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Comparison of Different Strategies in Revision Arthroplasty of the Knee with Severe Bone Loss: A Systematic Review and Meta-Analysis of Clinical Outcomes

Published:March 07, 2022DOI:https://doi.org/10.1016/j.arth.2022.02.103

      Highlights

      • Survivorship outcomes for porous metal cones and porous-coated sleeves are similar as those for impaction grafts and sleeves at midterm follow-up.
      • Clinical outcomes favor cones over sleeves.
      • The quality of literature is gradually improving.
      • Further studies addressing bone defects in revision arthroplasty should target both porous metal implants and grafts.

      Abstract

      Background

      In revision total knee arthroplasty large bone lesions can jeopardize correct implant orientation and fixation. Different strategies have been proposed to tackle this issue. The purpose of this review and meta-analysis is to evaluate the midterm clinical and survivorship results of porous cones and porous-coated sleeves compared to morselized and structural grafts.

      Methods

      We performed a systematic review of the literature on the different strategies targeting moderate to large metaphyseal bone defects. The literature was evaluated for methodological quality. We analyzed results on survivorship using logistic regression correcting for follow-up time and number of knees. We compared these results using forest plots for early and midterm follow-up. Clinical outcome was evaluated by comparing standardized mean difference of patient-related outcome measures.

      Results

      A total of 77 articles analyzing 4,391 knees were included. The logistic regression curve showed a nonsignificant odds ratio (OR) at 10 years of 0.91 (95% confidence interval [CI] 0.699-1.192, P = .49) for failure comparing all porous implants with all grafting procedures. The available clinical reports show a bigger standardized mean difference increase for tantalum cones (OR 3.04, 95% CI 1.71-4.37) than for porous sleeves (OR 1.72, 95% CI 0.88-2.57).

      Conclusion

      Our analysis shows that the size and quality of the literature on metaphyseal bone defects is progressively improving. Porous implants are effective in tackling metaphyseal bone defects showing good survivorship outcome at midterm follow-up. In younger patients with less constrained prosthetic implants, surgeons might still consider the use of grafts without risking worse outcomes.

      Keywords

      Following the sharp increase in the number of primary knee arthroplasties performed over the years, we witnessed a commensurate increase in revision arthroplasty procedures [
      • Fingar K.R.
      • Stocks C.
      • Weiss A.J.
      • Steiner C.A.
      Most frequent operating room procedures performed in U.S. Hospitals, 2003–2012: statistical brief #186.
      ,
      • Wallace I.J.
      • Worthington S.
      • Felson D.T.
      • Jurmain R.D.
      • Wren K.T.
      • Maijanen H.
      • et al.
      Knee osteoarthritis has doubled in prevalence since the mid-20th century.
      ,
      • Schwartz A.M.
      • Farley K.X.
      • Guild G.N.
      • Bradbury T.L.
      Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030.
      ]. Estimates expect these numbers to keep increasing in the coming decades [
      • Kurtz S.
      • Ong K.
      • Lau E.
      • Mowat F.
      • Halpern M.
      Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
      ,
      • Nemes S.
      • Rolfson O.
      • W-Dahl A.
      • Garellick G.
      • Sundberg M.
      • Kärrholm J.
      • et al.
      Historical view and future demand for knee arthroplasty in Sweden.
      ,
      • Abdelaziz H.
      • Jaramillo R.
      • Gehrke T.
      • Ohlmeier M.
      • Citak M.
      Clinical survivorship of aseptic revision total knee arthroplasty using hinged knees and tantalum cones at minimum 10-year follow-up.
      ,
      • Singh J.A.
      • Yu S.
      • Chen L.
      • Cleveland J.D.
      Rates of total joint replacement in the United States: future projections to 2020-2040 using the national inpatient sample.
      ]. The survivorship and clinical results for primary procedures have been relatively successful and reliable [
      • Khan M.
      • Osman K.
      • Green G.
      • Haddad F.S.
      The epidemiology of failure in total knee arthroplasty.
      ]. Those for revision arthroplasty have been significantly less satisfying [
      • Siqueira M.B.P.
      • Klika A.K.
      • Higuera C.A.
      • Barsoum W.K.
      Modes of failure of total knee arthroplasty: registries and realities.
      ].
      Revision arthroplasty of the knee is a demanding procedure. The long-term goal of this surgery is to achieve a well-fixed, stable knee that improves the patient’s functional status and quality of life. The technical goals include proper limb alignment, restoration of the joint line, precise prosthesis positioning, symmetrical ligament balancing, and adequate joint motion [
      • Bourne R.B.
      • Crawford H.A.
      Principles of revision total knee arthroplasty.
      ,
      • Ponzio D.Y.
      • Austin M.S.
      Metaphyseal bone loss in revision knee arthroplasty.
      ]. Bone defects or inadequate bone stock are frequently encountered during this surgery. They are obstacles to achieving these goals. In revision settings bone loss is often multifactorial and attributed to stress shielding, osteolysis, osteonecrosis, periprosthetic joint infection, mechanical loss due to abrasions of a grossly loose implant, or iatrogenic causes during implant resection [
      • Ponzio D.Y.
      • Austin M.S.
      Metaphyseal bone loss in revision knee arthroplasty.
      ,
      • Qiu Y.Y.
      • Yan C.H.
      • Chiu K.Y.
      • Ng F.Y.
      Review article: bone defect classifications in revision total knee arthroplasty.
      ]. Some consensus exists for the management of minor lesions, defined as the Anderson Orthopaedic Research Institute (AORI) type I [
      • ENGH G.A.
      Bone defect classification.
      ]. The strategy concerning the larger lesions, AORI type II and III, is still a subject of debate [
      • Beckmann N.A.
      • Mueller S.
      • Gondan M.
      • Jaeger S.
      • Reiner T.
      • Bitsch R.G.
      Treatment of severe bone defects during revision total knee arthroplasty with structural allografts and porous metal cones-A systematic review.
      ,
      • Bohl D.D.
      • Brown N.M.
      • McDowell M.A.
      • Levine B.R.
      • Sporer S.M.
      • Paprosky W.G.
      • et al.
      Do porous tantalum metaphyseal cones improve outcomes in revision total knee arthroplasty?.
      ,
      • Sandiford N.A.
      • Misur P.
      • Garbuz D.S.
      • Greidanus N.V.
      • Masri B.A.
      No difference between trabecular metal cones and femoral head allografts in revision TKA: minimum 5-year followup.
      ].
      The epiphyseal zone in revision surgery is either compromised by the bone defects or too weak to sustain primary fixation [
      • Ponzio D.Y.
      • Austin M.S.
      Metaphyseal bone loss in revision knee arthroplasty.
      ]. Additional fixation in the diaphysis and the metaphysis has been advocated in the zonal concept by Morgan-Jones et al [
      • Morgan-Jones R.
      • Oussedik S.I.S.
      • Graichen H.
      • Haddad F.S.
      Zonal fixation in revision total knee arthroplasty.
      ]. To obtain fixation in the diaphysis a cemented or cementless stem can be used. To achieve stability in the metaphysis, several strategies have been used. Traditionally, morselized or structural allografts or autografts were employed to reconstruct the defects. More recently, porous-coated sleeves have been used to obtain fixation in this zone. Porous metal cones have also been introduced as a metallic reconstruction of the metaphysis.
      The porous metal implants have now been around for more than a decade and the midterm results are being published [
      • Kamath A.F.
      • Lewallen D.G.
      • Hanssen A.D.
      Porous tantalum metaphyseal cones for severe tibial.
      ]. Since their introduction, only a few studies have compared the outcome of the more recent porous implants with the traditional graft techniques [
      • Beckmann N.A.
      • Mueller S.
      • Gondan M.
      • Jaeger S.
      • Reiner T.
      • Bitsch R.G.
      Treatment of severe bone defects during revision total knee arthroplasty with structural allografts and porous metal cones-A systematic review.
      ,
      • Bohl D.D.
      • Brown N.M.
      • McDowell M.A.
      • Levine B.R.
      • Sporer S.M.
      • Paprosky W.G.
      • et al.
      Do porous tantalum metaphyseal cones improve outcomes in revision total knee arthroplasty?.
      ,
      • Sandiford N.A.
      • Misur P.
      • Garbuz D.S.
      • Greidanus N.V.
      • Masri B.A.
      No difference between trabecular metal cones and femoral head allografts in revision TKA: minimum 5-year followup.
      ]. They show mixed results. The purpose of this meta-analysis is to compare the results of 4 different revision techniques for AORI type II or III bone defects at the time of revision TKA.

