Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 23, Issue 6, pp 1598–1609 | Cite as

Patients achieved greater range of movement when using high-flexion implants

  • Canfeng Li
  • Yi Zeng
  • Bin ShenEmail author
  • Jing Yang
  • Zongke Zhou
  • Pengde Kang
  • Fuxing Pei



NexGen Legacy Posterior Stabilized high-flexion prostheses (LPS-Flex) have been popularized as an alternative to NexGen standard prostheses (LPS) in total knee arthroplasty (TKA). Advocates of this new generation prosthesis suggest improved postoperative knee flexion. The purpose of this study was to summarize the best evidence for comparing the range of motion (ROM) and functional outcomes of LPS-Flex prostheses and LPS in TKA.


Electronic databases were systematically searched to identify relevant randomized controlled trials (RCTs). The last date for our research was July 2014. Our search strategy was followed the requirements of the Cochrane Library Handbook. The methodological quality was assessed, and the data were extracted independently by two authors.


Nine studies that included 978 knees met our inclusion criteria for review. The results showed that there was larger postoperative ROM (1.62, 95 % CI 0.52–2.72) in the LPS-Flex group than in the LPS group. There was not a statistically significant difference in the clinical functional scores and complications between the LPS-Flex group and the LPS group in TKA. The pooled mean differences were as follows: total KSS, −0.64 (95 % CI −1.41 to 0.13); functional KSS, −0.53 (95 % CI −1.51 to 0.45); HSS, 0.23 (95 % CI −0.87 to 1.33); complications, 0.49 (95 % CI 0.20–1.24); and radiolucent lines, 1.56 (95 % CI 0.68–3.55).


The preliminary results indicate that the NexGen LPS-Flex prosthesis provides an alternative to the NexGen LPS prosthesis, with greater range of motion and without severe complications or radiographic outcomes. The clinical advantages were not shown in the KSS or the HSS. Thus, the selection of a high-flexion prosthesis should depend on the characteristics of the patient, particularly high motivation and poor preoperative ROM. The potential benefits in the medium- and long-term outcomes require confirmation by larger, multicenter and well-conducted RCTs.

Level of evidence

Therapeutic study, Level I.


High-flexion prosthesis Standard prosthesis Range of motion Total knee arthroplasty 



This research was funded by the China Health Ministry Program (201302007). No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.


