Functional Flexion Instability After Rotating-Platform Total Knee Arthroplasty

Background: We sought to define “at risk” loading conditions associated with rotating-platform total knee arthroplasty (TKA-RP) implants that predispose to insert subluxation and spinout and to quantify tolerances for flexion-extension gap asymmetry and laxity in order to prevent these adverse events.

Methods: Biomechanical testing was performed on 6 fresh-frozen cadaveric limbs with a TKA-RP implant with use of a gap-balancing technique, followed by sequential femoral component revision with variable-thickness polyethylene inserts to systematically represent 5 flexion-extension mismatch and asymmetry conditions. Each configuration was subjected to mechanical loading at 0°, 30°, and 60°. Rotational displacement of the insert on the tibial baseplate, lateral compartment separation, and insert concavity depth were measured with use of a digital caliper. Yield torque, a surrogate for ease of insert rotation and escape of the femoral component, was calculated with use of custom MATLAB code.

Results: Design-intended insert rotation decreased with increasing knee flexion angles in each loading configuration. Likewise, yield torque increased with increasing joint flexion and decreased with increasing joint laxity in all testing configurations. Insert instability and femoral condyle displacement were reproduced in positions of increasing knee flexion and asymmetrical flexion gap laxity. The depth of lateral polyethylene insert concavity determined femoral condylar capture and defined a narrow tolerance of <2 mm in the smallest implant sizes for flexion gap asymmetry leading to rotational insert instability.

Conclusions: Decreased femoral-tibial articular surface conformity with increasing knee flexion and asymmetrical flexion gap laxity enable paradoxical motion of the femoral component on the upper insert surface rather than the undersurface, as designed.

Clinical Relevance: Mobile-bearing TKA-RP is a technically demanding procedure requiring a snug symmetrical flexion gap. As little as 2 mm of asymmetrical lateral flexion laxity can result in decreased conformity, condyle liftoff, and insert subluxation. Flexion beyond 30° decreases bearing surface contact area and predisposes to reduced insert rotation and mechanical malfunction.