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Computer-assisted gap balancing technique improves outcome in total knee arthroplasty, compared with conventional measured resection technique

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The objective of this prospective study was to compare the functional outcome of conventional measured resection technique and computer-assisted gap balancing technique in TKA.


140 patients were randomized into two groups. The conventional measured resection technique without computer navigation was performed in Group 1 and the computer-assisted gap balancing technique in Group 2. Range of motion, clinical laxity assessment with KT-1000 arthrometer, postoperative radiological films and various functional knee scores were documented at 6 months and 2 years.


At 2 years, there were significantly more patients (five patients, 7%) in the Group 1 with flexion contractures of more than 5° (P = 0.05). There were significantly more outliers in the Group 1 (eight patients, 11%), who demonstrated anterior tibial translation >5 mm, than Group 2 (two patients, 3%) (P = 0.041). The total excursion at 20° was significantly higher in Group 1 at 6 months (P = 0.012) and after 2 years (P = 0.031). Group 2 was able to demonstrate significantly better limb alignment with fewer outliers (more than 3° varus/valgus) than Group 1. At 6-month follow-up, Group 2 demonstrated better outcomes in Function Score (P = 0.040) and Total Oxford Score (P = 0.031). At 2-year review, Group 2 had better outcome in the Total Oxford Score (0.030).


Computer-assisted gap balancing technique was able to achieve more precise soft tissue balance and restoration of limb alignment with better knee scores as compared to the conventional measured resection technique in total knee arthroplasty.

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  1. 1.

    Bach BR Jr, Warren RF, Flynn WM, Kroll M, Wickiewiecz TL (1990) Arthrometric evaluation of knees that have a torn anterior cruciate ligament. J Bone Joint Surg Am 72:1299–1306

  2. 2.

    Bauwens K, Matthes G, Wich M, Gebhard F, Hanson B, Ekkernkamp A, Stengel D (2007) Navigated total knee replacement. A meta-analysis. J Bone Joint Surg Am 89:261–269

  3. 3.

    Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS (1993) Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res 286:40–47

  4. 4.

    Bottros J, Gad B, Krebs V, Barsoum WK (2006) Gap balancing in total knee arthroplasty. J Arthroplast 21:11–15

  5. 5.

    Chin PL, Yang KY, Yeo SJ, Lo NN (2005) Randomized control trial comparing radiographic total knee arthroplasty implant placement using computer navigation versus conventional technique. J Arthroplast 20:618–626

  6. 6.

    Chmell MJ, Scott RD (2008) Balancing the posterior cruciate ligament during cruciate-retaining fixed and mobile-bearing total knee arthroplasty: description of the pull-out lift-off and slide-back tests. J Arthroplast 23:605–608

  7. 7.

    Crottet D, Kowal J, Sarfert SA, Maeder T, Bleuler H, Nolte LP, Durselen L (2007) Ligament balancing in TKA: evaluation of a force-sensing device and the influence of patellar eversion and ligament release. J Biomech 40:1709–1715

  8. 8.

    Daniel DM, Stone ML, Sachs R, Malcom L (1985) Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am J Sports Med 13:401–407

  9. 9.

    Dawson J, Fitzpatrick R, Murray D, Carr A (1998) Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg Br 80:63–69

  10. 10.

    Dejour D, Deschamps G, Garotta L, Dejour H (1999) Laxity in posterior cruciate sparing and posterior stabilized total knee prostheses. Clin Orthop Relat Res 364:182–193

  11. 11.

    Dennis DA, Komistek RD, Kim RH, Sharma A (2010) Gap balancing versus measured resection technique for total knee arthroplasty. Clin Orthop Relat Res 468:102–107

  12. 12.

    Dutton AQ, Yeo SJ (2009) Computer-assisted minimally invasive total knee arthroplasty compared with standard total knee arthroplasty. Surgical technique. J Bone Joint Surg Am 91:116–130

  13. 13.

    Ek ET, Dowsey MM, Tse LF, Riazi A, Love BR, Stoney JD, Choong PF (2008) Comparison of functional and radiological outcomes after computer-assisted versus conventional total knee arthroplasty: a matched-control retrospective study. J Orthop Surg (Hong Kong) 16:192–196

  14. 14.

    Ensini A, Catani F, Leardini A, Romagnoli M, Giannini S (2007) Alignments and clinical results in conventional and navigated total knee arthroplasty. Clin Orthop Relat Res 457:156–162

  15. 15.

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

  16. 16.

    Fehring TK (2000) Rotational Malalignment of the femoral component in total knee arthroplasty. Clin Orthop Relat Res 380:72–79

  17. 17.

    Forster IW, Warren-Smith CD, Tew M (1989) Is the KT1000 knee ligament arthrometer reliable? J Bone Joint Surg Br 71:843–847

  18. 18.

    Incavo SJ, Johnson CC, Beynnon BD, Howe JG (1994) Posterior cruciate ligament strain biomechanics in total knee arthroplasty. Clin Orthop Relat Res 309:88–93

  19. 19.

    Insall JN (1988) Presidential address to The Knee Society. Choices and compromises in total knee arthroplasty. Clin Orthop Relat Res 226:43–48

  20. 20.

    Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the knee society clinical rating system. Clin Orthop Relat Res 248:13–14

  21. 21.

    Insall JN, Easley ME (2001) Surgical techniques and instrumentation in total knee arthroplasty. In: Insall JN (ed) Surgery of the knee, 3rd edn. Churchill Livingston, Philadelphia, pp 1553–1557

  22. 22.