      Materials and Methods

      Before initiating the review, all authors agreed to, and followed, an explicit methodology for conducting the review which was set out in our protocol. After preliminary evaluation of the literature, the original protocol for the study was submitted and subsequently registered to the international prospective register of systematic reviews (PROSPERO). The protocol can be retrieved in the online database using the reference CRD42021237909.
      A systematic review of the literature was undertaken in accordance with the principles outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement [
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Altman D.
      • Antes G.
      • et al.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      ]. In February 2021, 5 electronic databases—PubMed, Medline, Embase, Web of Science and the Cochrane library—were searched.
      The resulting titles were screened for inclusion by at least 2 members of the investigational team using the online review tool RAYYAN [
      • Ouzzani M.
      • Hammady H.
      • Fedorowicz Z.
      • Elmagarmid A.
      Rayyan-a web and mobile app for systematic reviews.
      ]. Duplicates were identified and subsequently discarded. The abstracts of the remaining articles were evaluated by 3 team members on inclusion and exclusion criteria. After unblinding, the results were evaluated for any nonconcordance. If this was the case, it was discussed in the group until a consensus was reached. Full texts were further evaluated for inclusion criteria by 2 members of the team. The reference lists of all papers, as well as all major orthopedic journals, were screened to find additional articles.
      The inclusion criteria for this systematic review were defined as follows: all original, in vivo studies evaluating the survivorship and some form of clinical outcome of different strategies used to address severe metaphyseal bone damage in revision arthroplasty of the knee, defined according to the AORI classification as type II or III [
      • ENGH G.A.
      Bone defect classification.
      ]. Type I lesions were excluded because their treatment options are different and generally agreed upon. Studies published prior to the establishment of this classification were considered if the description of the defects corresponded with type II or more severe lesions. Randomized controlled trials, nonrandomized controlled trials, observational case control studies ,and case series were included. Both prospective and retrospective studies were allowed.
      Studies were excluded if they were expert opinions, case reports, or case series with <10 inclusions. We excluded studies with <2-year follow-up and those that did not report on the clinical outcome measures of the implants. All studies on primary arthroplasties or tumor surgery were excluded. Furthermore, studies involving diaphyseal bone lesions, not reconstructing the metaphysis were also excluded. We did not set limitations in publication date. Manuscripts in languages other than English, French, German, or Dutch were excluded.
      To assess the methodological quality of the included nonrandomized controlled trials, whether comparative or noncomparative, we used the Methodological Index for Non-Randomized Studies (MINORS) criteria [
      • Slim K.
      • Nini E.
      • Forestier D.
      • Kwiatkowski F.
      • Panis Y.
      • Chipponi J.
      Methodological index for non-randomized studies (Minors): development and validation of a new instrument.
      ] All studies were assessed by 2 authors separately. In case of disagreement, it was discussed until a consensus was reached.
      The extraction of the data was done by a primary assessor and subsequently validated by a secondary assessor both using a standardized extraction form. The data extracted included study characteristics, patient demographics, surgery specifications, defect classification and location, follow-up time (median or mean), survivorship that we defined as survival free from revision or removal of tibial or femoral components, clinical outcome measures including range of motion, extension deficit, and the Knee Society Score (KSS)—both Knee Score and Functional Score—according to Insall et al [
      • Insall J.N.
      • Dorr D.
      • Scott R.
      • Scott W.
      Knee society score rationale.
      ]. In addition, we collected the Oxford Knee Score, the Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and the Hospital of Special Surgery Score. If more than one measurement was available, we extracted the latest.
      To analyze statistics, we used MedCalc 2021 MedCalc Software Ltd (Oostende, Belgium) and SAS version 9.4 2021 SAS Institute Inc (Cary, NC, US). Descriptive statistics were used for patient characteristics. Correlation coefficients and linear regressions were used to evaluate the study characteristics by time. Our primary outcome survivorship is a binary patient-level outcome. It was analyzed using logistic meta-regression on study level. This allowed us to calculate odds ratios between different groups, evaluated using chi-squared. As a sensitivity test we calculated the odds ratio based on follow-up time. Based on the study size and size of the effect observed, 95% confidence intervals (CIs) were calculated and visualized in Forest plots. Separate plots were made to evaluate survivorship between 2 and 5 years which we called “early survivorship” and over 5 years, called “mid-term survivorship.” Plots were further divided per type of technique addressing bone loss. The pooled data were collected, and a summary estimate 95% CI was defined using a random effects model, in one instant I2 was 22% so we used a fixed effects model. Publication bias was assessed by Funnel plots and Egger’s tests. To analyze clinical outcome, we compared mean and weighted means from preoperative and postoperative patient-reported outcome measures (PROMs). The changes in PROMs and range of motion were compared between preoperative and postoperative results. As these results depend on the preoperative score, these numbers are misleading to compare by absolute increase. To try to homogenize these parameters between studies we calculated a standardized mean difference for those studies indicating a preoperative and postoperative mean as well as a standard deviation.

      Results

      Search Results

      Our search resulted in 4,044 hits. After reviewing the titles, 1,002 studies were further evaluated. After evaluation and duplicate removal, 836 studies did not meet the inclusion criteria. The full text of the remaining 166 studies were reviewed. Through cross-referencing these articles, we were able to locate one extra record. After thoroughly scrutinizing the texts, 77 records met the inclusion criteria and were evaluated in this study (Fig. 1).
      The 77 studies included consisted of 11 comparative studies of which 1 was a randomized controlled trial and 10 were cohort designs. The other 66 studies were set up as case series. Overall, there were 16 studies with a prospective and 61 with a retrospective design.

