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Unveiling the link: highly porous tantalum-augmented implants and periprosthetic joint infection in revision total knee arthroplasty—a systematic review and meta-analysis

BMC Musculoskeletal Disorders volume 26, Article number: 408 (2025) Cite this article

Abstract

Background

The trend of the literature suggests that tantalum (Ta) may possess antibacterial properties. However, no consensus has been reached on Ta's preventive role in periprosthetic joint infection (PJI) in patients undergoing revision total knee arthroplasty (rTKA).

Question

What is the PJI incidence rate after rTKA using Ta-augmented implants for both septic and all-cause revision reasons? Is there a difference in the PJI rate following rTKA performed using Ta-augmented implants compared to non-Ta implants?

Methods

Using 5 major databases, the authors searched for studies reporting the rate of PJIs following rTKA using Ta-augmented implants until January 2022. The PJI rates for the Ta group were pooled, compared to the control group, and presented as odds ratios (OR) and 95% confidence intervals (CI) using forest plots.

Results

Thirty eligible studies involving 881 knees were included. The overall PJI rate following rTKA using Ta-augmented implants was 8.1% (CI = 6.6%-9.9%). Specifically, in cases of septic revision, the infection rate was 15.7% (95% CI = 11.7%-20.7%). The comparative analysis indicated a similar PJI rate between the Ta- augmented and non-Ta group across 3 studies, which was found to be similar (OR = 0.52, 95% CI = 0.13–2.0, P = 0.35).

Conclusion

PJI poses a significant risk following both aseptic and septic revision rTKA, even when Ta-augmented implants were administrated. The rate of PJI after rTKA was similar for Ta- augmented implants and non-Ta implants. Further rigorous studies with a high level of evidence are essential to definitively determine the potential impact of Ta derivatives on infection rates following rTKA, particularly in septic revision.

Level of evidence

IV.

Peer Review reports

Introduction

Periprosthetic joint infection (PJI) is a catastrophic complication following total joint arthroplasty (TJA) and continues to be a challenge for orthopedic surgeons. PJIs occur in approximately 2% of primary total knee arthroplasty (TKA) procedures [1,2,3,4]. There is a higher incidence of PJI in revision TKAs (rTKAs), as high as 8% within two years [5]. PJI recurrence is also high in septic cases following two-stage rTJA (7–33%), complicating the situation [6,7,8,9,10].

Trabecular Metal (TM) implants, which consist of a porous carbon structure covered by a porous Tantalum (Ta) covering, are becoming increasingly popular in complex reconstructive procedures in cases of massive bone loss, such as rTKA [11, 12]. Ta possesses high porosity, which facilitates osteointegration, and its elastic properties are similar to trabecular bone, minimizing stress shielding and reducing micromotion due to superior frictional characteristics [13]. Many studies claim that using highly porous Ta is associated with a lower incidence of PJIs in patients undergoing rTJA compared with other materials [14,15,16,17,18]. Based on laboratory studies, pure Ta is less likely to be affected by Staphylococcus aureus adhesion than materials frequently used for orthopedic implants, such as titanium alloys [16]. TM has a porous surface resembling dense cancellous bone, which allows vascularized soft tissue to proliferate on the surfaces while maintaining a high level of attachment strength [19, 20]. TM-conditioned media also increased leukocytes'phagocytosis and chemotactic response [17]. However, Ta's innate antimicrobial properties and clinical efficacy remain unclear [20, 21].

"International Consensus Meeting (ICM) 2018"asked members about the efficacy of highly porous Ta in preventing SSIs and PJIs in patients undergoing revision arthroplasty, especially in treating PJI (PJI recurrence) [11, 22]. There has been no consensus on this challenging question, which remains controversial [23]. In this context, we aim to address the following questions through the current systematic review and meta-analysis: 1. What is the incidence of PJI following rTKA using Ta- augmented implants? 2. Is there a difference in the rate of PJI after rTKA performed with Ta- augmented implants compared with the lack thereof? 3. Considering only rTKA for septic reasons, are Ta-augmented implants associated with a reduced risk of postoperative PJI?

