Abstract
Purpose
The purpose of this study was to evaluate the differences in flexion space balance when the femoral component is implanted parallel to the surgical transepicondylar axis (TEA) or with 3° of external rotation from the posterior condylar line (PoCoLi). It was hypothesized that implantation parallel to the TEA will produce a more reliably balanced flexion space.
Methods
Forty-eight consecutive patients with a varus deformity were prospectively randomized to undergo total knee arthroplasty with a femoral component implanted parallel the TEA, or with 3° of external rotation from the PoCoLi. The posterior condylar angle (PCA) was measured. Intraoperative load measurements were taken at 10°, 45°, and 90° of flexion.
Results
The PCA was similar between groups (TEA group: 4.2° ± 1.5° and PoCoLi group: 4.0° ± 1.3°; n.s.). The mean difference in load values between the medial and lateral compartments was significantly lower in the TEA group than in the PoCoLi group at the 45 (0 ± 8 vs. 9 ± 13 lbs; respectively, p = 0.008) and 90° flexion angles (1 ± 9 vs. 10 ± 15 lbs; respectively, p = 0.01). The PoCoLi group had a linear increase in the difference of load values between the medial and lateral compartments with increasing magnitude of the posterior condylar angle (45°, p = 0.0013; 90°, p = 0.0006), but this was not observed in the TEA group.
Conclusion
Femoral component implantation parallel to the TEA resulted in a more balanced flexion gap as compared to implantation at 3° of external rotation from the PoCoLi. The intraoperative use of the TEA rather than the PoCoLi to set femoral component rotation may provide a more balanced flexion space and decrease the need for extensive soft tissue releases.
Level of evidence
II.
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References
Akagi M, Matsusue Y, Mata T, Asada Y, Horiguchi M, Iida H et al (1999) Effect of rotational alignment on patellar tracking in total knee arthroplasty. Clin Orthop Relat Res 366:155–163
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 28:1528–1532
Dennis DA, Komistek RD, Kim RH, Sharma A (2010) Gap balancing versus measured resection technique for total knee arthroplasty. Clin Orthop Relat Res 468:102–107
Franceschini V, Nodzo SR, Gonzalez Della Valle A (2016) Femoral component rotation in total knee arthroplasty: a comparison between transepicondylar axis and posterior condylar line referencing. J Arthroplasty 31:2917–2921
Goudarz Mehdikhani K, Morales Moreno B, Reid JJ, de Paz Nieves A, Lee YY, Gonzalez Della Valle A (2016) An algorithmic, pie-crusting medial soft tissue release reduces the need for constrained inserts patients with severe varus deformity undergoing total knee arthroplasty. J Arthroplasty 31:1465–1469
Griffin FM, Insall JN, S cuderi GR (2000) Accuracy of soft tissue balancing in total knee arthroplasty. J Arthroplasty 15:970–973
Griffin FM, Insall JN, Scuderi GR (1998) The posterior condylar angle in osteoarthritic knees. J Arthroplasty 13:812–815
Gustke KA, Golladay GJ, Roche MW, Elson LC, Anderson CR (2014) A new method for defining balance: promising short-term clinical outcomes of sensor-guided TKA. J Arthroplasty 29:955–960
Gustke KA, Golladay GJ, Roche MW, Jerry GJ, Elson LC, Anderson CR (2014) Increased satisfaction after total knee replacement using sensor-guided technology. Bone Jt J 96-B:1333–1338
Incavo SJ, Wild JJ, Coughlin KM, Beynnon BD (2007) Early revision for component malrotation in total knee arthroplasty. Clin Orthop Relat Res 458:131–136
Jenny JY, Boeri C (2004) Low reproducibility of the intra-operative measurement of the transepicondylar axis during total knee replacement. Acta Orthop Scand 75:74–77
