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Knee. 2014 Jan;21(1):156-61. doi: 10.1016/j.knee.2013.09.002. Epub 2013 Sep 19.

Effects of surgical variables in balancing of total knee replacements using an instrumented tibial trial.

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Department of Orthopaedic Surgery, New York University, Hospital for Joint Diseases, United States. Electronic address:
Department of Orthopaedic Surgery, New York University, Hospital for Joint Diseases, United States.



In total knee surgery, typically the bone cuts are made first to produce the correct overall alignment. This is followed by balancing, often using spacer blocks to obtain equal parallel gaps in flexion and extension. Recently an electronically instrumented tibial trial has been introduced, which measures lateral and medial contact forces. The goal of our study was to determine the effect of different surgical variables; changing component sizes, modifying bone cuts, or ligament releases; on the contact forces, as a method to achieve balancing.


A special rig was designed to fit on a standard operating table, on which tests on 10 lower extremity specimens were carried out. After making bone cuts for a posterior cruciate retaining knee using a navigation system, tibial thickness was determined in extension using the Sag Test. Different Surgical Variables were then implemented, and the changes in the condylar forces were determined throughout flexion using the Heel Push Test.


condylar forces were found to consist of gravity forces due to the weight of the leg plus forces due to pretension in the collateral ligaments. The pretension force averaged 145 N but there was considerable variation because of ligament stiffness properties. Balancing from an imbalanced state could be achieved with adjustments within only 2° or 2 mm.


The instrumented tibial trial provided force information which indicated which surgical correction options to carry out to achieve balancing. From an initial unbalanced state, relatively small changes could produce balancing, indicating the sensitivity of the procedure.


Non-clinical. This study will assist in the balancing of the knee at total knee replacement surgery.


Instrumented tibial trial; Knee balancing; Ligament balancing; Total knee surgery; Total knee technique

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