Acta Orthop. Belg.

, 2018 84, 245-250 ORIGINAL STUDY

Indications for primary rotating-hinge total knee arthroplasty.

Is there consensus?

Jan Dauwe, Hilde Vandenneucker

From the University Hostipals Leuven, Belgium

The use of rotating-hinge systems in total knee regarding the use on rotating-hinge prostheses in
arthroplasty is most often seen in revision setting total knee arthroplasty (TKA) is contradictory.
where excessive bone loss, ligamentous instability and/ Several authors consider such devices to be useful in
or extensor mechanism dysfunction may necessitate salvage procedures after numerous failed revisions.
an increased level of component constraint. However, Others have described encouraging outcomes
this implant type is also being increasingly used in
regarding revision surgery; especially for (a)septic
the primary setting. The aim of this study is to review
literature concerning the use of third generation
loosening and persistent ligamentous instability
rotating-hinge devices focusing on the indications for (10,11,14,15,20) and even primary TKA for severe
primary cases. varus/valgus deformities or instable knee joints (10).
Literature was searched for following search Data reported in literature about fully constraint
terms: total knee arthroplasty, primary indication, knee implants in revision setting are abundant, while
constraint, rotating hinge knee, knee prosthesis, evidence on the use of rotating-hinge knee systems
hinged knee, total knee replacement. Additional in primary TKA is scarce. However, rotating-hinge
papers were identified by screening references and devices in total knee arthroplasty are increasingly
similar articles. All papers dealing with first or second used in primary setting (2). The small number of
generation rotating-hinge implants and revision cases published clinical studies pertaining to primary
were discarded. hinged knee replacement suggests that this type of
After conducting a large literature search, we
implant involves functional improvements and rates
concluded that third generation rotating-hinge
implants should be considered in limited indications
of survival comparable to conventional cemented
in which ligamentous tibiofemoral instability is the knee replacements (1-3,6,7,13,17-19,22,26,31,33,35-37).
core indication. Nevertheless, Martin et al. recently published data
showing that the survival free from revision surgery
Keywords: Rotating-hinge ; primary ; total knee arthro- is significantly lower in rotating-hinge devices
plasty ; hinged knee.

INTRODUCTION n Jan Dauwe.

n Hilde Vandenneucker.
Rotating-hinge knee prostheses are fully University Hospitals Leuven, Belgium.
constraint knee implants that offer maximal stability Correspondence : Jan Dauwe, UZ Leuven, Herestraat 49,
to the knee joint. Evidence found in literature 3000 Leuven, Belgium
E-mail : [email protected]
© 2018, Acta Orthopaedica Belgica.

No benefits or funds were received in support of this study.

The authors report no conflict of interests. Acta Orthopædica Belgica, Vol. 84 - 3 - 2018

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 246 jan dauwe, hilde vandenneucker

