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Bone resection for mechanically aligned total knee arthroplasty creates frequent gap modifications and imbalances

  • William Blakeney
  • Yann Beaulieu
  • Benjamin Puliero
  • Marc-Olivier Kiss
  • Pascal-André VendittoliEmail author
KNEE
  • 30 Downloads

Abstract

Purpose

The objective of this study was to calculate bone resection thicknesses and resulting gap sizes, simulating a measured resection mechanical alignment (MA) technique for total knee arthroplasty (TKA).

Methods

MA bone resections were simulated on 1000 consecutive lower limb CT scans from patients undergoing TKA. Femoral rotation was aligned with either the surgical trans-epicondylar axis (TEA) or with 3° of external rotation to the posterior condyles (PC). Imbalances in the extension space, flexion space, medial compartment and lateral compartment were calculated.

Results

Extension space imbalances (≥ 3 mm) occurred in 25% of varus and 54% of valgus knees and severe imbalances (≥ 5 mm) were present in up to 8% of varus and 19% of valgus knees. Higher flexion space imbalance rates were created with TEA versus PC (p < 0.001). Using TEA, only 49% of varus and 18% of valgus knees had < 3 mm of imbalance throughout the extension and flexion spaces, and medial and lateral compartments.

Conclusion

A systematic use of the simulated measured resection MA technique for TKA leads to many cases with imbalance. Some imbalances may not be correctable surgically and may result in TKA instability. Modified versions of the MA technique or other alignment methods that better reproduce knee anatomies should be explored.

Level of evidence

2.

Keywords

Knee Alignment Mechanical Gap Ligament balance Arthroplasty Total knee replacement Bone cuts 

Notes

Funding

No funding was received to perform this study.

Compliance with ethical standards

Conflict of interest

The authors declared that they have no conflict of interest.

Ethical approval

This article used anonymous data from an existing collection of CT scans and does not contain any studies with human participants performed by any of the authors.

Informed consent

For this type of study formal consent is not required.

