“As an increasing number of younger adults in their 40s and 50s consider total knee replacement, many wonder how long knee implants last before requiring a revision procedure,” says William J. Long, MD, FRCSC, an HSS hip and knee surgeon and the senior author of the study. “The findings from our study—the largest and longest follow-up of patients under 55 undergoing total knee replacement—confirm that young patients can be confident their initial knee implants will allow them to pursue a high level of activity and more than likely last the rest of their lives.”

HSS orthopedic surgeons designed the longitudinal study to track outcomes for patients 55 years of age and younger who had total knee replacements between 1977 and 1992. During that period, they used knee prostheses known as the Insall-Burstein I and Insall-Burstein II—predecessors of implants used today that provide posterior stability. Both designs were conceived and developed at HSS. Previously, the investigators conducted patient follow-ups at 10, 25, and 30 years following surgery.

For this final report, Dr. Long and colleagues analyzed outcomes after 40 years for 81 patients aged 33 to 55 years. The analysis included 107 knees in total. Overall, 70% of patients in the study had no revision procedures in their lifetime. Patients were three to four times more likely to have passed away after 40 years than to have required a revision. Remarkably, among the 49 patients who received the original Insall-Burstein I prostheses, 80% did not have any revision surgeries.

“Considering that today's knee replacements have addressed the pitfalls leading to the majority of revisions for mechanical issues in Insall-Burstein I and Insall-Burstein II implants, these are very reassuring findings," says Dr. Long.

Dr. Long also examined six patients (eight knees) in person, and lead and presenting author Aaron Weinblatt, BA, contacted many more patients by phone. There were no signs of loosening nor were there any changes in symmetry or alignment of the original components. Additionally, patients reported an ongoing improved level of activity after surgery.

This was supported by patient-reported activity data collected for eight patients (10 knees) and measured using the Tegner Activity Scale (TAS). Before undergoing total knee replacement, the average TAS score was only 1.5, indicating they could work in a sedentary job and walk on uneven ground but not hike or backpack. At 40 years, their average TAS score was 2.7, indicating the ability to work in light labor occupations and participate in recreational activities such as swimming and walking in forests.

“Patients requiring a total knee replacement should not delay having surgery,” Dr. Long says. “Our study results highlight that those who undergo knee replacement sooner are more likely to maintain a high level of activity that contributes to a healthy, longer-term lifespan.”

Dr. Long adds that a previous HSS study published in 2014 at the 30-year follow-up showed that for the small percentage of patients who required revisions, the vast majority were doing well, with an average TAS score of 3.0, a good range of motion and no signs of loosening. ²

Authors: Aaron I. Weinblatt, BA, Victoria E. Bergstein, BA, Walter L. Taylor, MPhil, BS, Stephen Lyman, PhD, Felix C. Oettl, MD, W. Norman Scott, MD, FAAOS, William J. Long, MD, FRCSC.

Reference:

¹ Weinblatt AI, Bergstein VE, Taylor WL, Lyman S, Oettl FC, Scott WN, Long WJ. Total knee replacement in young, active patients: long-term follow-up and functional outcome: A final follow-up of previous report. Accessed February 10, 2025, at https://submissions.mirasmart.com/AAOS2025/Itinerary/PresentationDetail.aspx?evdid=2532

² Long WJ, Bryce CD, Hollenbeak CS, Benner RW, Scott WN. Total knee replacement in young, active patients: long-term follow-up and functional outcome: a concise follow-up of a previous report. J Bone Joint Surg Am. 2014 Sep 17;96(18):e159. Accessed February 19, 2025, at  https://pubmed.ncbi.nlm.nih.gov/25232089/  

What follows are highlights from these studies:

Limiting Use of Tourniquets During Knee Replacement Surgery Improves Patient Outcomes

Tourniquets have traditionally been used during TKA to reduce blood loss and the need for transfusions. However, a new study of almost 18,000 patients from 2019 to 2023 found that prolonged tourniquet use was linked to increased pain, higher opioid use, and a longer recovery. 

“We found that limiting tourniquet use was associated with slightly lower rates of opioid use to control pain after surgery and a quicker ability to complete physical therapy and leave the hospital,” said Brian P. Chalmers, MD, hip and knee surgeon at HSS and co-senior author of the study.

Thanks to advances in medicine and technology, tourniquets may not be needed as often. For example, tranexamic acid (TXA) is now commonly used to effectively reduce bleeding and lower the likelihood of patients requiring a blood transfusion.

“If you have a drug that has this beneficial effect, then the need for a tourniquet may be reduced,” explained Alejandro Gonzalez Della Valle, MD, hip and knee surgeon at HSS and co-senior author of the research. “If you limit tourniquet use, patients will hurt less and will move sooner, and that will allow patients to go home sometimes the same day.” 

