Archives of Orthopaedic and Trauma Surgery

, Volume 134, Issue 4, pp 543–553 | Cite as

Bone loss following knee arthroplasty: potential treatment options

  • Michele VassoEmail author
  • Philippe Beaufils
  • Simone Cerciello
  • Alfredo Schiavone Panni
Knee Revision Surgery



The management of bone loss is a crucial aspect of the revision knee arthroplasty. Bone loss can hinder the correct positioning and alignment of the prosthetic components, and can prevent the achievement of a stable bone–implant interface. There is still controversy regarding the optimal management of knee periprosthetic bone loss, especially in large defects for which structural grafts, metal or tantalum augments, tantalum cones, porous metaphyseal sleeves, and special prostheses have been advocated. The aim of this review was to analyze all possible causes of bone loss and the most advanced strategies for managing bony deficiency within the knee joint reconstruction.

Materials and methods

Most significant and recent papers about the management of bone defects during revision knee arthroplasty were carefully analyzed and reviewed to report the most common causes of bone loss and the most effective strategies to manage them.


Modular metal and tantalum augmentation showed to provide more stable and durable knee revisions compared to allografts, limited by complications such as graft failure, fracture and resorption. Moreover, modular augmentation may considerably shorten operative times with a potential decrease of complications, above all infection which has been frequently associated to the use of allografts.


Modular augmentation may significantly reduce the need for allografting, whose complications appear to limit the long-term success of knee revisions.


Revision knee arthroplasty Knee reconstruction Bone loss Augments Tantalum Allografts 


