Top

Clinical Orthopaedics and Related Research®

Published in:

01-05-2013 | Symposium: Special Considerations for TKA in Asian Patients

Brief Followup Report: Does High-flexion Total Knee Arthroplasty Allow Deep Flexion Safely in Asian Patients?

Authors: Hyuk-Soo Han, MD, PhD, Seung-Baik Kang, MD, PhD

Published in: Clinical Orthopaedics and Related Research® | Issue 5/2013

Abstract

Background

The long-term survivorship of TKA in Asian countries is comparable to that in Western countries. High-flexion TKA designs were introduced to improve flexion after TKA. However, several studies suggest high-flexion designs are at greater risk of femoral component loosening compared with conventional TKA designs. We previously reported a revision rate of 21% at 11 to 45 months; this report is intended as a followup to that study.

Questions/purposes

Do implant survival and function decrease with time and do high-flexion activities increase the risk of premature failure?

Methods

We prospectively followed 72 Nexgen LPS-flex fixed TKAs in 47 patients implanted by a single surgeon between March 2003 and September 2004. We determined the probability of survival using revision as an end point and compared survival between those who could and those who could not perform high-flexion activities. Minimum followup was 0.9 years (median, 6.5 years; range, 0.9–8.6 years).

Results

Twenty-five patients (33 knees) underwent revision for aseptic loosening of the femoral component at a mean of 4 years (range, 1–8 years). The probability of revision-free survival for aseptic loosening was 67% and 52% at 5 and 8 years, respectively. Eight-year cumulative survivorship was lower in patients capable of squatting, kneeling, or sitting crosslegged (31% compared with 78%). There were no differences in the pre- and postoperative mean Hospital for Special Surgery scores and maximum knee flexion degrees whether or not high-flexion activities could be achieved.

Conclusions

Overall midterm high-flexion TKA survival in our Asian cohort was lower than that of conventional and other high-flexion designs. This unusually high rate of femoral component loosening was associated with postoperative high-flexion activities.

Level of Evidence

Level IV, prospective study. See the Guidelines for Authors for a complete description of levels of evidence.

Argenson JN, Scuderi GR, Komistek RD, Scott WN, Kelly MA, Aubaniac JM. In vivo kinematic evaluation and design considerations related to high flexion in total knee arthroplasty. J Biomech. 2005;38:277–284.PubMedCrossRef

Bauman RD, Johnson DR, Menge TJ, Kim RH, Dennis DA. Can a high-flexion total knee arthroplasty relieve pain and restore function without premature failure? Clin Orthop Relat Res. 2012;470:150–158.PubMedCrossRef

Bellemans J, Banks S, Victor J, Vandenneucker H, Moemans A. Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty. Influence of posterior condylar offset. J Bone Joint Surg Br. 2002;84:50–53.PubMedCrossRef

Bin SI, Nam TS. Early results of high-flex total knee arthroplasty: comparison study at 1 year after surgery. Knee Surg Sports Traumatol Arthrosc. 2007;15:350–355.PubMedCrossRef

Bollars P, Luyckx JP, Innocenti B, Labey L, Victor J, Bellemans J. Femoral component loosening in high-flexion total knee replacement: an in vitro comparison of high-flexion versus conventional designs. J Bone Joint Surg Br. 2011;93:1355–1361.PubMed

Cho SD, Youm YS, Park KB. Three- to six-year follow-up results after high-flexion total knee arthroplasty: can we allow passive deep knee bending? Knee Surg Sports Traumatol Arthrosc. 2011;19:899–903.PubMedCrossRef

Coggon D, Croft P, Kellingray S, Barrett D, McLaren M, Cooper C. Occupational physical activities and osteoarthritis of the knee. Arthritis Rheum. 2000;43:1443–1449.PubMedCrossRef

Coughlin KM, Incavo SJ, Doohen RR, Gamada K, Banks S, Beynnon BD. Kneeling kinematics after total knee arthroplasty: anterior-posterior contact position of a standard and a high-flex tibial insert design. J Arthroplasty. 2007;22:160–165.PubMedCrossRef

Endres S, Wilke A. High flexion total knee arthroplasty—mid-term follow up of 5 years. Open Orthop J. 2011;5:138–142.PubMedCrossRef

10.

Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res. 1989;248:9–12.PubMed

11.

Felson DT, Hannan MT, Naimark A, Berkeley J, Gordon G, Wilson PW, Anderson J. Occupational physical demands, knee bending, and knee osteoarthritis: results from the Framingham Study. J Rheumatol. 1991;18:1587–1592.PubMed

12.