Dr. Della Valle notes that limiting tourniquet use can also reduce opioid consumption. The reason that tourniquet use during TKA has been associated with increased post-operative pain is because the device compresses the quadricep and hamstring muscles to restrict blood flow during the operation. The increased pain may impact the time it takes to complete rehabilitation.

Surgeons have also traditionally used tourniquets to keep the area between the knee implant and the bone as dry as possible, which helps bone cement create a stronger bond between the bone and the implant, potentially reducing the risk of loosening over time.

“Recent studies have shown that you can obtain a dry field without using a tourniquet, reducing its necessity during TKA,” explained Dr. Chalmers.  

Another development that has lessened the need for the use of tourniquets is cementless fixation, in which a specially-designed implant that allows the bone to grow into the implant and achieve long-term fixation without the use of cement.

There is currently no consensus in the literature or among surgeons throughout the country on the use of tourniquets during TKA. Surgeons use these devices differently based on individual patient needs. Some use a tourniquet from the time of incision until the implant is fixated to the bone, while others use it only during cementation or throughout the entire procedure until the wound is closed and the dressings are in place. Some surgeons may opt not to use a tourniquet at all. 

“What sets this study apart is that it captures what surgeons are doing in their daily practice,” said Dr. Chalmers. “To our knowledge, this is the only paper that addresses several different ways surgeons use tourniquets during TKA, including no usage, limited usage, and full usage.”

The study’s authors conclude that reduced tourniquet use should be considered within the realm of multiple advances that help patients recover faster after surgery and with less pain. These include newer drugs and tools used to reduce pain and blood loss during surgery, two major factors that often prolong hospital stays.

“Any measures we can take around the time of surgery to help those factors can significantly improve patient outcomes,” said Dr. Della Valle.

NSAIDs Reduce Risk of Fibrosis Needing Further Treatment after Knee Replacement Surgery

A new study led by surgeons at HSS shows that patients who were prescribed a non-steroidal anti-inflammatory drug (NSAID) after TKA had a reduced risk of developing painful scar tissue, a condition known as arthrofibrosis, which often requires additional procedures. The findings also shed light on the durations for NSAID use to prevent fibrosis following surgery.

In arthrofibrosis, excessive scar tissue forms in and around a joint after an operation. It can lead to stiffness, pain and reduced range of motion in the joint. Approximately 2% to 6% of patients require a minimally invasive procedure called manipulation under anesthesia (MUA) to treat this complication.

The researchers found that patients who were prescribed an NSAID had a significantly lower incidence of MUAs (5.3%) 90 days after surgery compared to those who did not have an NSAID prescription (12.6%). The study included more than 23,000 people who had TKA at HSS between 2017 and 2021.

“This study highlights the importance of NSAID use for early recovery after TKA,” says Peter K. Sculco, MD, hip and knee surgeon at HSS and senior author of the study. “These medications are associated with lower rates of fibrotic pain and stiffness requiring an intervention such as MUA.”

He added that decreased risk was not seen in patients who used NSAIDs for more than four weeks, suggesting patients stop within one month’s time to get the most benefit.

Some patients, however, cannot use NSAID medications due to risk of bleeding or gastrointestinal or kidney issues.

“We now use steroids for one week after TKA in patients who are unable to take NSAIDs,” explained Dr. Sculco. “However, further research is necessary to determine the effect of steroids on MUA rates and the appropriate dose and duration for this group of patients.”

Local Anesthetic Leads to Better Patient Outcomes after Revision Knee Replacement Surgery

A new study led by surgeons at HSS found that the use of a new local anesthetic at the time of revision TKA enabled patients to leave the hospital sooner and recover faster.

According to the findings, a recently introduced pain medication known as extended-release, dual-acting local anesthetic (ERDALA) used at the time of aseptic revision TKA was associated with better patient outcomes. These included completing physical therapy sooner, shorter hospital stays, and more patients being discharged within one day after surgery.

Approximately 5% to 10% of patients need aseptic revision TKA, a surgical procedure done to address loosening, stiffness, or instability of a non-infected knee joint that was previously replaced with TKA.

The study reviewed outcomes of 171 patients who had aseptic revision TKA at HSS between January 2021 and May 2023. Patients either received ERDALA (51.5%) or standard of care periarticular injections (PAI) (48.5%) during surgery. The researchers found that patients who received ERDALA went home nearly a day sooner and cleared physical therapy approximately 20 hours faster than those who received PAI.

“ERDALA did not reduce pain scores or the total amount of opioids prescribed in this study but was associated with helping patients reach early recovery milestones sooner,” noted Dr. Peter Sculco, who is also senior author of this study. “This medication can be a valuable tool in rapid recovery strategies used in aseptic revision TKA, which can lead to patients walking better and getting home faster.”

He added that further research is needed to explore these strategies in the revision population, especially as more revision surgeries are performed in the outpatient setting.