The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 8

Scientific Articles | August 01, 2007

Rotating Hinged Total Knee Replacement: Use with Caution

Aidin Eslam Pour, MD¹; Javad Parvizi, MD, FRCS¹; Nicholas Slenker, BS¹; James J. Purtill, MD¹; Peter F. Sharkey, MD¹

¹ Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Stryker Orthopaedics. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Rothman Institute at Jefferson, Philadelphia, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Aug 01;89(8):1735-1741. doi: 10.2106/JBJS.F.00893

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Abstract

Background: A rotating hinged total knee prosthesis may be utilized for the treatment of global instability or severe bone loss around the knee. Older generations of rotating hinged designs were associated with suboptimal outcomes. We evaluated the outcome of salvage knee reconstructions that had been performed with use of modern-generation modular segmental kinematic rotating hinged total knee prostheses.

Methods: The cohort included forty-three patients (twenty-nine women and fourteen men) who underwent forty-four knee arthroplasties for the treatment of a non-neoplastic condition with use of a modern-generation kinematic rotating hinged prosthesis. Revision of a previous total knee arthroplasty in the presence of massive bone loss was the most common indication for surgery. Complete clinical and radiographic data were collected for all patients after a mean duration of follow-up of 4.2 years.

Results: Reconstruction with a rotating hinged total knee prosthesis provided substantial improvement in function and reduction in pain. However, a relatively large number of complications and failures (including revision because of periprosthetic infection [three knees], aseptic loosening [four], and periprosthetic fracture [one]) were encountered, with a mean time to failure of 1.7 years. The rate of prosthetic survival was 79.6% at one year and 68.2% at five years with revision or reoperation as the end point.

Conclusions: The present study highlights the commonly held opinion that a modular kinematic rotating hinged total knee prosthesis has a role for salvage reconstruction of the knee. In light of the relatively high rate of complications, we believe that this salvage procedure should be reserved primarily for elderly and sedentary patients.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

There has been a steady increase in the number of revision total knee arthroplasties being performed^1,2. Aseptic loosening, instability, infection, wear, and osteolysis are some of the common reasons for revision arthroplasty³. A minimally constrained conventional prosthesis can be used during revision knee arthroplasty in most patients^4-7. However, the presence of severe bone loss, global instability, and highly comminuted distal femoral fractures occasionally may necessitate the use of a more constrained prosthesis such as a rotating hinged prosthesis.

Hinged prostheses were first designed and used for knee reconstruction after the resection of neoplasms⁸. The first designs were truly a fixed hinge with a metal-on-metal articulation that allowed for movement in only one plane of flexion and extension, without allowing varus or valgus tilt, axial rotation, or distraction. This resulted in the transmission of excessive interfacial forces to the bone-cement interface and early failure of the prosthesis^1,9-16.

There have been improvements in the design of these prostheses in recent years, the most important of which is the ability of the implant to rotate^1,17. This design theoretically provides a more congruent articulation, leading to a decrease in wear and transmitted interfacial stresses. In addition, modular fluted stems have been added to improve the alignment and to allow for press-fit fixation. Modular segments also have been incorporated to allow for the filling of the massive intramedullary bone defects that are frequently encountered in difficult revision cases^1,18. All of these improvements were implemented in an effort to decrease the complications that were encountered following the use of constrained total knee prostheses¹.

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Fig. 1-A and Fig. 1-B: Figs. 1-A, 1-B, and1-C Radiographs of the knee of a seventy-year-old patient who sustained a periprosthetic femoral fracture after a fall injury, five years after total knee arthroplasty. Figs. 1-A and 1-B Anteroposterior (Fig. 1-A) and lateral (Fig. 1-B) radiographs made after the fracture.

The purpose of the present study was to evaluate the outcomes of salvage knee reconstructions that had been performed with use of modern-generation modular segmental kinematic rotating hinged prostheses.

Materials and Methods

Materials and Methods | Results | Discussion | References

Demographic Data

Prior to the initiation of the study, institutional review board approval and patient consent for participation in the study were obtained. From 1997 to 2003, forty-four total knee arthroplasties were performed in forty-three patients with use of a rotating hinged knee prosthesis at our institution. The study group included twenty-nine women and fourteen men who had a mean age of 71.8 years (range, fifty-five to eighty-eight years) at the time of the index procedure. The mean body mass index was 32.0 kg/m² (range, 17.9 to 50.2 kg/m²). Detailed clinical and radiographic data were collected prospectively for all patients. The majority of patients in this cohort had preexisting comorbidities, including diabetes (ten patients), obesity (four), rheumatoid arthritis (two), chronic renal failure (two), malignant disease (one), hepatitis C (one), and systemic lupus erythematosus (one). Thirteen of the forty-four knees had a history of periprosthetic infection.

