Abstract
Purpose
The purpose of this study was to evaluate the influence of intra-operative soft tissue balancing and distal femoral cutting on flexion contracture in navigated TKA.
Methods
This was a prospective cohort study. Fifty-nine patients of primary navigation-assisted TKA were included with over 15° of flexion contracture and excluded valgus knees. Among the cases, 43 cases were performed with soft tissue balancing procedures only, and 16 cases were performed with soft tissue balancing and additional distal femoral bone cutting. The mean preoperative flexion contracture was 17.5° ± 2.7°. The angles of flexion contracture were recorded at each surgical step with navigation.
Results
The mean difference in flexion contracture angle between initial angle and angle after medial release was 5.2° ± 2.8°. The mean difference in flexion contracture angle between medial release step and after posterior cruciate ligament (PCL) release was 2.5° ± 2.2°. The mean difference in flexion contracture angle between PCL release step and after routine bone cutting was 3.1° ± 3.2°. The mean difference in flexion contracture angle between after trial insertion and after posterior clearing procedure was 2.7° ± 1.9°. Among the cases, TKA with 2 mm additional bone cutting were performed in 16 cases. The mean difference in flexion contracture angle after additional femoral bone cutting was 4.8° ± 2.1°.
Conclusion
The medial release and 2 mm additional bone cutting could correct flexion contracture by 5°. The appropriate soft tissue balancing and bone cutting could correct flexion contracture intra-operatively up to 5° in each step.
Level of evidence
II.
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References
Bae DK, Song SJ (2011) Computer assisted navigation in knee arthroplasty. Clin Orthop Surg 3:259–267
Bathis H, Perlick L, Tingart M, Luring C, Zurakowski D, Grifka J (2004) Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique. J Bone Joint Surg Br 86:682–687
Bengs BC, Scott RD (2006) The effect of distal femoral resection on passive knee extension in posterior cruciate ligament-retaining total knee arthroplasty. J Arthroplasty 21:161–166
Cross MB, Nam D, Plaskos C, Sherman SL, Lyman S, Pearle AD, Mayman DJ (2012) Recutting the distal femur to increase maximal knee extension during TKA causes coronal plane laxity in mid-flexion. Knee 19:875–879
Daines BK, Dennis DA (2014) Gap balancing vs. measured resection technique in total knee arthroplasty. Clin Orthop Surg 6:1–8
Dennis DA (2001) The stiff total knee arthroplasty: causes and cures. Orthopedics 24:901–902
Fehring TK, Odum SM, Griffin WL, McCoy TH, Masonis JL (2007) Surgical treatment of flexion contractures after total knee arthroplasty. J Arthroplasty 22:62–66
Heesterbeek PJ, Haffner N, Wymenga AB, Stifter J, Ritschl P (2015) Patient-related factors influence stiffness of the soft tissue complex during intraoperative gap balancing in cruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 15:15. doi:10.1007/s00167-015-3694-5
Hohman DW Jr, Nodzo SR, Phillips M, Fitz W (2015) The implications of mechanical alignment on soft tissue balancing in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23:3632–3636
Ishida K, Shibanuma N, Matsumoto T, Sasaki H, Takayama K, Toda A, Kuroda R, Kurosaka M (2015) Factors affecting intraoperative kinematic patterns and flexion angles in navigated total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23:1741–1747
Kawamura H, Bourne RB (2001) Factors affecting range of flexion after total knee arthroplasty. J Orthop Sci 6:248–252
Kim J, Nelson CL, Lotke PA (2004) Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am 86-A:1479–1484
Kim SJ, MacDonald M, Hernandez J, Wixson RL (2005) Computer assisted navigation in total knee arthroplasty: improved coronal alignment. J Arthroplasty 20:123–131
Lam LO, Swift S, Shakespeare D (2003) Fixed flexion deformity and flexion after knee arthroplasty. What happens in the first 12 months after surgery and can a poor outcome be predicted? Knee 10:181–185
