Ye ZHANG, Yu ZHANG, Jian-Ning SUN, Lun AN, Xiang-Yang CHEN, Shuo FENG

Comparison of outcomes between gap balancing and measured resection techniques for total knee arthroplasty: A prospective, randomized, controlled trial

Objective: The aim of this study was to compare the effect of Gap Balancing (GB) versus Measured Resection (MR) techniques onthe early clinical and radiological results of Total Knee Arthroplasty (TKA).Methods: In this prospective study, 99 patients (99 knees) who underwent unilateral TKA between March 2018 and January 2019were randomly allocated to one of two groups: The GP group, TKA with GB technique (19 male, 31 female; mean age = 55.9 ±16.5)and the MR group, TKA with MR technique (19 male, 30 female; mean age = 54.2 ± 18.7). Patients in both groups werecomparable in terms of the demographic and clinical data. The angle of cutting block to PCA and Cutting Thickness of theMedial and Lateral Condyle (CTMC, CTLC) were intraoperatively measured. In radiographic analysis, Preoperative MechanicalFemorotibial Angle (Pre-mFTA), Postoperative Mechanical Femorotibial Angle (Post-mFTA), and joint line changes wereexamined. Femoral component Rotation Angle (FCRA) was also measured by computed tomography. In gait analysis, thespatiotemporal parameters (walking speed, step length, and single support time) and kinematics parameters (flexion angle,extension angle, and transversal rotation) were collected at 12 months postoperatively. Furthermore, Western Ontario andMcMaster Universities Arthritis Index (WOMAC) were performed at 12 months after surgery.Results: CTMC and CTLC were both significantly higher in GB group than in the MR group (9.8±2.0 mm vs 8.5 ± 1.2 mm; 7.9 ±1.8mm vs 6.8 ± 1.4mm; P = 0.001, P = 0.002, respectively). Angle of cutting block to PCA was statistically lower in GB group than inthe MR group (1.7 ± 1.5° vs 3.1 ± 0.5 °; P < 0.001). FCRA is greater in the GB group compared to the MR group, but the differencedid not reach statistical significance (1.2 ± 2.8 ° vs 0.7 ± 2.0 °; P > 0.05). Although post-mFTA significantly improved comparedwith pre-mFTA in both groups, no significant difference was observed in the changes of post-mFTA between the two groups (0.9± 1.7° vs 0.3 ± 1.8°, P > 0.05). No significant differences were determined between the two groups in spatiotemporal gaitparameters including walking speed, step length, and single support time. The sagittal max knee flexion range was significantlylarger in the GB group than in the MR group (49.27 ± 5.24 ° vs 45.99 ± 8.21 °, P < 0.05). The flexion range did not reach the level ofthe control group. There was no significant difference between the two groups in WOMAC at 12 months follow-up (P > 0.05).Conclusion: Evidence from this study has revealed GB and MR techniques have both little effect on early clinical results of TKA.Nonetheless, GB technique can provide better knee flexion in the early postoperative gait status compared with MR technique. Level of Evidence: Level I, Therapeutic Study

___

1. Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am. 2004;86(5):963-974. 10. 2106/00004623-200405000-00012

2. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patient satisfaction after total knee arthroplasty: Who is satisfied and who is not? Clin Orthop Relat Res. 2010;468(1):57-63. 10.1007/s11999-009-1119-9

3. Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS. Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res. 1993;(286):40-47.

