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Objectives and questions: This study aimed to evaluate the safety of primary Total knee arthroplasty (TKA) in patients aged ≥90 years by assessing complication and mortality rates. Additionally, we compared these outcomes with those of younger patient groups and identified comorbidities associated with increased morbidity and mortality.

Material and methods: Data for this study was obtained from the German Arthroplasty Registry. The study included 392,929 patients aged ≥60 years who underwent primary TKA for gonarthrosis. Of these, 1,284 patients were ≥90 years old. Patients were divided into four age groups: (I) 60–69 years, (II) 70–79 years, (III) 80–89 years, and (IV) ≥90 years. Minor complications, major complications, and mortality during postoperative follow-up were recorded and compared based on age group and preoperative comorbidities. Mortality rates were further compared with those of the general population using data from the Federal Statistical Office of Germany.

Results: Minor complications occurred in 58% (745/1,284) of cases in Group IV, compared to 21% (29,867/144,978) in Group I (p<0.001), with postoperative anemia being the most common (38%). Major complications were significantly more frequent in nonagenarians (18%, 233/1,284) than in sexagenarians (5.2%, 7,524/144,978, p<0.001). One-year mortality increased with age, occurring in 4.0%, 9.6%, 17%, and 36% of patients in Groups I–IV, respectively. Kaplan-Meier estimates showed significantly higher mortality for patients with minor and major complications.

Discussion and conclusions: Older age and comorbidities increase complications and mortality after TKA. However, implant-related complications remain low, and with careful selection, nonagenarians can safely undergo TKA, given their lower one-year mortality than the general population.