Impact of Component Alignment and Soft Tissue Release on 2-Year Outcomes in Total Knee Arthroplasty

Vigdorchik, Jonathan M.; Wakelin, Edgar A.; Koenig, Jan; Ponder, Corey; Plaskos, Christopher; DeClaire, Jeffrey H.; Lawrence, Jeffrey M.; Keggi, John M.

doi:10.1016/j.arth.2022.04.042

Cited by 30 publications

(17 citation statements)

References 27 publications

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“…As a result, a significantly higher proportion of knees in the sensor guided group received a soft‐tissue release (28.6% vs 40.1%, p = 0.045). When combined with a recent study by Vigdorchik et al [29] showing worse 2‐year outcomes when soft‐tissue releases are performed, this may explain the difference in result compared to our study in which only 2/56 (3.5%) of knees which satisfied all balance and laxity windows received a soft‐tissue release.…”

Section: Discussioncontrasting

confidence: 66%

Intra‐operative laxity and balance impact 2‐year pain outcomes in TKA: a prospective cohort study

Wakelin,

Ponder,

Randall

et al. 2023

Knee surg. sports traumatol. arthrosc.

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Purpose The objective of this study was to determine if intra-operatively measured joint gaps are associated with 2-year pain outcomes in total knee arthroplasty (TKA) and whether balance and laxity windows could be defined throughout flexion to optimize 2-year pain outcomes. Our hypothesis is that intra-operative joint gaps are associated with 2 year post-operative pain outcome. Methods A prospective study investigating 310 robotically assisted TKAs was performed. Final intra-operative joint gap data were recorded using a digital tensioner and component alignment data were recorded by the robotics system. Patient demographics and Knee Injury and Osteoarthritis Outcome Score (KOOS) were recorded pre-operatively and KOOS and Hospital for Special Surgery (HSS) satisfaction were recorded at 2 years post-op. A random search Simulated Annealing (SANN) optimisation algorithm was used to determine global optimum laxity and balance windows at different flexion angles which maximized the 2-year KOOS pain scores. The windows were combined to determine the impact of achieving optimal laxity and balance throughout flexion. To improve clinical utility, boundaries identified by the SANN algorithm were rounded to the nearest 0.5 mm before statistical analysis. Results Laxity and balance windows were defined in extension (Med lax: -2.0 to 2.5 mm, Lat lax: -0.5 to 2.5 mm, Balance: -3.0 to 0.0 mm), mid-flexion (Med lax: -1.0 to 2.5 mm, Lat lax: -0.5 to 3.0 mm, Balance: -2.0 to 2.0 mm), and flexion (Med lax: -2.0 to 3.5 mm, Lat lax: -2.0 to 1.5 mm, Balance: -3.0 to 3.0 mm). When all windows were satisfied, the greatest difference in KOOS pain score was observed (100.0 vs 94.4, p < 0.0001). The highest percentage of knees satisfying the Patient Acceptable Symptom State (PASS) for KOOS pain was also observed in knees which satisfied all windows compared to knees which did not (93% vs 71%, p = 0.0009). The proportion of knees which satisfy the PASS threshold decreased in knees which only satisfied 1-3 (29%) or 4-6 (69%) windows (p ≤ 0.0018). No optimal windows were found between component alignment and KOOS pain outcome (p ≥ 0.1180). High satisfaction was found across all groups (≥ 95%). Conclusion Intra-operatively measured joint gaps are associated with all KOOS sub-score outcomes at 2 years after TKA. Optimal windows for a clinically relevant improvement in post-operative KOOS pain were defined for laxity and balance but not for alignment indicating balance may have a greater impact on outcome than alignment. Level of evidence II.

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Section: Discussioncontrasting

confidence: 66%

Intra‐operative laxity and balance impact 2‐year pain outcomes in TKA: a prospective cohort study

Wakelin,

Ponder,

Randall

et al. 2023

Knee surg. sports traumatol. arthrosc.