compared to unconstraint implants, especially after MATERIALS AND METHODS

a long-term follow-up (30).
The aim of this study is to review literature A literature search was conducted in databases
concerning the use of third generation rotating- PubMed and Web of Science using the following
hinge implants in primary cases focusing on the search terms: total knee arthroplasty, primary
operative indications. indication, constraint, rotating hinge knee, knee
The amelioration in biomechanical design of prosthesis, hinged knee, total knee replacement.
the hinged knee prosthesis has had a big impact Systematic reviews and clinical trials with at least
on clinical results. Therefore, we present a short evidence level IV were included. A minimum
overview of the history and evolution in design of follow-up of two years was required and clinical
the rotating-hinge knee implant. trials older than fifteen years were discarded. Other
The first hinged total knee prosthesis was exclusion criteria were the use of first or second
introduced by Walldius in 1951. First generation generation rotating-hinge prostheses and revision
hinge prostheses were highly constraint, allowing TKA. Additional papers were found by screening
only simple flexion and extension. These constraint reference lists and similar articles. Abstract was the
designs transferred high stresses to the implant- first step for evaluation and full text was obtained
cement-bone interfaces, resulting in early prosthetic where needed. All clinical trials withheld from
loosening. Overall, these generation of prostheses literature matching our inclusion criteria were
had unacceptable complications and early failure searched for primary indications. Furthermore,
rates (16). Literature also learned us that relative our review was supported using the PRISMA
maltracking of the patella was described when guidelines (27).
using simple fixed hinged implants.
A second generation of hinged prostheses RESULTS
followed with design modifications that decreased
prosthetic constraint by including axial rotation and Eleven retrospective clinical studies published in
varus-valgus motion of the hinge. These hinged medical literature matched our provided inclusion
knee designs were a clinical improvement, but criteria and are enlisted in table I. This overview
unacceptably high failure rates and numerous table shows a promising series of survival rates
complications continued (16,24,32). Generally, ranging from 75% to 100% with a minimum
second generation implants are no longer used. follow-up of twenty-eight months and a maximum
Further design evolution led to third generation of fifteen years. In every clinical trial failure was
modular, mobile bearing, hinged prostheses. These defined as revision surgery for any cause.
implants demonstrated significant improvements in Indications for the use of rotating-hinge implants
design with concomitant improvements in clinical in primary setting were predominantly collateral
results in short- and midterm follow-up (3,4,18,19). ligament insufficiency, bony destruction of
Besides, the phenomena of relative maltracking the distal femur or proximal tibia, hyperlaxity,
of the patella has been solved with the rotational hyperextension, axial deformity of more than 20
hinged prostheses allowing internal and external degrees, severe rheumatoid arthritis or Charcot
movement in the knee joint (9,23). arthropathy. These indications proposed by Gehrke
Additional follow-up and research is necessary to et al. (9) are a brief summary of all indications
evaluate the long-term success of third generation summed up in other clinical studies we extracted
implants. However, a very recent study published from literature. Furthermore, this research group
in The Bone and Joint Journal showed some stated that patients younger than 75 years in
contrasting results (30). whom stability could be obtained with unconstraint
implants are contraindicated for the use of a
rotating-hinge device. This limitation is based
on the fact that possible revisions and fixations

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 indications for primary rotating-hinge total knee arthroplasty 247

