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Balancing the flexion gap first in total knee arthroplasty leads to better preservation of posterior condylar offset resulting in better knee flexion

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose of this study is to determine whether the flexion first balancing technique, developed in an attempt to solve the dissatisfaction due to instability in total knee arthroplasties, leads to better restoration of joint line height and medial posterior condylar offset. This might result in better knee flexion, compared to the classic extension first gap balancing technique. The secondary objective is to show non-inferiority of the flexion first balancing technique in terms of clinical outcomes as measured by the Patient Reported Outcome Measurements.

Methods

A cohort of 40 patients (46 knee replacements) operated using the flexion first balancing technique was retrospectively analyzed and compared with a cohort of 51 patients (52 knee replacements) operated using the classic gap balancing technique. Radiographic analysis of the coronal alignment, joint line height and posterior condylar offset was performed. Clinical and functional outcome data were analyzed pre- and postoperatively and compared between both groups. The two sample t test, Mann–Whitney U test, Chi-square test and a linear mixed model were used for performing statistical analyses, after normality analyses were executed.

Results

Radiologic evaluation showed a decrease in posterior condylar offset using the classic gap balancing technique (p = 0.040) versus no change using the flexion first balancing technique (p = n.s.). No statistically significant differences were noted for joint line height and coronal alignment. Using the flexion first balancer technique leads to a greater postoperative range of motion with deeper flexion (p = 0.002) and a better Knee injury and Osteoarthritis Outcome Score (KOOS) (p = 0.025).

Conclusion

The Flexion First Balancing technique is a valid and safe technique for TKA, resulting in better preservation of PCO with consequently greater postoperative flexion and better KOOS scores.

Level of evidence

III.

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Abbreviations

TKA:

Total knee arthroplasty

ROM:

Range of motion

PCO:

Posterior condylar offset

MCL:

Medial collateral ligament

FFB:

Flexion First Balancing

PROMs:

Patient Reported Outcome Measurements

GAP:

Classic extension first gap balancing

VAS:

Visual Analogue Scale

OKS:

Oxford Knee score

KOOS-PS:

Knee injury and Osteoarthritis Outcome Score-Physical Function Short Form

EQ-5D:

EuroQol-5D

JLH:

Joint line height

(c)ATJL:

(Corrected) adductor tubercle joint line distance

(c)PCO:

(Corrected) posterior condylar offset

PCL:

Posterior cruciate ligament

n.s.:

Not significant

HKA:

Hip-knee-ankle

CWF:

Coronal femoral width

LFW:

Lateral femoral width

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Acknowledgements

None.

Funding

Belgian Society of Orthopedics & Traumatology (BVOT) research grant.

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Authors and Affiliations

  1. Orthopedic Surgery, University of Ghent, Corneel Heyymanslaan 10, 9000, Ghent, Oost-Vlaanderen, Belgium

    An-Sofie Van de Kelft

  2. Orthopedic Department, AZ Nikolaas, Sint-Niklaas, Oost-Vlaanderen, Belgium

    Kris De Mulder, Jo De Schepper & Bart Vundelinckx

  3. Orthopedic Department, UZGent, Ghent, Oost-Vlaanderen, Belgium

    Jan Victor

Authors
  1. An-Sofie Van de Kelft
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Contributions

ASVDK collected the pre- and postoperative data and drafted the manuscript. BV performed the total knee arthroplasties and participated in the design and content of the manuscript. JDS performed the total knee arthroplasties as well and reviewed the final manuscript. The statistical cell of the University of Hasselt conducted the statistical analyses. KDM and JV reviewed the final manuscript. All authors read and approved the final manuscript.

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Correspondence to An-Sofie Van de Kelft.

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Not necessary as retrospective study design.

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Van de Kelft, AS., De Mulder, K., De Schepper, J. et al. Balancing the flexion gap first in total knee arthroplasty leads to better preservation of posterior condylar offset resulting in better knee flexion. Knee Surg Sports Traumatol Arthrosc 31, 3792–3798 (2023). https://doi.org/10.1007/s00167-023-07346-7

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