the knee society | virtual fellowship
THE KNEE SOCIETY | VIRTUAL FELLOWSHIP CHAPTER 4 “LIGAMENT BALANCING”
Chapter 4: LIGAMENT BALANCING: MEDIAL, LATERAL, POSTERIOR CAPSULE, and PCL considerations Presented by: William M. Mihalko MD PhD; Kenneth A. Krackow, MD and Leo A. Whiteside, MD COPYRIGHT © 2016 THE KNEE SOCIETY
INTRODUCTION Proper ligament balancing
after TKA is desired to optimize stability and implant longevity (Sharkey 2002 CORR, Callaghan 2004, Lombardi 2013) Multiple release techniques of medial and lateral structures have been reported and many surgeons use different techniques to test for flexion and extension gap balancing.
INTRODUCTION The techniques used
intraoperatively to test for balancing include spacer blocks, tensioners, and varus and valgus stress with trial components in place
STEPS BEFORE BALANCING THE SOFT TISSUE SLEEVE: MATCHED RESECTION First all bone cuts are made on the femur
and tibia. Osteophyte excision is then carried out to
assure no soft tissues are affected. If Tibia cut is made first still need
osteophyte excision and gap balancing assessment.
REVIEW OF PREVIOUS STUDIES Several cadaveric investigations
of medial and lateral structural release for ligament balancing On the medial side these have
included release off of the tibia or pie crusting of the soft tissue sleeve On the lateral side traditional
techniques included sharp release off of the femoral side of the joint and pie crusting has been reported targeting tight strucures.
COPYRIGHT © 2016 THE KNEE SOCIETY
TESTING PCL IN CR TKA In 900 of flexion: Posterior femoral condyles should be in the posterior half of tibial tray A posterior drawer test should not exceed 10mm with a solid end point If PCL is excessively tight the trial insert may lift off anteriorly from the trial tray. If this occurs then balancing the PCL should be considered. COPYRIGHT © 2016 THE KNEE SOCIETY
MEDIAL PIE CRUSTING IN THE VARUS KNEE The anterior half of the medial soft
tissue sleeve allowed more effect in flexion while the posterior half allowed more effect in extension
Mihalko WM, Woodard EL, Hebert CT, Crockarell JR, Williams JL. Biomechanical validation of medial pie-crusting for soft-tissue balancing in knee arthroplasty. J Arthroplasty. 2015 Feb;30(2):296-9. Whiteside LA, Saeki K, Mihalko WM Functional medial ligament balancing in TKA. Clin Orthop Relat Res. 2000 Nov;(380):45-57.
OTHER BALANCING TECHNIQUES FOR THE VARUS KNEE: REDUCTION OSTEOTOMY Down size the tibia
baseplate and shift the implant to lateral edge Shave off the excess
sclerotic bone medially Aids in patellar tracking
and affords some laxity to medial soft tissue sleeve.
COPYRIGHT © 2016 THE KNEE SOCIETY
COPYRIGHT © 2016 THE KNEE SOCIETY
COPYRIGHT © 2016 THE KNEE SOCIETY
COPYRIGHT © 2016 THE KNEE SOCIETY
LATERAL SOFT TISSUE RELEASES FOR THE VALGUS KNEE Structures available for release
include: Lateral collateral ligament
Popliteus tendon Iliotibial band
Posterolateral corner Posterior capsule/LG In general structures are
released off of the femoral side of the joint.
Valgus Case Presentation
Popliteus
LCL
SOFT TISSUE PIE CRUSTING IN THE VALGUS KNEE Pie crusting of lateral soft tissue sleeve made
popular by Ranawat and others Biomechanical evaluation has shown the
greatest change occurs when the LCL is effectively released Mihalko WM, Krackow KA: J Arthroplasty. 2000
Apr;15(3):347-53. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ,
Rossi R, Babhulkar S. J Bone Joint Surg Am. 2005 Sep;87 Suppl 1(Pt 2):271-84.
SAME PC TECHNIQUE: FEEL WHAT IS TIGHT
Using spacer blocks or a tensioning device or trial components to fill the gap in flexion and extension Feel the tight structures or “bands” and target only these structures with PC COPYRIGHT © 2016 THE KNEE SOCIETY
COPYRIGHT © 2016 THE KNEE SOCIETY
OUTSIDE IN ITB PIE CRUSTING Develop lateral plane
Feel the area that is tight on
the ITB Make sure most posterior
aspect all the way to Biceps Femoris is checked COPYRIGHT © 2016 THE KNEE SOCIETY
THE VALGUS KNEE AND THE POSTERIOR CAPSULE Posterior capsule and if
need be lateral head of gastrocnemius in a valgus deformity if a flexion contracture persists COPYRIGHT © 2016 THE KNEE SOCIETY
CONCLUSIONS Regardless of the technique for testing soft tissue balancing
similar results can be obtained The importance is that regardless of technique utilized that the
knee is checked for balancing in both extension and flexion and the appropriate tight structures targeted for release during the procedure to balance the flexion and extension gaps.
