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Do high flexion posterior stabilised total knee arthroplasty designs increase knee flexion? A meta analysis

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Abstract

Purpose

This systematic literature review analysed the change in range of knee flexion from pre-operative values, following conventional posterior stabilised (PS) and high-flexion (H-F) PS total knee arthroplasty (TKA).

Methods

We calculated the weighted mean differences of pre- and postoperative flexion using meta-analysis with random effect modelling. Eighteen studies met our inclusion criteria. These data included a total of 2,104 PS knees that received conventional implants and 518 knees that received H-F implants.

Results

The pooled gain in flexion was 4.70° in the conventional group (p <0.0001) and 4.81° in the H-F group (p = 0.0008). In the subgroup analysis, the Western patient group showed significant difference in the gain of flexion with both implants. In contrast, no significant gain in flexion was observed in the Asian patient group.

Conclusions

These results suggest that improvement of preoperative flexion after TKA using current H-F PS prostheses is similar to that of conventional PS prostheses.

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References

  1. Ritter MA, Campbell ED (1987) Effect of range of motion on the success of a total knee arthroplasty. J Arthroplasty 2:95–97

    Article  PubMed  CAS  Google Scholar 

  2. Rowe PJ, Myles CM, Walker C, Nutton R (2000) 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 12:143–155

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  Google Scholar 

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

    Google Scholar 

  6. Dennis DA, Komistek RD, Scuderi GR, Zingde S (2007) Factors affecting flexion after total knee arthroplasty. Clin Orthop Relat Res 464:53–60

    PubMed  Google Scholar 

  7. Li G, Schule S, Zayontz S, Maloney W, Rubash H (2003) Improving flexion in total knee arthroplasty. The adult knee, vol 2. Lippincott Williams & Wilkins, Philadelphia

  8. 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 428:174–179

    Google Scholar 

  9. Li G, Most E, Sultan PG, Schule S, Zayontz S, Park SE, Rubash HE (2004) Knee kinematics with a high-flexion posterior stabilized total knee prosthesis: An in vitro robotic experimental investigation. J Bone Joint Surg Am 86-A:1721–1729

    PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  11. 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 87:1470–1475

    Article  PubMed  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  13. 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 90:37–42

    Article  PubMed  CAS  Google Scholar 

  14. Malik A, Salas A, Ben Ari J, Ma Y, Gonzalez Della Valle A (2010) Range of motion and function are similar in patients undergoing TKA with posterior stabilised and high-flexion inserts. Int Orthop 34(7):965–972

    Google Scholar 

  15. 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 24:33–38

    Article  PubMed  Google Scholar 

  16. 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 15:350–355

    Article  PubMed  Google Scholar 

  17. Kanekasu K, Banks SA, Honjo S, Nakata O, Kato H (2004) Fluoroscopic analysis of knee arthroplasty kinematics during deep flexion kneeling. J Arthroplasty 19:998–1003

    Article  PubMed  Google Scholar 

  18. Laskin RS (2007) The effect of a high-flex implant on postoperative flexion after primary total knee arthroplasty. Orthopedics 30:86–88

    PubMed  Google Scholar 

  19. 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 20:674–679

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  21. Murphy M, Journeaux S, Russell T (2009) High-flexion total knee arthroplasty: A systematic review. Int Orthop 33:887–893

    Article  PubMed  Google Scholar 

  22. Gandhi R, Tso P, Davey JR, Mahomed NN (2009) High-flexion implants in primary total knee arthroplasty: A meta-analysis. Knee 16:14–17

    Article  PubMed  Google Scholar 

  23. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: Clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon study group. Scand J Med Sci Sports 10:2–11

    Article  PubMed  CAS  Google Scholar 

  24. Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, Gotzsche PC, Lang T (2001) The revised consort statement for reporting randomized trials: Explanation and elaboration. Ann Intern Med 134:663–694

    PubMed  CAS  Google Scholar 

  25. Khanna A, Gougoulias N, Longo UG, Maffulli N (2009) Minimally invasive total knee arthroplasty: A systematic review. Orthop Clin North Am 40:479–489

    Article  PubMed  Google Scholar 

  26. Parsley BS, Conditt MA, Bertolusso R, Noble PC (2006) Posterior cruciate ligament substitution is not essential for excellent postoperative outcomes in total knee arthroplasty. J Arthroplasty 21:127–131

    Article  PubMed  Google Scholar 

  27. Gioe TJ, Glynn J, Sembrano J, Suthers K, Santos ER, Singh J (2009) Mobile and fixed-bearing (all-polyethylene tibial component) total knee arthroplasty designs. A prospective randomized trial. J Bone Joint Surg Am 91:2104–2112

    Article  PubMed  Google Scholar 

  28. Cheng K, Ridley D, Bird J, McLeod G (2010) Patients with fixed flexion deformity after total knee arthroplasty do just as well as those without: Ten-year prospective data. Int Orthop 34:663–667

