The Journal of Arthroplasty xxx (2015) xxx–xxx

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral

Comparison With Standard Total Knee Arthroplasty
Man Soo Kim, MD, Ju Hwan Kim, MD, In Jun Koh, MD, PhD, Sung Won Jang, MD,
Da Hoon Jeong, MD, Yong In, MD, PhD
Department of Orthopaedic Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this study was to determine whether the high-flexion total knee prosthesis significantly improves
Received 24 July 2015 knee flexion in vivo. Forty-four patients undergoing same-day bilateral total knee arthroplasty for primary oste-
Accepted 4 September 2015 oarthritis of both knees were randomized to receive a standard posterior-stabilized knee prosthesis (P.F.C. Sigma;
Available online xxxx
DePuy Johnson & Johnson, Warsaw, IN) in one knee and a high-flexion concept posterior-stabilized knee prosthe-
sis (LOSPA; Corentec, Inc, Seoul, Korea) in the other knee and were followed up for 2 years postoperatively. The
Keywords:
total knee arthroplasty
mean postoperative range of motion was 128.8° (range, 100°-144°) in the LOSPA group and 128.5° (range, 100°-
range of motion 142°) in the P.F.C. Sigma group (P = .744). There were no significant differences in the postoperative mean Knee
randomized clinical trial Society score and Western Ontario and McMaster Universities Osteoarthritis Index score between the LOSPA and
outcomes P.F.C. Sigma groups (P = .839 and P = .972, respectively). Despite theoretical range of motion advantages of
knee implant design high-flexion prosthesis, there were no group differences with regard to range of motion, clinical outcomes, and
the incidence of radiolucent lines at final follow-up assessment.
© 2015 Elsevier Inc. All rights reserved.

Over the last decade, there have been multiple innovations in total high-flexion and standard knee designs, analysis of pure designs may
knee arthroplasty (TKA) implant design aimed at improving knee flex- be required.
ion [1-7]. The design modifications have focused on increasing the con- The LOSPA total knee system (Corentec, Inc, Seoul, Korea) was intro-
tact area between the femoral component and the polyethylene insert. duced to enhance deep knee flexion after surgery (approved by the
The so-called high-flexion femoral component has an extended sagittal Food and Drug Administration under 510(k)). This system requires re-
curve and a thicker posterior condyle by 2 to 4 mm replacing the addi- moval of additional bone from the posterior femoral condyle to add
tional bone cut to maintain contact area at deep knee flexion. Theoreti- 10-mm posterior condyle at a large posterior radius of the femoral com-
cally, the contact area increment supports the posterior femoral ponent. The extension of the posterior condyle increases contact area at
translation and thereby increases range of motion [1-7]. The femoral deep knee flexion angles, thereby accommodating femoral rollback and
cam and tibial post designs are also modified to increase the contact sur- increasing range of flexion. In addition, the femoral component has a
face area and stability at deep knee flexion angles [1,2,4]. In addition, more rounded contour and a deepened patellar groove to help deep
there is an anterior cut out of the polyethylene insert to decrease the po- flexion through reducing joint capsule overstuffing. The tibial insert
tential for impingement of the extensor mechanism [8]. also has a deep flexion favoring design. The posterior surface of the in-
Although published studies comparing the knee range of motion be- sert is released, and the posterior edge is chamfered to avoid early
tween the standard and high-flexion prostheses have been mixed [6,9- bone implant impingement (Fig. 1).
11], recent meta-analyses on this subject do not support the proposition In this study, we performed a prospective, randomized study to
that high-flexion prostheses provide functional advantages over stan- compare the ranges of motion of the LOSPA posterior-stabilized (PS)
dard prostheses [12-14]. As in various controlled trials, the number of total knee system and standard P.F.C. Sigma PS total knee system
implants has been limited to certain knee systems that have both (DePuy Johnson & Johnson, Warsaw, IN) in patients undergoing same-
day bilateral TKAs. P.F.C. Sigma knee, which was introduced in 1984,
has had excellent long-term survivorship of 11 to 17 years [15-18].
The posterior condylar thickness of the P.F.C. femoral component is
only 8 mm with a short radius. The polyethylene insert does not have
No author associated with this paper has disclosed any potential or pertinent conflicts the so-called “high-flexion” design (Fig. 1). We examined 3 hypotheses:
which may be perceived to have impending conflict with this work. For full disclosure (1) the range of motion of the knee with a LOSPA prosthesis would be
statements refer to http://dx.doi.org/10.1016/j.arth.2015.09.001.
Reprint requests: Yong In, MD, Department of Orthopaedic Surgery, Seoul St Mary's
better than those with a P.F.C. Sigma prosthesis; (2) clinical outcomes
Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, and patient satisfaction would be better in patients having a
Seocho-Gu, Seoul, 137-701, Republic of Korea. LOSPA prosthesis than those with a P.F.C. Sigma prosthesis; and