Conflict of interest



  1. 1.
    Alexander GE, Bernasek TL, Crank RL, Haidukewych GJ (2013) Cementless metaphyseal sleeves used for large tibial defects in revision total knee arthroplasty. J Arthroplast 28:604–607CrossRefGoogle Scholar
  2. 2.
    Huten D (2013) Femorotibial bone loss during revision total knee arthroplasty. Orthop Traumatol Surg Res 99(1 Suppl):S22–S33PubMedCrossRefGoogle Scholar
  3. 3.
    Rao BM, Kamal TT, Vafaye J, Moss M (2013) Tantalum cones for major osteolysis in revision knee replacement. Bone Joint J 95:1069–1074PubMedCrossRefGoogle Scholar
  4. 4.
    Dalury DF, Pomeroy DL, Gorab RS, Adams MJ (2013) Why are total knee arthroplasties being revised? J Arthroplast 28(8 Suppl):120–121CrossRefGoogle Scholar
  5. 5.
    Kasahara Y, Majima T, Kimura S, Nishiike O, Uchida J (2013) What are the causes of revision total knee arthroplasty in Japan? Clin Orthop Relat Res 471:1533–1538PubMedCrossRefGoogle Scholar
  6. 6.
    Gallo J, Goodman SB, Konttinen YT, Wimmer MA, Holinka M (2013) Osteolysis around total knee arthroplasty: a review of pathogenetic mechanisms. Acta Biomater 9:8046–8058PubMedCrossRefGoogle Scholar
  7. 7.
    Wiggers EC, Johnson W, Tucci M, Benghuzzi H (2011) Biochemical and morphological changes associated with macrophages and osteoclasts when challenged with infection—biomed 2011. Biomed Sci Instrum 47:183–188PubMedGoogle Scholar
  8. 8.
    Chen J, Cui Y, Li X, Miao X, Wen Z, Xue Y, Tian J (2013) Risk factors for deep infection after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 133:675–687PubMedCrossRefGoogle Scholar
  9. 9.
    Goldvasser D, Marchie A, Bragdon LK, Bragdon CR, Weidenhielm L, Malchau H (2013) Incidence of osteolysis in total knee arthroplasty: comparison between radiographic and retrieval analysis. J Arthroplast 28:201–206CrossRefGoogle Scholar
  10. 10.
    Kendrick BJ, Simpson DJ, Kaptein BL, Valstar ER, Gill HS, Murray DW, Price AJ (2011) Polyethylene wear of mobile-bearing unicompartmental knee replacement at 20 years. J Bone Joint Surg 93:470–475CrossRefGoogle Scholar
  11. 11.
    Zeng Y, Shen B, Yang J, Zhou ZK, Kang PD, Pei FX (2013) Is there reduced polyethylene wear and longer survival when using a mobile-bearing design in total knee replacement? A meta-analysis of randomised and non-randomised controlled trials. Bone Joint J 95:1057–1063PubMedCrossRefGoogle Scholar
  12. 12.
    Lachiewicz PF, Geyer MR (2011) The use of highly cross-linked polyethylene in total knee arthroplasty. J Am Acad Orthop Surg 19:143–151PubMedGoogle Scholar
  13. 13.
    Schiavone Panni A, Vasso M, Cerciello S, Maccauro G (2011) Metallosis following knee arthroplasty: a histological and immunohistochemical study. Int J Immunopathol Pharmacol 24:711–719PubMedGoogle Scholar
  14. 14.
    Citak M, Gessmann J, Fehmer T, Russe O, Schildhauer TA, Seybold D (2011) Two-stage revision of infected total knee arthroplasty using a distraction spacer. Technol Health Care 19:167–171PubMedGoogle Scholar
  15. 15.
    Johnson AJ, Sayeed SA, Naziri Q, Khanuja HS, Mont MA (2012) Minimizing dynamic knee spacer complications in infected revision arthroplasty. Clin Orthop Relat Res 470:220–227PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Romanò CL, Gala L, Logoluso N, Romanò D, Drago L (2012) Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers. Knee Surg Sports Traumatol Arthrosc 20:2445–2453PubMedCrossRefGoogle Scholar
  17. 17.
    Nettrour JF, Polikandriotis JA, Bernasek TL, Gustke KA, Lyons ST (2013) Articulating spacers for the treatment of infected total knee arthroplasty: effect of antibiotic combinations and concentrations. Orthopedics 36:19–24CrossRefGoogle Scholar
  18. 18.
    Rogers BA, Middleton FR, Shearwood-Porter N, Kinch S, Roques A, Bradley NW, Browne M (2011) Does cyclical loading affect the elution of antibiotics from articulating cement knee spacers? J Bone Joint Surg 93:914–920CrossRefGoogle Scholar
  19. 19.
    Silvestre A, Almeida F, Renovell P, Morante E, López R (2013) Revision of infected total knee arthroplasty: two-stage reimplantation using an antibiotic-impregnated static spacer. Clin Orthop Surg 5:180–187PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Engh GA, Ammeen D (1998) Classification and preoperative radiographic evaluation: knee. Orthop Clin North Am 29:205–217PubMedCrossRefGoogle Scholar
  21. 21.
    Rand JA (1991) Bone deficiency in total knee arthroplasty: use of metal wedge augmentation. Clin Orthop Relat Res 271:63–71PubMedGoogle Scholar
  22. 22.
    Daines BK, Dennis DA (2013) Management of bone defects in revision total knee arthroplasty. Instr Course Lect 62:341–348PubMedGoogle Scholar
  23. 23.
    Gudnason A, Milbrink J, Hailer NP (2011) Implant survival and outcome after rotating-hinge total knee revision arthroplasty: a minimum 6-year follow-up. Arch Orthop Trauma Surg 131:1601–1607PubMedCrossRefGoogle Scholar
  24. 24.
    Kuchinad RA, Garbedian S, Rogers BA, Backstein D, Safir O, Gross AE (2011) The use of structural allograft in primary and revision knee arthroplasty with bone loss. Adv Orthop. doi: 10.4061/2011/578952 PubMedCentralPubMedGoogle Scholar
  25. 25.
    Schmitz HC, Klauser W, Citak M, Al-Khateeb H, Gehrke T, Kendoff D (2013) Three-year follow up utilizing tantal cones in revision total knee arthroplasty. J Arthroplast 28:1556–1560CrossRefGoogle Scholar
  26. 26.
    Vasso M, Beaufils P, Schiavone Panni A (2013) Constraint choice in revision knee arthroplasty. Int Orthop 37:1279–1284PubMedCrossRefGoogle Scholar
  27. 27.
