Mid-term clinical outcomes of a posterior stabilized total knee prosthesis for Japanese patients: A minimum follow-up of 5 years

Published:December 01, 2022DOI:



      A high–flexion posterior-stabilized total knee prosthesis has been developed for the Asian population. The component design was based on computed tomography images of Japanese osteoarthritic knees. The femoral component is composed of zirconia ceramics, which exhibit low friction and high durability. The present study aimed to evaluate the mid-term clinical outcomes of this implant.


      This study included 334 knees of 210 patients who underwent primary total knee arthroplasty with this implant at our hospital between October 2010 and December 2014. The patients comprised 28 men and 172 women with an average age of 73 years. The average follow-up period was 5.9 years, and the follow-up rate was 71.1%. Clinical outcomes were assessed using the Knee Society scoring system, 2011 Knee Society questionnaire, and Knee Injury and Osteoarthritis Outcome Score. Kaplan–Meier survivorship analysis was performed to determine the cumulative prosthesis survival rate.


      In terms of clinical outcomes at the final follow-up, the average ranges of motion were −2.0 in extension and 126.7 in flexion. The Knee Society knee and function scores were 94.2% and 72.6%, respectively. With revision surgery or radiographic failure for any reason as the endpoint, the survival rates at 5 and 9 years were 98.2% and 95.5%, respectively. The most common reason for revision surgery or radiological failure was aseptic loosening.


      Despite several revision cases mainly due to aseptic loosening, the present study found that this new high-flexion posterior-stabilized total knee arthroplasty prosthesis design showed comparable results for Asian populations with other PS prosthesis.

      Levels of evidence

      Level Ⅱ (Prospective cohort study).


