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Contemporary Rotating Hinged Prostheses inPrimary Total Knee Arthroplasty
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. Fig. 35.4 Preoperative standing hip–knee–ankle radiograph of
the patient demonstrating windswept deformity of the bilateral
lower extremities with moderate varus alignment of the right lower
extremity and severe valgus alignment of the left lower extremity
c
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. Fig. 35.6 Postoperative radiographs including anteroposterior a,
lateral b, and sunrise c views of the patient’s left knee demonstrating
a well-xed and well-aligned cemented contemporary rotating-hinge
TKA
. Fig. 35.5 a, b Intraoperative clinical photographs of the patient’s left knee demonstrating severe tricompartmental degenerative changes
with substantial erosion of the posterolateral tibia and lateral facet of the patella
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B. M. Wooster and M. P. Abdel
. Fig. 35.7 Postoperative standing hip–knee–ankle radiograph of
the patient demonstrating improvement in mechanical alignment of
left lower extremity following left total knee arthroplasty with a
rotating-hinge TKA
ial resection is performed with an oscillating saw. The
tibia is sized and the alignment of the tibial resection
is assessed with a drop rod to the second ray of the
foot with the ankle in neutral exion. The tibial nishing template is secured to the proximal tibia with pins
utilizing the middle of the tibial tubercle and tibial
crest as anatomic landmarks for appropriate rotation.
The tibial stem keel punch guide is then applied to the
tibial nishing template and the keel is punched in the
proximal tibia. Thereafter, the intramedullary canal of
the tibia is opened with a stepped drill and the canal
is reamed with uted reamers until there is appropriate chatter in the diaphysis. Typically, that is 14mm in
diameter at a depth of 175mm. In most scenarios, this
allows for a 12mm stem with a 2mm cement mantle. A
50–75mm stem extender is usually more than adequate
in the primary setting.
> Of note, the reamer should be pulsed proximally
rather than being utilized in a continuous fashion to
prevent complete denudation of cancellous bone (and
thus inhibition of interdigitation of the bone cement
in the intramedullary canal).
It has become the preference of the senior author (MPA)
to utilize a tibial cone (. Fig.35.9) when performing an
RH TKA given the increased loads at the bone–cement
interface. Preparation for the tibial cone is performed
with a milling reamer over the intramedullary reamer
and is typically sized large enough to accept the revision
tibial component for the RH TKA.
. Fig. 35.8 Intraoperative clinical photograph demonstrating
excellent exposure of the knee joint facilitated by complete takedown
of the collateral ligaments from their femoral insertions
35.3.3 Femoral Preparation
A pilot hole is drilled slightly anterior to the femoral insertion of the posterior cruciate ligament with a
stepped drill. Thereafter, an intramedullary guide rod is
introduced with a distal femoral cutting guide set to 6°
of valgus (as that is what is mandated by most manufacturers). The distal femoral cutting block is secured to the
femur with pins and the distal femoral resection is performed with an oscillating saw. At a minimum, 10–12mm
of distal femoral bone should be removed from the distal
aspect of the medial femoral condyle. After completion
of the distal femoral resection, spacer blocks specic to
the RH construct are utilized to assess the mechanical
alignment of the limb and ensure the knee comes out
to full extension. If full extension is not possible, additional distal femoral bone must be removed. The femur
is then sized with femoral sizing templates and the corresponding three-in-one cutting block is secured to the
distal femur with pins. Rotation of the cutting block is
set in line with the transepicondylar axis of the femur
to make a rectangle with the in situ tibial trial, which
should be cut perpendicular to the coronal and sagittal
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. Fig. 35.9 Intraoperative clinical photographs demonstrating two types of highly porous metaphyseal tibial cone augments including
Stryker Triathlon® Tritanium tibial cone a and Zimmer Trabecular Metal™ tibial cone b
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axes of the tibia. If anything, additional external rotation is placed to assist with patellofemoral tracking. The
anterior femoral, anterior chamfer, and posterior condylar resections are carefully performed with an oscillating saw after the soft tissues on the posterior aspect
of the femur are taken directly off the bone to protect
the neurovascular bundle from injury by the saw blade.
Fluted reamers are then sequentially advanced into the
femoral canal until there is appropriate chatter in the
diaphysis. Typically, the diameter is 15mm for a 13mm
stem with a 2mm cement mantle. Moreover, the length
of the stem in the primary setting is usually 50–75mm.
