Comparison of risk for postoperative hyperextension between cruciate retaining and posterior stabilized total knee arthroplasties



The incidence of postoperative hyperextension and factors affecting hyperextension needs to be investigated separately for cruciate retaining (CR) and posterior stabilized (PS) total knee arthroplasties (TKAs), because the mechanism for preventing hyperextension is different according to the bearing design. The purpose of the study was to compare the incidence of postoperative hyperextension between CR and PS TKAs and analyze the factors affecting the postoperative hyperextension.


Matched 213 CR and PS TKAs with Persona® prosthesis were retrospectively reviewed. The preoperative demographics, clinical and radiographic knee condition, and pelvic incidence were similar between groups. Appropriate knee extension (0°–5°), confirmed with a goniometer, was achieved intraoperatively. The knee sagittal angle was radiographically measured preoperatively and at 2 years postoperative. The incidence of hyperextension (sagittal angle < − 5°) was investigated. The factors affecting the postoperative hyperextension were analyzed in terms of age, sex, preoperative mechanical axis, knee sagittal angle, postoperative posterior tibial slope (PTS), change of posterior femoral offset, and pelvic incidence.


The knee sagittal angle was not significantly different preoperatively between CR and PS TKAs. The postoperative knee sagittal angle was 2.9° in CR TKAs and 4.4° in PS TKAs (p = 0.004). The incidence of postoperative hyperextension was 11.7% (25/213) in CR TKAs and 4.2% (9/213) in PS TKAs (p = 0.007). The preoperative sagittal angle, postoperative PTS, and pelvic incidence were the significant factors affecting the postoperative hyperextension in CR TKAs (odds ratio 0.869, 2.205, and 1.045, respectively); the preoperative sagittal angle was only the significant factor in PS TKAs (odds ratio 0.857)


Postoperative knee hyperextension occurred more frequently and was affected by more factors in CR TKAs than PS TKAs. Efforts to avoid hyperextension and closed observation are required in TKAs performed in patients with the risk factors.

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  1. 1.

    Koo K, Silva A, Chong HC, Chin PL, Chia SL, Lo NN, Yeo SJ (2016) Genu recurvatum versus fixed flexion after total knee arthroplasty. Clin Orthop Surg 8(3):249–253

    Article  Google Scholar 

  2. 2.

    Kim SH, Ro DH, Cho Y, Lee YM, Lee S, Lee MC (2017) What is the ideal degree of extension after primary total knee arthroplasty? J Arthroplasty 32(9):2717–2724

    Article  Google Scholar 

  3. 3.

    Siddiqui MM, Yeo SJ, Sivaiah P, Chia SL, Chin PL, Lo NN (2012) Function and quality of life in patients with recurvatum deformity after primary total knee arthroplasty: a review of our joint registry. J Arthroplasty 27(6):1106–1110

    Article  Google Scholar 

  4. 4.

    Lee SS, Kim JH, Heo JW, Moon YW (2019) Gradual change in knee extension following total knee arthroplasty using ultracongruent inserts. Knee 26(4):905–913

    Article  Google Scholar 

  5. 5.

    Lee HJ, Park YB, Lee DH, Kim KH, Ham DW, Kim SH (2019) Risk factors of hyperextension and its relationship with the clinical outcomes following mobile-bearing total knee arthroplasty. Arch Orthop Trauma Surg 139(9):1293–1305

    Article  Google Scholar 

  6. 6.

    Okamoto S, Okazaki K, Mitsuyasu H, Matsuda S, Mizu-Uchi H, Hamai S, Tashiro Y, Iwamoto Y (2014) Extension gap needs more than 1-mm laxity after implantation to avoid post-operative flexion contracture in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22(12):3174–3180

    Article  Google Scholar 

  7. 7.

    Wang WJ, Liu F, Zhu YW, Sun MH, Qiu Y, Weng WJ (2016) Sagittal alignment of the spine-pelvis-lower extremity axis in patients with severe knee osteoarthritis: a radiographic study. Bone Jt Res 5(5):198–205

    CAS  Article  Google Scholar 

  8. 8.

    Celestre PC, Dimar JR 2nd, Glassman SD (2018) Spinopelvic parameters: lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope: what does a spine surgeon need to know to plan a lumbar deformity correction? Neurosurg Clin N Am 29(3):323–329

    Article  Google Scholar 

  9. 9.

