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Improved total knee arthroplasty pain outcome when joint gap targets are achieved throughout flexion

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Achieving a balanced knee is accepted as an important goal in total knee arthroplasty; however, the definition of ideal balance remains controversial. This study therefore endeavoured to determine: (1) whether medio-lateral gap balance in extension, midflexion, and flexion are associated with improved outcome scores at one-year post-operatively and (2) whether these relationships can be used to identify windows of optimal gap balance throughout flexion.

Methods

135 patients were enrolled in a multicenter, multi-surgeon, prospective investigation using a robot-assisted surgical platform and posterior cruciate ligament sacrificing gap balancing technique. Joint gaps were measured under a controlled tension of 70–90 N from 10°–90° flexion. Linear correlations between joint gaps and one-year KOOS outcomes were investigated. KOOS Pain and Activities of Daily Living sub-scores were used to define clinically relevant joint gap target thresholds in extension, midflexion, and flexion. Gap thresholds were then combined to investigate the synergistic effects of satisfying multiple targets.

Results

Significant linear correlations were found throughout extension, midflexion, and flexion. Joint gap thresholds of an equally balanced or tighter medial compartment in extension, medial laxity ± 1 mm compared to the final insert thickness in midflexion, and a medio-lateral imbalance of less than 1.5 mm in flexion generated subgroups that reported significantly improved KOOS pain scores at one year (median ∆ = 8.3, 5.6 and 2.8 points, respectively). Combining any two targets resulted in further improved outcomes, with the greatest improvement observed when all three targets were satisfied (median ∆ = 11.2, p = 0.002).

Conclusion

Gap thresholds identified in this study provide clinically relevant and achievable targets for optimising soft tissue balance in posterior cruciate ligament sacrificing gap balancing total knee arthroplasty. When all three balance windows were achieved, clinically meaningful pain improvement was observed.

Level of Evidence

Level II.

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Acknowledgements

The authors would like to acknowledge the critical data collection and study administration performed by: Jayne Crofut, Katie Mabee, Sharon Stewart, Cindy Murphy, Kathryn Darley and Alex Friedl, and the data processing and analysis performed by Anna Geraghty. We dedicate this work to the memory of Dr. Leonid Dabuzhsky, 1952 –2019. Dr Dabuzhsky was extremely passionate and actively involved in this project from the start. His contribution was immense, and his unwavering dedication to his patients’ care will continue to inspire us.

Funding

No external funding was provided for this study.

Author information

Authors and Affiliations

  1. Corin Ltd, Raynham, MA, USA

    Edgar A. Wakelin, Sami Shalhoub & Christopher Plaskos

  2. Gundersen Health System, Viroqua, WI, USA

    Jeffrey M. Lawrence

  3. Connecticut Joint Replacement Institute, Hartford, CT, USA

    John M. Keggi

  4. DeClaire LaMacchia Orthopaedic Institute, Rochester Hills, MI, USA

    Jeffrey H. DeClaire

  5. Flagstaff Bone and Joint, Flagstaff, AZ, USA

    Amber L. Randall

  6. Oklahoma Sports and Orthopedics Institute, Edmond, OK, USA

    Corey E. Ponder

  7. NYU Langone Long Island Hospital, Mineola, NY, USA

    Jan A. Koenig

  8. Hospital for Special Surgery, New York, NY, USA

    Stephen Lyman

  9. Kyushu University School of Medicine, Fukuoka, Japan

    Stephen Lyman

Authors
  1. Edgar A. Wakelin
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  2. Sami Shalhoub
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Contributions

EW designed study, performed statistical analysis, interpretation of results and drafted manuscript. SS designed study, assisted in interpretation of results and edited manuscript, JL, JK, JD, AR, CEP, JAK assisted in study design, performed clinical data capture and clinical interpretation of results, and reviewed manuscript, SL developed and reviewed statistical analysis methodology and assisted in drafting and editing the manuscript, CP conceived and designed study, assisted in interpretation of results and drafting and editing the manuscript.

Corresponding author

Correspondence to Edgar A. Wakelin.

Ethics declarations

Conflict of interest

EW, SS: paid employees of Corin. CP: paid employee, stock options in Corin. JL: paid consultant and speaker to Corin and Stryker. JK: paid consultant, speaker and research support from Corin. JD: paid consultant, speaker and research support Corin, Smith and Nephew and Zimmer Biomet. Royalties from Zimmer Biomet AR: paid consultant, speaker and research support to Corin. CEP: paid consultant, speaker, research support and Royalties from Corin. Paid consultant to Styker and Med 7. Share holder of Joint Development LLC JAK: paid consultant, research support, paid speaker and royalties from Corin SL: paid consultant from Corin and Cell Source (Tokyo).

Ethical approval

Ethical approval was obtained for this study through New England Independent Review Board (No: 120170260).

Informed consent

Informed consent was obtained for all patients within this study before participating in study protocol.

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Wakelin, E.A., Shalhoub, S., Lawrence, J.M. et al. Improved total knee arthroplasty pain outcome when joint gap targets are achieved throughout flexion. Knee Surg Sports Traumatol Arthrosc 30, 939–947 (2022). https://doi.org/10.1007/s00167-021-06482-2

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  • DOI: https://doi.org/10.1007/s00167-021-06482-2

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