Comparison of Ligament-Balancing Techniques During Total Knee Arthroplasty

Ligament-balancing techniques are utilized to balance the flexion and extension gaps of the knee during total knee arthroplasty. Many different techniques to test for ligament balancing (as well as different structural release techniques and sequences of structural release) have been reported1-9. Distraction testing methods include the use of tension jigs, laminar spreaders, and spacer blocks or in-line traction to assess the joint gap after the femoral and tibial bone cuts have been made. This concept was popularized by Freeman et al.1 and Insall et al.2 and involves distracting the joint space in both flexion and extension to balance the gaps created when the joint gap is filled with prosthetic components (Fig. 1). The change in the shape of the joint gap from flexion to extension has been termed “gap kinematics,” and the goal is to balance these gaps during total knee arthroplasty4,5,7. Another technique for testing ligament balancing utilizes trial components to fill the gaps followed by application of varus and valgus stresses to test for laxity of the medial and lateral soft-tissue sleeves3,8,9. Whether one utilizes a distraction technique or trial components with application of varus and valgus stresses to assess soft-tissue balancing, the knee should be balanced in both flexion and extension.