    Ishii Y, Matsuda Y, Ishii R, Sakata S, Omori G (2005) Sagittal laxity in vivo after total knee arthroplasty. Arch Orthop Trauma Surg 125:249–253

  23. 23.

    Kim YH, Kim JS, Yoon SH (2008) A recession of posterior cruciate ligament in posterior cruciate-retaining total knee arthrosplasty. J Arthroplast 23:999–1004

  24. 24.

    Krackow KA, Mihalko WM (1999) Flexion-extension joint gap changes after lateral structure release for valgus deformity correction in total knee arthroplasty: a cadaveric study. J Arthroplast 14:994–1004

  25. 25.

    Laskin RS (2001) The Genesis total knee prosthesis: a ten-year follow-up study. Clin Orthop Relat Res 388:95–102

  26. 26.

    Mahaluxmivala J, Bankes MJ, Nicolai P, Aldam CH, Allen PW (2001) The effect of surgeon experience on component positioning in 673 press fit condylar posterior cruciate-sacrificing total knee arthroplasties. J Arthroplast 16:635–640

  27. 27.

    Matziolis G, Krocker D, Weiss U, Tohtz S, Perka C (2007) A prospective, randomized study of computer-assisted and conventional total knee arthroplasty. Three-dimensional evaluation of implant alignment and rotation. J Bone Joint Surg Am 89:236–243

  28. 28.

    Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr AJ, Dawson J (2007) The use of the Oxford hip and knee scores. J Bone Joint Surg Br 89:1010–1014

  29. 29.

    Olcott CW, Scott RD (1999) The Ranawat Award. Femoral component rotation during total knee arthroplasty. Clin Orthop Relat Res 367:39–42

  30. 30.

    Ranawat CS, Padgett DE, Ohashi Y (1989) Total knee arthroplasty for patients younger than 55 years. Clin Orthop Relat Res 248:27–33

  31. 31.

    Ritter MA, Lutgring JD, Davis KE, Berend ME, Pierson JL, Meneghini RM (2007) The role of flexion contracture on outcomes in primary total knee arthroplasty. J Arthroplast 22:1092–1096

  32. 32.

    Steiner ME, Brown C, Zarins B, Brownstein B, Koval PS, Stone P (1990) Measurement of anterior-posterior displacement of the knee. A comparison of the results with instrumented devices and with clinical examination. J Bone Joint Surg Am 72:1307–1315

  33. 33.

    Stockl B, Nogler M, Rosiek R, Fischer M, Krismer M, Kessler O (2004) Navigation improves accuracy of rotational alignment in total knee arthroplasty. Clin Orthop Relat Res 426:180–186

  34. 34.

    Stulberg SD (2003) How accurate is current TKR instrumentation? Clin Orthop Relat Res 416:177–184

  35. 35.

    Tew M, Forster IW (1987) Effect of knee replacement on flexion deformity. J Bone Joint Surg Br 69:395–399

  36. 36.

    Tigani D, Sabbioni G, Ben Ayad R, Filanti M, Rani N, Del Piccolo N (2010) Comparison between two computer-assisted total knee arthroplasty: gap-balancing versus measured resection technique. Knee Surg Sports Traumatol Arthrosc 18:1304–1310

  37. 37.

    Tingart M, Lüring C, Bäthis H, Beckmann J, Grifka J, Perlick L (2008) Computer-assisted total knee arthroplasty versus the conventional technique: how precise is navigation in clinical routine? Knee Surg Sports Traumatol Arthrosc 16:44–50

  38. 38.

    Van Hal CT, van Hellemondt GG, Wymenga AB, Jacobs WC (2007) The anterior-posterior laxity after total knee arthroplasty inserted with a ligament tensor. Knee Surg Sports Traumatol Arthrosc 15:1019–1022

  39. 39.

    Viskontas DG, Skrinskas TV, Johnson JA, King GJ, Winemaker MJ, Chess DG (2007) Computer-assisted gap equalization in total knee arthroplasty. J Arthroplast 22(3):334–342

  40. 40.

    Ware JE Jr, Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30:473–483

  41. 41.

    Warren PJ, Olanlokun TK, Cobb AG, Walker PS, Iverson BF (1994) Laxity and function in knee replacements. A comparative study of three prosthetic designs. Clin Orthop Relat Res 305:200–208

  42. 42.

    White SH, O’Connor JJ, Goodfellow JW (1991) Sagittal plane laxity following knee arthroplasty. J Bone Joint Surg Br 73:268–270

  43. 43.

    Winemaker MJ (2002) Perfect balance in total knee arthroplasty: the elusive compromise. J Arthroplast 17:2–10

  44. 44.

    Worland RL, Jessup DE, Johnson J (1997) Posterior cruciate recession in total knee arthroplasty. J Arthroplast 12:70–73

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The authors declare that they have no conflict of interest.

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Correspondence to Hee-Nee Pang.

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Pang, H., Yeo, S., Chong, H. et al. Computer-assisted gap balancing technique improves outcome in total knee arthroplasty, compared with conventional measured resection technique. Knee Surg Sports Traumatol Arthrosc 19, 1496–1503 (2011). https://doi.org/10.1007/s00167-011-1483-3

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  • Knee
  • Computer
  • Gap
  • Soft tissue
  • Balancing
  • Replacement
  • Arthroplasty