Methods

Population (P), Intervention (I), Comparison (C), and Outcome (O)

P: Patients undergoing rTKA

I: Using porous Ta- augmented component(s)

C: Using Non-Ta implants

O: Periprosthetic joint infection (PJI)

Screening and search strategy

Our study was performed under PRISMA guidelines- Preferred Reporting Items for Systematic Reviews and Meta-Analyses [24]. The current review has been registered through"The International Prospective Register of Systematic Reviews"(PROSPERO, registration ID: CRD42021268518, available at https://www.crd.york.ac.uk/PROSPERO). The"Tehran University of Medical Sciences"institutional review board has approved the study (Approval ID: IR.TUMS.MEDICINE.REC.1400.1333).

We searched Medline, Embase, Scopus, Web of Science, and Cochrane Library using a variety of keywords as well as database-specific heading vocabulary until January 2022, including"Tantalum"or"Trabecular metal"AND"Infection"or"PJI"AND"Total knee arthroplasty"or"TKA"or"revision arthroplasty". The search query has been modified per each database's search policy. In addition, a hand search of relevant bibliographies was conducted.

Covidence's online systematic review software was used to import all records (https://www.covidence.org). In 2 steps of title/abstract screening and full-text screening, 2 independent reviewers (P.R and R.M) independently assessed all imported articles for eligibility according to the distinct inclusion/exclusion criteria. A third reviewer (SMJ.M) was consulted to resolve conflicts in this and other sections.

Criteria for inclusion and exclusion

The original studies reporting the incidence of PJI following rTKA using Ta- augmented materials were included in the current study. Our exclusion criteria included 1) studies that excluded PJIs, 2) non-human studies, 3) non-English literature, 4) reviews, congress abstracts, commentaries, and book chapters, and 5) less than 3-month follow-ups for PJI incidence.

Assessment of study quality

The quality of the included studies was assessed using the Newcastle Ottawa Scale (NOS) [25]. Selection, comparability, and outcome assessment were the 3 qualifying domains. The total points ranged from 0 to 9, with higher scores indicating higher quality. Studies with a score of 7 or more are considered high-quality, while those with a score of 4 or less are considered low-quality.

Extraction and collection of data

Two reviewers (P.M. and M.ME) extracted data from eligible retrieved articles and organized them into a pre-designed table. The following variables were extracted: primary author's name, year of publication, country, study design, follow-up period, study groups and population, sex, age, indications for revision, re-revision rate, PJI rate, PJI recurrence rate in septic revision cases, and details regarding Ta- augmented materials.

Statistical analysis and data synthesis

Eligible retrieved data were meta-analyzed using Comprehensive Meta-Analysis Software (version 3). The pooled prevalence of PJI following rTKA with Ta was determined. The odds ratio (OR) was used to compare the outcome of the Ta- augmented materials with the control groups. In addition, the incidence of PJI following rTKA to treat PJI was also determined (septic revisions). The funnel plot and Egger test were also used to evaluate publication bias. We applied the I2 test to identify heterogeneity among eligible studies. We assumed that I2 values of 25%, 50%, and 75% would result in low, moderate, and high heterogeneity, respectively [26]. Random-effect models were used when the I2 exceeded 50%.

We performed a leave-one-out meta-analysis (sensitivity analysis) to identify the sources of heterogeneity. We excluded studies containing less than 10 persons as the denominator of prevalence from our analysis. Whenever we are faced with the same authors from the same population presenting more complete results, the former study is also excluded from the analysis. A significant P-value was determined to be < 0.05.

Results

Search results and demographic features

Figure 1 illustrates the process of identifying articles for inclusion. Our comprehensive search strategy and manual search investigation identified 3633 publications, of which 30 met our eligibility criteria [15, 27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55]. A summary of the key characteristics of the eligible studies is presented in Table 1. A total of 30 rTKA studies included 881 knees and consisted of 4 case series, 2 prospective, and 24 retrospective cohort studies. The mean follow-up period ranged from 17 to 126.5 months.

Fig. 1
figure 1

PRISMA diagram of the screening process

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Table 1 Summary of the characteristics and outcomes of the included studies
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Quality assessment

Based on quality assessment using NOS, 9 studies (30%) were rated as high quality, 16 (53.3%) as medium quality, and 5 (16.7%) as low quality (Table 2). The mean (SD) NOS score is measured at 5.7 ± 1.8, and the quality of the studies is considered medium to high overall.

