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Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 108e113
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Review article

Ligament balancing in total knee arthroplastydMedial stabilizing technique

Shuichi Matsuda*, Hiromu Ito
Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
Received 5 January 2015; revised 8 April 2015; accepted 6 July 2015
Available online 7 August 2015

Abstract

Ligament balancing is one of the most important surgical techniques for successful total knee arthroplasty. It has traditionally been rec-
ommended that medial and lateral as well as flexion and extension gaps are equal. This article reviews the relevant literature and discusses the
clinical importance of the aforementioned gaps. Current evidence indicates that achieving medial stability throughout the range of motion should
be a high priority in ligament balancing in total knee arthroplasty. Finally, the medial stabilising surgical technique, which aims to achieve good
medial stability in posterior cruciate-retaining total knee arthroplasty, is introduced.
Copyright © 2015 Asia Pacific Knee, Arthroscopy and Sports Medicine Society. Published by Elsevier (Singapore) Pte Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: alignment; biomechanics; implant design; ligament balancing; total knee arthroplasty

Introduction the goal of soft tissue balancing is unclear. The classical

concept of TKA is the achievement of equal medial and lateral
Total knee arthroplasty (TKA) involves resection of the gaps as well as equal flexion and extension gaps. However,
medial and lateral menisci; moreover, the anterior cruciate this concept and whether it is possible in all cases remains
ligament is usually resected, and the posterior cruciate ligament controversial. In this article, the concept of ligament balancing
(PCL) is sometimes sacrificed. Therefore, knee stability should is subcategorised into four parts: medial extension, medial
be achieved by the remaining ligamentous structures and flexion, lateral extension, and lateral flexion gaps.
articular surface geometry. Varusevalgus and rotational sta-
bility can be obtained mainly by proper tensioning of collateral Medial extension gap: how tight/loose can the knee be
and capsular ligaments.1 Therefore, surgical technique is crit- left?
ical for maintaining knee stability after TKA. This review
article summarises previous reports and our studies, and dis- How tight the knee can be left in extension intraoperatively
cusses the most important factors in ligament balancing in TKA to avoid postoperative flexion contracture remains unclear.3 A
for osteoarthritis with varus deformity. Furthermore, a surgical few studies have evaluated the relationship between intra-
technique for achieving adequate medial stability is introduced. operative soft tissue tension and postoperative extension
angle.4 Therefore, we evaluated the effect of extension gap on
Principles of ligament balancing in TKA postoperative flexion contracture.5 In that study, intraoperative
extension gap was evaluated in 75 knees with varus deformity
Recent technological advances have enabled the accurate after TKA using the NexGen LPS (Zimmer, Warsaw, IN,
evaluation of soft tissue tension intraoperatively.2 However, USA). The gap was measured with a femoral component using
a tension device applying a distraction force of 178 N. A
* Corresponding author. Department of Orthopaedic Surgery, Kyoto Uni- “component gap” was defined as the distance calculated by
versity, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. subtracting the selected thickness of the tibial component,
E-mail address: [email protected] (S. Matsuda). including the polyethylene liner from the measured gap.

http://dx.doi.org/10.1016/j.asmart.2015.07.002
2214-6873/Copyright © 2015 Asia Pacific Knee, Arthroscopy and Sports Medicine Society. Published by Elsevier (Singapore) Pte Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 S. Matsuda, H. Ito / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 108e113 109

