CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 416, pp. 167–173
Optimizing Flexion After Total
Knee Arthroplasty
Advances in Prosthetic Design
Peter G. Sultan, MD**; Ephrat Most, MS**,**; Steven Schule, MD**;
Guoan Li, PhD**; and Harry E. Rubash, MD**
The clinical results with most modern total knee
arthroplasty (TKA) designs are highly satisfactory
regarding pain relief and improving walking abi-
lity. However, one problem that has not been
addressed fully by most current designs is the abi-
lity to consistently achieve flexion greater than
1208. Although the human knee is capable of flex-
ion of more than 1508, an analysis of the results
of contemporary TKA reveals that on average,
patients rarely flex beyond 1208. Key factors in-
fluencing range of flexion after TKA include pre-
operative knee motion, surgical technique, pros-
thetic design, and rehabilitation. The success of
any total knee system may in part be linked to its
ability to optimally restore normal kinematic func-
tion. Some arthroplasty designs currently are
available that incorporate modifications aimed
at improving range of flexion, but limited data
currently are available on their function and po-
tential advantages. Currently, an in vitro experi-
mental model incorporating robotics is being used
to investigate the kinematics of the native knee and
From the *Harvard Medical School, MGH/BIDMC Boston,
MA; **Mechanical Engineering, Massachusetts Institute of
Technology, Cambridge, MA.
Funding for EM was provided by The Hugh Hampton
Young Memorial Fund Fellowship, Massachusetts Institute
of Technology, Cambridge, MA.
Reprint requests to Harry Rubash, MD, Orthopaedic Sur-
gery, Massachusetts General Hospital, Harvard Medical
School, 55 Fruit Street, Suite GRB 624, Boston, MA 02114.
Phone: 617-724-9904; Fax: 617-726-2351; E-mail: hrubash@
partners.org.
DOI: 10.1097/01.blo.0000081937.75404.ed
167
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B 2003 Lippincott Williams & Wilkins, Inc.
various TKA designs at flexion angles beyond 1208.
This robotic model in conjunction with clinical
studies may provide an understanding of the lim-
itations of contemporary knee designs regarding
achieving higher degrees of knee flexion. This may
lead to the refinement of existing designs and de-
velopment of newer prostheses that may enhance
the range of flexion that is achievable after TKA.
Total knee arthroplasty is a reliable and widely
used surgical procedure. Initially developed to
relieve pain in patients with severe arthritis of
the knee, the procedure has evolved such that
current designs and modern surgical techniques
are capable of providing long-term success rates
in excess of 85% at 10 to 15 years follow-
up.9,11,12,26,29,34,37,38 In general, the clinical
results with most modern TKA designs are sa-
tisfactory regarding pain relief and improving
walking ability. However, one major problem
that has not been addressed fully is that patients
do not gain high degrees of flexion after TKA.
Perhaps even more startling is that even patients
with good preoperative ROM often lose deep
flexion (defined as flexion beyond 1208) after
TKA.3,38
Knee flexion is integral to function in many
situations of every day life and the amount of
flexion has been linked to functional outcome
and activities of daily living.21 In many situa-
tions, patients require flexion beyond 908. For
example, to squat and kneel, an individual would

168 Sultan et al
require as much as 1608 flexion.41 Bathtub use
requires 1358 flexion.35 To check the line for a
putt on the green in golf requires that the in-
dividual be able to squat, which requires knee
flexion greater than 1208. Overall, sufficient knee
flexion is essential to the lifestyle of individuals
who participate in recreational activities as part
of their daily life. In addition, some individuals
require knee flexion greater than 1208 for their
work.40
Unfortunately, the flexion achieved after con-
temporary TKA rarely exceeds 12081,7,10,13,15,16,
22,24,30–32,34
Initial experiences with the cruciate-
sacrificing total condylar prostheses produced
results with flexion limited in the range of 908
to 958. This degree of flexion approaches the
theoretical limit for this prosthetic design.17 Du-
ring the 30-year evolutionary process that has
brought the TKA to its modern form, improved
flexion has been achieved with posterior-stabi-
lized and PCL-retaining prostheses. Data pooled
from multiple studies reveal a mean flexion of
1008 to 1158 with both types of prostheses.5,27
Current prosthetic designs and surgical techni-
ques may not be meeting the needs of patients
who require deep knee flexion for their daily
activities.
FLEXION OF THE NATIVE KNEE
The mechanisms that allow for deep flexion of
the native knee first must be understood to have
basis for understanding the limitation of motion
after arthroplasty. Native knee flexion is guided
by the geometry of the articulating surfaces and
the soft tissues about and within the knee, which
includes the ligaments and menisci. Limitation
on native knee flexion may be attributable in
part to the presence of posterior osteophytes and
quadriceps contracture.
