Skip to main content

Effect of mediolateral gap difference on postoperative outcomes in navigation-assisted total knee arthroplasty using an ultracongruent insert and the medial stabilising technique

Knee Surgery, Sports Traumatology, Arthroscopy (2023)Cite this article

Abstract

Purpose

This study was aimed to compare the clinical, functional, and radiographic outcomes between symmetric and asymmetric extension and mediolateral gap balance after navigation-assisted (NA) total knee arthroplasty (TKA) using ultracongruent (UC) insets and the medial stabilising technique (MST).

Methods

In all, 363 knees of 275 patients who underwent mechanical alignment-target NA TKA with MST between January 2015 and December 2017 were analysed. Patients were divided into balanced (extension mediolateral gap difference ≤ 2 mm) and tight medial (difference ≥ 3 mm) groups. Pre- and postoperative clinical, functional (range of motion, Western Ontario and McMaster University Osteoarthritis [WOMAC] index, Knee Society Knee Score [KSKS], and Knee Society Function Score [KSFS]) and radiographic (hip–knee–ankle [HKA] angle, femoral condylar offset, extension angle [a minus indicates hyperextension], and joint line distance) outcomes were compared between the groups. Student’s t- or Chi-squared test was used to compare the outcomes.

Results

Among the 363 knees analysed, 279 (77%) were assigned to the balanced group and 84 (23%) to the tight medial group. The preoperative HKA angle was significantly greater in the tight medial group than in the balanced group (9.7° ± 4.1° vs 14.3° ± 4.7°, P < 0.001). The postoperative WOMAC index, KSKS, and KSFS were similar between the groups. The change in the joint line distance was not significantly different (1.5 ± 3.7 vs 2.0 ± 3.3; n.s).

Conclusion

The clinical, functional, and radiographic outcomes, including joint line distance, were comparable between the tight medial and balanced group after mechanical alignment-targeted UC TKA with MST.

Level of evidence

Level III, retrospective comparative study.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Data availability statement

The data that support the finding of this study are available from the corresponding author, upon reasonable request.

References

  1. An VVG, Twiggs J, Leie M, Fritsch BA (2019) Kinematic alignment is bone and soft tissue preserving compared to mechanical alignment in total knee arthroplasty. Knee 26:466–476

    Article  Google Scholar 

  2. Azukizawa M, Kuriyama S, Nakamura S, Nishitani K, Lyman S, Morita Y et al (2018) Intraoperative medial joint laxity in flexion decreases patient satisfaction after total knee arthroplasty. Arch Orthop Trauma Surg 138:1143–1150

    Article  Google Scholar 

  3. Becker R, Baker K, Hommel H, Bernard M, Kopf S (2019) No correlation between rotation of femoral components in the transverse plane and clinical outcome after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 27:1456–1462

    Article  Google Scholar 

  4. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15:1833–1840

    CAS  Google Scholar 

  5. Choi BS, Kim JM, Han HS (2022) Decision-making factors and their thresholds for total knee arthroplasty in lateral tibiofemoral osteoarthritis patients: a retrospective cohort study. Knee Surg Relat Res 34:41

    Article  Google Scholar 

  6. Clement ND, Bardgett M, Weir D, Holland J, Gerrand C, Deehan DJ (2018) What is the minimum clinically important difference for the WOMAC index after TKA? Clin Orthop Relat Res 476:2005–2014

    Article  Google Scholar 

  7. Graichen H, Lekkreusuwan K, Eller K, Grau T, Hirschmann MT, Scior W (2022) A single type of varus knee does not exist: morphotyping and gap analysis in varus OA. Knee Surg Sports Traumatol Arthrosc 30:2600–2608

    Article  Google Scholar 

  8. Herschmiller T, Grosso MJ, Cunn GJ, Murtaugh TS, Gardner TR, Geller JA (2018) Step-wise medial collateral ligament needle puncturing in extension leads to a safe and predictable reduction in medial compartment pressure during TKA. Knee Surg Sports Traumatol Arthrosc 26:1759–1766

    Article  Google Scholar 

  9. Hess S, Moser LB, Robertson EL, Behrend H, Amsler F, Iordache E et al (2022) Osteoarthritic and non-osteoarthritic patients show comparable coronal knee joint line orientations in a cross-sectional study based on 3D reconstructed CT images. Knee Surg Sports Traumatol Arthrosc 30:407–418

    Article  Google Scholar 

  10. Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the knee society clinical rating system. Clin Orthop Relat Res 248:13–14

    Article  Google Scholar 

  11. Ishibashi K, Sasaki E, Sasaki S, Kimura Y, Yamamoto Y, Ishibashi Y (2020) Medial stabilizing technique preserves anatomical joint line and increases range of motion compared with the gap-balancing technique in navigated total knee arthroplasty. Knee 27:558–564

