The natural knee allows multi-planar freedoms of rotation and translation, while retaining stability in the antero-posterior direction. It allows flexion with roll back, and medial, lateral and central rotation movements. The natural femoral condyles of the knee are spiral, therefore inducing a side to side translatory movement during flexion and extension. Incorporating all these features is vital in successful knee replacement design.
The different knee designs currently in use demonstrate different deficiencies in knee function. A study of 150 Posterior Cruciate (PCL) Retaining Total Knee Replacements  has shown that in 72% of knees direct impingement of the tibial insert posteriorly against the back of the femur was responsible for blocking further flexion. The mean pre-operative range of flexion was 105° and post-operative was 105.9°. For every 2mm decrease in posterior condylar offset, the maximum flexion was reduced by 12.2°.
The major disadvantage of the Posterior Stabilised (PS) Total Knee Replacement is gross anterior to posterior mid-flexion instability . The Medial Rotation Total Knee Replacement is good in mid-flexion but not in high flexion where the femur slides forward on the tibia leading to impingement.
The Birmingham Knee Replacement (BKR) is a rotating platform knee design which is stable throughout the range of flexion. In high flexion, the BKR brings the femur to the back of the tibia. The BKR also has spiral femoral condyles, matching the natural kinematics of the knee. The combined static and dynamic effect is 10mm lateral translation of the femur in flexion and vice versa in extension.
Results for seventy nine BKRs (in seventy two patients) show the best Oxford Knee Score of 12 at follow up – excluding ten patients whose inferior scores were due to other pathologies. Knee flexion results show a 21° post-operative improvement in range of flexion.
On objective independent testing, maximum walking speed is slower for patients with a standard knee replacement (6.5km/h) and the loading through the replaced side does not match the normal side. Comparatively, patients with a BKR have a faster maximum walking speed of 11km/h and the loading closely matches that of the normal knee.
Studies based on the National Joint Register PROMs data  show that nearly thirty percent of Total Knee Replacement patients are not much better since their operation. A lot of improvement is needed in the design of knee replacements in order to achieve better function for knee replacement patients.