Journal of Orthopaedics 23 (2021) 60–66

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Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

Reasons for failure in primary total knee arthroplasty - An analysis of

prospectively collected registry data
Dominic T. Mathis a, b, *, 1, Leif Lohrer b, 1, Felix Amsler c, Michael T. Hirschmann a, b
a
University of Basel, 4051, Basel, Switzerland
b
Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland
c
Amsler Consulting, 4059, Basel, Switzerland

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: The aim of this study was to determine the causes leading to a first revision of primary total knee
Total knee arthroplasty arthroplasty (TKA) in a specialized knee centre and compare the results with previously published data.
Failure Methods: Prospectively collected data of a consecutive number of 195 patients after primary TKA and who un­
Indication
derwent first revision surgery after completing the diagnostic algorithm for persistent knee pain were included.
Revision
Implants
Data was prospectively collected from a specialized knee centre in which the patients presented between 2015
Total knee replacement and 2020 and retrospectively analysed. Indications for revision surgery were categorized using all available
Switzerland information from patients’ records. Patients were divided into early (up to two years) and late revision (more
than two years).
Results: Overall mean time from index to revision surgery was 3.6 years. 49% of knee revisions occurred in the
first two years, 51% after two years. 86% of the patients were referred to the knee centre from other surgeons.
The most frequent reason for revision was instability, followed by patellofemoral problems, extensor mechanism
insufficiency and malalignment. The most frequently performed revision was complete removal and re-
implantation of a semi constrained implant design (52.5%) followed by revision using a full constrained
implant design (16%). Secondary patella-resurfacing as part of complete revision was carried out in 71.5% of the
cases. The majority of the patients showed concurrent reasons for TKA failure with significant correlations
amongst another. Furthermore, correlations were identified between indications for revision surgery and revision
implant designs.
Conclusion: In a specialized knee centre the most common indications for the first TKA revision were instability
and patellofemoral and/or extensor mechanism insufficiency followed by malalignment. In most patients there
was not only one failure mode, but a combination of many. It is important to establish a standardized diagnostic
algorithm to facilitate comprehensive and efficient diagnostics and the optimal treatment.

1. Introduction Germany6 and 2′ 284 in Switzerland7 in 2018. National registries report

Total knee arthroplasty (TKA) is the treatment of choice for patients
with an advanced osteoarthritis (OA) of the knee. Most patients after
TKA recover well and experience pain relief within 3–6 months.1
Nevertheless, about 10–30% of the patients report ongoing or recurrent
pain or are not satisfied and require revision surgery.2 The number of
revision TKA is rising in many countries, with 10′ 507 in the United
States,3 6′ 357 in United Kingdom,4 25′ 567 in Australia,5 13′ 378 in
revision rates between 3 and 12%, depending on the length of the
observed period and included interventions.3,5,7
Previous studies have analysed failure modes after primary TKA.
According to those results, the most frequent causes of failure are
infection, loosening, instability, arthrofibrosis, and osteolysis.8–14 Some
authors differentiated between early (within the first two years after
primary TKA) and late (thereafter) revisions and found polyethylene
wear and accordingly aseptic loosening as most common failure mode

* Corresponding author. Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz,
Switzerland.,
E-mail address: dominic.mathis@unibas.ch (D.T. Mathis).
URL: http://www.kneedoctor.ch (D.T. Mathis).
1
The first and second authors contributed equally.

https://doi.org/10.1016/j.jor.2020.12.008
Received 1 November 2020; Accepted 8 December 2020
Available online 31 December 2020
0972-978X/© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.
D.T. Mathis et al.
for late revisions.11,15 Fehring et al. reported that infection and insta­
bility were the most common indications for revision in the early failure
group.9 However, modes of failure have changed over the last decade.
Whereas revisions due to polyethylene wear and subsequent osteolysis
became less prevalent as a result of improved polyethylene quality and
manufacturing, infection rates on the contrary were increasing.8,11,16–19
Most data on the causes of TKA failure and further revision surgery
are obtained from national joint registries, health care providers and
multicentre studies.9,11,14,20 These data are not very specific and pro­
vided from many different persons who might have different judgments
for assessing the revision causes. Neither was a thorough and stan­
dardized diagnostic workup, including a detailed patient history, clin­
ical examination, radiological, serological and microbiological
investigations, carried out systematically in the majority of the patients.
This impedes the careful identification or exclusion of all possible failure
modes and thus select the right strategy for the revision surgery. In
particular, many of these studies report only one main reason which
indicated revision surgery and fail to illustrate a more detailed picture of
the revision causes.
The aim of this study was to assess the most common reasons for
failure of primary TKA by reporting the indications for first TKA revision
surgery in a large single-centre series. It was hypothesised that the
modes of failure differ from previously published data, especially
regarding the number of concurrent reasons for failure in one patient.
2. Methods
A prospectively collected consecutive number of 195 patients after
primary TKA (27% (N = 54) primary patellar resurfacing) who com­
plained about persistent knee pain and subsequently underwent first
revision surgery were included in this retrospective cohort study. The
indication for primary TKA was in 86% (N = 172) primary OA and in
14% (N = 28) secondary OA. Data was prospectively collected from a
specialized knee centre in which the patients presented between 2015
and 2020 due to persistent pain after primary TKA. All patients followed
a previously published, standardized diagnostic algorithm (Fig. 1)21
including a detailed patient history and clinical examination, blood
tests, joint aspiration in the operating room (OR), intraoperative find­
ings, culture and histology results, and various imaging modalities
depending on the evaluated failure mode(s) (Table 1). The latter include
Fig. 1. The “Bruderholz” standardized diagnostic algorithm for patients with pain after total knee arthroplasty. WB, weight bearing; SPECT/CT, single photon
emission computed tomography/computer tomography.
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Journal of Orthopaedics 23 (2021) 60–66
standardized (anterior-posterior and lateral weight bearing, patellar
skyline view) and stress radiographs, conventional computerised to­
mography (CT), magnetic resonance imaging (MRI) and combined
single-photon emission computed tomography/computed tomography
using technetium-99 m hydroxymethylene diphosphonate
(99m-Tc-HDP-SPECT/CT). At the end of this standardized clarification
procedure, the revision reason(s) was/were determined for all patients
by one expert knee surgeon (senior orthopaedic consultant, MTH) for
each patient in a standardized manner and documented in the consul­
tation and surgery report. The failure categories were aseptic loosening,
periprosthetic infection, instability, polyethylene wear/osteolysis,
arthrofibrosis/stiffness, malalignment, patellofemoral and/or extensor
mechanism insufficiency, periprosthetic fracture, irritation of iliotibial
band (ITB) and others. In case of more than one causes for revision all
causes were reported. A member of the study group (L.L.) reviewed all
available reports and collected the aforementioned revision reasons and
revision interventions performed.
Revision was defined according to the Swiss National Registry: “A
revision procedure is a secondary surgical procedure of a patient’s knee
joint whereby the complete primary implant or parts thereof are
replaced by new components”.7 Secondary patella-resurfacing due to
progression of OA was also considered as revision procedure. Only first
revisions after primary TKA were included. Patients, who have suffered
a trauma, underwent revision surgery in other hospitals between pri­
mary TKA and presentation at our knee centre were excluded from this
study (N = 19).
The study was approved by the local ethical committee
(2017–02048) and was performed in accordance with the ethical stan­
dards of the responsible committee and with the guidelines of the Hel­
sinki Declaration of 1975, as revised in 2008. A written informed
consent was signed by every patient.
Aseptic loosening is described as the failure of the integration be­
tween a prosthesis and bone in the absence of infection. Loosening re­
ported in the first few years of implantation of a prosthesis is most likely
due to failure of the implant to gain fixation, however, loosening in later
years likely reflects loss of fixation due to bone resorption.22 A recent
meta-analysis suggested that SPECT/CT is the most diagnostically ac­
curate modality for the detection of aseptic loosening in TKA.22 There­
fore, the activity of bone tracer uptake (BTU) in SPECT/CT was
evaluated in this study to diagnose aseptic loosening.23 All patients with
D.T. Mathis et al. Journal of Orthopaedics 23 (2021) 60–66

