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All issues Volume 11 (2025) SICOT-J, 11 (2025) 18 Full HTML
Open Access
Review
Issue
SICOT-J
Volume 11, 2025
Article Number 18
Number of page(s) 13
Section Knee
DOI https://doi.org/10.1051/sicotj/2025010
Published online 19 March 2025

© The Authors, published by EDP Sciences, 2025

Licence Creative CommonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction

The hinged prosthesis in total knee arthroplasty (TKA) was first introduced as a surgical implant made from an acrylic resin in 1951 by Walldius [1]. Following this, further first-generation hinged prostheses were created using metallic components. This included Shier’s stainless-steel hinged knee in 1953, Young’s Vitallium hinged knee in 1958, Guepar’s chrome-cobalt-molybdenum alloy hinged knee and Stanmore’s acrylic polymer with nylon axle hinged knee in 1969. These designs allowed only flexion-extension motion with one degree of freedom and relied directly on the implants to support the patient’s body weight [2]. The multi-directional forces across these implants led to early bearing wear and premature component loosening [2]. Second-generation hinged prostheses were developed to provide additional axial rotation with two degrees of freedom and included a polyethylene insert to minimise bearing wear. These were also prone to premature component loosening due to the high sheer forces at the bone-implant interface, altered knee biomechanics and patella maltracking [2]. Further design modifications have led to the development of third-generation hinge components, which allow for rotational movements of the implant [2]. These theoretically provide a more congruent articulation, decreasing implant wear and reducing inter-facial stresses. Modular segments have also been incorporated into modern hinge knee implant designs, allowing larger intramedullary bone defects to be filled. Despite these design features, concerns remain over implant survivorship, functional outcomes and complications following the use of hinge knee prostheses.

This narrative review provides an overview of the indications and complications of rotating hinged total knee replacement (RHTKA) and aims to assist surgeons in decision-making regarding the use of these prostheses.

Indications for RHTKA implants

Patients with severe deformities, extensive bone loss, or ligamentous deficiency may require increased levels of constraint to optimise stability following TKA [2, 3]. In primary TKA, hinged implants may be indicated in patients with collateral ligamentous insufficiency, distal femoral or proximal tibial osseous defects, instability, knee extensor mechanism deficit, severe rheumatoid arthritis, severe varus/valgus deformities, Charcot arthropathy or oncological reconstruction [2, 4, 5]. In revision TKA, hinged implants may also be used for periprosthetic fractures [4, 6–8] and septic revisions with significant bone loss and soft tissue compromise [9].

Range of motion and functional outcomes

RHTKA prostheses have been associated with an increased range of motion (ROM) and improved functional outcomes following primary and revision TKA. Yeroushalmi et al. showed an average range of motion (ROM) increase of 9 degrees compared with pre-operatively for 18 complex primary and 129 revision patients who had an RHTKA [10]. In a systematic review, Stroobant et al. identified 1131 patients who had revision surgery with a RHTKA and showed a mean ROM improvement from 69.1 to 104.1 degrees [11]. When comparing RHTKA between the primary and revision settings, studies have shown a non-statistically significant difference in final ROM [6, 12]. Collectively, these results show net improvement in ROM gain when using an RHTKA, with no significant difference in the ROM improvement when used for either the primary or revision setting. Neuhaus et al. [6] reviewed outcomes in 98 patients undergoing primary TKA and 22 patients undergoing revision TKA with the hinged EnduRo prosthesis (Aesculap AG, Tuttlingen, Germany). They reported improvements in the ROM using a goniometer for measurement (108.7°–117.9° in primary RHTKA and 110.7°–114.6° in revision RHTKA), knee society scores (kKSS) (35–89.5 for primary RHTKA and 37.5–78.1 for revision RHTKA) and functional knee society scores(fKSS) values (57.3 and 56.7–73.5 and 67.8 for primary RHTKA and revision RHTKA respectively) at five years follow-up. The primary RHTKA group improved their functional outcomes more than the revision group at a five-year follow-up. Similarly, Efe et al. [12] reported improvements in functional outcomes using hinged components in primary and revision TKA, though statistical differences were not found between primary and revision cases at five-year follow-up (Table 1).

