The Clinical Outcomes of Measured Resection and Gap Balancing Techniques in Primary Total Knee Arthroplasty: A Meta-analysis

Abstract

Background At present, the clinical efficacy of measured resection (MR) and gap balancing (GB) techniques in total knee arthroplasty (TKA) is still controversial. The objective of this study was to evaluate the clinical outcome indexes of the two surgical methods through a meta-analysis.

Methods The literature was systematically searched on PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), WANFANG, Weipu (VIP), and China Biomedical Literature (CBM) electronic databases inception until June 12, 2022. RevMan 5.3 software (the Nordic Cochrane Center, the Cochrane Collaboration, Copenhagen, Denmark) was used to analyze all data of this study. The Cochrane risk bias assessment tool is a risk bias evaluation criterion recommended by the Cochrane Handbook for systematic reviews.

Results Eleven studies involving 1268 knees in total were included. The main outcome indexes showed that the Knee Society Score (KSS) knee score (MD: −1.40; 95% CI: −2.57 to −0.22; p = 0.02) and KSS knee function score (MD: −3.11; 95% CI: −3.72 to −2.50; p < 0.001) in the GB group were higher 1 year after operation, while femoral component rotation angle (FCRA; MD: −0.75; 95% CI: −1.34 to −0.07; p = 0.03) and the osteotomy volume of the posterior medial femoral condyle (MD: −0.76; 95% CI; −1.13 to −0.38; p < 0.001) were greater in the GB group. In addition, there was no significant difference in the joint line change (MD: −0.03; 95% CI: −0.07 to 0.01; p = 0.16) between the two groups. Secondary outcome results showed that the knee joint range of motion (ROM) in 3 months, and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score after 1 year were better in the GB group. However, the operation time of the MR group was shorter. In addition, this study revealed no significant differences in post-complications between these two groups.

Conclusion Although the GB technique may not provide better radiographic results or reduce the complication rate, the recovery of joint function showed earlier improvement.

Zusammenfassung

Hintergrund Derzeit ist die klinische Wirksamkeit von gemessenen Resektions- (MR) und Gap-Balancing-Techniken (GB) in der totalen Kniearthroplastik (TKA) noch umstritten.

Ziel Diese Studie wird die klinischen Ergebnisindizes der beiden chirurgischen Methoden durch eine Metaanalyse bewerten.

Methoden Bis zum 12. Juni 2022 wurden systematische Literaturrecherchen aus elektronischen Datenbanken durchgeführt, darunter PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), WANFANG, Weipu (VIP) und China Biomedical Literature (CBM). Die RevMan 5.3 Software wurde verwendet, um alle Daten dieser Studie zu analysieren. Zur Beurteilung der Literaturqualität wurde das Cochrane Risk Bias Assessment Tool verwendet.

Ergebnisse Es wurden 11 Studien mit insgesamt 1268 Knien eingeschlossen. Die wichtigsten Ergebnisindizes zeigten, dass der Knee Society Score (KSS; MD: −1,40; 95%-KI: −2,57 bis −0,22; P = 0,02) und der KSS-Kniefunktions-Score (MD: −3,11; 95%-KI: −3,72 bis −2,50; P < 0,001) in der GB-Gruppe 1 Jahr nach der Operation höher waren. Der Rotationswinkel der femoralen Komponente (FCRA; MD: −0,75; 95%-KI: −1,34 bis −0,07; P = 0,03) und das Osteotomievolumen des hinteren medialen Femurkondylus (MD: −0,76; 95%-KI: −1,13 bis −0,38; P < 0,001) waren in der GB-Gruppe größer. Darüber hinaus gab es keinen signifikanten Unterschied in der Änderung der Gelenklinie (MD: −0,03; 95%-KI: −0,07 bis 0,01; P = 0,16) zwischen den beiden Gruppen. Sekundäre Endpunkte zeigten, dass der Bewegungsumfang des Kniegelenks (ROM) in 3 Monaten und der Western Ontario and McMaster University Osteoarthritis Index (WOMAC) in 1 Jahr in der GB-Gruppe besser waren. Allerdings war die Operationszeit der MR-Gruppe kürzer. Darüber hinaus hat diese Studie keine signifikanten Unterschiede in den Postkomplikationen zwischen diesen beiden Techniken gezeigt.