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“…Recent work by Vigdorchik et al. [ 1 ] has shown alignment has no impact on outcome, yet soft-tissue release may negatively impact KOOS scores out to 2 years postoperatively. The impact of workflow on resection angle and frequency of soft-tissue release was not investigated here; however, our results suggest a TF approach with a predictive balancing tool allowing a target balance to be achieved more accurately may help reduce the need for soft-tissue releases and improve outcomes.…”

Section: Discussionmentioning

confidence: 99%

Impact of a Digital Balancing Tool on Femur and Tibial First Total Knee Arthroplasty: A Prospective Nonrandomized Controlled Trial

Koenig¹,

Wakelin²,

Passano³

et al. 2022

Arthroplasty Today

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“…The ability to balance knees through bone modifications is growing in utilization as it leads to more predictable results both technically and functionally. [23][24][25][26][27][28][29] Balancing a knee in the coronal plane is commonly an asymmetric approach, as addition of varus-valgus addresses the overtensioned compartment, rather than resecting symmetric bone leading to increased gap in the contralateral compartment and potentially an elevated joint line. 29 Robotic utilization is evolving and gives surgeons the confidence in modifying coronal alignment prior to and after trailing.…”

Section: Discussionmentioning

confidence: 99%

“…Ahn and Cho et al (28) documented improved balancing through bone resections with improved outcomes. Vigdorchik et al (29) reported on the Impact of Component Alignment and Soft Tissue Release on 2-Year Outcomes in Total Knee Arthroplasty, he found the addition of soft tissue releases after bony cuts is associated with worse KOOS scores out to 2 years and was more prevalent in knees with worse deformity, while no such association was found for alignment.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

Correction of Coronal Deformity and Intercompartmental Imbalance through Bone Resection

Roche,

Law

2023

J Knee Surg

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Introduction This chapter discusses the correction of coronal deformity and intercompartmental imbalance through bone resection in total knee arthroplasty (TKA). To achieve functional knee balance, coronal, rotational, and sagittal alignment are critical to successful patient outcomes. Though variations in coronal alignment are debated as a correlate to positive results, advancements in utilizing implant position, alignment, and soft tissue balance to improve patient outcomes and function are an evolving discussion. Materials and Methodology The study draws upon existing literature, clinical studies, and surgical techniques related to TKA, including advancements in navigation and robotics. Results The study highlights the importance of individualized alignment strategies for varus and valgus knees. While mechanical neutral alignment has shown excellent long-term data (1), re-evaluating the anatomic recreation of the patient's joint line obliquity is now being studied extensively (2,3). Sensor data and navigation systems contribute to improved outcomes and patient satisfaction. Discussion The evolution of navigation and robotics has led surgeons to achieve their target angles consistently and accurately; now, the discussion is around the most effective alignment targets (4). The classification of various phenotypes assists in the proposed starting points for implant position, but soft tissue tension is required in the input data to achieve global balance and stable motion. Each approach's advantages and limitations are considered. Conclusion In conclusion, achieving optimal coronal alignment, joint line obliquity, and soft tissue balance is crucial for successful TKA outcomes. Personalized alignment philosophies, supported by 3D data and sensor technology, are evolving to minimize critical errors and enhance functional results. Robotic assistance and future advancements in AI and machine learning hold promise for further improving TKA outcomes in the quest for soft tissue stabilization.

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Impact of Component Alignment and Soft Tissue Release on 2-Year Outcomes in Total Knee Arthroplasty

Cited by 30 publications

References 27 publications

Intra‐operative laxity and balance impact 2‐year pain outcomes in TKA: a prospective cohort study

Intra‐operative laxity and balance impact 2‐year pain outcomes in TKA: a prospective cohort study

Impact of a Digital Balancing Tool on Femur and Tibial First Total Knee Arthroplasty: A Prospective Nonrandomized Controlled Trial

Correction of Coronal Deformity and Intercompartmental Imbalance through Bone Resection

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