Failure of the Tibial Insert in a Rotating Hinge Total Knee Arthroplasty

doi:10.1016/j.arth.2010.08.008

The Journal of Arthroplasty

Volume 26, Issue 6, September 2011, Pages 977.e5-977.e8

https://doi.org/10.1016/j.arth.2010.08.008 Get rights and content

Abstract

There has been a steady increase in the number of revision total knee arthroplasties being performed in the United States. Hinge knee prostheses are used predominantly in complex primary or revision arthroplasties, often as salvage procedures. Significant improvement of the articulation between the rotating hinge mechanism and tibial component has decreased the stresses that contributed to earlier failures in previous generation designs. Two cases of fracture of the tibial metal post in the rotating hinge of a revision total knee arthroplasty were evaluated and treated at our institution within a 1-month period. We present our experience with this construct failure and subsequent patient management.

Section snippets

Case 1

A 58-year-old retired male police officer presented for management of an infected right TKA. Four years after a primary TKA procedure, the patient has undergone 2 irrigation and debridement procedures followed by long-term intravenous antibiotic treatment before presentation. The patient denied knee instability, yet he reported deteriorating knee function with decreasing range of motion, which limited walking, maneuvering stairs, and rising from a seated position.

Physical examination revealed

Case 2

A 65-year-old retired kindergarten teacher underwent bilateral-staged TKAs. She was subsequently diagnosed with an infection of the left TKA and was treated with a 2-stage reconstruction, ultimately implanting a Depuy S-ROM Noiles rotating hinge system. This implant was again chosen because of severe medial and lateral collateral ligament incompetence and a large flexion gap imbalance. Her laxity mandated the use of a 23-mm Limb Preservation System tibial insert, the thickest available, which

Discussion

Early designs of a fixed uniaxial hinge prosthesis were found to give stability to the diseased knee; however, excess torsion applied to the bone and metal articulation appeared to result in early osteolysis and loosening of the components 3, 6. The second generation's suboptimal design led to high failure rates as well [4]. Third-generation designs, such as the Noiles S-ROM rotating hinge knee, incorporated design features that offered improved torsional stability for fixation as well as

References (10)

JonesR.E. et al.
Total knee arthroplasty using the S-ROM mobile-bearing hinge prosthesis
J Arthroplasty
(2001)
BarrackR.L. et al.
The use of a modular rotating hinge component in salvage revision total knee arthroplasty
J Arthroplasty
(2000)
SharkeyP.F. et al.
Why are total knee arthroplasties failing today?
Orthop Relat Res
(2002)
HoeffelD.P. et al.
Revision total knee arthroplasty: current rationale and techniques for femoral component revision
Clin Orthop Relat Res
(2000)
KesterM.A. et al.
An evaluation of the mechanical failure modalities of a rotating hinge knee prosthesis
Clin Orthop Relat Res
(1988)

There are more references available in the full text version of this article.

Cited by (19)

