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Speaker: Avoid tissue releases to achieve ligamentous balance in TKA
Cutting the bone may help balance the soft tissues during TKA.
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By cutting the tibia first during primary total knee arthroplasty, an investigator found joint balance can be obtained in the soft tissues without resorting to the conventional practice of cutting ligaments to achieve balance.
David E. Beverland, MD, FRCS, of Belfast, United Kingdom, said that because the collateral ligaments do not contract he never releases them when performing a total knee arthroplasty (TKA).
“I have been using this technique since 2001, doing it in 6,000 consecutive knees, over 98% of cementless and all mobile bearing, with no revisions to date for mechanical loosening,” Beverland said at the Current Concepts in Joint Replacement Winter Meeting. “Essentially, the concept I am proposing is leaving the ligaments alone and cutting the bone to balance the soft tissues as opposed to the conventional philosophy, which is to cut the soft tissues to balance the bone cuts.”
Gap alignment comes first
Instead of focusing on limb alignment during TKA, Beverland focuses on gap alignment. To do this in a varus knee, the tibia-first technique is used and anterior-posterior cuts are made using a femoral guide positioner. Osteophytes are then removed from the knee.
This technique successfully aligns the soft tissue tension of the ligaments to the center of the femoral tension, Beverland said.
“This is the key step. I do a pre-cut, or a conservative cut, at 5° on the distal femur. You use a spacer block, and you use it for two purposes. First of all, to measure the size and depth of the gap, but more importantly, to assess the balance of the gap. If the gap is not balanced, then instead of releasing ligaments, I simply recut the femur at a different angle to balance or align the gap. I do not recut the tibia,” Beverland said.
According to Beverland, the goal is pre-morbid alignment. Once any osteophytes are carefully removed, he said this technique works in the vast majority of varus knees and therefore the posterolateral capsule is rarely ever released.
Keep it balanced
However, in a fixed valgus knee, the posterolateral capsule often has to be cut during the procedure before the recut on the distal femur is made, which is the only difference in the valgus knee technique compared with the varus knee technique, he said.
As such, Beverland said usually there are far less osteophytes to deal with in a valgus knee both on the femur and tibia.
“The key thing after the pre-cut in the valgus knee is to assess the gap. If the gap is less than 2 mm, then I make a recut of the same angle. If it is 2 mm to 5 mm, I recut at a new angle to make the gap rectangular. If it is over 5 mm, then that is when you have to consider a release of the posterolateral capsule,” he said. – by Robert Linnehan
- Reference:
- Beverland DE. Paper #127. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 10-13, 2014; Orlando, Fla., USA.
- For more information:
- David E. Beverland, MD, FRCS, can be reached at Musgrave Hospital, 20 Stockman’s Lane, Belfast BT9 7JB, United Kingdom; email: david.beverland@belfasttrust.hscni.net.
Disclosure: Beverland reports no relevant financial disclosures.
Perspective
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Jean-Noel A. Argenson, MD
There are two basic principles to achieve a mobile, well-aligned and stable knee following total knee arthroplasty (TKA): either make the bone cuts with appropriate landmarks for rotation and then balance the soft tissues for any residual deformity or use a tension device to determine the appropriate rotation based on the tension of the soft tissues.
This abstract refers to the latter one, including the concept of individual axis alignment rather than the commonly accepted alignment of the limb applicable to every knee following TKA.
This raises the issue of defining what is the proper alignment for each individual to restore a mobile, well-aligned and stable knee following TKA, which is in theory the ideal scenario, but one must also include the potential of outliers, especially in varus, if proper individual alignment is not defined correctly or excessive varus is achieved related to the inexperience of the operator.
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