techniques could be problematic after cementing primary setting. Implant survival and functional
the tibial and femoral long stems of the implant at improvements after primary rotating-hinge TKA
index procedure. were comparable to conventional unconstraint knee
Gehrke et al. (9) and Martin et al. (30) published replacement designs. Rates of failure were similar
both comprehensive retrospective clinical trials, irrespective of the indications for surgery. The five-
respectively including 238 and 246 patients. These year survival rate was 96.8% in a large analysis
studies were the biggest clinical trials found in of 964 patients undergoing primary hinged TKA
literature. The latter is the only paper presenting between 2003 and 2010. Various hinged models
long-term results of primary TKA using rotating- were used but commonest implants were third
hinge implants. After a follow-up period of twenty generation rotating hinges. Primary indications
years, Martin et al. (30) presented a survival rate of were not reported clearly. In contrast to this cohort
40.3% whereas at ten years of follow-up the overall study, Martin et al. (30) presented findings of
implant revision-free survival was 74.6%. In this implant failure rates significantly higher in rotating-
study the data were compared to those for routine, hinge population compared to patients undergoing
non-constraint TKA, and showed a survival rate at unconstraint primary TKA. It is likely that the
ten years and twenty years of respectively 94.2% implant survivorship in the rotating-hinge group
and 84.6%. was lower than in the unconstraint group because of
Additionally, primary neuromuscular indications the nature of the underlying abnormalities present
for rotating-hinge TKA in primary setting were in this cohort of patients. To our best of knowledge,
not described in any clinical trial enlisted in table Martin et al. conducted the largest series of 246
I. However, Jones et al. (19) published a review in primary rotating-hinge patients in one clinical trial
which flail knee and poliomyelitis were cited as and were the first publishing long-term results of
neuromuscular indications for this implant type. twenty years follow-up.
Patients with these deficits might benefit from the Analogously with data of Baker et al. (2), our
rotating-hinge knee system as hyperextension stop. literature search revealed survival rates ranging from
75 to 100% at short-and midterm follow-up (Table
DISCUSSION I). These numbers have to be interpret carefully.
A first remark comprised the survival rate of 89%
To our knowledge, indications for rotating-hinge in both clinical trials of Guenoun et al. (12) and
devices in primary TKA are very vague and barely Hernandez-Vaquero et al. (13) respectively at three
reported in literature. Several authors are somewhat and four years follow-up. Guenoun et al. included
aloof with the use of this implant because of 33 of 85 patients undergoing a rotating-hinge TKA
its notorious history of complications and assess in revision setting, whereas Hernandez-Vaquero et
none or very narrow indications. Anyhow, the al. included only five patients undergoing primary
small number of published reports suggests that rotating-hinge TKA of a total of twenty-six patients.
these implants produce functional improvement Secondly, Kowalczewski et al. (25) included a very
and rates of survival comparable to conventional small number of twelve patients resulting in a
unconstraint TKA. Furthermore, it should be noted less reliable but maximal survival rate of hundred
that rotating-hinge devices are being increasingly percent at ten years follow-up.
used in primary setting by orthopaedic and trauma Lozano et al. (28) conducted an observational
surgeons all over the world. clinical study comparing preoperative WOMAC
In a level II prospective cohort study, Baker (Western Ontario and McMaster Universities)
et al. (2) revealed promising findings concerning index to postop WOMAC score after primary
primary third generation rotating-hinge prostheses. third generation rotating-hinge TKA. Lozano et
The research group concluded that hinged knee al. reported a statistically significant improvement
replacement can be considered as a viable alternative in WOMAC index in patients with a BMI (Body
to traditional unconstraint designs in complex Mass Index) of 35-40 kg/m2. The change in obese

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Table I. — Literature summary of third generation rotating-hinge implants used in primary total knee arthroplasty ranked chronologically.
Survival rate in all clinical studies is free from revision for any cause.

Clinical study Year Number of Primary indications Follow-up Results

implants
Petrou et al. (33) 2004 100 Osteoarthritis, rheumatoid arthritis 11 years Survival rate: 96%
(7-15) (15 years)
Guenoun et al. (12) 2009 52/85 Osteoarthritis, tumour (1 case) 36 months Survival rate: 89% (3
(0-75) years)
Hernandez-Vaquero et al. (13) 2010 5/26 Bone loss, medial ligamentous 46 months Survival rate: 89% (4
instability, varus/valgus deformity (24-107) years)

Yang et al. (37) 2011 50 Osteoarthritis, rheumatoid arthritis, 15 years Survival rate: 87%
ligament instability, axial defor- (10-18) (15 years)
mity, posttraumatic arthritis

Efe et al. (8) 2012 21/49 Osteoarthritis, rheumatoid arthritis, 55 months Survival rate: 95%
posttraumatic arthritis (10-133) (prim)

Lozano et al. (28) 2012 111 Osteoarthritis and varus/valgus de- 28 months Survival rate was not
formity due to rheumatoid arthritis (17-36) clearly declared. Six
and posttraumatic arthropathy deep infections were
reported.
Bistolfi et al. (5) 2013 72 Axial defects, rheumatoid arthritis, 174 months Survival rate: 86% (5
tibial plateau fracture, secondary (156-193) years)
arthritis after tibial osteotomy
Kowalczewski et al. (25) 2013 12 Joint destruction, axial deformities, Minimum Survival rate: 100%
MCL disruption 10 years (10 years)
Sanguineti et al. (34) 2014 25/45 Osteoarthritis, rheumatoid arthritis, 42 months Survival rate: 96% (5
posttraumatic arthritis (20-128) years)
(prim)
Gehrke et al. (9) 2014 238 Patients >75 years: 13,5 years Survival rate:
+ collateral ligament insufficiency 90% (13 years)
or
+ bony destruction of tibial plateau
or femoral condyles
+ hyperlaxity or
+ hyperextension or
+ fixed varus/valgus deformity >
20° or
+ severe rheumatoid arthritis or
Charcot joint
Martin et al. (30)l 2016 246 Degenerative joint disease, post- 20 years Survival rate: 75%
traumatic arthritis, inflammatory (10 years), 40% (20
arthritis, congenital or paediatric years)
condition

