Gap Balancing, Measured Resection, and Kinematic Alignment

Mercuri, John J; Pepper, Andrew M; Werner, Jordan; Vigdorchik, Jonathan M.

doi:10.2106/jbjs.rvw.18.00026

Cited by 24 publications

(28 citation statements)

References 44 publications

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“…Balancing in extension first, as was done in our study, was considered more reliable, as releases were more precise [10]. Although surgical procedures to achieve this should follow a systematised and progressive order [1,11] STR increases the complexity of the procedure [12], so a correct alternative would be to do it only if necessary, knowing this could be helpful in pre-operative planning. A tool for objective quantification of the femorotibial space, resulting from limb alignment and the manoeuvre performed [13,14] was CAS.…”

Section: Discussionmentioning

confidence: 75%

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Can the need for soft tissue release in total knee replacement be predicted pre-operatively? A study based on surgical navigation

Hernández-Vaquero

Noriega-Fernandez

Roncero-Gonzalez

et al. 2021

International Orthopaedics (SICOT)

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Introduction In complex and deformed knees, soft tissue release (STR) is required to obtain symmetry in the femorotibial gap. The objective of this study was to attempt to predict the need for soft tissue release using surgical navigation in total knee replacement (TKR). Methods Prospective and non-randomized study. One hundred thirty knees. At the start of navigation, an attempt was made to correct the femorotibial mechanical axis by applying force to the medial or lateral side of the knee (varus-valgus stress angle test). A gap balanced technique with computer-assisted surgery (CAS) was performed in all cases. The ligaments were tensioned, and using CAS visualization and control, progressive STR was performed in the medial or lateral side until a symmetry of the femorotibial gap was achieved. Results Eighty-two patients had a varus axis ≥ 3° and 38 had a valgus axis (P < 0.001). STR was performed under navigation control in 38.5% of cases, lateral release (LR) in 12 cases, and medial release (MR) in 38 cases. After performing the varus-valgus stress angle test (VVSAT), the axis of 0° could be restored at some point during the manoeuvre in 28 cases. STR was required in 44.6% of varus cases and 27% of valgus cases (P = 0.05). A significant relationship was found between the previous deformity and the need for MR (P < 0.001) or LR (P = 0.001). STR was more common in male patients (P = 0.002) and as obesity increased. Conclusion This study shows that pre-operative factors favouring the need to perform STR in a TKR implant can be defined.

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Section: Discussionmentioning

confidence: 75%

“…The objective of the total knee replacement (TKR) is to achieve a well-aligned and well-balanced knee [1]. Creation of symmetric balanced flexion and extension gaps (difference less than 3 mm) is a surgical goal of a TKR, which often requires a soft tissue release (STR) at the time of implantation [2].…”

Section: Introductionmentioning

confidence: 99%

Can the need for soft tissue release in total knee replacement be predicted pre-operatively? A study based on surgical navigation

Hernández-Vaquero

Noriega-Fernandez

Roncero-Gonzalez

et al. 2021

International Orthopaedics (SICOT)

View full text Add to dashboard Cite

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“…Different authors investigated the outcome of total knee arthroplasty (TKA) and demonstrated that up to 20% of the patients are not satisfied with their knee function after TKA [ 4 , 9 , 10 , 13 , 20 ] Pain, instability, and limitation of the range of motion are the most commonly reported symptoms among unsatisfied patients, while the major causes reported of unsuccessful TKA are inadequate alignment and errors in balancing [ 4 , 9 ]. With the aim of improving outcomes, there is an increasing focus on different alignment options [ 17 ] and soft-tissue balancing techniques [ 18 ]. As standard instrumentations might not be accurate enough to achieve either of these, balancing tools, patient-specific instrumentations (PSI) and, more recently, computer and robotic-assisted TKA have been introduced to help surgeons to adopt hybrid techniques and, at the same time, to optimize alignment, reducing the number of outliers [ 6 , 13 , 14 , 21 ].…”

Section: Introductionmentioning

confidence: 99%

High accuracy of a new robotically assisted technique for total knee arthroplasty: an in vivo study