Schlussfolgerung Obwohl die Gap-Balancing-Technik möglicherweise keine besseren Röntgenergebnisse liefert oder die Komplikationsrate reduziert, war die Wiederherstellung der Gelenkfunktion frühzeitig besser.

Keywords

gap balancing technique - measured resection technique - knee - total knee arthroplasty - meta-analysis - clinical outcomes

Schlüsselwörter

Spaltausgleichsverfahren - messbare Resektionstechnik - Knie - Metaanalyse - klinische Ergebnisse

Publikationsverlauf

Eingereicht: 22. Dezember 2022

Angenommen: 07. März 2023

Artikel online veröffentlicht:
23. Mai 2023

• References

• 1 Arden N, Nevitt MC. Osteoarthritis: epidemiology. Best Pract Res Clin Rheumatol 2006; 20: 3-25 DOI: 10.1016/j.berh.2005.09.007. (PMID: 16483904)
• 2 Kurtz S, Ong K, Lau E. et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89: 780-785 DOI: 10.2106/JBJS.F.00222. (PMID: 17403800)
• 3 Ritter MA, Faris PM, Keating EM. et al. Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res 1994; (299) 153-156 (PMID: 8119010)
• 4 Daines BK, Dennis DA. Gap balancing vs. measured resection technique in total knee arthroplasty. Clin Orthop Surg 2014; 6: 1-8 DOI: 10.4055/cios.2014.6.1.1. (PMID: 24605183)
• 5 She GR, Zha ZG. Gap balancing versus measured resection in primary total knee arthroplasty: A retrospective cohort study protocol. Medicine (Baltimore) 2020; 99: e20017 DOI: 10.1097/MD.0000000000020017. (PMID: 32443303)
• 6 W-Dahl A, Robertsson O. Similar outcome for total knee arthroplasty after previous high tibial osteotomy and for total knee arthroplasty as the first measure. Acta Orthop 2016; 87: 395-400 DOI: 10.1080/17453674.2016.1195663. (PMID: 27339330)
• 7 Migliorini F, Eschweiler J, Mansy YE. et al. Gap balancing versus measured resection for primary total knee arthroplasty: a meta-analysis study. Arch Orthop Trauma Surg 2020; 140: 1245-1253 DOI: 10.1007/s00402-020-03478-4. (PMID: 32409905)
• 8 Moon YW, Kim HJ, Ahn HS. et al. Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2016; 95: e5006 DOI: 10.1097/MD.0000000000005006. (PMID: 27684862)
• 9 Li S, Luo X, Wang P. et al. Clinical Outcomes of Gap Balancing vs Measured Resection in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis Involving 2259 Subjects. J Arthroplasty 2018; 33: 2684-2693 DOI: 10.1016/j.arth.2018.03.015. (PMID: 29656972)
• 10 Huang T, Long Y, George D. et al. Meta-analysis of gap balancing versus measured resection techniques in total knee arthroplasty. Bone Joint J 2017; 99-B: 151-158 DOI: 10.1302/0301-620X.99B2.BJJ-2016-0042.R2. (PMID: 28148655)
• 11 Xiao Q, Liu B, Zhao B. Gap balancing improve squat function and knee function: a randomized controlled trial comparing gap balancing and measured resection. J Orthop Surg Res 2021; 16: 242 DOI: 10.1186/s13018-021-02367-9. (PMID: 33832531)
• 12 Zhang Y, Zhang Y, Sun JN. et al. Comparison of outcomes between gap balancing and measured resection techniques for total knee arthroplasty: A prospective, randomized, controlled trial. Acta Orthop Traumatol Turc 2021; 55: 239-245 DOI: 10.5152/j.aott.2021.20160. (PMID: 34100365)
• 13 Wu D, Si LN, Wu LZ. et al. Effects of two different osteotomy methods on lower limb alignment and cartilage degeneration in patients after total knee joint surgery. J Pract Med 2022; 38: 415-420