patients was statistically significant with respect severe and morbid obesity population. The research
to both non-obese and overweight patients. To our group did not suggest possible explanations for
knowledge, this clinical study was the only one this significant improvement in obese patients. In
found in literature assuming that this type of implant our opinion and experience, primary rotating-hinge
device could be functionally more beneficial in a devices could be an indication in severe and morbid

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 indications for primary rotating-hinge total knee arthroplasty 249

obesity patients since the higher risk of progressive generally excellent (29). Nevertheless, we suggest
ligamentous insufficiency of the knee joint due that a prospective randomised controlled trial
to extra weight. However, it should be taken into concerning ‘border indications’ e.g. severe or
account that Katzer et al. (21) reported that obesity morbid obesity, neurological diseases eventually
was a predisposing factor for prosthetic loosening. resulting in insufficient muscular control, should
Anyhow, Body Mass Index should be considered be considered for approval by the ethical boards.
as an important factor in preoperative planning of It is clear that in those situations preoperative knee
primary rotating-hinge total knee arthroplasty. stability is endangered. According to us, those
The principle aim in the current literature high-quality clinical studies in order to improve the
review was to provide indications for the use of evidence based medicine information concerning
rotating-hinge devices in primary setting. Recent the use of fully constraint implants in primary TKA
literature was consulted and primary indications are required.
were extracted out of eleven retrospective clinical By conclusion, hinged total knee arthroplasty in
trials. We suggest that indications for the use of general has undergone a unique design evolution.
rotating-hinge implants in primary setting should be Despite this evolution, the lowest amount of
collateral ligament insufficiency, bony destruction implant constraint to achieve a stable and functional
of the distal femur or proximal tibia, hyperlaxity, knee should be used at primary surgical procedure
hyperextension, axial deformity of more than 20 based on mid-term and especially long-term results
degrees, severe rheumatoid arthritis or Charcot presented in the current review. Third generation
arthropathy in patients older than seventy-five. rotating hinges should be reserved for specific
An exception should be made for oncological indications with ligamentous instability as overall
indications. We were not able to find new or indication since we believe that tibiofemoral
modern indications in current literature. Although instability is the final result of all other indications
we propose considering severe and morbid obesity mentioned in medical literature.
(BMI ≥35-40 kg/m2) as an extra positive criteria in
primary rotating-hinge knee surgery after correct
indication assessment. REFERENCES
In our opinion, this literature review cannot
be considered as a guideline for indications of 1. Appleton P, Moran M, Houshian S, Robinson CM.
rotating-hinges in primary setting but provides us Distal femoral fractures treated by hinged total knee
replacement in elderly patients. J Bone Joint Surg Br. 2006 ;
of a summary of most important and most frequent 88 :1065-70.
indications. There are no randomised controlled 2. Baker P, Critchley R, Gray A, Jameson S, Gregg P, Port
trials existing in literature comparing survival rates A, et al. Mid-term survival following primary hinged total
or outcomes between third generation rotating- knee replacement is good irrespective of the indication for
hinge designs and routine unconstraint implants in surgery. Knee Surgery, Sport Traumatol Arthrosc. 2014 ;
22 : 599-608.
primary TKA. This lack of high evidence studies
3. Barrack R, Lyons T, Ingraham R, Johnson J. The use
may seem obvious taking the ethical point of of a modular rotating hinge component in salvage revision
view into account. We agree that randomisation total knee arthroplasty. J Arthroplasty. 2000 ; 15 : 858-66.
of patients for an unconstraint implant or a fully 4. Barrack R. Evolution of the rotating hinge for complex
constraint rotating-hinge device, without correcting total knee arthroplasty. Clin Orthop Relat Res. 2001 ;
292-9.
for possible indications requiring a more constraint 5. Bistolfi A, Lustig S, Rosso F, et al. Results With 98
design, would be an ethical issue. First of all will Endo-Modell Rotating Hinge Prostheses for Primary Knee
an unconstraint knee implant most certainly fail Arthroplasty. Orthopedics. SLACK Incorporated; 2013 ;
when using in conditions of severe bone loss or 36 : 746-52.
6. Böhm P, Holy T. Is there a future for hinged prostheses
ligamentous insufficiency. Secondly, the results in primary total knee arthroplasty? A 20-year survivorship
of conventional primary TKA for well-assessed analysis of the Blauth prosthesis. J Bone Joint Surg Br.
indications such as end-stage osteoarthritis are 1998 ; 80 : 302-9.

