The relevance of ligament balancing in total knee arthroplasty: how important is it? A systematic review of the literature

Babazadeh, Sina; Stoney, James D.; Lim, Ken‐Hong; Choong, Peter

doi:10.4081/or.2009.e26

Cited by 80 publications

(58 citation statements)

References 99 publications

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“…Of the ligaments considered, lateral compartment loading was most sensitive to the ITB. Given the clinical significance of soft tissue balancing and known effects on long-term TKR function and longevity [66], our modeling framework may aid surgeons in positioning components and in planning soft tissue releases.…”

Section: Discussionmentioning

confidence: 99%

The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement

Vignos

Lenhart

et al. 2016

Journal of Biomechanical Engineering

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The study objective was to investigate the influence of coronal plane alignment and ligament properties on total knee replacement (TKR) contact loads during walking. We created a subject-specific knee model of an 83-year-old male who had an instrumented TKR. The knee model was incorporated into a lower extremity musculoskeletal model and included deformable contact, ligamentous structures, and six degrees-of-freedom (DOF) tibiofemoral and patellofemoral joints. A novel numerical optimization technique was used to simultaneously predict muscle forces, secondary knee kinematics, ligament forces, and joint contact pressures from standard gait analysis data collected on the subject. The nominal knee model predictions of medial, lateral, and total contact forces during gait agreed well with TKR measures, with root-mean-square (rms) errors of 0.23, 0.22, and 0.33 body weight (BW), respectively. Coronal plane component alignment did not affect total knee contact loads, but did alter the medial-lateral load distribution, with 4 deg varus and 4 deg valgus rotations in component alignment inducing þ17% and À23% changes in the first peak medial tibiofemoral contact forces, respectively. A Monte Carlo analysis showed that uncertainties in ligament stiffness and reference strains induce 60.2 BW uncertainty in tibiofemoral force estimates over the gait cycle. Ligament properties had substantial influence on the TKR load distributions, with the medial collateral ligament and iliotibial band (ITB) properties having the largest effects on medial and lateral compartment loading, respectively. The computational framework provides a viable approach for virtually designing TKR components, considering parametric uncertainty and predicting the effects of joint alignment and soft tissue balancing procedures on TKR function during movement.

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Section: Discussionmentioning

confidence: 99%

The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement

Vignos

Lenhart

et al. 2016

Journal of Biomechanical Engineering

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“…20 Ligamentous alignment and component attenuation are intrinsically linked. 13 Imbalance may manifest as stiffness, instability, prosthetic loosening, tibiofemoral incongruency, or as defects in patellofemoral tracking. 13,21 In a study by Babazadeh et al, 86% of knees with asymmetrical component wear lacked ligamentous balance.…”

Section: Etiology Of Tka Failurementioning

confidence: 99%

“…13 Imbalance may manifest as stiffness, instability, prosthetic loosening, tibiofemoral incongruency, or as defects in patellofemoral tracking. 13,21 In a study by Babazadeh et al, 86% of knees with asymmetrical component wear lacked ligamentous balance. This study also found that balanced knees have a significantly lower rate of prosthetic loosening.…”

Section: Etiology Of Tka Failurementioning

confidence: 99%

“…Micromotion in an asymmetric joint may result in accelerated osteoclast activity leading to osteolysis and component loosening or failure. 13 Sharkey et al reviewed the etiology of revision in 781 failed TKAs and determined that aseptic loosening was most common cause along with a significant number of revisions due to instability (Fig. 4).…”

Section: Etiology Of Tka Failurementioning

confidence: 99%

“…35 Osteoarthritis results in articular osteophyte formation, ligamentous imbalance, and irreversible joint deformity. 13 Total knee arthroplasty has proven to be both effective in significantly reducing pain associated with osteoarthritis and significantly more cost effective than prolongation with non-surgical methods. 14,15 These factors make TKA a highly desirable treatment option.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

How are we addressing ligament balance in TKA? A literature review of revision etiology and technological advancement

Smith

Elson

Anderson

et al. 2016

Journal of Clinical Orthopaedics and Trauma

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A geometric ratio to predict the flexion gap in total knee arthroplasty

Elmasry

Sculco

Kia

et al. 2020

Journal Orthopaedic Research

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Measured resection is a common technique for obtaining symmetric flexion and extension gaps in posterior‐stabilized (PS) total knee arthroplasty (TKA). A known limitation of measured resection, however, is its reliance on osseous landmarks to guide bone resection and component alignment while ignoring the geometry of the surrounding soft tissues such as the medial collateral ligament (MCL), a possible reason for knee instability. To address this clinical concern, we introduce a new geometric proportion, the MCL ratio, which incorporates features of condylar geometry and MCL anterior fibers. The goal of this study was to determine whether the MCL ratio can predict the flexion gaps and to determine whether a range of MCL ratio corresponds to balanced gaps. Six computational knee models each implanted with PS TKA were utilized. Medial and lateral gaps were measured in response to varus and valgus loads at extension and flexion. The MCL ratio was related to the measured gaps for each knee. We found that the MCL ratio was associated with the flexion gaps and had a stronger association with the medial gap (β = −7.2 ± 3.05, P < .001) than with the lateral gap (β = 3.9 ± 7.26, P = .04). In addition, an MCL ratio ranging between 1.1 and 1.25 corresponded to balanced flexion gaps in the six knee models. Future studies will focus on defining MCL ratio targets after accounting for variations in ligament properties in TKA patients. Our results suggest that the MCL ratio could help guide femoral bone resections in measured resection TKA, but further clinical validation is required.

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The relevance of ligament balancing in total knee arthroplasty: how important is it? A systematic review of the literature

Cited by 80 publications

References 99 publications

The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement

The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement

How are we addressing ligament balance in TKA? A literature review of revision etiology and technological advancement

A geometric ratio to predict the flexion gap in total knee arthroplasty

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