http://dx.doi.org/10.1016/j.arth.2015.09.001
0883-5403/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Kim MS, et al, Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral Comparison With Standard Total Knee
Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.09.001
2 M.S. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

(range, 21.2-35.2 kg/m2). All surgeries were performed by the senior au-
thor. The operation procedure was identical in LOSPA and P.F.C. Sigma
groups. All procedures were performed through a subvastus approach
under general anesthesia with tourniquet inflation to 300 mm Hg.
Bone cuts were performed using the company's own cutting blocks ac-
cording to the prosthesis by approximating proper implant size and
gap balance. The amount of bone removed from the posterior femoral
condyle was 10 mm in the LOSPA prosthesis and 8 mm in the P.F.C.
Sigma prosthesis to be replaced by the femoral component. All patellae
were resurfaced, and all components were cemented with Refobacin
bone cement (Bioment, Warsaw, IN). All patients received the same re-
habilitation programs. On the first postoperative day, all patients began
full weight-bearing walking with the use of a walker. They started active
range motion exercises. The closed suction drain was removed 48 hours
after operation. We did not use a continuous passive motion machine,
but we encouraged patients to perform active range of motion exercise
under our supervision. We used the oral medication, celecoxib 200 mg
q day, for all patients for pain control for a period of 6 weeks.
Clinical and radiographic evaluation was done at postoperative 6
weeks, 3 months, 6 months, 1 year, and then yearly thereafter. Each
knee was evaluated according to Knee Society score [19] and Western
Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
score [20] by an independent investigator. At the time of each follow-
up, active range of motion of the knee was measured using a standard
60-cm goniometer in supine position by one of the authors who were
blinded to the inserted implant. All the complications were recorded.
At each follow-up visit, weight-bearing knee anteroposterior, lateral,
and skyline radiographs were taken. Each radiograph was assessed for
the presence or absence of radiolucent lines. Implant position was ra-
diographically evaluated by anatomical axis of the limb, the alignment
of the components, posterior femoral condylar offset, and the presence
Fig. 1. Comparison of LOSPA PS total knee system (A and B) and P.F.C. Sigma PS total
and location of radiolucent lines by Knee Society TKA roentgenographic
knee system (C and D). The femoral component of LOSPA system has a thicker and
elongated posterior condyle (asterisk and arrow) than that of P.F.C. Sigma system evaluation and scoring system [21].
(double asterisk). The posterior edge of the tibial insert of the LOSPA system is
beveled for high flexion (dotted arrow). Statistical Analysis