4. Luyckx T, Peeters T, Vandenneucker H, Victor J, Bellemans J. Is adapted measured resection superior to gap-balancing in determining femoral component rotation in total knee replacement? J Bone Joint Surg Br. 2012;94(9):1271- 1276. 10.1302/0301-620X.94B9.28670

5. Nikolaides AP, Kenanidis EI, Papavasiliou KA, Sayegh FE, Tsitouridis L, Kapetanos GA. Measured resection versus gap balancing technique for femoral rotational alignment: A prospective study. J Orthop Surg (Hong Kong). 2014;22(2):158-162. 10.1177/230949901402200208

6. Yip DK, Zhu YH, Chiu KY, Ng TP. Distal rotational alignment of the Chinese femur and its relevance in total knee arthroplasty. J Arthroplasty. 2004;19 (5):613-619. 10.1016/j.arth.2003.11.008

7. Fehring TK. Rotational malalignment of the femoral component in total knee arthroplasty. Clin Orthop Relat Res. 2000;(380):72-79. 10.1097/00003086- 200011000-00010

8. Hernandez-Hermoso JA, Nescolarde-Selva L, Rodriguez-Montserrat D, Martinez-Pastor JC, Garcia-Oltra E, Lopez-Marne S. Different femoral rotation with navigated flexion-gap balanced or measured resection in total knee arthroplasty does not lead to different clinical outcomes. Knee Surg Sports Traumatol Arthrosc. 2020;28:1805-1813 10.1007/s00167-019-05591-3

9. Foge DA, Baldini TH, Hellwinkel JE, Hogan CA, Dayton MR. The role of complete posterior cruciate ligament release in flexion gap balancing for total knee arthroplasty. J Arthroplasty. 2019;34(7s):S361-s365. 10.1016/j.arth.2019. 03.017

10. Sabbioni G, Rani N, Del Piccolo N, Ben Ayad R, Carubbi C, Tigani D. Gap balancing versus measured resection technique using a mobile-bearing prosthesis in computer-assisted surgery. Musculoskelet Surg. 2011;95(1):25-30. 10. 1007/s12306-011-0110-2

11. Daines BK, Dennis DA. Gap balancing vs. measured resection technique in total knee arthroplasty. Clin Orthop Surg. 2014;6(1):1-8. 10.4055/cios. 2014.6.1.1

12. Kahlenberg CA, Elmasry S, Mayman DJ, et al. Posterior condylar bone resection and femoral implant thickness vary by up to 3 mm across implant systems: Implications for flexion gap balancing. Knee Surg Sports Traumatol Arthrosc. 2019;27(7):2140-2144. 10.1007/s00167-019-05422-5

13. Yau WP, Chiu KY, Tang WM. How precise is the determination of rotational alignment of the femoral prosthesis in total knee arthroplasty: An in vivo study. J Arthroplasty. 2007;22(7):1042-1048. 10.1016/j.arth.2006.12.043

14. Freeman MAR, Samuelson KM, Levack B, de Alencar PG. Knee Arthroplasty at the London Hospital 1975–1984. Clin Orthop Relat Res. 1986;(205):12-20.

15. Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthop Relat Res. 1985;(192):13-22.

16. Elmasry SS, Imhauser CW, Wright TM, et al. Neither anterior nor posterior referencing consistently balances the flexion gap in measured resection total knee arthroplasty: A computational analysis. J Arthroplasty. 2019;34(5):981- 986. 10.1016/j.arth.2019.01.052

17. Springer BD, Parratte S, Abdel MP. Measured resection versus gap balancing for total knee arthroplasty. Clin Orthop Relat Res. 2014;472(7):2016-2022. 10. 1007/s11999-014-3524-y

18. Sheth NP, Husain A, Nelson CL. Surgical techniques for total knee arthroplasty: Measured resection, gap balancing, and hybrid. J Am Acad Orthop Surg. 2017;25(7):499-508. 10.5435/JAAOS-D-14-00320

19. Churchill JL, Khlopas A, Sultan AA, Harwin SF, Mont MA. Gap-Balancing versus measured resection technique in total knee arthroplasty: A comparison study. J Knee Surg. 2018;31(1):13-16. 10.1055/s-0037-1608820

