Comparison of intraoperative soft tissue balance measurement between two tensor systems in total knee arthroplasty

Navigated instrumentation and ligament tensioning device enhances initial gap acquisition during total knee arthroplasty procedure: A cadaveric study

Purpose

Gap-balanced total knee arthroplasty (TKA) technique relies on initial ligament evaluation, particularly in patient-specific implantation using computer-assisted technologies. This cadaveric study aimed to compare the reproducibility and reliability of medial and lateral gap measurements between manual stress testing and dynamic ligament balancer.

Methods

Initial gap acquisitions were assessed from eight cadaveric knees (four specimens) during the same navigated TKA procedure by five differently skilled surgeons (three seniors and two juniors). Medial and lateral gaps were sequentially acquired from extension to maximum knee flexion, applying manual stress prior to any bone cuts (conventional technique), and using intra-articular tensioning device placed between the tibial cut and the native femur (instrumented technique). Reproducibility was assessed using intraclass correlation coefficient (ICC), stratified by the measurement technique, the type of gaps and the operator experience. Differences in gaps (mm) between techniques were assessed using the Bland and Altmann method.

Results

The instrumented technique showed higher ICCs than the conventional technique for medial and lateral gaps (0.87 vs. 0.60, P = 0.002, and 0.92 vs. 0.25, p < 0.0001, respectively), and showed no difference in ICCs between medial and lateral gap acquisitions (0.87 vs. 0.92, p = 0.8). Senior surgeons achieved higher ICCs than juniors, while non-significant with both techniques. Differences in gaps between techniques increased with knee flexion angle (0.8, 2.8 and 3.5 mm at 10°, 45° and 90° of flexion angle, respectively) and decreased with the operator experience (p = 0.003).

Conclusion

The instrumented balancing technique offered better reproducibility than using manual valgus and varus stress, when measuring medial and lateral gaps. Tensioning devices may play a significant role in enhancing initial gap acquisition, disregarding the flexion angle and the operator experience.

Level of Evidence

Level IV (observational study involving cadaveric specimens).

Medial osteophyte resection width correlates with correction of the medio-lateral component gap imbalance during posterior-stabilized total knee arthroplasty

BACKGROUND

There is a lack of robust evidence for a correlation between the medial osteophyte resection and correction of the medio-lateral gap imbalance during total knee arthroplasty. The purpose of the present study was to quantify the effect of osteophyte resection on the medio-lateral component gap imbalance during posterior-stabilized total knee arthroplasty.

METHODS

Forty-five cases of primary posterior-stabilized total knee arthroplasty using the measured resection technique with posterior-stabilized prosthesis for varus knee osteoarthritis were reviewed. Medial and lateral joint gaps at 0°, 10°, 45°, and 90° of flexion, and maximum flexion were measured intraoperatively before and after the osteophyte resection. The relationship between medial osteophyte resection width and change of joint varus angle and medial component gap were assessed using Pearson's correlation coefficient.

FINDINGS

Medial component gap and joint varus angle values at post medial osteophyte resection were significantly larger and lower than at pre-resection (Medial gap: pre 9.5 ± 1.8 mm, post 10.3 ± 1.8 mm, P < 0.001, Joint angle: pre 5.2 ± 2.9°, post 4.2 ± 2.9°, P < 0.001). There was no significant difference between pre and post medial osteophyte resection in lateral component gaps. Per each 1 mm of medial osteophyte resection width, increases of 0.13 mm medial component gap and 0.2° valgus were observed (Medial gap: r = 0.38, P < 0.001, Joint angle: r = 0.38, P < 0.001).

INTERPRETATION

Medial osteophyte resection increases the medial component gap without lateral component gap increase, while decreasing the joint varus angle in primary posterior-stabilized total knee arthroplasty for varus knee osteoarthritis. Osteophyte resection width was found to correlate with correction of the medio-lateral component gap imbalance.

The intraoperative gap differences due to joint distraction force differences in total knee arthroplasty are affected by preoperative lower limb alignment and body mass index

BACKGROUND

Soft tissue balance is important for a good clinical result in total knee arthroplasty. Nevertheless, the appropriate evaluation of the intraoperative gap has not been established. We investigated the relationship between physical characteristics and gap differences due to distraction force, in order to determine whether intraoperative adjustment of the distraction force can be considered based on the physical characteristics of the patient.

METHODS

A total of 115 varus knees in which primary total knee arthroplasty was performed were retrospectively evaluated. The component gaps were measured under 60 and 80 N. The gap difference under 60 and 80 N was calculated. We performed a linear regression analysis to determine the correlation between the gap differences and patient parameters.

FINDINGS

Each gap was significantly larger under 80 N than under 60 N. The component gap difference is larger in the lateral compartment than in the medial compartment at each knee flexion angle. The gap difference negatively correlated with preoperative hip-knee-ankle angle at a knee flexion of 0° and 120° (r = -0.21, -0.19; p = 0.02, 0.05) and positively correlated with BMI in the lateral compartment at a knee flexion of 90° (r = 0.31, p < 0.001).