As with preparing the tibial canal, the femoral reamer
should be utilized in a pulsatile fashion to avoid reaming
away all of the cancellous bone.
Similar to the tibial side, it has become the preference
of the senior author (MPA) to utilize femoral cones
(. Fig. 35.10) when performing an RH TKA given the
increased loads at the bone–cement interface. Preparation
for the femoral cone is performed with a milling reamer
over the intramedullary reamer and is typically sized
large enough to accept the revision femoral component
for the RH TKA.
35.3.4 Patellar Preparation
The patella is everted with the knee in extension and stabilized with a pair of pointed towel clamps. Excessive
osteophytes are removed with a rongeur and the patella
is circumferentially denervated with electrocautery. The
thickness of the patella is measured with a caliper and
the patella resection is performed free-hand with an
oscillating saw to restore the patellar height. However,
the patella is never resected below 12mm. The patellar
thickness is reassessed in four quadrants to ensure an
even resection. The patella is sized and anchor holes are
preferentially drilled on the superomedial aspect of the
patella. The trial patellar component is then placed and
a partial lateral facetectomy is performed with a highspeed burr or rongeur.
35.3.5 Trialing
Trial femoral and tibial components are assembled on
the back table and impacted onto the prepared bony
surfaces. Knee stability (in the form of obtaining full
extension without recurvatum) and patellar tracking are
tested with trial spacer inserts of various thicknesses.
Intraoperative radiographs (anteroposterior and lateral)
are obtained to conrm appropriate sizing, positioning,
and alignment of all the components. If patellar maltracking is encountered, the tourniquet is deated and
patellar tracking is reassessed. If maltracking persists
with the tourniquet deated, then a lateral release is performed with care taken to preserve the superior lateral
geniculate artery. After sizing, positioning, alignment,
stability, and patellar tracking are deemed satisfactory,
the trial components are removed, the wound is copiously irrigated with sterile saline via pulsatile lavage, and
the exposed bony surfaces are thoroughly dried.
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c d
. Fig. 35.10 Intraoperative clinical photographs demonstrating two types of highly porous metaphyseal femoral cone augments including
Stryker Triathlon® Tritanium femoral cone a and b and Zimmer Trabecular Metal™ femoral cone c and d
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35.3.6 Final Implant Placement
Final implants are opened and assembled according
to manufacturer guidelines on the back table. Cement
restrictors are placed in the tibia and femur at depths
only a few millimeters past the end of the stems. This
allows for excellent pressurization of the cement into the
cancellous bone. Thereafter, the uncemented tibial and
femoral cones are impacted.
> Cementation of the nal tibial and femoral compo-
nents are completed separately with the tibia performed rst.
Two batches of 40mg low-viscosity polymethylmethacrylate bone cement are mixed by hand on the back table
with a combination of 2 g of vancomycin and 2.4g of
gentamicin powder. After achieving a doughy consistency, liberal amounts of cement are applied to the back
of the nal tibial component baseplate and the exposed
bony surfaces of the tibia with a cement gun. The nal
tibial component is impacted into place through the
uncemented cone, ensuring rotation is kept in line with
the middle of the tibial tubercle and tibial crest. Excess
cement is meticulously removed with a freer and the
cement is allowed to completely cure. Attention is then
turned to cementation of the nal femoral and patellar components. Cementation of the nal femoral component is performed in a similar fashion as previously
described for the tibial component with care taken to
ensure that rotation remains in line with the transepicondylar axis of the femur. Finally, cement is applied
to the patellar surface by hand and the nal patellar
component is clamped into place until the cement has
completely cured.
After all the cement has cured, the knee is then
brought to approximately 45° of exion to facilitate
nal assembly of the hinge. A tibial sleeve is rst inserted
into the tibial baseplate and the nal polyethylene insert
is secured into place. The rotating tibial platform is then
placed into the polyethylene insert. The femoral bushings are inserted into the femoral component with care
to ensure that the anges are inside the intercondylar
cutout. The rotating tibial platform is then aligned with
the femoral component bushings and the axle is slid
through the assembly housing with care to ensure that
the axle recess is aligned inferiorly. The bumper (typically neutral) is then aligned with the axle recess and
gently impacted into place.
The wound is copiously irrigated with a dilute betadine solution followed by sterile saline via pulse lavage.