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        • Park K.K.
        • Chang C.B.
        • Kang Y.G.
        • Seong S.C.
        • Kim T.K.
        Correlation of maximum flexion with clinical outcome after total knee replacement in Asian patients.
        J Bone Jt Surg Br Vol. 2007 May; 89: 604-608
        • Noble P.C.
        • Gordon M.J.
        • Weiss J.M.
        • Reddix R.N.
        • Conditt M.A.
        • Mathis K.B.
        Does total knee replacement restore normal knee function?.
        Clin Orthop Relat Res. 2005 Feb; : 157-165
        • Heyse T.J.
        • Ries M.D.
        • Bellemans J.
        • Goodman S.B.
        • Scott R.D.
        • Wright T.M.
        • et al.
        Total knee arthroplasty in patients with juvenile idiopathic arthritis.
        Clin Orthop Relat Res. 2014; 472: 147-154
        • Mahfouz M.
        • Abdel Fatah E.E.
        • Bowers L.S.
        • Scuderi G.
        Three-dimensional morphology of the knee reveals ethnic differences..
        Clinical Orthop Related Res [Comparative Study]. 2012 Jan; 470: 172-185
        • Yanagisawa K.
        • Watanabe T.
        • Koga H.
        • Sekiya I.
        • Muneta T.
        • Jinno T.
        Do the distal femur and the proximal tibia have narrower aspect ratios in smaller knees? : a morphological analysis of osteoarthritic knees in the Japanese population using computed tomography.
        Knee. 2021 Sep 29; : 84-92
        • Oonishi H.
        • Ueno M.
        • Kim S.C.
        • Oonishi H.
        • Iwamoto M.
        • Kyomoto M.
        Ceramic versus cobalt-chrome femoral components; wear of polyethylene insert in total knee prosthesis.
        J Arthroplasty. 2009 Apr; 24: 374-382
        • Innocenti M.
        • Civinini R.
        • Carulli C.
        • Matassi F.
        • Villano M.
        The 5-year results of an oxidized zirconium femoral component for TKA.
        Clin Orthop Relat Res. 2010; 468: 1258-1263
        • Innocenti M.
        • Carulli C.
        • Matassi F.
        • Carossino A.M.
        • Brandi M.L.
        • Civinini R.
        Total knee arthroplasty in patients with hypersensitivity to metals.
        Int Orthop. 2014 Feb; 38: 329-333
        • Panfili E.
        • Pierdicca L.
        • Salvolini L.
        • Imperiale L.
        • Dubbini J.
        • Giovagnoni A.
        Magnetic resonance imaging (MRI) artefacts in hip prostheses: a comparison of different prosthetic compositions.
        La Radiologia medica. 2014 Feb; 119: 113-120
        • Watanabe T.
        • Muneta T.
        • Koga H.
        • Horie M.
        • Nakamura T.
        • Otabe K.
        • et al.
        In-vivo kinematics of high-flex posterior-stabilized total knee prosthesis designed for Asian populations.
        Int Orthop. 2016 Nov; 40: 2295-2302
        • Watanabe T.
        • Aoki A.
        • Hoshi K.
        • Muneta T.
        • Sekiya I.
        • Koga H.
        Anterior tibial post impingement during stair climbing: a kinematic analysis and clinical outcomes.
        J Arthroplasty [Res Support, Non-U.S. Gov't]. 2019 Feb; 34: 379-384
        • Watanabe T.
        • Koga H.
        • Katagiri H.
        • Otabe K.
        • Nakagawa Y.
        • Muneta T.
        • et al.
        Coronal and sagittal laxity affects clinical outcomes in posterior-stabilized total knee arthroplasty: assessment of well-functioning knees.
        Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2020 May; 28: 1400-1409
        • Watanabe T.
        • Gamada K.
        • Koga H.
        • Sekiya I.
        • Muneta T.
        • Jinno T.
        Characteristic kinematics of floor-sitting activities after posterior-stabilized total knee arthroplasty determined using model-based shape-matching techniques.
        Knee. 2021 Mar; 29: 571-579
        • Watanabe T.
        • Gamada K.
        • Koga H.
        • Sekiya I.
        • Muneta T.
        • Jinno T.
        Consistent femoral external rotation during weight-bearing knee flexion is associated with better patient-reported pain and mediolateral balance after total knee arthroplasty.
        Clin Biomech. 2021 Aug; 88105438
        • Ariga A.
        • Kohno Y.
        • Nakagawa Y.
        • Watanabe T.
        • Katagiri H.
        • Ohara T.
        • et al.
        Simultaneous bilateral total knee arthroplasty is safe and effective for patients in different ages.
        J Orthop Sci Off J Jpn Orthopaedic Assoc. 2021 Oct 9; S0949-2658: 283-289
        • Watanabe T.
        • Muneta T.
        • Yagishita K.
        • Hara K.
        • Koga H.
        • Sekiya I.
        Closed suction drainage is not necessary for total knee arthroplasty: a prospective study on simultaneous bilateral surgeries of a mean follow-up of 5.5 years.