Table 2 Quality assessment result based on Newcastle–Ottawa Scale (NOS)
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PJI rate after all-cause rTKA

Qualitative synthesis

According to 30 studies investigating the infection rate following rTKA using Ta implants, the PJI rate ranges from 0 to 13%. Three eligible case–control articles compared the rate of PJI between the Ta and the control group [27, 35, 38], among which 2 reported recurrences of PJI in septic revision cases. In the Ta- augmented implants and control groups, PJI rates ranged from 0–6.1% and 1.1–10.2%, respectively [27].

A prospective study by Bedard et al. evaluated the limb alignment and stem positioning of 115 patients who underwent revision TKA using uncemented stems (21 Ta cones and 94 without cones). There were no revisions required, but one patient from the non-Ta cone group required arthrodesis after recurrent PJI (PJI: 0 vs. 1.1%, P > 0.05). A 9-year follow-up study conducted by Sandiford et al. revealed no significant difference between TM Cones (n = 14) and Femoral Head Allografts (n = 30) in the management of substantial structural defects of the femur and tibia during rTKA (PJI: 0 vs. 3%, P > 0.05). The Ta group did not experience any PJIs. A study by Bohl et al. compared porous Ta metaphyseal cones with traditional hybrid stem fixation (n = 49) to address bone defects following rTKA with 3.5 years of follow-up. PJI rates were not significantly different between groups (3 vs. 5% PJI patients, P > 0.05). However, considering the study's small population size and low statistical power, it is prudent to interpret the results cautiously.

Quantitative synthesis

Table 3 summarizes the results of the quantitative syntheses. Meta-analysis showed a pooled rate of 8.1% (95% CI = 6.6%− 9.9%) after all-cause rTKA with Ta implant (Fig. 2). The studies had low heterogeneity (I2 = 0.0, Q/df = 0.6). Egger's test and funnel plots revealed publication bias among the studies (Egger's P = 0.008) (Fig. 3).

Table 3 Summary of quantitative synthesis
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Fig. 2
figure 2

Meta-analysis of PJI rate after all-cause rTKA using Ta-augmented implant

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Fig. 3
figure 3

Funnel plot showing publication bias

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The rate of PJI between Ta- augmented and non-Ta groups (three comparative studies) was similar (OR = 0.52, 95% CI = 0.13–2.0, P = 0.35) (Fig. 4). The studies had low heterogeneity (I2 = 0.0, Q/df = 0.27), and no publication bias was detected (Egger's P = 0.32). The NOS assessment indicates that none of these studies is of low quality. The sensitivity analysis indicated no change in the result when one study was omitted (P > 0.05).

Fig. 4
figure 4

PJI rate is similar between the Ta- augmented and the non-Ta groups for all-cause rTKA

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PJI rate after rTKA in septic cases (re-infection)

Seventeen studies were found to report the recurrence of PJI in septic revision cases [6, 15, 28, 31,32,33, 36, 42, 46, 50, 53, 56,57,58], of which 2 studies compared the latter incidence between Ta cones and lack thereof [27, 38]. The rate of PJI after rTKA in septic revisions (re-infection) ranged between 0 to 75%. Re-infection rates have been reported to be 16.6% and 8.3% for the Ta-cones compared to non-Ta, respectively, in the Bohl et al. study and 0 vs. 3.8% in the Bedard et al. study [27].

Quantitative synthesis

Meta-analysis of nine studies revealed that the pooled rate of PJI after rTKA with Ta in septic cases (re-infection) was 15.7% (95% CI = 11.7%− 20.7%) (Fig. 5) (Table 3). The studies had moderate heterogeneity (I2 = 35.5, Q/df = 1.5), and no publication bias was detected (Egger's P = 0.44). Since there were few studies with a comparison group, no analysis was performed to compare the PJI rate after rTKA in septic cases between the Ta- augmented and the non-Ta group.

Fig. 5
figure 5

Pooled rate of infection after rTKA with Ta- augmented in septic revisions (re-infection)

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Summary of representative studies

According to Chalmers et al. [29], PJI indications for rTKA were an independent risk factor for reoperation (HR = 4.2, P = 0.002), and Abdelaziz et al. The study also found that it has a significant effect on cone revision following index surgery (P < 0.001) [36]. This necessitates paying attention to septic revisions and considering preventive measures to minimize re-infection risk.