INTERPRETATION

The difference in the intraoperative gap due to the joint distraction force was affected by the preoperative HKA axis angle and the body mass index in the lateral compartment. Surgeons should consider the effect of preoperative limb alignment and body mass index in interpreting intraoperative gap measurement.

Arthroplasty Surgeons Differ in Their Intraoperative Soft Tissue Assessments: A Study in Human Cadavers to Quantify Surgical Decision-making in TKA

BACKGROUND

In TKA, soft tissue balancing is assessed through manual intraoperative trialing. This assessment is a physical examination via manually applied forces at the ankle, generating varus and valgus moments at the knee while the surgeon visualizes the lateral and medial gaps at the joint line. Based on this examination, important surgical decisions are made that influence knee stability, such as choosing the polyethylene insert thickness. Yet, the applied forces and the assessed gaps in this examination represent a qualitative art that relies on each surgeon's intuition, experience, and training. Therefore, the extent of variation among surgeons in conducting this exam, in terms of applied loads and assessed gaps, is unknown. Moreover, whether variability in the applied loads yields different surgical decisions, such as choice of insert thickness, is also unclear. Thus, surgeons and developers have no basis for deciding to what extent the applied loads need to be standardized and controlled during a knee balance exam in TKA.

QUESTIONS/PURPOSES

(1) Do the applied moments in soft tissue assessment differ among surgeons? (2) Do the assessed gaps in soft tissue assessment differ among surgeons? (3) Is the choice of insert thickness associated with the applied moments?

METHODS

Seven independent human cadaveric nonarthritic lower extremities from pelvis to toe were acquired (including five females and two males with a mean age of 73 ± 7 years and a mean BMI of 25.8 ± 3.8 kg/m 2 ). Posterior cruciate ligament substituting (posterior stabilized) TKA was performed only on the right knees. Five fellowship-trained knee surgeons (with 24, 15, 15, 7, and 6 years of clinical experience) and one chief orthopaedic resident independently examined soft tissue balance in each knee in extension (0° of flexion), midflexion (30° of flexion), and flexion (90° of flexion) and selected a polyethylene insert based on their assessment. Pliable force sensors were wrapped around the leg to measure the loads applied by each surgeon. A three-dimensional (3D) motion capture system was used to measure knee kinematics and a dynamic analysis software was used to estimate the medial and lateral gaps. We assessed (1) whether surgeons applied different moments by comparing the mean applied moment by surgeons in extension, midflexion, and flexion using repeated measures (RM)-ANOVA (p < 0.05 was assumed significantly different); (2) whether surgeons assessed different gaps by comparing the mean medial and lateral gaps in extension, midflexion, and flexion using RM-ANOVA (p < 0.05 was assumed significantly different); and (3) whether the applied moments in extension, midflexion, and flexion were associated with the insert thickness choice using a generalized estimating equation (p < 0.05 was assumed a significant association).

RESULTS

The applied moments differed among surgeons, with the largest mean differences occurring in varus in midflexion (16.5 Nm; p = 0.02) and flexion (7.9 Nm; p < 0.001). The measured gaps differed among surgeons at all flexion angles, with the largest mean difference occurring in flexion (1.1 ± 0.4 mm; p < 0.001). In all knees except one, the choice of insert thickness varied by l mm among surgeons. The choice of insert thickness was weakly associated with the applied moments in varus (β = -0.06 ± 0.02 [95% confidence interval -0.11 to -0.01]; p = 0.03) and valgus (β = -0.09 ± 0.03 [95% CI -0.18 to -0.01]; p= 0.03) in extension and in varus in flexion (β = -0.11 ± 0.04 [95% CI -0.22 to 0.00]; p = 0.04). To put our findings in context, the greatest regression coefficient (β = -0.11) indicates that for every 9-Nm increase in the applied varus moment (that is, 22 N of force applied to the foot assuming a shank length of 0.4 m), the choice of insert thickness decreased by 1 mm.

CONCLUSION

In TKA soft tissue assessment in a human cadaver model, five surgeons and one chief resident applied different moments in midflexion and flexion and targeted different gaps in extension, midflexion, and flexion. A weak association between the applied moments in extension and flexion and the insert choice was observed. Our results indicate that in the manual assessment of soft tissue, changes in the applied moments of 9 and 11 Nm (22 to 27 N on the surgeons' hands) in flexion and extension, respectively, yielded at least a 1-mm change in choice of insert thickness. The choice of insert thickness may be more sensitive to the applied moments in in vivo surgery because the surgeon is allowed a greater array of choices beyond insert thickness.