Lee HJ, Lee JS, Jung HJ, Song KS, Yang JJ, Park CW (2011) Comparison of joint line position changes after primary bilateral total knee arthroplasty performed using the navigation-assisted measured gap resection or gap balancing techniques. Knee Surg Sports Traumatol Arthrosc 19:2027–2032
Lustig S, Lavoie F, Selmi TA, Servien E, Neyret P (2008) Relationship between the surgical epicondylar axis and the articular surface of the distal femur: an anatomic study. Knee Surg Sports Traumatol Arthrosc 16:674–682
Matsumoto T, Tsumura N, Kubo S, Shiba R, Kurosaka M, Yoshiya S (2005) Influence of hip position on knee flexion angle in patients undergoing total knee arthroplasty. J Arthroplasty 20:669–673
Matsuzaki T, Matsumoto T, Kubo S, Muratsu H, Matsushita T, Kawakami Y, Ishida K, Oka S, Kuroda R, Kurosaka M (2014) Tibial internal rotation is affected by lateral laxity in cruciate-retaining total knee arthroplasty: an intraoperative kinematic study using a navigation system and offset-type tensor. Knee Surg Sports Traumatol Arthrosc 22:615–620
McPherson EJ, Cushner FD, Schiff CF, Friedman RJ (1994) Natural history of uncorrected flexion contractures following total knee arthroplasty. J Arthroplasty 9:499–502
Mihalko WM, Whiteside LA (2003) Bone resection and ligament treatment for flexion contracture in knee arthroplasty. Clin Orthop Relat Res 406:141–147
Okamoto S, Okazaki K, Mitsuyasu H, Matsuda S, Mizu-Uchi H, Hamai S, Tashiro Y, Iwamoto Y (2014) Extension gap needs more than 1-mm laxity after implantation to avoid post-operative flexion contracture in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22:3174–3180
Perry J, Antonelli D, Ford W (1975) Analysis of knee-joint forces during flexed-knee stance. J Bone Joint Surg Am 57:961–967
Rhee SJ, Seo CH, Suh JT (2013) Navigation-assisted total knee arthroplasty for patients with extra-articular deformity. Knee Surg Relat Res 25:194–201
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 Arthroplasty 22:1092–1096
Ritter MA, Stringer EA (1979) Predictive range of motion after total knee replacement. Clin Orthop Relat Res 143:115–119
Schurman DJ, Matityahu A, Goodman SB, Maloney W, Woolson S, Shi H, Bloch DA (1998) Prediction of postoperative knee flexion in Insall-Burstein II total knee arthroplasty. Clin Orthop Relat Res 353:175–184
Scuderi GR, Kochhar T (2007) Management of flexion contracture in total knee arthroplasty. J Arthroplasty 22:20–24
Smith CK, Chen JA, Howell SM, Hull ML (2010) An in vivo study of the effect of distal femoral resection on passive knee extension. J Arthroplasty 25:1137–1142
Su EP (2012) Fixed flexion deformity and total knee arthroplasty. J Bone Joint Surg Br 94:112–115
Takayama K, Matsumoto T, Kubo S, Muratsu H, Ishida K, Matsushita T, Kurosaka M, Kuroda R (2012) Influence of intra-operative joint gaps on post-operative flexion angle in posterior cruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 20:532–537
Tashiro Y, Uemura M, Matsuda S, Okazaki K, Kawahara S, Hashizume M, Iwamoto Y (2012) Articular cartilage of the posterior condyle can affect rotational alignment in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 20:1463–1469
Tew M, Forster IW (1987) Effect of knee replacement on flexion deformity. J Bone Joint Surg Br 69:395–399
Walton NP, Jahromi I, Dobson PJ, Angel KR, Lewis PL, Campbell DG (2005) Arthrofibrosis following total knee replacement; does therapeutic warfarin make a difference? Knee 12:103–106
Whiteside LA, Mihalko WM (2002) Surgical procedure for flexion contracture and recurvatum in total knee arthroplasty. Clin Orthop Relat Res 404:189–195
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Kim, S.H., Lim, JW., Jung, HJ. et al. Influence of soft tissue balancing and distal femoral resection on flexion contracture in navigated total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25, 3501–3507 (2017). https://doi.org/10.1007/s00167-016-4269-9
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DOI: https://doi.org/10.1007/s00167-016-4269-9