hybrid or cementless
knee arthroplasties is about the same as that of patients
receiving cemented knee arthroplasty. Again, as in most
Nordic countries, cementless xation is by the NJR
reported to be associated with slightly lower implant
survival after 10years (National Joint Registry 2019).
Lower implant survivorship in cementless compared
with both cemented and hybrid TKA is also described in
a register study from New Zealand (Nugent etal. 2019).
> Although less popular today, the use of cemented
monoblock polyethylene tibial components has
proven to be fairly successful, both in Sweden and in
England & Wales (Gudnason et al. 2014; National
Joint Registry 2019).
In parallel with the development of cementless xation
of TKA, this type of xation has also gained popularity
in UKA.
> A recent Finnish register-based comparison of
cementless with cemented xation of a specic UKA
indicates a slightly lower revision risk for uncemented
components after 5years.
However, in that study, implant survival of both
cementless and cemented UKA is clearly inferior to
that of cemented TKA (Knifsund etal. 2019). Cementless xation of the same specic UKA device is also
reported to have improved 10-year implant survival
rates over those after cemented xation within the setting of a register study from the NJR (Mohammad
etal. 2020).
Numerous observational studies, both register-based
and smaller cohort studies, support the notion that
the addition of antibiotics to bone cement improves
long- term implant survival after total joint arthroplasty, a nding that has been related to a reduced risk
of revisions for infections (Engesaeter etal. 2003). In
the Nordic countries, antibiotic-loaded bone cement
is routinely used in both total and unicompartmental
cemented knee arthroplasty. However, there are indications that the use of antibiotic-loaded bone cement is
not as clearly associated with a reduced risk of revision
for infections after TKA as after total hip arthroplasty.
According to a recent study on a large cohort from the
NJR, the risk of being revised due to PJI seems higher
in patients receiving cemented when compared with
cementless TKA xation (Lenguerrand etal. 2019), and
in a Canadian register study, the addition of antibiotics
to polymethacrylate bone cement in TKA seems not as
clearly associated with a reduced risk of revision due to
infection as is the case after cemented total hip arthroplasty (Bohm etal. 2014).
40.5 Patient-Reported Outcomes
Patients younger than 55years of age do not only have
a longer life expectancy than older patients but the average younger patient will also have to return to work for
around 10 years before retirement. Workload, leisure
time, family, and economic situations of the younger
patients are thus quite different compared to patients
close to retirement or to those who are already retired.
Younger patients expect to perform higher in many
activities of daily life, both during work and leisure time,
and sometimes at a challenging level (Witjes etal. 2017).
The fundamentally different life situation and increased
expectations among younger patients are reected not
only in their increased risk of revision but also in their
patient-reported outcomes.
Patient-reported outcomes after knee arthroplasty
in younger patients are not as extensively investigated
when compared to those of the elderly population,
and ndings derived from younger knee arthroplasty
cohorts are not consistent. The inconsistencies may be
explained by selection bias, smaller sample sizes, lower
response rates when it comes to answering questionnaires, the type of PROM used, and investigated time
frames. Further, the interpretation of what a difference
in PROMs between groups really means from a clinical
Arthroplasty Register Data: Outcomes ofKnee Arthroplasty inYounger Patients
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40
perspective is debated since statistically signicant differences in large register cohorts may not be clinically
relevant.
While some studies on younger patients report more
pain and inferior function after TKA, others report
similar outcomes as in the elderly (Wood etal. 2013;
Williams et al. 2013; Haynes et al. 2017; Townsend
etal. 2018; Clement etal. 2018). On the other hand,
even if younger patients preoperatively report more
preoperative pain and lower function than older age
groups (Nyvang etal. 2019) other studies indicate that
they can experience similar or even better improvements
in PROMs after arthroplasty surgery (Williams etal.
2013; Street etal. 2013).
However, there are no denitions of what a successful outcome after knee arthroplasty surgery in terms of
PROMs is, mostly because the surgical goals vary with
age, sex, underlying diagnosis, health status, and so forth.