    Article  Google Scholar 

  12. Kim CW, Lee CR, Gwak HC, Kim JH, Kwon YU, Kim DY (2020) The Effects of surgical technique in total knee arthroplasty for Varus osteoarthritic knee on the rotational alignment of femoral component: gap balancing technique versus measured resection technique. J Knee Surg 33:144–151

    Article  Google Scholar 

  13. Kim JS, Cho CH, Lee MC, Han HS (2021) Risk factors of de novo hyperextension developed after posterior cruciate ligament substituting total knee arthroplasty: a matched case-control study. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-021-06618-4

    Article  Google Scholar 

  14. Lee HJ, Kim SH, Park YB (2020) Selective medial release using multiple needle puncturing with a spacer block in situ for correcting severe varus deformity during total knee arthroplasty. Arch Orthop Trauma Surg 140:1523–1531

    Article  Google Scholar 

  15. Lee KJ, Moon JY, Song EK, Lim HA, Seon JK (2012) Minimum two-year results of revision total knee arthroplasty following infectious or non-infectious causes. Knee Surg Relat Res 24:227–234

    Article  Google Scholar 

  16. Lee SS, Kim JH, Heo JW, Moon YW (2019) Gradual change in knee extension following total knee arthroplasty using ultracongruent inserts. Knee 26:905–913

    Article  Google Scholar 

  17. Lee SY, Yang JH, Lee YI, Yoon JR (2016) A novel medial soft tissue release method for Varus deformity during total knee arthroplasty: femoral origin release of the medial collateral ligament. Knee Surg Relat Res 28:153–160

    Article  Google Scholar 

  18. Liu DW, Martinez Martos S, Dai Y, Beller EM (2022) The femoral intercondylar notch is an accurate landmark for the resection depth of the distal femur in total knee arthroplasty. Knee Surg Relat Res 34:32

    Article  CAS  Google Scholar 

  19. Migliorini F, Eschweiler J, Mansy YE, Quack V, Schenker H, Tingart M et al (2020) Gap balancing versus measured resection for primary total knee arthroplasty: a meta-analysis study. Arch Orthop Trauma Surg 140:1245–1253

    Article  Google Scholar 

  20. Miralles-Munoz FA, Gonzalez-Parreno S, Martinez-Mendez D, Gonzalez-Navarro B, Ruiz-Lozano M, Lizaur-Utrilla A et al (2022) A validated outcome categorization of the knee society score for total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 30:1266–1272

    Article  Google Scholar 

  21. Moorthy V, Lai MC, Liow MHL, Chen JY, Pang HN, Chia SL et al (2021) Similar postoperative outcomes after total knee arthroplasty with measured resection and gap balancing techniques using a contemporary knee system: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 29:3178–3185

    Article  Google Scholar 

  22. Nagai K, Muratsu H, Kanda Y, Tsubosaka M, Kamenaga T, Miya H et al (2018) Intraoperative soft tissue balance using novel medial preserving gap technique in posterior-stabilized total knee arthroplasty: comparison to measured resection technique. Knee Surg Sports Traumatol Arthrosc 26:3474–3481

    Article  Google Scholar 

  23. Okamoto S, Okazaki K, Mitsuyasu H, Matsuda S, Mizu-Uchi H, Hamai S et al (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

    Article  Google Scholar 

  24. Okamoto Y, Nakajima M, Jotoku T, Otsuki S, Neo M (2016) Capsular release around the intercondylar notch increases the extension gap in posterior-stabilized rotating-platform total knee arthroplasty. Knee 23:730–735

    Article  Google Scholar 

  25. Okazaki K, Miura H, Matsuda S, Takeuchi N, Mawatari T, Hashizume M et al (2006) Asymmetry of mediolateral laxity of the normal knee. J Orthop Sci 11:264–266

    Article  Google Scholar 

  26. Pawar P, Naik L, Sahu D, Bagaria V (2021) Comparative study of pinless navigation system versus conventional instrumentation in total knee arthroplasty. Clin Orthop Surg 13:358–365

    Article  Google Scholar 

  27. Piovan G, Farinelli L, Screpis D, Iacono V, Povegliano L, Bonomo M et al (2022) Distal femoral osteotomy versus lateral unicompartmental arthroplasty for isolated lateral tibiofemoral osteoarthritis with intra-articular and extra-articular deformity: a propensity score-matched analysis. Knee Surg Relat Res 34:34

    Article  Google Scholar 

  28. Ramappa M (2015) Midflexion instability in primary total knee replacement: a review. SICOT J 1:24

    Article  Google Scholar 

  29. Rossi R, Cottino U, Bruzzone M, Dettoni F, Bonasia DE, Rosso F (2019) Total knee arthroplasty in the varus knee: tips and tricks. Int Orthop 43:151–158