      Study and Patient Characteristics

      The total number of patients considered for evaluation in all cohorts combined was 4,388 (4,391 knees). After the study-specific exclusions were implemented, a total of 3,801 knees remained in all respective records. The study sizes ranged from 10 to 204 knees. The mean age of all patients analyzed was 67.98 years with study means ranging from 59 to 79 years. The mean follow-up reported ranged from 24 to 126.5 months (median 48 months).
      There were 27 studies having at least one arm evaluating revisions in which porous cones were used [
      • Abdelaziz H.
      • Jaramillo R.
      • Gehrke T.
      • Ohlmeier M.
      • Citak M.
      Clinical survivorship of aseptic revision total knee arthroplasty using hinged knees and tantalum cones at minimum 10-year follow-up.
      ,
      • Bohl D.D.
      • Brown N.M.
      • McDowell M.A.
      • Levine B.R.
      • Sporer S.M.
      • Paprosky W.G.
      • et al.
      Do porous tantalum metaphyseal cones improve outcomes in revision total knee arthroplasty?.
      ,
      • Sandiford N.A.
      • Misur P.
      • Garbuz D.S.
      • Greidanus N.V.
      • Masri B.A.
      No difference between trabecular metal cones and femoral head allografts in revision TKA: minimum 5-year followup.
      ,
      • Kamath A.F.
      • Lewallen D.G.
      • Hanssen A.D.
      Porous tantalum metaphyseal cones for severe tibial.
      ,
      • Fosco M.
      • Amendola L.
      • Fantasia R.
      • Pipino G.
      • Tigani D.
      Revision total knee arthroplasty: experience with tantalum cones in severe bone loss.
      ,
      • Girerd D.
      • Parratte S.
      • Lunebourg A.
      • Boureau F.
      • Ollivier M.
      • Pasquier G.
      • et al.
      Total knee arthroplasty revision with trabecular tantalum cones: preliminary retrospective study of 51 patients from two centres with a minimal 2-year follow-up.
      ,
      • Howard J.L.
      • Kudera J.
      • Lewallen D.G.
      • Hanssen A.D.
      Early results of the use of tantalum femoral cones for revision total knee arthroplasty.
      ,
      • Jacquet C.
      • Ros F.
      • Guy S.
      • Parratte S.
      • Ollivier M.
      • Argenson J.N.
      Trabecular metal cones combined with short cemented stem allow favorable outcomes in aseptic revision total knee arthroplasty.
      ,
      • Jensen C.L.
      • Winther N.
      • Schrøder H.M.
      • Petersen M.M.
      Outcome of revision total knee arthroplasty with the use of trabecular metal cone for reconstruction of severe bone loss at the proximal tibia.
      ,
      • Lachiewicz P.F.
      • Bolognesi M.P.
      • Henderson R.A.
      • Soileau E.S.
      • Vail T.P.
      Can tantalum cones provide fixation in complex revision knee arthroplasty?.
      ,
      • Long W.J.
      • Scuderi G.R.
      Porous tantalum cones for large metaphyseal tibial defects in revision total knee arthroplasty. A minimum 2-year follow-up.
      ,
      • Meneghini R.M.
      • Lewallen D.G.
      • Hanssen A.D.
      Use of porous tantalum metaphyseal cones for severe tibial bone loss during revision total knee replacement.
      ,
      • Panda I.
      • Wakde O.
      • Singh H.
      • Rajgopal A.
      Management of large bone defects around the knee using porous tantalum trabecular metal cones during complex primary and revision total knee arthroplasty.
      ,
      • Potter G.D.
      • Abdel M.P.
      • Lewallen D.G.
      • Hanssen A.D.
      Midterm results of porous tantalum femoral cones in revision total knee arthroplasty.
      ,
      • Rajgopal A.
      • Kumar S.
      • Aggarwal K.
      Midterm outcomes of tantalum metal cones for severe bone loss in complex primary and revision total knee arthroplasty.
      ,
      • Rao B.M.
      • Kamal T.T.
      • Vafaye J.
      • Moss M.
      Tantalum cones for major osteolysis in revision knee replacement.
      ,
      • Remily E.A.
      • Dávila Castrodad I.M.
      • Mohamed N.S.
      • Wilkie W.A.
      • Kelemen M.N.
      • Delanois R.E.
      Short-term outcomes of 3D-printed titanium metaphyseal cones in revision total knee arthroplasty.
      ,
      • Schmitz H.C.R.
      • Klauser W.
      • Citak M.
      • Al-Khateeb H.
      • Gehrke T.
      • Kendoff D.
      Three-year follow up utilizing tantal cones in revision total knee arthroplasty.
      ,
      • Tetreault M.W.
      • Perry K.I.
      • Pagnano M.W.
      • Hanssen A.D.
      • Abdel M.P.
      Excellent two-year survivorship of 3D-printed metaphyseal cones in revision total knee arthroplasty: a reliable and safe reamer-based system.
      ,
      • Brown N.M.
      • Bell J.A.
      • Jung E.K.
      • Sporer S.M.
      • Paprosky W.G.
      • Levine B.R.
      The use of trabecular metal cones in complex primary and revision total knee arthroplasty.
      ,
      • Jensen C.L.
      • Petersen M.M.
      • Schrøder H.M.
      • Lund B.
      Bone mineral density changes of the proximal tibia after revision total knee arthroplasty. A randomised study with the use of porous tantalum metaphyseal cones.
      ,
      • Abdelaziz H.
      • Biewald P.
      • Anastasiadis Z.
      • Haasper C.
      • Gehrke T.
      • Hawi N.
      • et al.
      Midterm results after tantalum cones in 1-stage knee exchange for periprosthetic joint infection: a single-center study.
      ,
      • Burastero G.
      • Cavagnaro L.
      • Chiarlone F.
      • Alessio-Mazzola M.
      • Carrega G.
      • Felli L.
      The use of tantalum metaphyseal cones for the management of severe bone defects in septic knee revision.
      ,
      • De Martino I.
      • De Santis V.
      • Sculco P.K.
      • D’Apolito R.
      • Assini J.B.
      • Gasparini G.
      Tantalum cones provide durable mid-term fixation in revision TKA.
      ,
      • Denehy K.M.
      • Abhari S.
      • Krebs V.E.
      • Higuera-Rueda C.A.
      • Samuel L.T.
      • Sultan A.A.
      • et al.
      Metaphyseal fixation using highly porous cones in revision total knee arthroplasty: minimum two year follow up study.
      ,
      • Derome P.
      • Sternheim A.
      • Backstein D.
      • Malo M.
      Treatment of large bone defects with trabecular metal cones in revision total knee arthroplasty: short term clinical and radiographic outcomes.
      ,
      • Erivan R.
      • Tracey R.
      • Mulliez A.
      • Villatte G.
      • Paprosky W.
      Medium term clinical outcomes of tibial cones in revision knee arthroplasty.
      ]. The total number of cones analyzed in the included studies was 1,649 (in 1,455 knees). There were 21 studies with porous sleeves [
      • Agarwal S.
      • Azam A.
      • Morgan-Jones R.
      Metal metaphyseal sleeves in revision total knee replacement.
      ,
      • Agarwal S.
      • Neogi D.S.
      • Morgan-Jones R.
      Metaphyseal sleeves in revision total knee arthroplasty: minimum seven-year follow-up study.
      ,
      • Huang R.
      • Barrazueta G.
      • Ong A.
      • Orozco F.
      • Jafari M.
      • Coyle C.
      • et al.
      Revision total knee arthroplasty using metaphyseal sleeves at short-term follow-up.
      ,
      • Klim S.M.
      • Amerstorfer F.
      • Bernhardt G.A.
      • Sadoghi P.
      • Gruber G.
      • Radl R.
      • et al.
      Septic revision total knee arthroplasty: treatment of metaphyseal bone defects using metaphyseal sleeves.
      ,
      • Klim S.M.
      • Amerstorfer F.
      • Bernhardt G.A.
      • Sadoghi P.
      • Hauer G.
      • Leitner L.
      • et al.
      Excellent mid-term osseointegration and implant survival using metaphyseal sleeves in revision total knee arthroplasty.
      ,
      • Lai M.C.
      • Chen J.Y.
      • Liow M.H.L.
      • Tay D.K.J.
      • Lo N.N.
      • Pang H.N.
      • et al.
      Is constraint implant with metaphyseal sleeve a viable option for revision TKR with preoperative coronal plane instability and bone defect?.
      ,
      • Lycke C.
      • Zajonz D.
      • Brand A.
      • Prietzel T.
      • Heyde C.E.
      • Roth A.
      • et al.
      Metaphyseal sleeves in arthroplasty of the knee: a suitable tool in management of major metaphyseal bone loss.
      ,
      • Martin-Hernandez C.
      • Floria-Arnal L.J.
      • Muniesa-Herrero M.P.
      • Espallargas-Doñate T.
      • Blanco-Llorca J.A.
      • Guillen-Soriano M.
      • et al.
      Mid-term results for metaphyseal sleeves in revision knee surgery.
      ,
      • Panesar K.
      • Al-Mouazzen L.
      • Nessa L.
      • Jonas S.C.
      • Agarwal S.
      • Morgan-Jones R.
      Revision total knee arthroplasty using an uncemented metaphyseal sleeve, rotating hinge prosthesis: a case series of 99 patients.
      ,
      • Stefani G.
      • Mattiuzzo V.
      • Prestini G.
      Revision total knee arthroplasty with metaphyseal sleeves without stem: short-term results.
      ,
      • Thorsell M.
      • Hedström M.
      • Wick M.C.
      • Weiss R.J.
      Good clinical and radiographic outcome of cementless metal metaphyseal sleeves in total knee arthroplasty: retrospective study of 31patients with minimum 5-year follow-up.
      ,
      • Watters T.S.
      • Martin J.R.
      • Levy D.L.
      • Yang C.C.
      • Kim R.H.
      • Dennis D.A.
      Porous-coated metaphyseal sleeves for severe femoral and tibial bone loss in revision TKA.
      ,
      • Alexander G.E.
      • Bernasek T.L.
      • Crank R.L.
      • Haidukewych G.J.