Rossi

Sangaletti

Perticarini

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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Purpose Over the last decade, robotic TKA gained popularity for improving the accuracy of implant positioning and reducing outliers in limb alignment comparing to conventional jig-based TKA. Hypothesis of this study was that this newly designed robotically assisted system will achieve a high level of accuracy for bone resection. Purpose of the study was to evaluate the accuracy of the system. Methods For this study, 75 knees in 75 patients were operated using a new, robotic system (ROSA ® Knee System; Zimmer Biomet, Warsaw, IN) with a Posterior Stabilized Total Knee Arthroplasty (Persona ® Knee System). The planned, validated and measured angles and cuts for the distal and posterior femur, for the proximal tibia and for the final coronal alignment on long standing x-rays were compared. Results A statistically significant difference was found only between the average planned and the average validated angle for femoral flexion, tibial coronal axis, medial and lateral cuts; the average difference was in any case below 1 mm or under 1 degree with SD < 1. No statistical difference was found between planned validated and measured cuts. Average difference between planned HKA and measured was 1.2 ± 1.1. No statistically significant difference was found. Conclusions The results of this study demonstrated that using this new surgical robot in total knee arthroplasty it is possible to perform accurate bone cuts and to achieve the planned angles and resections.

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“…The precise positioning and alignment of the prosthesis in the coronal and sagittal planes and the balance of the soft tissues are critical to the recovery of function after TKA [ 5 , 6 ]. Gap balancing (GB) and measured resection (MR) are two different surgical techniques that can be used to achieve this goal [ 5 , 7 – 10 ].…”

Section: Introductionmentioning

confidence: 99%

“…The MR technique uses anatomical markers such as the transepicondylar axis (TEA), anteroposterior (AP) axis, or the posterior condylar axis (PCA) to determine the rotation of the femoral prosthesis [ 5 , 7 , 11 ]. However, some researchers have shown that MR technology has great variability in setting the rotation of the femoral components due to individual differences in anatomical landmarks [ 12 , 13 ].…”

Section: Introductionmentioning

confidence: 99%

Spacer-based gap balancing is useful in total knee arthroplasty: a 3-year follow-up of a retrospective study

Song

Liu

et al. 2021

J Orthop Surg Res

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Background Which technique, gap balancing or measured resection, can obtain better femoral component alignment and soft tissue balance in total knee arthroplasty (TKA) is still controversial. This study aimed to determine whether the gap balancing technique using a modified spacer block in TKA can result in better postoperative clinical outcomes than the measured resection technique. Methods A total of 124 patients who underwent consecutive primary TKA between May 2016 and August 2018 were retrospectively reviewed. The gap balancing technique assisted by a modified spacer block was used in 61 patients, and the measured resection technique was used in 63 patients. The surgical, imaging and knee function outcomes of the two groups were compared. Results The thickness of the posterior medial condyle bone resection using the modified spacer block tool in gap balancing was significantly larger than that of the MR technique (P = 0.001). Compared with the measured resection group, the gap balancing group had a greater external rotation resection angle of the femur (4.06 ± 1.10° vs. 3.19 ± 0.59°, P < 0.001°). Despite these differences, the mean ROM, KSS scores, and WOMAC scores at the 6-week, 1-year, and 2-year follow-ups were not significantly different. Postoperatively, there was no significant difference between the two groups in mechanical axis measurements (P = 0.275), the number of HKA outliers (P = 0.795) or the joint line displacement (P = 0.270). Conclusion The functional outcomes of the gap balancing technique based on the modified spacer are similar to those of measured resection at 3 years. Compared with the MR technique, the GB technique resulted in a greater external rotation resection angle and thicker posterior medial condylar cuts in TKA with knee varus.

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Gap Balancing, Measured Resection, and Kinematic Alignment

Cited by 24 publications

References 44 publications

Can the need for soft tissue release in total knee replacement be predicted pre-operatively? A study based on surgical navigation

Can the need for soft tissue release in total knee replacement be predicted pre-operatively? A study based on surgical navigation

High accuracy of a new robotically assisted technique for total knee arthroplasty: an in vivo study

Spacer-based gap balancing is useful in total knee arthroplasty: a 3-year follow-up of a retrospective study

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