        J Arthroplasty. 2016 Mar; 31: 641-645
        • Iida T.
        • Minoda Y.
        • Kadoya Y.
        • Matsui Y.
        • Kobayashi A.
        • Iwaki H.
        • et al.
        Mid-term clinical results of alumina medial pivot total knee arthroplasty.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20 (2012/08/01): 1514-1519
        • Cho S.D.
        • Youm Y.S.
        • Park K.B.
        Three- to six-year follow-up results after high-flexion total knee arthroplasty: can we allow passive deep knee bending?.
        Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2011 Jun; 19: 899-903
        • Bae D.K.
        • Cho S.D.
        • Im S.K.
        • Song S.J.
        Comparison of midterm clinical and radiographic results between total knee arthroplasties using medial pivot and posterior-stabilized prosthesis—a matched pair analysis.
        J Arthroplasty. 2016; 31 (2016/02/01/): 419-424
        • Kobayashi S.
        • Niki Y.
        • Harato K.
        • Nagura T.
        • Nakamura M.
        • Matsumoto M.
        Rheumatoid arthritis patients achieve better satisfaction but lower functional activities as compared to osteoarthritis patients after total knee arthroplasty.
        J Arthroplasty. 2019 Mar; 34 (e1): 478-482
        • Tanaka Y.
        • Nakamura S.
        • Kuriyama S.
        • Nishitani K.
        • Ito H.
        • Lyman S.
        • et al.
        Intraoperative physiological lateral laxity in extension and flexion for varus knees did not affect short-term clinical outcomes and patient satisfaction.
        Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2020 Dec; 28: 3888-3898
        • Giaretta S.
        • Berti M.
        • Micheloni G.M.
        • Ceccato A.
        • Marangoni F.
        • Momoli A.
        Early experience with the ATTUNE total knee replacement system.
        Acta Biomed. 2019 Oct 29; 90: 98-103
        • Lunebourg A.
        • Parratte S.
        • Gay A.
        • Ollivier M.
        • Garcia-Parra K.
        • Argenson J.-N.
        Lower function, quality of life, and survival rate after total knee arthroplasty for posttraumatic arthritis than for primary arthritis.
        Acta Orthop. 2015; 86: 189-194
        • Nakamura S.
        • Ito H.
        • Nakamura K.
        • Kuriyama S.
        • Furu M.
        • Matsuda S.
        Long-term durability of ceramic tri-condylar knee implants: a minimum 15-year follow-up.
        J Arthroplasty. 2017 Jun; 32: 1874-1879
        • Xiang S.
        • Zhao Y.
        • Li Z.
        • Feng B.
        • Weng X.
        Clinical outcomes of ceramic femoral prosthesis in total knee arthroplasty: a systematic review.
        J Orthop Surg Res. 2019 Feb 19; 14: 57
        • Hamilton W.G.
        • McAuley J.P.
        • Dennis D.A.
        • Murphy J.A.
        • Blumenfeld T.J.
        • Politi J.
        THA with delta ceramic on ceramic: results of a multicenter investigational device exemption trial.
        Clin Orthop Relat Res. 2010; 468: 358-366
        • Lee Y.K.
        • Ha Y.C.
        • Yoo J.J.
        • Koo K.H.
        • Yoon K.S.
        • Kim H.J.
        Alumina-on-alumina total hip arthroplasty: a concise follow-up, at a minimum of ten years, of a previous report.
        J Bone Jt Surg Am Vol. 2010 Jul 21; 92: 1715-1719
        • Kumahashi N.
        • Uchio Y.
        • Kitamura N.
        • Satake S.
        • Iwamoto M.
        • Yasuda K.
        Biomechanical comparison of the strength of adhesion of polymethylmethacrylate cement to zirconia ceramic and cobalt-chromium alloy components in a total knee arthroplasty.
        J Orthop Sci Off J Jpn Orthopaedic Assoc. 2014 Nov; 19: 940-947
        • Hamadouche M.
        • Boutin P.
        • Daussange J.
        • Bolander M.E.
        • Sedel L.
        Alumina-on-Alumina total hip arthroplasty : a minimum 18.5-year follow-up study.
        JBJS. 2002; 84
        • Han H.S.
        • Kang S.B.
        • Yoon K.S.
        High incidence of loosening of the femoral component in legacy posterior stabilised-flex total knee replacement.
        J Bone Jt Surg Br Vol. 2007 Nov; 89: 1457-1461
        • Gallo J.
        • Goodman S.B.
        • Konttinen Y.T.
        • Wimmer M.A.
        • Holinka M.
        Osteolysis around total knee arthroplasty: a review of pathogenetic mechanisms.
        Acta Biomater. 2013 Sep; 9: 8046-8058
        • Watanabe T.
        • Koga H.
        • Horie M.
        • Katagiri H.
        • Sekiya I.
        • Muneta T.
        Post-cam design and contact stress on tibial posts in posterior-stabilized total knee prostheses: comparison between a rounded and a squared design.
        J Arthroplasty. 2017 Dec; 32: 3757-3762