Guo L, Yang L, Briard JL, Duan XJ, Wang FY. Long-term survival analysis of posterior cruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2012;20:1760–1765.PubMedCrossRef

13.

Han HS, Kang SB, Yoon KS. High incidence of loosening of the femoral component in legacy posterior stabilised-flex total knee replacement. J Bone Joint Surg Br. 2007;89:1457–1461.PubMedCrossRef

14.

Hefzy MS, Kelly BP, Cooke TD, al-Baddah AM, Harrison L. Knee kinematics in-vivo of kneeling in deep flexion examined by bi-planar radiographs. Biomed Sci Instrum. 1997;33:453–458.PubMed

15.

Huang CH, Ma HM, Lee YM, Ho FY. Long-term results of low contact stress mobile-bearing total knee replacements. Clin Orthop Relat Res. 2003;416:265–270.PubMedCrossRef

16.

Huang HT, Su JY, Wang GJ. The early results of high-flex total knee arthroplasty: a minimum of 2 years of follow-up. J Arthroplasty. 2005;20:674–679.PubMedCrossRef

17.

Kim TH, Lee DH, Bin SI. The NexGen LPS-flex to the knee prosthesis at a minimum of three years. J Bone Joint Surg Br. 2008;90:1304–1310.PubMedCrossRef

18.

Kim YH, Sohn KS, Kim JS. Range of motion of standard and high-flexion posterior stabilized total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am. 2005;87:1470–1475.PubMedCrossRef

19.

Kim YH, Yoon SH, Kim JS. The long-term results of simultaneous fixed-bearing and mobile-bearing total knee replacements performed in the same patient. J Bone Joint Surg Br. 2007;89:1317–1323.PubMedCrossRef

20.

Kurosaka M, Yoshiya S, Mizuno K, Yamamoto T. Maximizing flexion after total knee arthroplasty: the need and the pitfalls. J Arthroplasty. 2002;17:59–62.PubMedCrossRef

21.

Li PL, Zamora J, Bentley G. The results at ten years of the Insall-Burstein II total knee replacement. Clinical, radiological and survivorship studies. J Bone Joint Surg Br. 1999;81:647–653.PubMedCrossRef

22.

Luo SX, Su W, Zhao JM, Sha K, Wei QJ, Li XF. High-flexion vs conventional prostheses total knee arthroplasty: a meta-analysis. J Arthroplasty. 2011;26:847–854.PubMedCrossRef

23.

Ma HM, Lu YC, Ho FY, Huang CH. Long-term results of total condylar knee arthroplasty. J Arthroplasty. 2005;20:580–584.PubMedCrossRef

24.

Malik A, Salas A, Ben Ari J, Ma Y, Gonzalez Della Valle A. Range of motion and function are similar in patients undergoing TKA with posterior stabilised and high-flexion inserts. Int Orthop. 2010;34:965–972.PubMedCrossRef

25.

McCalden RW, MacDonald SJ, Bourne RB, Marr JT. A randomized controlled trial comparing ‘high-flex’ vs ‘standard’ posterior cruciate substituting polyethylene tibial inserts in total knee arthroplasty. J Arthroplasty. 2009;24:33–38.PubMedCrossRef

26.

Meftah M, Ranawat AS, Ranawat CS. Safety and efficacy of a rotating-platform, high-flexion knee design three- to five-year follow-up. J Arthroplasty. 2012;27:201–206.PubMedCrossRef

27.

Mehin R, Burnett RS, Brasher PM. Does the new generation of high-flex knee prostheses improve the post-operative range of movement? A meta-analysis. J Bone Joint Surg Br. 2010;92:1429–1434.PubMedCrossRef

28.

Most E, Sultan PG, Park SE, Papannagari R, Li G. Tibiofemoral contact behavior is improved in high-flexion cruciate retaining TKA. Clin Orthop Relat Res. 2006;452:59–64.PubMedCrossRef

29.

Mulholland SJ, Wyss UP. Activities of daily living in non-Western cultures: range of motion requirements for hip and knee joint implants. Int J Rehabil Res. 2001;24:191–198.PubMedCrossRef

30.

Nagura T, Matsumoto H, Kiriyama Y, Chaudhari A, Andriacchi TP. Tibiofemoral joint contact force in deep knee flexion and its consideration in knee osteoarthritis and joint replacement. J Appl Biomech. 2006;22:305–313.PubMed

31.

Nakamura S, Takagi H, Asano T, Nakagawa Y, Kobayashi M, Nakamura T. Fluoroscopic and computed tomographic analysis of knee kinematics during very deep flexion after total knee arthroplasty. J Arthroplasty. 2010;25:486–491.PubMedCrossRef

32.

