Clinical Orthopaedics and Related Research®

, Volume 471, Issue 5, pp 1504–1511

High-flexion Prosthesis Improves Function of TKA in Asian Patients Without Decreasing Early Survivorship

  • Bum-Sik Lee
  • Jong-Won Chung
  • Jong-Min Kim
  • Kyung-Ah Kim
  • Seong-Il Bin
Symposium: Special Considerations for TKA in Asian Patients



Two previous studies recently raised the possibility of a high risk of early femoral components loosening with high-flexion (HF) prostheses in Asian populations and suggested that the high failure rate of HF TKAs was associated with HF ability. However, these findings are controversial given other studies reporting a low incidence of aseptic failures in HF prostheses.


We therefore determined (1) the rate of achieving postoperative HF after HF TKA; (2) whether the aseptic loosening rate of HF prostheses is high; and (3) whether the survivorship was worsened in patients who achieved postoperative deep knee flexion in our cohort of Korean patients.


We retrospectively reviewed 488 patients who had 698 primary TKAs using the NexGen® Legacy Posterior-Stabilized Flex system implanted from 2003 to 2010. There were 40 men and 448 women with a mean age of 68 years. We obtained Hospital for Special Surgery scores, maximal flexion, and radiographs. The minimum followup for functional and radiographic evaluations was 2 years (median, 4.8 years; range, 2–8.7 years). We performed a survival analysis on all patients for aseptic loosening.


Three hundred sixty knees (52%) could achieve ≥ 135° maximum flexion. Six of the 698 knees (0.9%) developed aseptic loosening (three femoral and three tibial). The survival at 5 years for aseptic loosening was 99.1%. The overall survival for aseptic failure did not differ between knees that achieved HF and those that did not.


We observed a low incidence of early aseptic loosening of HF designs in this series. Our findings suggest HF TKAs have high survival in Asian patients at 5 years although half of the patients attained maximum flexion more than 135° postoperatively.