The tourniquet is deated and meticulous hemostasis is
achieved with electrocautery. The wound is then closed
in sequential layers and sterile dressings are applied.
35.4 Indications forRotating Hinges
inPrimary TKA
The utilization of RHs in complex primary TKA has
been steadily increasing since the turn of the twentyrst century. According to the National Joint Registry
for England and Wales, the use of RHs in primary TKA
experienced a fourfold increase between 2003 and 2010
(National Joint Registry for England and Wales 2010).
Similarly, the use of these implants in primary TKA
has nearly doubled from 2010 to 2018 according to the
Norwegian Arthroplasty Register (Norwegian National
Advisory Unit on Arthroplasty and Hip Fractures
2019).
Despite the increasing utilization of RHs in primary
TKA, specic non-oncologic indications for their use
remain controversial in the literature. Some authors suggest imposing strict limitations on the use of these
devices in primary TKA. Gehrke et al. (2014) recommend that the use of RHs in primary TKA be restricted
to patients older than 75years who possess either of the
following:
5 Collateral ligament insufciency
5 Bony destruction of the distal femur or proximal
tibia
5 Hyperlaxity
5 Fixed varus or valgus deformity greater than 20°
5 Severe rheumatoid arthritis
These selected indications were established by the
authors after nding age- and deformity-related discrepancies in the mid-term revision-free survival rates
of the Endo-Model® prosthesis (Waldemar Link; Hamburg, Germany). In their study, the authors retrospectively reviewed the mid-term outcomes and survival of
this specic type of RH in a cohort of 238 patients with
a mean age of 67 years. The overall survivorship free
of all-cause revision for the entire cohort was 90% at
13 years. However, after adjusting survival by age at
implantation, the 13-year survivorship free of all-cause
revision was 94% for patients older than 60years compared to only 77% for patients younger than 60years
old. Similarly, after adjusting for preoperative deformity, the 13-year survivorship free of all-cause revision
for patients with a preoperative varus deformity was
97% while survivorship was only 79% in patients with a
preoperative valgus deformity.
> Based on these results, the authors concluded that
RHs can be safely and effectively utilized in primary
TKA for selected indications. However, they emphasized that the need for these devices in primary TKA
is exceedingly rare with <2% of the primary TKAs
performed at their institution in 1year.
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There are other non-oncologic indications beyond the
criteria suggested by Gehrke etal. (2014) where the use
of RHs in the primary TKA may be warranted. Specically, patients with neuropathic (Charcot) arthropathy
or neuromuscular conditions. Patients with neuropathic
arthropathy can develop rapid and progressive joint
destruction, deformity, and instability resulting from
loss of nociception attributable to various etiologies
(. Fig.35.11) (Bae etal. 2009; Tibbo etal. 2018). Consequently, many surgeons recommend utilizing implants
with increased levels of constraint when performing
TKA in these patients, regardless of age. Tibbo et al.
(2018) recently investigated implant utilization and con-
temporary mid-term results of primary TKA in patients
with neuropathic arthropathy attributed to multiple
underlying conditions. Their study included 27 patients
(37 knees) with a mean age of 60 years. Posterior stabilized implants were used in 19% of cases (7 knees),
varus-valgus constrained (VVC) devices were used in
46% of cases (18 knees), and RHs were utilized in 35%
of cases (13 knees). Supplemental xation with highly
porous metaphyseal cones was used in 16% of the cases
(5 knees). Kaplan–Meier estimated survivorship free of
all-cause revision was 91% at 5years and 70% at 10years.
However, estimated survivorship free of all-cause reoperation was much lower at 83% at 5years and 65% at
10years. The majority of revisions and re-operations in
this cohort were related to postoperative wound issues
and periprosthetic joint infection (PJI). Conversely, revisions due to aseptic loosening or mechanical failure of
the implants were rare. In fact, the survivorship free
of aseptic loosening was 100% at 5 years and 88% at
10years. The authors attributed these ndings to poor
host characteristics and the selective use of highly porous
metaphyseal cones in these patients.
Although the incidence of poliomyelitis has signi-
cantly decreased since the introduction of its vaccine,
patients aficted by this condition develop varying
degrees of generalized hypotonia (Tigani etal. 2009).
Muscle weakness often leads to compensated gait patterns that result in characteristic deformities of the knee
joint. Specically, patients with poliomyelitis often present with signicant knee exion contractures and recurvatum deformities related to imbalances in quadriceps
and hamstring function (Tigani et al. 2009).