Ng FY, Wong HL, Yau WP, Chiu KY, Tang WM. Comparison of range of motion after standard and high-flexion posterior stabilised total knee replacement. Int Orthop. 2008;32:795–798.PubMedCrossRef

33.

Nutton RW, van der Linden ML, Rowe PJ, Gaston P, Wade FA. A prospective randomised double-blind study of functional outcome and range of flexion following total knee replacement with the NexGen standard and high flexion components. J Bone Joint Surg Br. 2008;90:37–42.PubMedCrossRef

34.

Park KK, Chang CB, Kang YG, Seong SC, Kim TK. Correlation of maximum flexion with clinical outcome after total knee replacement in Asian patients. J Bone Joint Surg Br. 2007;89:604–608.PubMedCrossRef

35.

Scuderi GR, Hedden DR, Maltry JA, Traina SM, Sheinkop MB, Hartzband MA. Early clinical results of a high-flexion, posterior-stabilized, mobile-bearing total knee arthroplasty: a US investigational device exemption trial. J Arthroplasty. 2012;27:421–429.PubMedCrossRef

36.

Seon JK, Song EK, Lee JY. Comparison of range of motion of high-flexion prosthesis and mobile-bearing prosthesis in total knee arthroplasty. Orthopedics. 2005;28:s1247–1250.PubMed

37.

Sharma A, Komistek RD, Scuderi GR, Cates HE Jr. High-flexion TKA designs: what are their in vivo contact mechanics? Clin Orthop Relat Res. 2007;464:117–126.PubMed

38.

Sultan PG, Most E, Schule S, Li G, Rubash HE. Optimizing flexion after total knee arthroplasty: advances in prosthetic design. Clin Orthop Relat Res. 2003;416:167–173.PubMedCrossRef

39.

Sumino T, Gadikota HR, Varadarajan KM, Kwon YM, Rubash HE, Li G. Do high flexion posterior stabilised total knee arthroplasty designs increase knee flexion? A meta analysis. Int Orthop. 2011;35:1309–1319.PubMedCrossRef

40.

Tanavalee A, Ngarmukos S, Tantavisut S, Limtrakul A. High-flexion TKA in patients with a minimum of 120 degrees of pre-operative knee flexion: outcomes at six years of follow-up. Int Orthop. 2011;35:1321–1326.PubMedCrossRef

41.

Thambyah A, Goh JC, De SD. Contact stresses in the knee joint in deep flexion. Med Eng Phys. 2005;27:329–335.PubMedCrossRef

42.

Weeden SH, Schmidt R. A randomized, prospective study of primary total knee components designed for increased flexion. J Arthroplasty. 2007;22:349–352.PubMedCrossRef

43.

Weiss JM, Noble PC, Conditt MA, Kohl HW, Roberts S, Cook KF, Gordon MJ, Mathis KB. What functional activities are important to patients with knee replacements? Clin Orthop Relat Res. 2002;404:172–188.PubMedCrossRef

44.

Zhang Y, Hunter DJ, Nevitt MC, Xu L, Niu J, Lui LY, Yu W, Aliabadi P, Felson DT. Association of squatting with increased prevalence of radiographic tibiofemoral knee osteoarthritis: the Beijing Osteoarthritis Study. Arthritis Rheum. 2004;50:1187–1192.PubMedCrossRef

Title: Brief Followup Report: Does High-flexion Total Knee Arthroplasty Allow Deep Flexion Safely in Asian Patients?
Authors: Hyuk-Soo Han, MD, PhD
Seung-Baik Kang, MD, PhD
Publication date: 01-05-2013
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 5/2013
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-012-2628-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Brief Followup Report: Does High-flexion Total Knee Arthroplasty Allow Deep Flexion Safely in Asian Patients?

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 5/2013

Does Femoral Rotation Influence Anteroposterior Alpha Angle, Lateral Center-edge Angle, and Medial Proximal Femoral Angle? A Pilot Study

Editor’s Spotlight/Take 5: Comparative Responsiveness and Minimal Clinically Important Differences for Idiopathic Ulnar Impaction Syndrome (DOI 10.1007/s11999-013-2843-8)

Endoscopic Carpal Tunnel Release Is Preferred Over Mini-open Despite Similar Outcome: A Randomized Trial

Contact Patch to Rim Distance Predicts Metal Ion Levels in Hip Resurfacing

A Long Femoral Stem Is Not Always Required in Hip Arthroplasty for Patients With Proximal Femur Metastases

Editorial: Duplicate Submission and Dual Publication: What Is So Wrong With Them?