Postoperative extension angle was measured by radiography. Lateral extension gap: should it be equal to the medial
The knee was extended by the patient's own leg weight when side?
the heel was raised 10 cm above the table. Flexion contracture
was defined as the angle between the anatomical axis of the Our study of normal knees shows that the lateral side
distal femur and the proximal tibia exceeding 5 . As a result, should be 2.5 laxer than the medial side.6 Here, we discuss
the tight group (medial component gap: <0 mm) showed 10% the case of osteoarthritic knees. We investigated knee laxity of
flexion contracture at 1 year postoperatively, the slightly tight osteoarthritic knees during TKA.13 In that study, the extension
group (medial component gap: 0e1 mm) still had 8% flexion gap was measured after the distal part of the femur and
contracture, and the group with knees with >1 mm medial proximal part of the tibia were resected. The patients were
component gap showed no flexion contracture. These results divided into the mild, moderate, and severe varus groups,
suggest that >1 mm laxity at the medial side after implantation which had preoperative hipekneeeankle angles of <10 ,
is necessary to avoid flexion contracture. 10e20 , and >20 , respectively. Measurements were made
How loose can the knee be left? First and foremost, the after removing osteophytes with a distraction force of 178 N.
patient should not feel unstable. One benchmark would be the The results show that lateral soft tissue laxity increased with
stability of normal knees. We previously measured knee laxity increasing severity of knee deformities. However, the medial
in normal knees by stress radiography and found that the side did not contract with increasing varus deformity. These
medial side was opened 2.4 when a valgus stress of 147 N results suggest that release on the medial side is unnecessary
was applied.6 Ishii et al7 report that excellent clinical results to make a space for implant replacement, even in severely
were achieved in patients with 3e4 valgus laxity after TKA. deformed knees.
These studies suggest that 2e4 laxity does not make patients However, gap imbalance increases with increasing knee
feel unstable after TKA. Therefore, we suggest that medial deformity up to 5 mm, prompting the determination of solu-
extension laxity should be 1e3 mm to avoid flexion contrac- tions for this imbalance. One of the classical methods for
ture and a feeling of instability (note that 1 medial laxity treating this situation is medial release. Krackow and
equals approximately 1.05 mm when the transverse diameter Mihalko14 report that complete release of the medial collateral
of the tibia is 80 mm). ligament (MCL) increases medial instability to 6.9 in full
extension but to 13.4 in 90 of flexion. Furthermore, Mullaji
Medial flexion gap: should it be adjusted to the et al15 state that releasing the MCL by 6e8 cm enlarges the
extension gap? medial extension and flexion gaps to 2.8 mm and 7.0 mm,
respectively. These findings highlight the difficultly in man-
A clinical study by Takayama et al8 indicates that tight aging extension imbalance by medial release alone; medial
flexion decreases range of motion after TKA. In addition, release would cause flexion instability in such cases.
Jeffcote et al9 report that a flexion gap that is more than 2 mm Another important point is how much ligament imbalance can
greater than the extension gap decreases tibial forces in deep be left. Here, we focus on lift-off motion, because joint laxity
knee flexion. Therefore, flexion tightness should definitely be theoretically increases the risk of lift-off motion. As lift-off
avoided, but how much looseness can be tolerated? In normal motion of the femoral component possibly increases wear of
knees, at the medial side, knee laxity at flexion is almost the articular surface,16 it should be avoided after TKA. Hamai
equal to knee laxity in extension or slightly lax at 1e2 mm.10 et al17 evaluated the effect of static knee instability by stress
We previously evaluated the effect of looseness in knee radiography on dynamic lift-off motion in fluoroscopy; the static
flexion on clinical outcome in 50 patients after TKA.11 Stress varusevalgus laxity or differences in the laxities (i.e., imbalance)
radiographs were taken while a lateral traction force of 50 N on the stress radiograph did not influence lift-off. Moreover, 90%
was applied perpendicular to the lower leg at 80 knee of their patients had neutral alignment. We also evaluated effects
flexion, and the angle between a line tangential to the femoral of alignment and ligament balance on lift-off motion using
condyles and a line through the tibial joint surface was computer simulations, which have recently been used and vali-
measured. Patient satisfaction, symptoms, and knee function dated in the field of TKA.18e24 We used KneeSIM software
according to the new Knee Society scoring system were (LifeMOD/KneeSIM 2010; LifeModeler Inc., San Clemente,
compared between the knees with 3 medial flexion laxity CA, USA) to evaluate the effects of alignment and laxity on lift-
(medial loose group) and those with <3 medial flexion laxity off motion. Our results show that lift-off motion occurs with 5
(medial tight group). The scores of the medial loose and tight varus alignment, or with a combination of 2 varus deformity and
groups were 22 and 30 for satisfaction (out of 40), 16 and 20 2 mm lateral laxity.25 However, no lift-off motion was detected in
for symptoms (out of 25), and 19 and 24 for standard activ- knees with neutral to 1 varus malalignment even when the knees
ities (out of 30), respectively. Our fluoroscopic analysis also had 5 mm lateral laxity.
showed that a greater medial flexion gap caused larger In summary, lateral laxity of 3 is close to normal condi-
anterior translation in knee flexion.12 On the basis of these tions, which would not cause a feeling of instability. Lateral
studies, we recommend that the medial flexion gap should be laxity theoretically increases the risk of lift-off motion, how-
close to the medial extension gap to achieve near-normal ever, these risks would decrease with neutral alignment.
knee conditions as well as to improve postoperative func- Lateral laxity up to 5 in extension would be acceptable when
tion and patient satisfaction. neutral alignment is achieved.
110 S. Matsuda, H. Ito / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 108e113