Acta Orthopædica Belgica, Vol. 84 - 3 - 2018

Dauwe.indd 249 1/02/19 14:58

 250 jan dauwe, hilde vandenneucker

7. Choong P, Sim F, Pritchard D, et al. Megaprostheses after 24. Knutson K, Knutson K, Lindstrand A. Survival of Knee
resection of distal femoral tumors. A rotating hinge design Arthroplasties - A Nation-wide multicentre investigation of
in 30 patients followed for 2-7 years. Acta Orthop Scand. 8000 cases. J Bone Jt Surg. 1986 ; 68 : 795-803.
1996 ; 67 : 345-51. 25. Kowalczewski J, Marczak D, Synder M, Sibiński M.
8. Efe T, Roessler P, Heyse T, et al. Mid-term results after Primary rotating-hinge total knee arthroplasty: Good
implantation of rotating-hinge knee prostheses: primary outcomes at mid-term follow-up. J Arthroplasty. 2014 ;
versus revision. Orthop Rev (Pavia). 2012 ;4 : e35. 29 : 1202-6.
9. Gehrke T, Kendoff D, Haasper C. The role of hinges in 26. Lachiewicz P, Soileau E. Ten-Year Survival and Clinical
primary total knee replacement. Bone Joint J. 2014 ; 96-B : Results of Constrained Components in Primary Total Knee
93-5. Arthroplasty. J Arthroplasty. 2006 ; 21 : 803-8.
10. Giurea A, Neuhaus H, Miehlke R, et al. Early results of 27. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA
a new rotating hinge knee implant. Biomed Res Int. 2014 ; statement for reporting systematic reviews and meta-
2014 : 948520. analyses of studies that evaluate health care interventions:
11. Gudnason A, Milbrink J, Hailer NP. Implant survival explanation and elaboration. J Clin Epidemiol. 2009 ; 62 :
and outcome after rotating-hinge total knee revision 1-34.
arthroplasty: a minimum 6-year follow-up. Archives of 28. Lozano LM, Opez V, Ríos J, et al. Clinical Study Better
Orthop Trauma Surg. 2011 ; 1-7. Outcomes in Severe and Morbid Obese Patients (BMI >
12. Guenoun B, Latargez L, Freslon M, et al. Complications 35 kg/m 2 ) in Primary Endo-Model Rotating-Hinge Total
following rotating hinge Endo-Modell knee arthroplasty. Knee Arthroplasty. Sci World J. 2012 ; 5.
Orthop Traumatol Surg Res. 2009 ; 95 :5 29-36. 29. Lützner J, Hübel U, Kirschner S, et al. Langzeitergebnisse
13. Hernández-Vaquero D, Sandoval-García M. Hinged in der Knieendoprothetik. Der Chir. 2011 ; 82 : 618-24.
total knee arthroplasty in the presence of ligamentous 30. Martin J, Beahrs T, Stuhlman C, Trousdale R. Complex
deficiency. Clin Orthop Rel Res Springer-Verlag ; 2010 : Primary Total Knee Arthroplasty. J Bone Jt Surg. 2016 7 ;
1248-53. 98 : 1459-70.
14. Hossain F, Patel S, Haddad F. Midterm assessment of 31. Mavrodontidis A, Andrikoula S, Kontogeorgakos V, et
causes and results of revision total knee arthroplasty. Clin al. Application of the Endomodel rotating hinge knee