a
Table 1 Early failure was defined as failures that occurred two years and less after
Revision causes and time to first revision. SD, standard deviation. OA, osteoar­ primary TKA, late failure thereafter.
thritis. PE, polyethylene. PF, patellofemoral. Sy, syndrome. PCL, posterior cru­
ciate ligament. suspicious component loosening underwent 99m-Tc-HDP-SPECT/CT
Overall Time to revision Time to Failurea imaging following a standardized protocol.23–26 These patients
Failure mode N (%) (yrs), mean ± SD
Early N Late N received a commercial 700 MBq (18.92 mCi) 99m-Tc-HDP injection
N = 200 (range)
(%) (%) (Malinckrodt, Wollerau, Switzerland). SPECT/CT was performed using a
N = 98 N= hybrid system (Symbia T16, Siemens, Erlangen, Germany), which con­
102 sists of a pair of low-energy, high-resolution collimators and a dual-head
Aseptic loosening 28 (14) 3.5 ± 3.3 12 16 gamma camera with an integrated 16-slice CT scanner (collimation of
(0.5–17.4) (12.2) (15.7) 16 × 0.75 mm). Planar scintigraphic images were taken in the perfusion
femoral 9 (4.5) 3.6 ± 2.3 (0.5–8) 2 (2) 7 (6.9)
phase (immediately after injection), the soft tissue phase (1–5 min after
tibial 25 (12.5) 3.7 ± 3.4 11 14
(1.1–17.4) (11.2) (13.7) injection) and the delayed metabolic phase (2 h after injection).
Periprosthetic infection 9 (4.5) 6.9 ± 8.2 4 (4.1) 5 (4.9) SPECT/CT was performed with a matrix size of 128 × 128, an angle step
(0.6–24.2) of 32, and a time per frame of 25 s 2 h after injection. BTU activity was
High grade 6 (3) 9.2 ± 9.3 2 (2) 4 (3.9) volumetrically measured in 3D in various anatomical areas according to
(0.6–24.2)
Low grade 3 (1.5) 2.2 ± 2 (1–4.5) 2 (2) 1 (1)
a previously validated localization scheme.23
Instability (I.) 116 (58) 3.3 ± 3.3 58 58 Periprosthetic infection was diagnosed based on the 2018 definition
(0.7–16.5) (59.2) (56.9) of periprosthetic hip and knee infection by the Infectious Diseases So­
Multidirectional I. 16 (8) 2.9 ± 1.9 7 (7.1) 9 (8.8) ciety (IDSA).27 A revision involving two stages or more because of
(0.7–7.3)
infection was considered as two events.
Anteroposterior I. 30 (15) 2.7 ± 2.2 15 15
(0.7–9.8) (15.3) (14.7) The failure mode instability was assessed by positive clinical history,
Medial I. 23 (11.5) 3.2 ± 3.0 11 12 physical examination and suitable radiological imaging. Clinical history
(0.8–12.9) (11.2) (11.8) includes recurrent knee swelling, a sense of knee instability with or
Lateral I. 51 (25.5) 3.4 ± 3.7 25 26 without giving-way, in particular instability that was worse on
(0.7–16.5) (25.5) (25.5)
Posterior I. 19 (9.5) 3.1 ± 3.3 7 (7.1) 12
descending stairs and pain in general. Then, an objective physical ex­
(1.1–15.4) (11.8) amination was performed by the expert knee surgeon (MTH) that
Flexion I. 57 (28.5) 3.1 ± 3.0 30 27 included the observation of the gait (including varus-thrusting), the
(0.8–16.5) (30.6) (26.5) evaluation of the limb alignment in a standing position and testing of
Extension I. 10 (5) 5.2 ± 4.8 2 (2) 8 (7.8)
varus-valgus and anteroposterior stability at full extension and 30◦ /90◦
(0.9–15.7)
Posterior dislocation 1 (0.5) 15.4 0 (0) 1 (1) flexion, and the drawer test. Radiological assessment involved stress
Polyethylene wear/ 4 (2) 13.6 ± 8.2 0 (0) 4 (3.9) radiographs in the anterior–posterior projection with full extension and
osteolysis (2.5–21.1) 30◦ flexion for assessment of varus and valgus laxity as well as in lateral