PROMs are commonly reported as mean values that fail
to illustrate the outliers, and – when presented as an
arithmetic mean– they also give no hint of the proportion of patients that have improved after surgery. This
proportion may oftentimes be of greater interest than a
statistical mean difference, and the “Outcome Measures
in Rheumatology–The Osteoarthritis Research Society
International” (OMERACT–OARSI) responder criteria can be used to evaluate this (Pham etal. 2004). The
responder criteria are based on a combination of absolute and relative changes in pain, function, and total
WOMAC score 1 year after surgery. These criteria have
not been frequently used to compare younger with older
patients, however, there seems to be no clear correlation
of outcome with age (Weber etal. 2018).
> The proportion of younger patients reporting that
they are satised with TKA surgery is lower com-
pared to older patients: 83–86% in the young vs.
91–92% in the older patients (Williams etal. 2013;
Scott et al. 2016; Lange et al. 2018; Clement et al.
2018).
The question whether UKA confers better patientreported outcome when compared with TKA is debated.
A recently published systematic review and meta- analysis
of patient-reported outcomes after total vs. unicompartmental knee arthroplasty describes no relevant differences
in pain– but better function in patients with UKA (Wilson etal. 2019). In contrast, a 5-year follow- up of a randomized controlled trial (RCT) indicates no statistically
or clinically signicant difference in Oxford Knee Score
between patients operated with a total compared to a unicompartmental knee arthroplasty (Beard etal. 2019). In
that study, 82% of patients receiving UKA and 77% of
patients with TKA were satised with the surgery, with-
out a statistically signicant difference.
Several national arthroplasty registers collect
patient-reported outcomes as part of the evaluation
after surgery (Wilson etal. 2019). However, few registers report patient-reported outcomes in their annual
reports. The SKAR has collected and reported patientreported outcomes since 2012 from an increasing number of participating units (Swedish Knee Arthroplasty
Register 2019). An analysis of almost 15,000 TKA
patients, whereof 800 patients were younger than
55years, indicates similar pain and activities of daily
living in patients younger than 55years when compared
with older patients. However, younger patients reported
more other symptoms, more problems in sports and recreation function, and lower knee-related quality of life
compared to the older age groups 1 year after surgery
when measured by the KOOS. 88% of patients younger
than 55years were considered as OMERACT–OARSI
responders, a very similar proportion as among older
patients (89–90%). The SKAR has an anchor question
on patients’ expectations since these may inuence satisfaction as well as pain and function postoperatively.
> 12% of patients younger than 55 years report high
expectations but were not satised with the surgery,
compared to 7% in patients 65–74years of age.
Independently of age-group, patients with higher expectations report considerable inferior outcomes in all ve
dimensions of the KOOS instrument.
Conclusion
z
From a register perspective, TKA and UKA result in
good implant survival even in younger patients, but the
risk of revision is consistently higher in younger than
in older patients, irrespective of whether total or partial
arthroplasty is performed. UKA confers a higher risk
of revision when compared to TKA, also in younger
age groups. Cemented xation of total knee arthroplasty gives the most reliable long-term results in terms
of implant survival, but some hybrid and inverse hybrid
techniques seem to achieve similar results. Patientreported outcome is not extensively studied in patients
younger than 55years of age, but younger patients seem
to attain similar gains in terms of reduced pain and
increased function as elderly patients. However, when
compared with the elderly population, a lower proportion of young patients is satised with the outcome after
surgery, possibly because younger patients have higher
demands and expectations on their knee function when
compared to the elderly knee arthroplasty population.
In conclusion, register data support that despite mostly
good results after total and unicompartmental knee
arthroplasty, younger patients are at higher risk of both
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N. P. Hailer and A. W-Dahl
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implant failure, inferior function, and dissatisfaction,
ndings that should be weighed in when counseling
younger patients prior to knee arthroplasty.
Take-Home Messages
5 An increasing number of younger patients is
operated with partial or total knee arthroplasty.
5 The proportion of patients who have undergone
prior surgery in the index knee is higher in
younger patients, and the proportion of primary
osteoarthritis is lower than in the elderly, both
of which can contribute to an inferior outcome.
5 Knee arthroplasty patients younger than 55 at
the time of surgery are at higher risk of implant
revision.
5 Revision rates are higher after unicompartmen-
tal than after total knee arthroplasty, even in
younger patients.
5 Younger patients gain knee function just as the
elderly do.
5 Young patients are, however, more often dissat-
ised with the outcome of their procedure than
elderly patients.
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