101

Design forms of total knee replacement

P S Walker* and S Sathasivam

Department of Biomedical Engineering, University College London and Royal National Orthopaedic Hospital Trust,
Stanmore, Middlesex, UK

Abstract: The starting point of this article is a general design criterion applicable to all types of
total knee replacement. This criterion is then expanded upon to provide more specifics of the required
kinematics, and the forces which the total knee must sustain. A characteristic which differentiates
total knees is the amount of constraint which is required, and whether the constraint is translational
or rotational. The different forms of total knee replacement are described in terms of these constraints,
starting with the least constrained unicompartments to the almost fully constrained fixed and rotating
hinges. Much attention is given to the range of designs in between these two extreme types, because
they constitute by far the largest in usage. This category includes condylar replacements where the
cruciate ligaments are preserved or resected, posterior cruciate substituting designs and mobile bearing
knees. A new term, ‘guided motion knees’, is applied to the growing number of designs which control
the kinematics by the use of intercondylar cams or specially shaped and even additional bearing
surfaces. The final section deals with the selection of an appropriate design of total knee for specific
indications based on the design characteristics.

Keywords: total knee replacement, unicompartmental, condylar replacement knees, mobile bearing
knees, guided motion knees, rotating hinges

1 DESIGN CRITERION FOR TOTAL KNEE
REPLACEMENT
Although there are numerous individual designs of total
knee replacement ( TKR) available today, there are only
a limited number of design forms or types. This article
is restricted to the design and functional aspects of total
knees, without reference to aspects such as wear and
fixation. A design criterion can be proposed which
relates to the mechanical function of the knee with the
TKR implanted: after implantation, the forces in the
remaining structures and the kinematics of the joint are
restored to normal.
This criterion can be applied to all design forms and
is effectively a measure of the performance of the design.
The criterion is clearly applicable to those knees with
limited pathology and where the patient is potentially
capable of an active lifestyle. In such cases, normal func-
tion for that age of patient may be achievable. On the
other hand, if the knee already has loss of ligaments and
bone in an elderly patient with a low activity level, the
word ‘normal’ must be referenced to what is possible for
The MS was received on 27 May 1999 and was accepted after revision
for publication on 31 August 1999.
* Corresponding author: Department of Biomedical Engineering, Royal
National Orthopaedic Hospital, Brockley Hall, Stanmore, Middlesex
HA7 4LP, UK.
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that patient, given the status of the muscles and soft
tissues around the knee, as well as the overall condition
of the patient.
1.1 Knee motion and kinematics
A number of investigators have measured the motion of
cadaveric knee specimens under defined conditions with
generally similar findings. In the sagittal plane, as the
femur is flexed on a fixed tibia, the contact point of the
femur on the tibia displaces posteriorly, controlled by
the geometry of the four-bar linkage consisting of the
cruciate ligaments and the joint surfaces [1]. The
mechanical implications of this motion are that the lever
arm of the posterior muscles is increased towards exten-
sion, thus providing an effective brake to hyperextension
whereas, in flexion, the lever arm of the quadriceps is
increased for efficiency of activities such as stair climbing
and rising from a seated position. In addition, the pos-
terior displacement of the femur in high flexion allows
clearance of the posterior structures, increasing the range
of flexion.
To describe the motion in rigid-body terms, reference
axes need to be defined in the femur and tibia. For the
femur, some researchers have used a transverse line pass-
ing through the centres of the posterior lateral and
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102 P S WALKER AND S SATHASIVAM

medial condyles [2]. Using this axis system, the six
degrees of freedom of motion were determined with the
knee in a modified Oxford knee testing rig [3], where a
moment was applied to the femur, and the quadriceps
was continuously shortened and lengthened to produce
flexion–extension. It was found that, as the knee flexed,
the predominant motions were posterior displacement
and internal rotation of the femur on the tibia. Other
researchers [4, 5] have proposed a transverse femoral
axis through the epicondylar line and have used an opti-
mization technique to show that, with reasonable accu-
racy, the passive motion could be described by a femoral
rotation about this axis, coupled with a rotation of the
tibia about an axis parallel to and medial to its long axis
(Fig. 1). Feikes et al. [6 ] also expressed the motion par-
ameters as a function of flexion angle, calling it the
‘unique path of passive motion’. More recently, Williams
et al. [7] have used magnetic resonance imaging data
from both cadaveric specimens and human subjects, to
explain the above motion pattern in terms of the
geometry of the knee, in particular that of the lateral
and medial femoral condyles in the sagittal plane. An
important implication of reproducing normal motion in
a TKR is in obtaining the correct length patterns of the
cruciate and collateral ligaments because these structures
will determine the laxity and stability during function.
The motion determined under passive or controlled
conditions as described above can be regarded as a ‘mid-
path motion’. This motion path will deviate under three
different conditions:
1. An anterior–posterior (A–P) force or an internal–
external torque is applied. When such forces are
applied, displacements and rotations are produced
called ‘laxity’. The concept of an ‘envelope of passive
motion’ has been advanced to describe the boundaries
within which the laxity of the knee can lie, for defined
forces and torques [8]. The laxity of the knee is least
in extension, increases up to about 20° of flexion,
remains reasonably constant throughout most of the
motion and then reduces slightly towards full flexion.
The model of Churchill et al. [5] (Fig. 1) has been
expanded upon to represent laxity about the mid-
path motion.
2. If an A–P force is applied and then a torque is sub-
sequently applied, the rotational laxity is less than in
the absence of the A–P force. Similarly, a torque fol-
lowed by an A–P force will result in a reduced A–P
displacement. This is termed ‘coupled motion’ and is
due to the pre-tightening of soft tissues [9].
3. If a compressive force is applied along the axis of the
tibia, all the laxities are reduced, A–P more so than