Lateral flexion gap: should the objective be a is approximately 32% in men and 17% in women. They
rectangular gap? suggest that aiming for neutral alignment can result in over-
correction in some patients and report that patients with a
The gap technique rotates the femoral component to achieve slight undercorrection have better function and pain scores
equal medial and lateral flexion gaps, forming a rectangular than those with neutral alignment.38 Their cadaveric study
gap.26 Many clinical and cadaveric studies show that in normal shows that restoration of constitutional alignment in TKA
knees, the lateral soft tissue is laxer than the medial soft tissue leads to more physiological strain in the collateral ligaments.39
during flexion.6,10,27 Corroborating this, an magnetic resonance However, there is no definite way to determine the degree of
imaging study by Tokuhara et al28 shows that the lateral side is constitutional varus in a patient, and the “safe zone” of varus
4.6 mm laxer than the medial side. Kobayashi et al29 report that alignment is unknown. Some clinical studies report that
lateral laxity during knee flexion is related to good range of undercorrection does not worsen clinical results40 and that
motion. Another clinical study by Seon et al30 shows no dif- design modification can prevent wear problems even with
ference between knees with rectangular and nonrectangular malalignment.41e43 Nevertheless, concerns about tibial
flexion gaps with respect to knee score or range of motion. Our collapse in varus alignment remain.44e46
fluoroscopic analysis shows that lateral static instability at knee Howell et al47,48 propose kinematic alignment as a way to
flexion is not related to lift-off motion during stairway upe- maximally utilise ligamentous function. Better functional re-
down motion.11 Thus, to date, no studies indicate that a rect- sults were reported with kinematically aligned TKA than
angular flexion gap can improve clinical results. Although a mechanically aligned TKA.49 Kinematically aligned TKA
certain degree of lateral laxity in flexion is acceptable, there are aims to reproduce the preosteoarthritic joint surface and does
not enough data to clarify the “safe range” of imbalance with not align with any axis that has been used in the mechanical
regard to patient symptoms or implant longevity. axis method. However, the precise preosteoarthritic
An important question is how much rotation of the femoral morphology cannot be determined, and this technique incurs a
component is required to achieve a rectangular gap in clinical risk of coronal malalignment, especially for patients with se-
situations. Fehring31 reports that the femoral component is vere constitutional varus. Although these two new ideas have
rotated by approximately 7e8 from the posterior condylar axis, some unresolved problems,50 they pose the very interesting
whereas another study by Heesterbeek et al32 reports a rotation of idea that postoperative knee function can be improved by
3e12 . After medial release, the femoral component tends to be preserving ligamentous tension rather than by sticking to the
in more internal rotation, which can be considered the worst-case mechanical alignment.
scenario. If medial release is performed to produce an equal
medialelateral extension gap, the medial flexion gap usually Surgical technique: medial stabilising TKA
increases more than the extension gap. Finally, the femoral
component should be rotated internally to produce a rectangular The abovementioned clinical and biomechanical studies
flexion gap. Many studies report that an internally rotated indicate that achieving near-normal medial stability in knee
femoral component causes patellofemoral problems33e35 and extension and flexion is very important for better functional
worsens knee function.36 As mentioned above, the medial soft outcomes. By contrast, no results indicate that lateral stability
tissue structure is not contracted (i.e., normal) even in severely should be close to the medial side. For longevity, aiming for
deformed varus knees, whereas lateral soft tissue structure is neutral alignment still seems to be the best target, because
stretched (i.e., abnormal). Therefore, if the normal side is there is no safe zone for malalignment. Here, we propose a
released to adjust it to the abnormal side, another abnormal medial stabilising technique for posterior cruciate-retaining
condition, i.e., medial instability, would occur. TKA. This technique aims for neutral coronal alignment
On the basis of the available clinical and biomechanical with near-normal medial stability.
studies, we recommend that the following principles should be
followed for ligament balancing in TKA for varus knees: (1) Femoral bone resection
the medial extension gap should be within 1e3 mm to avoid
flexion contracture and a feeling of instability; (2) the medial In the proposed technique, the distal femur is cut perpen-
flexion gap should be equal to the medial extension gap (or dicular to its mechanical axis. The level of bone cutting is
1e2 mm larger), because this provides close to normal sta- adjusted so that the same thickness of bone as the implant is
bility and a larger medial flexion gap would worsen knee resected from the medial side. The thickness of the resected
function; (3) lateral extension laxity up to 3 does not cause bone should be measured using callipers. Rotational alignment
severe clinical problems, or a risk of lift-off motion decreases of the femoral component is adjusted to the surgical epi-
with neutral alignment; and (4) the femoral component should condylar axis to improve patellar tracking. The size of the
not be internally rotated to adjust the flexion gap. femoral component is determined on the basis of the posterior
reference. The amount of bone resected is very important for
Alignment and ligament balancing achieving proper tension of the MCL and PCL. Considering
that the distal part of the femur is more worn than the posterior
Bellemans et al37 report that the incidence of a natural limb part,51e53 the size and location of the femoral component are
alignment of 3 varus, which is termed constitutional varus, determined so that the resected bone at the medial posterior
 S. Matsuda, H. Ito / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 108e113 111

