Gap balancing versus measured resection in TKA—Evidence for/against measured resection

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Measured resection is a total knee arthroplasty (TKA) technique that relies on bony landmarks to set component placement and adapts the soft tissues to the chosen implant position. It is an effective method and commonly used by surgeons around the globe. In Part 3 of this article series we look at measured resection and explore the benefits and shortcomings of this technique.

 

 

Establishing acceptable component positioning and soft tissue tensioning are two important aspects of TKA that influence patient outcomes [1, 2, 3]. If these considerations are not adequately addressed then patients can experience pain and implant malfunction or wear [4]. Studies have shown that between 8 and 19% of patients report being dissatisfied with their TKA for various reasons, including pain and unmet expectations [5, 6]. A few problems that could result from malrotation and/or incorrect soft tissue tensioning are: patellofemoral instability [7], anterior knee pain [8], arthrofibrosis [9], and flexion gap instability [10].

Measured resection is one technique commonly used by surgeons during TKA to attain correct alignment and soft tissue tension, and ideally deliver a pain-free knee that allows patients a return to daily activities [11]. It has been suggested that North American surgeons predominantly use measured resection versus gap balancing, while the use of the techniques is likely more variable within Europe [12]. Part 1 of this article series explains why surgeons would prefer one technique over the other.

 

Measured resection philosophy

Measured resection is characterized by the use of bony landmarks to determine femoral component rotation [7, 13, 14]. With this technique, and in contrast to gap balancing, bone cuts are made before soft tissue tensioning takes place. Generally, three bony landmarks are referenced [12, 15]. These are the: transepicondylar axis (TEA) (surgical and anatomical); anteroposterior axis (AP) or ‘Whiteside’s line’; and posterior condylar axis (PCA). These axes should not be used singularly, but in combination [11] as unique variations in anatomy and/or deformity can skew femoral component placement [8]. Additionally, surgeons may have difficulty accurately identifying these landmarks during TKA [8]. Figure 1 shows these landmarks.

 

Figure 1. The transepicondylar axis (TEA), anterior-posterior (AP) (Whiteside’s line), and posterior condylar (PCA) axis. (CC) Daines BK, Dennis DA. Gap balancing vs. measured resection technique in total knee arthroplasty. Clin Orthop Surg. 2014 Mar;6(1):1-8. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942594/.

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  • Transepicondylar axis (TEA)
  • Anterioposterior axis (AP)
  • Posterior condylar axis (PCA)
  • A note about intraoperative identification of axes
  • The pros of measured resection
  • The cons of measured resection
  • Conclusion
  • References

Part 1 | Brief comparison of the techniques

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Part 2 | Evidence for/against gap balancing

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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Matthew P Abdel MD

Mayo Clinic
Rochester, United States

Philipp von Roth MD

Charité—University Medicine Berlin
Berlin, Germany

This issue was created by Word+Vision Media Productions, Switzerland

 

References

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