Consequently, the utilization of devices with increased
constraint is similarly advocated when performing primary TKA in patients with this condition. There are few
studies in the literature reporting on the outcomes of
primary TKA in patients with poliomyelitis. In a systematic review of six retrospective case series, Prasad etal.
(2018) explored implant utilization trends and mid-term
outcomes of primary TKA in 82 patients with poliomyelitis. The mean age of the patients was 63years. Thirtysix patients (44%) possessed preoperative recurvatum
deformities ranging from 5° to 30°. Cruciate- retaining
(CR) implants were used in 24% of patients, PS devices
were used in 35% of patients, VVC implants were used in
14% of patients, and RHs were used in 27% of patients.
At a mean follow-up of 6years, there were only 6 patients
(7%) who required revision TKA. Indications for revision included PJI (2 patients), instability (2 patients),
periprosthetic fracture (1 patient), and aseptic loosening
(1 patient). Ten (28%) of the 36 patients with a preoperative recurvatum deformity developed recurrent deformity after surgery. Although this complication was
observed most commonly in patients who received CR
devices (5 patients), deformity recurrence was also
observed in 4 patients who received VVC devices and 1
patient who received an RH.Only 2 patients with post-
ab
. Fig. 35.11 Preoperative radiographs including anteroposterior a
and lateral b views of a patient with neuropathic arthropathy of the
right knee demonstrating extensive bony destruction of the distal
femur and proximal tibia. Images c and d demonstrate intraoperative
photographs of the left knee of the same patient
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operative deformity recurrence required revision TKA
and were successfully treated by increasing the level of
implant constraint.
35.5 Clinical Outcomes
35.5.1 Short- andMid-Term Outcomes
The increased utilization of RHs in primary TKA has
been supported in the literature by a number of studies
demonstrating that the early outcomes of these devices
are comparable to implants with lesser constraint. In a
retrospective analysis of the National Joint Registry for
England and Wales, Baker etal. (2014) found that the
mid-term survival of RHs in primary TKA was similar
to unconstrained implants irrespective of the indication
for surgery. Their study included 964 patients with a
mean age of 73years who underwent primary TKA with
several types of RHs. Indications for surgery included
osteoarthritis (71%), inammatory arthritis (10%), and
post-traumatic arthritis (8%). The survivorship free of
all-cause revision for the entire cohort at 5 years was
97% and was not dependent on the primary indication
for surgery. Specically, the 5-year survivorship free of
all-cause revision was 97% for patients with osteoarthritis, 96% for patients with inammatory arthritis, and
100% for patients with post-traumatic arthritis (p=not
signicant). The authors noted that these survival rates
were comparable to the 5-year survivorship free of allcause revision of cemented, unconstrained primary
TKAs reported in the same National Registry database
(96%) and the Australian National Registry database
(95%). Multiple studies have similarly demonstrated
promising short- and mid-term survivorship of RHs
in primary TKA for multiple indications (Zhang etal.
2014; Bistol etal. 2013; Bohler etal. 2017; Sanguineti
etal. 2014; Badawy etal. 2019; Efe etal. 2012; Neri etal.
2019; Kowalczewski etal. 2014).
> Based on these results, many authors consider RHs as
not only necessary but also safe and effective options
for complex primary TKA in elderly patient populations.
types of RHs at a single tertiary referral center between
1979 to 2013. Indications included degenerative joint
disease (19%), congenital or pediatric conditions (13%),
post-traumatic arthritis (12%), inammatory arthritis
(2%), and other (53%). Kaplan–Meier estimated survivorship free of all-cause revision was 75% at 10years
but decreased to 40% at 20years. The estimated survivorship free of all-cause re-operation for this cohort was
even lower at both 10years (49%) and 20years (17%).
In the same study, the authors subsequently com-
pared the survivorship of RHs to VVC (n= 427) and
unconstrained (n = 27,994) devices in patients who
underwent primary TKA for similar indications. After
adjusting for potential confounding factors, the estimated survivorship free of all-cause revision was not
signicantly different between the RH and unconstrained cohorts at 10 and 20 years (Hazard Ratio
[HR]=1.5; p=0.05). However, the adjusted survivorship free of all-cause re-operation was signicantly
lower in patients with RHs compared to the unconstrained cohort at 10 and 20years (HR=2.07; p<0.001).