    Boulay C, Tardieu C, Hecquet J, Benaim C, Mouilleseaux B, Marty C, Prat-Pradal D, Legaye J, Duval-Beaupere G, Pelissier J (2006) Sagittal alignment of spine and pelvis regulated by pelvic incidence: standard values and prediction of lordosis. Eur Spine J 15(4):415–422

    CAS  Article  Google Scholar 

  10. 10.

    Czaprowski D, Stolinski L, Tyrakowski M, Kozinoga M, Kotwicki T (2018) Non-structural misalignments of body posture in the sagittal plane. Scoliosis Spinal Disord 13:6

    Article  Google Scholar 

  11. 11.

    Bae DK, Song SJ, Park CH, Ko YW, Lee H (2017) A comparison of the medium-term results of total knee arthroplasty using computer-assisted and conventional techniques to treat patients with extraarticular femoral deformities. J Arthroplasty 32(1):71–78

    Article  Google Scholar 

  12. 12.

    Song SJ, Park CH, Bae DK (2019) What to know for selecting cruciate-retaining or posterior-stabilized total knee arthroplasty. Clin Orthop Surg 11(2):142–150

    Article  Google Scholar 

  13. 13.

    Song SJ, Lee HW, Park CH (2020) A current prosthesis with a 1-mm thickness increment for polyethylene insert could result in fewer adjustments of posterior tibial slope in cruciate-retaining total knee arthroplasty. J Arthroplasty.

    Article  PubMed  Google Scholar 

  14. 14.

    Indelli PF, Graceffa A, Marcucci M, Baldini A (2016) Rotational alignment of the tibial component in total knee arthroplasty. Ann Transl Med 4(1):3

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Giesinger JM, Hamilton DF, Jost B, Behrend H, Giesinger K (2015) WOMAC, EQ-5D and knee society score thresholds for treatment success after total knee arthroplasty. J Arthroplasty 30(12):2154–2158

    Article  Google Scholar 

  16. 16.

    Stickley CD, Wages JJ, Hetzler RK, Andrews SN, Nakasone CK (2017) Standard radiographs are not sufficient for assessing knee mechanical axis in patients with advanced osteoarthritis. J Arthroplasty 32(3):1013–1017

    Article  Google Scholar 

  17. 17.

    Clarke HD (2012) Changes in posterior condylar offset after total knee arthroplasty cannot be determined by radiographic measurements alone. J Arthroplasty 27(6):1155–1158

    Article  Google Scholar 

  18. 18.

    Bae DK, Song SJ, Kim HJ, Seo JW (2013) Change in limb length after high tibial osteotomy using computer-assisted surgery: a comparative study of closed- and open-wedge osteotomies. Knee Surg Sports Traumatol Arthrosc 21(1):120–126

    Article  Google Scholar 

  19. 19.

    Lee HW, Song SJ, Bae DK, Park CH (2019) The influence of computer-assisted surgery experience on the accuracy and precision of the postoperative mechanical axis during computer-assisted lateral closing-wedge high tibial osteotomy. Knee Surg Relat Res 31(1):15

    CAS  Article  Google Scholar 

  20. 20.

    Ewald FC (1989) The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12

    Google Scholar 

  21. 21.

    Matz J, Howard JL, Morden DJ, MacDonald SJ, Teeter MG, Lanting BA (2017) Do changes in patellofemoral joint offset lead to adverse outcomes in total knee arthroplasty with patellar resurfacing? A Radiographic Review. J Arthroplasty 32(3):783–787 (e781)

    Article  Google Scholar 

  22. 22.

    Chang MJ, Kang SB, Chang CB, Han DH, Park HJ, Hwang K, Park J, Hwang IU, Lee SA, Oh S (2020) Posterior condylar offset changes and its effect on clinical outcomes after posterior-substituting, fixed-bearing total knee arthroplasty: anterior versus posterior referencing. Knee Surg Relat Res 32(1):10

    Article  Google Scholar 

  23. 23.

    Coleman JL, Widmyer MR, Leddy HA, Utturkar GM, Spritzer CE, Moorman CT 3rd, Guilak F, DeFrate LE (2013) Diurnal variations in articular cartilage thickness and strain in the human knee. J Biomech 46(3):541–547

    Article  Google Scholar 

  24. 24.

