Increased risk of revision for high flexion total knee replacement with thicker tibial liners

R. S. Namba, M. C. S. Inacio, G. Cafri


The outcome of total knee replacement (TKR) using components designed to increase the range of flexion is not fully understood. The short- to mid-term risk of aseptic revision in high flexion TKR was evaluated. The endpoint of the study was aseptic revision and the following variables were investigated: implant design (high flexion vs non-high flexion), the thickness of the tibial insert (≤ 14 mm vs > 14 mm), cruciate ligament (posterior stabilised (PS) vs cruciate retaining), mobility (fixed vs rotating), and the manufacturer (Zimmer, Smith & Nephew and DePuy). Covariates included patient, implant, surgeon and hospital factors. Marginal Cox proportional hazard models were used.

In a cohort of 64 000 TKRs, high flexion components were used in 8035 (12.5%). The high flexion knees with tibial liners of thickness > 14 mm had a density of revision of 1.45/100 years of observation, compared with 0.37/100 in non-high flexion TKR with liners ≤ 14 mm thick. Relative to a standard fixed PS TKR, the NexGen (Zimmer, Warsaw, Indiana) Gender Specific Female high flexion fixed PS TKR had an increased risk of revision (hazard ratio (HR) 2.27 (95% confidence interval (CI) 1.48 to 3.50)), an effect that was magnified when a thicker tibial insert was used (HR 8.10 (95% CI 4.41 to 14.89)).

Surgeons should be cautious when choosing high flexion TKRs, particularly when thicker tibial liners might be required.

Cite this article: Bone Joint J 2014;96-B:217–23.


  • The authors would like to thank all Kaiser Permanente orthopaedic surgeons and the staff of the Department of Surgical Outcomes and Analysis who have contributed to the success of the National Total Joint Replacement Registry. We would also like to thank Cindy Chen, BS for her work on the implants classification used for this study and preparing the analytical data used.

    No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

    This article was primary edited by J. Scott and first-proof edited by G. Scott.

  • Received June 13, 2013.
  • Accepted October 24, 2013.
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