Burn, Edward

Murray, DW

Pinedo-Villanueva, R

Prieto-Alhambra, D

The Lancet

English

Burn, E

Pinedo Villanueva, R

Prieto Alhambra, D

Oxford University Research Archive (ORA)

Knee and hip replacements and the risk of revision

Oxford University Research Archive

Risk of revision after knee and hip replacement: even better than reported after accounting for the competing risk of death We read with interest the papers by Evans et al.1,2 on implant survival after knee and hip replacement. Based on an exhaustive literature review and meta-analysis, they found long-term implant survival to be better than generally thought. The studies included by the authors typically used Kaplan-Meier estimates for survival, where losses to follow-up are treated as noninformative. The implication of this is not trivial. With sufficient follow-up, the event of interest (i.e. revision surgery) would eventually occur for all subjects.3 However, after a primary knee or hip replacement, individuals have a competing risk of mortality which means that that they may never undergo a revision surgery. The survival estimates provided therefore answer a patient’s question: “what is my risk of having had a revision if I am still alive in 25 years?”. Answering the question “what is my risk of having a revision?”, however, requires taking the competing risk of mortality into account.4 We combined the estimates for risk of revision from the work by Evans et al.1,2 (assuming that risk was distributed evenly across time) with estimates for the risk of mortality from UK lifetables5 using a Markov model, with results summarised in Figure 1. It can be seen that the probability of revision at 25 years is 5 to 10 percentage points lower than would be estimated based on Kaplan-Meier estimates alone. Answers to both questions are likely of interest, and we hope these estimates help to contextualise those from Evans et al.1,2  References 1 Evans JT, Walker RW, Evans JP, Blom AW, Sayers A, Whitehouse MR. How long does a knee replacement last ? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019; 393: 655–63. 2 Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last ? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019; 393: 647–54. 3 Austin PC, Lee DS, Fine JP. Introduction to the Analysis of Survival Data in the Presence of Competing Risks. Circulation 2016; 133: 601–9. 4 Putter H, Fiocco M, Geskus RB. Tutorial in biostatistics : Competing risks and multi-state models. 2007; : 2389–430. 5 Office for National Statistics. National life tables: UK (2013-2015). https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/datasets/nationallifetablesunitedkingdomreferencetables (accessed Aug 9, 2018).           

Knee and hip replacements and the risk of revision: Correspondence

https://ora.ox.ac.uk/objects/uuid:1bc2ea3a-eaf7-4414-8fa7-8f4abddc2f86/files/m9567e9c0568701ac45c90fced7437001

Knee and hip replacements and the risk of revision: Correspondence

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