Statistical analysis of failure times in total joint replacement

Time to revision is an important criterion describing the quality of implants in total joint surgery. Estimates of failure probabilities are required to inform a patient about the risk of suffering a reoperation. Also, regression models are used for comparing different prosthesis designs. Typically, patients dying before a revision are considered as censored for time to prosthesis failure. We argue that this technique is inadequate for estimation of failure probabilities and insufficient for comparison of different designs. We propose a new approach based on a competing risk model to account for concurrent mortality. We describe differences in the estimation of failure probabilities and in the interpretation of regression models for implant failure. Additionally, we introduce a random effects term in the regression model to account for potential dependencies in the failure times of bilaterally treated patients. The new approach is illustrated with fictitious data and data from an observational study conducted at a specialized hospital in Switzerland.