Archives of Orthopaedic and Trauma Surgery

, Volume 138, Issue 8, pp 1143–1150 | Cite as

Intraoperative medial joint laxity in flexion decreases patient satisfaction after total knee arthroplasty

  • Masayuki Azukizawa
  • Shinichi KuriyamaEmail author
  • Shinichiro Nakamura
  • Kohei Nishitani
  • Stephen Lyman
  • Yugo Morita
  • Moritoshi Furu
  • Hiromu Ito
  • Shuichi Matsuda
Knee Arthroplasty



The relationship between postoperative tibiofemoral ligament balance and patient satisfaction in total knee arthroplasty (TKA) has been explored previously. However, the optimal intraoperative medial–lateral ligament balance during knee flexion in terms of postoperative patient satisfaction remains unknown. We evaluated the effect of intraoperative flexion instability on patient satisfaction after TKA.

Materials and methods

This study consisted of 46 knees with varus osteoarthritis undergoing TKA. Medial–lateral component gaps at 0° knee extension and 90° flexion were measured intraoperatively using a knee balancer. Differences in postoperative patient outcomes at 3 weeks and 1 year were compared between medially tight knees in 90° flexion with a medial component gap of < 4 mm and medially loose knees in 90° flexion with a gap of ≥ 4 mm. Outcomes were measured using the 2011 Knee Society Scoring System (2011 KS).


The median total 2011 KS score at 1 year postoperatively in the medially loose knees [median 97; interquartile range (IQR) 75–117] was significantly lower than that in the medially tight knees (median 128; IQR 104–139, P < 0.01), while preoperative and 3-week postoperative scores were similar. In addition, medial flexion gaps were not significantly associated with total 2011 KS scores before surgery or at 3 weeks postoperatively. However, at 1 year after surgery, medial component flexion gaps were negatively associated with the total 2011 KS score (R = − 0.42; P < 0.01) and the 2011 KS satisfaction subscale score (R = − 0.36; P = 0.01).


Excessive intraoperative medial joint laxity of ≥ 4 mm at 90° flexion progressively decreased patient satisfaction for 1 year. Since intraoperative medial laxity in flexion is likely to interfere with functional recovery after TKA, medial stabilization during TKA is important throughout knee flexion.

Level of evidence

Therapeutic study, Level III.


Total knee arthroplasty Patient satisfaction Intraoperative medial joint laxity Joint gap Knee flexion 



No funds were received for this study.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interests.

Ethical approval

An institutional review board approved this study.

Informed consent

Informed consent to participate in the study was obtained for all patients prior to the surgical procedure.