Surgical Data

All patients received either the Kinematic rotating hinged knee implant (Stryker Orthopaedics, Mahwah, New Jersey) (thirty-one knees) or the Finn rotating hinged prosthesis (Biomet, Warsaw, Indiana) (thirteen knees). The indications for surgery included massive bone loss secondary to a failed arthroplasty (twenty-seven), instability (ten), periprosthetic fracture (four), or a comminuted distal femoral fracture (three). A mean of two interim revision procedures (range, zero to three interim revision procedures) were performed before implantation of the hinged total knee prosthesis.

Both the University of Pennsylvania bone defect classification system (ranging from 1 to 150, with a higher score indicating worse bone loss) and the Anderson Orthopaedic Research Institute bone defect classification system (with type 1 representing "intact," type 2 representing "damaged," and type 3 representing "deficient") were used to assess the severity of bone loss for the twenty-seven knees that received a hinged total knee prosthesis for the treatment of bone loss^19-21. The mean bone loss score with use of the University of Pennsylvania system was 40.4 (range, 18 to 101) for the femoral side and 39.4 (range, 24 to 95) for the tibial side. Twenty-four patients were classified as having a type-3 bone loss and three patients were classified as having type-2 bone loss according to the Anderson Orthopaedic Research Institute bone defect classification system.

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Fig. 1-C: Because of severe bone loss and poor quality of the remaining bone, precluding the use of a conventional prosthesis, a hinged total knee prosthesis was utilized.

Clinical and radiographic evaluations of all patients were performed by an orthopaedic surgeon (J.P.). The functional instruments that were used in the present study included the Knee Society score²² and the SF-36 score ²³. All patients completed the standard SF-36 and Knee Society questionnaires both before the index procedure and at the time of the latest follow-up. The range of motion and stability of the knee were assessed by the operating surgeons before the procedure and by the primary investigator (P.F.S.) at the time of the latest follow-up.

All procedures were performed through a medial parapatellar arthrotomy and under tourniquet control. Antibiotic-impregnated cement containing tobramycin and/or vancomycin was utilized in all cases. The components were fully cemented in forty-one knees and were press-fit in the diaphysis with cementing of the metaphyseal portion in three knees. The mean tourniquet time was 103 minutes.

Follow-up

The patients were enrolled in the study after the surgical procedure had been performed and were followed prospectively. The mean duration of follow-up was 4.2 years(range, two to eight years). All patients were followed for a minimum of two years, until failure of the prosthesis, or until death. There was one death during the follow-up period; the death was unrelated to the knee surgery. No other patient was lost to follow-up.

Radiographic Evaluation

Serial anteroposterior and lateral radiographs of the operatively treated joint were reviewed in detail. Preoperative radiographs were reviewed to assess bone stock, the position and status of the components, and the morphological characteristics of the fracture. The positions of the components were assessed by one orthopaedic surgeon (J.P.) and were considered to be optimal if the tibiofemoral angle was within 5° of neutral. Postoperative radiographs were evaluated for signs of loosening, bone loss, and alignment. The femur and tibia were divided into standard zones²⁴.

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Fig. 2: Kaplan-Meier curve, with revision or reoperation as the end point, demonstrating a survival rate of 79.6% at one year and 68.2% at five years.

Statistical Analysis

The changes in the Knee Society and SF-36 scores were evaluated with use of the Student t test, and the level of significance was set at p < 0.05. Kaplan-Meier analysis was used to determine the survival rate.

Results

Materials and Methods | Results | Discussion | References

Functional Evaluation

The Knee Society pain score improved from a preoperative mean of 28.9 points (range, —2 to 89 points) to a postoperative mean of 73.5 points (range, 33 to 86 points) (p = 0.001), and the Knee Society function score increased modestly from a preoperative mean of 40 points (range, 5 to 91 points) to a post-operative mean of 43 points (range, 30 to 100 points) (p = 0.86). The SF-36 physical functioning score improved from a preoperative mean of 28.3 points (range, 9 to 63.8 points) to a postoperative mean of 41.1 points (range, 14.5 to 72 points) (p = 0.151). The SF-36 mental functioning score improved from a preoperative mean of 54.5 points (range, 27.8 to 86.6 points) to a postoperative mean of 59.4 points (range, 20 to 85.9 points) (p = 0.823). Thirty-three patients (thirty-three knees) had a good to excellent functional outcome (minimal pain, full walking ability, and good to excellent SF-36 and Knee Society scores). Ten patients (eleven knees) had a fair to poor functional outcome (persistent knee pain, limited walking ability).

