Original Research

Knee Arthroplasty

Implant Survivorship and Complication Rates After Total Knee Arthroplasty With a Third-Generation Cemented System: 15-Year Follow-Up

Author Affiliation | Disclosures

Authors’ Disclosure Statement: Dr. Rosenberg reports that he is a consultant to and receives royalties from Zimmer Biomet. The other authors report no actual or potential conflict of interest in relation to this article.

Dr. Sartawi is Chairman, Department of Orthopaedics, Christie Clinic, Champaign, Illinois. Dr. Zurakowski is Director of Biostatistics, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts. Dr. Rosenberg is a Senior Orthopaedic Surgeon, Rush Medical College, Chicago, Illinois.

Address correspondence to: Muthana Sartawi, MD, Department of Orthopaedics, Christie Clinic, 2110 Fox Drive, Champaign, IL 61820 (email,


This work is a retrospective cohort study evaluating patients who had undergone third-generation cemented total knee arthroplasty (TKA) with prostheses (NexGen, Zimmer Biomet) utilizing posterior-stabilized (PS) and cruciate-retaining (CR) designs at a single center at their 15-year follow-up.

The purpose of this study is to determine the functional knee scores, reoperations, and long-term survivorship for patients with the NexGen Zimmer Biomet Knee system at the 15-year follow-up. In total, 99 patients who had undergone primary TKA were followed for 15 years.

At the 15-year follow-up, survivorship in both study groups was similar: 98% for PS TKAs and 100% for CR TKAs. The 2 groups also showed similar functionality: 80% of the PS implants and 89% of the CR implants were associated with no or mild pain (P = .40). Reoperation rates were 2% for the PS group and 0% for the CR group (P = .38). No differences in any of the outcomes analyzed were observed between patients who had CR TKA and those who had undergone PS TKA.

Our study found no significant differences in functional outcomes between PS and CR NexGen knee implants. Patients treated by both methods showed excellent longevity and survivorship at the 15-year follow-up.

Take-Home Points

  • TKA has a high success rate in pain relief and restoration of function in patients with severe osteoarthritis.
  • NexGen (Zimmer Biomet) knee implants showed excellent functional outcomes at 15 years.
  • There are no significant differences in functional outcomes between the PS and CR knee systems.
  • NexGen knee implants showed excellent longevity and survivorship at 15-year follow-up with no evidence of aseptic loosening.
  • There is an increased incidence of knee osteoarthritis in the younger population (<55 years of age).

Total knee arthroplasty (TKA) is an orthopedic procedure with increasing demand.1 Over the past 2 decades, a surge in TKA implants has been observed. Of the available prosthetic designs, only a few implants with long-term follow-up have been reported.2-9 The NexGen TKA system (Zimmer Biomet) has been shown to have excellent clinical and radiographic results at an intermediate follow-up term of 8 years.10 This system is a third-generation prosthetic design that was developed to improve problems seen with its predecessors, such as the Miller-Galante II system (Zimmer Biomet), the Insall-Burstein II system (Zimmer Biomet), and the Constrained Condylar Knee (Zimmer Biomet), which were mainly for patellar maltracking.11-17 The NexGen TKA system is a fixed-bearing system designed to include an anatomic femoral trochlea with the option of cruciate-retaining (CR), posterior-stabilized (PS), or more constrained implants. This study evaluates the long-term success of the CR and PS NexGen TKA systems. Outcomes measured include functional knee scores and reoperation rates at the 15-year follow-up. Based on the measured outcomes, potential differences between the PS and CR implants from this system are cited.

Material and Methods

Between July 1995 and July 1997, 334 consecutive primary TKAs were performed on 287 patients at our institution. In total, 167 patients (186 knees) underwent posterior CR TKAs with the NexGen CR prosthesis (Zimmer Biomet), and 120 patients (148 knees) underwent PS TKAs using the NexGen Legacy PS prosthesis (Zimmer Biomet). This retrospective double cohort study was reviewed and approved by our Institutional Review Board. At the 15-year postoperative follow-up, 99 patients were available (Figure 1).

The CR and PS implants were used with similar frequencies by the surgeons who performed the procedures. Patients were not randomized into either the PS- or CR-implant teams; the final decision on implant selection was left to the operating surgeon’s discretion. However, in addition to standard indications for TKA (pain and disability associated with severe arthritic change seen on radiographs and refractory to conservative measures), absolute contraindications to the CR implant included severe combined deformity (flexion contraction >30° combined with a varus or valgus deformity >20°) or posterior cruciate ligament insufficiency (often associated with inflammatory arthritis).

The surgical technique for the CR and PS designs was identical, and included a median parapatellar approach, femoral rotational alignment perpendicular to the transepicondylar axis, measured resection of the flexion and extension gaps, intramedullary femoral alignment, and extramedullary tibial alignment. All components were cemented, and the patella of each patient was resurfaced. All patients received preoperative antibiotics that were continued for 48 hours postoperatively, and 4 weeks of anticoagulation with dose-adjusted warfarin to maintain an international normalized ratio of 1.5 to 2.0.

Patients were observed postoperatively at the 5- to 8-year and 15-year time points. The 5-year data were previously published in 2005 by Bozic and colleagues.10 Patients available for follow-up at the 15-year time-point were evaluated using the 100-point Hospital for Special Surgery (HSS) knee scoring system, which assigns up to 30 points for pain, 22 points for function, 18 points for range of motion, and 10 points each for quadricep strength, deformity, and instability. In addition, common medical conditions limiting patient activity were assessed; these included joint replacement; arthritis in another joint, the back, or spine; weakness or fatigue; breathing or heart ailments; and others.

