{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T18:59:19Z","timestamp":1790103559810,"version":"4.0.1"},"reference-count":20,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"3","license":[{"start":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:00:00Z","timestamp":1782864000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Lifetime revision risk after total knee arthroplasty (TKA) is usually estimated from Kaplan-Meier survivorship, which treats death as noninformative censoring and overstates revision incidence when competing mortality is substantial. The bias increases with age. We quantified the discrepancy between Kaplan-Meier and competing-risk estimates and derived the age- and sex-specific probability of dying with the original TKA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>We analyzed 2,920 primary TKAs from a 15-year multisurgeon single-institution database linked to the New Zealand Joint Registry. Revision and death were modelled as competing events using Aalen-Johansen cumulative incidence functions and Fine-Gray subdistribution hazards, with patient-level clustering for bilateral cases. Kaplan-Meier estimates censoring death served as the benchmark. Cohort mortality was compared with the New Zealand population using standardized mortality ratios (SMRs) from 2017 to 2019 life tables.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>There were 155 revisions and 525 deaths (median follow-up 7.4 years). The 15-year revision estimate was 8.3% by Kaplan-Meier versus 7.4% by competing-risk estimation overall, and 5.6% versus 3.0% in patients aged 85 years or older (relative overestimation &gt;80%). At 10 years, cumulative incidence of revision was 5.7% (95% CI 4.8-6.7) versus 19.9% (18.2-21.8) for death, diverging with age (85 years or older: 3.0% versus 67.6%). 97% of patients aged 75 years or older died with the original TKA. Each 10-year age increment lowered the revision hazard (sHR 0.76, 0.61-0.94) and raised mortality (HR 2.33, 2.02-2.68). Cohort mortality was lower than the general population (SMR 0.73, 0.66-0.79). Among M\u0101ori, this relative advantage (SMR 0.66) was absent against the total population (SMR 1.11).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>Kaplan-Meier systematically overstates absolute lifetime revision incidence after TKA, most in older patients for whom competing mortality dominates. Age- and sex-specific competing-risk estimates provide more accurate preoperative figures and should be reported alongside Kaplan-Meier when presenting long-term revision risk.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence:<\/jats:title>\n                    <jats:p>\n                      Prognostic\n                      <jats:underline>Level III<\/jats:underline>\n                      . See Instructions for Authors for a complete description of levels of evidence.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.2106\/jbjs.oa.26.00217","type":"journal-article","created":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T18:00:27Z","timestamp":1790100027000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Will the Knee Outlive the Patient? Kaplan-Meier Systematically Overstates the Lifetime Risk of Revision After Total Knee Arthroplasty"],"prefix":"10.2106","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0608-3065","authenticated-orcid":false,"given":"Wayne","family":"Hoskins","sequence":"first","affiliation":[{"name":"Department of Orthopaedics, Whang\u0101rei Hospital, Te Whatu Ora Te Tai Tokerau, Whang\u0101rei, Aotearoa New Zealand"},{"name":"Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia"},{"name":"Northland Knee & Hip, Whangarei, Aotearoa New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8897-3688","authenticated-orcid":false,"given":"Charles A.","family":"Gusho","sequence":"additional","affiliation":[{"name":"Missouri Orthopedic Institute, University of Missouri, Columbia, Missouri"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4309-4185","authenticated-orcid":false,"given":"Kenrick","family":"Rosser","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics, Whang\u0101rei Hospital, Te Whatu Ora Te Tai Tokerau, Whang\u0101rei, Aotearoa New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,7]]},"reference":[{"issue":"10172","key":"R1-20260922","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1016\/S0140-6736(18)32531-5","article-title":"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","volume":"393","author":"Evans","year":"2019","journal-title":"The Lancet"},{"issue":"446","key":"R2-20260922","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1080\/01621459.1999.10474144","article-title":"A proportional hazards model for the subdistribution of a competing risk","volume":"94","author":"Fine","year":"1999","journal-title":"J Am Stat Assoc."},{"issue":"1","key":"R3-20260922","doi-asserted-by":"crossref","first-page":"2309499020902589","DOI":"10.1177\/2309499020902589","article-title":"Total knee arthroplasty reduces the risk of mortality in osteoarthritis patients up to 12 years: a Korean national cohort longitudinal follow-up study","volume":"28","author":"Choi","year":"2020","journal-title":"J Orthop Surg (Hong Kong)"},{"issue":"11","key":"R4-20260922","doi-asserted-by":"crossref","first-page":"e106","DOI":"10.3346\/jkms.2024.39.e106","article-title":"Life expectancy of patients undergoing total knee arthroplasty: comparison with general population","volume":"39","author":"Kim","year":"2024","journal-title":"J Korean Med Sci."