Arthrofibrosis/stiffness 28 (14) 2.3 ± 2.1 19 9 (8.8) projection in 15◦ and 90◦ flexion to assess for anterior and posterior
(0.3–9.6) (19.4)
laxity using a Telos stress device with 15 N force. In addition, for the
Malalignment 53 (26.5) 3 ± 2.9 29 24
(0.3–13.9) (29.6) (23.5) morphological assessment of the ligaments and surrounding soft tissue,
Patellofemoral/extensor 100 (50) 3 ± 2.6 48 (49) 52 MRI was performed in selected cases.
mechanism insufficiency (0.3–15.7) (51) Polyethylene wear/osteolysis was assessed by macroscopic findings
Progression OA patella 13 (6.5) 3.3 ± 2.9 5 (5.1) 8 (7.8)
on the insert and microscopic report, according to type I of the classi­
(0.8–11.6)
Patella baja 24 (12) 2.8 ± 3.1 15 9 (8.8) fication system describe by Krenn et al.28
(0.3–15.7) (15.3) Arthrofibrosis/stiffness was defined as a limited range of motion
Patella maltracking 5 (2.5) 1.8 ± 1.1 2 (2) 3 (2.9) (ROM) in flexion and/or extension, that is not attributable to an osseous
(0.3–2.8) or prosthetic block to movement from malaligned, malpositioned or
Patella dislocation 1 (0.5) 10 0 (0) 1 (1)
incorrectly sized components, metal hardware, ligament reconstruction,
Insufficiency/rupture 4 (2) 3.1 ± 2.5 1 (1) 3 (2.9)
tendon (patellar/ (0.8–6.6) infection, pain, chronic regional pain syndrome (CRPS) or other specific
quadriceps) causes, but due to soft-tissue fibrosis that was not present pre-
PE dislocation patella 1 (0.5) 5 0 (0) 0 (0) operatively.29
PF overstuffing 72 (36) 3.6 ± 2.8 35 37
Malalignment and malpositioning of the TKA components were
(1.4–11.1) (35.7) (36)
Periprosthetic fracture 6 (3) 5.2 ± 6.1 1 (1) 5 (4.) assessed radiologically with SPECT/CT. All patients with suspicious
(1.6–17.4) component positioning or alignment underwent 99m-Tc-HDP-SPECT/
Irritation iliotibial band 11 (5.5) 3.2 ± 2.1 4 (4.1) 7 (6.9) CT imaging following a standardized protocol.23–25 Mechanical align­
(1.2–7.6) ment and TKA position were assessed using a customized validated
Unexplained pain 6 (3) 5.5 ± 5.7 3 (3.1) 3 (2.9)
3D-software.23–25 The BTU values and measurements of the positioning
(0.9–12.9)
Others 11 (5.5) 4.2 ± 5.4 5 (5.1) 6 (5.9) of the TKA components was interpreted in accordance with the findings
(0–18.1) published by Awengen et al., in 2016.30
Painful ossification 2 (1) 1.7 ± 0.2 2 (2) 0 (0) Patellofemoral problems and extensor mechanism insufficiency
(1.6–1.8)
include progression of patella OA, patellar dislocation or instability,
Overloading Pes 1 (0.5) 2.5 0 (0) 1 (1)
anserine
maltracking, lateral patellar facet impingement, patella baja or alta,
Metallosis 1 (0.5) 18.1 0 (0) 1 (1) patella clunk syndrome, patellar component wear and loosening, tendon
Infrapatellar branch of 2 (1) 1.5 ± 1.4 1 (1) 1 (1) rupture or extensor insufficiency, patellofemoral overstuffing and
saphenous nerve sy. (0.6–2.5) avascular necrosis.31 The diagnosis was based on patient’s history,
Calcinosis cutis 1 (0.5) 9.6 0 (0) 1 (1)
detailed clinical examination of the extensor mechanism and patellofe­
Rupture PCL 1 (0.5) 1.1 1 (1) 0 (0)
End of stem pain 1 (0.5) 2.2 0 (0) 1 (1) moral joint and imaging diagnostics (e.g. conventional radiographs
Intercondylar cement 1 (0.5) 0 1 (1) 0 (0) including tangential radiographs of the patella, ultrasound, MRI,CT and
SPECT/CT).
Periprosthetic fractures were assessed by conventional radiographs