Table 1

Shows the main data and results from the included studies in this narrative review.

Bistolfi et al. [13] reviewed outcomes in 29 patients undergoing revision TKA using the NexGen RHTKA (Zimmer, Warsaw, Indiana). The authors reported improvements in the Hospital for Special Surgery knee score (HSS) (65.6–88.4) and ROM (90.9°–114.4°) at a mean 5-year follow-up. In another study, Perrin et al. [14] reviewed the outcomes of the Legion HK RHTKA (Smith and Nephew, Canada) in 12 patients undergoing primary TKA and 27 patients undergoing revision TKA. The authors reported improvements in functional and clinical scores at two years of follow-up. Statistically significant improvements in the OKS occurred within the first six months following surgery (16.9–28.1 p = < 0.001), with no further improvements occurring between 6 months and 2 years following surgery. A meta-analysis reviewing outcomes of the hinged prosthesis in primary TKA from seven studies found the mean improvement in the kKSS was 39.7 while the mean improvement in the fKSS was 40.2 at 2-to-15-year follow-up [15]. Several other studies have shown improvements in functional scores using hinged components in revision TKA for septic cases [16, 17]. The functional outcome scores in patients undergoing revision TKA for periprosthetic joint infection (PJI) were inferior compared with those undergoing revision for aseptic loosening or instability [18]. This inferiority may be related to the inevitable decrease in ROM with two-stage surgery in septic revision, and septic revision is indirectly related to larger bone defects due to failure to control persistent infection [19, 20].

Lim et al. [21] compared outcomes in 39 patients receiving condylar-constrained TKA implants (CCTKA) against 78 patients receiving RHTKA matched for gender, age, body mass index (BMI) and pre-operative clinical scores. The authors found that the CCTKA had significantly better post-operative fKSS scores (60.6 vs. 36.9 respectively, p < 0.001) and OKSs (23.0 vs. 29.1 respectively, p = 0.01) compared to the RHTKA group at two years follow-up. They also found that patients who received CCTKA were more satisfied with their surgery and felt their expectations had been met. These findings are supported by other studies comparing CCTKA with RHTKA implants [22, 23]. The authors speculated in the discussion that the more favourable outcomes they found of CCTKA implants might be due to the more extensive pathology that is generally an indication for RHTKA, with worse pre-operative pain and function scores due to this pathology. They also state that the difference in outcomes may be due to the non-standardised indications and the differing management of revision TKA between surgeons in terms of bone loss and soft tissue integrity. Finally, they hypothesised that the difference in kinematics between the RHK and CCK implants might be a further reason for the observed difference. However, further biomechanical studies will be needed to evaluate this.

The findings of these studies must be interpreted with caution as preoperative bone loss and ligamentous instability were not comprehensively matched between the treatment groups, and the outcomes may be influenced by potential confounders, such as a history of PJI, ambulation status and medical comorbidities and initial indication for receiving the specific type of implant.

Component migration

Achieving stable component fixation in TKA can be challenging owing to loss of native bone stock, pre-existing comorbidities such as osteoporosis, and multiple previous procedures. A concern with the RHTKA design is the sheer stress at the bone-implant interface leading to an increased risk of premature component loosening and implant failure. Radiostereometric analysis (RSA) may be used to assess component micromotion and subsequent risk of component loosening following TKA [24]. Laarhoven et al. [25] used RSA to assess component migration in 20 patients undergoing TKA with fully cemented RHTKA components. The authors reported that micromotion mainly occurred within the first six weeks following surgery and predominantly affected the femoral component of the TKA. None of the study patients had failures or further component loosening at two-year follow-up, suggesting that the early micromotion of the femoral component stabilised after the initial six-week post-operative period. The early micromotion in the femoral component may be attributed to increased torsional stressors on the femoral component, which may be related to the natural deviation of the femoral autonomic-mechanical axis. As previously mentioned by Farid et al. [26] design evolution should focus on the femoral component over the more stable tibial component. A separate study assessed outcomes using fully cemented hinged components in 147 patients undergoing primary or revision TKA and found patients had only femoral component loosening at 3.8 years follow-up [10]. Further clinical trials assessing the clinical significance of these findings are needed to establish the safe thresholds for early femoral component micromotion and the long-term impact on component survivorship.