CLINICAL RELEVANCE

Among five arthroplasty surgeons with different levels of experience and a chief resident, subjective soft tissue assessment yielded 1 to 2 mm of variation in their choice of insert thickness. Therefore, developers of tools to standardize soft tissue assessment in TKA should consider controlling the force applied by the surgeon to better control for variations in insert selection.

Comparison of the joint laxity of total knee arthroplasty evaluated by the distraction force and the varus-valgus force

BACKGROUND

Component gap (CG) measurement help surgeons evaluate intraoperative soft-tissue balance. One technique is measuring the CG using tensioner devices with distraction force. Another is to evaluate the laxity under a varus-valgus force using navigation or robotics. The aim was to compare the JL evaluated by CG and varus-valgus force between the different types of total knee arthroplasties.

METHODS

Forty-three bi-cruciate stabilized (BCS) knees and 33 bi-cruciate retaining (BCR) knees were included. After bone resection and soft tissue balancing, the CG was measured and after the final implantation and capsule closure, JL under a maximum varus-valgus stress was recorded with navigation. JL evaluated by the CG (JLCG) was defined as CG minus selected thickness of the tibial component and JL under varus-valgus force (JLVV) was defined as difference between varus-valgus angles without stress and maximum varus-valgus angles under varus-valgus force. The evaluations were performed at flexions of 10°, 30°, 60° and 90°.

RESULTS

Although JLCGs of lateral compartment of BCS were larger than those of BCR, no difference was found between JLVVs of BCS and BCR. Although JLCGs of lateral compartment did not change at each knee flexion angle in both BCS and BCR, JLVVs of lateral compartment increased by 3° from 10° to 90° knee flexion.

CONCLUSION

JLVVs of BCS and BCR were equivalent, whereas BCS showed larger JLCGs of lateral compartment. JLVVs of lateral compartment increased by 3° in the range from 10° to 90° knee flexion whereas JLCGs remained stable.

A tensor with a flat surface overestimates midflexion laxity in total knee arthroplasty: Comparison between a tensor with a flat-shaped surface and a tensor with an insert-shaped surface

BACKGROUND

Soft tissue balance is important for the success of total knee arthroplasty (TKA). Various types of tensors have been developed for the precise measurement of a gap. We hypothesized that the surface shape of the tensor that contacted the TKA component affected the gap measurement. This study aimed to compare the gaps obtained with flat and insert-shaped surface tensors.

METHODS

Two senior surgeons performed 95 TKAs (Vanguard-PS:55 knees; Persona-PS:40 knees). The joint gap was measured in each static knee flexion status (0°, 30°, 45°, 60°, 90°, 120°, and full flexion). We compared the gaps measured with a flat surface tensor and an insert-shape surface tensor. We defined a significant change as a gap difference of >1 mm with a statistical significance.

RESULTS

In Vanguard-PS, significant changes were observed at 30° and 45°. In Persona-PS, significant changes were observed at 30°, 45°, and 60°. In both implants, gaps measured with the flat tensor were larger than those measured with the insert tensor at approximately midflexion, and the significant changes disappeared in higher flexion position over midflexion.

CONCLUSIONS

The surface shape of the tensor affected the measurement of midflexion laxity in TKA. When measuring the gap with a flat tensor, the midflexion laxity was overestimated. A tensor with an insert-shaped surface should be used to measure the gap in TKA.

Navigation-based analysis of associations between intraoperative joint gap and mediolateral laxity in total knee arthroplasty

BACKGROUND

No data have demonstrated how joint gap measured under a distraction force is actually associated with mediolateral laxity evaluated under a varus-valgus force during total knee arthroplasty (TKA). This study aimed to investigate the correlations between them using a navigation system.

METHODS

A total of 113 primary navigated TKAs were included. After bone resection and soft-tissue balancing, the component gap was measured with a distraction force of 60 N and 80 N for both the medial and lateral compartment (i.e. a total of 120 N and 160 N) at 0°, 10°, 30°, 60°, 90°, and 120° knee flexion. After the final prosthetic implantation and capsule closure, mediolateral laxity under a maximum varus-valgus stress was recorded with image-free navigation at each knee flexion angle. The correlation between joint gap laxity (total differences between component gap and insert thickness in the medial and lateral compartment) and mediolateral laxity was analyzed using Spearman's rank correlation coefficient.

RESULTS

The joint gap laxity under both distraction forces showed significant positive correlations with mediolateral laxity at 10°, 30°, 60°, and 90° flexion, whereas no correlation was observed at extension and 120° flexion. The correlations were stronger in gap measurement under 80 N than 60 N at all examined ranges. In patients with body mass indexes (BMIs) ≥ 30 kg/m², the correlation became non-significant.

CONCLUSION

Intraoperative joint gap laxity was associated with mediolateral laxity after TKA, especially at mid-flexion angles. The factors weakening the correlations were a lower applied distraction force for gap measurement and a larger BMI.