(3) radiographic results would be the same in patients having a LOSPA Our primary outcome measurement was maximum flexion at 2
prosthesis as those of patients having a P.F.C. Sigma prosthesis. years postoperatively. An a priori sample size analysis was performed
based on an overall α of .05 and statistical power of 0.8. We designed
Materials and Methods the study to detect a difference of 5° of flexion with an SD of 9° [3].
The power analysis estimated that 40 patients needed to be enrolled
From February to September 2012, 50 patients (100 knees) were en- in both groups. Clinical outcomes (recorded by a Knee Society score
rolled into a prospective, randomized clinical trial. The study was ap- and a WOMAC score) and radiologic alignment of LOSPA and PFC pros-
proved by the Institutional review board of our hospital, and all theses were compared with the independent t test. Preoperative and
patients provided informed consent. All the patients underwent same- postoperative results were compared with a paired t test. The statistical
day bilateral TKAs with a different implant for each knee. Randomiza- analysis was performed using a statistical software package (SPSS 21;
tion to receive the P.F.C. Sigma prosthesis or the LOSPA prosthesis was SPSS, Inc, Chicago, IL), and the level of significance for all tests was set
accomplished with the use of sealed envelopes that contained the at 0.05.
names of 2 prostheses, and these were opened in the operating room
before the skin incision for the first of the 2 sequential TKAs. After open- Theory/Calculation
ing of the randomization envelope, the first knee received the prosthesis
indicated by the envelope, and the other knee received the other pros- Before the clinical trial, we compared the femoral rollback of P.F.C.
thesis. Each of the 50 patients received P.F.C. Sigma prosthesis on one Sigma PS prosthesis and LOSPA PS prosthesis with use of 3-dimensional
side and LOSPA prosthesis on the contralateral side. (3D) models to prove the theoretical range of motion advantage of the
Inclusion criteria were for patients who agreed to the study with the high-flexion concept prosthesis over the standard prosthesis. A 3D scan-
enrollees having bilateral degenerative osteoarthritis on both knees and ner (Surveyor DS-2030; Laser Design, Inc, Minneapolis, MN) collected 3D
requiring TKA. Patients were excluded if they had a diagnosis of inflam- images of the 2 prostheses. Femoral rollback was defined as the distance
matory arthritis, a flexion contracture of greater than 20°, a history of between the sulcus point which is the deepest point of the polyethylene
knee surgery on either knee, or those who refused to participate in the insert and the contact point between the femoral component and the
study. Six of these 50 patients did not complete the primary end point, polyethylene insert at a certain flexion angle of the knee [22]. The mea-
at 2 years postoperatively. Five patients were lost to follow-up, and 1 surements were performed at various angles of knee flexion (0°, 45°,
patient had an open reduction and internal fixation due to patellar frac- 90°, and 135°) using the SolidWorks 3D modeling program (SolidWorks
ture, leaving 44 patients (88 knees) who completed a minimum of 2- Co, Waltham, MA). At 135° knee flexion position, under the cam post con-
year follow-up (Fig. 2). tact condition, the femoral rollback of the LOSPA prosthesis was
There were 42 women and 2 men with a mean age of 70.7 ± 6.6 years 11.57 mm and that of P.F.C. Sigma prosthesis was 8.62 mm (Fig. 3). The
(range, 57-87 years). The mean body mass index was 26.5 ± 3.2 kg/m2 LOSPA prosthesis had increased contact area between the femoral

Please cite this article as: Kim MS, et al, Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral Comparison With Standard Total Knee
Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.09.001
 M.S. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx 3

CONSORT Flow diagram

Assessed for eligibility

(n = 51 patients, 102 knees)

Enrollment
Excluded (1 patient)
Participation refuse
(1 patient)

Randomized
(n = 50 patients, 100 knees)
Allocation

Allocated to standard design Allocated to high - flexion design

(P.F.C. Sigma, Depuy J & J) (LOSPA prosthesis, Corentec)
(n = 50, 50 knees) (n = 50, 50 knees)
Follow- Up

Dropouts (n = 6)
Lost to follow- up (n = 5)
Additional operation needed (n = 1)
(Patella Fracture after trauma)
Analysis

Analyzed Analyzed
(n =4 4 patients, 44 knees) (n = 44 patients, 44 knees)

Fig. 2. CONSORT (Consolidated Standards of Reporting Trials) flow diagram.