• 14 Moher D, Shamseer L, Clarke M. et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; 4: 1 DOI: 10.1186/2046-4053-4-1. (PMID: 25554246)
• 15 Wojtyniak JG, Britz H, Selzer D. et al. Data Digitizing: Accurate and Precise Data Extraction for Quantitative Systems Pharmacology and Physiologically-Based Pharmacokinetic Modeling. CPT Pharmacometrics Syst Pharmacol 2020; 9: 322-331 DOI: 10.1002/psp4.12511. (PMID: 32543786)
• 16 Egger M, Davey Smith G, Schneider M. et al. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629-634 DOI: 10.1136/bmj.315.7109.629. (PMID: 9310563)
• 17 Babazadeh S, Dowsey MM, Stoney JD. et al. Gap balancing sacrifices joint-line maintenance to improve gap symmetry: a randomized controlled trial comparing gap balancing and measured resection. J Arthroplasty 2014; 29: 950-954 DOI: 10.1016/j.arth.2013.09.036. (PMID: 24183325)
• 18 Cidambi KR, Robertson N, Borges C. et al. Intraoperative Comparison of Measured Resection and Gap Balancing Using a Force Sensor: A Prospective, Randomized Controlled Trial. J Arthroplasty 2018; 33: S126-S130 DOI: 10.1016/j.arth.2018.02.044. (PMID: 29602537)
• 19 Hommel H, Kunze D, Hommel P. et al. Small Improvements in Postoperative Outcome with Gap Balancing Technique Compared with Measured Resection in Total Knee Arthroplasty. Open Orthop J 2017; 11: 1236-1244 DOI: 10.2174/1874325001711011236. (PMID: 29290862)
• 20 Moorthy V, Lai MC, Liow MHL. et al. Similar postoperative outcomes after total knee arthroplasty with measured resection and gap balancing techniques using a contemporary knee system: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2021; 29: 3178-3185 DOI: 10.1007/s00167-020-06103-4. (PMID: 32556437)
• 21 Fan L, Yang D, Liu KY. et al. The comparison of gap balance technique and measured resection technique in total knee arthroplasty. Chin J Orthop 2019; 2019: 935-943
• 22 Nikolaides AP, Kenanidis EI, Papavasiliou KA. et al. Measured resection versus gap balancing technique for femoral rotational alignment: a prospective study. J Orthop Surg (Hong Kong) 2014; 22: 158-162 DOI: 10.1177/230949901402200208. (PMID: 25163946)
• 23 Tanaka K, Muratsu H, Mizuno K. et al. Soft tissue balance measurement in anterior cruciate ligament-resected knee joint: cadaveric study as a model for cruciate-retaining total knee arthroplasty. J Orthop Sci 2007; 12: 149-153 DOI: 10.1007/s00776-006-1108-8. (PMID: 17393270)
• 24 Jang ES, Connors-Ehlert R, LiArno S. et al. Accuracy of Reference Axes for Femoral Component Rotation in Total Knee Arthroplasty: Computed Tomography-Based Study of 2,128 Femora. J Bone Joint Surg Am 2019; 101: e125 DOI: 10.2106/JBJS.19.00438. (PMID: 31800427)
• 25 Lee DH, Park JH, Song DI. et al. Accuracy of soft tissue balancing in TKA: comparison between navigation-assisted gap balancing and conventional measured resection. Knee Surg Sports Traumatol Arthrosc 2010; 18: 381-387 DOI: 10.1007/s00167-009-0983-x. (PMID: 19924399)
• 26 Lee HJ, Lee JS, Jung HJ. et al. Comparison of joint line position changes after primary bilateral total knee arthroplasty performed using the navigation-assisted measured gap resection or gap balancing techniques. Knee Surg Sports Traumatol Arthrosc 2011; 19: 2027-2032 DOI: 10.1007/s00167-011-1468-2. (PMID: 21431374)