    Article  Google Scholar 

  30. Schelker BL, Moret CS, von Eisenhart-Rothe R, Graichen H, Arnold MP, Leclercq V et al (2022) The impact of different alignment strategies on bone cuts for neutral knee phenotypes in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07209-7

    Article  Google Scholar 

  31. Sekiya H, Takatoku K, Takada H, Sasanuma H, Sugimoto N (2009) Postoperative lateral ligamentous laxity diminishes with time after TKA in the varus knee. Clin Orthop Relat Res 467:1582–1586

    Article  Google Scholar 

  32. Shon OJ, Kim GB (2022) Does the degree of intraoperatively identified cartilage loss affect the outcomes of primary total knee arthroplasty without patella resurfacing? A prospective comparative cohort study. Knee Surg Relat Res 34:36

    Article  Google Scholar 

  33. Sim JA, Na YG, Go JY, Lee BK (2018) Clinical and radiologic evaluation of medial epicondylar osteotomy for varus total knee arthroplasty. Knee 25:177–184

    Article  Google Scholar 

  34. Song EK, Agrawal PR, Kim SK, Seo HY, Seon JK (2016) A randomized controlled clinical and radiological trial about outcomes of navigation-assisted TKA compared to conventional TKA: long-term follow-up. Knee Surg Sports Traumatol Arthrosc 24:3381–3386

    Article  CAS  Google Scholar 

  35. Toyooka S, Masuda H, Nishihara N, Miyamoto W, Kobayashi T, Kawano H et al (2022) Assessing the role of minimal medial tissue release during navigation-assisted Varus total knee arthroplasty based on the degree of preoperative Varus deformity. J Knee Surg 35:1236–1241

    Article  Google Scholar 

  36. Tsubosaka M, Muratsu H, Nakano N, Kamenaga T, Kuroda Y, Inokuchi T et al (2021) Knee stability following posterior-stabilized total knee arthroplasty: comparison of medial preserving gap technique and measured resection technique. J Knee Surg. https://doi.org/10.1055/s-0041-1729968

    Article  Google Scholar 

  37. Tsukeoka T, Tsuneizumi Y (2019) Residual medial tightness in extension is corrected spontaneously after total knee arthroplasty in varus knees. Knee Surg Sports Traumatol Arthrosc 27:692–697

    Article  Google Scholar 

  38. Tsukiyama H, Kuriyama S, Kobayashi M, Nakamura S, Furu M, Ito H et al (2017) Medial rather than lateral knee instability correlates with inferior patient satisfaction and knee function after total knee arthroplasty. Knee 24:1478–1484

    Article  Google Scholar 

  39. Ueyama H, Kanemoto N, Minoda Y, Nakagawa S, Taniguchi Y, Nakamura H (2022) Association of a wider medial gap (medial laxity) in flexion with self-reported knee instability after medial-pivot total knee arthroplasty. J Bone Joint Surg Am 104:910–918

    Article  Google Scholar 

  40. Zambianchi F, Bazzan G, Marcovigi A, Pavesi M, Illuminati A, Ensini A et al (2021) Joint line is restored in robotic-arm-assisted total knee arthroplasty performed with a tibia-based functional alignment. Arch Orthop Trauma Surg 141:2175–2184

    Article  Google Scholar 

  41. Zambianchi F, Giorgini A, Ensini A, Lombari V, Daffara V, Catani F (2021) Navigated, soft tissue-guided total knee arthroplasty restores the distal femoral joint line orientation in a modified mechanically aligned technique. Knee Surg Sports Traumatol Arthrosc 29:966–974

    Article  Google Scholar 

Download references

Funding

There is no funding source.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyangsi, Gyeonggido, Korea

    Sung-Sahn Lee

  2. Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon Street, Gangnam-Gu, Seoul, 06351, Korea

    Jeounghun Lee & Young-Wan Moon

  3. Arthroplasty Division, Taif University, Taif, Saudi Arabia

    Hail Alharthi

Authors
  1. Sung-Sahn Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jeounghun Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hail Alharthi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Young-Wan Moon
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Young-Wan Moon.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

The protocol used to evaluate radiographic findings and intraoperative navigation data was approved by our institution’s investigational review board (SMC2022-11-045).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lee, SS., Lee, J., Alharthi, H. et al. Effect of mediolateral gap difference on postoperative outcomes in navigation-assisted total knee arthroplasty using an ultracongruent insert and the medial stabilising technique. Knee Surg Sports Traumatol Arthrosc (2023). https://doi.org/10.1007/s00167-023-07324-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00167-023-07324-z

Keywords

  • Total knee arthroplasty
  • Medial stabilising technique
  • Navigation-assisted
  • Clinical outcomes
  • Functional outcomes
  • Alignment
  • Gap balance