component and the polyethylene insert. Theoretically, this increment group). However, there were no knees showing any sign of osteolysis
could support the posterior femoral translation and thereby increase at the 2-year follow-up. None of the knees had aseptic loosening of
range of motion. the femoral, tibial, or patellar component. No knee had subluxation or
dislocation of the tibiofemoral or the patellofemoral joint. In addition,
Results none of the patients required a manipulation after their operation, and
there were no major complications needing revision for any reason at
The preoperative and postoperative ranges of motion measures for this short-term follow-up period.
the knee are summarized in Table 1. There were no significant differ-
ences in the postoperative mean flexion contracture (P = .562), active Discussion
maximal flexion angle (P = .745), and range of motion (P = .744) be-
tween the LOSPA and P.F.C. Sigma groups. Several updated meta-analyses on the comparison between high-
The preoperative and postoperative clinical scores are summarized flexion and standard TKA designs have been published recently
in Table 2. The mean postoperative Knee Society score was 158.4 in [12-14]. Among them, Li et al [14] included the largest of the 18 ran-
the LOSPA group and 157.6 in the P.F.C. Sigma group (P = .839). The domized controlled trials on the subject. Although they found no signif-
mean postoperative total WOMAC score was 27.6 in the LOSPA group icant differences between high-flexion and standard TKA designs in
and 27.8 in the P.F.C. Sigma group (P = .972). terms of range of motion, knee scores, patient's satisfaction, and compli-
There were also no significant differences between the LOSPA and cations, the types of high-flexion and standard implants used in the ran-
P.F.C. Sigma groups with regard to preoperative and postoperative domized controlled trial were limited to NexGen knee system (Zimmer,
knee alignments using the femorotibial angle (P = .603 and P = .057, Warsaw, IN) (LPS-flex [4,6,11,23-30] or CR-flex [3,7]) or P.F.C. Sigma
respectively) (Table 3). Furthermore, there were no differences in im- knee system (RP-F [1,2,31,32] or CR 150 [33]). Because both NexGen
plant positioning parameters between the 2 groups (Table 3), and and P.F.C. Sigma high-flexion knee systems were designed from the
there was no significant difference in the postoperative posterior con- same original standard version, designs from the same knee family
dylar offset between the groups (P = .601). Four knees in each group might eliminate the implant difference variable in the randomized con-
had a radiolucent line on postoperative radiographs (2 in the zone 1 trolled trials. As most newly introduced knee implants include the high-
of the medial tibia and 2 in the zone 4 of the femoral condyle in each flexion concept in their femoral component or polyethylene design, the

Please cite this article as: Kim MS, et al, Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral Comparison With Standard Total Knee
Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.09.001
4 M.S. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

Fig. 3. Three-dimensional images showing contact points of LOSPA and P.F.C. Sigma systems in full extension (A and B) and in 135° flexion position (C and D). The distance from contact
point to sulcus point was 0.08 mm in LOSPA prosthesis and −2.52 mm in P.F.C. Sigma prosthesis in full extension and 11.57 mm in LOSPA prosthesis and 8.62 mm in P.F.C. Sigma prosthesis
in 135° flexion position.

LOSPA knee system is one of the high-flexion concept total knee pros- relatively short follow-up period of 2 years where we cannot be certain
theses specifically developed to enhance knee flexion. of long-term radiographic results or clinical outcomes. Finally, most of
The primary objective of this randomized controlled trial was to de- our enrollees were female (95.4%). This may have been hard to control
termine whether the high-flexion concept knee implant, LOSPA knee due to prevalence, incidence, and severity of osteoarthritis being higher
system, provided superior knee range of motion compared to a standard in women than men [34] including high sex differentials among
knee design which has been used in previous high-flexion comparison Asians [35].
studies. Our study revealed no significant differences in the range of mo- Femoral rollback is an important factor to achieve deep flexion of a
tion parameters for the knees receiving either the high-flexion or stan- normal knee [22]. Femoral rollback leads to an increase in the lever
dard PS total knee prosthesis at 2 years postoperatively. arm of the quadriceps muscle, thus reducing the load on patellofemoral
The strength of this study was the participation of patients undergo- joint and increasing the ability to extend the knee without excessive
ing bilateral TKAs, thus minimizing possible confounding variables. force from the quadriceps muscle [36]. Banks et al [37] analyzed 16 dif-
However, our study had some limitations. First, we compared 2 total ferent TKA prostheses which included PS, cruciate-retaining, mobile-
knee prosthesis designs that are not in the same knee system family. Al- bearing implants and reported that 1.4° of knee flexion was gained
though the LOSPA knee system has elongated femur and an upgraded per 1-mm increment of posterior femoral translation. Internal rotation
polyethylene design in accordance with the high-flexion concept, our of tibia is also essential in deep knee flexion, and it is observed during
study could not eliminate the “difference-in-design families” variable deep flexion in normal knee opposite to “screw-home” movement of
between the 2 prostheses. The LOSPA knee system did not have a stan- full extension [22]. Shi et al [38] evaluated femoral rollback and tibial in-
dard version with thinner posterior femoral condyle. Accordingly, we ternal rotation in different bearings of high-flexion PS design knees.
executed a feasibility testing using 3D models for this study, as there They found that femoral rollback and tibial internal rotation correlated
was a significant difference in femoral rollback between the 2 prosthe- with maximum flexion angle. The high-flexion knee prostheses were
ses. Recently, other manufacturers have introduced new total knee im- designed to enhance knee flexion by providing extended femoral con-
plants with a femoral component having 10-mm posterior condyle to dyles which allow posterior femoral rollback with increasing knee
enhance knee flexion. We believe that the benefit and safety of thicker flexion [1,3,4].
posterior condyle of a femoral component should be verified clinically We compared the femoral rollback of the LOSPA and P.F.C. Sigma
and not just by theoretical modeling. The second limitation was the knee systems using 3D models to test the feasibility of the high-

Table 1
Preoperative and Postoperative Ranges of Motion of the Knees Between Groups.

