Kinematic femoral alignment with gap balancing and patient-specific instrumentation in total knee arthroplasty: a randomized clinical trial

  • Hagen HommelEmail author
  • Matthew P. Abdel
  • Carsten Perka
Original Article • KNEE - ARTHROPLASTY


While patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) allows for transfer of the preoperative plan onto bony landmarks, the soft tissue balancing is not affected. The goals of this randomized clinical trial were to compare PSI and the measured resection technique (conventional) with PSI and the gap balancing technique. Fifty patients were randomized to TKA with conventional PSI (PSI-S) (n = 25) or to PSI with additional gap balancing (PSI-GB) (n = 25). All patients were clinically examined at 3 and 12 months postoperatively. Data on the range of motion, the Knee Society Score, the Western Ontario and McMasters Universities Osteoarthritis Index, the High-Flexion Knee Score (HFKS), and the Forgotten Joint Score (FJS) were compiled at follow-up. Statistically significant improvements were found for all clinical parameters in the PSI-GB group compared to the PSI-S group at 3 months postoperatively and for FS, FJS, and HFKS at 12 months. However, the relevance of these differences, as well as their effect on long-term outcomes, needs to be evaluated further. In conclusion, patient-specific instrumentation combined with gap balancing yielded good early clinical outcomes.


Total knee arthroplasty Patient-specific instrumentation Gap balancing Extension-first technique Randomized clinical trial 



This study was funded by Smith & Nephew GmbH, Hamburg, Germany. The sponsor had no involvement in the writing of the report or in the decision to submit the results for publication.

Compliance with ethical standards

The study complies with the current laws of the country in which it was performed.

Conflict of interest

Hagen Hommel has received research grants from Smith & Nephew, has received a speaker honorarium from Smith & Nephew during the conduct of the study, and has received a speaker honorarium from Smith & Nephew, DePuy and Aesculap, outside the submitted work. Matthew P. Abdel declares that he has no conflict of interest. Carsten Perka has received a speaker honorarium from DePuy, Smith & Nephew, Zimmer Biomet, Aesculap, outside the submitted work.

Ethical approval

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.

