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Intraoperative Joint Gaps Affect Postoperative Range of Motion in TKAs With Posterior-stabilized Prostheses

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Joint gaps and mediolateral (ML) soft tissue balance have long been known to affect clinical scores and patient function after TKA, but the relationship between gaps and soft tissue balance remain poorly defined. If specific relationships exist between soft tissue tension and patient function, then objective targets could be established to assist surgeons in achieving more consistent postoperative knee function.

Questions/purposes

By performing instrumented gap measurements during TKA, we sought to quantify the relationships between intraoperative soft tissue tension and clinical scores and patient function.

Methods

We prospectively followed 57 patients with 63 primary TKAs with posterior-stabilized prostheses. Joint gaps and ML soft tissue balance were measured intraoperatively from 0° to 135° with the patella reduced after independent bone cuts and soft tissue releases. We determined the relationships between these intraoperative measurements and postoperative ROM and Knee Society scores at minimum 2-year followup.

Results

Larger joint gaps at 120° and 135° flexion predicted larger postoperative knee flexion (r = 0.296 and r = 0.393, respectively), whereas larger gaps at 10° flexion predicted greater postoperative knee extension (r = 0.285). Knees with rectangular joint gaps did not show better ROM or Knee Society scores compared with knees with trapezoidal joint gaps. In the range of normal surgical variation, neither joint gaps nor gap asymmetry affected the incidence of postoperative instability.

Conclusions

Avoiding small joint gaps in extension and in deep flexion should allow patients who undergo TKAs to obtain maximum ROM.

Level of Evidence

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Acker SM, Cockburn RA, Krevolin J, Li RM, Tarabichi S, Wyss UP. Knee kinematics of high-flexion activities of daily living performed by male Muslims in the Middle East. J Arthroplasty. 2011;26:319–327.

    Article  PubMed  Google Scholar 

  2. Asano H, Muneta T, Sekiya I. Soft tissue tension in extension in total knee arthroplasty affects postoperative knee extension and stability. Knee Surg Sports Traumatol Arthrosc. 2008;16:999–1003.

    Article  PubMed  Google Scholar 

  3. Bellemans J, Banks S, Victor J, Vandenneucker H, Moemans A. Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty: influence of posterior condylar offset. J Bone Joint Surg Br. 2002;84:50–53.

    Article  PubMed  CAS  Google Scholar 

  4. Chalidis BE, Sachinis NP, Papadopoulos P, Petsatodis E, Christodoulou AG, Petsatodis G. Long-term results of posterior-cruciate-retaining Genesis I total knee arthroplasty. J Orthop Sci. 2011;16:726–731.

    Article  PubMed  Google Scholar 

  5. Dennis DA, Clayton ML, O’Donnell S, Mack RP, Stringer EA. Posterior cruciate condylar total knee arthroplasty: average 11-year follow-up evaluation. Clin Orthop Relat Res. 1992;281:168–176.

    PubMed  Google Scholar 

  6. Dennis DA, Komistek RD, Stiehl JB, Walker SA, Dennis KN. Range of motion after total knee arthroplasty: the effect of implant design and weight-bearing conditions. J Arthroplasty. 1998;13:748–752.

    Article  PubMed  CAS  Google Scholar 

  7. Griffin FM, Insall JN, Scuderi GR. Accuracy of soft tissue balancing in total knee arthroplasty. J Arthroplasty. 2000;15:970–973.

    Article  PubMed  CAS  Google Scholar 

  8. Hanratty BM, Thompson NW, Wilson RK, Beverland DE. The influence of posterior condylar offset on knee flexion after total knee replacement using a cruciate-sacrificing mobile-bearing implant. J Bone Joint Surg Br. 2007;89:915–918.

    Article  PubMed  CAS  Google Scholar 

  9. Harvey IA, Barry K, Kirby SP, Johnson R, Elloy MA. Factors affecting the range of movement of total knee arthroplasty. J Bone Joint Surg Br. 1993;75:950–955.

    PubMed  CAS  Google Scholar 

  10. Hemmerich A, Brown H, Smith S, Marthandam SS, Wyss UP. Hip, knee, and ankle kinematics of high range of motion activities of daily living. J Orthop Res. 2006;24:770–781.

    Article  PubMed  CAS  Google Scholar 

  11. Higuchi H, Hatayama K, Shimizu M, Kobayashi A, Kobayashi T, Takagishi K. Relationship between joint gap difference and range of motion in total knee arthroplasty: a prospective randomised study between different platforms. Int Orthop. 2009;33:997–1000.

