Gap Balancing vs. Measured Resection Technique in Total Knee Arthroplasty

A goal of total knee arthroplasty is to obtain symmetric and balanced flexion and extension gaps. Controversy exists regarding the best surgical technique to utilize to obtain gap balance. Some favor the use of a measured resection technique in which bone landmarks, such as the transepicondylar, the anterior-posterior, or the posterior condylar axes are used to determine proper femoral component rotation and subsequent gap balance. Others favor a gap balancing technique in which the femoral component is positioned parallel to the resected proximal tibia with each collateral ligament equally tensioned to obtain a rectangular flexion gap. Two scientific studies have been performed comparing the two surgical techniques. The first utilized computer navigation and demonstrated a balanced and rectangular flexion gap was obtained much more frequently with use of a gap balanced technique. The second utilized in vivo video fluoroscopy and demonstrated a much high incidence of femoral condylar lift-off (instability) when a measured resection technique was used. In summary, the authors believe gap balancing techniques provide superior gap balance and function following total knee arthroplasty.

Patellofemoral Crepitus after Total Knee Arthroplasty: Etiology and Preventive Measures

Patellofemoral crepitus and clunk syndrome are infrequent, yet troublesome complications of total knee arthroplasty with a reported incidence of 0%-18%. They are primarily associated with implantation of posterior cruciate substituting designs. These entities are the result of peripatellar fibrosynovial hyperplasia at the junction of the superior pole of the patella and the distal quadriceps tendon which becomes entrapped within the superior aspect of the intercondylar box of the femoral component during knee flexion. When the knee extends, a crepitant sensation occurs as the fibrosynovial tissue exits the intercondylar box. Numerous etiologies have been proposed such as femoral component designs with a high intercondylar box ratio, previous knee surgery, reduced patellar tendon length, thinner patellar components, reduced patella-patellar component composite thickness, and smaller femoral components. Preventative measures include choice of femoral components with a reduced intercondylar box ratio, use of thicker patellar components, avoidance of over-resection of the patella, and debridement of the fibrosynovial tissue at the time of knee arthroplasty. Most patients with crepitus are unaware of the problem or have minimal symptoms so that no treatment is required. If significant disability is incurred, symptoms can be eliminated in a high percentage of patients with arthroscopic debridement of the fibrosynovial hyperplasia.