Fig. 1 A mechanical representation of knee motion: flexion–extension about the epicondylar axis and
internal–external rotation about a medial axis in the tibia. Note that the posterior displacement of
the centre of the femur, and internal rotation of the tibia, are coupled with the flexion angle. (The
model is based on the work of Churchill et al. [5].) The model has been extended to include A–P
and rotational laxity, restrained by soft tissues (see the small figure on the right)
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 DESIGN FORMS OF TOTAL KNEE REPLACEMENT
rotation. The mechanism is that the dishing of the
joint surfaces, especially on the medial side, requires
that the two joint surfaces distract under A–P or
rotation, requiring energy input, including that due
to increased tensions in the soft tissues.
At this time most of the data available on the kinemat-
ics of the natural knee in activity has been obtained by
gait analysis techniques. Such techniques produce accu-
rate data on flexion–extension, but the other motion
data are less accurate due to the relative motions between
the skin markers and the bones themselves [10].
However, in one study, pins were fixed into the bones
themselves and the motion was measured during walking
[11]. The magnitudes of the A–P displacements and the
rotations were similar to those measured in the cadaveric
experiments noted above, but the relations between these
motions and the flexion angle were clearly influenced by
the external forces and the muscle forces. More recently,
fluoroscopic techniques have been used to determine
motions in squatting and climbing a step [12], but data
for walking and other activities will become available in
the near future.
1.2 Forces in the knee
The forces acting in the knee during activity were calcu-
lated as long ago as the late 1960s using a knee model
Fig. 2 Typical data for the forces at the knee joint in level walking, determined from telemetry of a distal
femoral replacement [16 ]. PAT-LIG, force in the patella ligament; PAT-FEM, force between the
patella and the anterior femur. The thick lines refer to the scale on the left. The thin lines refer to
the scale on the right
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103
with the input of gait analysis and force-plate data,
together with geometrical measurements of the limb
[13, 14]. The highest forces were obtained for descending
stairs or a slope and then ascending, and the lowest for
level walking. The more vigorous the activity, the higher
are the forces, as shown for active subjects walking
downhill where forces of 8 body-weight (BW ) were
obtained [15]. In one study, a telemeterized distal fem-
oral replacement was used to measure the forces directly,
the first such measurements of its kind in the knee [16 ].
In walking activities, where the flexion angles in stance
are about 20°, the patello-femoral forces are less than
2 BW but, in higher flexion, forces as high as 7 BW have
been calculated. From several studies, the shear forces
were determined to be higher in a direction that would
tense the posterior cruciate ligament (PCL). In the
telemetry study [16 ], the forces that would tense the
anterior cruciate ligament (ACL) in walking were found
to be small ( Fig. 2). There are significant axial torques
occurring during walking and other activities. The tor-
ques act at the foot as a consequence of the twisting of
the body as it swings over the planted foot. The direction
of the torque is internal, such that the lateral tibial pla-
teau tends to move anteriorly. In walking, Taylor et al.
[16 ] measured the torque at around 8 Nm.
Knowledge of the force magnitudes is important for
a number of reasons. In designing TKRs, the radii of
curvature of the bearing surfaces should be chosen to
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104 P S WALKER AND S SATHASIVAM

produce acceptable values of the contact areas and
stresses, taking account of the forces which occur in the
more strenuous activities and not only in level walking.
The varus or valgus moments redistribute the stresses
over the tibial surface and in extreme cases can result in
failure of trabecular bone or cause an intramedullary
stem to penetrate a cortex progressively due to bone
resorption. The shear forces and torques are of particular
interest to TKR because these forces are carried by the
remaining cruciate ligaments, the condylar surfaces,
plastic stabilizer posts or linkages such as hinges. In
addition, these forces act across the implant–bone
interface and can affect fixation. In order to predict the
long-term durability of TKRs, realistic force values are
needed for input to knee-simulating machines.
1.3 Geometry of the bearing surfaces
To describe the geometry and function of condylar
TKRs, certain definitions are useful. A parametric
description of the geometry of conventional condylar
replacements is useful for modelling the knee, for pre-
dicting kinematics and ligament-length patterns and for
calculating the stresses on the bearing surfaces ( Fig. 3)
[17]. In the sagittal view, most symmetric TKR designs
take an average between the lateral and medial profiles
of the natural knee [18], although some designs preserve
a lateral–medial difference to obtain a differential roll-
back in early flexion. If the posterior-superior radius
(RPSF ) is reduced, this is sometimes claimed to increase
the range of flexion, but in reality there is only a small
linear difference between the profiles whether a constant
or decreasing radius is used. Likewise, the linear differ-
ences in the profile between using several arcs rather
than two or three for the sagittal femoral profile is small.
An important geometrical parameter is the posterior-
distal transition angle (PDTA). If this is 20° or more,
the large distal radius will contact the tibia during the
entire stance phase of gait, reducing the contact stresses
on the plastic. However, there are two possible disadvan-
tages of this scheme. Firstly, the distal-anterior trochlea
can be too prominent, which can result in gait abnor-
malities due to the excessive forces required in the quad-
riceps and patellar ligament [19]. Secondly, there can be
a kinematic abnormality such that, in moving from
extension to mid-flexion, the origin of the femur will
displace anteriorly, which is opposite to the behaviour
in the natural knee. This is because, in the presence of
axial compressive forces and relatively low shear forces,
the femur locates at the bottom of the tibial dish. This
phenomenon may be seen in fluoroscopy studies of deep
knee bends or step ascending and descending, where the
femur is found to slide anteriorly with flexion and pos-
teriorly with extension [12, 20].
Constraint is the resistance to a particular degree of
freedom, such as A–P, internal–external rotation or
varus–valgus, when there is a compressive force acting
across the joint. This is measured in newtons of applied
force per millimetre of A–P displacement, or newton-
millimetres of applied torque per degree of rotation. If
the tibial surfaces are flat, the constraint is nominally
zero, except for friction. For dished tibial surfaces, the
curves are non-linear with an increase in constraint with
displacement from neutral. In a hinge the varus–valgus
and A–P constraint are infinite.
Laxity is the inverse of constraint and is measured in
millimetres per newton or degrees per newton-metre. For
flat or shallow tibial surfaces, the laxity is higher than
for more dished surfaces. For the latter, the laxity
reduces with distance or rotation from neutral. Laxity
can also mean the total displacement or rotation away