There is limited data surrounding patient factors and resultant component migration, especially within the RHTKA cohort. Two recent narrative reviews analysing component migration in TKA described that component migration might be attributed to low bone mineral density (BMD), with BMD known to also be related to age and gender [27, 28]. A post-mortem study by Howard et al. [29] looking at the contact fraction of various implant designs found that increasing age significantly impacted the fixation of the TKA components, with a reduction in contact fraction seen in the donors of higher age. However, there is a paucity of literature surrounding this topic, and further research, as well as correlation with hinged knee replacements is required.

Biomechanical evaluations

Conventional (bi-axial) and rotating (spherical central axis) hinge constructs vary in their stresses at the bone-implant interface. The bi-axial system only has flexion-extension and internal-external rotation motion, which transmits shear forces mainly to the bushing during the movement phases of the gait cycle [30]. The spherical axial system allows for varus-valgus, internal-external, and anteroposterior motion. In knee models with deficient medial and lateral collateral ligaments, the von Mises and shear stresses are lower in rotational hinged components compared with more constrained hinged implants [31]. Furthermore, rotational hinged implants have more uniform stress distribution on the polyethene liner, which may reduce bearing surface wear over time [30, 31]. The contact stress pattern seen in the spherical central axial system has been shown to be similar to non-constrained implant designs in TKA [30, 32].

The native femoral rollback is neutralised in hinged knee constructs, leading to less posterior motion than within the native knee joint or posterior stabilised designs for TKA. In addition, the hinge implant has rotation occurring at the centre of the hinge rather than in the medial tibial plateau, as observed in the native joint. In combination, these features lead to ventral prominence of the femoral axis relative to the native tibial axis and limited femoral rollback in flexion, which may lead to increased anterior knee pain and excessive patella pressures compared with the native knee and uncoupled implants in TKA [33].

Stem design plays a pivotal role in the stability of the construct. Biomechanical studies have demonstrated similar pull-out forces for both cemented long and short stems for small bone defects, and greater pull-out forces for cemented stems compared with uncemented stems [34]. For large bone defects, long uncemented stems and short cemented stems were found to have similar pull-out strengths [35]. The central rotational stem, being either cylindrical or conical in design, dictates how much distraction can occur before stem dislocation. Cylindrical central rotational stems are superior to conical stems, and implants with short stems of cylindrical design require greater distraction forces to dislocate compared with long-stem conical designs. These cylindrical central rotational stems were found to have lower angular laxity at any amount of distraction [34]. Other authors have reported no difference in the failure rates between conical and cylindrical stems for revision TKA and suggested that stem engagement <4 cm is associated with increased rates of aseptic loosening and tibial shaft pain [36].

Survivorship

RHTKA has component survivorship ranging from 51% to 92.5% at 10 years postoperatively [4, 37]. In a recent meta-analysis, the average survivorship for RHTKA was 92% and 82% at 5 and 10-year follow-ups, respectively [15]. It has been shown that the survivorship of primary RHTKA is higher in patients over the age of 60 years compared with those less than 60 years (94% vs. 77%) [38, 39] and patients with preoperative valgus deformities may have inferior survivorship compared to those with preoperative varus deformities (79% vs. 96%) [38]. The survivorship of RHTKA is correlated with the original indication for requiring an RHTKA, with the prosthesis rate of survival in the tumour patients being inferior to that of non-tumour patients (77% at 5 years and 69% at 10 years) [15]. This is primarily due to the recurrence of the tumour [15]. Baker et al. found that at the 5-year follow-up, there was no difference in survival when looking at the original indication of why the hinged implant was used as a replacement in the primary setting, comparing osteoarthritis with other inflammatory arthropathies and post-traumatic arthritis [40].

