A gap balancing technique for adjusting the component gap in total knee arthroplasty using a navigation system

Introduction: Recently, some studies showed assessment of the component gap is important for determination of the implant-inserted condition during total knee arthroplasty (TKA). We perform the modified gap technique with adjustment of the virtual gap which estimated by computer-aided design (CAD) using navigation system. The purpose of this study was to compare the virtual gap (CAD-gap) with the actual gap after inserting a femoral trial component (Trial-gap), and examine the usefulness of the surgical technique. Materials and methods: The subjects were 35 patients who underwent primary TKA using a navigation system and posterior-stabilized type TKA. The surgical procedure was to produce an extension gap, confirm the flexed CAD-gap on the navigation screen based on CAD data, and plan osteotomy of the femur. After osteotomy, the femoral component was inserted and the gap balance was measured. A tensor was used to adjust and measure the gap balance. Initial alignment, rotation of the femoral component, soft tissue balance in extension, final alignment after fixing all components, and the CAD - and Trial-gaps in both extension and flexion were evaluated. Results: The mean initial alignment angle, rotation angle of the femoral component, soft tissue balance angle and final alignment angle were 8.1 +/- 4.2 degrees varus, 3.5 +/- 1.3 degrees external rotation, 2.7 +/- 2.5 degrees varus and 0.4 +/- 1.4 degrees varus respectively. The mean medial and lateral CAD -gaps in extension were 10.8 +/- 2.5 and 13.7 +/- 2.5 mm, and the mean medial and lateral CAD-gaps in flexion were 12.2 +/- 2.2 and 13.9 +/- 2.7 mm. The equivalent Trial-gaps in extension and flexion were 10.5 +/- 2.6 and 11.4 +/- 3.1 mm, and 12.2 +/- 2.5 and 14.4 +/- 2.8 mm. The CAD- and Trial-gaps differed significantly only for lateral gaps in extension. Conclusion: In comparing the CAD-gap and the Trial-gap, only small difference was found in the lateral gap of extension. The other gaps in both extension and flexion were well maintained. We concluded adjustment of the CAD-gap during surgery using a navigation system can be used to adjust the actual component gap especially in the medial side. (C) 2020 Asia Pacific Knee, Arthroscopy and Sports Medicine Society. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).