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D.T. Mathis et al. Journal of Orthopaedics 23 (2021) 60–66

or computerised tomography. 58)) followed by patellofemoral and/or extensor mechanism insuffi­

Revision involving isolated secondary resurfacing of the patella was ciency (overall 50% (N = 100), early revisions 49% (N = 48), late re­
only categorized as a failure due to progression of OA, if the patient visions 51% (N = 52)), see Table 1 and Fig. 2 for details. The majority of
reported retropatellar pain, especially in flexion, with pathological the patients (59%) showed several causes for failure, only 41% pre­
findings on a series of tangential radiographs of the patella. Revisions sented one underlying failure mode. Although the early and late failure
were categorized into an early and a late failure group. An interval of groups were very equally balanced (N = 98 and 102) significant dif­
two years between primary TKA and first revision was considered as cut- ferences between the two groups were not found, with the exception of
off between the early and late failure modes.11 wear/osteolysis and arthrofibrosis/stiffness. Wear/osteolysis was the
more common indication for late revisions and arthrofibrosis/stiffness
for early revisions (p < 0.05).
2.1. Statistical analysis
The most frequently performed revision intervention was complete
removal and re-implantation of a semi constrained implant design
Results are presented as mean, standard deviation (SD) and range or
(52.5%, N = 105), followed by revision with re-implantation of a full
number and percentage. To compare group differences, t-tests for in­
constrained implant design (16%, N = 32); the revision was limited to
dependent samples or Chi-square tests were calculated. To test for re­
the isolated exchange of the femoral, tibial, patellar or insert component
lationships between the variables, Pearson-correlations (which are
in 1% (N = 2), 1% (N = 2), 2% (N = 4) and 5.5% (N = 11) of the cases. In
identical to phi when calculated between two dichotomous variables)
six patients (3%) the components were removed and replaced by a
are used. Two-sided p values < 0.05 were considered significant. All
posterior-stabilized TKA. Secondary patellar resurfacing due to OA
data were analysed by an independent professional statistician using
progression of the patella was performed as isolated intervention in 18%
IBM SPSS Statistics for Windows, version 26.0 (Armonk, NY: IBM Corp,
(N = 36) and as part of complete revision in 71.5% (N = 143) of the
USA).
cases; the patella was left unresurfaced during revision in only 2% (N =
4). In two patients (1%) a two-stage revision using a cement spacer was
3. Results
performed. All revisions were carried out by one senior revision TKA
surgeon (MTH).
This study group consisted of 200 knees in 195 patients who had first
Table 3 demonstrates correlations amongst various failure modes
revision TKA (right: left 49.5% (N = 99): 50.5% (N = 101)). The mean
and between failure modes and surgical interventions. The most
age of the total cohort at the time of revision was 66.3 years (standard
outstanding ones include: A positive correlation between patellofe­
deviation (SD) ± 10.7, range 24–87). Men comprised 39% (N = 76) of
moral/extensor mechanism insufficiency and malalignment (p < 0.01)
the knee failures and women 61% (N = 119). The mean of the patients
and wear/osteolysis and “unexplained” pain (p < 0.01) was found. On
had mild to moderate systemic diseases (ASA grade II; mean, SD 2.4 ±
the contrary, patellofemoral problems and/or extensor mechanism
0.6, range grade I-IV) and a body mass index of 29.3 kg/m2 (SD ± 5.5,
insufficiency shows negative correlations with instability (p < 0.001),
range 18–50). Overall mean time from index to revision surgery was 3.6
infection (p < 0.01) and aseptic loosening (p < 0.05). A rather intuitive
years (SD ± 3.9, range 0.2–24.2). 49% (N = 98) of knee revisions
finding was that secondary patellar resurfacing as isolated intervention
occurred in the first two years, 51% (N = 102) after 2 years. Due to the
was only carried out when the patients’ complaints were attributed to
set-up in a specialized knee centre with focus on painful TKA most of the
patellofemoral and/or extensor mechanism insufficiency and signifi­
included patients were referred from other surgeons to our clinic (86%).
cantly less when other causes were present.
Therefore, a total of 87 different surgeons have performed primary
arthroplasty.
The most frequent reason for revision was instability (overall 58%
(N = 116), early revisions 59.2% (N = 58), late revisions 56.9% (N =

Fig. 2. The percentages of patients with each revision indication stratified into early, late an overall subgroup are shown.

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D.T. Mathis et al. Journal of Orthopaedics 23 (2021) 60–66

Table 2
Comparison of previous reports and the present study on failure modes (%) after TKA. In some authors the percentages totalled >100% because some knees had more
than one mode of failure recorded.
Ref. and publication Origin N Mean time to Aseptic Wear/ Instability Infection Patello-femoral/extensor Mal-
year failure Loosening osteolysis mechanisma alignment

Fehring et al.,9 2001 US 279 <5 yr 3 7 26 38 8 12

Sharkey et al.,11 2002 US 212 NR (1.1–28 yr) 17/34 12/44 21/22 25/7.8 10/2 12/12
Schroer et al.,16 2013 US 844 5.9 yr (10d–31 19/31 1/10 25/19 23/16 7/6 8/7
yr)
Le et al.,35 2014 US 253 2.9 yr (SD ± 2.2) 14/13 2/9 26/18 24/25 4 7
Pitta el al,36 2018 US 405 2.1 yr (SD ± 1.7) 21.2 2.5 24.4 25.7 3 2.5
Postler et al.,45 2018 GER 402 6.2 yr (0.1–24.2 21.6 5.2 6.7 36.3 3.7 NR
yr)
Thiele et al.,19 2015 GER 358 1.5 yr/7.9 yr 12.7/34.7 0/18.5 23.9/18.5 26.8/8.9 11.3/3.2 18.3/10.5
Hossain et al.,10 2010 UK 349 7 yr (0.1–13,9) 3/12 1/12 4/3 12/21 3/2 4/3
National Registry,7 CH 8340 1.6 yr (SD ± 1.17) 34.5 5.8 15.9 17 25.7 10.4
2019
Present study CH 200 3.6 yr (0.2–24.2) 14 2 58 4.5 50 26.5
11 10 35 16
Sharkey et al., Hossain et al. and Le et al. : First number is early (<2years) failures, second number is late failures; Schroer et al. : First number is early (<2years)
failures, second is overall failures. Thiele et al.19: First number is early (<1year), second is late ((≥3 years).
N, qualified for revision surgery. NR, not reported.
US, United States; UK, United Kingdom; GER, Germany; CH, Switzerland.
a
Includes patellar dislocation or instability, maltracking, progression of osteoarthritis, lateral patellar facet impingement, patella baja/alta, patella clunk syndrome,
patellar component wear and loosening, tendon rupture or extensor insufficiency, patellofemoral overstuffing and avascular necrosis.