    Article  PubMed  Google Scholar 

  29. McCalden RW, MacDonald SJ, Charron KD, Bourne RB, Naudie DD (2010) The role of polyethylene design on postoperative TKA flexion: An analysis of 1534 cases. Clin Orthop Relat Res 468:108–114

    Article  PubMed  Google Scholar 

  30. 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 90:2579–2586

    Article  PubMed  CAS  Google Scholar 

  31. Tanzer M, Smith K, Burnett S (2002) Posterior-stabilized versus cruciate-retaining total knee arthroplasty: Balancing the gap. J Arthroplasty 17:813–819

    Article  PubMed  Google Scholar 

  32. 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 129:21–24

    Article  PubMed  Google Scholar 

  33. Victor J, Banks S, Bellemans J (2005) Kinematics of posterior cruciate ligament-retaining and -substituting total knee arthroplasty: A prospective randomised outcome study. J Bone Joint Surg Br 87:646–655

    Article  PubMed  CAS  Google Scholar 

  34. Zeh A, Davis J, Laskin R, Klima S, Wohlrab D (2009) Early results with the Genesis II Posterior Stabilized High Flexion knee prosthesis. A one year follow-up study. Acta Orthop Belg 75:792–800

    PubMed  Google Scholar 

  35. Maruyama S, Yoshiya S, Matsui N, Kuroda R, Kurosaka M (2004) Functional comparison of posterior cruciate-retaining versus posterior stabilized total knee arthroplasty. J Arthroplasty 19:349–353

    Article  PubMed  Google Scholar 

  36. Hasegawa M, Sudo A, Uchida A (2009) Staged bilateral mobile-bearing and fixed-bearing total knee arthroplasty in the same patients: A prospective comparison of a posterior-stabilized prosthesis. Knee Surg Sports Traumatol Arthrosc 17:237–243

    Article  PubMed  Google Scholar 

  37. Watanabe T, Muneta T, Ishizuki M (2009) Is a minimally invasive approach superior to a conventional approach for total knee arthroplasty? Early outcome and 2- to 4-year follow-up. J Orthop Sci 14:589–595

    Article  PubMed  Google Scholar 

  38. Maloney WJ, Schurman DJ (1992) The effects of implant design on range of motion after total knee arthroplasty. Total condylar versus posterior stabilized total condylar designs. Clin Orthop Relat Res 278:147–152

    Google Scholar 

  39. Bozic KJ, Kinder J, Meneghini RM, Zurakowski D, Rosenberg AG, Galante JO (2005) Implant survivorship and complication rates after total knee arthroplasty with a third-generation cemented system: 5 to 8 years followup. Clin Orthop Relat Res 430:117–124

    Google Scholar 

  40. W-Dahl A, Robertsson O, Lidgren L (2010) Surgery for knee osteoarthritis in younger patients. Acta Orthop 81:161–164

    Article  PubMed  Google Scholar 

  41. Schurman DJ, Rojer DE (2005) Total knee arthroplasty: Range of motion across five systems. Clin Orthop Relat Res 430:132–137

    Google Scholar 

  42. 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 32:811

    PubMed  Google Scholar 

  43. Ranawat CS (2003) Design may be counterproductive for optimizing flexion after TKR. Clin Orthop Relat Res 416:174–176

    Google Scholar 

  44. Nagura T, Dyrby CO, Alexander EJ, Andriacchi TP (2002) Mechanical loads at the knee joint during deep flexion. J Orthop Res 20:881–886

    Article  PubMed  Google Scholar 

  45. 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 89:1457–1461

    Article  PubMed  CAS  Google Scholar 

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

    PubMed  Google Scholar 

  47. Moynihan AL, Varadarajan KM, Hanson GR, Park SE, Nha KW, Suggs JF, Johnson T, Li G (2010) In vivo knee kinematics during high flexion after a posterior-substituting total knee arthroplasty. Int Orthop 34:497–503

    Article  PubMed  Google Scholar 

  48. Nakayama K, Matsuda S, Miura H, Iwamoto Y, Higaki H, Otsuka K (2005) Contact stress at the post-cam mechanism in posterior-stabilised total knee arthroplasty. J Bone Joint Surg Br 87:483–488

    PubMed  CAS  Google Scholar 

  49. Edwards JZ, Greene KA, Davis RS, Kovacik MW, Noe DA, Askew MJ (2004) Measuring flexion in knee arthroplasty patients. J Arthroplasty 19:369–372

    Article  PubMed  Google Scholar 

  50. Ritter MA, Harty LD, Davis KE, Meding JB, Berend ME (2003) Predicting range of motion after total knee arthroplasty. Clustering, log-linear regression, and regression tree analysis. J Bone Joint Surg Am 85-A:127–1285

    Google Scholar 

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Correspondence to Guoan Li.

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Sumino, T., Gadikota, H.R., Varadarajan, K.M. et al. Do high flexion posterior stabilised total knee arthroplasty designs increase knee flexion? A meta analysis. International Orthopaedics (SICOT) 35, 1309–1319 (2011). https://doi.org/10.1007/s00264-011-1228-4

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  • DOI: https://doi.org/10.1007/s00264-011-1228-4

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