Jerosch J, Peuker E, Philipps B, Filler T (2002) Interindividual reproducibility in perioperative rotational alignment of femoral components in knee prosthetic surgery using the transepicondylar axis. Knee Surg Sports Traumatol Arthrosc 10:194–197
Katz MA, Beck TD, Silber JS, Seldes RM, Lotke PA (2001) Determining femoral rotational alignment in total knee arthroplasty: reliability of techniques. J Arthroplasty 16:301–305
Kinzel V, Ledger M, Shakespeare D (2005) Can the epicondylar axis be defined accurately in total knee arthroplasty? Knee 12:293–296
Laskin RS (1995) Flexion space configuration in total knee arthroplasty. J Arthroplasty 10:657–660
Nakamura S, Ito H, Yoshitomi H, Kuriyama S, Komistek RD, Matsuda S (2015) Analysis of the flexion gap on in vivo knee kinematics using fluoroscopy. J Arthroplasty 30:1237–1242
Nodzo SR, Franceschini V, Gonzalez Della Valle A (2016) Intraoperative load-sensing variability during cemented, posterior-stabilized total knee arthroplasty. J Arthroplasty 32:66–70
Olcott CW, Scott RD (2000) A comparison of 4 intraoperative methods to determine femoral component rotation during total knee arthroplasty. J Arthroplasty 15:22–26
Pagnano MW, Hanssen AD (2001) Varus tibial joint line obliquity: a potential cause of femoral component malrotation. Clin Orthop Relat Res 392:68–74
Patel AR, Talati RK, Yaffe MA, McCoy BW, Stulberg SD (2014) Femoral component rotation in total knee arthroplasty: an MRI-based evaluation of our options. J Arthroplasty 29:1666–1670
Poilvache PL, Insall JN, Scuderi GR, Font-Rodriguez DE (1996) Rotational landmarks and sizing of the distal femur in total knee arthroplasty. Clin Orthop Relat Res 331:35–46
Romero J, Stahelin T, Binkert C, Pfirrmann C, Hodler J, Kessler O (2007) The clinical consequences of flexion gap asymmetry in total knee arthroplasty. J Arthroplasty 22:235–240
Schnaser E, Lee YY, Boettner F, Gonzalez Della Valle A (2015) The position of the patella and extensor mechanism affects intraoperative compartmental loads during total knee arthroplasty: a pilot study using intraoperative sensing to guide soft tissue balance. J Arthroplasty 30:1348–1353
Scott RD (2013) Femoral and tibial component rotation in total knee arthroplasty: methods and consequences. Bone Jt J 95-B:140–143
Scuderi GR, Komistek RD, Dennis DA, Insall JN (2003) The impact of femoral component rotational alignment on condylar lift-off. Clin Orthop Relat Res 410:148–154
Takahashi T, Wada Y, Yamamoto H (1997) Soft-tissue balancing with pressure distribution during total knee arthroplasty. J Bone Jt Surg Br 79:235–239
Wasielewski RC, Galante JO, Leighty RM, Natarajan RN, Rosenberg AG (1994) Wear patterns on retrieved polyethylene tibial inserts and their relationship to technical considerations during total knee arthroplasty. Clin Orthop Relat Res 299:31–43
Whiteside LA, Arima J (1995) The anteroposterior axis for femoral rotational alignment in valgus total knee arthroplasty. Clin Orthop Relat Res 321:168–172
Acknowledgements
This study was partially funded by the generous donation of Mr. Glenn Bergenfield and the Sidney Milton and Leoma Simon Foundation (Florida).
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One author is a paid consultant for Orthosensor outside the work of this manuscript. No funding or company participation was received for this work.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Informed consent was obtained from all individual participants included in the study.
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Nodzo, S.R., Franceschini, V., Cruz, D.S. et al. The flexion space is more reliably balanced when using the transepicondylar axis as compared to the posterior condylar line. Knee Surg Sports Traumatol Arthrosc 26, 3265–3271 (2018). https://doi.org/10.1007/s00167-018-4855-0
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DOI: https://doi.org/10.1007/s00167-018-4855-0