PEEK Bearing Materials for Total Joint Replacement
2019, PEEK Biomaterials Handbook, Second Edition
Over the past two decades, an extensive body of tribological literature has developed for polyaryletheretherketone (PEEK) and its composites under conditions relevant to total joint replacement applications. Within today’s value-based health-care paradigm, PEEK biomaterials continue to find new opportunities to thrive as candidates for orthopedic applications. In this chapter, we explore such opportunities, first within its original conception of carbon fiber-reinforced PEEK (CFR-PEEK) articulating against a ceramic or CoCr component. In addition, PEEK biomaterials have recently emerged as potential candidates for replacing CoCr femoral components in total knee replacement. This chapter also discusses niche applications for PEEK in small joint arthroplasty.
Fracture of the insert cone of a polyethylene liner in a failed posterior-stabilized, rotating-platform total knee arthroplasty
2018, Arthroplasty Today
Citation Excerpt :
An analogue of the yoke in rotating-hinge prostheses is the polyethylene insert cone in a PS RP-TKA. Although a PS RP-TKA and a rotating-hinge knee prosthesis are designed with different levels of constraint, some authors surmise that abnormal rotary moments of the polyethylene insert on the tibial tray increases cantilever stresses on the yoke [42-44]. Another mechanism of failure may be fatigue failure due to the normal adduction-abduction coronal plane moments which occur routinely during gait.
Failures unique to posterior cruciate-substituting total knee prostheses rarely include polyethylene post fractures but have been described. We report a case involving a fracture of the distal insert cone of a rotating-platform (RP) polyethylene liner in a primary total knee arthroplasty. This case highlights a 67-year-old male presenting with new-onset knee pain and recurrent effusions with osteolysis 11 years following placement of a posterior-stabilized, RP total knee arthroplasty. At the time of revision surgery, the polyethylene insert cone was found to be fractured just below the junction between cone and the body of the insert. Liner exchange, synovectomy, and osteolytic-defect curettage and cement packing were performed. One year following revision surgery, the patient is without pain and has returned to function without limitations. Clinicians must be aware of this possible failure with RP prostheses in the setting of pain with a stable knee, recurrent aseptic effusions, and osteolysis.
Rotating Hinge Implants for Complex Primary and Revision Total Knee Arthroplasty
2018, Journal of Arthroplasty
Contemporary rotating hinge knee (RHK) prosthesis has shown improved survival rates over earlier generations. However, reports of high complication and mechanical failure rates highlight the need for more clinical outcome data in the complex primary and revision setting. The purpose of this study is to report our results of using a contemporary rotating hinge for complex primary and revision total knee arthroplasty.
Using a prospectively maintained surgical database, 79 knees in 76 patients who underwent an RHK of a single design for either a complex primary (14 knees) or revision total knee arthroplasty (65 knees) were identified. This included 19% undergoing an RHK for periprosthetic joint infection and 32.9% who had concomitant extensor mechanism repair. The cohort consisted of 60 women and 16 men with a mean age of 66.7 years (range 39-89) at the time of surgery. Patient outcomes were assessed using Knee Society Scores and radiographs were reviewed for signs of wear and loosening. Failure rates were estimated using Kaplan-Meier survival curves.
At a minimum of 2 years, 13 patients had died and 4 were lost to follow-up, leaving 62 knees in 59 patients who were followed for a mean of 55.2 months (range 24-146). The mean Knee Society Scores improved from 35.7 to 66.2 points (P < .01). The incidence of complications was 38.7%. The most common complications were periprosthetic fracture, extensor mechanism rupture, and periprosthetic infection. Estimated survival was 70.7% at 5 years.
Despite improvements in design and biomaterials, there remains a relatively high complication rate associated with the use of a modern RHK implant. While aseptic loosening was rare, periprosthetic fracture, infection, and extensor mechanism failure were substantial emphasizing the complex nature of these cases.
Bone-prosthesis composite with rotating hinged-knee prosthesis in limb salvage surgery for high-grade sarcoma around the knee
2015, Journal of Arthroplasty
Citation Excerpt :
After a mean follow-up of 36 months, 9 patients (10.6%) had deep infections, 4 patients (4.7%) had patellar complications, and 3 patients (3.5%) had aseptic loosening [26]. Some implant-related complications in RHK prostheses or megaprostheses that have been reported include broken polyethylene bush, tibial metal stem fracture, breakage of tibial yoke bushing, tibial peg fracture [27], and polyethylene stopper fracture [27–31]. However, most of these reports were case reports, and the mentioned implant was inconsistent with different generations of design.
Bone prosthesis composite (BPC) had been widely-used in reconstruction after wide excision of malignant tumors around the knee. However, implant selection for BPC remains a dilemma. Forty-one patients with high-grade malignant bone tumors around the knee who underwent excision and reconstruction with BPC and rotating hinged knee (RHK) prosthesis were included. The mean follow-up time was 54 months (range, 31–78 months). The average Musculoskeletal Tumor Society Rating score was 93.4% (range, 73–100%). The mean range of motion was 125°. Complications included 2 local recurrences, 2 nonunions, and 1 peri-prosthetic fracture. The reconstruction with BPC using the RHK prosthesis provided consistently good functional results with a low complication rate. The RHK prosthesis is a promising choice for BPC reconstruction.
Failure of the Rotating-Hinge Knee Megaprosthesis
2013, Journal of Arthroplasty
Citation Excerpt :
Wang and Wang [15] described two cases of axis dislocation due to broken PE bearing bush. Schwarzkopf et al. [2] reported two cases of tibial metal stem fracture. Kawai et al. [5] presented two cases of breakage of tibial yoke and one case of breakage of tibial bushing.
Recently, rotating hinge knee prostheses were applied more frequently due to improving modern implant designs. They are predominantly used in specific conditions with major bone defect or insufficiency of the collateral ligaments around the knee, often as salvage procedures. A case of rotating hinge knee megaprosthesis failure due to isolated tibial polyethylene stopper broken, which was never reported before, was investigated and treated in our institution. We suggested that rotating hinge knee prosthesis with incompetent medial collateral ligament is apt to failure due to the high valgus moment during gait. Sacrificing lateral collateral ligament or cutting the femur in slightly less than the normal 5° to 7° valgus may eliminate the risk of complication.
Repeated Early Failure of a Newly Designed Hinged Knee System
2013, Journal of Arthroplasty
Citation Excerpt :
We feel that the design of this polyethylene insert is not robust enough to resist the forces across it, resulting in the deformation and subsequent hyperextension deformity. Recently, there have been 2 case reports of failure of the hinge post of a Depuy S-ROM Noiles rotating hinge system due to fatigue failure [11,12]. This was thought to occur secondary to a cantilever effect because of laxity of the joint and a large tibial insert size.
We report a case of acute and recurrent accelerated wear of the polyethylene bushings of the hinge mechanism in the Zimmer Segmental Knee System. This resulted in an unacceptable recurvatum deformity leading to multiple revision knee operations, which was unexpected in a modern design hinged knee system. A custom modification of the original design was used to prevent further recurvatum deformity. The current design of the hinge post mechanism in this system appears to be inadequate, which led to the development of a significant recurvatum deformity in our patient. Surgeons should be aware of this potential complication when considering the use of this revision knee system.

View all citing articles on Scopus

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

View full text

Case ReportFailure of the Tibial Insert in a Rotating Hinge Total Knee Arthroplasty

Abstract

Section snippets

Case 1

Case 2

Discussion

J Arthroplasty

J Arthroplasty

Why are total knee arthroplasties failing today?

Orthop Relat Res

Revision total knee arthroplasty: current rationale and techniques for femoral component revision

Clin Orthop Relat Res

An evaluation of the mechanical failure modalities of a rotating hinge knee prosthesis

Clin Orthop Relat Res

Case Report
Failure of the Tibial Insert in a Rotating Hinge Total Knee Arthroplasty