Fig. 3 Definition of the geometry of condylar replacements in the frontal and sagittal planes (the frontal
plane is shown in the two drawings on the left; the sagittal plane shown in the drawing on the right):
ROF, outer radius, femoral; RIF, inner radius, femoral; ROT, outer radius, tibial; RIT, inner radius,
tibial; BS, bearing spacing; RDF, radius at the distal part of the femur; RPF, radius in the posterior
part of the femur; RPSF, radius at the posterior-superior part of the femur; PDTA, posterior-distal
transition angle, where the large distal-anterior radius RDF meets the smaller distal-posterior radius
RPF; RPT, posterior radius, tibial; RAT, anterior radius, tibial. The two frontal geometries shown
have very different mechanical functions. (Redrawn from Sathasivam and Walker [17])
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 DESIGN FORMS OF TOTAL KNEE REPLACEMENT
from the neutral position on the application of a force
or a torque. Constraint and laxity can be measured in
simple test equipment and are useful measures of the
mechanical function of the knee in situ.
Conformity is a geometrical measure of the closeness
of fit of the contacting regions of the femoral and tibial
bearing surfaces. An appropriate measure of conformity
is relative radius of curvature. If the femoral convex
radius is RF and the tibial concave radius is RT, the
contact can be considered as a femoral radius (RR) on
a flat tibial surface, where 1/RR=1/RF−1/RT. Initially
it might be thought that constraint and conformity are
synonymous. However, consider two knees, one with
almost matching shallow profiles in the frontal view, and
the other almost matching ‘dished’ profiles. They are
both equally conforming but, in rotation, the shallow
surfaces are less constrained. This is illustrated in Fig. 3.
1.4 Replicating normal constraint
The ideal is that the constraint characteristics of the
natural knee are replicated after insertion of the TKR,
consistent with the design criterion stated above. One
solution to replicating both the constraint and the laxity
characteristics of the natural knee was proposed in the
geometry of the original total condylar design [21]
(Fig. 4). For a geometry with two partially conforming
radii in both frontal and sagittal planes, when there is
an axial compressive force acting, application of an A–P
shear force or a torque will result in a displacement or
a rotation, with an equilibrium position being reached
so as to produce reasonably normal laxity values.
However, in the absence of the cruciate ligaments, there
was no mechanism for inducing the displacements and
rotations described above and shown in Fig. 1.
Another approach to obtaining normal constraint in
condylar TKRs was to generate the tibial surface from
a computer model of the femoral surface that was a
Fig. 4 The double-dish geometry of the original total condylar design where the surfaces are partially con-
forming in the frontal and sagittal planes, to provide a combination of laxity and stability. The
cruciate ligaments are not required for this type of geometry [21]
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105
simplified geometric analogue of the natural femur
( Fig. 5) [22]. The general concept was introduced earlier
by Seedhom et al. [23], who moulded a femoral shell to
replicate the exact femoral surface anatomy and then
derived the shape of the tibial surface by a wax replica
of the inside of the joint with the menisci removed and
where the femur was put through a range of flexion. In
Walker’s [22] method, equations were written to describe
the laxity and stability characteristics of the natural knee,
and then the femoral component was displaced and
rotated, simultaneously moving the component upwards
according to the equations. The downward locus of the
multitude of points on the femoral surface accumulated
at all the flexion angles, displacements and rotations
described the tibial surface. It was assumed that the PCL
would induce the posterior translation with flexion. This
method of generating TKR surfaces was applied to the
design of the Kinemax TKR [24].
A factor which makes it difficult to replicate exactly
the natural constraint is the friction between the metal
and plastic surfaces. In the natural knee, the friction is
so small as to have a minimal effect on the kinematics.
In a TKR, however, the coefficient of friction is in the
range 0.05–0.1. The latter value will apply when small
amounts of debris become embedded in the plastic sur-
face [25] and is a phenomenon which has been measured
in hip joints also, attributed to small scratches on the
metal surface [26 ]. The importance of friction can be
appreciated in that, when a compressive force of 2000 N
is acting, the shear force required to overcome friction
is up to 200 N, which is at least half the maximum shear
forces occurring in activity. The effect is a reduction in
laxity, an increase in ‘stability’, reduced forces on the
cruciates and periods of ‘stick’ when the direction of the
shear force is reversed. This latter phenomenon was mea-
sured in a simulating machine, both under the appli-
cation of shear forces and torques and in a simulated
walking cycle [27].
It is important to take into consideration the effect of
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Fig. 5 Generation of the tibial surfaces of a TKR (different views of the same surface are shown) by defining
a femoral surface and then moving this in multiple positions in three dimensions according to equa-
tions describing the laxity and stability of the natural knee in both A–P and rotation [22]