• 27 Becker R, Malzdorf M, Stärke C. et al. No difference between tibia-first and femur-first techniques in TKA using computer-assisted surgery. Knee Surg Sports Traumatol Arthrosc 2012; 20: 2011-2016 DOI: 10.1007/s00167-012-1928-3. (PMID: 22366974)
• 28 Hirakawa Y, Hara M, Fujiwara A. et al. The relationship among psychological factors, neglect-like symptoms and postoperative pain after total knee arthroplasty. Pain Res Manag 2014; 19: 251-256 DOI: 10.1155/2014/471529. (PMID: 25101335)
• 29 Chen W, Sun JN, Hu ZH. et al. Cognitive behavioral therapy cannot relieve postoperative pain and improve joint function after total knee arthroplasty in patients aged 70 years and older. Aging Clin Exp Res 2021; 33: 3293-3302 DOI: 10.1007/s40520-021-01870-7. (PMID: 33991330)
• 30 Baker PN, van der Meulen JH, Lewsey J. et al. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Joint Surg Br 2007; 89: 893-900 DOI: 10.1302/0301-620X.89B7.19091. (PMID: 17673581)
• 31 Harman MK, Banks SA, Kirschner S. et al. Prosthesis alignment affects axial rotation motion after total knee replacement: a prospective in vivo study combining computed tomography and fluoroscopic evaluations. BMC Musculoskelet Disord 2012; 13: 206 DOI: 10.1186/1471-2474-13-206. (PMID: 23088451)
• 32 Castelli CC, Falvo DA, Iapicca ML. et al. Rotational alignment of the femoral component in total knee arthroplasty. Ann Transl Med 2016; 4: 4 DOI: 10.3978/j.issn.2305-5839.2015.12.66. (PMID: 26855940)
• 33 Berger RA, Rubash HE, Seel MJ. et al. Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res 1993; (286) 40-47 (PMID: 8425366)
• 34 Asano T, Akagi M, Nakamura T. The functional flexion-extension axis of the knee corresponds to the surgical epicondylar axis: in vivoanalysis using a biplanar image-matching technique. J Arthroplasty 2005; 20: 1060-1067 DOI: 10.1016/j.arth.2004.08.005. (PMID: 16376264)
• 35 Hanada H, Whiteside LA, Steiger J. et al. Bone landmarks are more reliable than tensioned gaps in TKA component alignment. Clin Orthop Relat Res 2007; 462: 137-142 DOI: 10.1097/BLO.0b013e3180dc92e7. (PMID: 17563704)
• 36 Katz MA, Beck TD, Silber JS. et al. Determining femoral rotational alignment in total knee arthroplasty: reliability of techniques. J Arthroplasty 2001; 16: 301-305 DOI: 10.1054/arth.2001.21456. (PMID: 11307126)
• 37 Arima J, Whiteside LA, McCarthy DS. et al. Femoral rotational alignment, based on the anteroposterior axis, in total knee arthroplasty in a valgus knee. A technical note. J Bone Joint Surg Am 1995; 77: 1331-1334 DOI: 10.2106/00004623-199509000-00006. (PMID: 7673281)
• 38 Yoshii I, Whiteside LA, White SE. et al. Influence of prosthetic joint line position on knee kinematics and patellar position. J Arthroplasty 1991; 6: 169-177 DOI: 10.1016/s0883-5403(11)80013-6. (PMID: 1875209)
• 39 Seon JK, Song EK. Joint line and patellar height restoration after revision total knee arthroplasty. Indian J Orthop 2016; 50: 159-165 DOI: 10.4103/0019-5413.177569. (PMID: 27053805)
• 40 Sheth NP, Husain A, Nelson CL. Surgical Techniques for Total Knee Arthroplasty: Measured Resection, Gap Balancing, and Hybrid. J Am Acad Orthop Surg 2017; 25: 499-508 DOI: 10.5435/JAAOS-D-14-00320. (PMID: 28644188)