      Cementless metaphyseal sleeves used for large tibial defects in revision total knee arthroplasty.
      ,
      • Wirries N.
      • Winnecken H.J.
      • Lewinski G.
      • Windhagen H.
      • Skutek M.
      Osteointegrative sleeves for metaphyseal defect augmentation in revision total knee arthroplasty: clinical and radiological 5-year follow-up.
      ,
      • Algarni A.D.
      Cementless metaphyseal sleeve fixation in revision knee arthroplasty: our experience with an Arabic population at the midterm.
      ,
      • Barnett S.L.
      • Mayer R.R.
      • Gondusky J.S.
      • Choi L.
      • Patel J.J.
      • Gorab R.S.
      Use of stepped porous titanium metaphyseal sleeves for tibial defects in revision total knee arthroplasty: short term results.
      ,
      • Bugler K.E.
      • Maheshwari R.
      • Ahmed I.
      • Brenkel I.J.
      • Walmsley P.J.
      Metaphyseal sleeves for revision total knee arthroplasty: good short-term outcomes.
      ,
      • Dalury D.F.
      • Barrett W.P.
      The use of metaphyseal sleeves in revision total knee arthroplasty.
      ,
      • Floría-Arnal L.J.
      • Gómez-Blasco A.
      • Roche-Albero A.
      • Panisello-Sebastia J.J.
      • Martin-Martinez A.
      • Martin-Hernández C.
      Tibial tray cementation is not necessary for knee revision with titanium metaphyseal sleeves: a mid-term prospective study in AORI 2B defects.
      ,
      • Gøttsche D.
      • Lind T.
      • Christiansen T.
      • Schrøder H.M.
      Cementless metaphyseal sleeves without stem in revision total knee arthroplasty.
      ,
      • Graichen H.
      • Strauch M.
      • Scior W.
      • Morgan-Jones R.
      Revisionsendoprothetik des Kniegelenks: Zementfreie, metaphysäre Fixation mittels Sleeves.
      ]. The number of implanted sleeves was more than 2,143 in 1491 knees (Dalury and Barrett, Lycke et al, and Lai et al did not publish the specific number of sleeves) [
      • Lai M.C.
      • Chen J.Y.
      • Liow M.H.L.
      • Tay D.K.J.
      • Lo N.N.
      • Pang H.N.
      • et al.
      Is constraint implant with metaphyseal sleeve a viable option for revision TKR with preoperative coronal plane instability and bone defect?.
      ,
      • Lycke C.
      • Zajonz D.
      • Brand A.
      • Prietzel T.
      • Heyde C.E.
      • Roth A.
      • et al.
      Metaphyseal sleeves in arthroplasty of the knee: a suitable tool in management of major metaphyseal bone loss.
      ,
      • Dalury D.F.
      • Barrett W.P.
      The use of metaphyseal sleeves in revision total knee arthroplasty.
      ]. There were 18 studies evaluating the use of structural allografts comprising a total of 549 knees [
      • Sandiford N.A.
      • Misur P.
      • Garbuz D.S.
      • Greidanus N.V.
      • Masri B.A.
      No difference between trabecular metal cones and femoral head allografts in revision TKA: minimum 5-year followup.
      ,
      • Bauman R.D.
      • Lewallen D.G.
      • Hanssen A.D.
      Limitations of structural allograft in revision total knee Arthroplasty.
      ,
      • Hockman D.E.
      • Ammeen D.
      • Engh G.A.
      Augments and allografts in revision total knee arthroplasty: usage and outcome using one modular revision prosthesis.
      ,
      • Lyall H.S.
      • Sanghrajka A.
      • Scott G.
      Severe tibial bone loss in revision total knee replacement managed with structural femoral head allograft. A prospective case series from the Royal London Hospital.
      ,
      • Mow C.S.
      • Wiedel J.D.
      Structural allografting in revision total knee arthroplasty.
      ,
      • Richards C.J.
      • Garbuz D.S.
      • Pugh L.
      • Masri B.A.
      Revision total knee arthroplasty. Clinical outcome comparison with and without the use of femoral head structural allograft.
      ,
      • Salai M.
      • Dudkiewicz I.
      • Blankstein A.
      • Israeli A.
      • Chechik A.
      • Amit Y.
      Bone allograft in revision total knee replacement.
      ,
      • Tsahakis P.J.
      • Beaver W.B.
      • Brick G.W.
      Technique and results of allograft reconstruction in revision total knee arthroplasty.
      ,
      • Van Loon C.J.M.
      • Wijers M.
      • de Waal Malefijt M.C.
      • Buma P.
      • Veth R.P.H.
      Femoral bone grafting in primary and revision total knee arthroplasty.
      ,
      • Wang J.W.
      • Hsu C.H.
      • Huang C.C.
      • Lin P.C.
      • Chen W.S.
      Reconstruction using femoral head allograft in revision total knee replacement: an experience in Asian patients.
      ,
      • Bezwada H.P.
      • Shah A.R.
      • Zambito K.
      • Cerynik D.L.
      • Johanson N.A.
      Distal femoral allograft reconstruction for massive osteolytic bone loss in revision total knee arthroplasty.
      ,
      • Burnett R.S.J.
      • Keeney J.A.
      • Maloney W.J.
      • Clohisy J.C.
      Revision total knee arthroplasty for major osteolysis.
      ,
      • Chun C.H.
      • Kim J.W.
      • Kim S.H.
      • Kim B.G.
      • Chun K.C.
      • Kim K.M.
      Clinical and radiological results of femoral head structural allograft for severe bone defects in revision TKA - a minimum 8-year follow-up.
      ,
      • Clatworthy M.G.
      • Ballance J.
      • Brick G.W.
      • Chandler H.P.
      • Gross A.E.
      The use of structural allograft for uncontained defects in revision total knee arthroplasty: a minimum five-year review.
      ,
      • Engh G.A.
      • Ammeen D.J.
      Use of structural allograft in revision total knee arthroplasty in knees with severe tibial bone loss.
      ,
      • Engh G.A.
      • Herzwurm P.J.
      • Parks N.L.
      Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty.
      ,
      • Franke K.F.
      • Nusem I.
      • Gamboa G.
      • Morgan D.A.F.
      Outcome of revision total knee arthroplasty with bone allograft in 30 cases.
      ,
      • Ghazavi M.T.
      • Stockley I.
      • Yee G.
      • Davis A.
      • Gross A.E.
      Reconstruction of massive bone defects with allograft in revision total knee arthroplasty.
      ]. There were 15 studies on morselized grafts evaluating 564 knees [
      • Salai M.
      • Dudkiewicz I.
      • Blankstein A.
      • Israeli A.
      • Chechik A.
      • Amit Y.
      Bone allograft in revision total knee replacement.
      ,
      • Van Loon C.J.M.
      • Wijers M.
      • de Waal Malefijt M.C.
      • Buma P.
      • Veth R.P.H.
      Femoral bone grafting in primary and revision total knee arthroplasty.
      ,
      • Burnett R.S.J.
      • Keeney J.A.
      • Maloney W.J.
      • Clohisy J.C.
      Revision total knee arthroplasty for major osteolysis.
      ,
      • Saragaglia D.
      • Estour G.
      • Nemer C.
      • Colle P.E.
      Revision of 33 unicompartmental knee prostheses using total knee arthroplasty: strategy and results.
      ,
      • Steens W.
      • Loehr J.F.
      • Wodtke J.
      • Katzer A.
      Morselized bone grafting in revision arthroplasty of the knee: a retrospective analysis of 34 reconstructions after 2-9 years.
      ,
      • Whiteside L.A.
      Cementless reconstruction of massive tibial bone loss in revision total knee arthroplasty.
      ,
      • Whiteside L.A.
      Cementless revision total knee arthroplasty.
      ,
      • Whiteside L.A.
      • Bicalho P.S.
      Radiologic and histologic analysis of morselized allograft in revision total knee replacement.
      ,
      • Barden B.
      • Fitzek J.G.
      • Löer F.
      Rotating platform components for revisions of hinged knee prostheses.
      ,
      • Benjamin J.
      • Engh G.
      • Parsley B.
      • Donaldson T.
      • Coon T.
      Morselized bone grafting of defects in revision total knee arthroplasty.
      ,
      • Bradley G.W.
      Revision total knee arthroplasty by impaction bone grafting.
      ,
      • Hanna S.A.
      • Aston W.J.S.
      • De Roeck N.J.
      • Gough-Palmer A.
      • Powles D.P.
      Cementless revision TKA with bone grafting of osseous defects restores bone stock with a low revision rate at 4 to 10 years.
      ,
      • Hilgen V.
      • Citak M.
      • Vettorazzi E.
      • Haasper C.
      • Day K.
      • Amling M.
      • et al.
      10-year results following impaction bone grafting of major bone defects in 29 rotational and hinged knee revision arthroplasties.
      ,
      • Lotke P.A.
      • Carolan G.F.
      • Puri N.
      Impaction grafting for bone defects in revision total knee arthroplasty.
      ,
      • Rudert M.
      • Holzapfel B.M.
      • von Rottkay E.
      • Holzapfel D.E.
      • Noeth U.
      Impaction-Bone-Grafting zur Rekonstruktion ausgedehnter Knochendefekte beim Knieprothesenwechsel.
      ].
      The overall number of knees analyzed per study arm was plotted according to publication year (Fig. 2) . The difference in numbers of knees analyzed resulted in a significant positive correlation coefficient r = 0.36 (corresponding P-value <.001). Linear regression showed a slope of 1.61, indicating a gradual increase of analyzed knees over time. The graph shows a clear shift toward studies on metal implants compared with grafts.
      Figure thumbnail gr1
      Fig. 1Flow diagram of the systematic review according to the PRISMA 2020 statement.
      Figure thumbnail gr2
      Fig. 2Number of knees analyzed per study set out by year. This graph clearly shows a trend toward larger study sizes and a shift toward research on sleeves and cones in the last decade.