The increased rate of re-operation in the RH cohort was
primarily attributed to higher risk of infection (HR=4;
p<0.001) and wound complications (HR=2; p<0.001).
> It is important to note that the mean age of patients
who received RHs in this study was signicantly lower
than the studies demonstrating favorable short- and
mid-term outcomes of these devices.
Further, congenital and pediatric conditions or “other”
diagnoses were cited as the primary indication for RH
in more than half of the patients in this study. These
characteristics likely contributed to the considerably
lower survivorship reported in this cohort at a longer
follow-up.
> Nevertheless, these results suggest that the early com-
parable outcomes of RHs to devices with lesser constraint may not persist with longer follow-up and
caution should, therefore, be exercised when utilizing
RHs in younger patient populations.
35.6 Complications
35.5.2 Long-Term Outcomes
Currently, there is a paucity of studies in the literature
that have investigated the long-term outcomes of RHs
in primary TKA.To our knowledge, Martin etal. (2016)
has published the only study reporting on the long-term
survival of these implants in primary arthroplasty setting. Their study included 246 patients with a mean age
of 52years who underwent primary TKA with several
35.6.1 Early Perioperative Complications
Although the utilization of RHs in primary TKA is often
reserved for complex pathology in patients who often
have multiple co-morbid conditions, the early perioperative complications do not appear different to patients
undergoing TKA with implants of lesser constraint.
Sodhi etal. (2018) recently used the American College
of Surgeons National Surgical Quality Improvement
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Program database to investigate the differences in the
30-day perioperative outcomes of over 151,000 TKAs
performed in the United States between 2011 and 2015.
In their study, the authors identied 99 patients with
a mean age of 67years who underwent primary TKA
with several types of RHs. Indications for RH were
not specied beyond excluding patients who underwent conversion or revision TKA or who received an
RH for malignancy. These patients were subsequently
propensity score-matched to a group of patients who
underwent primary TKA with unconstrained devices in
a 1:3 ratio based on patient demographics and medical
co-morbidities. Although the adjusted mean operative
times in the RH cohort were signicantly higher than
the unconstrained cohort (116 vs. 94min, p<0.001), no
differences were observed in 30-day readmission rates
(6% vs. 2%, p=0.1) or complication rates (13% vs. 12%,
p=0.86) between groups.
35.6.2 Delayed Complications
The comparable early perioperative complications
between patients undergoing primary TKA with RHs
and unconstrained devices may not persist with longer
follow-up. In a retrospective analysis of the Norwegian
Arthroplasty Register, Badawy etal. (2019) found that
the risk of revision of RHs at a mid-term follow-up
was signicantly higher than implants with lesser constraint. In their study, the authors identied 197 patients
with a mean age of 67 years who underwent primary
TKA with several types of RHs between 1994 and 2017.
Indications for surgery included osteoarthritis (33%),
inammatory arthritis (8%), post-fracture arthritis
(14%), post-ligament injury (19%), post-infection (5%),
instability (6%), neurologic sequelae (5%), and other
(10%). The authors compared the mid-term risk of revision of RHs to patients who underwent primary TKA
with VVC (n = 204) and unconstrained (n = 71,515)
implants for similar indications during the same timeframe. Kaplan–Meier estimated survivorship free of
all-cause revision at 5years was 95% for unconstrained
devices, 94% for VVC devices, and 86% for RHs. After
adjusting for potential confounding factors, patients
who underwent primary TKA with RHs demonstrated
a signicantly higher risk of revision compared to the
unconstrained cohort (HR=2.4; p < 0.001). Infection
was the major complication necessitating revision TKA
in all of the groups; however, this complication contributed to a higher percentage of revisions in the RH
cohort (73%), compared to the VVC (4%) and unconstrained (22%) cohorts. Interestingly, when revision for
infection was excluded from the analysis, Kaplan–Meier
estimated survivorship at 5years was 96% for all three
groups.
> Infection has been persistently demonstrated to be
the most common complication requiring revision of
contemporary RH devices in multiple studies (Bistol
etal. 2013; Neri etal. 2019; Yang etal. 2012; Guenoun
etal. 2009).
While the increased risk of infection associated with
RHs is multifactorial, poor host characteristics, deformity complexity, and the increased operative time
required to perform these procedures likely play predominant roles. Managing PJI in patients with RHs can
be particularly challenging. Successful removal of the
long stems and robust cement mantles often seen with
these devices can predispose patients to other complications, particularly intraoperative fractures (Gehrke etal.
