 MANAGEMENT FACTORIALS IN TOTAL KNEE ARTHROPLASTY

The role of hinges in primary total knee

replacement

T. Gehrke, The use of hinged implants in primary total knee replacement (TKR) should be restricted to
D. Kendoff, selected indications and mainly for elderly patients. Potential indications for a rotating
C. Haasper hinge or pure hinge implant in primary TKR include: collateral ligament insufficiency, severe
varus or valgus deformity (> 20°) with necessary relevant soft-tissue release, relevant bone
From HELIOS loss including insertions of collateral ligaments, gross flexion-extension gap imbalance,
ENDO-Klinik, ankylosis, or hyperlaxity. Although data reported in the literature are inconsistent, clinical
Hamburg, Germany results depend on implant design, proper technical use, and adequate indications. We
present our experience with a specific implant type that we have used for over 30 years and
which has given our elderly patients good mid-term results. Because revision of implants
with long cemented stems can be very challenging, an effort should be made in the future to
use shorter stems in modular versions of hinged implants.
Cite this article: Bone Joint J 2014;96-B(11 Suppl A):93–5.

In modern total knee replacement (TKR) the - Hyperlaxity

 T. Gehrke, MD, Consultant
Orthopaedic Surgeon, Surgeon
in Chief
 D. Kendoff, MD, PhD,
Consultant Orthopaedic
Surgeon
 C. Haasper, MD, PhD, MSc,
Consultant Orthopaedic
Surgeon
HELIOS ENDO-Klinik,
Orthopedic Department,
Holstenstr. 2, Hamburg, 20457,
Germany.
Correspondence should be sent
to Professor Dr C. Haasper;
e-mail: carl.haasper@endo.de
©2014 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.96B11.
34143 $2.00
Bone Joint J
2014;(11 Suppl A):93–5.
use of hinge and rotating hinge knee implants
is usually restricted to patients with severe
bony deformities or significant ligamentous
instability.1-4 Nevertheless, constrained pros-
theses still have their place in revision TKR.5,6
While the literature on the techniques and out-
comes of semi- and fully-constrained implants
in revision procedures is abundant, the reports
of the use of such systems in primary TKR are
scarce. Although some authors were able to
show good and excellent clinical results in
91% of patients and consequent survival rates
of a rotating hinge implant of up to 96% in
primary TKR after 15 years, another recent
study reported high complication rates of up to
25% of all operated patients using a rotating-
hinge implant.7
We give a short overview of our indications
for the use of a hinged implant in primary
TKR, including a technique that should lead
to adequate outcomes. We have highlighted
the current literature and briefly report our
experience with this type of implant over the
last 30 years.
Indications and contraindications
Our indications for hinged TKR as a primary
implant are patients older than 75 years with
at least one of the following conditions:
- Collateral ligament insufficiency
- Bony destruction of the tibial plateau or
femoral condyles
- Fixed valgus/varus deformity > 20°
- Severe rheumatoid arthritis
Contraindications include patients younger
than 75 years in whom stability can be
obtained with non-constrained implants. This
major limitation is based on the need to cement
in tibial and femoral long-stems, which makes
further revisions and fixation techniques in the
diaphyseal region problematic. Based on our
experience and data, we prefer the use of non-
rotating hinged implants to rotating ones in
severe valgus malalignment in order to
improve patellar tracking. In case of ipsilateral
hip replacement, a minimum distance of
50 mm should be maintained between the fem-
oral implants to reduce the risk of peri-pros-
thetic fractures.
Surgical technique
All standard approaches can be used and com-
plete detachment of the femoral insertion of
the collateral ligaments can be performed. In
severe valgus conditions, the popliteus tendon
and the lateral portion of the gastrocnemius
may be detached, if necessary.
Maximum rotational stability of the femoral
implant should be obtained in order to ensure
the longevity of the implant. Depending on
implant designs and manufacturer, conven-
tional resection blocks should be used when-
ever available. Special attention should be paid
to the rotational orientation of both the

VOL. 96-B, No. 11, NOVEMBER 2014 93

94 T. GEHRKE, D. KENDOFF, C. HAASPER

Table I. Literature summary of rotational hinged implants used in primary TKR. Some studies including primary and revision indications, as marked
in the type section.