Table 3
Pearson correlation amongst various failure modes and surgical interventions. Significant correlations in bold when positive and in italic when negative, *p < 0.05, **p
< 0.01, ***p < 0.001. ITB, iliotibial band; TKA, total knee arthroplasty; PS, posterior stabilized.
Pearson Instability PF/extensor Malalignment Infection Aseptic Wear/ Arthro- Fracture Irritation Pain Others
mechanism loosening osteolysis fibrosis/ ITB
insufficiency stiffness

Instability 1*** − 0.34*** − 0.06 − 0.21** 0.05 − 0.1 − 0.1 − 0.15* 0.07 − 0.09 − 0.11
PF/extensor − 0.34*** 1*** 0.22** − 0.22** − 0.14* − 0.07 0 0 − 0.11 0 − 0.02
mechanism
insufficiency
Malalignment − 0.06 0.22** 1*** − 0.08 − 0.05 − 0.09 0.02 − 0.04 − 0.05 0.03 − 0.05
Infection − 0.21** − 0.22** − 0.08 1*** − 0.02 − 0.03 − 0.02 − 0.04 − 0.05 − 0.04 − 0.05
Aseptic loosening 0.05 − 0.14* − 0.05 − 0.02 1*** 0.05 − 0.08 0.01 − 0.1 0.01 − 0.03
Wear/osteolysis − 0.1 − 0.07 − 0.09 − 0.03 0.05 1*** − 0.06 − 0.03 − 0.03 0.18** 0.12
Arthrofibrosis/ − 0.1 0 0.02 − 0.02 − 0.08 − 0.06 1*** − 0.07 − 0.1 0.1 0.03
stiffness
Fracture − 0.15* 0 − 0.04 − 0.04 0.01 − 0.03 − 0.07 1*** − 0.04 − 0.03 − 0.04
Irritation ITB 0.07 − 0.11 − 0.05 − 0.05 − 0.1 − 0.03 − 0.1 − 0.04 1*** − 0.04 0.13
Pain − 0.09 0 0.03 − 0.04 0.01 0.18** 0.1 − 0.03 − 0.04 1*** − 0.04
Others − 0.11 − 0.02 − 0.05 − 0.05 − 0.03 0.12 0.03 − 0.04 0.13 − 0.04 1***
Primary patella 0.11 − 0.32*** − 0.01 0.3*** − 0.08 − 0.01 0.01 0.09 − 0.05 − 0.11 0.1
resurf.
Secondary patella − 0.13 0.32*** 0.03 − 0.29*** 0.13 0.01 0 − 0.08 0.06 0.11 − 0.09
resurf.
Semi-constrained 0.33*** − 0.09 0.23*** − 0.18* 0.27*** − 0.15* − 0.02 − 0.13 0.01 − 0.01 − 0.08
TKA design
Fully-constrained 0.21** − 0.19** − 0.05 0.04 − 0.06 0.23*** 0.06 − 0.08 0.07 0.08 0.07
TKA design
PS TKA design − 0.03 − 0.06 − 0.04 0.1 0.01 − 0.03 − 0.07 − 0.03 − 0.04 − 0.03 0.09
Isolated tibial − 0.02 − 0.11 − 0.1 0.16* − 0.1 0.12 − 0.03 0.09 − 0.06 − 0.04 − 0.06
insert exchange
Isolated secondary − 0.5*** 0.39*** − 0.16* − 0.1 − 0.19** − 0.07 0 0.07 0 − 0.01 0.06
patella resurf.

4. Discussion
The most important findings and implications of this study were the
following:
Firstly, the most common indications for TKA revision in this study
cohort were instability and patellofemoral and/or extensor mechanism
insufficiency. These findings are different to most published data
(Table 2). This is not surprising since the majority of all revisions in this
study (86%) were referred to a specialized knee centre after primary
TKA performed elsewhere. Due to the standardized diagnostics
following a validated algorithm for painful patients after TKA in the
setting of a knee centre (Fig. 1), it is likely that the identified failure
modes might differ from those based on registries and studies carried out
in less specialized institutions. In 2002, Sharkey et al. found poly­
ethylene wear (25%) as the most prevalent mechanism for TKA revi­
sion11 and 12 years later they identified aseptic loosening (39.9%) as
most common failure mode.32 This shift of failure modes is most likely a
result of improved polyethylene quality and manufacturing, better
seating and anchorage mechanisms, and more highly polished
surfaces.8,16–18,33 Thiele et al. reported aseptic loosening (21.8%),
instability (21.8%) and malalignment (20.7%) as the most common
indications for revision.19 In the Swiss National joint registry aseptic
loosening (34.5%) followed by patellofemoral and/or extensor mecha­
nism insufficiency (25.7%) and instability (15.9%) are the most frequent