It has been reported that the femoral condyles
are offset posteriorly relative to the posterior fe-
moral cortex and that the medial and lateral
condyles have a lesser radius posteriorly than
distally18,42 (Fig 1). Deep flexion is made pos-
sible by the posterior space, which is in essence
formed proximal to the posterior femoral con-
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Clinical Orthopaedics
and Related Research
Fig 1. The femoral condyles are offset posteri-
orly relative to the posterior femoral cortex. Both
medial and lateral condyles have a lesser radius
posteriorly (R2) than distally (R1).
dyles. Without this offset, the posterior edge of
the tibial plateau and soft tissues would impinge
on the posterior cortex of the distal femur and
limit flexion. Similarly, posterior femoral trans-
lation (femoral rollback) also is essential for knee
flexion because it helps to create a space for the
tibia and intervening soft tissues posterior to the
femur42 (Fig 2).
At higher degrees of flexion, the posterior
surfaces of the femoral condyles articulate with
the posterior tibia. The normal tibia has a natu-
ral posterior slope of approximately 108, which
is vital to femoral rollback. In reconstruction
of the knee, failure to appreciate this posterior
slope could result in a tighter posterior capsule
and flexion space. In a three-dimensional compu-
ter model, the posterior tibial slope has been
shown to be the most important surgical variable
in optimizing flexion.42
RANGE OF FLEXION AFTER TKA
The factors influencing range of flexion after
TKA can be classified broadly into three major
groups: preoperative, intraoperative, and postop-
erative factors. Regarding preoperative influen-
ces, the factors considered most relevant in the
Number 416
November, 2003
Fig 2. As the flexion angle increases beyond
1108, the lateral meniscus slides off the tibia
posteriorly. This effectively provides the native
knee with a mobile support system, allowing the
lateral femur to roll off the back of the tibia.
literature include ROM, diagnosis, deformity,
age, gender, and patient weight.3,14,19,23,28,33,38
Intraoperative factors that may influence TKA
flexion include balancing of the flexion and
extension gap, patella resurfacing and tracking,
PCL management, wound closure, and compo-
nent sizing and prosthetic design. Postoperative
rehabilitation also plays a role in knee flexion and
covers such issues as the use of continuous
passive motion devices and the specifics of the
chosen physical therapy protocol.
PREOPERATIVE FACTORS
Although diagnosis, deformity, age, gender, and
patient weight all are considered important pre-
operative factors influencing TKA ROM, it is
widely agreed that the most important influence
on range of flexion after arthroplasty is preoper-
ative ROM.19,25 Poor long-standing preoperative
ROM may result in several changes that can
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Optimizing Flexion After Total Knee Arthroplasty 169
occur in and around the knee leading to limi-
tations to motion. For example, bony structural
changes, periarticular soft tissue fibrosis, and ex-
tensor mechanism stiffness may result from pro-
longed limitations on flexion. These changes
may be irreversible and so ROM after TKA may
be compromised.20
INTRAOPERATIVE FACTORS
A structure that deserves attention in a dis-
cussion of high-flexion of a TKA is the PCL. As
the knee flexes, this structure tightens and this
may effectively constrain the dimensions of the
flexion gap. Range of motion may be compro-
mised by an insufficient flexion gap. Therefore,
in instances where the PCL is retained, recession
of this structure has been suggested to obtain a
sufficient flexion gap and to avoid limiting
flexion.4 Use of a PCL-substituting design may
allow the surgeon to consistently attain a larger
and more predictable flexion gap as the flexion
gap increases after PCL removal. A larger flex-
ion gap may translate into improved flexion.8,39
Another structure affecting knee flexion is the
extensor mechanism. During flexion, the exten-
sor mechanism is stretched across the anterior
aspect of the knee. As this structure tightens at
higher degrees of flexion, it can limit motion.
Attempts at decreasing the forces seen by this
structure in the reconstructed knee may result
in increases in the range of flexion. The ex-
tensor mechanism may effectively be loosened
by resection of more than the standard amount
of patella during reconstruction. Unfortunate-
ly, patella fracture may result from excessive
patella resection during the resurfacing process.6
Overhanging osteophytes of the femur and
tibia are an additional factor requiring attention
in knee reconstruction with respect to ROM.
Overhanging posterior osteophytes cause early
posterior impingement and should be removed
because they may inhibit full flexion.
Finally, component positioning also may in-
fluence knee flexion. Achieving adequate pos-
terior tilt of the tibial component may result in an
enhanced range of flexion.

170 Sultan et al
POSTOPERATIVE FACTORS
Regarding postoperative factors, it has been re-
ported that rehabilitation plays a significant role
in achieving deep knee flexion.36 Relevant issues
include the use of continuous passive motion
devices and the specifics of the chosen physical
therapy protocol. Despite excellent surgical tech-
nique, soft tissue contracture can occur, which
may limit the range of flexion. Therefore, ag-
gressive rehabilitation accompanied by adequate
pain control may be necessary to optimize post-
operative results.
HIGH FLEXION ARTHROPLASTY
DESIGNS
The success of any total knee system may in part
be linked to its ability to optimally restore normal
kinematic function. Unfortunately, few arthro-
plasty components incorporate design-specific
features aimed at improving knee kinematics
at high flexion angles. Three examples of total
knee systems that incorporate design features
intended to improve knee kinematics in high
flexion include the Zimmer Legacy Knee LPS-
Flex (Zimmer Inc, Warsaw, IN), the Hy-flex II
total knee system (Depuy International Inc,
Leeds, United Kingdom), and the Bisurface knee
prosthesis (Kyocera, Kyoto, Japan).