Radiographic Findings

At the time of the latest follow-up, all unrevised components were found to be stable (Figs. 1-A, 1-B, and 1-C). Nonprogressive radiolucent lines were identified around the cemented portion of the femoral stem in eleven knees and around the tibial stem in eleven knees. The radiolucent line measured =2 mm in three of the eleven knees that had such a lesion around the femoral component; this line was located in zone 4 in one knee and zone 6 in two knees. The radiolucent line measured =2 mm in two of the eleven knees that had such a lesion around the tibial component; the line was located in zone 3 in both knees. These lines remained stable throughout the study period. The positions of the components were considered to be optimal in all forty-four knees. The mean limb alignment was 6.7° of valgus (range, 0° to 10° of valgus).

Complications

Medical complications included arrhythmia (one patient), postoperative confusion (one patient), pulmonary embolus (two patients), urinary tract infection (two patients), acute renal failure (one patient), and exacerbation of chronic renal failure (one patient).

Orthopaedic complications included three periprosthetic infections, which were treated with two-stage resection arthroplasty and reimplantation (two knees) or with incision and drainage (one). Two of these three knees had a history of periprosthetic infection. One of these knees had a second episode of periprosthetic infection after reimplantation of the rotating hinged total knee prosthesis. This necessitated a repeat resection arthroplasty and repeat reimplantation. A periprosthetic fracture occurred in one knee. The fracture initially was treated with open reduction and internal fixation, but the fixation failed and revision to another hinged prosthesis at a later date was required. Additional complications included aseptic loosening in four knees and extensor mechanism rupture in one knee.

There were seven revisions, which were performed at a mean of 1.7 years (range, 0.2 to 3.2 years). The reasons for revision arthroplasty included aseptic loosening (four knees), deep infection (two knees), and periprosthetic fracture (one knee) (Table I). Aseptic loosening involved the femoral component in three knees and the tibial component in one knee. All knees were revised with another hinged prosthesis. These patients were doing well at the time of the latest follow-up.

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TABLE I Details on Complications and Failures

Revisions and Reoperations	Complication/Failure	Time to Failure	Intervention	Outcome	Remarks
Revisions (total, 7 revisions in 7 knees)
1	Aseptic loosening	5.7 months	Revision arthroplasty	Fair	Incision and drainage for hematoma
2	Aseptic loosening	8 months	Revision arthroplasty	Fair	Reoperation to remove the retained cement, reoperation for extensor mechanism repair
3	Aseptic loosening	9 months	Revision arthroplasty	Fair	Incision and drainage for hematoma
4	Deep infection	10.3 months	Two-stage resection arthroplasty	Fair	Incision and drainage for hematoma
5	Periprosthetic fracture	10.5 months	Revision arthroplasty	Fair	Incision and drainage for hematoma, open reduction and internal fixation for periprosthetic fracture
6	Deep infection	12.8 months	Two-stage resection arthroplasty	Fair	Incision and drainage
7	Aseptic loosening	28.5 months	Revision arthroplasty	Fair	No reoperation
Reoperations (total, 15 reoperations in 12 knees)
1	Hematoma	6 days	Incision and drainage	Fair	None
2	Hematoma	7 days	Incision and drainage	Fair	Obesity, development of a periprosthetic fracture that was treated later with open reduction and internal fixation 4.2 months after revision to the hinged knee, needed another revision (see Case 5 in Revisions section above)
3	Hematoma	9 days	Incision and drainage	Fair	Aortic valve disease, needed another revision arthroplasty for aseptic loosening (see Case 1 in Revisions section above)
4	Hematoma	12 days	Incision and drainage	Fair	None (see Case 3 in Revisions section above)
5	Hematoma	12 days	Incision and drainage	Good	Hypertension
6	Hematoma	14 days	Incision and drainage	Good	Diabetes mellitus type II
7	Deep infection	15 days	Incision and drainage	Poor	Needed one incision and drainage twenty-eight days after revision to the hinged knee and one incision and drainage with gastrocnemius flap 8.2 months after revision to the hinged knee
8	Hematoma	48 days	Incision and drainage	Fair	None
9	Excision of retained cement	Same day	Excision of retained cement	Fair	Diabetes mellitus type II, reoperation for extensor mechanism repair 2.8 months after revision to the hinged knee, development of aseptic loosening (see Case 2 in Revisions section above)
10	Deep infection	2.8 months	Incision and drainage	Fair	Diabetes mellitus type II, hypertension, underwent a resection arthroplasty 12.8 months after revision to the hinged knee (see Case 6 in Revisions section above)
11	Deep infection	4.9 months	Incision and drainage	Fair	Rheumatoid arthritis, underwent a resection arthroplasty 10.3 months after surgery (see Case 4 in Revisions section above)
12	Hematoma	38.3 months	Incision and drainage	Fair	None