muscle and gait patterns on the motion and laxity behav-
iour of the natural (and TKR) knee in vivo. Such con-
siderations can place into perspective the studies of laxity
and stability carried out on cadaveric knees, or on the
living knee in laboratory conditions. In addition, if a
change occurs in the knee such as a ruptured ligament,
a resected ligament as part of a surgical procedure, or
the presence of a TKR, muscle and gait patterns may
well adapt to the altered mechanics. Examples of adap-
tation have been described for ACL-deficient knees and
for stair climbing with different TKR designs [28, 29].
2 FIXED-BEARING CONDYLAR
REPLACEMENTS
This type of design represents the major clinical usage
today. Typical modern-day condylar replacements are
shown in Fig. 6.
2.1 Preservation of both cruciates
The closest scheme for restoring normal constraint is to
retain the cruciate ligaments and to resurface the femoral
condyles in combination with shallow plastic tibial sur-
faces. This scheme is based on preserving as many of the
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anatomical structures as possible, thus minimizing the
shear forces on the plastic surface and on the fixation
and maintaining the proprioceptive effects of the liga-
ments. Preservation of both cruciates was used in early
unicompartmental designs (Marmor and Unicondylar),
where one or both sides of the joint were replaced,
and in designs with connected components ( Townley,
Duocondylar, Duopatella, Geomedic and Cloutier).
Gait analysis of such unicompartmentals has shown
almost normal kinematic patterns [29], supporting the
principle of this scheme. The ideal indications for pre-
serving both cruciates are in the younger and more active
patients where the bone geometry and the surrounding
ligaments are not severely compromised. However, cer-
tain factors have limited the practice of preserving both
cruciates:
1. Many designs have used close-to-flat plastic surfaces,
which have a high sensitivity to geometric placement,
tightness and slope of the tibial components in the
sagittal plane, resulting in an incidence of instability.
2. The plastic components have often been thin,
resulting in excessive wear and deformation.
However, in the Marmor design, which used net-
shape-moulded polyethylene, the destructive delami-
nation type of wear was not reported [30].
3. The surface area and the fixation methods of many
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 DESIGN FORMS OF TOTAL KNEE REPLACEMENT
Fig. 6 Typical condylar replacement TKRs: unicondylar, posterior cruciate-retaining and posterior cruciate-
substituting designs
of the unicompartmental components were inad-
equate, leading to a much higher rate of loosening
than in total condylar types of TKR.
4. The surgical procedure was difficult, partly due to the
limited exposure when both cruciates were preserved,
and to the lack of adequate bony landmarks for
instrument alignment.
In recent years, efforts have been made to overcome
these disadvantages, such as by improved surface
designs, more accurate instrumentation and techniques,
more wear-resistant polyethylenes, better fixation and
more rigorous selection of patients. The possibilities of
using small incisions with more rapid recovery has also
led to a resurgence of interest in unicompartmental
replacement [31, 32].
2.2 Preservation of the posterior cruciate
Today, almost two-thirds of the knees used world-wide
are of the PCL-preserving type, although there is a grad-
ual trend towards the posterior-cruciate-substituting
designs. There are several reasons why PCL preservation
became the most popular approach:
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107
1. Posterior displacement of the femur was considered
necessary for increasing the lever arm of the quadri-
ceps in flexion, and the PCL was shown to perform
that role in the natural knee.
2. PCL preservation in combination with shallow tibial
surfaces (and in some designs a posterior slope) was
thought to increase the range of flexion.
3. One-piece tibial components which covered the major
area of the upper tibia (not possible with ACL+PCL
preservation) produced durable fixation.
4. The surgical technique was easier than for ACL
+PCL preservation.
Laboratory studies using cadaveric knees demonstrated
the rationale for the above [33]. This study compared the
femoral–tibial contact points in the sagittal plane for flat
and dished tibial surfaces, and for PCL preservation versus
PCL resection. Preserving the PCL prevented an excess-
ively anterior contact point and the shear force was shared
between the ligament and the curved plastic surfaces. In
the absence of the PCL, the contact points were too
anterior for both flat and curved surfaces. However, the
proportion of the A–P shear force carried by the PCL was
later shown to be very dependent on the radius of the tibial
surfaces in the sagittal plane (RAT and RPT, in Fig. 3).
In laboratory studies where compressive and shear forces
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108 P S WALKER AND S SATHASIVAM
were applied, of magnitudes typical of those in activity,
even a moderate sagittal radius of about 60–70 mm limited
the A–P displacement to only a few millimetres [25]. The
tests were extended to TKR patients by applying shear
forces when the patients were standing on the knee. The
A–P displacements were inversely proportional to the
weight of the patient and, in a PCL-preserving design,
the PCL was calculated to be carrying about one-third of
the shear force. In a design without cruciates but with
more dished tibial surfaces, the displacements were small
and were limited almost entirely by the bearing surfaces
rather than by the soft tissues.
In condylar replacements in general, it is important to
determine the relative contributions of the bearing surfaces
and the soft tissues in carrying the various forces and
moments. This was studied using a specially designed knee
simulating machine where patterns of compressive force,
shear force, torque and flexion–extension were pro-
grammed in, and the resulting A–P displacements and
internal–external rotations measured [34]. One feature of
the simulator was that springs of appropriate stiffness were
used to simulate the soft tissue restraint. Full-strength
springs were used if a cruciate ligament (PCL) was present;
one-third-strength springs were used for a resected cruciate
ligament to represent the secondary restraints. For a knee
with low sagittal constraint and PCL preservation (sagittal
tibial radius of 80 mm or more), the displacement–force
( laxity) curves were compared with those of the normal
intact knee under different loads [35]. This is represented
by knee 1 in Fig. 7.
Comparing the laxity curves between the cadaveric
knee and condylar knee 1 shows the following:
1. The magnitudes of the A–P laxity are similar.
2. The curves all exhibit ‘strain stiffening’.
3. There is a shift in the neutral position after 10° of
flexion for the TKR.
4. For the TKR, when the direction of the shear force
changes, there is a period of ‘stick’ due to friction.
5. For both knees, the A–P laxity steadily reduces as the
compressive force is increased.
Consider the bar graphs on the right of Fig. 7. For
the low-constraint knee, the PCL reduced the A–P and
rotational laxities by an average of 30 per cent. Without
the PCL, the laxities are higher than ideal at more than
30° flexion, especially in rotation. For the high-constraint
knee (sagittal tibial radius of 60 mm or less) the PCL
made little difference to the laxities. The laxities were
much smaller than normal, especially in rotation at less
than 30° flexion.
The conclusions from this study are as follows:
1. Condylar TKRs of low constraint require at least the
PCL to limit the laxity.
2. With moderate constraint (sagittal tibial radius,
60–80 mm), the laxity values would be satisfactory
both with and without the PCL.
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3. For high constraint, the PCL is not required (it may
even produce a ‘kinematic mismatch’) but the laxity
values are much lower than for a natural knee.
In recent years, fluoroscopic techniques have been intro-
duced whereby accurate data of the relative motion
between the femur and the tibia can be determined in load-
bearing activities [12, 20, 36 ]. Interesting differences have
been demonstrated between designs which preserve or sub-
stitute for the ACL and the PCL. When normal subjects
performed deep knee bends, there was a posterior trans-
lation of the femur relative to the tibia. For ACL-deficient
knees, however, the motion patterns were inconsistent and
less continuous. This was due to the possibility of contact
points that were more posterior than normal in the absence
of the ACL. A similar behaviour was noted for a PCL-
retaining design with low sagittal constraint. The abnor-
mal motion is due to the large sagittal tibial radius and is
not due to the overall concept of a PCL-preserving design.
The data from this study can be explained more by the
shape of the bearing surfaces rather than by the role of the
PCL or the cam, based on the above data (Fig. 7) of Luger
et al. [35]. In the PCL-preserving designs, the tibial sur-
faces were shallow, allowing A–P sliding to occur
depending on the resultant of the external and muscle
forces. In the PCL-substituting designs on the other hand,
the dishing of the tibial surface would restrict A–P sliding,
resulting in less erratic motion.
2.3 Posterior stabilized designs
Returning to the type of design where both cruciates are
resected, the deficiencies of the original total condylar
design were addressed in two ways. Firstly, designs were
introduced where the bottom of the dish was more pos-
terior and the anterior upsweep was higher. This design
was used both with and without the PCL and showed
excellent clinical results in both configurations. Secondly,
an intercondylar cam was added to control the anterior
position of the femur on the tibia ( Fig. 8). One of the
first posterior stabilized designs was the kinematic stabil-
izer where the cam operated throughout the flexion
range to produce a continuous roll-back [37]. In the
Insall–Burstein posterior stabilized design, the inter-
condylar cam engaged at about 70° flexion and produced
posterior roll-back up to full flexion. Clinical results have
indicated that this feature has increased the range of
flexion by 10–15° compared with the original total
condylar design and that gait analysis was comparable
with PCL-retaining designs [38].
3 ALTERNATIVE CONDYLAR DESIGNS
3.1 Guided motion knees
A guided motion knee is defined as one which provides
some control or guidance to A–P translation and/or
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Fig. 7 Laxity comparisons between a typical cadaveric knee, and condylar TKRs measured in a knee simu-
lator: knee 1, low sagittal constraints; knee 2, medial-high sagittal constraint. An axial compressive
force was first applied and then a cyclic A–P force or a cyclic internal–external torque. Laxity curves
at different compressive forces and flexion angles are shown on the left, and total A–P and rotational
laxities at 2000 N compressive force (3 BW ) are shown on the right. (From Luger et al. [35])