20. Nagai K, Muratsu H, Takeoka Y, Tsubosaka M, Kuroda R, Matsumoto T. The influence of joint distraction force on the soft-tissue balance using modified gap-balancing technique in posterior-stabilized total knee arthroplasty. J Arthroplasty. 2017;32(10):2995-2999. 10.1016/j.arth.2017.04.058

21. Kim CW, Lee CR, Gwak HC, Kim JH, Kwon YU, Kim DY. 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. 2020;33:144-151 10.1055/s-0038-1676766

22. Papagiannis GI, Triantafyllou AI, Roumpelakis IM, Papagelopoulos PJ, Babis GC. Gait analysis methodology for the measurement of biomechanical parameters in total knee arthroplasties. A literature review. J Orthop. 2018;15 (1):181-185. 10.1016/j.jor.2018.01.048

23. Xu H, Hunt M, Bo Foreman K, Zhao J, Merryweather A. Gait alterations on irregular surface in people with Parkinson’s disease. Clin Biomech (Bristol, Avon). 2018;57:93-98. 10.1016/j.clinbiomech.2018.06.013

24. Cidambi KR, Robertson N, Borges C, Nassif NA, Barnett SL. Intraoperative comparison of measured resection and gap balancing using a force sensor: A prospective, randomized controlled trial. J Arthroplasty. 2018;33(7s):S126- S130. 10.1016/j.arth.2018.02.044

25. Sun ZH LJ, Tian ZW Mid-termfollow-up of gap balancing technique in total knee arthroplasty. Orthop J China. 21(13):1292-1296.

26. Lee HJ, Lee JS, Jung HJ, Song KS, Yang JJ, Park CW. Comparison of joint line position changes after primary bilateral total knee arthroplasty performed using the navigation-assisted measured gap resection or gap balancing techniques. Knee Surg Sports Traumatol Arthrosc. 2011;19(12):2027-2032. 10. 1007/s00167-011-1468-2

27. Moon YW, Kim HJ, Ahn HS, Park CD, Lee DH. Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: A meta-analysis. Medicine (Baltimore). 2016;95(39):e5006. 10.1097/MD. 0000000000005006

28. Babazadeh S, Dowsey MM, Vasimalla MG, Stoney JD, Choong PFM. Gap balancing sacrifices joint-line maintenance to improve gap symmetry: 5-year follow-up of a randomized controlled trial. J Arthroplasty. 2018;33(1):75-78. 10. 1016/j.arth.2017.08.021

29. Mercuri JJ, Pepper AM, Werner JA, Vigdorchik JM. Gap balancing, measured resection, and kinematic alignment: How, when, and why? JBJS Rev. 2019;7(3): e2. 10.2106/JBJS.RVW.18.00026

30. Kinzel V, Ledger M, Shakespeare D. Can the epicondylar axis be defined accurately in total knee arthroplasty? Knee. 2005;12(4):293-296. 10.1016/j. knee.2004.09.003

31. Oberg T, Karsznia A, Oberg K. Basic gait parameters: Reference data for normal subjects, 10-79 years of age. J Rehabil Res Dev. 1993;30(2):210-223.

32. Sparkes V, Whatling GM, Biggs P, et al. Comparison of gait, functional activities, and patient-reported outcome measures in patients with knee osteoarthritis and healthy adults using 3D motion analysis and activity monitoring: An exploratory case-control analysis. Orthop Res Rev. 2019;11:129-140. 10.2147/ORR.S199107

33. Brostrom EW, Esbjornsson AC, von Heideken J, Iversen MD. Gait deviations in individuals with inflammatory joint diseases and osteoarthritis and the usage of three-dimensional gait analysis. Best Pract Res Clin Rheumatol. 2012;26(3):409- 422. 10.1016/j.berh.2012.05.007

34. Kwon JW, Son SM, Lee NK. Changes of kinematic parameters of lower extremities with gait speed: A 3D motion analysis study. J Phys Ther Sci. 2015;27 (2):477-479. 10.1589/jpts.27.477