At the 15-year follow-up, patients were contacted via telephone to obtain their HSS knee scores. If patients were unavailable/unable to answer the questions asked, knee score information was collected from a first-degree relative or caretaker. Patients that could not be contacted by phone were sent a HSS knee score survey to their last known address. The online Social Security Death Index was queried for confirmation of death. If deceased, a first-degree relative was contacted for confirmation.

Survivorship was evaluated using revision for any reason and revision for aseptic loosening as separate endpoints via the Kaplan-Meier product-limit method, and the CR and PS TKA groups were compared using the log-rank test. The power of the study for detecting differences between the TKA groups was determined to be 80%, based on a moderate hazard ratio of 1.5, using the log-rank test. Differences between PS and CR TKAs were assessed using the Pearson chi-square test for knee pain and functional outcomes, Fisher’s exact test for patient limitations, such as joint replacement, and the non-parametric Mann Whitney U-test for median pain scores (Table 1). Spearman correlations between the patients’ self-reported knee scores (as a percentage of normal) and physician-based knee scores were performed to assess whether self-reported knee scores were significantly correlated with physician-based knee scores. Kaplan-Meier analysis was performed to evaluate time-related freedom from reoperation at 95% confidence intervals. Statistical analysis was conducted using IBM SPSS Statistics (version 21.0, IBM). Two-tailed P < .05 was considered statistically significant.


Of the 287 patients (334 knees) who had primary TKAs, 99 patients (121 knees; 75 CR and 46 PS) were available at the 15-year follow-up. A total of 155 patients (171 knees) died before the 15-year follow-up, and 33 (42 knees) were lost to follow-up (Figure 1). The functional status of the knees of patients who were lost to follow-up or who had died since the previous follow-up data were published is unknown.

Demographic and outcome data for the cohort of 121 TKAs (99 patients) are summarized in Table 2. The median age at surgery was 64 years, and 71% of the cohort was female.

At the 15-year follow-up, survivorship in both groups was similar: 98% for PS TKAs and 100% for CR TKAs. The 2 groups were also similar functionally: 80% of the PS implants and 89% of the CR implants were associated with no or mild pain (P = .40). Approximately half of the patients in both groups (52% PS; 50% CR; P = .88) required walking support (canes or walkers) and nearly half of both groups (46% PS; 48% CR; P = .62) could walk <5 blocks or only short distances in their homes. In addition, 46% of the patients in both groups reported needing arm assistance to functionally rise from a chair (P = .43); 91% of the patients in both groups could also walk up and down stairs (P = .77). No statistical difference in the medical conditions limiting the patients in the 2 groups was found: joint replacement (2% PS; 6% CR; P = .71), arthritis in another joint (43% PS; 45% CR; P = .84), back or spine arthritis (31% PS; 33% CR; P = 1.00), weakness or fatigue (24% PS; 25% CR; P = 1.00), breathing or heart ailments (11% PS; 20% CR; P = .40), and other reasons (27% PS; 25% CR; P = 1.00). In addition, median self-reported knee scores were 95 and 93 points for the PS and CR groups, respectively (P = .55).

Patients reported 2 complications since the previous 5- to 8-year follow-up, 1 in each group. The first case underwent a PS TKA that required open reduction internal fixation for a bilateral supracondylar peri-prosthesis femur fracture following a fall, which was subsequently complicated with infection and ultimately led to above-the-knee amputation. In the second case, a CR TKA patient experienced persistent swelling and knee instability. The patient followed up with a local orthopaedist, but to date, no reoperations on the knee have been reported.

Spearman correlations between the patients’ self-reported knee scores (as a percentage of normal) and physician-based knee scores were moderately correlated with physician-based knee scores (rs = 0.42; P < .001).

Reoperation rates were 2% for PS and 0% for CR (P = .38). Kaplan-Meier analysis was performed to evaluate time-related freedom from reoperation and no significance difference between the PS and CR groups was revealed (log-rank test = 1.40, P = .24, Figure 2).


The success of TKA in pain relief and restoration of function has led to increased demands for this surgery.1 Such demand has enabled the introduction of a new joint replacement prosthesis to the market.18 Considering the increased incidence of osteoarthritis in the younger population (<55 years of age), critically reviewing the longevity and durability of TKA implant designs is of great importance. Compared with other TKA implant designs, the NexGen Zimmer Biomet Knee system has shown excellent longevity at the 15-year follow-up.5,6,9,11-15 Our study began with 136 patients, and, after eliminating the deceased, those lost to follow-up, and non-responders, a total of 99 patients were available for the 15-year follow-up. At this time-point, 80% of the PS implants and 89% of the CR implants were associated with no or mild pain. Survivorship at the 15-year follow-up was similar in both groups: 98% for PS TKAs and 100% for CR TKAs. The reoperation rate was low in both groups, and no evidence of aseptic loosening was found. Based on our results, the NexGen Zimmer Biomet Knee system can be concluded to show excellent longevity and functional outcomes at the 15-year follow-up.

Our study includes several limiting factors that were taken into consideration during the analysis of the results. One of the main limitations of this work is that it required a 15-year follow-up of predominantly elderly patients; many of the participants may be expected to be deceased at this time-point. In our study, a total of 7 patients were confirmed to be deceased by a first-degree relative or the Social Security Death Index. In addition, unlike Bozic and colleagues’10 previous 5-year follow-up study, radiographic imaging data were not collected at the 15-year follow-up. However, given that this study aimed to assess the functional knee scores and reoperation rates of the PS and CR NexGen Zimmer Biomet Knee system, radiographic information did not appear to be necessary.


This study found no significant differences in functional outcomes between the PS and CR NexGen knee implants. Patients who received these implants showed excellent longevity and survivorship at their 15-year follow-up.

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