109
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110 P S WALKER AND S SATHASIVAM
Fig. 8 The first condylar designs using an intercondylar cam to produce roll-back of the contact point with
flexion, namely the kinematic (now Kinemax) stabilizer and the Insall–Burstein posterior stabilized
design
internal–external rotation, during flexion–extension, by
the interaction of femoral and tibial cams, bearing sur-
faces or other means. The overall goal of a guided
motion knee is to achieve the specified A–P translation
and internal–external rotation patterns by the use of
guide surfaces located, for example, in the intercondylar
region or by using the femoro-tibial bearing surfaces
themselves to guide the motion. The motion control can
be discrete or, preferably, guide the knee in the desired
neutral motion path, with regions of laxity about this
neutral path.
As described in Section 2, versions of guided motion
knees which have been in use for many years include the
kinematic (or Kinemax) stabilizer and the Insall–
Burstein posterior stabilized design ( Fig. 8). The aims
of these particular designs were as follows:
(a) to increase the quadriceps lever arm at high
flexion angles,
(b) to increase the range of flexion by preventing pos-
terior impingement of bone and soft tissues and
(c) to prevent posterior tibial subluxation in flexion
under the action of the hamstrings.
However, there are other arrangements of intercon-
dylar cams or guide surfaces that can achieve control of
A–P translation and offer possible advantages. In this
context, the following criteria can be added to those
above:
(d) to control the location of the femoral–tibial contact
points in the A–P direction and internal–external
rotation throughout the flexion range but to allow
some laxity about these contact points,
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(e) to guide the contact points posteriorly with flexion
(especially on the lateral side), and anteriorly with
extension, and
(f ) to produce internal tibial rotation progressively with
flexion and external rotation with extension.
It should be noted that these statements are consistent
with the mid-path motion described earlier in this article.
The rationale is to provide optimal muscle lever arms,
soft tissue tensions, and overall knee and leg alignment,
in order to restore natural function as closely as possible.
By using special computer programs, the above and
other types of intercondylar guide surface with required
patterns of A–P motion control can be synthesized
( Fig. 9). One type is a ‘saddle’ which can provide control
of A–P motion throughout a large fraction of the flexion
range [39] (Fig. 10). By varying the parameters of the
FGS, the A–P control can be biased to the mid-range,
with slight loss of control at each extreme, or shifted to
cover early or late flexion. It can be visualized that the
posterior surface of the anterior part of the tibial saddle
can be used to produce roll-back of the femoral–tibial
contact point throughout the flexion range, in a similar
way to the kinematic stabilizer, and other designs in cur-
rent use. In this arrangement, roll-forward as the knee
is extended would need to rely on the anterior surface
of the posterior part of the saddle, or dished tibial bear-
ing surfaces into which the femoral condyles would tend
to locate. Another possible scheme is a saddle that pro-
vides motion control in the first half of the flexion range
combined with a posterior stabilized feature providing
posterior displacement in late flexion.
Ingenious designs where convex tibial ‘saddles’ were
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used have been presented in the past. In one design [40]

the saddle moved the contact from anterior to posterior
during early flexion, the second part of flexion using a
ball-in-socket device. In another design [41], the saddle
shape was such as to induce pure rolling of the guided
surfaces during flexion–extension. In order to allow
internal–external rotation in all the above configur-
ations, the plastic component could be moved on a rotat-
ing platform.
Particular designs which can be classified as ‘guided
motion knees’ and which have been introduced up to
this time, include the following:

1. The saddle design shown in Fig. 10 has a saddle that

Fig. 9 Synthesis of intercondylar guide surfaces. The femoral
intercondylar guide surface is defined by three para-
metric circular arcs constrained to join tangentially. In
this way, a wide range of femoral guide surfaces
(FGSs) can be defined. By flexing the femoral compo-
nent with a defined contact roll-back pattern, the
matching tibial guide surface (TGS ) is generated [39]
controls A–P displacement throughout the flexion–
extension range. In this design (the Genius knee,
Astro Medical ) the plastic component consists of a
rotating platform that allows additional freedom of
A–P and unlimited internal–external rotation.
2. A conforming medial compartment in the form of
spherical surfaces, and a lateral compartment with
low conformity ( Fig. 11) (medial pivot knee, Wright
Medical, Memphis) is a close geometrical and
mechanical analogue to the natural joint surfaces if
the menisci are taken into consideration. However, in
the absence of one or both cruciates, there may be
no means to control the A–P contact point location
on the lateral side, although an advantage of the

Fig. 10 A single circle for the FGS generates a saddle for the TGS. By varying the orientation angle of the
circle, motion control in both the anterior and the posterior directions can be achieved in the first
half of the flexion range, in the middle range or in the second half of the flexion range. The saddle
design can be used in fixed-bearing or mobile-bearing configurations
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112 P S WALKER AND S SATHASIVAM
Fig. 11 The medial pivot knee ( Wright Medical ). The highly
conforming medial side provides a large contact area
and a pivot for internal–external rotation. The low
constraint of the lateral side allows for A–P trans-
lation, as in the natural knee
design is that the joint is fully conforming medially
where the highest joint forces are normally trans-
mitted.
3. The TRAC PS design [42] ( Fig. 12) is such that, from
0 to 8° flexion, the femoro-tibial contact is on an inner
pair of bearing surfaces with the bottom of the dish
anterior of centre and, from 8° to maximum flexion,
the contact is on an outer pair of bearing surfaces
with the bottom of the dish posterior of centre.
Intercondylar guide surfaces (with some similarity to
the saddle configuration in Fig. 10) produce the pos-
terior femoral displacement to transfer from the first
to the second pair of bearing surfaces. This design
achieves the ideal of anterior contact towards exten-
sion and posterior contact in high flexion, as well as
obtaining a large contact area for each pair of bearing
surfaces. One disadvantage of the design is that, for
the inner pair of bearing surfaces, the varus–valgus
stability is reduced. Rotational freedom is provided
by the plastic being pivoted in a ‘rotating platform’
configuration.
4. The Kyocera Bi-Surface design ( Fig. 13) uses conven-
tional, partially conforming bearing surfaces for the
approximate range 0–90° flexion. At 90°, the femoral
intracondylar convex spherical surface engages the
spherical concave surface at the posterior of the tibial
plastic. The main lateral and medial bearing surfaces
disengage and further flexion takes place on the
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Fig. 12 The TRAC PS (Biomet). In early flexion, the inner
femoral–tibial bearing surfaces provide an anterior
contact location; in the remainder of the flexion range,
the outer bearing surfaces provide more posterior
contact. Transfer between the pairs of bearing sur-
faces is achieved using an intercondylar cam
spherical surfaces. In allowing freedom of internal–
external rotation and a posterior axis of rotation, the
goal of this design is to facilitate a high range of
flexion.
Guided motion knees represent an interesting classifi-
cation of TKR. In the absence of one or both of the
cruciate ligaments, they offer a means of reproducing at
least some of the characteristics of the natural knee, and
possibly even similar laxity behaviour.
3.2 Mobile-bearing or meniscal knees
Designs where a moving plastic bearing is interposed
between the femoral condyle and the tibial plate, called
meniscal knees or mobile-bearing knees, were introduced
in the mid-1970s. These designs imitate the natural knee
in that the plastic components resemble the menisci, the
plastic accommodates A–P translations (as well as
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rotations), and a large contact area is maintained

