Flexion Instability After Total Knee Arthroplasty

Overview

Journal J Am Acad Orthop Surg

Publisher Wolters Kluwer

Specialties General Surgery
Orthopedics

Date 2019 Jan 25

PMID 30676514

Citations 20

Authors

Jeffrey B Stambough

Paul K Edwards

Erin M Mannen

C Lowry Barnes

Simon C Mears

Affiliations

Soon will be listed here.

Abstract

Flexion instability after total knee arthroplasty (TKA) is caused by an increased flexion gap compared with extension gap. Patients present with recurrent effusions, subjective instability (especially going downstairs), quadriceps weakness, and diffuse periretinacular pain. Manual testing for laxity in flexion is commonly done to confirm a diagnosis, although testing positions and laxity grades are inconsistent. Nonsurgical treatment includes quadriceps strengthening and bracing treatment. The mainstays to surgical management of femoral instability involve increasing the posterior condylar offset, decreasing the tibial slope, raising the joint line in combination with a thicker polyethylene insert, and ensuring appropriate rotation of implants. Patient outcomes after revision TKA for flexion instability show the least amount of improvement when compared with revisions for other TKA failure etiologies. Future work is needed to unify reproducible diagnostic criteria. Advancements in biomechanical analysis with motion detection, isokinetic quadriceps strength testing, and computational modeling are needed to advance the collective understanding of this underappreciated failure mechanism.

Citing Articles

Big data analysis reveals significant increases in complications, costs, and hospital stay in revision total knee arthroplasty compared to primary TKA.

Laver L, Maman D, Hirschmann M, Mahamid A, Bar O, Steinfeld Y Knee Surg Sports Traumatol Arthrosc. 2024; 33(3):1015-1024.

PMID: 39382040 PMC: 11848982. DOI: 10.1002/ksa.12499.

Aetiology of patient dissatisfaction following primary total knee arthroplasty in the era of robotic-assisted technology.

Gardner J, Roman E, Bhimani R, Mashni S, Whitaker J, Smith L Bone Jt Open. 2024; 5(9):758-765.

PMID: 39260450 PMC: 11390183. DOI: 10.1302/2633-1462.59.BJO-2024-0099.R1.

Surgeon-Applied Stress and a Ligament Tensor Instrument Provide a Similar Assessment of Preresection Flexion Laxity During Robotic Total Knee Arthroplasty.

Woelfle C, Weiner T, Sculco P, Sarpong N, Shah R, Cooper H Arthroplast Today. 2024; 28:101450.

PMID: 39071093 PMC: 11283011. DOI: 10.1016/j.artd.2024.101450.

Role and Results of Constrained Insert in Computer-Assisted Primary Total Knee Arthroplasty: A Propensity-Matched Study.

Jhurani A, Agarwal P, Sahni H, Ardawatia G, Srivastava M Arthroplast Today. 2024; 27:101423.

PMID: 38946924 PMC: 11214376. DOI: 10.1016/j.artd.2024.101423.

Effect of Posterior Tibial Slope on Knee Kinematics After Bicruciate-Retaining Total Knee Arthroplasty.

Dobrich J, Bauer S, Elicegui S, LaCour M, Ries M Arthroplast Today. 2024; 27:101417.

PMID: 38882467 PMC: 11180305. DOI: 10.1016/j.artd.2024.101417.

References

Vince K . Mid-flexion instability after total knee arthroplasty: woolly thinking or a real concern?. Bone Joint J. 2016; 98-B(1 Suppl A):84-8. DOI: 10.1302/0301-620X.98B1.36445. View

Sharkey P, Lichstein P, Shen C, Tokarski A, Parvizi J . Why are total knee arthroplasties failing today--has anything changed after 10 years?. J Arthroplasty. 2014; 29(9):1774-8. DOI: 10.1016/j.arth.2013.07.024. View

Wright T . Joint Stability in Total Knee Arthroplasty: What Is the Target for a Stable Knee?. J Am Acad Orthop Surg. 2016; 25 Suppl 1:S25-S28. DOI: 10.5435/JAAOS-D-16-00641. View

Alnahdi A, Zeni J, Snyder-Mackler L . Gait after unilateral total knee arthroplasty: frontal plane analysis. J Orthop Res. 2011; 29(5):647-52. PMC: 3754839. DOI: 10.1002/jor.21323. View