2014). Furthermore, the resultant bony defects and liga-
mentous instability that remain after explanation limit
options for staged re-implantation. Consequently, Gehrke etal. (2014) recommend the use of shorter stems and
modular versions of hinged implants during the index
procedure to help mitigate the future risk of complications should revision TKA be required for any reason.
> It is our recommendation that shorter cemented stems
with metaphyseal cones be utilized for this reason.
The incidence of failure of RHs attributable to aseptic loosening has signicantly decreased with modern
designs, but it remains a relatively common mode of
failure of these implants at mid-term follow-up. Neri
etal. (2019) investigated the survival rate and complication prole of several types of RHs in a cohort of 112
patients with a mean age of 68 years who underwent
primary TKA at 14 centers between 2006 and 2011.
Indications for surgery were severe deformity (55%),
arthritis and arthropathy (35%), and ligamentous deciency/instability (10%). The overall complication rate
in this cohort was 25% at a mean follow-up of 7years.
While the most common complication observed in these
patients was infection (11%), aseptic loosening occurred
in 4% of patients at this mid-term follow-up. Other
complications requiring revision cited in this study
included stiffness (5%) and patellofemoral instability
(4%). Multiple studies have demonstrated similar rates
of aseptic loosening of contemporary RHs at mid-term
follow-up (Baker etal. 2014; Bistol etal. 2013; Badawy
etal. 2019).
The utilization of uncemented highly porous metaph-
yseal cones may be a successful technique to mitigate the
risk of aseptic loosening in primary TKA with contemporary RHs. Highly porous metaphyseal cones have
been demonstrated in the literature to successfully reduce
the risk of aseptic loosening in revision TKA by decreasing stress at the bone–cement interface (Meneghini etal.
2009; Kamath etal. 2015). The role of these augments in
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primary TKA has been less studied. Cottino etal. (2017)
recently reported on the mid-term outcomes of 392
patients (408 knees) who received several types of RHs at
a single academic institution between 2002 and 2012 for
various non-oncologic indications including complex
primary (18%) and revision (82%) TKA (Cottino etal.
2017). Mean age of patients was 69years. Highly porous
metaphyseal cones (Trabecular Metal; Zimmer, Warsaw,
IN) were utilized in 28% of the patients. Although the
authors reported that the cumulative incidence of any
revision in this cohort was 10% at 2 years and 23% at
10years, the cumulative incidence of revision for aseptic
loosening was only 2% at 2 years and 5% at 10years.
Kaplan–Meier survivorship analysis demonstrated a
trend toward a lower risk of revision in the cohort of
patients with highly porous metaphyseal cones, but this
was not statistically signicant (HR=0.69; p=0.20).
> These results suggest that the utilization of highly
porous metaphyseal cone augments may reduce the
risk of failure of contemporary RHs attributed to
aseptic loosening at mid-term follow-up, but further
studies investigating these augments in complex primary TKA at longer follow-up are needed.
Take-Home Messages
5 The primary non-oncologic indications for contem-
porary RHs in primary TKAs include elderly patient
populations with gross knee instability, excessive
femoral or tibial bone loss, severe coronal or sagittal
deformity, or incompetent extensor mechanisms.
5 The mid-term outcomes and implant survivorship
of RHs in primary TKAs appear comparable to
implants with lesser constraint in large registry
databases, but these comparable outcomes may not
persist with longer follow-up.
5 PJI remains the most common complication
requiring revision in primary TKAs with RHs and
patients with modiable risk factors should
undergo optimization prior to proceeding with surgical intervention.
5 Failure of RHs attributable to aseptic loosening
has decreased with improvements in implant
design, but remains a common mode of failure at
mid-term follow-up.
5 The risk of aseptic loosening with RHs in primary
TKA may be further mitigated by the concomitant
utilization of highly porous metaphyseal cones, but
additional studies are needed.
Conclusion
z
There has been a wave of enthusiasm for the use of
RHs in complex primary TKAs. While the specic nononcologic indications for the use of these devices in primary TKA remain controversial, many authors agree
that RHs may be safely and effectively utilized in elderly
patient populations with knee pathology that precludes
the use of implants with lower levels of constraint.