      Quality Evaluation

      We analyzed the evolution in quality by plotting the MINORS score according to the year of publication (Fig. 3) . We saw a statistically significant positive correlation coefficient r = 0.35 (P = .002). Linear regression demonstrated a progressive increase in quality score over time (slope 0.15).
      Figure thumbnail gr3
      Fig. 3MINORS score per study set out by year. This graph clearly demonstrates an increase in the quality of the literature throughout the years.

      Survivorship

      Based on the mean follow-up and reporting on survivorship of the implant, we calculated mean survival with a 95% CI. These results are presented in a forest plot (Fig. 4, Fig. 5) . We report the early survivorship (2-5 years) separately from the midterm survivorship (5-10 years). At early survivorship we see a combined survivorship of 93.74% (95% CI 91.67-95.54). Only sleeves with 95.81% (95% CI 93.92-97.25) show a slightly better result. Cones 93.23% (95% CI 89.59-96.12), structural allografts 90.52% (95% CI 77.04-98.15), and impaction grafting 92.18% (95% CI 83.99-97.61) all show a slightly but not significant lower trend.
      Figure thumbnail gr4
      Fig. 4Forest plots. Overview of forest plots separated by technique used to address bone loss and by early (<60 months) or midterm follow-up (≥60).
      Figure thumbnail gr5
      Fig. 5Pooled means. Overview of the means and confidence interval derived from the pooled means per technique to address bone loss. Results for early above, midterm below.
      At midterm survivorship we observed a total survivorship of 89.85% (95% CI 86.04-93.11). Both sleeves with 90.14% (95% CI 81.24-96.40) and impaction grafting 90.87% (95% CI 78.36-98.32) show slightly better results. Structural allografts 89.26% (95% CI 82.12-94.75) and cones 89.32% (95% CI 82.49-94.62) are below this mean although again none of these means differ significantly.
      Structural allografts (102 knees at early and 366 knees at midterm survivorship) and impaction grafts (185 knees at early and 254 knees at midterm survivorship) have clearly smaller sample sizes than the cones (758 knees at early and 546 knees at midterm survivorship) and sleeves (608 knees at early and 666 knees at midterm survivorship). This accounts for the bigger 95% CIs observed for these techniques. Egger’s tests on all groups were not significant.
      The results of the meta-regression analysis (Fig. 6) also show a very similar pattern. The risk of failure shows no difference when comparing all implants (sleeves and cones) with all grafts (impaction/morselized and structural). We see a regression curve with an odds ratio for failure at 10 years (125.5 months) of 0.91 for implants compared with grafts (95% CI 0.699-1.192) that is not significant (P = .49).
      Figure thumbnail gr6
      Fig. 6Failure rate. Linear regression showing failure of the revision arthroplasty. The dots represent study means. The graph compares a curve for the combination of impaction graft and structural allografts and one for the combination of sleeves and cones.

