Superior Survival of Fully Cemented Fixation Compared to Hybrid Fixation in a Single Design Rotating Hinge Knee Implant

Published:December 02, 2021DOI:



      Clinical observations revealed higher rates of aseptic loosening for hybrid fixated rotating hinge knee implants compared to fully cemented ones. We hypothesize that the use of a fully cemented fixation technique had a higher survival rate for aseptic loosening compared to a hybrid fixation technique in a rotating hinge knee implant.


      All procedures of patients who were treated with the RT-PLUS rotating hinge knee implant (Smith & Nephew, Memphis, TN) between 2010 and 2018 were included. Primary outcome was revision for aseptic loosening. Kaplan-Meier survivorship and Cox proportional hazard regression analysis were performed to calculate survival rates and hazard ratios.


      A total of 275 hinge knee implants were placed in 269 patients (60 primary procedures, 215 revisions). Median follow-up was 7.3 ± 3.9 years. In total, 24 components (16 hybrid femur, 2 fully cemented femur, 6 hybrid tibia; all revision procedures) in 19 patients were revised for aseptic loosening. Kaplan-Meier survivorship analysis showed superior survival rates of fully cemented components (femur 97.1%; tibia 100%) compared to hybrid fixated components (femur 89.5%; tibia 95.9%) at the 10-year follow-up. Multivariate Cox hazard analysis showed a significantly higher risk of aseptic loosening for hybrid fixated components, a prior stemmed component and the femoral component.