  1. 1.
    Ahmed I, Gray AC, van der Linden M, Nutton R (2009) Range of flexion after primary TKA: the effect of soft tissue release and implant design. Orthopedics 32:811PubMedGoogle Scholar
  2. 2.
    Argenson JN, Komistek RD, Mahfouz M, Walker SA, Aubaniac JM, Dennis DA (2004) A high flexion total knee arthroplasty design replicates healthy knee motion. Clin Orthop Relat Res 428:174–179CrossRefPubMedGoogle Scholar
  3. 3.
    Barink M, DeWaalMalefijt M, Celada P, Vena P, Van Kampen A, Verdonschot N (2008) A mechanical comparison of high-flexion and conventional total knee arthroplasty. Proc Inst Mech Eng H 222:297–307CrossRefPubMedGoogle Scholar
  4. 4.
    Bellemans J, Banks S, Victor J, Vandenneucker H, Moemans A (2002) Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty. Influence of posterior condylar offset. J Bone Joint Surg Br 84:50–53CrossRefPubMedGoogle Scholar
  5. 5.
    Bin SI, Nam TS (2007) Early results of high-flex total knee arthroplasty: comparison study at 1 year after surgery. Knee Surg Sports Traumatol Arthrosc 15:350–355CrossRefPubMedGoogle Scholar
  6. 6.
    Chaudhary R, Beaupre LA, Johnston DW (2008) Knee range of motion during the first two years after use of posterior cruciate-stabilizing or posterior cruciate-retaining total knee prostheses. A randomized clinical trial. J Bone Joint Surg Am 90:2579–2586CrossRefPubMedGoogle Scholar
  7. 7.
    Dennis DA, Heekin RD, Clark CR, Murphy JA, O’Dell TL, Dwyer KA (2013) Effect of implant design on knee flexion. J Arthroplasty 28:429–438CrossRefPubMedGoogle Scholar
  8. 8.
    Endres S (2011) High-flexion versus conventional total knee arthroplasty: a 5-year study. J Orthop Surg 19:226–229Google Scholar
  9. 9.
    Gandhi R, Tso P, Davey JR, Mahomed NN (2009) High-flexion implants in primary total knee arthroplasty: a meta-analysis. Knee 16:14–17CrossRefPubMedGoogle Scholar
  10. 10.
    Guild GN, Labib SA (2014) Clinical outcomes in high flexion total knee arthroplasty were not superior to standard posterior stabilized total knee arthroplasty. A multicenter, prospective, randomized study. J Arthroplasty 29:530–534CrossRefPubMedGoogle Scholar
  11. 11.
    Hamilton WG, Sritulanondha S, Engh CA Jr (2011) Results of prospective, randomized clinical trials comparing standard and high-flexion posterior-stabilized TKA: a focused review. Orthopedics 34:e500–e503CrossRefPubMedGoogle Scholar
  12. 12.
    Han HS, Kang SB, Yoon KS (2007) High incidence of loosening of the femoral component in legacy posterior stabilised-flex total knee replacement. J Bone Joint Surg Br 89:1457–1461CrossRefPubMedGoogle Scholar
  13. 13.
    Hepinstall MS, Ranawat AS, Ranawat CS (2010) High-flexion total knee replacement: functional outcome at one year. HSS J 6:138–144CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13–23CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Huang HT, Su JY, Wang GJ (2005) The early results of high-flex total knee arthroplasty: a minimum of 2 years of follow-up. J Arthroplasty 20:674–679CrossRefPubMedGoogle Scholar
  16. 16.
    Jain S, Pathak AC, Kanniyan K, Kulkarni S, Tawar S, Mane P (2013) High-flexion posterior-stabilized total knee prosthesis: is it worth the hype? Knee Surg Relat Res 25:100–105CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Kim YH, Sohn KS, Kim JS (2005) Range of motion of standard and high-flexion posterior stabilized total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am 87:1470–1475CrossRefPubMedGoogle Scholar
  18. 18.
    Kim TH, Lee DH, Bin SI (2008) The NexGen LPS-flex to the knee prosthesis at a minimum of three years. J Bone Joint Surg Br 90:1304–1310CrossRefPubMedGoogle Scholar
  19. 19.
    Kim YH, Choi Y, Kim JS (2009) Range of motion of standard and high-flexion posterior cruciate-retaining total knee prostheses a prospective randomized study. J Bone Joint Surg Am 91:1874–1881CrossRefPubMedGoogle Scholar
  20. 20.
    Kim YH, Park JW, Kim JS (2012) High-flexion total knee arthroplasty: survivorship and prevalence of osteolysis: results after a minimum of ten years of follow-up. J Bone Joint Surg Am 94:1378–1384CrossRefPubMedGoogle Scholar
  21. 21.
    Klein GR, Restrepo C, Hozack WJ (2006) The effect of knee component design changes on range of motion evaluation in vivo by a computerized navigation system. J Arthroplasty 21:623–627CrossRefPubMedGoogle Scholar
  22. 22.
    Lee BS, Kim JM, Lee SJ, Jung KH, Lee DH, Cha EJ, Bin SI (2011) High-flexion total knee arthroplasty improves flexion of stiff knees. Knee Surg Sports Traumatol Arthrosc 19:936–942CrossRefPubMedGoogle Scholar
  23. 23.
    Lee BS, Chung JW, Kim JM, Kim KA, Bin SI (2013) High-flexion prosthesis improves function of TKA in Asian patients without decreasing early survivorship. Clin Orthop Relat Res 471:1504–1511CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Li N, Tan Y, Deng Y, Chen L (2014) Posterior cruciate-retaining versus posterior stabilized total knee arthroplasty: a meta-analysis of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc 22(3):556–564CrossRefPubMedGoogle Scholar
