Why Knee Replacements Fail, and How Technology Can Help

    It is estimated that more than 1 million total knee arthroplasty (TKA) procedures will be performed in the US this year, along with more than 127,000 revision TKAs. [1]

    The number of unicompartmental knee arthroplasty (UKA) is also likely to rise, fueled by the increased incidence and prevalence of knee osteoarthritis (OA).

    Combine that with the push by payers to decrease costs while shifting more financial risk to providers and it is easy to see the imperative for surgeons to understand why knee replacements fail. Knowing the modes of failure for modern TKA and UKA, Brian Perkinson, MD, told attendees at ICJR’s inaugural Emerging Technologies in Joint Replacement course, will help drive the advances needed to improve patient outcomes.

    RELATED: Register for the 2nd Annual Emerging Technologies in Joint Replacement course

    Fortunately, the literature has great deal to say about historical and modern causes of failure in TKA and UKA, according to Dr. Perkinson, from the Bone and Joint Institute in Franklin, Tennessee, which he summarized during his presentation.

    TKA Failures

    A 1982 study by Rand et al [2] showed TKA failures occurring less than 3 years after the index surgery, primarily due to loosening, instability, and malalignment. Moreland [3] found that loosening and instability were still the top 2 reasons for failure 6 years later, but by about 2 decades after Rand’s study, infection was the top cause of TKA failure, followed by instability and loosening of cementless TKAs. [4]

    An award-winning paper by Sharkey et al [5] divided causes of TKA failure into early (less than 2 years after the procedure) and late (more than 2 years after the procedure):

    Early Failures

    • Infection
    • Instability
    • Arthrofibrosis
    • Loosening

    Late Failures

    • Polyethylene wear
    • Loosening
    • Instability
    • Infection

    Ten years later, Sharkey et al [6] updated their findings, noting that infection was still the top cause of early failures, but aseptic loosening had risen to the top for late failures.

    More recently, data from the New Zealand registry found a cumulative probability of TKA failure of 6% at 15 years, with infection and aseptic loosening as the top causes of early and late failure, respectively. [7] In a retrospective review of data from a single institution, Pitta et al [8] found infection and arthrofibrosis to be the leading reasons for TKA failure at less than 2 years after surgery, with instability and aseptic loosening causing most failures after 2 years.

    UKA Failures

    Dr. Perkinson said that the literature consistently reports higher failure rates for UKA than for TKA. However, surgeons working at high-volume centers and consistently using the same implants report good outcomes:

    • 98% survival at 10 years and 96% at 13 years for Berger et al [9]
    • 83% survival with a mobile-bearing implant and 91% with a fixed-bearing implant for Neufeld et al [10]
    • 85% survival at 10 years for Lombardi et al [11]

    Kleeblad et al [12] reported 97% survival at 5.7 years with robotic-assisted medial UKA. Their most common failure mode was aseptic loosening.

    In a systematic review of 37 cohort studies and 2 registry-based studies of UKA, van der List et al [13] found that the top overall failure modes were aseptic loosening, progression of OA, and unexplained pain. They then divided the failure modes into early (less than 5 years after the procedure) and late (more than 5 years after the procedure):

    Early Failures

    • Aseptic loosening
    • Progression of OA
    • Bearing dislocation

    Late Failures

    • Progression of OA
    • Aseptic loosening
    • Polyethylene wear

    Click on the image above to watch Dr. Perkinson’s presentation from the Emerging Technologies in Joint Replacement course and learn more about failure modes for TKA and UKA.

    Other faculty members at the Emerging Technologies in Joint Replacement course addressed possible solutions to the issues Dr. Perkinson outlined. Click on the images below to watch their presentations.

    Sensor-Based Balancing in Total Knee Arthroplasty
    Martin W. Roche Jr. MD

    What I’ve Learned from Robotics in Total Knee Arthroplasty
    Preetesh D. Patel MD

    Why Should Surgeons Customize TKA Implants?
    Vivek S. Neginhal MD

    Can CT-Based Technology in Total Knee Arthroplasty Improve Clinical Outcomes
    J. Craig Morrison MD

    Imageless Robotics in Total Knee Arthroplasty
    Vivek S. Neginhal MD


    1. Rand JA, Bryan RS. Rand Revision after total knee arthroplasty. Orthop Clin North Am. 1982 Jan;13(1):201-12.
    2. Moreland JR. Mechanisms of failure in total knee arthroplasty. Clin Orthop Relat Res. 1988 Jan;(226):49-64.
    3. Fehring TK, Odum S, Griffin WL, Mason JB, Nadaud M. Early failures in total knee arthroplasty. Clin Orthop Relat Res. 2001 Nov;(392):315-8.
    4. 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 Nov;(404):7-13.
    5. 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 Sep;29(9):1774-8. doi: 10.1016/j.arth.2013.07.024. Epub 2014 Jul 5.
    6. Koh CK, Zeng I, Ravi S, Zhu M, Vince KG, Young SW. Periprosthetic joint infection is the main cause of failure for modern knee arthroplasty: an analysis of 11,134 knees. Clin Orthop Relat Res. 2017 Sep;475(9):2194-2201. doi: 10.1007/s11999-017-5396-4. Epub 2017 Jun 1.
    7. 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 Feb;33(2):407-414. doi: 10.1016/j.arth.2017.09.041. Epub 2017 Sep 25.
    8. Berger RA, Meneghini RM, Jacobs JJ, Sheinkop MB, Della Valle CJ, Rosenberg AG, Galante JO. Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up. J Bone Joint Surg Am. 2005 May;87(5):999-1006.
    9. Neufeld ME, Alberts A, Greidanus NV, Garbuz DS, Masri BA. A comparison of mobile and fixed-bearing unicompartmental knee arthroplasty at a minimum 10-year follow-up. J Arthroplasty. 2018 Jun;33(6):1713-1718. doi: 10.1016/j.arth.2018.01.001. Epub 2018 Jan 11.
    10. Alnachoukati OK, Barrington JW, Berend KR, Kolczun MC, Emerson RH, Lombardi AV Jr, Mauerhan DR. Eight hundred twenty-five medial mobile-bearing unicompartmental knee arthroplasties: the first 10-year us multi-center survival analysis. J Arthroplasty. 2018 Mar;33(3):677-683. doi: 10.1016/j.arth.2017.10.015. Epub 2017 Oct 16.
    11. Kleeblad LJ, Borus TA, Coon TM, Dounchis J, Nguyen JT, Pearle AD. Midterm survivorship and patient satisfaction of robotic-arm-assisted medial unicompartmental knee arthroplasty: a multicenter study. J Arthroplasty. 2018 Jun;33(6):1719-1726. doi: 10.1016/j.arth.2018.01.036. Epub 2018 Jan 31.
    12. van der List JP, Zuiderbaan HA, Pearle AD. Why do medial unicompartmental knee arthroplasties fail today? J Arthroplasty. 2016 May;31(5):1016-21. doi: 10.1016/j.arth.2015.11.030. Epub 2015 Dec 7.