Level of Evidence

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


  1. 1.
    Ahmed I, Gray AC, van der Linden M, Nutton R. Range of flexion after primary TKA: the effect of soft tissue release and implant design. Orthopedics. 2009;32:811.PubMedGoogle Scholar
  2. 2.
    Bach CM, Biedermann R, Goebel G, Mayer E, Rachbauer F. Reproducible assessment of radiolucent lines in total knee arthroplasty. Clin Orthop Relat Res. 2005;434:183–188.PubMedCrossRefGoogle Scholar
  3. 3.
    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.PubMedCrossRefGoogle Scholar
  4. 4.
    Bertin KC. Cruciate-retaining total knee arthroplasty at 5 to 7 years followup. Clin Orthop Relat Res. 2005;436:177–183.PubMedCrossRefGoogle Scholar
  5. 5.
    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.PubMedCrossRefGoogle Scholar
  6. 6.
    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.PubMedGoogle Scholar
  7. 7.
    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.PubMedCrossRefGoogle Scholar
  8. 8.
    Choi WC, Lee S, Seong SC, Jung JH, Lee MC. Comparison between standard and high-flexion posterior-stabilized rotating-platform mobile-bearing total knee arthroplasties: a randomized controlled study. J Bone Joint Surg Am. 2010;92:2634–2642.PubMedCrossRefGoogle Scholar
  9. 9.
    D’Lima DD, Steklov N, Fregly BJ, Banks SA, Colwell CW Jr. In vivo contact stresses during activities of daily living after knee arthroplasty. J Orthop Res. 2008;26:1549–1555.PubMedCrossRefGoogle Scholar
  10. 10.
    Dalury DF, Gonzales RA, Adams MJ, Gruen TA, Trier K. Midterm results with the PFC Sigma total knee arthroplasty system. J Arthroplasty. 2008;23:175–181.PubMedCrossRefGoogle Scholar
  11. 11.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.PubMedCrossRefGoogle Scholar
  12. 12.
    Dobbs HS. Survivorship of total hip replacements. J Bone Joint Surg Br. 1980;62:168–173.PubMedGoogle Scholar
  13. 13.
    Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res. 1989;248:9–12.PubMedGoogle Scholar
  14. 14.
    R, Tso P, Davey JR, Mahomed NN. High-flexion implants in primary total knee arthroplasty: a meta-analysis. Knee. 2009;16:14–17.Google Scholar
  15. 15.
    Gonzalez MH, Mekhail AO. The failed total knee arthroplasty: evaluation and etiology. J Am Acad Orthop Surg. 2004;12:436–446.PubMedGoogle Scholar
  16. 16.
    Gupta SK, Ranawat AS, Shah V, Zikria BA, Zikria JF, Ranawat CS. The PFC Sigma RP-F TKA designed for improved performance: a matched-pair study. Orthopedics. 2006;29:S49–52.PubMedGoogle Scholar
  17. 17.
    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.PubMedCrossRefGoogle Scholar
  18. 18.
    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.PubMedCrossRefGoogle Scholar
  19. 19.
    Insall JN, Ranawat CS, Aglietti P, Shine J. A comparison of four models of total knee-replacement prostheses. J Bone Joint Surg Am. 1976;58:754–765.PubMedGoogle Scholar
  20. 20.
    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.PubMedCrossRefGoogle Scholar
  21. 21.
    Kim TK, Chang CB, Kang YG, Kim SJ, Seong SC. Causes and predictors of patient’s dissatisfaction after uncomplicated total knee arthroplasty. J Arthroplasty. 2009;24:263–271.PubMedCrossRefGoogle Scholar
  22. 22.
    Kim TK, Kwon SK, Kang YG, Chang CB, Seong SC. Functional disabilities and satisfaction after total knee arthroplasty in female Asian patients. J Arthroplasty. 2010;25:458–464.PubMedCrossRefGoogle Scholar
  23. 23.
    Kim TW, Park SH, Suh JT. Comparison of mobile-bearing and fixed-bearing designs in high flexion total knee arthroplasty: using a navigation system. Knee Surg Relat Res. 2012;24:25–33.PubMedCrossRefGoogle Scholar
  24. 24.
    Kim YH, Choi Y, Kim JS. Comparison of a standard and a gender-specific posterior cruciate-substituting high-flexion knee prosthesis: a prospective, randomized, short-term outcome study. J Bone Joint Surg Am. 2010;92:1911–1920.PubMedCrossRefGoogle Scholar
  25. 25.
    Kim YH, Choi Y, Kwon OR, Kim JS. Functional outcome and range of motion of high-flexion posterior cruciate-retaining and high-flexion posterior cruciate-substituting total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am. 2009;91:753–760.PubMedCrossRefGoogle Scholar
  26. 26.
    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.PubMedCrossRefGoogle Scholar
  27. 27.
    King TV, Scott RD. Femoral component loosening in total knee arthroplasty. Clin Orthop Relat Res. 1985;194:285–290.PubMedGoogle Scholar
  28. 28.
    Kotani A, Yonekura A, Bourne RB. Factors influencing range of motion after contemporary total knee arthroplasty. J Arthroplasty. 2005;20:850–856.PubMedCrossRefGoogle Scholar