Evangelista P, Laster S, Lenz N, Sheth N, Schwarzkopf R . A Computer Model of Mid-Flexion Instability in a Balanced Total Knee Arthroplasty. J Arthroplasty. 2018; 33(7S):S265-S269. DOI: 10.1016/j.arth.2018.02.021. View

Babis G, Trousdale R, Morrey B . The effectiveness of isolated tibial insert exchange in revision total knee arthroplasty. J Bone Joint Surg Am. 2002; 84(1):64-8. DOI: 10.2106/00004623-200201000-00010. View

Rullkoetter P, Fitzpatrick C, Clary C . How Can We Use Computational Modeling to Improve Total Knee Arthroplasty? Modeling Stability and Mobility in the Implanted Knee. J Am Acad Orthop Surg. 2016; 25 Suppl 1:S33-S39. DOI: 10.5435/JAAOS-D-16-00640. View

Ramappa M . Midflexion instability in primary total knee replacement: a review. SICOT J. 2016; 1:24. PMC: 4849283. DOI: 10.1051/sicotj/2015020. View

Chang M, Lim H, Lee N, Moon Y . Diagnosis, causes and treatments of instability following total knee arthroplasty. Knee Surg Relat Res. 2014; 26(2):61-7. PMC: 4061408. DOI: 10.5792/ksrr.2014.26.2.61. View

10.

Abdel M, Pulido L, Severson E, Hanssen A . Stepwise surgical correction of instability in flexion after total knee replacement. Bone Joint J. 2014; 96-B(12):1644-8. DOI: 10.1302/0301-620X.96B12.34821. View

11.

Yercan H, Ait Si Selmi T, Sugun T, Neyret P . Tibiofemoral instability in primary total knee replacement: a review, Part 1: Basic principles and classification. Knee. 2005; 12(4):257-66. DOI: 10.1016/j.knee.2005.01.004. View

12.

Wang H, Simpson K, Ferrara M, Chamnongkich S, Kinsey T, Mahoney O . Biomechanical differences exhibited during sit-to-stand between total knee arthroplasty designs of varying radii. J Arthroplasty. 2006; 21(8):1193-9. DOI: 10.1016/j.arth.2006.02.172. View

13.

Petrie J, Haidukewych G . Instability in total knee arthroplasty : assessment and solutions. Bone Joint J. 2016; 98-B(1 Suppl A):116-9. DOI: 10.1302/0301-620X.98B1.36371. View

14.

Luttjeboer J, Benard M, Defoort K, van Hellemondt G, Wymenga A . Revision Total Knee Arthroplasty for Instability-Outcome for Different Types of Instability and Implants. J Arthroplasty. 2016; 31(12):2672-2676. DOI: 10.1016/j.arth.2016.06.062. View

15.

Clarke H, Scuderi G . Flexion instability in primary total knee replacement. J Knee Surg. 2003; 16(2):123-8. View

16.

Schwab J, Haidukewych G, Hanssen A, Jacofsky D, Pagnano M . Flexion instability without dislocation after posterior stabilized total knees. Clin Orthop Relat Res. 2005; 440:96-100. DOI: 10.1097/00003086-200511000-00018. View

17.

Kannan A, OConnell R, Kalore N, Curtin B, Hull J, Jiranek W . Revision TKA for Flexion Instability Improves Patient Reported Outcomes. J Arthroplasty. 2015; 30(5):818-21. DOI: 10.1016/j.arth.2014.12.010. View

18.

Yoshihara Y, Arai Y, Nakagawa S, Inoue H, Ueshima K, Fujiwara H . Assessing coronal laxity in extension and flexion at a minimum of 10 years after primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2015; 24(8):2512-6. DOI: 10.1007/s00167-015-3601-0. View

19.

Rajgopal A, Panjwani T, Rao A, Dahiya V . Are the Outcomes of Revision Knee Arthroplasty for Flexion Instability the Same as for Other Major Failure Mechanisms?. J Arthroplasty. 2017; 32(10):3093-3097. DOI: 10.1016/j.arth.2017.05.010. View

20.

Rodriguez-Merchan E . Instability following total knee arthroplasty. HSS J. 2012; 7(3):273-8. PMC: 3192893. DOI: 10.1007/s11420-011-9217-0. View