64
D.T. Mathis et al.
indications for TKA revision.7 The reason for the high frequency of
related revisions due to patellofemoral problems and/or extensor
mechanism insufficiency in our cohort but also generally in Switzerland
might be due to the relatively low percentage of patients who undergo
primary patellar resurfacing (26.5%).7 Subsequently, secondary patellar
resurfacing has been performed in the vast majority of the patients in
this cohort (71.5%). The discrepancy between this high number of
secondary patellar resurfacing (71.5%) and the relatively few revision
indications due to progression of patellar OA (6.5%) are explained by
the fact, that with a revision TKA it is generally indicated to resurface the
patella due to the less patella friendly design features of a revision
TKA.34
The high incidence of instability in this cohort (58%) was observed,
albeit to a lesser extent, in other contemporary studies.16,19,35,36 While
other common modes of failure such as aseptic loosening and prosthetic
infection have been studied extensively, there is a lack of evidence in
relation to instability as a mode of failure. A considerable number of
definitions for knee instability exist in the current literature.37,38 An
assessment of an unstable knee requires standardized and comprehen­
sive diagnostics including clinical and radiological screenings to obtain
the correct diagnosis.39–42 Prerequisites, which in modern medicine,
also as a result of technical advances, are much more fulfilled than in the
past.
The same applies to malalignment, which was found in 26.5% of all
patients. Our study group demonstrated in 2011 that 3D-CT is the most
accurate method to determine TKA component position relating to the
mechanical axis. However, most authors use axial 2D-CT slices for
measurement of component position, although it has been shown that
these measurements are very variable and less reliable.43,44 It is there­
fore not surprising that in this study cohort, in which 3D-CT is regularly
used as a firm component of a standardized algorithm (Fig. 1) mala­
lignment is diagnosed with increasing frequency. However, one has to
differentiate symptomatic from asymptomatic malalignment. Only
when the symptoms of the patients match the imaging findings it is a
symptomatic malalignment.
Aseptic loosening and periprosthetic joint infection might be regar­
ded as “simple” revisions treating with the exchange of the loose
component and debridement, antibiotics, implant retention (DAIR),
respectively. These cases might be treated in smaller hospitals whereas
complex revisions for instability, patellofemoral and/or extensor
mechanism insufficiency and malalignment were more frequently
referred to our department.
Secondly, for the majority of the patients in this cohort more than
one reason for failure was found. It appears to be common in literature,
if failure was due to multiple reasons, only the dominant cause was
mentioned.9,16,19,35,45,46 However, the few authors who have listed
more than one cause of failure have not reported the percentages of
multiple reasons.7,11 Only a very recent study of Postler et al. has pub­
lished numbers on concurrent reasons for TKA failure in one patient.
They found in 88.6% of all patients more than one reason indicating
revision surgery.45 These results in combination with our findings un­
derline the general opinion that TKA revision surgery is complex and
challenging and require a lot of experience.47,48 It is therefore crucial to
identify all possible failure modes in order to treat the patient
adequately.
Thirdly, significant differences in terms of demographics, indications
and performed revision procedures could not be found between the early
and late failure group. The only exception constitutes wear/osteolysis
with higher incidence for late revisions (3.9%) and arthrofibrosis/stiff­
ness for early revisions (19.4%). This distribution is in accordance with
previous findings of Postler et al., Thiele et al. and Sharkey et al.19,32,45
According to their findings wear/osteolysis accounts for 8.2%, 18.5%
and 5% of late revisions and arthrofibrosis/stiffness for 9.2%, 7% and
10% of early revisions. There is a lack of consensus on the diagnostic
criteria for arthrofibrosis of the knee, which obscures its true prevalence
after surgical procedures.29 That might be an explanation why the
65
Journal of Orthopaedics 23 (2021) 60–66
incidence varies widely in literature (1%–13% postoperatively)
including the findings of this study (9%–19%).49 Nevertheless, arthro­
fibrosis represents 28% of hospital readmissions due to surgical com­
plications within 90 days of discharge, and constitutes a serious early
complication after TKA.11,35,36,46
With regard to wear/osteolysis, however, the literature proves to be
very clear and states this problem unsurpassed as a long-term compli­
cation with the incidence in most series beyond 10-years.50 Our findings
with a mean time to revision of 13.6 ± 8.2 years are thus in line with the
common tenet.
Fourthly, 105 of the 200 included first revisions were treated with
complete removal and re-implantation of a semi constrained implant
design (52.5%), followed by isolated secondary patellar resurfacing
(18%, N = 36) and complete revision with re-implantation of a full
constrained implant design (16%, N = 32). Previously published data
reported lower frequencies for complete revisions (approx. 30–35%),
but a higher proportion of isolated tibial insert exchange (approx. 14%)
due to larger percentage of infection in their cohorts.7,51 The choice of
implant design was based on thorough preoperative and intraoperative
evaluation. The surgical goals of revision TKA are to obtain stable fix­
ation of the prosthesis to host bone, to restore the pre-arthroplasty
height of the joint line, to obtain a stable range of motion compatible
with the patient’s activities of daily living, and to achieve these goals
while using the least degree of prosthetic constraint so that soft tissues
may share in load transfer. Thus, the surgeon is faced with the question,
“How much constraint is needed?”
However, our choice of implant can be compared with other findings
in literature. Hossain et al. retrospectively reviewed 349 revision knee
arthroplasties and found a similar distribution between semi (43%) and
full constrained (21%) implant design.10
Finally, pain after TKA is usually the main reason for choosing a knee