throughout all or much of the flexion range. The purpose
of such designs is to minimize the wear and deformation
of the plastic and to allow for natural kinematics. There
are a number of mechanical schemes that can be specified
for a mobile-bearing knee (Fig. 14):

1. Internal–external rotation only is allowed. This has

the advantage of allowing the knee to locate at
a preferred rotational orientation, and to adjust to
a new position without resistance (except friction)
during activity.
2. Internal–external rotation about a medial axis is
allowed. This produces more anatomical motion that
occurs where the centres of internal–external rotation
in the horizontal plane of the upper tibia are located
on the medial side.
3. Internal–external rotation and A–P translation are
allowed. This allows the knee to locate at a preferred
rotational and translational orientation during func-
tion. It can also allow natural knee kinematics where
the location of the medial axis of rotation varies due
to knee laxity, although this would ideally require
that both cruciates are present at the correct tensions.
4. Internal–external rotation is allowed and A–P trans-
lation is guided by a femoro-tibial cam, such as a
posterior stabilizer or ‘saddle’. This is potentially
preferable to a configuration with rotation only
because it produces posterior translation in high
Fig. 13 The Bi-Surface ( Kyocera). After 90° flexion, the inter- flexion, but it requires partially conforming femoro-
condylar femoral spherical surface articulates in a tibial bearing surfaces.
dish in the plastic surface. This combination of a pos-
5. This is as above, but where the tibial cam is fixed to
terior contact and low constraint to rotation is
the tibial plate. Because the plastic meniscus (or two
designed to maximize the range of flexion
menisci) slides in an A–P manner, the femoral–plastic
surfaces can be fully conforming. A design of this
type has so far not emerged.

Fig. 14 Motion schemes for meniscal bearing or mobile-bearing knees (see text for detailed explanations)
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114 P S WALKER AND S SATHASIVAM
In all the above, rotation and A–P translation can be
unlimited or limited by stops. Clinical experience has
shown few problems with unlimited rotation for uncom-
plicated primary cases. However, in the absence of one
or both cruciates, limits to A–P translation seem
advisable.
Referring now to specific designs, the Oxford knee
(Fig. 15) was intended to be used as a unicompartmental
replacement with preservation of both of the cruciates
so that the A–P pattern of motion could be achieved by
a four-bar linkage mechanism. The lateral and medial
bearings are independent and there is sufficient clearance
to allow for internal–external rotation. By providing
only for the femoro-tibial surfaces, the sagittal radii
could be made constant, thus producing complete area
contact throughout the range of motion. Studies of pass-
ive motion in patients demonstrated that the menisci
translated posteriorly with flexion, the lateral more than
the medial [43]. However, such passive studies do not
replicate functional conditions where variable shear and
torque force will be present. The wear depth in retrievals
has been much less than for total hips [44].
Fig. 15 Different mobile bearing designs. Each design can be
classified mechanically according to Fig. 14: top left,
Oxford (Biomet); top right, LCS rotating platform
(DePuy); bottom left, MBK (Zimmer); bottom right,
Polyzoides Rotaglide (Corin)
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In the New Jersey meniscal knee (LCS), introduced
at about the same time as the Oxford, a one-piece metal
tibial component was provided with tracks for sliding of
two plastic menisci. In terms of freedom of motion, this
was similar to the Oxford. When the LCS was used with-
out the ACL, the menisci sometimes displaced too far
posteriorly, causing problems including fracture of the
menisci themselves [45]. In terms of replicating natural
knee mechanics, both the Oxford and the New Jersey
were less constrained than the natural knee on the
medial side.
A new version of the New Jersey knee was later intro-
duced, namely the rotating platform. The femoro-tibial
contact was designed to be fully conforming up to about
20° of flexion, covering walking, but at higher flexion
there was partial conformity up to full flexion. It is
difficult to avoid this compromise in a femoral compo-
nent design that includes a patellar flange and where the
sagittal profile is similar to anatomical. This design has
the advantage of simplicity and the long-term clinical
results have been excellent with few mechanical prob-
lems. In terms of reproducing natural mechanics, while
there is freedom of internal–external rotation, there
is no provision for A–P translation and, when, for
example, the lateral condyle moves posteriorly, the
medial condyle moves anteriorly which is unphysiologi-
cal. The consequence of this mechanism may be less than
optimal muscle lever arms and a possible loss of some
flexion. Recently, a new version of the LCS has been
introduced, the A–P glide, where freedom of A–P trans-
lation is superimposed on the rotation.
The Polyzoides Rotaglide [46 ] was probably the first
to include both rotation and A–P translation in a one-
piece plastic design. This was achieved by locating the
plastic on a smooth metal plate, with stops acting in
slots and recesses to limit the motion. Limitation of
motion was considered necessary because the design
required the resection of both of the cruciates. Another
feature of this design was complete conformity through-
out the entire flexion range. This was achieved by a nega-
tive PDTA ( Fig. 3). The compromise was a patellar
flange which was recessed more than anatomical in the
distal-anterior region.
The MBK design solved the problem of obtaining
complete femoro-tibial conformity throughout flexion,
while maintaining an anatomically shaped patellar flange
and sagittal profile. This was achieved by separating the
lateral and medial, and patello-femoral bearing surfaces.
This resulted in notches at the sides of the anterior fem-
oral component, where the posterior-distal radius is car-
ried forwards. There is sufficient medial–lateral width to
provide for all three bearing surfaces.
Although it might be considered that mobile bearing
knees are less constrained in certain degrees of freedom
than most fixed-bearing designs, there are two factors
which modify this view. Firstly, in a fixed-bearing knee,
relative femoral-tibial displacements can take place by
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rolling, which is not the case for a mobile-bearing knee.
Secondly, friction between the plastic mobile bearing and
the tibial plate can have a significant effect in a mobile
bearing design, as well as in a fixed-bearing design [27].
The result can be periods of stick and slip with reduced
overall displacements and rotations in a mobile bearing
design [47].
1. Stability is provided in all degrees of freedom, varus–
valgus and hyperextension being particularly import-
ant, although there can be some laxity (e.g. rota-
tional ) in one or more degrees of freedom.
2. A linkage of some type, such as a hinge, provides
stability and prevents subluxation or dislocation.
3. Intramedullary stems are required to provide
adequate fixation.