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TABLE I Details on Complications and Failures

Revisions and Reoperations	Complication/Failure	Time to Failure	Intervention	Outcome	Remarks
Revisions (total, 7 revisions in 7 knees)
1	Aseptic loosening	5.7 months	Revision arthroplasty	Fair	Incision and drainage for hematoma
2	Aseptic loosening	8 months	Revision arthroplasty	Fair	Reoperation to remove the retained cement, reoperation for extensor mechanism repair
3	Aseptic loosening	9 months	Revision arthroplasty	Fair	Incision and drainage for hematoma
4	Deep infection	10.3 months	Two-stage resection arthroplasty	Fair	Incision and drainage for hematoma
5	Periprosthetic fracture	10.5 months	Revision arthroplasty	Fair	Incision and drainage for hematoma, open reduction and internal fixation for periprosthetic fracture
6	Deep infection	12.8 months	Two-stage resection arthroplasty	Fair	Incision and drainage
7	Aseptic loosening	28.5 months	Revision arthroplasty	Fair	No reoperation
Reoperations (total, 15 reoperations in 12 knees)
1	Hematoma	6 days	Incision and drainage	Fair	None
2	Hematoma	7 days	Incision and drainage	Fair	Obesity, development of a periprosthetic fracture that was treated later with open reduction and internal fixation 4.2 months after revision to the hinged knee, needed another revision (see Case 5 in Revisions section above)
3	Hematoma	9 days	Incision and drainage	Fair	Aortic valve disease, needed another revision arthroplasty for aseptic loosening (see Case 1 in Revisions section above)
4	Hematoma	12 days	Incision and drainage	Fair	None (see Case 3 in Revisions section above)
5	Hematoma	12 days	Incision and drainage	Good	Hypertension
6	Hematoma	14 days	Incision and drainage	Good	Diabetes mellitus type II
7	Deep infection	15 days	Incision and drainage	Poor	Needed one incision and drainage twenty-eight days after revision to the hinged knee and one incision and drainage with gastrocnemius flap 8.2 months after revision to the hinged knee
8	Hematoma	48 days	Incision and drainage	Fair	None
9	Excision of retained cement	Same day	Excision of retained cement	Fair	Diabetes mellitus type II, reoperation for extensor mechanism repair 2.8 months after revision to the hinged knee, development of aseptic loosening (see Case 2 in Revisions section above)
10	Deep infection	2.8 months	Incision and drainage	Fair	Diabetes mellitus type II, hypertension, underwent a resection arthroplasty 12.8 months after revision to the hinged knee (see Case 6 in Revisions section above)
11	Deep infection	4.9 months	Incision and drainage	Fair	Rheumatoid arthritis, underwent a resection arthroplasty 10.3 months after surgery (see Case 4 in Revisions section above)
12	Hematoma	38.3 months	Incision and drainage	Fair	None

There were fifteen reoperations, including thirteen incision and drainage procedures in eleven knees, the removal of retained cement in one knee (which had later development of an extensor mechanism rupture requiring repair), and open reduction and internal fixation for the treatment of a periprosthetic fracture in one knee (Table I).

Kaplan-Meier analysis revealed a survival rate of 79.6% at one year and 68.2% at five years with revision or reoperation as the end point (Fig. 2).

Discussion

Materials and Methods | Results | Discussion | References

The number and complexity of revision total knee arthroplasties continue to rise. With the aging population and the use of total knee arthroplasty in a relatively younger patient population, the number of revision arthroplasties in general, and complex failures in particular, will undoubtedly increase further. Severe bone loss and instability are some of the challenging problems facing reconstructive orthopaedic surgeons. The modern generation of rotating hinged total knee replacements can be valuable in the treatment of these problems.

The clinical outcome of the rotating hinged total knee arthroplasty has been evaluated in several studies, and the results have been variable^13,25-29. The early generation of rotating hinged devices did achieve slightly better results than the original fixed hinged implants did, but the long-term results continued to be disappointing^30-33. Although these rotating hinged devices did allow for axial rotation and distraction, suboptimal instrumentation and implant design probably resulted in continued high complication rates¹.