Orthop Rel Res. 2010 ; 1221-8. prosthesis for knee osteoarthritis. J Surg Orthop Adv.
15. Hwang S, Kong J, Nam D, et al. Revision total knee 2008 ; 17 : 179-84.
arthroplasty with a cemented posterior stabilized, condylar 32. Morgan H, Battista V, Leopold SS. Constraint in primary
constrained or fully constrained prosthesis: A minimum total knee arthroplasty. J Am Acad Orthop Surg. 2005 ; 13 :
2-year follow-up analysis. Clin Orthop Surg. 2010 ; 2 : 112-20. 515-24.
16. James V, Bono M. Revision Total Knee Arthroplasty. 33. Petrou G, Petrou H, Tilkeridis C, Stavrakis T, Kapetsis
2005. 270. T, Kremmidas N, et al. Medium-term results with a
17. Jones RE, Barrack RL, Skedros J. Modular, mobile- primary cemented rotating-hinge total knee replacement.
bearing hinge total knee arthroplasty. Clin Orthop Relat A 7- to 15-year follow-up. J Bone Joint Surg Br. 2004 ;
Res. 2001 ; 306-14. 86 : 813-7.
18. Jones R, Skedros JG, Chan A, et al. Total knee arthroplasty 34. Sanguineti F, Mangano T, Formica M, Franchin F.
using the S-ROM mobile-bearing hinge prosthesis. J Total knee arthroplasty with rotating-hinge Endo-Model
Arthroplast. 2001 ; 16 : 279-87. prosthesis: clinical results in complex primary and revision
19. Jones R. Total knee arthroplasty with modular rotating- surgery. Arch Orthop Trauma Surg. 2014 ; 134 : 1601-7.
platform hinge. Orthopedics. 2006 ; 29 : 80-2. 35. Sprenger T, Doerzbacher J. Long-term follow-up of the
20. Joshi N, Navarro-Quilis A. Is There a Place for Rotating- GSB II total knee used in primary total knee arthroplasty. J
Hinge Arthroplasty in Knee Revision Surgery for Aseptic Arthroplasty. 2002 ; 17 : 176-83.
Loosening? J Arthroplasty. 2008 ; 23 : 1204-11. 36. van Loon C, Pluk C, de Waal Malefijt M, et al. The
21. Katzer A, Sellckau R, Siemssen W, von Foerstér G. GSB total knee arthroplasty. A medium- and long-term
ENDO-Modell Rotating Knee prosthesis: a functional follow-up and survival analysis. Arch Orthop Trauma
analysis. J Orthop Traumatol. 2002 ; 3 : 163-70. Surg. 2001 ; 121 : 26-30.
22. Kawai A, Healey J, Boland P, et al. A rotating-hinge knee 37. Yang J, Yoon J, Oh C, Kim T. Primary total knee
replacement for malignant tumors of the femur and tibia. J arthroplasty using rotating-hinge prosthesis in severely
Arthroplasty. 1999 ; 14 : 187-96. affected knees. Knee Surg, Sports Trauma, Arthrosc.
23. Keblish P, Varma A, Greenwald AS. Patellar resurfacing Springer-Verlag ; 2012 : 517-23.
or retention in total knee arthroplasty. A prospective study
of patients with bilateral replacements. J Bone Joint Surg
Br. 1994 ; 76 : 930-7.

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