Follow up
Year Type of prosthesis (mean in a) n Cumulative survival rate
Nieder10 1991 ENDO model (Link, Hamburg, Germany) 6.5 1837 95%
Steckel et al14 2005 Blauth (Aesculap, Tuttlingen, Germany) 10 227 90%
Böhm and Holy15 1998 Blauth 20 422 93.6%
Zinck & Sellckau16 2000 ENDO model 5 to 6 2682 > 95%
Blauth and 1990 Blauth 10 497 89%
Hassenpflug17
Guenoun12 2009 ENDO model (primary and revisions) 3 to 4 85 < 85%
Rand et al18 1987 Kinematic rotating hinge (primary and revisions) 4 to 5 50 < 60% (all complications)
(Stryker-Howmedica, Michigan, USA)
Petrou et al11 2004 ENDO model 11 100 96%
Argenson and 2000 ENDO model 6 to 7 194 > 90%
Aubaniac19
Shaw et al20 1989 Kinematic Rotating Hinge (primary and revisions) 2 to 3 54 < 70% (all complications)
Springer et al21 2001 Kinematic rotating hinge 6 69 < 70% (all complications)
Rinta-Kiikaa et al22 1997 ENDO model & Kinematic Rotating Hinge 5 to 6 48 79% to 84%
Westrich et al23 2000 Finn rotating hinge (Biomet, Bridgend, UK) 2 to 3 24 100% survival complications 12.5%
Yang et al24 2012 ENDO model 15 50 14% deep infections
Engelbrecht at al9 1981 ENDO model > 10 1074 Aseptic loosening 6%, 2% infections,
4% dislocations
Mavrodontidis et al25 2008 ENDO model 8 to 15 136 Excellent HSS score in 83%
Own data 2014 ENDO model 13.5 238 90%

femoral and tibial component, especially in rotating-hinged
implants, as increased internal rotation may lead to lateral-
isation of patellar tracking. Currently, shorter, modular,
fully-cemented stems are available and these implants have
reduced the stem length to about 8 or 9 cm, which might
facilitate easier revisions in the future.
A tourniquet should be used to improve cement penetra-
tion. Basic principles of modern cementation should be
used, including the use of a medullary plug, pulsatile lav-
age, a stem centraliser, and vacuum mixing. Post-
operatively, full weight-bearing is permissible for all
patients and active exercises are started on the first day
after surgery with no special limitations.
Results
We have data for 238 primary TKRs (of which 189 were
female) and the mean age at surgery was 67 years (26 to
88). All patients were treated in 1993 with a primary TKR
(fully cemented long-stemmed Endo model by Waldemar
Link, Hamburg, Germany) and follow-up was performed
after more than 13 years. Of these 238 patients, 141 (59%)
were available for radiological and clinical follow-up with
the TKR still in place, and we used the HSS score1,2 and vis-
ual analogue score (VAS) for pain as measures of assess-
ment. A total of 62 patients died of unrelated causes (26%)
and 19 patients underwent a revision operation (8%), 16
(7%) were lost to follow-up. The patella was not replaced
in any of the cases.
The mean post-operative knee range of movement was
118° (95° to 130°). Two patients underwent a post-
operative closed manipulation. Clinical evaluation accord-
ing to the HSS demonstrated excellent results in 54% of the
patients (100 to 85 points), good results in 20% (84 to 70
points); fair in 12% (6 to 60 points), and poor in 14% (less
than 60 points). Patients’ self-assessment based on the VAS
pain revealed a very good result in 78%, good results in
16%, fair in 3%, and poor in 3%. Indications for early
implant revision were secondary patellofemoral arthritis in
six patients (2.5%), deep infection in five (2%), failure of
the rotating hinge mechanism in three (1%), instability in
two (0.8%), femoral component loosening in one (0.5%),
extensor mechanism disruption in one (0.5%) and trau-
matic femoral fracture in one (0.5%). We also identified
nine patients (3.7%) who underwent revision surgery with-
out component exchange. Consequently, the overall com-
plication rate, including surgical revisions, was 10% at
final follow-up.
In summary, the overall survival rate at 13 years follow-up
with revision for any cause as an end point was 90%. How-
ever, when adjusting for the patients’ age at primary implan-
tation, the overall survival rate for patients older than 60
years was 94%, and only 77% in patients younger than 60.
Evaluation of the primary survival rate in relation to the pre-
operative deformity of the affected lower extremity revealed
that patients with pre-operative varus deformity had a cumu-
lative survival rate of 97% after 13 years, whereas patients
with valgus deformity had a survival rate of 79%.
Discussion
The current use of hinge implants in primary TKR remains
unusual and should be restricted to selected cases. We advo-
cate the use of unconstrained implants whenever applic-
able. In 2013, we performed 1445 primary TKRs in our
hospital of which 26 were treated with a rotating or simple
hinge (1.8% of all primary TKR). Current indications are
clearly defined and should be reserved for elderly patients.
Inconsistent results of the use of hinged implants in pri-
mary TKR have been described in the literature.8-10

