The Use of Structural Allograft for Uncontained Defects in Revision Total Knee Arthroplasty

Background: To our knowledge, the medium to long-term outcome after revision knee arthroplasty with structural allograft augmentation for reconstruction of uncontained defects has not been determined. The purpose of the present study was to assess the outcome for patients managed with such a procedure.

Methods: We prospectively followed fifty patients who had fifty-two revision knee replacements with sixty-six structural grafts performed at three institutions. Twenty-nine knees (twenty-seven patients) were independently evaluated at a mean of 96.9 months (range, sixty to 189 months) by an investigator who had not been involved in the index procedure. Twelve knees (23%) had a repeat revision at a mean of 70.7 months (range, twenty-six to 157 months). The allograft was retained in two of these patients. Eleven patients died at a mean of ninety-three months (range, sixty-one to 128 months) after the procedure; the structural allograft and implants were intact, and the patients were not awaiting revision at the time of death.

Results: Clinical evaluation revealed that the mean modified Hospital for Special Surgery knee score had improved from 32.5 points preoperatively to 75.6 points at the time of the review and the mean range of motion had increased from 60.5° preoperatively to 88.6°. Failure was defined as an increase of less than 20 points in the modified Hospital for Special Surgery knee score at the time of the review or the need for an additional operation related to the allograft. Thirteen knee replacements failed, yielding a 75% success rate. Five knees had graft resorption, resulting in implant loosening. Four knee replacements failed because of infection, and two knees had nonunion between the host bone and the allograft. Two knees (one patient) did not have a 20-point improvement in the knee score. The survival rate of the allografts was 72% (95% confidence interval, 69% to 75%) at ten years. On radiographic analysis, none of the surviving grafts had severe resorption, one had moderate resorption, and two had mild resorption. One knee had a loose tibial component, and three knees had nonprogressive tibial radiolucent lines. All four knees were asymptomatic.

Conclusions: Our results demonstrate that allografts used in revision knee replacement in patients with the difficult problem of massive bone loss have an encouraging medium-term rate of survival.