A systematic review by Knight et al. [41] found that for all age groups except those over 75, the survivorship of hinged versus fixed stabilised TKA in the primary setting was comparable. The patients over 75 showed higher revision rates with hinged implants secondary to periprosthetic fractures, possibly related to higher rates of osteoporosis in the elderly and higher implant-to-bone stress at the stem. However, they could not comment on the significance of this. They found that when the indication for primary TKA was osteoarthritis, there were no significant differences in survivorship for these patients, however for the indication of periarticular fracture, the hinged knee outperformed the fixed stabilized TKA, with a cumulative percent revision rate of 0.9% versus 3.4% for that of the fixed stabilised TKA. The authors attributed this to the lack of collateral ligament support in these fractures, and the constrained nature of the hinged implant being able to accommodate the instability created by this loss.

A meta-analysis by Yoon et al. [23] included outcomes from 12 studies reporting on revision TKA and found that RHTKA had superior survivorship compared with CCTKA (87.4% vs 75%) at short-term (<5 years) follow-up, but comparable outcomes (81.3% vs 83.8%) were found between the two groups at mid-term (5–10 years) follow-up. The increased constraint in the RHTKA group may improve early implant stability and survivorship. However, the increased sheer forces at the bone-implant interface may lead to increased aseptic loosening with longer-term follow-up [1]. Badawy et al. [42] reviewed outcomes from the Norwegian Arthroplasty register and reported that CCTKA had improved survivorship compared with RHTKA at two- and five-year follow-ups. Importantly, when infection as the reason for the revision was excluded, the RHTKA, CCTKA and conventional TKAs had similar survivorships of 96% at 5 years follow-up [42]. Similarly, Stroobant et al. [11] conducted a meta-analysis using 40 studies and found no differences in survivorship between RHTKA (91%) and CCTKA (89%) at five-year follow-ups.

A systemic review by Xu et al. in 2022 [43] reviewed outcomes for hinged implants in both primary and revision TKA. For primary TKA with hinged implants, the median survivorship was 93.4% at one year and 85.9% at five years. For revision, TKA, the median survivorship was 79.6% at one year, 77% at five years and 65.1% at 10 years follow-up [43]. Perrin et al. [14] reported 100% survivorship for primary TKAs with hinged implants at one and two years of follow-up, with 91% and 85.9% survivorship for revision TKAs with hinged implants at one and two years, respectively. The inferior survivorship for revision TKA is likely related to pre-existing factors, including the indication as to why the patient requires revision, such as septic or aseptic loosening, bone loss and reduced bone quality. Chen et al. [16] reviewed outcomes specifically in patients undergoing revision TKA with hinged implants for PJI and reported survivorship of 86% at two years and 70% at five-year follow-up. The main reasons for failure requiring revision surgery were recurrence of the infection and aseptic loosening. Other studies reviewing outcomes in both primary and revision hinge replacement have reported overall survivorship of 89–93% at two years and 79% at five years follow-up [13, 44].

Complications

Despite improvements in the design and materials used in hinged implants for TKAs, the overall complication rates associated with their use range from 9.2% to 63% [45]. Higher rates of complications have been reported in patients undergoing TKAs with hinged implants for revision surgery compared with primary surgery. Of note, most complications with hinged implants in revision TKA occur within two years post-operatively [7, 45, 46], and the most commonly reported complications include aseptic loosening, stiffness, periprosthetic fractures, PJI, stiffness and extensor mechanism failure [14, 47]. Less common complications include patellar instability and prosthetic dislocation (0.7–4.4%) [48]. These complications may reflect a selection bias as patients undergoing hinged knee implants may be elderly with multiple comorbidities, poor physiological reserve and have had multiple previous knee procedures. Therefore, the additional risk of these complications due to the implant design is challenging to quantify.

In the primary setting, PJI (11%) remains the most common mode of failure. Aseptic loosening tends to affect the femoral implant more than the tibial implant, with an increased risk of loosening in patients who are younger at the time of replacement or undergoing revision surgery [47]. As expected, high stress at the bone-cement interface and osteolysis of the polyethylene liner are the main causes of aseptic loosening [49]. When periprosthetic fractures occurred, this was most commonly found in the femur [47].