The LPS-Flex is a posterior-stabilized TKA
designed to accommodate flexion to 1558. By
extending the area of the posterior femoral con-
dyles, this component is designed to provide a
greater arc of flexion by attempting to prevent
‘‘digging in’’ of the posterior femur into the tibial
articular surface (Fig 3). Second, the tibial PE
insert incorporates a deep anterior patellar cut-
out to reduce tension on the extensor mechanism
by providing greater clearance for the patellar
tendon during deep flexion. Finally, the prosthe-
sis incorporates a modified posterior-stabilized
cam-spine mechanism to attempt to increase sub-
luxation resistance and enhance posterior femoral
translation at deep flexion angles.
The Hy-flex II total knee system incorpor-
ates several design paradigms that are aimed at
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Clinical Orthopaedics
and Related Research
Fig 3. The extended area of the posterior con-
dyles is designed to allow the tibiofemoral com-
ponents to articulate through a greater arc of
flexion in attempts to prevent digging in of the
metal condyle into the articular surface. The dot-
ted line represents the dimensions of the compo-
nent before the modification.
providing an increase in the amount of flexion
achievable after TKA. These include: (1) a small
posterior femoral condylar radius; (2) 48 pos-
terior slope for the tibial joint surface; and (3)
equal tension of the soft tissues obtained by using
a ligament tensor. In one study of 84 patients
with RA this prosthesis was implanted into 114
knees. At 1 year followup, the average flexion
was reported to be 122.18 ± 158 with 71.9% of
knees obtaining 1208 flexion or greater.43
The Bisurface knee prosthesis incorporates
one design-specific feature aimed at improving
knee flexion. At the midposterior portion of the
femoral and tibial components, there is a secon-
dary articulation similar to a ball and socket joint
that acts as a posterior-stabilizing cam mecha-
nism promoting femoral rollback. This addi-
tional articulation also serves as a load-bearing
surface in high flexion, which is intended to
prevent tibiofemoral impingement. In a series of
223 consecutive primary TKAs using the Bisur-
face design, the mean postoperative range of
flexion was 1248.2 However, in this series, the
mean preoperative flexion was 1198.
DISCUSSION
Although the human knee may be capable of
flexion up to 1608, an analysis of the results
Number 416
November, 2003
of contemporary TKA reveals that on average,
patients rarely flex beyond 1208. Unfortunately,
the precise biomechanical mechanisms that inhi-
bit higher knee flexion after TKA still are
unknown. Until now, most in vivo and in vitro
biomechanical studies related to knee arthro-
plasty have focused on knee function below 1208
flexion. As a result, the biomechanical mecha-
nisms that limit higher knee flexion remain
unclear. To our knowledge, limited data have
been reported on the capability of current TKA
systems to reproduce native knee kinematics
beyond 1208 flexion.
Currently, an in vitro experimental model
incorporating robotics is being used to investi-
gate the capability of various TKA designs to
restore intact, native knee kinematics at flexion
angles of as much as 1508 (Fig 4). Until now,
we have investigated the capabilities of fixed
and mobile-bearing posterior cruciate-stabilized
TKA to restore native knee kinematics using
an in vitro robotic experimental set-up at high
flexion angles (> 1208) under simulated muscle
loads. This study directly compared the intact
Fig 4. The illustration shows the robotic setup
allowing for in vitro experimentation to determine
the capability of various TKA designs to restore
native knee kinematics at flexion angles as great
as 1508.
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Optimizing Flexion After Total Knee Arthroplasty 171
knee, fixed-bearing, and mobile-bearing TKAs
on the same knee. The results from this study
show that fixed-bearing, and mobile-bearing ar-
throplasties restored approximately 90% of the
native knee at high flexion angles. No statisti-
cally significant difference (p > 0.05) was detected
regarding tibial rotation between fixed-bearing,
and mobile-bearing TKAs or between the TKAs
and the native knee. The results from this study
suggest that the knee is highly constrained at
highflexion. These data provide important kine-
matic information regarding the behavior of dif-
fering arthroplasty designs at high flexion angles.
Ultimately this robotic model in conjunction
with clinical studies may provide an understand-
ing of the limitations of contemporary knee
designs regarding achieving deep flexion, lead-
ing to the development of prostheses that may
enhance kinematics and result in enhancement
of range of flexion that is achievable after TKA.
In general, the clinical results of TKA are
satisfactory regarding pain relief and overall func-
tion. However, patients almost uniformly do not
achieve high degrees of flexion after knee re-
placement. The influences on range of flexion
after TKA are multifactorial. Influential con-
cepts include preoperative knee motion, surgical
technique, prosthetic design, and rehabilitation
issues. Although some arthroplasty designs cur-
rently are available that incorporate modifi-
cations aimed at improving range of flexion,
limited data currently are available on their func-
tion and potential advantages. Through addition-
al investigation into the motion of the native
knee and a deeper understanding of the limita-
tions of contemporary total knee designs, newer
implants may be created that accommodate for
improved flexion.
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