Preoperative Postoperative 2 Years

LOSPA (n = 44) P.F.C. Sigma (n = 44) P LOSPA (n = 44) P.F.C. Sigma (n = 44) P

ROM (°)a 113.0 ± 14.8 (80-137) 111.5 ± 17.5 (70-135) .651 128.8 ± 7.3 (100-144) 128.4 ± 7.0 (100-142) .744
[108.8-117.4] [105.9-116.5] [126.9-131.4] [126.0-130.5]
Flexion contracture (°) 7.6 ± 7.3 (0-30) 7.0 ± 7.3 (0-25) .716 0.1 ± 0.7 (0-5) 0.2 ± 1.0 (0-5) .562
[5.6-9.7] [5.0-9.4] [0.0-0.4] [0.0-0.6]
Maximum flexion (°) 120.7 ± 11.9 (100-137) 118.3 ± 14.3 (80-135) .403 129.0 ± 7.3 (100-144) 128.5 ± 7.1 (100-142) .745
[117.0-124.2] [113.9-122.2] [126.9-131.4] [126.1-130.6]

Abbreviation: ROM, range of motion.

a
The values are presented as mean and SD with the range in parentheses and the 95% confidence interval in brackets.

Please cite this article as: Kim MS, et al, Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral Comparison With Standard Total Knee
Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.09.001
 M.S. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx 5

Table 2
Preoperative and Postoperative Clinical Scores.

Preoperative Postoperative (2 Years)

LOSPA (n = 44) P.F.C. Sigma (n = 44) P LOSPA (n = 44) P.F.C. Sigma (b = 44) P

KSSa 102.3 ± 21.2 (42-143) 104.7 ± 23.9 (17-145) .617 158.4 ± 19.2 (95-192) 157.6 ± 19.6 (9-192) .839
[95.4-108.4] [96.6-111.2] [152.2-163.9] [151.8-163.0]
Pain 24.0 ± 8.5 (0-40) 24.6 ± 8.8 (0-40) .759 46.1 ± 6.2 (20-50) 45.3 ± 6.2 (20-50) .549
[21.3-26.3] [21.8-27.0] [44.2-47.8] [43.4-47.0]
Function 78.3 ± 18.3 (32-113) 80.1 ± 19.6 (7-125) .649 112.3 ± 17.4 (50-142) 112.3 ± 17.7 (50-142) .990
[72.3-83.4] [73.5-85.9] [107.1-117.0] [107.0-117.1]
b
WOMAC 132.7 ± 43.0 (56-217) 126.0 ± 44.9 (20-216) .473 27.6 ± 19.7 (0-78) 27.8 ± 23.0 (0-112) .972
[120.8-144.7] [113.0-139.1] [21.7-33.9] [21.4-34.6]
Pain 26.3 ± 10.2 (8-50) 24.6 ± 9.8 (5-45) .407 2.5 ± 3.8 (0-15) 3.0 ± 5.4 (0-23) .599
[23.5-29.3] [20.4-27.7] [1.3-3.6] [1.6-4.6]
Stiffness 9.0 ± 4.8 (0-18) 8.5 ± 4.7 (0-16) .636 2.4 ± 2.7 (0-8) 2.6 ± 3.2 (0-11) .771
[7.6-10.3] [7.2-9.8] [1.6-3.2] [1.7-3.5]
Function 97.4 ± 31.3 (28-161) 90.6 ± 34.6 (10-161) .339 22.8 ± 16.6 (0-57) 22.2 ± 17.7 (0-78) .882
[88.3-106.1] [80.4-101.0] [17.9-28.1] [17.3-27.4]

Abbreviation: KSS, Knee Society score.

a
The values are presented as mean and SD with the range in parentheses and the 95% confidence interval in brackets.
b
Modified version of the WOMAC score.
This questionnaire includes 24 questions. The range of score is 0 to 240 points.