  29. 29.
    Lee BS, Lee SJ, Kim JM, Lee DH, Cha EJ, Bin SI. No impact of severe varus deformity on clinical outcome after posterior stabilized total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2011;19:960–966.PubMedCrossRefGoogle Scholar
  30. 30.
    Massin P, Dupuy FR, Khlifi H, Fornasieri C, De Polignac T, Schifrine P, Farenq C, Mertl P. Does hyperflex total knee design improve postoperative active flexion? Orthop Traumatol Surg Res. 2010;96:376–380.PubMedCrossRefGoogle Scholar
  31. 31.
    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.PubMedCrossRefGoogle Scholar
  32. 32.
    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.PubMedCrossRefGoogle Scholar
  33. 33.
    Murphy M, Journeaux S, Russell T. High-flexion total knee arthroplasty: a systematic review. Int Orthop. 2009;33:887–893.PubMedCrossRefGoogle Scholar
  34. 34.
    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.PubMedCrossRefGoogle Scholar
  35. 35.
    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.PubMedCrossRefGoogle Scholar
  36. 36.
    Piedade SR, Pinaroli A, Servien E, Neyret P. Revision after early aseptic failures in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2009;17:248–253.PubMedCrossRefGoogle Scholar
  37. 37.
    Ritter MA, Harty LD, Davis KE, Meding JB, Berend ME. Predicting range of motion after total knee arthroplasty. Clustering, log-linear regression, and regression tree analysis. J Bone Joint Surg Am. 2003;85:1278–1285.PubMedGoogle Scholar
  38. 38.
    Rowe PJ, Myles CM, Walker C, Nutton R. Knee joint kinematics in gait and other functional activities measured using flexible electrogoniometry: how much knee motion is sufficient for normal daily life? Gait Posture. 2000;12:143–155.PubMedCrossRefGoogle Scholar
  39. 39.
    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.PubMedCrossRefGoogle Scholar
  40. 40.
    Seng C, Yeo SJ, Wee JL, Subanesh S, Chong HC, Lo NN. Improved clinical outcomes after high-flexion total knee arthroplasty: a 5-year follow-up study. J Arthroplasty. 2011;26:1025–1030.PubMedCrossRefGoogle Scholar
  41. 41.
    Seon JK, Park JK, Shin YJ, Seo HY, Lee KB, Song EK. Comparisons of kinematics and range of motion in high-flexion total knee arthroplasty: cruciate retaining vs substituting designs. Knee Surg Sports Traumatol Arthrosc. 2011;19:2016–2022.PubMedCrossRefGoogle Scholar
  42. 42.
    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.PubMedGoogle Scholar
  43. 43.
    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.PubMedCrossRefGoogle Scholar
  44. 44.
    Tanzer M, Smith K, Burnett S. Posterior-stabilized versus cruciate-retaining total knee arthroplasty: balancing the gap. J Arthroplasty. 2002;17:813–819.PubMedCrossRefGoogle Scholar
  45. 45.
    Tarabichi S, Tarabichi Y, Hawari M. Achieving deep flexion after primary total knee arthroplasty. J Arthroplasty. 2010;25:219–224.PubMedCrossRefGoogle Scholar
  46. 46.
    Victor J, Ries M, Bellemans J, Robb WM, Van Hellemondt G. High-flexion, motion-guided total knee arthroplasty: who benefits the most? Orthopedics. 2007;30:77–79.PubMedGoogle Scholar
  47. 47.
    Weeden SH, Schmidt R. A randomized, prospective study of primary total knee components designed for increased flexion. J Arthroplasty. 2007;22:349–352.PubMedCrossRefGoogle Scholar
  48. 48.
    Windsor RE, Scuderi GR, Moran MC, Insall JN. Mechanisms of failure of the femoral and tibial components in total knee arthroplasty. Clin Orthop Relat Res. 1989;248:15–19; discussion 19–20.Google Scholar
  49. 49.
    Wohlrab D, Hube R, Zeh A, Hein W. Clinical and radiological results of high flex total knee arthroplasty: a 5 year follow-up. Arch Orthop Trauma Surg. 2009;129:21–24.PubMedCrossRefGoogle Scholar
  50. 50.
    Yagishita K, Muneta T, Ju YJ, Morito T, Yamazaki J, Sekiya I. High-flex posterior cruciate-retaining vs posterior cruciate-substituting designs in simultaneous bilateral total knee arthroplasty: a prospective, randomized study. J Arthroplasty. 2012;27:368–374.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Bum-Sik Lee
    • 1
  • Jong-Won Chung
    • 2
  • Jong-Min Kim
    • 3
  • Kyung-Ah Kim
    • 4
  • Seong-Il Bin
    • 3
  1. 1.Department of Orthopedic Surgery, College of MedicineCatholic UniversityIncheonKorea
  2. 2.Barun Joint OrthopedicsSeongnam-siKorea
  3. 3.Department of Orthopedic Surgery, College of MedicineUniversity of Ulsan, Asan Medical CenterSeoulKorea
  4. 4.Department of Biomedical Engineering, College of MedicineChungbuk National UniversityCheongju-siKorea

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