    Article  PubMed  Google Scholar 

  12. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–14.

    PubMed  Google Scholar 

  13. Kawamura H, Bourne RB. Factors affecting range of flexion after total knee arthroplasty. J Orthop Sci. 2001;6:248–252.

    Article  PubMed  CAS  Google Scholar 

  14. Kurosaka M, Yoshiya S, Mizuno K, Yamamoto T. Maximizing flexion after total knee arthroplasty: the need and the pitfalls. J Arthroplasty. 2002;17(4 suppl 1):59–62.

    Article  PubMed  Google Scholar 

  15. Kuster MS, Bitschnau B, Votruba T. Influence of collateral ligament laxity on patient satisfaction after total knee arthroplasty: a comparative bilateral study. Arch Orthop Trauma Surg. 2004;124:415–417.

    Article  PubMed  CAS  Google Scholar 

  16. Matsuda Y, Ishii Y, Noguchi H, Ishii R. Effect of flexion angle on coronal laxity in patients with mobile-bearing total knee arthroplasty prostheses. J Orthop Sci. 2005;10:37–41.

    Article  PubMed  Google Scholar 

  17. Matsuda Y, Ishii Y, Noguchi H, Ishii R. Varus-valgus balance and range of movement after total knee arthroplasty. J Bone Joint Surg Br. 2005;87:804–808.

    Article  PubMed  CAS  Google Scholar 

  18. Matsumoto T, Mizuno K, Muratsu H, Tsumura N, Fukase N, Kubo S, Yoshiya S, Kurosaka M, Kuroda R. Influence of intra-operative joint gap on post-operative flexion angle in osteoarthritis patients undergoing posterior-stabilized total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2007;15:1013–1018.

    Article  PubMed  Google Scholar 

  19. Matsumoto T, Muratsu H, Tsumura N, Mizuno K, Kuroda R, Yoshiya S, Kurosaka M. Joint gap kinematics in posterior-stabilized total knee arthroplasty measured by a new tensor with the navigation system. J Biomech Eng. 2006;128:867–871.

    Article  PubMed  Google Scholar 

  20. Meneghini RM, Ritter MA, Pierson JL, Meding JB, Berend ME, Faris PM. The effect of the Insall-Salvati ratio on outcome after total knee arthroplasty. J Arthroplasty. 2006;21(6 suppl 2):116–120.

    Article  PubMed  Google Scholar 

  21. Mitts K, Muldoon MP, Gladden M, Jr, Padgett DE. Instability after total knee arthroplasty with the Miller-Galante II total knee: 5- to 7-year follow-up. J Arthroplasty. 2001;16:422–427.

    Article  PubMed  CAS  Google Scholar 

  22. Mulholland SJ, Wyss UP. Activities of daily living in non-Western cultures: range of motion requirements for hip and knee joint implants. Int J Rehabil Res. 2001;24:191–198.

    Article  PubMed  CAS  Google Scholar 

  23. Nicholls RL, Schirm AC, Jeffcote BO, Kuster MS. Tibiofemoral force following total knee arthroplasty: comparison of four prosthesis designs in vitro. J Orthop Res. 2007;25:1506–1512.

    Article  PubMed  Google Scholar 

  24. Parsley BS, Conditt MA, Bertolusso R, Noble PC. Posterior cruciate ligament substitution is not essential for excellent postoperative outcomes in total knee arthroplasty. J Arthroplasty. 2006;21(6 suppl 2):127–131.

    Article  PubMed  Google Scholar 

  25. Rand JA, Ilstrup DM. Survivorship analysis of total knee arthroplasty: cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am. 1991;73:397–409.

    PubMed  CAS  Google Scholar 

  26. Ritter MA, Harty LD, Davis KE, Meding JB, Berend ME. Predicting range of motion after total knee arthroplasty: clustering, log-linear regression, and regression tree analysis. J Bone Joint Surg Am. 2003;85:1278–1285.

    PubMed  Google Scholar 

  27. Sambatakakis A, Attfield SF, Newton G. Quantification of soft-tissue imbalance in condylar knee arthroplasty. J Biomed Eng. 1993;15:339–343.

    Article  PubMed  CAS  Google Scholar 

  28. Sasanuma H, Sekiya H, Takatoku K, Takada H, Sugimoto N. Evaluation of soft-tissue balance during total knee arthroplasty. J Orthop Surg (Hong Kong). 2010;18:26–30.