Specically, patients with gross knee instability, excessive femoral or tibial bone loss, severe coronal or sagittal deformity, or incompetent extensor mechanisms may
benet from an RH TKA.The mid-term outcomes and
survivorship of RHs in primary TKAs support their use
in elderly patients as they appear comparable to implants
with lesser constraint. However, the high failure rates of
RHs demonstrated with longer follow-up warrants surgeons to exercise caution when selecting these implants,
especially in younger patient populations. Infection
remains the most common complication requiring revision in RHs and this risk appears to be multifactorial in
nature. Consequently, it is imperative that patients with
modiable risk factors for infection be effectively optimized prior to undergoing surgery. While the incidence
of aseptic loosening has signicantly improved with
modern implant designs, it remains a common mode of
failure at mid-term follow-up. The concomitant utilization of highly porous metaphyseal cones with RHs may
further decrease the risk of aseptic loosening in contemporary RHs, but further studies are required.
References
Badawy M, Fenstad AM, Furnes O (2019) Primary constrained and
hinged total knee arthroplasty: 2- and 5-year revision risk compared with unconstrained total knee arthroplasty: a report on
401 cases from the Norwegian Arthroplasty Register 1994-2017.
Acta Orthop 5:467–472
Bae DK, Song SJ, Yoon KH, Noh JH (2009) Long-term outcome of
total knee arthroplasty in Charcot joint: a 10- to 22-year follow up. J Arthroplasty 8:1152–1156
Baker P, Critchley R, Gray A, Jameson S, Gregg P, Port A, Deehan
D (2014) Mid-term survival following primary hinged total knee
replacement is good irrespective of the indication for surgery.
Knee Surg Sports Traumatol Arthrosc 3:599–608
Barrack RL (2001) Evolution of the rotating hinge for complex total
knee arthroplasty. Clin Orthop Relat Res 392:292–299
Bistol A, Lustig S, Rosso F, Dalmasso P, Crova M, Massazza G
(2013) Results with 98 Endo-Modell rotating hinge prostheses
for primary knee arthroplasty. Orthopedics 6:e746–e752
Bohler C, Kolbitsch P, Schuh R, Lass R, Kubista B, Giurea A (2017)
Midterm results of a new rotating hinge knee implant: a 5-year
follow-up. Biomed Res Int 2017:7532745
Chelman B, Walker PS, Shoji H, Erkman MJ (1975) Kinematics of
the knee after prosthetic replacements. Clin Orthop Relat Res
108:149–157
Cottino U, Abdel MP, Perry KI, Mara KC, Lewallen DG, Hanssen
AD (2017) Long-term results after total knee arthroplasty with
contemporary rotating-hinge prostheses. J Bone Joint Surg Am
4:324–330
Dauwe J, Vandenneucker H (2018) Indications for primary rotating-
hinge total knee arthroplasty. Is there consensus? Acta Orthop
Belg 3:245–250
408
https://t.me/medicina_free
B. M. Wooster and M. P. Abdel
35
Efe T, Roessler PP, Heyse TJ, Hauk C, Pahrmann C, Getgood A,
Schmitt J (2012) Mid-term results after implantation of rotatinghinge knee prostheses: primary versus revision. Orthop Rev
(Pavia) 4:e35
Flynn LM (1979) The noiles hinge knee prosthesis with axial rota-
tion. Orthopedics 6:602–605
Gehrke T, Kendoff D, Haasper C (2014) The role of hinges in pri-
mary total knee replacement. Bone Joint J 11(Supple A):
93–95
Guenoun B, Latargez L, Freslon M, Defossez G, Salas N, Gayet LE
(2009) Complications following rotating hinge Endo-Modell
(Link) knee arthroplasty. Orthop Traumatol Surg Res 7:529–536
Herbert JJ, Herbert A (1973) A new total knee prosthesis. Clin
Orthop Relat Res 94:202–210
Hoogland T, Bosma G (1981) The Attenborough total knee arthro-
plasty. Neth J Surg 5:237–242
Jackson JP, Elson RA (1973) Evaluation of the Walldius and other
prostheses for knee arthroplasty. Clin Orthop Relat Res 94:
104–114
Jones GB (1973) Total knee replacement-the Walldius hinge. Clin