Informed consent

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


  1. 1.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4):780–785PubMedGoogle Scholar
  2. 2.
    Maratt JD, Lee YY, Lyman S, Westrich GH (2015) Predictors of satisfaction following total knee arthroplasty. J Arthroplasty 30(7):1142–1145CrossRefPubMedGoogle Scholar
  3. 3.
    Romero J, Stahelin T, Wyss T, Hofmann S (2003) Significance of axial rotation alignment of components of knee prostheses. Orthopade 32(6):461–468CrossRefPubMedGoogle Scholar
  4. 4.
    Thienpont E, Bellemans J, Victor J, Becker R (2013) Alignment in total knee arthroplasty, still more questions than answers. Knee Surg Sports Traumatol Arthrosc 21(10):2191–2193CrossRefPubMedGoogle Scholar
  5. 5.
    Daniilidis K, Tibesku CO (2014) A comparison of conventional and patient-specific instruments in total knee arthroplasty. Int Orthop 38(3):503–508CrossRefPubMedGoogle Scholar
  6. 6.
    Matziolis G, Pfiel S, Wassilew G, Boenicke H, Perka C (2011) Kinematic analysis of the flexion axis for correct femoral component placement. Knee Surg Sports Traumatol Arthrosc 19(9):1504–1509CrossRefPubMedGoogle Scholar
  7. 7.
    Daines BK, Dennis DA (2014) Gap balancing vs. measured resection technique in total knee arthroplasty. Clin Orthop Surg 6(1):1–8CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Victor J, Dujardin J, Vandenneucker H, Arnout N, Bellemans J (2014) Patient-specific guides do not improve accuracy in total knee arthroplasty: a prospective randomized controlled trial. Clin Orthop Relat Res 472(1):263–271CrossRefPubMedGoogle Scholar
  9. 9.
    Fitz W, Jager S, Rieger JS, Seebach E, Bitsch RG (2015) Femoral rotation in total knee arthroplasty: a comparison of patient individualized jigs with gap balancing in relation to anatomic landmarks. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3836-9 Google Scholar
  10. 10.
    Hube R, Mayr HO, Kalteis T, Matziolis G (2011) Extension first technique for TKA implantation. Oper Orthop Traumatol 23(3):241–248CrossRefPubMedGoogle Scholar
  11. 11.
    Mihalko WM, Saleh KJ, Krackow KA, Whiteside LA (2009) Soft-tissue balancing during total knee arthroplasty in the varus knee. J Am Acad Orthop Surg 17(12):766–774CrossRefPubMedGoogle Scholar
  12. 12.
    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(12):1833–1840PubMedGoogle Scholar
  13. 13.
    Ewald FC (1989) The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12Google Scholar
  14. 14.
    Behrend H, Giesinger K, Giesinger JM, Kuster MS (2012) The “forgotten joint” as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. J Arthroplasty 27(3):430–436CrossRefPubMedGoogle Scholar
  15. 15.
    Na SE, Ha CW, Lee CH (2012) A new high-flexion knee scoring system to eliminate the ceiling effect. Clin Orthop Relat Res 470(2):584–593CrossRefPubMedGoogle Scholar
  16. 16.
    Singh JA, Schleck C, Harmsen WS, Lewallen DG (2013) Responsiveness and predictive ability of the Knee Society Scale (KSS) Score. Paper presented at the American College of Rheumatology, San Diego, CAGoogle Scholar
  17. 17.
    Julious SA (2004) Sample sizes for clinical trials with normal data. Stat Med 23(12):1921–1986CrossRefPubMedGoogle Scholar
  18. 18.
    Sassoon A, Nam D, Nunley R, Barrack R (2015) Systematic review of patient-specific instrumentation in total knee arthroplasty: new but not improved. Clin Orthop Relat Res 473(1):151–158CrossRefPubMedGoogle Scholar
  19. 19.
    Springer BD, Parratte S, Abdel MP (2014) Measured resection versus gap balancing for total knee arthroplasty. Clin Orthop Relat Res 472(7):2016–2022CrossRefPubMedGoogle Scholar
  20. 20.
    Pfitzner T, Rohner E, Preininger B, Perka C, Matziolis G (2012) Femur positioning in navigated total knee arthroplasty. Orthopedics 35(10 Suppl):45–49CrossRefPubMedGoogle Scholar
  21. 21.
    Daniilidis K, Tibesku C (2013) Frontal plane alignment after total knee arthroplasty using patient-specific instruments. Int Orthop 37(1):45–50CrossRefPubMedGoogle Scholar
  22. 22.
    Becker R, Malzdorf M, Starke C, Randolf P, Lohmann C (2012) No difference between tibia-first and femur-first techniques in TKA using computer-assisted surgery. Knee Surg Sports Traumatol Arthrosc 20(10):2011–2016CrossRefPubMedGoogle Scholar
  23. 23.
    Pang HN, Yeo SJ, Chong HC, Chin PL, Ong J, Lo NN (2011) Computer-assisted gap balancing technique improves outcome in total knee arthroplasty, compared with conventional measured resection technique. Knee Surg Sports Traumatol Arthrosc 19(9):1496–1503CrossRefPubMedGoogle Scholar
  24. 24.
    Dossett HG, Swartz GJ, Estrada NA, LeFevre GW, Kwasman BG (2012) Kinematically versus mechanically aligned total knee arthroplasty. Orthopedics 35(2):e160–e169PubMedGoogle Scholar
  25. 25.
    Thienpont E, Schwab PE, Fennema P (2014) A systematic review and meta-analysis of patient-specific instrumentation for improving alignment of the components in total knee replacement. Bone Jt J 96(8):1052–1061CrossRefGoogle Scholar
  26. 26.
    Hommel H, Perka C, Pfitzner T (2016) Preliminary results of a new surgical technique in total knee arthroplasty (TKA) using the native ligament tension for femoral implant positioning in varus osteoarthritis. Arch Orthop Trauma Surg 136(7):991–997CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France 2016

Authors and Affiliations

  • Hagen Hommel
    • 1
    Email author
  • Matthew P. Abdel
    • 2
  • Carsten Perka
    • 3
  1. 1.Clinic for Orthopedics, Sports Medicine and RehabilitationKrankenhaus Märkisch Oderland GmbHWriezenGermany
  2. 2.Department of Orthopedic SurgeryMayo ClinicRochesterUSA
  3. 3.Center for Musculoskeletal Surgery, Orthopedic DepartmentCharité University HospitalBerlinGermany

Personalised recommendations