  1. 1.
    Akagi M, Nakamura T, Matsusue Y, Ueo T, Nishijyo K, Ohnishi E (2000) The bisurface total knee replacement: a unique design for flexion. Four-to-nine-year follow-up study. J Bone Jt Surg Am 82:1626–1633CrossRefGoogle Scholar
  2. 2.
    Anderson JG, Wixson RL, Tsai D, Stulberg SD, Chang RW (1996) Functional outcome and patient satisfaction in total knee patients over the age of 75. J Arthroplast 11:831–840CrossRefGoogle Scholar
  3. 3.
    Aunan E, Kibsgård TJ, Diep LM, Röhrl SM (2015) Intraoperative ligament laxity influences functional outcome 1 year after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23:1684–1692CrossRefPubMedGoogle Scholar
  4. 4.
    Bell SW, Young P, Drury C, Smith J, Anthony I, Jones B, Blyth M, McLean A (2014) Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee 21:272–277CrossRefPubMedGoogle Scholar
  5. 5.
    Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS (1993) Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res 286:40–47Google Scholar
  6. 6.
    Bhattee G, Moonot P, Govindaswamy R, Pope A, Fiddian N, Harvey A (2014) Does malrotation of components correlate with patient dissatisfaction following secondary patellar resurfacing? Knee 21:247–251CrossRefPubMedGoogle Scholar
  7. 7.
    Ettinger M, Calliess T, Howell SM (2017) Does a positioning rod or a patient-specific guide result in more natural femoral flexion in the concept of kinematically aligned total knee arthroplasty? Arch Orthop Trauma Surg 137:105–110CrossRefPubMedGoogle Scholar
  8. 8.
    Ewald FC (1989) The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12Google Scholar
  9. 9.
    Fleeton G, Harmer AR, Nairn L, Crosbie J, March L, Crawford R, van der Esch M, Fransen M (2016) Self-reported knee instability before and after total knee replacement surgery. Arthritis Care Res 68:463–471CrossRefGoogle Scholar
  10. 10.
    Goh GS, Liow MH, Bin Abd Razak HR, Tay DK, Lo NN, Yeo SJ (2017) Patient-reported outcomes, quality of life, and satisfaction rates in young patients aged 50 years or younger after total knee arthroplasty. J Arthroplast 32:419–425CrossRefGoogle Scholar
  11. 11.
    Ghosh KM, Merican AM, Iranpour F, Deehan DJ, Amis AA (2012) Length-change patterns of the collateral ligaments after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 20:1349–1356CrossRefPubMedGoogle Scholar
  12. 12.
    Hamamoto Y, Ito H, Furu M, Ishikawa M, Azukizawa M, Kuriyama S, Nakamura S, Matsuda S (2015) Cross-cultural adaptation and validation of the Japanese version of the new Knee Society Scoring System for osteoarthritic knee with total knee arthroplasty. J Orthop Sci 20:849–853CrossRefPubMedGoogle Scholar
  13. 13.
    Heck DA, Robinson RL, Partridge CM, Lubitz RM, Freund DA (1998) Patient outcomes after knee replacement. Clin Orthop Relat Res 356:93–110CrossRefGoogle Scholar
  14. 14.
    Kawahara S, Okazaki K, Matsuda S, Mitsuyasu H, Nakahara H, Okamoto S, Iwamoto Y (2014) Medial sixth of the patellar tendon at the tibial attachment is useful for the anterior reference in rotational alignment of the tibial component. Knee Surg Sports Traumatol Arthrosc 22:1070–1075CrossRefPubMedGoogle Scholar
  15. 15.
    Krackow KA, Mihalko WM (1999) The effect of medial release on flexion and extension gaps in cadaveric knees: implications for soft-tissue balancing in total knee arthroplasty. Am J Knee Surg 12:222–228PubMedGoogle Scholar
  16. 16.
    Kuriyama S, Ishikawa M, Furu M, Ito H, Matsuda S (2014) Malrotated tibial component increases medial collateral ligament tension in total knee arthroplasty. J Orthop Res 32:1658–1666CrossRefPubMedGoogle Scholar
  17. 17.
    Kuster MS, Bitschnau B, Votruba T (2004) Influence of collateral ligament laxity on patient satisfaction after total knee arthroplasty: a comparative bilateral study. Arch Orthop Trauma Surg 124:415–417CrossRefPubMedGoogle Scholar
  18. 18.
    Lützner J, Krummenauer F, Günther KP, Kirschner S (2010) Rotational alignment of the tibial component in total knee arthroplasty is better at the medial third of tibial tuberosity than at the medial border. BMC Musculoskelet Disord 11:57CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Markolf KL, Mensch JS, Amstutz HC (1976) Stiffness and laxity of the knee: the contributions of the supporting structures. A quantitative in vitro study. J Bone Jt Surg Am 58:583–594CrossRefGoogle Scholar
  20. 20.
    Matsuda S, Kawahara S, Okazaki K, Tashiro Y, Iwamoto Y (2013) Postoperative alignment and ROM affect patient satisfaction after TKA. Clin Orthop Relat Res 471:127–133CrossRefPubMedGoogle Scholar
  21. 21.
    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 22:615–620CrossRefPubMedGoogle Scholar
  22. 22.
    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 Arthroplast 30:1237–1242CrossRefGoogle Scholar
  23. 23.
    Nakamura S, Kobayashi M, Ito H, Nakamura K, Ueo T, Nakamura T (2010) The Bi-Surface total knee arthroplasty: minimum 10-year follow-up study. Knee 17:274–278CrossRefPubMedGoogle Scholar
  24. 24.
    Nakano N, Matsumoto T, Muratsu H, Takayama K, Kuroda R, Kurosaka M (2016) Postoperative knee flexion angle is affected by lateral laxity in cruciate-retaining total knee arthroplasty. J Arthroplast 31:401–405CrossRefGoogle Scholar
  25. 25.
    Oh CS, Song EK, Seon JK, Ahn YS (2015) The effect of flexion balance on functional outcomes in cruciate-retaining total knee arthroplasty. Arch Orthop Trauma Surg 135:401–406CrossRefPubMedGoogle Scholar
  26. 26.
    Okamoto S, Okazaki K, Mitsuyasu H, Matsuda S, Iwamoto Y (2013) Lateral soft tissue laxity increases but medial laxity does not contract with varus deformity in total knee arthroplasty knee. Clin Orthop Relat Res 471:1334–1342CrossRefPubMedGoogle Scholar
  27. 27.
    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 22:3174–3180CrossRefPubMedGoogle Scholar
  28. 28.
    Okazaki K, Miura H, Matsuda S, Takeuchi N, Mawatari T, Hashizume M, Iwamoto Y (2006) Asymmetry of mediolateral laxity of the normal knee. J Orthop Sci 11:264–266CrossRefPubMedGoogle Scholar
  29. 29.
    Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN (2012) The new knee society knee scoring system. Clin Orthop Relat Res 470:3–19CrossRefPubMedGoogle Scholar
  30. 30.
    Seah RB, Yeo SJ, Chin PL, Yew AKS, Chong HC, Lo NN (2014) Evaluation of medial-lateral stability and functional outcome following total knee arthroplasty: results of a single hospital joint registry. J Arthroplast 29:2276–2279CrossRefGoogle Scholar
  31. 31.
    Tokuhara Y, Kadoya Y, Nakagawa S, Kobayashi A, Takaoka K (2004) The flexion gap in normal knees. An MRI study. J Bone Jt Surg Br 86:1133–1136CrossRefGoogle Scholar
  32. 32.
    Tsukeoka T, Tsuneizumi Y (2016) Varus and valgus stress tests after total knee arthroplasty with and without anesthesia. Arch Orthop Trauma Surg 136:407–411CrossRefPubMedGoogle Scholar
  33. 33.
    Tsukiyama H, Kuriyama S, Kobayashi M, Nakamura S, Furu M, Ito H, Matsuda S (2017) Medial rather than lateral knee instability correlates with inferior patient satisfaction and knee function after total knee arthroplasty. Knee 24:1478–1484CrossRefPubMedGoogle Scholar
  34. 34.
    Yamakado K, Kitaoka K, Yamada H, Hashiba K, Nakamura R, Tomita K (2003) Influence of stability on range of motion after cruciate-retaining TKA. Arch Orthop Trauma Surg 123:1–4CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
  2. 2.Healthcare Research InstituteHospital for Special SurgeryNew YorkUSA
  3. 3.Department of Orthopaedic SurgeryFuru ClinicKogaJapan

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