4 DESIGNS PROVIDING VARUS–VALGUS
STABILITY
These designs can either be unlinked, as in the superstab-
ilizer-constrained condylar (CCK ) designs, or linked as
in fixed or rotating hinges. The former can be regarded
as an extension of designs with intercondylar guide sur-
faces described above, but where the plastic post is elev-
ated [39]. This arrangement provides for posterior
displacement of the contact point in high flexion, some
anterior displacement towards extension, and partial
control of A–P displacement in the mid-range. In Fig. 16,
this type of design is generated using the software shown
in Fig. 9. The main value of this design is in providing
varus–valgus stability. An important design goal is to
maximize the area of the plastic post for bending stiffness
and strength. However, under extreme varus loading
activities, a plastic post bends and deforms over time,
making it unreliable in sustaining such loading in the
long term [48]. In most designs a metal reinforcing pin
within the plastic post is provided, which improves the
stiffness and strength. However, to provide more rigid
and long-lasting support to varus–valgus moments,
some type of linked device is needed.
Over the years, numerous different linked designs have
been introduced. The largest numbers continue to be
used in Europe whereas, in the USA, the tendency is to
use the most conservative design whenever possible, even
if substantial soft-tissue balancing is required. The
characteristics of a linked design are as follows:
The most conservative type of linked TKR is the inter-
condylar hinge ( Fig. 17). The linkage is housed in the
intercondylar region, preserving the condyles on each
side. Variations of this type include the Attenborough,
the St Georg Endo model [49], the rotating hinge, the
Sheehan, the Rotaflex, the Gshwend and the PFC
S-ROM. The bearing surfaces can be extended to the
full width of the knee, an advantage for reducing
the varus–valgus bending moments on the linkage. The
patello-femoral resurfacing has been absent in some
designs but ideally should be included. Advantages of
an intercondylar design are preservation of bone and the
fact that the axis of rotation can be placed in an anatom-
ical location. The disadvantages of an intercondylar
design are the relatively restricted size of the bearing
components, with an increased potential for wear and
deformation, the possibility of fracture of the femoral
condyles on either side of the intracondylar housing, the
difficulty of linking the components at surgery and the
possibility of dislocation in extreme loading conditions
(in some designs).
The least conservative type of linked TKR is the fixed
hinge or rotating hinge. Placement is achieved by resec-
tion of about 25 mm from the distal femoral condyles,
and 10 mm from the upper tibia. An axle is then used
to connect the femoral and tibial components, usually
with plastic bushings to act as the bearing. The total
thickness of the implant is dictated by the required
dimensions of the axle and bushings, and the ideal
placement of the axle, which is close to the level of the

Fig. 16 The method shown in Fig. 9 used to generate a superstabilizer–constrained condylar design. Motion
control is provided in early and late flexion, while in the mid-range there is contact near the top of
the plastic post. The parameters R1, R2 and R3 were chosen to maximize the area of the plastic
post, thus maximizing bending stiffness and varus–valgus stability
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116 P S WALKER AND S SATHASIVAM

Fig. 17 Designs of rotating hinges with different bone resections and rotational schemes: (a) Link-Endo
model ( Waldemar-Link), a condylar replacement with an intercondylar rotation mechanism;
(b) kinematic ( Kinemax) rotating hinge (Stryker-Howmedica), posterior-distal straight-across axle,
partially conforming rounded cylindrical surfaces providing progressive rotational restraint; (c) Finn
knee system (Biomet), with similar axis system to (b), flat plastic on metal plate, rotation limited
by stud in groove; (d ) SMILES rotating hinge (Stanmore Implants Worldwide), tibial fork for axle
allowing continuous patellar flange, with similar rotation mechanism to (b)