CCJR SUPPLEMENT TO THE BONE & JOINT JOURNAL

 THE ROLE OF HINGES IN PRIMARY TOTAL KNEE REPLACEMENT
Although some authors were able to show good and excel-
lent clinical results and good survival rates of rotating-
hinge implants,9-11 others found high complication
rates,12,13 (Table I).14-25 Guenon et al12 had an unacceptably
high complication rate of > 30% in primary cases and 24%
in revisions using a rotating hinge design.11 In addition,
reported infection rates in these two reports were enormous
with 11% in primary and 9% in revision cases. Although
the exact reasons and mechanisms of such high complica-
tions rates are unclear, there might be other confounding
factors to explain them, other than failure of the implant.
Such high general complication rates do not usually
reflect on the implant design.26-28 Several implants have
shown inferior outcomes and unacceptably high failure
rates, and were withdrawn from the market.29 In contrast,
previous reports of rotating-hinge implants in primary
TKR revealed more favourable results at a minimum of ten
years follow-up.9-11
There are several factors that limit the use of a fully-
cemented, long-stemmed implant in primary TKR. Revi-
sion of implants with a complete removal of the cement
mantle can be time consuming and may predispose the
patient to complications including fractures. Conversion to
a lower-constraint implant becomes impossible and re-
cementing into sclerotic non-cancellous bone risks early
loosening. Finally, relative maltracking of the patella is
described when using simple hinged implants, due to the
limited rotational movement of the tibia in relation to the
femur. This, however, has been solved with rotational
hinged prostheses, where a 15° to 20° internal-external
movement becomes possible in the knee.
Conclusions
Rotating-hinge implants in primary TKR may still be con-
sidered for elderly patients with limited indications. We
have had over 30 years’ experience with this specific
implant type, which has, in our hands, good midterm
results. Revision of long cemented stems can be challenging
and future trends in implant design to include shorter stems
are welcome.
The author or one or more of the authors have received or will receive benefits
for personal or professional use from a commercial party related directly or
indirectly to the subject of this article. In addition, benefits have been or will be
directed to a research fund, foundation, educational institution, or other non-
profit organisation with which one or more of the authors are associated.
This paper is based on a study which was presented at the 30th Annual Winter
2013 Current Concepts in Joint Replacement® meeting held in Orlando, Florida,
11th – 14th December.
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