      Fully cemented fixation showed superior survival rates for aseptic loosening compared to hybrid fixation in a single design rotating hinge knee implant. A prior stemmed component appears to be a risk factor for aseptic loosening and the femoral component seems to be more prone to loosening.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Pasquier G.
        • Ehlinger M.
        • Mainard D.
        The role of rotating hinge implants in revision total knee arthroplasty.
        EFORT Open Rev. 2019; 4: 269-278
        • Kouk S.
        • Rathod P.A.
        • Maheshwari A.V.
        • Deshmukh A.J.
        Rotating hinge prosthesis for complex revision total knee arthroplasty: a review of the literature.
        J Clin Orthop Trauma. 2018; 9: 29-33
        • Wang C.
        • Pfitzner T.
        • von Roth P.
        • Mayr H.O.
        • Sostheim M.
        • Hube R.
        Fixation of stem in revision of total knee arthroplasty: cemented versus cementless—a meta-analysis.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3200-3211
        • Kosse N.M.
        • van Hellemondt G.G.
        • Wymenga A.B.
        • Heesterbeek P.J.C.
        Comparable stability of cemented vs press-fit placed stems in revision total knee arthroplasty with mild to moderate bone loss: 6.5-year results from a randomized controlled trial with radiostereometric analysis.
        J Arthroplasty. 2017; 32: 197-201
        • Fleischman A.N.
        • Azboy I.
        • Fuery M.
        • Restrepo C.
        • Shao H.
        • Parvizi J.
        Effect of stem size and fixation method on mechanical failure after revision total knee arthroplasty.
        J Arthroplasty. 2017; 32: S202-S208.e1
        • Heesterbeek P.J.C.
        • Wymenga A.B.
        • Van Hellemondt G.G.
        No difference in implant micromotion between hybrid fixation and fully cemented revision total knee arthroplasty: a randomized controlled trial with radiostereometric analysis of patients with mild-to-moderate bone loss.
        J Bone Joint Surg Am. 2016; 98: 1359-1369
        • El-Zayat B.F.
        • Heyse T.J.
        • Fanciullacci N.
        • Labey L.
        • Fuchs-Winkelmann S.
        • Innocenti B.
        Fixation techniques and stem dimensions in hinged total knee arthroplasty: a finite element study.
        Arch Orthop Trauma Surg. 2016; 136: 1741-1752
        • Guttowski D.
        • Polster V.
        • Huber G.
        • Morlock M.M.
        • Püschel K.
        • Nüchtern J.
        Comparative biomechanical in vitro study of different modular total knee arthroplasty revision stems with bone defects.
        J Arthroplasty. 2020; 35: 3318-3325
        • Farid Y.R.
        • Thakral R.
        • Finn H.A.
        Intermediate-term results of 142 single-design, rotating-hinge implants: frequent complications may not preclude salvage of severely affected knees.
        J Arthroplasty. 2015; 30: 2173-2180
        • Engh G.A.
        • Ammeen D.J.
        Classification and preoperative radiographic evaluation: Knee.
        Orthop Clin North Am. 1998; 29: 205-217
        • Yeroushalmi D.
        • Van Laarhoven S.
        • Tang A.
        • Heesterbeek P.J.C.
        • Van Hellemondt G.
        • Schwarzkopf R.
        Short- to midterm outcomes of a novel guided-motion rotational hinged total knee arthroplasty.
        J Knee Surg. 2021;
        • Van Kempen R.W.T.M.
        • Schimmel J.J.P.
        • Van Hellemondt G.G.
        • Vandenneucker H.
        • Wymenga A.B.
        Reason for revision TKA predicts clinical outcome: prospective evaluation of 150 consecutive patients with 2-years followup knee.
        Clin Orthop Relat Res. 2013; 471: 2296-2302
        • Parvizi J.
        • Tan T.L.
        • Goswami K.
        • Higuera C.
        • Della Valle C.
        • Chen A.F.
        • et al.
        The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria.
        J Arthroplasty. 2018; 33: 1309-1314.e2
        • Baier C.
        • Lüring C.
        • Schaumburger J.
        • Köck F.
        • Beckmann J.
        • Tingart M.
        • et al.
        Assessing patient-oriented results after revision total knee arthroplasty.
        J Orthop Sci. 2013; 18: 955-961
        • Rodríguez-Merchán E.C.
        • Gómez-Cardero P.
        • Martínez-Lloreda Á.
        Revision knee arthroplasty with a rotating-hinge design in elderly patients with instability following total knee arthroplasty.
        J Clin Orthop Trauma. 2015; 6: 19-23
        • Deehan D.J.
        • Murray J.
        • Birdsall P.D.
        • Holland J.P.
        • Pinder I.M.
        The role of the rotating hinge prosthesis in the salvage arthroplasty setting.
        J Arthroplasty. 2008; 23: 683-688
        • Guenoun B.
        • Latargez L.
        • Freslon M.
        • Defossez G.
        • Salas N.
        • Gayet L.E.
        Complications following rotating hinge Endo-Modell (Link®) knee arthroplasty.
        Orthop Traumatol Surg Res. 2009; 95: 529-536
        • Joshi N.
        • Navarro-Quilis A.
        Is there a place for rotating-hinge arthroplasty in knee revision surgery for aseptic loosening?.
        J Arthroplasty. 2008; 23: 1204-1211
        • Neri T.
        • Boyer B.
        • Papin P.E.
        • Martz P.
        • Vaz G.
        • Eichler D.
        • et al.
        Contemporary rotating hinge arthroplasty can safely be recommended in complex primary surgery.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 1780-1788
        • Sanguineti F.
        • Mangano T.
        • Formica M.
        • Franchin F.
        Total knee arthroplasty with rotating-hinge endo-model prosthesis: clinical results in complex primary and revision surgery.
        Arch Orthop Trauma Surg. 2014; 134: 1601-1607
        • Gudnason A.
        • Milbrink J.
        • Hailer N.P.
        Implant survival and outcome after rotating-hinge total knee revision arthroplasty: a minimum 6-year follow-up.
        Arch Orthop Trauma Surg. 2011; 131: 1601-1607
        • Wilke K.
        • Daniel Kunze P.H.
        • Hommel H.
        Rotating hinge total knee arthroplasty RT-PLUS solution: a clinical and radiographic follow-up.
        J Orthop Rheumatol. 2016; 3: 1-4
        • Giurea A.
        • Neuhaus H.J.
        • Miehlke R.
        • Schuh R.
        • Lass R.
        • Kubista B.
        • et al.
        Early results of a new rotating hinge knee implant.
        Biomed Res Int. 2014; 2014: 948520
        • Levent A.
        • Suero E.M.
        • Gehrke T.
        • Bakhtiari I.G.
        • Citak M.
        Risk factors for aseptic loosening in complex revision total knee arthroplasty using rotating hinge implants.
        Int Orthop. 2021; 45: 125-132
        • Morgan-Jones R.
        • Oussedik S.I.S.
        • Graichen H.
        • Haddad F.S.
        Zonal fixation in revision total knee arthroplasty.
        Bone Joint J. 2015; 97-B: 147-149
        • Belt M.
        • Smulders K.
        • van Houten A.
        • Wymenga A.
        • Heesterbeek P.
        • van Hellemondt G.
        What is the reliability of a new classification for bone defects in revision TKA based on preoperative Radiographs?.
        Clin Orthop Relat Res. 2020; 478: 2057-2064
        • Cottino U.
        • Abdel M.P.
        • Perry K.I.
        • Mara K.C.
        • Lewallen D.G.
        • Hanssen A.D.
        Long-term results after total knee arthroplasty with contemporary rotating-hinge prostheses.
        J Bone Joint Surg Am. 2017; 99: 324-330
        • Kearns S.M.
        • Culp B.M.
        • Bohl D.D.
        • Sporer S.M.
        • Della Valle C.J.
        • Levine B.R.
        Rotating hinge implants for complex primary and revision total knee arthroplasty.
        J Arthroplasty. 2018; 33: 766-770