epicondyles. A lower or more posterior axle location will
reduce bone resection but will result in abnormal track-
ing of the patella. It should be noted that an important
requirement in the placement of hinged replacements is
that the patella locates at the correct level on the femoral
flange with the knee in extension.
The fixed hinge is the simpler design, applicable to
patients of low demand who require only a stable knee.
Examples are the Guépar, the St Georg, the Blauth and
the Stanmore. Some of the long-term clinical follow-ups
have shown survivorship similar to that of condylar
knees [50]. The rotating hinge, however, results in a
more ‘natural feel’ to the patient and is more durable in
the long term. Examples are the kinematic rotating
hinge, the Finn, the Lacey, the Noiles (now the PFC
S-ROM ) and the SMILES. More bone resection, how-
ever, is required to accommodate the extra bearing sur-
face compared with the fixed hinge. The rotation can be
achieved by a flat polished metal surface pivoted on a
flat plastic surface, or by a convex metal surface in a
Proc Instn Mech Engrs Vol 214 Part H
dished plastic surface. The latter is preferable because it
provides a ‘soft’ limit to rotation, reducing the possibility
of instability or patello-femoral subluxation. Clinical
follow-up studies have demonstrated improved perform-
ance of rotating hinges compared with fixed hinges [51].
Cases with bone loss, including revision, need special
consideration. Augments, such as spacers and wedges,
are useful for filling bone defects and for accurately
reproducing the joint line. The augments can be screwed
or cemented to the main components. For larger defects,
space fillers made from metal or plastic are an alternative
to bone grafting. Stems are useful for bypassing such
larger defects or for protecting against fractures. When
the TKR design carries varus–valgus moments, intra-
medullary stems are needed. In older patients, cemented
stems are preferable. Uncemented fluted stems can be
used if there is sufficient cortical thickness in order to
reduce the stress shielding of the cancellous bone near
the joint. Empirically, suitable stem lengths for super-
stabilizer types are 100–120 mm, while for rotating and
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 DESIGN FORMS OF TOTAL KNEE REPLACEMENT
fixed hinges 120–150 mm is needed. Revision of a failed
cemented stem requires a new stem at least 50 mm longer
[52]. In all cases, stem centralizers are needed to prevent
the stem tip from impacting the cortical wall, which fre-
quently produces osteolysis, penetration and even bone
fracture. For cases with abnormal geometry, especially
of very small size where bone preservation is a pre-
requisite, custom superstabilizers have been designed
and made using computer aided design–computer aided
manufacturing (CAD/CAM ) [53].
5 DESIGN SELECTION
5.1 The ideal design of condylar replacement
The main advantages of a fixed-bearing condylar
replacement are its simplicity and, as the clinical experi-
ence has shown, its reliability with good to excellent
function in the large majority of cases and a survivorship
of around 95 per cent at 10 years. However, it would be
erroneous to assume that all condylars can be regarded
as equivalent. As the above discussion has shown, there
are major differences in function depending upon the
surface geometry and whether or not the cruciates are
preserved. Concerning the surface geometry, shallow
surfaces with preservation of both cruciates must remain
as the ideal. The realization of such a concept can range
from a unicompartmental design used on both sides of
the joint, to a total condylar type with cut-outs for the
cruciates. However, in order to obtain the asymmetry of
the kinematics, namely internal rotation as well as pos-
terior translation with flexion, the tibial surface should
be dished on the medial side to limit the A–P translation
to a few millimetres, while the lateral surface should
be shallow.
Designing for preservation of the PCL only is prob-
lematic because, while, with accurate surgery, femoral
roll-back with flexion can be achieved, there is no driver
for roll-forward on extending the knee. Hence tibial sur-
faces that are flat or shallow in the sagittal plane with
the intention of allowing normal A–P translations result
in unpredictable contact locations and motions.
However, a compromise can be achieved by moderate
dishing of the tibial surface so that, on extending the
knee from a flexed position, the femoral surface will slide
and roll forwards to locate at the bottom of the dish.
With this scheme, reasonably normal laxity character-
istics can be achieved.
For cruciate resection, generation of the surfaces to
produce normal laxity and stability under functional
loads results in moderate constraint. However, when the
compressive forces are reduced, the stability is
insufficient. Hence increased constraint is required, but
this has the effect of reducing the laxity under weight-
bearing conditions. For that reason cruciate-sacrificing
and cruciate-substituting designs are overconstrained
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117
compared with the natural knee. To what extent this
adversely affects function is debatable, but it is not con-
sistent with the design criterion stated at the start of this
article. A possible solution is to use a posterior stabilized
or saddle type but with the plastic component as a
rotation platform. Several designs of this type are
already in clinical evaluation. However, increased wear
is a possibility because of the introduction of the
additional bearing surface.
Concerning the patellar flange, because not resurf-
acing is preferred in many cases, a flange with an ana-
tomical skyline view is suitable. To maximize the contact
area and to allow for interchangeability, a conical
patellar resurfacing with a medially biased peak has
advantages.
5.2 The ideal ‘alternative’ design
It is much more difficult to compare designs in the
‘alternative design’ category than in the fixed-bearing
category because of the wide variety, the limited
follow-up with several of the configurations and the
likely introduction of yet more designs. The advantages
of the mobile bearing designs are low wear volume and
low deformation, freedom of rotational and/or A–P pos-
ition, and the ability to determine a ‘home position’ for
each knee in particular activities.
However, the disadvantages are less inherent con-
straint than in the natural knee due to flat plastic–tibial
plate bearing and lack of smooth motion (A–P and
rotation) in function, due to periods of stick and to the
inability of the femoral–tibial surface to roll as in a fully
conforming design. If the introduction of cross-linked
polyethylenes substantially reduces the wear and delami-
nation in partially conforming designs, one of the advan-
tages of mobile bearing would be removed.
Guided motion knees are an attractive option because
the femoral–tibial position can be defined within limits
in both A–P and rotation. For example, a saddle design
( Fig. 10) can control A–P motion over a substantial part
of the flexion range. Such an arrangement seems prefer-
able to a traditional PS design, which has a plastic post
of restricted size, and which only provides for a single
action, namely roll-back in high flexion. If it was
required to provide internal rotation with flexion (as in
the natural knee), intercondylar guide surfaces could be
combined with bearing surfaces such as in the medial
pivot knee (Fig. 11).
In the formulation of guided motion knees, it is evi-
dent that intercondylar guide surfaces need to be such
that dislocation could not occur except under extreme
situations, that cam contact points are not so high that
component tilting and loosening could occur and that
insertion is feasible. Such criteria can be avoided by
adopting the approach of the Kyocera Bi-Surface design
( Fig. 13). Here, the bearing surfaces are shallow and rely
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118 P S WALKER AND S SATHASIVAM
for stability on the principles of the original total condy-
lar design, namely by providing sufficient constraint
from dished bearing surfaces.
One of the key issues in all the above designs is
whether the laxity should be ‘allowed’, ‘constrained’ or
‘guided’. Concerning the femoral–tibial A–P position,
there is a strong rationale for the TKR, with or without
the assistance of ligaments, providing roll-back with
flexion and roll-forward on extension. Nevertheless,
mechanical analysis and experimentation on each design
are needed to show that this indeed provides the desired
advantages in muscle forces. The situation regarding
internal–external rotation is not so clear, namely as to
what advantages are provided by either allowing free-
dom of rotation or guiding rotation with flexion. Further
studies are needed on this issue.
5.3 The ideal varus–valgus design
When varus–valgus constraint is required, the choice is
between the superstabilizer CCK type and the rotating
hinge. The clinical results of the former, and the small
amount of bone resection required for insertion support
its viability, although there can be an incidence of pro-
gressive varus deformity due to deformation of the plas-
tic post. In addition, stability in high flexion may be a
problem. Hence, specific designs where the strength of
the plastic tibial post is maximized and the femoral–
tibial bearing surface constraint is maximized are an
advantage. However, there are indications where a
linked design such as a rotating hinge is preferable. These
indications are where there has already been consider-
able bone loss, where there is a serious soft tissue insta-
bility and where guaranteed stability is needed. Long-
term fixation appears to be better when metallic rather
than plastic intramedullary stems are used. Given that
the durability of knee hinges can be comparable with
that of standard condylar replacements.
ACKNOWLEDGEMENTS
The input from the staff of the Centre for Biomedical
Engineering, University College London, Royal
National Orthopaedic Hospital Trust, is gratefully
acknowledged. Thanks are due to Marilyn Englehardt
and Jarmila Dodd for the preparation of this
manuscript.
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