Abstract
Purpose
The aim of this study was to identify if constitutional alignment and preoperative radiologic parameters determined whether medial gap balancing was required in mechanically aligned total knee arthroplasty (TKA).
Methods
Two hundred and sixty three patients with 394 consecutive knees who underwent primary TKAs were retrospectively analysed in this study. Selective sequential multiple needle puncturing (MNP) was performed for medial ligament balancing when required. Constitutional alignment, which was determined using the Coronal Plane Alignment of the Knee (CPAK) classification, as well as preoperative and postoperative radiologic parameters was evaluated to identify factors which predicted the need for MNP.
Results
One hundred and fifty eight (40.1%) knees required medial ligament balancing with MNP. Patients who required MNP during surgery had significantly more constitutional varus, more varus preoperative mechanical Hip–Knee–Ankle angle (mHKA), smaller preoperative medial proximal tibial angle (MPTA) and a larger change in mHKA and MPTA after surgery than those who did not. Patients with constitutional varus also had a higher incidence of having had MNP to both anterior and posterior superficial medial collateral ligament (sMCL) fibres. There was no significant difference in preoperative lateral distal femoral angle (LDFA), posterior tibial slope (PTS) and varus–valgus difference (VVD) between groups.
Conclusion
Ligament balancing using MNP was determined by constitutional alignment rather than medial soft tissue contracture. Patients with constitutional varus who had a larger medio-lateral gap difference in extension also had a higher incidence of having had MNP to both anterior and posterior sMCL fibres.
Level of evidence
Retrospective comparative study, level IV.
Similar content being viewed by others
Data Availability
Not applicable.
References
Graichen H, Lekkreusuwan K, Eller K, Grau T, Hirschmann MT, Scior W (2022) A single type of varus knee does not exist: morphotyping and gap analysis in varus OA. Knee Surg Sports Traumatol Arthrosc 30:2600–2608
Hernandez-Vaquero D, Noriega-Fernandez A, Roncero-Gonzalez S, Ruete-Gil GL, Fernandez-Carreira JM (2022) Can the need for soft tissue release in total knee replacement be predicted pre-operatively? A study based on surgical navigation. Int Orthop 46:815–821
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 27:1378–1384
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 27:1385–1393
Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclerq V, Hess S (2019) Functional knee phenotypes: a novel classification for phenotyping the coronal lower limb alignment based on the native alignment in young non-osteoarthritic patients. Knee Surg Sports Traumatol Arthrosc 27:1394–1402
Howell SM (2019) Calipered kinematically aligned total knee arthroplasty: an accurate technique that improves patient outcomes and implant survival. Orthopedics 42:126–135
Jenny JY, Baldairon F, Hirschmann MT (2022) Functional knee phenotypes of OA patients undergoing total knee arthroplasty are significantly more varus or valgus than in a non-OA control group. Knee Surg Sports Traumatol Arthrosc 30:2609–2616
Jhurani A, Agarwal P, Aswal M, Meena I, Srivastava M, Sheth NP (2020) Do spacer blocks accurately estimate deformity correction and gap balance in total knee arthroplasty? A prospective study with computer navigation. Knee 27:214–220
Kamei G, Ishibashi S, Yoshioka K, Sakurai S, Inoue H, Ishikawa M et al (2021) Accuracy of total knee arthroplasty using the modified gap technique based on the bone gap: an evaluation of the bone gap with a distal femoral trial component. Arthroplasty 3:17
Kamei G, Ishibashi S, Yoshioka K, Sakurai S, Inoue H, Mochizuki Y et al (2022) Evaluation of the flexion gap with a distal femoral trial component in posterior-stabilized total knee arthroplasty. Knee Surg Related Res 34:10
Kim MS, Koh IJ, Choi YJ, Kim YD, In Y (2017) Correcting severe varus deformity using trial components during total knee arthroplasty. J Arthroplasty 32:1488–1495
Kwak IH, Lee SS, Lee J, Lee DH (2022) Effects of severe varus deformity on soft tissue balancing in total knee arthroplasty. J Clin Med 12:263
Lee OS, Elazab A, Lee YS (2019) Preoperative varus-valgus stress angle difference is valuable for predicting the extent of medial release in varus deformity during total knee arthroplasty. Knee Surg Relat Res 31:12–18
Luderer V, Strauch M, Hirschmann MT, Graichen H (2023) Independent of the preoperative coronal deformity, adjusted mechanical alignment leads in a high percentage to non-anatomical tibial and femoral bone cuts. Knee Surg Sports Traumatol Arthrosc 31:3784–3791
MacDessi SJ, Griffiths-Jones W, Harris IA, Bellemans J, Chen DB (2021) Coronal plane alignment of the knee (CPAK) classification. Bone Joint J. 103-b:329–337
Marcovigi A, Zambianchi F, Giorgini A, Digennaro V, Catani F (2016) The impact of bone deformity on osteoarthritic varus knee correctability. J Arthroplasty 31:2677–2684
Matsumoto T, Takayama K, Ishida K, Hayashi S, Hashimoto S, Kuroda R (2017) Radiological and clinical comparison of kinematically versus mechanically aligned total knee arthroplasty. Bone Joint J. 99-b:640–646
Oussedik S, Abdel MP, Victor J, Pagnano MW, Haddad FS (2020) Alignment in total knee arthroplasty. Bone Joint J. 102-b:276–279
Schelker BL, Moret CS, Sava MP, von Eisenhart-Rothe R, Graichen H, Arnold MP et al (2023) The impact of different alignment strategies on bone cuts in total knee arthroplasty for varus knee phenotypes. Knee Surg Sports Traumatol Arthrosc 31:1840–1850
Schelker BL, Moret CS, von Eisenhart-Rothe R, Graichen H, Arnold MP, Leclercq V et al (2023) The impact of different alignment strategies on bone cuts for neutral knee phenotypes in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 31:1267–1275
Scott RD, Chmell MJ (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 Arthroplasty 23:605–608
Siong FT, Kim TW, Kim SC, Lee ES, Jaffar MSA, Lee YS (2020) Efficacy and safety of functional medial ligament balancing with stepwise multiple needle puncturing in varus total knee arthroplasty. J Arthroplasty 35:380–387
Yamada M, Nakajima A, Sonobe M, Akatsu Y, Yamamoto K, Saito J et al (2023) The impact of postoperative inclination of the joint line on clinical outcomes in total knee arthroplasty using a prosthesis with anatomical geometry. Sci Rep 13:979
Funding
This work was supported by the grant funded by the National Research Foundation of Korea (No.2021R1A2C1092657). Institutional Review Board approval was obtained before performing the study (B-2212-796-101).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no conflict of interest in performing this work.
Ethical approval statement
The study protocol was approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-2212-796-101) prior to commencement. This study was designed and conducted following the STROBE guidelines and in agreement with the Declaration of Helsinki.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Ho, J.P.Y., Cho, J.H., Nam, H.S. et al. Constitutional alignment predicts medial ligament balancing in mechanically aligned total knee arthroplasty for varus knees. Knee Surg Sports Traumatol Arthrosc 31, 5940–5949 (2023). https://doi.org/10.1007/s00167-023-07660-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-023-07660-0