Chapter 4: LIGAMENT BALANCING: MEDIAL, LATERAL, POSTERIOR CAPSULE, and PCL considerations Presented by: William M. Mihalko MD PhD; Kenneth A. Krackow, MD and Leo A. Whiteside, MD COPYRIGHT © 2016 THE KNEE SOCIETY
INTRODUCTION Proper ligament balancing
after TKA is desired to optimize stability and implant longevity (Sharkey 2002 CORR, Callaghan 2004, Lombardi 2013) Multiple release techniques of medial and lateral structures have been reported and many surgeons use different techniques to test for flexion and extension gap balancing.
INTRODUCTION The techniques used
intraoperatively to test for balancing include spacer blocks, tensioners, and varus and valgus stress with trial components in place
STEPS BEFORE BALANCING THE SOFT TISSUE SLEEVE: MATCHED RESECTION First all bone cuts are made on the femur
and tibia. Osteophyte excision is then carried out to
assure no soft tissues are affected. If Tibia cut is made first still need
osteophyte excision and gap balancing assessment.
REVIEW OF PREVIOUS STUDIES Several cadaveric investigations
of medial and lateral structural release for ligament balancing On the medial side these have
included release off of the tibia or pie crusting of the soft tissue sleeve On the lateral side traditional
techniques included sharp release off of the femoral side of the joint and pie crusting has been reported targeting tight strucures.
COPYRIGHT © 2016 THE KNEE SOCIETY
TESTING PCL IN CR TKA In 900 of flexion: Posterior femoral condyles should be in the posterior half of tibial tray A posterior drawer test should not exceed 10mm with a solid end point If PCL is excessively tight the trial insert may lift off anteriorly from the trial tray. If this occurs then balancing the PCL should be considered. COPYRIGHT © 2016 THE KNEE SOCIETY
MEDIAL PIE CRUSTING IN THE VARUS KNEE The anterior half of the medial soft
tissue sleeve allowed more effect in flexion while the posterior half allowed more effect in extension
Mihalko WM, Woodard EL, Hebert CT, Crockarell JR, Williams JL. Biomechanical validation of medial pie-crusting for soft-tissue balancing in knee arthroplasty. J Arthroplasty. 2015 Feb;30(2):296-9. Whiteside LA, Saeki K, Mihalko WM Functional medial ligament balancing in TKA. Clin Orthop Relat Res. 2000 Nov;(380):45-57.
OTHER BALANCING TECHNIQUES FOR THE VARUS KNEE: REDUCTION OSTEOTOMY Down size the tibia
baseplate and shift the implant to lateral edge Shave off the excess
sclerotic bone medially Aids in patellar tracking
and affords some laxity to medial soft tissue sleeve.
COPYRIGHT © 2016 THE KNEE SOCIETY
COPYRIGHT © 2016 THE KNEE SOCIETY
COPYRIGHT © 2016 THE KNEE SOCIETY
COPYRIGHT © 2016 THE KNEE SOCIETY
LATERAL SOFT TISSUE RELEASES FOR THE VALGUS KNEE Structures available for release
include: Lateral collateral ligament
Popliteus tendon Iliotibial band
Posterolateral corner Posterior capsule/LG In general structures are
released off of the femoral side of the joint.
Valgus Case Presentation
Popliteus
LCL
SOFT TISSUE PIE CRUSTING IN THE VALGUS KNEE Pie crusting of lateral soft tissue sleeve made
popular by Ranawat and others Biomechanical evaluation has shown the
greatest change occurs when the LCL is effectively released Mihalko WM, Krackow KA: J Arthroplasty. 2000
Apr;15(3):347-53. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ,
Rossi R, Babhulkar S. J Bone Joint Surg Am. 2005 Sep;87 Suppl 1(Pt 2):271-84.
SAME PC TECHNIQUE: FEEL WHAT IS TIGHT
Using spacer blocks or a tensioning device or trial components to fill the gap in flexion and extension Feel the tight structures or “bands” and target only these structures with PC COPYRIGHT © 2016 THE KNEE SOCIETY
COPYRIGHT © 2016 THE KNEE SOCIETY
OUTSIDE IN ITB PIE CRUSTING Develop lateral plane
Feel the area that is tight on
the ITB Make sure most posterior
aspect all the way to Biceps Femoris is checked COPYRIGHT © 2016 THE KNEE SOCIETY
THE VALGUS KNEE AND THE POSTERIOR CAPSULE Posterior capsule and if
need be lateral head of gastrocnemius in a valgus deformity if a flexion contracture persists COPYRIGHT © 2016 THE KNEE SOCIETY
CONCLUSIONS Regardless of the technique for testing soft tissue balancing
similar results can be obtained The importance is that regardless of technique utilized that the
knee is checked for balancing in both extension and flexion and the appropriate tight structures targeted for release during the procedure to balance the flexion and extension gaps.