An important cause of failure in revision RHTKA is PJI, particularly following one or two-stage revision surgery for a previous PJI. Chen et al. [16] reviewed outcomes in 58 patients undergoing second-stage revision TKA with hinged implants for PJI and reported infection-free survival was 68.9% at two years and 60.6% at five-year follow-ups. The multi-variate analysis found that obesity (HR = 3.11), high-virulence pathogens (HR = 3.44) and polymicrobial infection (HR = 3.59) were independent risk factors for PJI. Green et al. [50] reviewed outcomes in 85 patients undergoing revision RHTKA with previous infection against 65 patients undergoing revision RHTKA for aseptic reasons. The study found that the septic group had an increase in return to the operating room (46% versus 25%, p = 0.01), with revision-free survival improved in the aseptic group. RHTKA implants that were associated with concomitant flap reconstruction had an even higher risk for requiring revision surgery, with a 3-fold increase noted in Green’s study using regression analysis (p < 0.0001). A further complication noted in RHTKA was dislocation. Dislocation of the implant may occur if the flexion-extension gaps are not balanced, though this is becoming less common with modern hinged implant designs that have an anti-dislocation mechanism [2, 44, 47, 51]. Pre-operative workup is essential for patient optimisation to decrease the risk of PJI, including nutritional support and weight control, smoking cessation and multi-resistant organism eradication.

Conclusion

RHTKA remains an essential part of the armamentarium in primary and revision cases with poor bone stock, soft tissue compromise, gross instability, and periprosthetic fractures. Studies have shown that an RHTKA may be used in both primary and revision scenarios to improve the ROM and functional outcomes. RSA has shown that some RHTKA designs are associated with early femoral component micromotion, but this has not translated to increased failure or revision rates. RHTKA designs may transfer the centre of rotation anteriorly, leading to increased anterior knee pain and abnormal patella pressures. Implant survivorship with modern rotating hinge implant designs is comparable to CCTKA at mid-term follow-up. The most common complications with an RHTKA include aseptic loosening, PJI, stiffness, and fractures. There is a paucity of evidence in regards to key factors such as the activity level of the patient and how this may influence the results of RHTKA, the difference in cost between prostheses and how this may influence the implant of choice, variations in rehabilitation protocols for RHTKA compared to others, time required for return to work or sport following RHTKA, or differences in surgical technique which may influence a surgeon’s predilection for one type of prosthesis over another. These may be areas of research in the future.

Funding

This article did not received any specific funding.

Conflicts of interest

T. Oliver, H. Humphries and T.D Luo have no conflicts of interest to declare. B. Kayani is a board member of The Bone and Joint Journal and receives funding from the British Orthopaedic Association and Orthopaedics Research UK. Fares. S. Haddad reports board membership on The Bone & Joint Journal and membership on the BOSTAA Executive Committee and is a Trustee of the British Orthopaedic Association. F. S. Haddad also reports multiple research study grants from Stryker, Smith & Nephew, Corin, International Olympic Committee, and National Institutes of Health and Research, royalties or licenses from Smith & Nephew, Stryker, Corin, and MatOrtho, consulting fees from Stryker, speaker payments from Stryker, Smith & Nephew, Zimmer, and AO Recon, and support for attending meetings and/or travel from Stryker, Smith & Nephew, AO Recon, and The Bone & Joint Journal.

Data availability statement

The research data associated with this article are included within the article.

Author contribution statement

T. Oliver: Performed literature search, wrote manuscript; T.D. Luo/B. Kayani/F.S. Haddad/H. Humphries – edited manuscript.

Ethics approval

Ethical approval was not required.

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Cite this article as: Oliver TC, Kayani B, Luo TD, Humphries H & Haddad FS (2025) Current concepts in total knee arthroplasty: Rotating hinge prostheses. SICOT-J 11, 18. https://doi.org/10.1051/sicotj/2025010.

All Tables

Table 1

Shows the main data and results from the included studies in this narrative review.

In the text

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