specialist. The causes for persistent or recurrent pain after TKA are
manifold and sometimes difficult to identify. Nevertheless, surgeons
should never fail to make every effort to find the cause of the pain. It is
the common sense, that revision operations should only be performed if
the cause(s) of the complaints described have been identified and fit the
clinical picture, as revision surgery for unexplained pain has consistently
been shown to result in poor outcomes.47,48,52,53 Thus, the diagnosis
“unexplained pain” should not be an indication for a TKA revision but
rather the symptom that has an underlying cause. According to this, in
our study pain was only diagnosed in connection with a “true” indica­
tion, in particular with wear/lysis (significant) and arthrofibrosis/stiff­
ness (tendency).
Several limitations of the present study have to be acknowledged.
Most patients of this study (86%) were referred to our specialized knee
centre for their first TKA revision and thus, this cohort is heterogeneous
in terms of number of different surgeons and mean time to failure. This
most probably caused a selection of more complicated revisions and
therefore the frequencies differ from other studies or registries. Another
limitation of this study is the fact that functional failure, which includes
patients with low functional and clinical scores for the operated knee
who did not have any further interventions, were not taken into
consideration.
The strength of this study compared to registry data is that the causes
for failure are much more likely to be accurate as a dedicated research
fellow was meticulously combing through several reports of consulta­
tion and surgery to collect the necessary data related to revision surgery.
5. Conclusion
This study illustrated the main indications for the first TKA revisions
in a specialized knee centre in Switzerland. The most frequent reasons
for revision were instability, patellofemoral and/or extensor mechanism
insufficiency and malalignment. The majority of the patients showed
concurrent reasons for TKA failure with significant correlations amongst
another. Only if we understand why a TKA fails one can tailor the
D.T. Mathis et al.
diagnostic and treatment algorithm in this direction. In the current
climate of increasingly short resources an efficient diagnostic and
treatment algorithm should be able to detect the most important failure
modes in TKA.
Declaration of competing interest
None declared.
References
1 Vilardo L, Shah M. Chronic pain after hip and knee replacement. Tech Reg Anesth Pain
Manag. 2011;15:110–115.
2 Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of
patients report long-term pain after total hip or knee replacement for osteoarthritis?
A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2
(1), e000435.
3 No authors listed American joint replacement registry (AJRR). Sixth AJRR annual
report 2019 on hip and knee arthroplasty data https://connect.ajrr.net/hubfs/PDFs%
20and%20PPTs/AAOS_AJRR_2019_Annual_Report_Update_FINAL_150DPI.pdf?ut
m_campaign=2019%20AJRR%20AR&utm_medium=email&_hsenc=p2ANqtz-_R9e
0yFLoCd0ilZVdi-Kx2fWPDNQKU55Z-MaFp5uUfeJUAIm2rJh-Lca146_R2hFgmvbRS
s0CNPzjVEuIFjUh5cnj8k4QZYaNRm3lAyiu-JH3Pc2s&_hsmi=79114016&ut
m_content=79114016&utm_source=hs_automation&hsCtaTracking=f8fa4e79-6709
-45d2-b51b-908382b7d5a7%7Cb61796dc-af0d-4a90-9b72-871845865e0b; 2019.
Accessed August 9, 2020.
4 No authors listed National joint registry for england, Wales, Northern Ireland and the
Isle of Man. 16th annual report 2019 https://reports.njrcentre.org.uk/Portals/0/P
DFdownloads/NJR%2016th%20Annual%20Report%202019.pdf; 2019. Accessed
August 9, 2020.
5 No authors listed Australian orthopaedic association (AOA). National joint
replacement registry (NJRR) hip and knee arthroplasty annual report 2019 https
://aoanjrr.sahmri.com/documents/10180/668596/Hip%2C+Knee%26+Shoulder+
Arthroplasty/c287d2a3-22df-a3bb-37a2-91e6c00bfcf0; 2019. Accessed August 9,
2020.
6 No authors listed Endoprothesenregister deutschland (EPRD). Jahresbericht; 2019. htt
ps://www.eprd.de/fileadmin/user_upload/Jahresbericht_2019_doppelseite_2.0.pdf.
Accessed August 9, 2020.
7 No authors listed Swiss national joint registry. SIRIS Report 2019 https://www.
siris-implant.ch/de/index.php?section=Downloads&download=145; 2019.
Accessed August 9, 2020.
8 Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty
in the United States. Clin Orthop Relat Res. 2010;468(1):45–51.
9 Fehring TK, Odum S, Griffin WL, Mason JB, Nadaud M. Early failures in total knee
arthroplasty. Clin Orthop Relat Res. 2001;(392):315–318.
10 Hossain F, Patel S, Haddad FS. Midterm assessment of causes and results of revision
total knee arthroplasty. Clin Orthop Relat Res. 2010;468(5):1221–1228.
11 Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Insall Award paper.
Why are total knee arthroplasties failing today? Clin Orthop Relat Res. 2002;404:
7–13.
12 Vince KG. Why knees fail. J Arthroplasty. 2003;18(3 Suppl 1):39–44.
13 Callaghan JJ, O’Rourke MR, Saleh KJ. Why knees fail: lessons learned. J Arthroplasty.
2004;19(4 Suppl 1):31–34.
14 Vessely MB, Whaley AL, Harmsen WS, Schleck CD, Berry DJ. The Chitranjan
Ranawat Award: long-term survivorship and failure modes of 1000 cemented
condylar total knee arthroplasties. Clin Orthop Relat Res. 2006;452:28–34.
15 Khan M, Osman K, Green G, Haddad FS. The epidemiology of failure in total knee
arthroplasty: avoiding your next revision. Bone Joint Lett J. 2016;98-B(1 Suppl A):
105–112.
16 Schroer WC, Berend KR, Lombardi AV, et al. Why are total knees failing today?
Etiology of total knee revision in 2010 and 2011. J Arthroplasty. 2013;28(8 Suppl):
116–119.
17 Kasahara Y, Majima T, Kimura S, Nishiike O, Uchida J. What are the causes of
revision total knee arthroplasty in Japan? Clin Orthop Relat Res. 2013;471(5):
1533–1538.
18 Koh IJ, Cho WS, Choi NY, Kim TK, Kleos Korea Research G. Causes, risk factors, and
trends in failures after TKA in Korea over the past 5 years: a multicenter study. Clin
Orthop Relat Res. 2014;472(1):316–326.
19 Thiele K, Perka C, Matziolis G, Mayr HO, Sostheim M, Hube R. Current failure
mechanisms after knee arthroplasty have changed: polyethylene wear is less
common in revision surgery. J Bone Joint Surg Am. 2015;97(9):715–720.
20 Mulhall KJ, Ghomrawi HM, Scully S, Callaghan JJ, Saleh KJ. Current etiologies and