Orthop Relat Res 94:50–57
Jones RE (2006) Total knee arthroplasty with modular rotating-
platform hinge. Orthopedics 9(Suppl):S80–S82
Kamath AF, Lewallen DG, Hanssen AD (2015) Porous tantalum
metaphyseal cones for severe tibial bone loss in revision knee
arthroplasty: a ve to nine-year follow-up. J Bone Joint Surg Am
3:216–223
Kester MA, Cook SD, Harding AF, Rodriguez RP, Pipkin CS (1988)
An evaluation of the mechanical failure modalities of a rotating
hinge knee prosthesis. Clin Orthop Relat Res 228:156–163
Knutson K, Lindstrand A, Lidgren L (1986) Survival of knee arthro-
plasties. A nation-wide multicentre investigation of 8000 cases. J
Bone Joint Surg Br 5:795–803
Kowalczewski J, Marczak D, Synder M, Sibinski M (2014) Primary
rotating-hinge total knee arthroplasty: good outcomes at midterm follow-up. J Arthroplasty 6:1202–1206
Lettin AW, Deliss LJ, Blackburne JS, Scales JT (1978) The Stanmore
hinged knee arthroplasty. J Bone Joint Surg Br 3:327–332
Martin JR, Beahrs TR, Stuhlman CR, Trousdale RT (2016) Complex
primary Total knee arthroplasty: long-term outcomes. J Bone
Joint Surg Am 17:1459–1470
Matthews LS, Sonstegard DA, Kaufer H (1973) The spherocentric
knee. Clin Orthop Relat Res 94:234–241
Mazas FB (1973) Guepar total knee prosthesis. Clin Orthop Relat
Res 94:211–221
Meneghini RM, Lewallen DG, Hanssen AD (2009) Use of porous
tantalum metaphyseal cones for severe tibial bone loss during
revision total knee replacement. Surgical technique. J Bone Joint
Surg Am 91:131–138
National Joint Registry for England and Wales (2010) 8th Annual Report.
https://www.njrcentre.org.uk/njrcentre/Portals/0/Documents/
NJR%208th%20Annual%20Report%202011pdf
Neri T, Boyer B, Papin PE, Martz P, Vaz G, Eichler D, Ehlinger M,
Pasquier G (2019) Contemporary rotating hinge arthroplasty
can safely be recommended in complex primary surgery. Knee
Surg Sports Traumatol Arthrosc
Norwegian National Advisory Unit on Arthroplasty and Hip
Fractures; Report June 2019 (2019). http://nrlweb.ihelse.net/eng/
Rapporter/Report2019_english.pdf
Prasad A, Donovan R, Ramachandran M, Dawson-Bowling S,
Millington S, Bhumbra R, Achan P, Hanna SA (2018) Outcome
of total knee arthroplasty in patients with poliomyelitis: a systematic review. EFORT Open Rev 6:358–362
Sanguineti F, Mangano T, Formica M, Franchin F (2014) Total knee
arthroplasty with rotating-hinge Endo-Model prosthesis: clinical results in complex primary and revision surgery. Arch Orthop
Trauma Surg 11:1601–1607
Sculco TP (2006) The role of constraint in total knee arthoplasty. J
Arthroplasty 4(Suppl 1):54–56
Sheehan JM (1978) Arthroplasty of the knee. J Bone Joint Surg Br
3:333–338
Shiers LG (1954) Arthroplasty of the knee; preliminary report of
new method. J Bone Joint Surg Br 4:553–560
Sodhi N, Patel YH, George J, Sultan AA, Anis HK, Newman JM,
Kryzak TJ, Khlopas A, Moskal JT, Mont MA (2018) Operative
time, length of stay, short-term readmission, and complications
after hinged primary total knee arthroplasty: a propensity score
matched analysis. J Knee Surg 10:940–945
Tibbo ME, Chalmers BP, Berry DJ, Pagnano MW, Lewallen DG,
Abdel MP (2018) Primary total knee arthroplasty in patients
with neuropathic (Charcot) arthropathy: contemporary results. J
Arthroplasty 9:2815–2820
Tigani D, Fosco M, Amendola L, Boriani L (2009) Total knee
arthroplasty in patients with poliomyelitis. Knee 6:501–506
Yang JH, Yoon JR, Oh CH, Kim TS (2012) Primary total knee
arthroplasty using rotating-hinge prosthesis in severely affected
knees. Knee Surg Sports Traumatol Arthrosc 3:517–523
Zhang F, Liu Y, Xiao Y, Liu W (2014) Clinical outcomes of primary
rotating-hinge knee arthroplasty for knees with severe deformity.
Chin Med J 9:1791–1793
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