flexion concept. By extending the posterior femoral condyle as a result groups. In the LOSPA knee group, the tibial insert contacted to posterior
of 2-mm increase in the thickness of the posterior condyle, the LOSPA femoral condyle until maximum knee flexion while the tibial insert
PS knee system theoretically showed better femoral rollback than the touches the back of the femur at maximum knee flexion in the P.F.C.
P.F.C. Sigma PS knee system. However, contrary to expectations, this the- Sigma group (Fig. 4). The high-flexion prosthesis provided an increased
oretical benefit of LOSPA knee system was not reflected in the clinical contact area between femoral and tibial components more than the
outcomes. There were no statistical differences between the 2 implants standard prosthesis. However, there was no difference in range of mo-
in terms of knee range of motion, clinical scores, and radiographic results. tion between groups as long as the posterior condylar offset was main-
Changes in posterior femoral condylar offset can have an influence tained between groups. The potential clinical implication of an
on knee range of motion after TKA [39,40]. Massin and Gournay [40] re- improved contact area in the high-flexion knees may require a longer
ported that a 3-mm decrease of posterior condylar offset could reduce postsurgery follow-up.
knee flexion by 10° before the occurrence of tibiofemoral impingement. There is concern that high-flexion designs accelerate early aseptic
Bellemans et al [39] found that, in 72% of knees, direct impingement of loosening more than a conventional TKA implant [41-43]. In our
tibial insert posteriorly against the posterior femur was the factor re- study, nonsignificant linear radiolucent lines were observed at zone 4
sponsible for blocking further flexion. In the present study, the changes of the femoral component in 2 cases in each group at the minimum 2
in posterior condylar offset did not significantly differ between LOSPA years follow-up. For a secure fixation, we applied the bone cement on
and P.F.C. Sigma knees. The reason may be because the additional 2- both implant and bone surfaces including posterior femoral condyles.
mm bone resection was replaced by the 2-mm thicker posterior condyle It was believed that use of a femoral component with 10-mm posterior
of the femoral component in the LOSPA knee system. However, the con- condyle replacing the same thickness condylar cutting might dispel
tact feature at maximum knee flexion was different between the 2 worries about early loosening. In spite of the relatively short follow-

Table 3
Radiographic Knee Alignment, Implant Positioning, and Prevalence of Radiolucent Lines.

LOSPA (n = 44) P.F.C. Sigma (n = 44) P

Knee alignment
Preoperative FTAa (°) Varus 3.1 ± 4.8 (varus 12.9 to valgus 10.8) Varus 2.5 ± 5.2 (varus 13.7 to valgus 9) .603
[varus 4.3 to varus 1.8] [varus 4.1 to varus 0.7]
Postoperative FTA (°) Valgus 6.1 ± 2.3 (valgus 0.8-11.3) Valgus 5.0 ± 2.2 (valgus 1.2-11.6) .057
[valgus 5.2-6.8] [valgus 4.4-5.7]
Femoral component position
Coronal (°) 96.4 ± 1.6 (92.5-98.9) 95.9 ± 1.7 (92.3-100.2) .157
[95.9-96.8] [95.5-96.4]
Sagittal (°) 1.7 ± 1.0 (0-4.2) 1.7 ± 1.3 (0.1-5.9) .957
[1.4-2.0] [1.3-2.2]
Tibial component position
Coronal (°) 89.2 ± 1.8 (81.3-92.9) 88.8 ± 1.3 (85.2-91.9) .246
[88.7-89.8] [88.4-89.2]
Sagittal (°) 85.3 ± 1.8 (81.8-91.2) 85.6 ± 1.3 (83.3-90.5) .487
[84.8-86.0] [85.2-86.1]
Posterior condylar offset (mm) 29.1 ± 2.8 (22.8-36.7) 29.4 ± 2.8 (24.4-35.5) .601
[28.3-30.0] [28.7-30.2]
Radiolucent lines (n) 4 4 1.0

Abbreviation: FTA, femorotibial angle.

a
The values are presented as mean and SD with the range in parentheses and the 95% confidence interval in brackets.

Please cite this article as: Kim MS, et al, Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral Comparison With Standard Total Knee
Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.09.001
6 M.S. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

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Please cite this article as: Kim MS, et al, Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral Comparison With Standard Total Knee
Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.09.001
 M.S. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx 7

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Please cite this article as: Kim MS, et al, Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral Comparison With Standard Total Knee
Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.09.001