In Abdelaziz et al.'s study [36], 72 patients underwent one-stage rTKA for PJI using porous Ta cones to reconstruct extensive bone loss. 15 patients (21%) underwent re-revision surgery, of whom eight (11.1%) were diagnosed with PJI. Most of the reinfections were caused by new pathogens (6 out of 8), and all had been previously diagnosed with PJI. Failure rates for tibial and femoral cones were not significantly different (P = 0.6). However, previous septic revision significantly increased the risk of failure (P < 0.001). According to their findings, one-stage rTKA with Ta metaphyseal cones provided satisfactory cone-related and infection-free survival rates with acceptable functional outcomes following PJI with severe bone loss.

Burastero et al. [28] retrospectively evaluated 60 patients who underwent two-staged rTKA for PJI and used 94 Ta cones to manage massive bone defects. After 44 months of follow-up, there was no evidence of loosening or migration of any cones. A total of 2 failures (3.3%) occurred following the recurrence of PJI, but no mechanical failures related to the cone were reported, with a survival rate of 97.8%. This study demonstrated that Ta metaphyseal cones effectively treat metaphyseal defects following two-stage rTKA for PJI.

A retrospective study by Fosco et al. [58] examined 11 knees (12 cones) undergoing rTKA that harbored type 2B/3 Engh bone defects. After 39.8 months of follow-up, there was no evidence of re-infection. A radiological assessment revealed no evidence of aseptic loosening or component migration. In all cases, a lack of re-infection or aseptic loosening supports using Ta metaphyseal cones for rTKA with large amounts of bone defects. In addition, they exclude any possibility that TM cones are related to the recurrence of infection.

In Long et al.'s study [53], PJI recurrence rates in septic revision cases were as high as 67%. A retrospective review of 16 cases of rTKA performed using porous Ta tibial cones for bone defects was conducted with a mean follow-up of 31 months. The study included three cases of staged re-implantation for PJI, of which 2 (67%) experienced recurrent sepsis, which required the removal of an adequately fixed cone. There is no evidence that porous Ta cone use is responsible for the high re-infection rate (2/3) in this complex group of patients. They believe porous cones are a superior alternative to placing large metal augments or large amounts of dead bone.

Martino et al. [42] retrospectively evaluated the clinical outcomes of 18 patients (18 knees) who underwent rTKA with 26 Ta cone applications (13 femoral and 13 tibial). Reoperations due to recurrent PJI (2 out of 13, 15.4%) were recorded after a mean of 6 years in these 2 cones despite good osseointegration. Radiographs taken during the last 6 years showed no evidence of migration or loosening of the implants.

Discussion

The major finding of this study was that the overall rate of postoperative PJI following rTKA with Ta-augmented material was 8.1%. In contrast, the rate of PJI was comparable between Ta-augmented and non-Ta groups (P > 0.05). When rTJA was performed as part of a septic revision, the infection rate was 15.7% for rTKAs. The PJI rates after rTKA (8.1%) were similar to those reported in the Divano et al. systematic review of rTKA with Ta cones (7.1%) [59]. The articles also generally agreed that Ta-augmented implants are an effective method of treating bone defects following rTKA for septic and aseptic reasons and have a high survival rate.

Porous Ta coatings possess several advantages, including reduced stress shielding, decreased micromotion, improved osteointegration, and prevention of bone resorption [11]. Though a growing body of literature asserts that Ta has intrinsic antimicrobial characteristics and bioactive properties, there is a lack of consensus. Recent trend literature has raised doubts regarding previously published literature [11, 16, 60, 61].

Several laboratory studies have revealed that the adhesion potency of S. aureus to pure Ta is lower than that of orthopedic implant materials, and Ta may inhibit S. aureus proliferation [16, 20]. Additionally, high levels of human leukocyte activation and increased releases of cytokines are expected when Ta-conditioned media is incubated [17]. In this regard, activated leukocytes on the surface of TM materials might facilitate local host defense [17]. However, little evidence in vivo supports the intrinsic antimicrobial properties of Ta. [20, 21]. Harrison et al. reported that Ta does not have inherent anti-biofilm or antimicrobial properties against S. epidermidis and S. aureus compared to titanium [21].