References

  1. 1.
    Albanese CV, Rendine M, De Palma F, Impagliazzo A, Falez F, Postacchini F et al (2006) Bone remodelling in THA: a comparative DXA scan study between conventional implants and a new stemless femoral component. A preliminary report. Hip Int 16(Suppl 3):9–15CrossRefGoogle Scholar
  2. 2.
    Alghamdi A, Rahme M, Lavigne M, Masse V, Vendittoli PA (2014) Tibia valga morphology in osteoarthritic knees: importance of preoperative full limb radiographs in total knee arthroplasty. J Arthroplasty 29:1671–1676CrossRefGoogle Scholar
  3. 3.
    Almaawi AM, Hutt JRB, Masse V, Lavigne M, Vendittoli P-A (2017) The impact of mechanical and restricted kinematic alignment on knee anatomy in total knee arthroplasty. J Arthroplasty 32:2133–2140CrossRefGoogle Scholar
  4. 4.
    Bonnin MP, Saffarini M, Nover L, van der Maas J, Haeberle C, Hannink G et al (2017) External rotation of the femoral component increases asymmetry of the posterior condyles. Bone Joint J 99-B:894–903CrossRefGoogle Scholar
  5. 5.
    Christensen CP, Stewart AH, Jacobs CA (2013) Soft tissue releases affect the femoral component rotation necessary to create a balanced flexion gap during total knee arthroplasty. J Arthroplasty 28:1528–1532CrossRefGoogle Scholar
  6. 6.
    Daines BK, Dennis DA (2014) Gap balancing vs. measured resection technique in total knee arthroplasty. Clin Orthop Surg 6:1–8CrossRefGoogle Scholar
  7. 7.
    Freeman MA, Swanson SA, Todd RC (1973) Total replacement of the knee using the Freeman–Swanson knee prosthesis. Clin Orthop Relat Res 94:153–170CrossRefGoogle Scholar
  8. 8.
    Gu Y, Roth JD, Howell SM, Hull ML (2014) How frequently do four methods for mechanically aligning a total knee arthroplasty cause collateral ligament imbalance and change alignment from normal in white patients? AAOS exhibit selection. J Bone Joint Surg Am 96:e101CrossRefGoogle Scholar
  9. 9.
    Gustke KA, Golladay GJ, Roche MW, Elson LC, Anderson CR (2014) Primary TKA patients with quantifiably balanced soft-tissue achieve significant clinical gains sooner than unbalanced patients. Adv Orthop 2014:628695CrossRefGoogle Scholar
  10. 10.
    Hess S, Moser LB, Amsler F, Behrend H, Hirschmann MT (2019) Highly variable coronal tibial and femoral alignment in osteoarthritic knees: a systematic review. Knee Surg Sports Traumatol Arthrosc 27:1368–1377CrossRefGoogle Scholar
  11. 11.
    Hirschmann MT, Hess S, Behrend H, Amsler F, Leclercq V, Moser LB (2019) Phenotyping of hip-knee-ankle angle in young non-osteoarthritic knees provides better understanding of native alignment variability. Knee Surg Sports Traumatol Arthrosc 27:1378–1384CrossRefGoogle Scholar
  12. 12.
    Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclercq V, Hess S (2019) Phenotyping the knee in young non-osteoarthritic knees shows a wide distribution of femoral and tibial coronal alignment. Knee Surg Sports Traumatol Arthrosc 27:1385–1393CrossRefGoogle Scholar
  13. 13.
    Howell SM, Howell SJ, Kuznik KT, Cohen J, Hull ML (2013) Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category? Clin Orthop Relat Res 471:1000–1007CrossRefGoogle Scholar
  14. 14.
    Huang T, Long Y, George D, Wang W (2017) Meta-analysis of gap balancing versus measured resection techniques in total knee arthroplasty. Bone Joint J 99-B:151–158CrossRefGoogle Scholar
  15. 15.
    Hunt NC, Ghosh KM, Athwal KK, Longstaff LM, Amis AA, Deehan DJ (2014) Lack of evidence to support present medial release methods in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22:3100–3112CrossRefGoogle Scholar
  16. 16.
    Hutt JRB, LeBlanc MA, Massé V, Lavigne M, Vendittoli PA (2016) Kinematic TKA using navigation: surgical technique and initial results. Orthop Traumatol Surg Res 102:99–104CrossRefGoogle Scholar
  17. 17.
    Jarvelin J, Hakkinen U, Rosenqvist G, Remes V (2012) Factors predisposing to claims and compensations for patient injuries following total hip and knee arthroplasty. Acta Orthop 83:190–196CrossRefGoogle Scholar
  18. 18.
    Jawhar A, Hutter K, Scharf HP (2016) Outcome in total knee arthroplasty with a medial-lateral balanced versus unbalanced gap. J Orthop Surg (Hong Kong) 24:298–301CrossRefGoogle Scholar
  19. 19.
    Kwak DS, In Y, Kim TK, Cho HS, Koh IJ (2016) The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 24:188–194CrossRefGoogle Scholar
  20. 20.
    Le DH, Goodman SB, Maloney WJ, Huddleston JI (2014) Current modes of failure in TKA: infection, instability, and stiffness predominate. Clin Orthop Relat Res 472:2197–2200CrossRefGoogle Scholar
  21. 21.
    Lee GC, Lotke PA (2012) Can surgeons predict what makes a good TKA? Intraoperative surgeon impression of TKA quality does not correlate with knee society scores. Clin Orthop Relat Res 470:159–165CrossRefGoogle Scholar
  22. 22.
    Li G, Park SE, DeFrate LE, Schutzer ME, Ji L, Gill TJ et al (2005) The cartilage thickness distribution in the tibiofemoral joint and its correlation with cartilage-to-cartilage contact. Clin Biomech (Bristol, Avon) 20:736–744CrossRefGoogle Scholar
  23. 23.
    McAuliffe MJ, Roe J, Garg G, Whitehouse SL, Crawford R (2017) The varus osteoarthritic knee has no coronal contractures in 90 degrees of flexion. J Knee Surg 30:297–303Google Scholar
  24. 24.
    Mihalko WM, Whiteside LA, Krackow KA (2003) Comparison of ligament-balancing techniques during total knee arthroplasty. J Bone Joint Surg Am 85-A(Suppl 4):132–135CrossRefGoogle Scholar
  25. 25.
    Niki Y, Sassa T, Nagai K, Harato K, Kobayashi S, Yamashita T (2017) Mechanically aligned total knee arthroplasty carries a risk of bony gap changes and flexion-extension axis displacement. Knee Surg Sports Traumatol Arthrosc 25:3452–3458CrossRefGoogle Scholar
  26. 26.
    Park IS, Ong A, Nam CH, Ahn NK, Ahn HS, Lee SC et al (2014) Transepicondylar axes for femoral component rotation might produce flexion asymmetry during total knee arthroplasty in knees with proximal tibia vara. Knee 21:369–373CrossRefGoogle Scholar
  27. 27.
    Peters CL, Jimenez C, Erickson J, Anderson MB, Pelt CE (2013) Lessons learned from selective soft-tissue release for gap balancing in primary total knee arthroplasty: an analysis of 1216 consecutive total knee arthroplasties: AAOS exhibit selection. J Bone Joint Surg Am 95:e152CrossRefGoogle Scholar
  28. 28.
    Riviere C, Iranpour F, Auvinet E, Aframian A, Asare K, Harris S et al (2017) Mechanical alignment technique for TKA: are there intrinsic technical limitations? Orthop Traumatol Surg Res 103:1057–1067CrossRefGoogle Scholar
  29. 29.
    Riviere C, Iranpour F, Auvinet E, Howell S, Vendittoli PA, Cobb J et al (2017) Alignment options for total knee arthroplasty: a systematic review. Orthop Traumatol Surg Res 103:1047–1056CrossRefGoogle Scholar
  30. 30.
    Saeki K, Mihalko WM, Patel V, Conway J, Naito M, Thrum H et al (2001) Stability after medial collateral ligament release in total knee arthroplasty. Clin Orthop Relat Res 392:184–189CrossRefGoogle Scholar
  31. 31.
    Sharkey PF, Lichstein PM, Shen C, Tokarski AT, Parvizi J (2014) Why are total knee arthroplasties failing today—has anything changed after 10 years? J Arthroplasty 29:1774–1778CrossRefGoogle Scholar
  32. 32.
    Unitt L, Sambatakakis A, Johnstone D, Briggs TW, Balancer Study G (2008) Short-term outcome in total knee replacement after soft-tissue release and balancing. J Bone Joint Surg Br 90:159–165CrossRefGoogle Scholar
  33. 33.
    Whiteside LA (2002) Soft tissue balancing: the knee. J Arthroplasty 17:23–27CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of SurgeryCIUSSS-de-L’Est-de-L’Ile-de-Montréal, Université de Montréal, Hôpital Maisonneuve RosemontMontréalCanada
  2. 2.Department of SurgeryAlbany Health CampusAlbanyAustralia
  3. 3.Department of SurgeryUniversité de MontréalMontréalCanada

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