SOFT TISSUE BALANCING IN TKR

INTRODUCTION
• Both medial and lateral ligaments
may be stretched or contracted with
time
• It is essential to balance these
ligament in both the coronal and
sagittal plane to obtain an optimum
outcome.
 PATHOPHYSIOLOGY
concave side
• tight ligaments that need release
convex side
• stretched ligaments that need tightening
 VARUS DEFORMITY
Anatomy
• medial side is tight (concave), lateral side
stretched (convex)
Goals
• create precise bone cuts
• release the tight medial ligaments
• tighten the lax lateral ligaments
• balance flexion and extension gaps by adjustment
of polyethylene bearing thicknesss
 1.MEDIAL EXPOSURE
• Make the initial exposure to include
release of the deep MCL off the tibia
to the posteromedial corner of the
knee.
 2.BONE CUTS
• Make the bone cuts using the
preferred technique (intramedullary
or extramedullary guide, computer
navigation, custom cutting blocks).
 3.OSTEOPHYTES REMOVAL
• Remove all osteophytes on the femur and the
tibia
• because they can tent the medial soft-tissue
sleeve and effectively shorten the MCL.
 4.PCL RELEASE
• Make sure the PCL is resected before
balancing.
• Because the PCL is a secondary medial
stabilizer, take care not to release the entire
soft-tissue sleeve off the tibia because it may
overshoot the gap.
• In general, less soft-tissue release is needed to
balance a varus knee once the PCL is resected.
 5.SUPERFICIAL MCL RELEASE
• Assess the flexion and extension gaps.
• If the gaps are tight, release the
superficial MCL subperiosteally off the
proximal tibia, but do not completely
release it off the tibia.
• Recheck the gaps in flexion and
extension.
 6.SEMI MEMBRANOSUS RELEASE
• If the extension gap is tight only medially in
extension, the posterior oblique ligament
portion can be subperiosteally released now
or later in the soft-tissue balancing procedure.
• If the extension gaps remains tight medially,
the semimembranosus and posteromedial
capsule can be released.
• If the flexion gap is tight, the anterior
aspect of the superficial MCL and the
pes anserinus insertion can be
released.
 7.RESIDUAL LCL LAXITY
• If the entire soft-tissue sleeve is
released and the medial gap is still
tight (as is usually the case with
severe varus deformity), consider
advancing the LCL.
 VALGUS DEFORMITY
Anatomy
• lateral side is tight (concave), medial side
stretched (convex)
Goals
• create precise bone cuts
• release the tight lateral ligaments
• tighten the lax medial ligaments
• balance flexion and extension gaps by adjustment
of polyethylene bearing thicknesss
STEPS
• Make the bone cuts using preferred
technique
• 2. Remove osteophytes
• 3. Release lateral capsule from tibia.
• 4. Release LCL off lateral epicondyle if
both extension and flexion gaps are tight
• 5. Release iliotibial band if tight in
extension
• 6. Release of popliteus tendon
• 7. Release the posterior capsule off the
lateral femoral condyle
• 8. Release the lateral head of
gastrocnemius if further correction is
needed.
• 9. consider advancement of the MCL.
 PIE-CRUSTING TECHNIQUE
• Another technique used for soft tissue
balancing in knees with valgus or varus
deformity.
• This technique allows the surgeon to direct
the lengthening of soft-tissue supporting
structures according to which areas are taut
under tension or under varus and valgus stress
in the operating room.
• Multiple stabs made with a scalpel blade or
large needle parallel to the joint line are used
to effectively elongate the areas of the soft-
tissue sleeve that are under undue tension
A, Knee with valgus deformity before intraarticular release of posterolateral aspect
of capsule (PC). Note trapezoidal extension gap.
B, Correction of deformity after release of posterolateral aspect of capsule and
pie-crusting of iliotibial band. Note resulting rectangular extension gap.
FLEXION/CONTRACTURE DEFORMITY
Anatomy
• concave side is posterior- needs to be released
Posterior release order
• 1) posterior femoral & posterior tibial
osteophytes
• 2) posterior capsule
• 3) additional resection of distal femur
• 4) gastronemius muscles (medial and lateral)
• All releases are performed with knee at 90
degrees of flexion
-allows the popliteal artery to fall posteriorly to
decrease risk of injury
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