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Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: A meta-analysis.

ABSTRACT: This meta-analysis was designed to compare the accuracy of soft tissue balancing and femoral component rotation as well as change in joint line positions, between the measured resection and gap balancing techniques in primary total knee arthroplasty.Studies were included in the meta-analysis if they compared soft tissue balancing and/or radiologic outcomes in patients who underwent total knee arthroplasty with the gap balancing and measured resection techniques. Comparisons included differences in flexion/extension, medial/lateral flexion, and medial/lateral extension gaps (LEGs), femoral component rotation, and change in joint line positions. Finally, 8 studies identified via electronic (MEDLINE, EMBASE, and the Cochrane Library) and manual searches were included. All 8 studies showed a low risk of selection bias and provided detailed demographic data. There was some inherent heterogeneity due to uncontrolled bias, because all included studies were observational comparison studies.The pooled mean difference in gap differences between the gap balancing and measured resection techniques did not differ significantly (-0.09?mm, 95% confidence interval [CI]: -0.40 to +0.21?mm; P = 0.55), except that the medial/LEG difference was 0.58?mm greater for measured resection than gap balancing (95% CI: -1.01 to -0.15?mm; P = 0.008). Conversely, the pooled mean difference in femoral component external rotation (0.77°, 95% CI: 0.18° to 1.35°; P = 0.01) and joint line change (1.17?mm, 95% CI: 0.82 to 1.52?mm; P?

SUBMITTER: Moon YW

PROVIDER: S-EPMC5265955 | biostudies-literature | 2016 Sep

REPOSITORIES: biostudies-literature

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Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: A meta-analysis.

Moon Young-Wan YW Kim Hyun-Jung HJ Ahn Hyeong-Sik HS Park Chan-Deok CD Lee Dae-Hee DH

Medicine 20160901 39

<h4>Background</h4>This meta-analysis was designed to compare the accuracy of soft tissue balancing and femoral component rotation as well as change in joint line positions, between the measured resection and gap balancing techniques in primary total knee arthroplasty.<h4>Methods</h4>Studies were included in the meta-analysis if they compared soft tissue balancing and/or radiologic outcomes in patients who underwent total knee arthroplasty with the gap balancing and measured resection techniques ...[more]

PMID: 27684862

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Project description:BackgroundWhen using the gap-balancing technique for TKA, excessive medial release and varus proximal tibial resection can be associated with internal rotation of the femoral component. Previous studies have evaluated the causes of femoral component rotational alignment with a separate factor analysis using unadjusted statistical methods, which might result in treatment effects being attributed to confounding variables.Questions/purposes(1) What pre- and intraoperative factors are associated with internal rotation of the femoral component in TKA using the gap balancing technique? (2) To what degree does femoral component rotation as defined by the navigation system differ from rotation as measured by postoperative CT?MethodsThree hundred seventy-seven knees that underwent computer-assisted primary TKA attributable to degenerative osteoarthritis with varus or mild valgus alignment in which medial soft tissue release was performed, and those with preoperative radiographs including preoperative CT between October 2007 and June 2014 were included in the study. To achieve a balanced mediolateral gap, the structures released during each medial release step were as follows: Step 1, deep medial collateral ligament (MCL); Step 2, superficial MCL (proximal, above the pes anserine tendon) and semimembranosus tendon; and Step 3, the superficial MCL (distal, below the pes anserine tendon). Knees with internal rotation of the femoral component, which was directed by navigation, to achieve a rectangular mediolateral flexion gap were considered cases, and knees without internally rotated femoral components were considered controls. Univariable analysis of the variables (age, sex, BMI, operated side, preoperative hip-knee-ankle angle, preoperative medial proximal tibial angle, preoperative rotation degree of the clinical transepicondylar axis [TEA] relative to the posterior condylar axis [PCA], coronal angle of resected tibia, resection of the posterior cruciate ligament, type of prosthesis, and extent of medial release) of cases and controls was performed, followed by a multivariable logistic regression analysis on those factors where p equals 0.15 or less. For an evaluation of navigation error, 88 knees that underwent postoperative CT were analyzed. Postoperative CT scans were obtained for patients with unexplained pain or stiffness after the operations. Using the paired t-test and Pearson's correlation analysis, the postoperative TEA-PCA measured with postoperative CT was compared with theoretical TEA-PCA, which was calculated with preoperative TEA-PCA and actual femoral component rotation checked by the navigation system.ResultsAfter controlling for a relevant confounding variable such as postoperative hip-knee-ankle angle, we found that the extent of medial release (Step 1 as reference; Step 2: odds ratio [OR], 5.7, [95% CI, 2.2-15]; Step 3: OR, 22, [95% CI, 7.8-62], p < 0.001) was the only factor we identified that was associated with internal rotation of the femoral component. With the numbers available, we found no difference between the mean theoretical postoperative TEA-PCA and the postoperative TEA-PCA measured using postoperative CT (4.8° ± 2.7º versus 5.0° ± 2.3º; mean difference, 0.2° ± 1.5º; p = 0.160).ConclusionsExtent of medial release was the only factor we identified that was associated with internal rotation of the femoral component in gap-balancing TKA. To avoid internal rotation of the femoral component, we recommend a carefully subdivided medial-releasing technique, especially for the superficial MCL because once the superficial MCL has been completely released it cannot easily be restored.Level of evidenceLevel III, therapeutic study.

Project description:Introduction:Recently, some studies showed assessment of the component gap is important for determination of the implant-inserted condition during total knee arthroplasty (TKA). We perform the modified gap technique with adjustment of the virtual gap which estimated by computer-aided design (CAD) using navigation system. The purpose of this study was to compare the virtual gap (CAD-gap) with the actual gap after inserting a femoral trial component (Trial-gap), and examine the usefulness of the surgical technique. Materials and methods:The subjects were 35 patients who underwent primary TKA using a navigation system and posterior-stabilized type TKA. The surgical procedure was to produce an extension gap, confirm the flexed CAD-gap on the navigation screen based on CAD data, and plan osteotomy of the femur. After osteotomy, the femoral component was inserted and the gap balance was measured. A tensor was used to adjust and measure the gap balance. Initial alignment, rotation of the femoral component, soft tissue balance in extension, final alignment after fixing all components, and the CAD- and Trial-gaps in both extension and flexion were evaluated. Results:The mean initial alignment angle, rotation angle of the femoral component, soft tissue balance angle and final alignment angle were 8.1 ± 4.2° varus, 3.5 ± 1.3°external rotation, 2.7 ± 2.5° varus and 0.4 ± 1.4° varus respectively. The mean medial and lateral CAD-gaps in extension were 10.8 ± 2.5 and 13.7 ± 2.5 mm, and the mean medial and lateral CAD-gaps in flexion were 12.2 ± 2.2 and 13.9 ± 2.7 mm. The equivalent Trial-gaps in extension and flexion were 10.5 ± 2.6 and 11.4 ± 3.1 mm, and 12.2 ± 2.5 and 14.4 ± 2.8 mm. The CAD- and Trial-gaps differed significantly only for lateral gaps in extension. Conclusion:In comparing the CAD-gap and the Trial-gap, only small difference was found in the lateral gap of extension. The other gaps in both extension and flexion were well maintained. We concluded adjustment of the CAD-gap during surgery using a navigation system can be used to adjust the actual component gap especially in the medial side.

Dataset Information

Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: A meta-analysis.

Publications

Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: A meta-analysis.

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