  25. 25.
    Lingard EA, Katz JN, Wright RJ, Wright EA, Sledge CB (2001) Validity and responsiveness of the Knee Society Clinical Rating System in comparison with the SF-36 and WOMAC. J Bone Joint Surg Am 83-a:1856-1864Google Scholar
  26. 26.
    Luo SX, Su W, Zhao JM, Sha K, Wei QJ, Li XF (2011) High-flexion vs conventional prostheses total knee arthroplasty: a meta-analysis. J Arthroplasty 26:847–854CrossRefPubMedGoogle Scholar
  27. 27.
    McCalden RW, MacDonald SJ, Bourne RB, Marr JT (2009) A randomized controlled trial comparing “high-flex” vs “standard” posterior cruciate substituting polyethylene tibial inserts in total knee arthroplasty. J Arthroplasty 24:33–38CrossRefPubMedGoogle Scholar
  28. 28.
    Mehin R, Burnett RS, Brasher PM (2010) Does the new generation of high-flex knee prostheses improve the post-operative range of movement?: a meta-analysis. J Bone Joint Surg Br 92:1429–1434CrossRefPubMedGoogle Scholar
  29. 29.
    Murphy M, Journeaux S, Russell T (2009) High-flexion total knee arthroplasty: a systematic review. Int Orthop 33:887–893CrossRefPubMedCentralPubMedGoogle Scholar
  30. 30.
    Nam SW, Lee YS, Kwak JH, Kim NK, Lee BK (2012) A Comparison of the Clinical and Radiographic Results of Press Fit Condylar Rotating-Platform High-Flexion and Low Contact Stress Mobile Bearing Prosthesis in Total Knee Arthroplasty: short term Results. Knee Surg Relat Res 24:7–13CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Nieuwenhuijse MJ, van der Voort P, Kaptein BL, Van der Linden-van der Zwaag HM, Valstar ER, Nelissen RG (2013) Fixation of high-flexion total knee prostheses: five-year follow-up results of a four-arm randomized controlled clinical and roentgen stereophotogrammetric analysis study. J Bone Joint Surg Am 95:e1411-11CrossRefPubMedGoogle Scholar
  32. 32.
    Noble PC, Gordon MJ, Weiss JM, Reddix RN, Conditt MA, Mathis KB (2005) Does total knee replacement restore normal knee function? Clin Orthop Relat Res 431:157–165CrossRefPubMedGoogle Scholar
  33. 33.
    Nutton RW, van der Linden ML, Rowe PJ, Gaston P, Wade FA (2008) 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 90:37–42CrossRefPubMedGoogle Scholar
  34. 34.
    Ranawat CS (2003) Design may be counterproductive for optimizing flexion after TKR. Clin Orthop Relat Res 416:174–176CrossRefPubMedGoogle Scholar
  35. 35.
    Report on the Ontario Joint Replacement Registry (2006) Edited (Toronto, Ontario, Canada)Google Scholar
  36. 36.
    Ritter MA, Campbell ED (1987) Effect of range of motion on the success of a total knee arthroplasty. J Arthroplasty 2:95–97CrossRefPubMedGoogle Scholar
  37. 37.
    Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L (2000) Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand 71:262–267CrossRefPubMedGoogle Scholar
  38. 38.
    Sancheti KH, Laud NS, Bhende H, Reddy G, Pramod N, Mani JN (2009) The INDUS knee prosthesis—prospective multicentric trial of a posteriorly stabilized high-flex design: 2 years follow-up. Indian J Orthop 43:367–374CrossRefPubMedCentralPubMedGoogle Scholar
  39. 39.
    Seng C, Yeo SJ, Wee JL, Subanesh S, Chong HC, Lo NN (2011) Improved clinical outcomes after high-flexion total knee arthroplasty: a 5-year follow-up study. J Arthroplasty 26:1025–1030CrossRefPubMedGoogle Scholar
  40. 40.
    Singh H, Mittal V, Nadkarni B, Agarwal S, Gulati D (2012) Gender-specific high-flexion knee prosthesis in Indian women: a prospective randomised study. J Orthop Surg 20:153–156Google Scholar
  41. 41.
    Smith TO, King JJ, Hing CB (2012) A meta-analysis of randomised controlled trials comparing the clinical and radiological outcomes following minimally invasive to conventional exposure for total knee arthroplasty. Knee 19(1):1–7CrossRefPubMedGoogle Scholar
  42. 42.
    Sumino T, Gadikota HR, Varadarajan KM, Kwon YM, Rubash HE, Li G (2011) Do high flexion posterior stabilised total knee arthroplasty designs increase knee flexion? A meta analysis. Int Orthop 35:1309–1319CrossRefPubMedCentralPubMedGoogle Scholar
  43. 43.
    W-Dahl A, Robertsson O, Lidgren L (2010) Surgery for knee osteoarthritis in younger patients. Acta Orthop 81:161–164CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Weeden SH, Schmidt R (2007) A randomized, prospective study of primary total knee components designed for increased flexion. J Arthroplasty 22:349–352CrossRefPubMedGoogle Scholar
  45. 45.
    Wohlrab D, Hube R, Zeh A, Hein W (2009) Clinical and radiological results of high flex total knee arthroplasty: a 5 year follow-up. Arch Orthop Trauma Surg 129:21–24CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Authors and Affiliations

  • Canfeng Li
    • 1
  • Yi Zeng
    • 1
  • Bin Shen
    • 1
    Email author
  • Jing Yang
    • 1
  • Zongke Zhou
    • 1
  • Pengde Kang
    • 1
  • Fuxing Pei
    • 1
  1. 1.The Orthopedic Department, West China HospitalSichuan UniversityChengduChina

Personalised recommendations