},{"issue":"6","key":"R5-20260922","doi-asserted-by":"crossref","first-page":"1414","DOI":"10.1097\/CORR.0000000000000673","article-title":"How does mortality risk change over time after hip and knee arthroplasty?","volume":"477","author":"Harris","year":"2019","journal-title":"Clin Orthop Relat Res"},{"issue":"6","key":"R6-20260922","doi-asserted-by":"crossref","first-page":"1471","DOI":"10.1016\/j.arth.2024.11.012","article-title":"Patient and surgical factors associated with long-term mortality outcomes up to fifteen years after total hip and knee arthroplasty: an Australian orthopaedic Association National Joint Replacement Registry study","volume":"40","author":"Zhou","year":"2025","journal-title":"J Arthroplasty"},{"issue":"17","key":"R7-20260922","doi-asserted-by":"crossref","first-page":"2229","DOI":"10.3390\/healthcare13172229","article-title":"Associations between common hip and knee osteoarthritis treatments and all-cause mortality","volume":"13","author":"Orchard","year":"2025","journal-title":"Healthcare (Basel)"},{"issue":"6","key":"R8-20260922","doi-asserted-by":"crossref","first-page":"935","DOI":"10.4055\/cios22088","article-title":"Total knee arthroplasty: is it safe? A single-center study of 4,124 patients in South Korea","volume":"15","author":"Ko","year":"2023","journal-title":"Clin Orthop Surg"},{"issue":"10077","key":"R9-20260922","doi-asserted-by":"crossref","first-page":"1424","DOI":"10.1016\/S0140-6736(17)30059-4","article-title":"The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study","volume":"389","author":"Bayliss","year":"2017","journal-title":"Lancet"},{"issue":"5","key":"R10-20260922","doi-asserted-by":"crossref","first-page":"814","DOI":"10.1016\/j.arth.2022.01.056","article-title":"Demand matching total joint replacement patients results in reduction of post-discharge costs","volume":"37","author":"Blevins","year":"2022","journal-title":"J Arthroplasty"},{"key":"R11-20260922","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1016\/j.artd.2021.08.019","article-title":"Understanding the 30-day mortality burden after revision total knee arthroplasty","volume":"11","author":"Sinclair","year":"2021","journal-title":"Arthroplasty Today"},{"issue":"11","key":"R12-20260922","doi-asserted-by":"crossref","first-page":"2389","DOI":"10.1002\/sim.2712","article-title":"Tutorial in biostatistics: competing risks and multi-state models","volume":"26","author":"Putter","year":"2007","journal-title":"Stat Med."},{"issue":"3","key":"R13-20260922","doi-asserted-by":"crossref","first-page":"1141","DOI":"10.1214\/aos\/1176350951","article-title":"A class of K-sample tests for comparing the cumulative incidence of a competing risk","volume":"16","author":"Gray","year":"1988","journal-title":"Ann Stat"},{"issue":"408","key":"R14-20260922","doi-asserted-by":"crossref","first-page":"1074","DOI":"10.1080\/01621459.1989.10478874","article-title":"The robust inference for the Cox proportional hazards model","volume":"84","author":"Lin","year":"1989","journal-title":"J Am Stat Assoc."},{"issue":"1","key":"R15-20260922","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1111\/j.1541-0420.2011.01640.x","article-title":"On estimation in relative survival","volume":"68","author":"Pohar","year":"2012","journal-title":"Biometrics"},{"issue":"9596","key":"R16-20260922","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","article-title":"The strengthening the reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"370","author":"von Elm","year":"2007","journal-title":"Lancet"},{"issue":"6","key":"R17-20260922","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1002\/(SICI)1097-0258(19990330)18:6<695::AID-SIM60>3.0.CO;2-O","article-title":"Estimation of failure probabilities in the presence of competing risks: new representations of old estimators","volume":"18","author":"Gooley","year":"1999","journal-title":"Stat Med."},{"issue":"5","key":"R18-20260922","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1302\/0301-620X.104B5.BJJ-2021-1219.R1","article-title":"Monitoring the lifetime risk of revision knee arthroplasty over a decade: a population-level analysis of Australian national registry data","volume":"104-B","author":"Ackerman","year":"2022","journal-title":"Bone Jt J."},{"issue":"10","key":"R19-20260922","doi-asserted-by":"crossref","first-page":"3456","DOI":"10.1016\/j.arth.2021.05.015","article-title":"Contemporary mortality rate and outcomes in nonagenarians after primary total knee arthroplasty","volume":"36","author":"Dagneaux","year":"2021","journal-title":"J Arthroplasty"},{"issue":"12","key":"R20-20260922","doi-asserted-by":"crossref","first-page":"3147","DOI":"10.1016\/j.arth.2025.05.067","article-title":"Comparing facility costs, patient-reported outcome measures, and revision rates in cementless and cemented primary total knee arthroplasty: findings from a propensity score-matched patient-level value analysis of 380 procedures with a mean 4.3-year follow-up","volume":"40","author":"Peterson","year":"2025","journal-title":"J Arthroplasty"}],"container-title":["JBJS Open Access"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.OA.26.00217","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T18:00:31Z","timestamp":1790100031000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.OA.26.00217"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":20,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.2106\/jbjs.oa.26.00217","relation":{},"ISSN":["2472-7245","2472-7245"],"issn-type":[{"value":"2472-7245","type":"electronic"},{"value":"2472-7245","type":"print"}],"subject":[],"published":{"date-parts":[[2026,7]]}}}