Assessing the non-inferiority of prosthesis constructs used in total and unicondylar knee replacements using data from the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man: a benchmarking study.

Objectives: To investigate the relative performance of knee replacement constructs compared with the best performing construct and illustrate the substantial variability in performance.
Design: A non-inferiority study.
Setting: England and Wales.
Participants: All primary total and unicondylar knee replacements performed and registered in the National Joint Registry between 1 April 2003 and 31 December 2016.
Main Outcome Measures: Kaplan-Meier failure function for knee replacement constructs. Failure difference between best performing construct (the benchmark) and other constructs.
Methods: Using a non-inferiority analysis, the performance of knee replacement constructs by brand were compared with the best performing construct. Construct failure was estimated using the 1-Kaplan Meier method, that is, an estimate of net failure. The difference in failure between the contemporary benchmark construct and all other constructs were tested.
Results: Of the 449 different knee replacement constructs used, only 27 had ≥500 procedures at risk at 10 years postprimary, 18 of which were classified as inferior to the benchmark by at least 20% relative risk of failure. Two of these 18 were unicondylar constructs that were inferior by at least 100% relative risk. In men, aged 55-75 years, 12 of 27 (44%) constructs were inferior by at least 20% to the benchmark at 7 years postprimary. In women, aged 55-75 years, 8 of 32 (25%) constructs were inferior at 7 years postprimary. Very few constructs were classified as non-inferior to the contemporary benchmark.
Conclusions: There are few knee replacement constructs that can be shown to be non-inferior to a contemporary benchmark. Unicondylar knee constructs have, almost universally, at least 100% worse revision outcomes compared with the best performing total knee replacement. These results will help to inform patients, clinicians and commissioners when considering knee replacement surgery.
Competing Interests: Competing interests: Submitted work as described in the funding statement; AWB and MRW are coapplicants on a grant from Stryker investigating the outcome of the triathlon total knee replacement; there are no other financial relationships with any organisations that might have an interest in the submitted work in the previous three years, and there are no other relationships or activities that could appear to have influenced the submitted work.
(© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)