    Draper CE, Besier TF, Gold GE, Fredericson M, Fiene A, Beaupre GS, Delp SL (2006) Is cartilage thickness different in young subjects with and without patellofemoral pain? Osteoarthr Cartil 14(9):931–937

    CAS  Article  Google Scholar 

  25. 25.

    Gwinner C, Fuchs M, Sentuerk U, Perka CF, Walter TC, Schatka I, Rogasch JMM (2019) Assessment of the tibial slope is highly dependent on the type and accuracy of the preceding acquisition. Arch Orthop Trauma Surg 139(12):1691–1697

    Article  Google Scholar 

  26. 26.

    Oka S, Matsumoto T, Muratsu H, Kubo S, Matsushita T, Ishida K, Kuroda R, Kurosaka M (2014) The influence of the tibial slope on intra-operative soft tissue balance in cruciate-retaining and posterior-stabilized total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22(8):1812–1818

    Article  Google Scholar 

  27. 27.

    Cabuk H, Imren Y, Tekin AC, Dedeoglu SS, Gurbuz H (2018) High varus angle and lower posterior tibial slope associated with PCL injury in cruciate retaining total knee arthroplasty: an MRI study. J Knee Surg 31(3):277–283

    Article  Google Scholar 

  28. 28.

    Amin I, Moroz A (2017) Anterior cruciate ligament and posterior cruciate ligament tears. Musculoskeletal sports and spine disorders. Springer, Berlin, pp 265–267

    Google Scholar 

  29. 29.

    Montgomery RL, Goodman SB, Csongradi J (1993) Late rupture of the posterior cruciate ligament after total knee replacement. Iowa Orthop J 13:167–170

    CAS  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ (1998) Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop Relat Res.

    Article  PubMed  Google Scholar 

  31. 31.

    Shultz SJ, Schmitz RJ, Nguyen AD, Levine BJ (2010) Joint laxity is related to lower extremity energetics during a drop jump landing. Med Sci Sports Exerc 42(4):771–780

    Article  Google Scholar 

  32. 32.

    Takatsu T, Itokazu M, Shimizu K, Brown TD (1998) The function of posterior tilt of the tibial component following posterior cruciate ligament-retaining total knee arthroplasty. Bull Hosp Jt Dis 57(4):195–201

    CAS  PubMed  Google Scholar 

  33. 33.

    Cinotti G, Sessa P, Amato M, Ripani FR, Giannicola G (2017) Preserving the PCL during the tibial cut in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25(8):2594–2601

    CAS  Article  Google Scholar 

  34. 34.

    Vigdorchik JM, Sharma AK, Feder OI, Buckland AJ, Mayman DJ, Carroll KM, Sculco PK, Long WJ, Jerabek SA (2020) Stiffness after total knee arthroplasty: is it a result of spinal deformity? J Arthroplasty.

    Article  PubMed  Google Scholar 

  35. 35.

    Cheng X, Zhang K, Sun X, Zhao C, Li H, Zhao J (2017) Analysis of compensatory mechanisms in the pelvis and lower extremities in patients with pelvic incidence and lumbar lordosis mismatch. Gait Posture 56:14–18

    Article  Google Scholar 

  36. 36.

    Sullivan TB, Marino N, Reighard FG, Newton PO (2018) Relationship between lumbar lordosis and pelvic incidence in the adolescent patient: normal cohort analysis and literature comparison. Spine Deform 6(5):529–536

    Article  Google Scholar 

  37. 37.

    Warschawski Y, Garceau S, Frenkel Rutenberg T, Dahduli O, Wolfstadt J, Backstein D (2020) Revision total knee arthroplasty for patellar dislocation in patients with malrotated TKA components. Arch Orthop Trauma Surg 140(6):777–783

    Article  Google Scholar 

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The following authors have made substantial contributions to the following: (1) the conception and design of the study (SJS, CHP), provision of study materials or patients (SJS), acquisition of data (CHP), analysis and interpretation of data (CHP). (2) Drafting the article (SJS, KIK, and CHP), (3) final approval of the version to be submitted (SJS and KIK, and CHP).

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Correspondence to Cheol Hee Park.

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This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the institutional review board.

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Song, S.J., Kim, K.I. & Park, C.H. Comparison of risk for postoperative hyperextension between cruciate retaining and posterior stabilized total knee arthroplasties. Arch Orthop Trauma Surg (2021).

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  • Knee
  • Arthroplasty
  • Cruciate retaining
  • Posterior stabilized
  • Hyperextension