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Are competing risks models appropriate to describe implant failure?

Adrian Sayers1,2, Jonathan T Evans1, Michael R Whitehouse1,3

  • 1a Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital , Bristol.

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|March 10, 2018
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Competing risks and Kaplan-Meier methods estimate different outcomes in arthroplasty research. Kaplan-Meier is best for implant failure, while competing risks include mortality, potentially underestimating implant failure rates.

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Area of Science:

  • Orthopedic Surgery
  • Biostatistics
  • Medical Research Methodology

Background:

  • Competing risks models are increasingly used in arthroplasty literature.
  • This trend stems from concerns about bias in Kaplan-Meier estimates.
  • However, differences in interpreting net vs. crude failure are often overlooked.

Purpose of the Study:

  • To illustrate the interpretational differences between competing risks and Kaplan-Meier methods.
  • To clarify the appropriate use of each method in arthroplasty research.
  • To address potential misinterpretations of failure rates.

Main Methods:

  • A simple simulation study was employed.
  • The simulation compared competing risks and Kaplan-Meier methodologies.
  • Key differences in estimating failure quantities were analyzed.

Main Results:

  • Competing risks models estimate crude failure, while Kaplan-Meier estimates net failure.
  • Crude failure estimates from competing risks models are generally lower than net failure estimates from Kaplan-Meier.
  • Both methods provide unbiased estimates under specific conditions (no confounding for competing risks, no selection for Kaplan-Meier).

Conclusions:

  • Kaplan-Meier methods are suitable for describing implant failure.
  • Competing risks models estimate the combined risk of revision surgery and mortality.
  • Surgeons and researchers must carefully consider the application and interpretation of competing risks models to avoid misleading conclusions about implant performance.