Does lucency equate to revision? A five-year retrospective review of Attune and Triathlon total knee arthroplasty

The Attune^® total knee arthroplasty system was introduced in 2013 to address lingering issues of patient dissatisfaction. However, recent literature reports concerns of early tibial tray debonding. The aim of this study was to compare the incidence of radiolucent lines, survivorship and patient reported outcome-measures between the Attune^® system and the well-established Triathlon^® system.

This retrospective database review was conducted at a single institution in Cork, Ireland. All primary Attune^® (N = 445) and Triathlon^® (N = 285) systems implanted between 2015 and 2016 were reviewed. Radiolucent lines were assessed for those with a minimum two-year radiological follow-up (Attune^® = 338; Triathlon^® = 231). X-rays were taken post op, at 6 months, 2 years and 5 years. Radiolucent lines were documented using the Modern Knee Society Radiographic System. Five-year survival was assessed using Kaplan–Meier analysis with the Log Rank method to determine statistical significance. The Oxford Knee Score and EQ-5D-5L, were collected pre-op, at 6 months, 2 years and 5 years post-operatively and compared using the Kruskal–Wallis Test.

The Attune^® had a higher proportion of radiolucent lines at the tibial tray [87.1% (54/62) vs 61.4% (27/44); p = 0.001] and at the implant–cement interface [62.9% (39/62) vs 43.2% (19/44); p = 0.02]. Conversely, the Triathlon^® had a higher proportion AT the femur [38.6% (17/44) vs 12.9% (8/62); p = 0.001] and at the cement–bone interface [56.8% (25/44) vs 37.1% (23/62); p = 0.02]. The overall frequency of radiolucent lines was similar in both the Attune^® and Triathlon^® groups [17.8%, (60/338) vs 17.7%, (41/231); p = 0.49]. There was no difference in revision-free survival analysis at 5 years (Attune^® 97.8% vs Triathlon^® 95.8%; p = 0.129). The Attune^® performed better at 5 years in the Oxford Knee Score [Attune^® = 42.6 (SD 5.2) vs Triathlon^® = 41 (SD 6.4); p = 0.001] and in the EQ-5D [Attune^® = 0.773 (SD 0.187) vs Triathlon^® = 0.729 (SD 0.218); p = 0.013]. There was no difference at 5 years in the EQ-VAS [Attune^® = 80.4 (SD 13.7) vs Triathlon^® = 78.5 (SD 15.3); p = 0.25].

The Attune^® system exhibited a higher incidence of  radiolucent lines at the tibial tray. However, this did not lead to decreased survivorship at medium term follow-up compared to the Triathlon^®. Furthermore, improvements in patient reported outcomes modestly favoured the Attune^® system.

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