modes of failure in total knee arthroplasty revision. Clin Orthop Relat Res. 2006;446:
45–50.
21 Hirschmann MT, Henckel J, Rasch H. SPECT/CT in patients with painful knee
arthroplasty-what is the evidence? Skeletal Radiol. 2013;42(9):1201–1207.
22 Barnsley L, Barnsley L. Detection of aseptic loosening in total knee replacements: a
systematic review and meta-analysis. Skeletal Radiol. 2019;48(10):1565–1572.
23 Hirschmann MT, Amsler F, Rasch H. Clinical value of SPECT/CT in the painful total
knee arthroplasty (TKA): a prospective study in a consecutive series of 100 TKA. Eur
J Nucl Med Mol Imag. 2015;42(12):1869–1882.
24 Rasch H, Falkowski AL, Forrer F, Henckel J, Hirschmann MT. 4D-SPECT/CT in
orthopaedics: a new method of combined quantitative volumetric 3D analysis of
66
Journal of Orthopaedics 23 (2021) 60–66
SPECT/CT tracer uptake and component position measurements in patients after
total knee arthroplasty. Skeletal Radiol. 2013;42(9):1215–1223.
25 Hirschmann MT, Wagner CR, Rasch H, Henckel J. Standardized volumetric 3D-
analysis of SPECT/CT imaging in orthopaedics: overcoming the limitations of
qualitative 2D analysis. BMC Med Imag. 2012;12:5.
26 Murer AM, Hirschmann MT, Amsler F, Rasch H, Huegli RW. Bone SPECT/CT has
excellent sensitivity and specificity for diagnosis of loosening and patellofemoral
problems after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2020;28
(4):1029–1035.
27 Parvizi J, Tan TL, Goswami K, et al. The 2018 definition of periprosthetic hip and
knee infection: an evidence-based and validated criteria. J Arthroplasty. 2018;33(5):
1309–1314 e1302.
28 Morawietz L, Krenn V. [The spectrum of histomorphological findings related to joint
endoprosthetics]. Pathologe. 2014;35(Suppl 2):218–224.
29 Kalson NS, Borthwick LA, Mann DA, et al. International consensus on the definition
and classification of fibrosis of the knee joint. Bone Joint Lett J. 2016;98-B(11):
1479–1488.
30 Awengen R, Rasch H, Amsler F, Hirschmann MT. Symptomatic versus asymptomatic
knees after bilateral total knee arthroplasty: what is the difference in SPECT/CT? Eur
J Nucl Med Mol Imag. 2016;43(4):762–772.
31 Parker DA, Dunbar MJ, Rorabeck CH. Extensor mechanism failure associated with
total knee arthroplasty: prevention and management. J Am Acad Orthop Surg. 2003;
11(4):238–247.
32 Sharkey PF, Lichstein PM, Shen C, Tokarski AT, Parvizi J. Why are total knee
arthroplasties failing today–has anything changed after 10 years? J Arthroplasty.
2014;29(9):1774–1778.
33 Cerquiglini A, Henckel J, Hothi H, et al. Retrieval analysis of contemporary
antioxidant polyethylene: multiple material and design changes may decrease
implant performance. Knee Surg Sports Traumatol Arthrosc. 2019;27(7):2111–2119.
34 Parvizi J, Mortazavi SM, Devulapalli C, Hozack WJ, Sharkey PF, Rothman RH.
Secondary resurfacing of the patella after primary total knee arthroplasty does the
anterior knee pain resolve? J Arthroplasty. 2012;27(1):21–26.
35 Le DH, Goodman SB, Maloney WJ, Huddleston JI. Current modes of failure in TKA:
infection, instability, and stiffness predominate. Clin Orthop Relat Res. 2014;472(7):
2197–2200.
36 Pitta M, Esposito CI, Li Z, Lee YY, Wright TM, Padgett DE. Failure after modern total
knee arthroplasty: a prospective study of 18,065 knees. J Arthroplasty. 2018;33(2):
407–414.
37 Wilson CJ, Theodoulou A, Damarell RA, Krishnan J. Knee instability as the primary
cause of failure following Total Knee Arthroplasty (TKA): a systematic review on the
patient, surgical and implant characteristics of revised TKA patients. Knee. 2017;24
(6):1271–1281.
38 Longo UG, Candela V, Pirato F, Hirschmann MT, Becker R, Denaro V. Midflexion
instability in total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol
Arthrosc. 2020. https://doi.org/10.1007/s00167-020-05909-6.
39 Petrie JR, Haidukewych GJ. Instability in total knee arthroplasty : assessment and
solutions. Bone Joint Lett J. 2016;98-B(1 Suppl A):116–119.
40 Cottino U, Sculco PK, Sierra RJ, Abdel MP. Instability after total knee arthroplasty.
Orthop Clin N Am. 2016;47(2):311–316.
41 Hirschmann MT, Becker R. The Unhappy Total Knee Replacement: A Comprehensive
Review and Management Guide. Springer International Publishing; 2015.
42 Murer M, Falkowski AL, Hirschmann A, Amsler F, Hirschmann MT. Threshold values
for stress radiographs in unstable knees after total knee arthroplasty. Knee Surg Sports
Traumatol Arthrosc. 2020. https://doi.org/10.1007/s00167-020-05964-z.
43 Hirschmann MT, Konala P, Amsler F, Iranpour F, Friederich NF, Cobb JP. The
position and orientation of total knee replacement components: a comparison of
conventional radiographs, transverse 2D-CT slices and 3D-CT reconstruction. J Bone
Joint Surg Br. 2011;93(5):629–633.
44 Skowronek P, Arnold M, Starke C, et al. Intra- and postoperative assessment of
femoral component rotation in total knee arthroplasty: an EKA knee expert group
clinical review. Knee Surg Sports Traumatol Arthrosc. 2020. https://doi.org/10.1007/
s00167-020-06006-4.
45 Postler A, Lutzner C, Beyer F, Tille E, Lutzner J. Analysis of total knee arthroplasty
revision causes. BMC Muscoskel Disord. 2018;19(1):55.
46 Dalury DF, Pomeroy DL, Gorab RS, Adams MJ. Why are total knee arthroplasties
being revised? J Arthroplasty. 2013;28(8 Suppl):120–121.
47 Hofmann S, Seitlinger G, Djahani O, Pietsch M. The painful knee after TKA: a
diagnostic algorithm for failure analysis. Knee Surg Sports Traumatol Arthrosc. 2011;
19(9):1442–1452.
48 Mandalia V, Eyres K, Schranz P, Toms AD. Evaluation of patients with a painful total
knee replacement. J Bone Joint Surg Br. 2008;90(3):265–271.
49 Cheuy VA, Foran JRH, Paxton RJ, Bade MJ, Zeni JA, Stevens-Lapsley JE.
Arthrofibrosis associated with total knee arthroplasty. J Arthroplasty. 2017;32(8):
2604–2611.
50 Naudie DD, Ammeen DJ, Engh GA, Rorabeck CH. Wear and osteolysis around total
knee arthroplasty. J Am Acad Orthop Surg. 2007;15(1):53–64.
51 Delanois RE, Mistry JB, Gwam CU, Mohamed NS, Choksi US, Mont MA. Current
epidemiology of revision total knee arthroplasty in the United States. J Arthroplasty.
2017;32(9):2663–2668.
52 Phillips JR, Hopwood B, Stroud R, Dieppe PA, Toms AD. The characterisation of
unexplained pain after knee replacement. Br J Pain. 2017;11(4):203–209.
53 Jacofsky DJ, Della Valle CJ, Meneghini RM, Sporer SM, Cercek RM. Revision total
knee arthroplasty: what the practicing orthopaedic surgeon needs to know. Instr
Course Lect. 2011;60:269–281.