      Clinical Outcome

      All reported clinical outcome parameters showed better means for the postoperative assessment than preoperative, provided both were reported. The most used parameter was the KSS. Descriptive statistics on the mean postoperative KSS compare different bone filling techniques. Porous cones showed a score of 77.25, out of a 100 based on 20 studies, porous-coated sleeves 78.60 (12 studies), structural allografts 84.89 (8 studies), and impaction grafting 83.14 (7 studies). When compensating for study size we got the following weighted means: porous cones had 76.92, based on 19 studies totaling 993 patients, sleeves had 78.38 (12 studies, 809 patients), structural allografts 84.97 (8 studies, 190 patients), and impaction grafting 82.55 (6 studies, 144 patients). The range of the preoperative means were smaller comparing the different techniques: porous cones had 44.49, based on 22 studies, sleeves had 41.24 (9 studies), structural allografts 41.42 (5 studies), and impaction grafting 42.76 (8 studies).
      To be more accurately comparing preoperative and postoperative values, we used the standardized mean difference to evaluate the gain in function. However, too few reports indicated preoperative and postoperative KSS results with corresponding standard deviations. Therefore, we had to combine the standardized mean differences (SMDs) of all reported PROMs. Even then there were only enough results to compare reports on cones and sleeves (Fig. 7) . The forest plots show a random effects model demonstrating a greater increase for porous cones SMD of 2.77 (95% CI 1.81-3.73 based on 8 studies) than for porous-coated sleeves SMD of 1.54 (95% CI 0.78-2.30 based on 7 studies).
      Figure thumbnail gr7
      Fig. 7Standardized mean difference. Forest plots showing standardized mean differences of different studies. The resulting pooled mean with confidence interval seems to favor the porous cones.

      Discussion

      Revision arthroplasty of the knee is a challenging procedure. A reliable technique to address the pitfalls created by bone defects is necessary to achieve good and consistent results. Our analysis shows that over the last 3 decades the literature on the subject has seen a significant rise in quality. Study populations are getting larger and study designs are gradually improving. The study of porous metal implants has largely replaced that of structural or morselized grafts although some still investigate it [
      • Boettner F.
      • Bechler U.
      • Springer B.
      • Faschingbauer M.
      • Jungwirth-Weinberger A.
      Impaction bone grafting in revision total knee arthroplasty—using mesh and cone to contain the defect: a report of 3 cases.
      ]. The ease of use and the reproducibility of those porous metal implant technique can help explain this trend. Our analysis confirms overall good results for survivorship and increased clinical function of the revision arthroplasties using both the porous-coated sleeves and the porous metal cones to tackle the metaphyseal bone defects at mid-term follow-up.
      This meta-analysis compared the outcome of porous implants with those reported for grafts. Comparative studies of these techniques are rare. We were surprised to find no statistically significant difference in survivorship data between both options at midterm.
      Our review has several limitations. Nearly all included studies used a cohort or case series design. Just over 80% of studies followed patients only retrospectively. Studies on grafts are generally older. The more recent studies have the benefit of using more modern prosthesis designs. Older studies have worse study designs making them more prone to bias. The majority of the most recent studies published on the use of grafts show good results at midterm. Chun et al published a study in 2014 on grafts with a mean follow-up of 107 months. They reported no re-revisions of those knees during this period. Although one knee failed but could not be revised because of general health issues [
      • Chun C.H.
      • Kim J.W.
      • Kim S.H.
      • Kim B.G.
      • Chun K.C.
      • Kim K.M.
      Clinical and radiological results of femoral head structural allograft for severe bone defects in revision TKA - a minimum 8-year follow-up.
      ], Wang et al published a series in 2013 on the results of 30 revisions using structural allografts to create contained defects that were subsequently filled with morselized grafts. All revisions survived at a mean of 76 months despite asymptomatic nonunion of 2 structural grafts [
      • Wang J.W.
      • Hsu C.H.
      • Huang C.C.
      • Lin P.C.
      • Chen W.S.
      Reconstruction using femoral head allograft in revision total knee replacement: an experience in Asian patients.
      ]. Sandiford et al compared structural allografts to porous cones and found no difference in survivorship or clinical outcome between the 2 groups with 93% and 91% survival respectively. They compared 30 grafts with 15 cones with all of them using the same constrained prosthesis [
      • Sandiford N.A.
      • Misur P.
      • Garbuz D.S.
      • Greidanus N.V.
      • Masri B.A.
      No difference between trabecular metal cones and femoral head allografts in revision TKA: minimum 5-year followup.
      ]. The use of different prosthetic implants and the only partial reporting of their use, is another limitation. Although we see better results in the reports on grafts using a less constrained implant, the reporting is too fragmented to draw significant conclusions. The use of a hinged implant might explain the significantly worse results reported in Hilgen et al [
      • Hilgen V.
      • Citak M.
      • Vettorazzi E.
      • Haasper C.
      • Day K.
      • Amling M.
      • et al.
      10-year results following impaction bone grafting of major bone defects in 29 rotational and hinged knee revision arthroplasties.
      ].
      Another limitation is the heterogeneity in reporting on clinical data. This makes interstudy evaluation difficult. Although the wide adaptation of the AORI classification has been instrumental to facilitate comparisons between different studies, it is difficult to classify all bone lesions. There is no difference between contained and uncontained lesions. This is mostly a concern for morselized grafts although several authors have successfully proposed strategies to convert uncontained lesions to contained ones [
      • Wang J.W.
      • Hsu C.H.
      • Huang C.C.
      • Lin P.C.
      • Chen W.S.
      Reconstruction using femoral head allograft in revision total knee replacement: an experience in Asian patients.
      ,
      • Whiteside L.A.
      Cementless reconstruction of massive tibial bone loss in revision total knee arthroplasty.
      ,
      • Lotke P.A.
      • Carolan G.F.
      • Puri N.
      Impaction grafting for bone defects in revision total knee arthroplasty.
      ,
      • Maculé F.
      • Segur J.M.
      • Vilalta C.
      • Suso S.
      The use of fascia lata and bone allograft for uncontained defects in revision knee arthroplasty.
      ]. A further limitation is that we could not separate septic from aseptic reasons as a mode of failure of the revision arthroplasty for all included studies. A final limitation is the different factors known to influence the outcome of a revision. These are patient characteristics and indication for revision [
      • Abdelaziz H.
      • Jaramillo R.
      • Gehrke T.
      • Ohlmeier M.
      • Citak M.
      Clinical survivorship of aseptic revision total knee arthroplasty using hinged knees and tantalum cones at minimum 10-year follow-up.
      ,
      • Jacquet C.
      • Ros F.
      • Guy S.
      • Parratte S.
      • Ollivier M.
      • Argenson J.N.
      Trabecular metal cones combined with short cemented stem allow favorable outcomes in aseptic revision total knee arthroplasty.
      ,
      • Schmitz H.C.R.
      • Klauser W.
      • Citak M.
      • Al-Khateeb H.
      • Gehrke T.
      • Kendoff D.
      Three-year follow up utilizing tantal cones in revision total knee arthroplasty.
      ,
      • Bugler K.E.
      • Maheshwari R.
      • Ahmed I.
      • Brenkel I.J.
      • Walmsley P.J.
      Metaphyseal sleeves for revision total knee arthroplasty: good short-term outcomes.
      ,
      • Floría-Arnal L.J.
      • Gómez-Blasco A.
      • Roche-Albero A.
      • Panisello-Sebastia J.J.
      • Martin-Martinez A.
      • Martin-Hernández C.
      Tibial tray cementation is not necessary for knee revision with titanium metaphyseal sleeves: a mid-term prospective study in AORI 2B defects.
      ,
      • Richards C.J.
      • Garbuz D.S.
      • Pugh L.
      • Masri B.A.
      Revision total knee arthroplasty. Clinical outcome comparison with and without the use of femoral head structural allograft.
      ,
      • Bezwada H.P.
      • Shah A.R.
      • Zambito K.
      • Cerynik D.L.
      • Johanson N.A.
      Distal femoral allograft reconstruction for massive osteolytic bone loss in revision total knee arthroplasty.
      ,
      • Franke K.F.
      • Nusem I.
      • Gamboa G.
      • Morgan D.A.F.
      Outcome of revision total knee arthroplasty with bone allograft in 30 cases.
      ,
      • Steens W.
      • Loehr J.F.
      • Wodtke J.
      • Katzer A.
      Morselized bone grafting in revision arthroplasty of the knee: a retrospective analysis of 34 reconstructions after 2-9 years.
      ,
      • Hilgen V.
      • Citak M.
      • Vettorazzi E.
      • Haasper C.
      • Day K.
      • Amling M.
      • et al.
      10-year results following impaction bone grafting of major bone defects in 29 rotational and hinged knee revision arthroplasties.
      ,
      • Graichen H.
      • Scior W.
      • Strauch M.
      Direct, cementless, metaphyseal fixation in knee revision arthroplasty with sleeves-short-term results.
      ]. By evaluating large numbers of revisions, we attempted to diminish their effect.