    Hanna SA, Aston WJ, de Roeck NJ, Gough-Palmer A, Powles DP (2011) Cementless revision TKA with bone grafting of osseous defects restores bone stock with a low revision rate at 4 to 10 years. Clin Orthop Relat Res 469:3164–3171PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Hongvilai S, Tanavalee A (2012) Review article: management of bone loss in revision knee arthroplasty. J Med Assoc Thai 95(Suppl 10):S230–S237PubMedGoogle Scholar
  29. 29.
    Naim S, Toms AD (2013) Impaction bone grafting for tibial defects in knee replacement surgery. Results at two years. Acta Orthop Belg 79:205–210PubMedGoogle Scholar
  30. 30.
    Hilgen V, Citak M, Vettorazzi E, Haasper C, Day K, Amling M, Gehrke T, Gebauer M (2013) 10-year results following impaction bone grafting of major bone defects in 29 rotational and hinged knee revision arthroplasties: a follow-up of a previous report. Acta Orthop 84:387–391PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Howard JL, Kudera J, Lewallen DG, Hanssen AD (2011) Early results of the use of tantalum femoral cones for revision total knee arthroplasty. J Bone Joint Surg Am 93:478–484PubMedCrossRefGoogle Scholar
  32. 32.
    Lachiewicz PF, Bolognesi MP, Henderson RA, Soileau ES, Vail TP (2012) Can tantalum cones provide fixation in complex revision knee arthroplasty? Clin Orthop Relat Res 470:199–204PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Haidukewych GJ, Hanssen A, Jones RD (2011) Metaphyseal fixation in revision total knee arthroplasty: indications and techniques. J Am Acad Orthop Surg 19:311–318PubMedGoogle Scholar
  34. 34.
    Beckmann J, Lüring C, Springorum R, Köck FX, Grifka J, Tingart M (2011) Fixation of revision TKA: a review of the literature. Knee Surg Sports Traumatol Arthrosc 19:872–879PubMedCrossRefGoogle Scholar
  35. 35.
    Panni AS, Vasso M, Cerciello S (2012) Modular augmentation in revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-012-2258-1 Google Scholar
  36. 36.
    Steens W, Loehr JF, Wodtke J, Katzer A (2008) Morselized bone grafting in revision arthroplasty of the knee: a retrospective analysis of 34 reconstructions after 2–9 years. Acta Orthop 79:683–688PubMedCrossRefGoogle Scholar
  37. 37.
    Lotke PA, Carolan GF, Puri N (2006) Impaction grafting for bone defects in revision total knee arthroplasty. Clin Orthop Relat Res 446:99–103PubMedCrossRefGoogle Scholar
  38. 38.
    Ghazavi MT, Stockley I, Yee G, Davis A, Gross AE (1997) Reconstruction of massive bone defects with allograft in revision total knee arthroplasty. J Bone Joint Surg Am 79:17–25PubMedCrossRefGoogle Scholar
  39. 39.
    Backstein D, Safir O, Gross A (2006) Management of bone loss: structural grafts in revision total knee arthroplasty. Clin Orthop Relat Res 446:104–112PubMedCrossRefGoogle Scholar
  40. 40.
    Clatworthy MG, Ballance J, Brick GW, Chandler HP, Gross AE (2011) The use of structural allograft for uncontained defects in revision total knee arthroplasty: a minimum five-year review. J Bone Joint Surg Am 83:404–411Google Scholar
  41. 41.
    Bauman RD, Lewallen DG, Hanssen AD (2009) Limitations of structural allograft in revision total knee arthroplasty. Clin Orthop Relat Res 467:818–824PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Brand MG, Daley RJ, Ewald FC, Scott RD (1989) Tibial tray augmentation with modular metal wedges for tibial bone stock deficiency. Clin Orthop Relat Res 248:71–79PubMedGoogle Scholar
  43. 43.
    Haas SB, Insall JN, Montgomery W 3rd, Windsor RE (1995) Revision total knee arthroplasty with use of modular components with stems inserted without cement. J Bone Joint Surg Am 77:1700–1707PubMedGoogle Scholar
  44. 44.
    Werle JR, Goodman SB, Imrie SN (2002) Revision total knee arthroplasty using large distal femoral augments for severe metaphyseal bone deficiency: a preliminary study. Orthopedics 25:325–327PubMedGoogle Scholar
  45. 45.
    Patel JV, Masonis JL, Guerin J, Bourne RB, Rorabeck CH (2004) The fate of augments to treat type-2 bone defects in revision knee arthroplasty. J Bone Joint Surg 86:195–199CrossRefGoogle Scholar
  46. 46.
    Wood GC, Naudie DD, MacDonald SJ, McCalden RW, Bourne RB (2009) Results of press-fit stems in revision knee arthroplasties. Clin Orthop Relat Res 467:810–817PubMedCentralPubMedCrossRefGoogle Scholar
  47. 47.
    Meneghini RM, Lewallen DG, Hansesen AD (2008) Use of porous tantalum metaphyseal cones for severe tibial bone loss during revision total knee replacement. J Bone Joint Surg Am 90:78–84PubMedCrossRefGoogle Scholar
  48. 48.
    Malhotra R, Garg B, Kumar V (2011) Dual massive skeletal allograft in revision total knee arthroplasty. Indian J Orthop 45:368–371PubMedCentralPubMedCrossRefGoogle Scholar
  49. 49.
    Qiu YY, Yan CH, Chiu KY, Ng FY (2012) Review article: treatments for bone loss in revision total knee arthroplasty. J Orthop Surg 20:78–86Google Scholar
  50. 50.
    Wang JW, Hsu CH, Huang CC, Lin PC, Chen WS (2013) Reconstruction using femoral head allograft in revision total knee replacement: an experience in Asian patients. Bone Joint J 95-B:643–648PubMedCrossRefGoogle Scholar
  51. 51.
    Richards CJ, Garbuz DS, Pugh L, Masri BA (2011) Revision total knee arthroplasty: clinical outcome comparison with and without the use of femoral head structural allograft. J Arthroplast 26:1299–1304CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Michele Vasso
    • 1
    Email author
  • Philippe Beaufils
    • 2
  • Simone Cerciello
    • 1
  • Alfredo Schiavone Panni
    • 1
  1. 1.Department of Medicine and Science for HealthUniversity of MoliseCampobassoItaly
  2. 2.Department of Orthopedics and Trumatology, Versailles “Andrè Mignot” HospitalVersailles Saint Quentin UniversityLe ChesnayFrance

Personalised recommendations