condyle is 1e2 mm thicker than the implant thickness (Figure.

1). This procedure avoids excessive tension of the MCL or
PCL throughout knee motion.

Tibial bone resection

The tibia should also be cut perpendicular to the mechan-

ical axis in the coronal plane. Maintaining the preoperative
tibial slope is important for achieving PCL function.54e56
However, to preserve the PCL attachment and avoid exces-
sive slope, we may cut the proximal tibia with a posterior
slope that is 2e3 less than the preoperative slope.57,58
Approximately 10 mm of bone is resected from the most
proximal part of the lateral tibial plateau, however, resection
level and posterior slope should be changed according to the
knee implant system. Rotational alignment of the tibial Figure 2. Extension gap measurement. The medial extension gap is measured
component is adjusted to the anteroposterior axis of the tibia using a small tensor. The tensor shows a gap of 11 mm, therefore, a 10-mm
tibial component was selected to achieve a 1-mm intercomponent gap.
(i.e., the Akagi line59) to avoid rotational mismatch between
the femoral and tibial components.
tibial slope. Because the PCL is more difficult to manage if
Ligament balancing in extension loose, a relatively tight PCL is planned. The medial flexion
gap is then measured using the tensor (Figure. 3); if the gap is
With the femoral trial component, the medial extension gap smaller than that in extension, the tension of the PCL is too
is measured using a small tensor applying a distraction force of tight, because the PCL is the primary restraint for medial
89 N (Figure. 2). The thickness of the tibial insert is selected so flexion stability.60 There are three options to resolve this
that an intercomponent gap of >1 mm is achieved in order to situation: decreasing the anteroposterior size of the femoral
avoid flexion contracture.5 No medial release is usually component, increasing the tibial slope, or releasing the PCL.
required to make spaces for implants when adequate amounts We prefer using knee systems that allow an adjustable ante-
of bones are resected from the femoral and tibial sides. Lateral roposterior size or tibial slope without additional bone
laxity up to 3 can be left, because this does not cause severe resection, because the effect of PCL release is uncertain.
clinical problems. Extensive medial release is not recom- Because the rotational alignment of the femoral component is
mended for achieving an equal mediolateral extension gap, adjusted to the bony landmark in this surgical technique, the
because this procedure would cause medial laxity in flexion. lateral soft tissue may be laxer than the medial side in varus
knees. When the PCL and MCL are retained, ligamentous
Ligament balancing in flexion release solely on the medial soft tissue cannot resolve this
ligament imbalance. However, as described above, creating a
The proposed surgical technique might tighten the PCL rectangular flexion space is not always necessary for suc-
when the proximal tibia is cut with a decreased posterior cessful TKA.

Figure 1. Surgical planning of the femoral resection. (A) A 9-mm section (same thickness as that of the implant) is resected from the distal medial part. (B) A 13-
mm section (1 mm thicker than the implant; NexGen CR Flex) is resected from the posterior medial part.
112 S. Matsuda, H. Ito / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 108e113

retaining TKA, and the technique described herein is one

example of a medial stabilising surgical technique.

Conflicts of interest

The authors have no conflicts of interest relevant to this

article.

Funding/support

No financial or material support of any kind was received

for the work described in this article.

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