      Conclusions

      Porous implants seem effective in tackling metaphyseal bone defects and have a very good survivorship outcome at midterm follow-up. In younger patients with less constrained prosthetic implants, surgeons might still consider the use of grafts without risking worse outcomes. Further comparative studies clarifying the exact indications for the use of grafts are warranted.

      Acknowledgments

      The authors would like to thank Geert Byttebier for his tireless effort to optimize the statistical analysis of this study as well as proofreading the manuscript.

      Appendix A. Supplementary Data

      Appendices

      Appendix A

      Database String Query

      (((revision knee arthroplasty) OR (Revision knee replacement)) OR (((knee replacement) OR (knee arthroplasty)) AND (Revision))) AND (((bone loss) OR (bone defect)) OR (porous metal implant) OR (metaphyseal cone) OR (metaphyseal cones) OR (porous metal cones) OR (metaphyseal sleeve) OR (metaphyseal sleeves) OR (porous metal sleeve) OR (titanium cone) OR (titanium cones) OR (metal augment) OR (impaction grafting) OR (morselized bone graft) OR (bone allograft) OR (structural allograft) OR (diaphyseal stem) OR (modular stem)).

      Appendix B

      Table B1Overview Table of Papers Used in the Meta-Analysis.
      YearAuthorJournalType of PublicationDesignBone Defect TechniquePatients in the CohortPROMs
      2020Abdelaziz et alJ ArthroplastyCase seriesRetrospectivePorous cones91HSS
      2019Abdelaziz et al.J ArthroplastyCase seriesRetrospectivePorous cones38KSS
      2013Agarwal et alBone Joint JCase seriesRetrospectivePorous-coated sleeves103OKS
      2018Agarwal et alKneeCase seriesRetrospectivePorous-coated sleeves103OKS
      2013Alexander et alJ ArthroplastyCase seriesRetrospectivePorous-coated sleeves41KSS
      2020Algarni et alAdv OrthopCase seriesRetrospectivePorous-coated sleeves27KSS
      2004Barden et alClin Orthop Relat ResCase seriesProspectiveMorselized grafts21KSS
      2014Barnett et alJ ArthroplastyCase seriesRetrospectivePorous-coated sleeves51KSS
      2009Bauman et alClin Orthop Relat ResCase seriesRetrospectiveStructural allografts74KSS
      2001Benjamin et alClin Orthop Relat ResCase seriesRetrospectiveMorselized grafts46KSS (range)
      2006Bezwada et alJ ArthroplastyCase seriesRetrospectiveStructural allografts10VAS, KSS
      2018Bohl et alJ ArthroplastyCohortRetrospectivePorous cones vs control98KSS
      2000BradleyClin Orthop Relat ResCase seriesRetrospectiveMorselized grafts21KSS
      2015Bugler et alJ ArthroplastyCase seriesRetrospectivePorous-coated sleeves45KSS, OKS
      2018Burastero et alJ ArthroplastyCase seriesRetrospectivePorous cones60KSS, OKS
      2009Burnett et alIowa Orthop JCohortRetrospectiveMorselized grafts vs structural allografts26VAS, KSS
      2014Chun et alKneeCase seriesRetrospectiveStructural allografts32HSS
      2001Clatworthy et alJ Bone Joint Surg AmCase seriesProspectiveStructural allografts58HSS
      2016Dalury and BarrettKneeCase seriesRetrospectivePorous-coated sleeves45KSS
      2015De Martino et alClin Orthop Relat ResCase seriesRetrospectivePorous cones18KSS
      2019Denehy et alJ ArthroplastyCase seriesProspectivePorous cones68KSS
      2014Derome et alJ ArthroplastyCase seriesRetrospectivePorous cones31KSS
      2007Engh and AmmeenJ Bone Joint Surg AmCase seriesProspectiveStructural allografts47KSS
      1997Engh et alJ Bone Joint Surg AmCase seriesRetrospectiveStructural allografts37KSS, HSS
      2021Erivan et alArch Orthop Trauma SurgCase seriesRetrospectivePorous cones61KOOS
      2021Floría-Arnal et alKnee Surg Sports Traumatol ArthroscCohortProspectivePorous-coated sleeves60KSS, WOMAC
      2013Fosco et alEur Orthop TraumatolCase seriesRetrospectivePorous cones10KSS
      2013Franke et alActa Orthop BelgCase seriesRetrospectiveStructural allografts30KSS
      1997Ghazavi et alJ Bone Joint Surg AmCase seriesRetrospectiveStructural allografts28HSS
      2016Girerd et alOrthop Traumatol Surg ResCase seriesRetrospectivePorous cones51KSS, KOOS
      2016Gøttsche D. et al.Arch Orthop Trauma SurgCase seriesRetrospectivePorous-coated sleeves71KSS, OKS
      2015Graichen et alJ ArthroplastyCase seriesProspectivePorous-coated sleeves156KSS
      2011Hanna et alClin Orthop Relat ResCase seriesRetrospectiveMorselized grafts64OKS
      2013Hilgen et alActa OrthopCase seriesRetrospectiveMorselized grafts29KSS, WOMAC
      2005Hockman et alJ ArthroplastyCohortRetrospectiveStructural allografts vs control62KSS
      2011Howard et alJ Bone Joint Surg AmCase seriesRetrospectivePorous cones26KSS
      2014Huang et alOrthopedicsCase seriesProspectivePorous-coated sleeves92KSS
      2021Jacquet et alJ ArthroplastyCohortRetrospectivePorous cones vs control204KSS
      2014Jensen et alKneeCase seriesProspectivePorous cones36KSS
      2015Kamath et alJ Bone Joint Surg AmCase seriesProspectivePorous cones63KSS
      2018Klim et alJ ArthroplastyCase seriesRetrospectivePorous-coated sleeves57KSS, WOMAC
      2020Klim et alKnee Surg Sports Traumatol ArthroscCase seriesRetrospectivePorous-coated sleeves99KSS, WOMAC
      2012Lachiewicz et alClin Orthop Relat ResCase seriesRetrospectivePorous cones33KSS
      2020Lai et alJ Orthop SurgCohortRetrospectivePorous-coated sleeves vs control51KSS, OKS
      2009Long et alJ ArthroplastyCase seriesRetrospectivePorous cones15
      2006Lotke et alClin Orthop Relat ResCase seriesProspectiveMorselized grafts45KSS
      2009Lyall et alKneeCase seriesProspectiveStructural allografts15KSS
      2021Lycke et alDer OrthopädeCase seriesRetrospectivePorous-coated sleeves12VAS, KSS, HSS
      2017Martin-Hernandez et alKnee Surg Sports Traumatol ArthroscCase seriesProspectivePorous-coated sleeves150KSS
      2008Meneghini et alJ Bone Joint Surg AmCase seriesProspectivePorous cones15KSS
      1996Mow and WiedelJ ArthroplastyCase seriesRetrospectiveStructural allografts15HSS
      2018Panda et alSemin ArthroplastyCase seriesRetrospectivePorous cones84KSS
      2021Panesar et alJ ArthroplastyCase seriesRetrospectivePorous-coated sleeves99OKS
      2016Potter et alJ Bone Joint Surg AmCase seriesRetrospectivePorous cones157KSS
      2021Rajgopal et alArthroplasty TodayCase seriesRetrospectivePorous cones62KSS
      2013Rao et alBone Joint JCase seriesRetrospectivePorous cones26KSS, OKS
      2020Remily et alOrthopedicsCase seriesRetrospectivePorous cones54KSS
      2011Richards et alJ ArthroplastyCohortRetrospectiveStructural allografts vs control72OKS
      2015Rudert et alOper Orthop TraumatolCase seriesRetrospectiveMorselized grafts28KSS, WOMAC
      2000Salai et alCell Tissue BankCohortRetrospectiveMorselized grafts vs structural allografts vs control137HSS