    Google Scholar 

  29. Schai PA, Thornhill TS, Scott RD. Total knee arthroplasty with the PFC system: results at a minimum of ten years and survivorship analysis. J Bone Joint Surg Br. 1998;80:850–858.

    Article  PubMed  CAS  Google Scholar 

  30. Scuderi GR. The stiff total knee arthroplasty: causality and solution. J Arthroplasty. 2005;20(4 suppl 2):23–26.

    Article  PubMed  Google Scholar 

  31. Tokuhara Y, Kadoya Y, Nakagawa S, Kobayashi A, Takaoka K. The flexion gap in normal knees: an MRI study. J Bone Joint Surg Br. 2004;86:1133–1136.

    Article  PubMed  CAS  Google Scholar 

  32. Unitt L, Sambatakakis A, Johnstone D, Briggs TW; Balancer Study Group. Short-term outcome in total knee replacement after soft-tissue release and balancing. J Bone Joint Surg Br. 2008;90:159–165.

    Article  PubMed  CAS  Google Scholar 

  33. Wallace AL, Harris ML, Walsh WR, Bruce WJ. Intraoperative assessment of tibiofemoral contact stresses in total knee arthroplasty. J Arthroplasty. 1998;13:923–927.

    Article  PubMed  CAS  Google Scholar 

  34. Waslewski GL, Marson BM, Benjamin JB. Early, incapacitating instability of posterior cruciate ligament-retaining total knee arthroplasty. J Arthroplasty. 1998;13:763–767.

    Article  PubMed  CAS  Google Scholar 

  35. Watanabe T, Muneta T, Ishizuki M. Is a minimally invasive approach superior to a conventional approach for total knee arthroplasty? Early outcome and 2- to 4-year follow-up. J Orthop Sci. 2009;14:589–595.

    Article  PubMed  Google Scholar 

  36. Whiteside LA. Cementless total knee replacement: nine- to 11-year results and 10-year survivorship analysis. Clin Orthop Relat Res. 1994;309:185–192.

    PubMed  Google Scholar 

  37. Whiteside LA, Arima J. The anteroposterior axis for femoral rotational alignment in valgus total knee arthroplasty. Clin Orthop Relat Res. 1995;321:168–172.

    PubMed  Google Scholar 

  38. Winemaker MJ. Perfect balance in total knee arthroplasty: the elusive compromise. J Arthroplasty. 2002;17:2–10.

    Article  PubMed  CAS  Google Scholar 

  39. Wyss T, Schuster AJ, Christen B, Wehrli U. Tension controlled ligament balanced total knee arthroplasty: 5-year results of a soft tissue orientated surgical technique. Arch Orthop Trauma Surg. 2008;128:129–135.

    Article  PubMed  Google Scholar 

  40. Yamakado K, Kitaoka K, Yamada H, Hashiba K, Nakamura R, Tomita K. Influence of stability on range of motion after cruciate-retaining TKA. Arch Orthop Trauma Surg. 2003;123:1–4.

    PubMed  Google Scholar 

  41. Yoshino N, Watanabe N, Watanabe Y, Fukuda Y, Takai S. Measurement of joint gap load in patella everted and reset position during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2009;17:484–490.

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank Hirotsugu Muratsu MD, for advice on using the intraoperative joint gap tensor developed at Kobe University.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo, Japan

    Toshifumi Watanabe MD, PhD, Takeshi Muneta MD, PhD & Ichiro Sekiya MD, PhD

  2. Department of Mechanical & Aerospace Engineering, University of Florida, Gainesville, FL, USA

    Toshifumi Watanabe MD, PhD & Scott A. Banks PhD

  3. Department of Orthopaedic Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan

    Toshifumi Watanabe MD, PhD

Authors
  1. Toshifumi Watanabe MD, PhD
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  2. Takeshi Muneta MD, PhD
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  3. Ichiro Sekiya MD, PhD
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  4. Scott A. Banks PhD
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Corresponding author

Correspondence to Toshifumi Watanabe MD, PhD.

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Each author certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Each author certifies that Tsuchiura Kyodo General Hospital and the University of Florida approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan.

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Watanabe, T., Muneta, T., Sekiya, I. et al. Intraoperative Joint Gaps Affect Postoperative Range of Motion in TKAs With Posterior-stabilized Prostheses. Clin Orthop Relat Res 471, 1326–1333 (2013). https://doi.org/10.1007/s11999-012-2755-z

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  • DOI: https://doi.org/10.1007/s11999-012-2755-z

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