Walker et al. reported good short-term results in terms of pain relief and restoration of range of motion in association with early-generation rotating hinged implants³³. However, that study was limited to twenty-two patients with an average duration of follow-up of only twelve months. Despite the early success in terms of functional improvement, a number of serious complications, such as tibial tubercle avulsion, cortical bone perforation, patellar subluxation, and progressive radiolucency, were encountered. Rand et al. reviewed the first fifty rotating hinged knee arthroplasties that were performed at their institution³¹. The clinical results for thirty-eight total knees were evaluated after an average duration of follow-up of fifty months. A satisfactory result was reported in association with 76% of the revision procedures and 80% of the primary procedures. The complications were numerous and included patellar instability (22%; eleven of fifty), deep infection 16% (eight of fifty), and implant fracture (6%; three of fifty). Shaw et al. reviewed the outcome for thirty-eight knees that had received an early-generation hinged total knee replacement and found an 86% satisfaction rate after a minimum duration of follow-up of twenty-five months³². The major complication in that series was patellar instability, which was found in association with four of twenty primary procedures and six of eighteen revision procedures. In addition, evidence of aseptic radiolucency was found in six of the thirty-eight knees.

The results of total knee arthroplasties performed with use of the newer generation of rotating hinged knee implants have been reviewed in several studies^1,34. The modern implants have undergone numerous design improvements; however, it has not yet been well established whether these improvements translate into improved clinical results. Barrack reported satisfying clinical results in a study of twenty-three modern-generation hinged total knee replacements¹. After an average duration of follow-up of fifty-eight months, the patients in that cohort obtained substantial functional improvements. The investigator observed no progressive radiolucent lines at the time of short-term follow-up. Complications included one intraoperative distal femoral fracture, one case of patellar subluxation, and one peroneal nerve palsy. The investigator concluded that, in the short and intermediate terms, modern-generation rotating hinged components can be used successfully in complex cases.

To our knowledge, all published reports to date have praised the success of the rotating hinged prosthesis in restoring function and alleviating pain. A few reports have highlighted the major complications that can occur in association with the use of these fully constrained prostheses. Springer et al. recently reported on the early results of distal femoral replacement for nonneoplastic limb salvage in a study of twenty-six knees and highlighted some of major associated complications². In that report, periprosthetic infection (five knees) was the main cause of failure. The investigators concluded that the use of constrained prostheses should be reserved for elderly and sedentary patients.

The reason for the high rate of complications associated with the use of distal femoral replacement is likely multifactorial. The severity of bone loss, preexistent comorbidities such as diabetes, and multiple previous surgical procedures all potentially serve to compromise the outcome of a constrained knee arthroplasty. While we can speculate about the reasons for the development of these complications, no one can dispute the complexity of the situation when failure of these constrained devices occurs. On the basis of some relatively encouraging recent reports on the outcome of the rotating hinged prosthesis, it is possible that over-utilization of these devices can and does occur. The present study serves to reiterate the notion that a high rate of complex complications and failures can be encountered in association with the use of constrained devices, even modern-generation prostheses. Deep infection rates ranging from 14.5% to 19.2%^2,25,35 and aseptic loosening rates of as high as 20%^32,33,36 continue to compromise the outcome of these devices. Patellofemoral instability was not seen in any of the patients in our cohort, perhaps attesting to improvements in the design of modern prostheses.

The current study has some limitations. Its retrospective nature with all of the inherent shortcomings of such a study design in terms of the uniformity of data collection is an important limitation. The relatively short duration of follow-up and the relatively small patient population are other limitations. Finally, the study combined a group of patients with varied preoperative diagnoses, and because of the small population size, we were not able to discern a difference in outcome on the basis of the underlying diagnosis.

Despite these limitations, it is our opinion that the suboptimal survival of the rotating hinged prosthesis requires an evaluation of our current indications for the use of these devices. They should be considered as a salvage device and used primarily for elderly and sedentary patients with complex knee problems. ?

References

Materials and Methods | Results | Discussion | References

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Topics

knee region ; knee joint ; prosthesis implantation ; infection ; knee replacement arthroplasty ; osteopenia ; periprosthetic fractures ; knee prosthesis, total

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Aidin Eslam Pour, Javad Parvizi, Nicholas Slenker, James J. Purtill, Peter F. Sharkey; Rotating Hinged Total Knee Replacement: Use with Caution. The Journal of Bone & Joint Surgery. 2007 Aug;89(8):1735-1741.

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