      2009Saragaglia et alInt OrthopCase seriesRetrospectiveMorselized grafts33KSS
      2013Schmitz et alJ ArthroplastyCase seriesRetrospectivePorous cones44VAS, KSS
      2008Steens et alActa OrthopCase seriesRetrospectiveImpaction grafting36KSS
      2017Stefani et alJointsCase seriesRetrospectivePorous-coated sleeves51KSS, WOMAC
      2020Tetreault et alBone Joint JCase seriesRetrospectivePorous cones139KSS
      2018Thorsell et alActa OrthopCase seriesRetrospectivePorous-coated sleeves37VAS, KOOS
      1994Tsahakis et alClin Orthop Relat ResCase seriesRetrospectiveStructural allografts15KSS
      1999van Loon et alActa Orthop BelgCohortRetrospectiveMorselized grafts vs structural allografts22KSS
      2013Wang et alBone Joint JCase seriesRetrospectiveStructural allograft28KSS
      2017Watters et alJ ArthroplastyCase seriesRetrospectivePorous-coated sleeves108KSS
      1989WhitesideClin Orthop Relat ResCase seriesProspectiveMorselized grafts20
      1993WhitesideClin Orthop Relat ResCase seriesProspectiveMorselized grafts56
      2019Wirries et alJ ArthroplastyCase seriesRetrospectivePorous-coated sleeves61KSS
      2015Brown et alJ ArthroplastyCase seriesRetrospectivePorous cones115KSS
      2017Sandiford et alClin Orthop Relat ResCase seriesRetrospectiveStructural allografts and porous cones44OKS, WOMAC
      2012Jensen et alInt OrthopRCTProspectivePorous cones vs control40KSS
      1998Whiteside et alClin Orthop Relat ResCase seriesRetrospectiveMorselized grafts63KSS
      RCT, randomized controlled trial; OKS, Oxford Knee Score; KSS, Knee Society Score; HSS, Hospital of Special Surgery; VAS, Visual Analog Scale; KOOS, Knee Injury and Osteoarthritis Outcome Score; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
      Table B2Prisma Checklist.
      Adapted from Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/.
      Section and TopicItem #Checklist ItemPage
      Title
       Title1Identify the report as a systematic review1
      Abstract
       Abstract2See the PRISMA 2020 for Abstracts checklist2, title page
      Introduction
       Rationale3Describe the rationale for the review in the context of existing knowledge4
       Objectives4Provide an explicit statement of the objective(s) or question(s) the review addresses4
      Methods
       Eligibility criteria5Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses5
       Information sources6Specify all databases, registers, websites, organizations, reference lists, and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted4
       Search strategy7Present the full search strategies for all databases, registers, and websites, including any filters and limits used25 (Appendix A)
       Selection process8Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process4, 5
       Data collection process9Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process5
       Data items10aList and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (eg, for all measures, time points, analyses), and if not, the methods used to decide which results to collect5-6
      10bList and define all other variables for which data were sought (eg, participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information5-6
       Study risk of bias assessment11Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process5
       Effect measures12Specify for each outcome the effect measure(s) (eg, risk ratio, mean difference) used in the synthesis or presentation of results6
       Synthesis methods13aDescribe the processes used to decide which studies were eligible for each synthesis (eg, tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5))6
      13bDescribe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions6
      13cDescribe any methods used to tabulate or visually display results of individual studies and syntheses6
      13dDescribe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used6
      13eDescribe any methods used to explore possible causes of heterogeneity among study results (eg, subgroup analysis, meta-regression)NA
      13fDescribe any sensitivity analyses conducted to assess robustness of the synthesized results6
       Reporting bias assessment14Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases)6
       Certainty assessment15Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome6
      Results
       Study selection16aDescribe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram7, Figure 1
      16bCite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excludedNA
       Study characteristics17Cite each included study and present its characteristics7, Table B1
       Risk of bias in studies18Present assessments of risk of bias for each included study8, 9, Figure 4
       Results of individual studies19For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), ideally using structured tables or plots8, 9 Fig. 4, Fig. 5
       Results of syntheses20aFor each synthesis, briefly summarize the characteristics and risk of bias among contributing studies8
      20bPresent results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (eg, confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect8, 9, Figures 4-6
      20cPresent results of all investigations of possible causes of heterogeneity among study resultsNA
      20dPresent results of all sensitivity analyses conducted to assess the robustness of the synthesized resultsFigure 6
       Reporting biases21Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed9
       Certainty of evidence22Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.8, 9
      Discussion
       Discussion23aProvide a general interpretation of the results in the context of other evidence10
      23bDiscuss any limitations of the evidence included in the review10, 11
      23cDiscuss any limitations of the review processes used10,11
      23dDiscuss implications of the results for practice, policy, and future research11,12
      Other information
       Registration and protocol24aProvide registration information for the review, including register name and registration number, or state that the review was not registered4
      24bIndicate where the review protocol can be accessed, or state that a protocol was not prepared4
      24cDescribe and explain any amendments to information provided at registration or in the protocolNone
       Support25Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the reviewTitle page
       Competing interests26Declare any competing interests of review authorsConflict of interest forms
       Availability of data, code and other materials27Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the reviewNone are publicly available

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