Ta cone application during rTKA has been demonstrated to be a feasible option in severe metaphyseal defects, providing an excellent outcome regarding implant stability and survival [62]. However, the definitive indication for septic revision surgery, particularly for extensive bone loss, is unknown. The 2018 International Consensus Meeting on Musculoskeletal Infection has also failed to draw a conclusive conclusion regarding the effectiveness of Ta augments in preventing re-infection following a one-stage exchange procedure [11]. In revision hip arthroplasty clinical settings, Tokarski et al. showed a trend toward a lower infection rate in the Ta cup group than in the Ti cup group (2.9% vs. 5%, P > 0.05). Considering only septic revisions, the PJI rate in the Ta group was significantly lower (3.1% vs. 17.5%, P < 0.05). In contrast, several studies have not found significant differences between Ta and non-Ta implants [22, 63,64,65,66]. The use of cones is widely practiced in rTKA, with reported benefits including reliable osseointegration with bone, the ability to fill defects, and effective stress transfer. However, the widespread metaphyseal cone application has been questioned, as it adds complexity to achieve implant stability and poses substantial costs of nearly $4,000 per cone [27, 28].

Despite promising outcomes, some investigations have raised concerns regarding the distinct Ta-related disadvantage. Ta implants require extreme removal efforts when indicated for circumstances such as recalcitrant PJIs in which there may be no bone stock at the end of the procedure. The removal of Ta implants faces a potential challenge, as the literature lacks data regarding extracting porous Ta cones [15, 51].

The current study has several limitations. Since several of the eligible retrieved articles had a moderate level of evidence and quality, and most of them were retrospective studies with small sample sizes, a considerable bias may threaten the study's conclusion. It is recommended that longitudinal randomized clinical trials (RCTs) be conducted to investigate the anti-infection properties of Ta administered in the context of rTKA. However, the overall PJI rate is relatively low, making conducting either an RCT or a prospective cohort study challenging. Moreover, several studies did not distinguish between aseptic and septic reasons for the revision. As another limitation, most studies evaluated only patients suffering from extensive bone loss during revision surgery, and these results should only be interpreted for this complex subset of patients. We also acknowledge the limited number of eligible studies distinguishing reconstruction solely using Ta-coated implants vs. lack thereof. The characteristics of mixed implants may inherently affect the findings for isolating Ta's effects. Hence, the definitive interpretation remains debatable. While our findings suggest that adding Ta is not associated with a higher incidence of prosthetic joint infection (PJI), they do not definitively determine Ta’s role in PJI prevention.

Conclusions

PJI following all-cause and septic-cause rTKA is a serious complication and is not uncommon among patients, even those using Ta-coated materials. The rate of PJI after rTKA was similar for Ta-coated materials and lack thereof. The current study confirms that adding Ta does not decrease the risk of PJI following rTKA. Future investigations are warranted to establish the significance of Ta's preventive role in PJI.

Data availability

Not applicable.

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Acknowledgements

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The International Prospective Register of Systematic Reviews (PROSPERO) registration ID

CRD42021268518.

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Authors and Affiliations

  1. Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran

    Peyman Mirghaderi, Mohammad Mirahmadi Eraghi, Reza Mirghaderi & Payman Rahimzadeh

  2. Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran

    Peyman Mirghaderi, Mohammad Mirahmadi Eraghi, Reza Mirghaderi, Payman Rahimzadeh & Seyed Mohammad Javad Mortazavi

  3. Student Research Committee, School of Medicine, Islamic Azad University, Qeshm International Branch, Qeshm, Iran

    Mohammad Mirahmadi Eraghi

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Contributions

“P. Mirghaderi and SMJ. Mortazavi contributed to the study's conception and design. P. Rahimzadeh and R. Mirghaderi did the screening, table design, and first draft of the manuscript. P. Mirghaderi and M. Mirahmadi Eraghi analyzed the data and extracted data. Supervising, editing, and introducing the concept were performed by SMJ. Mortazavi. All authors commented on previous versions of the manuscript and revised them. All authors read and approved the final manuscript.”

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Correspondence to Seyed Mohammad Javad Mortazavi.

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The study was declared to be of no ethical concern by the university's ethics committee (Approval code: IR.TUMS.MEDICINE.REC.1400.1333).

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Mirghaderi, P., Eraghi, M.M., Mirghaderi, R. et al. Unveiling the link: highly porous tantalum-augmented implants and periprosthetic joint infection in revision total knee arthroplasty—a systematic review and meta-analysis. BMC Musculoskelet Disord 26, 408 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08640-w

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Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

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