Soft Tissue Balancing in Total Knee Arthroplasty

1. Front Matter

   Pages i-xi

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2. Native Knee

   1. Front Matter

      Pages 1-1

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   2. Anatomy and Biomechanics of the Native Knee and Its Relevance for Total Knee Replacement

      • Kyle Muckenhirn, Jorge Chahla, Robert F. LaPrade

      Pages 3-15

   3. Soft Tissue Balance of the Native Knee Provides Guidance for Balancing a Total Knee Arthroplasty

      • Joshua D. Roth, Stephen M. Howell

      Pages 17-27

   4. Kinematics of the Normal Native Knee

      • Jan Victor

      Pages 29-37

3. Operative Procedure 1: Primary TKA

   1. Front Matter

      Pages 39-39

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   2. Primary Principles in Soft Tissue Balancing

      • Jacobus H. Müller, Willem van der Merwe

      Pages 41-48

   3. Measured (Anatomical Reference) Resection Technique for Cruciate-Retaining Total Knee Arthroplasty

      • Shaw Akizuki, Hiroshi Horiuchi

      Pages 49-57

   4. PS: Gap Technique

      • Myung Chul Lee

      Pages 59-64

   5. Bicruciate-Retaining TKA: How to Achieve Near-Normal Kinematics

      • Rob Middleton, Andrew Price

      Pages 65-77

   6. Five Quality Assurance Steps for Balancing a Kinematically Aligned Total Knee Arthroplasty

      • Stephen M. Howell, Alexander J. Nedopil

      Pages 79-96

4. Operative Procedure 2: Primary TKA

   1. Front Matter

      Pages 97-97

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   2. Operative Procedure: Varus Knee

      • David Figueroa, Francisco Figueroa

      Pages 99-105

   3. Valgus Knee: Severe Cases Included

      • Jaroslaw Czekaj, Timothy Lording, Sébastien Lustig

      Pages 107-126

   4. Complicated Cases: Recurvatum and Severe Contracture

      • Ricardo Varatojo, Ricardo Telles de Freitas, Mário Vale

      Pages 127-138

   5. Operative Procedure for Primary TKR: How to Increase ROM

      • Samih Tarabichi, Ahmed El-Naggar, Mohamed Adi

      Pages 139-149

5. Assessment in Primary TKA

   1. Front Matter

      Pages 151-151

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   2. Assessment in Primary TKA: Intraoperative Assessment Tensor

      • Tomoyuki Matsumoto, Hirotsugu Muratsu, Ryosuke Kuroda

      Pages 153-169

   3. Intraoperative Assessment with Computer Navigation

      • Gianmarco V. M. Regazzola, Myles R. J. Coolican

      Pages 171-180

6. Clinical Relevance: Primary TKA

   1. Front Matter

      Pages 181-181

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In this booklet, experts from across the world, including members of the ISAKOS Knee Arthroplasty Committee, offer clear, up-to-date guidance on all aspects of soft tissue or ligament balancing in primary total knee arthroplasty with the aim of enabling the reader to achieve optimal patient outcomes. After an introduction explaining the normal soft tissue condition in the native knee, surgical procedures are described, including techniques for the management of severe deformity. The most striking feature of the booklet, however, is the many pages devoted to the accurate evaluation and clinical relevance of ligament balancing. Different techniques and devices for intraoperative soft tissue assessment are discussed, highlighting, for example, the use of gap-measuring devices or trial liners with load-bearing sensors to achieve more objective evaluation. Above all, special attention is devoted to the crucial issue of the impact of intraoperative soft tissue balance on postoperative results. In the closing chapter, very experienced surgeons introduce intraoperative troubleshooting in order to assist successful completion of arthroplasty.

• Kinematics
• Range of motion
• Varus knee
• Valgus knee
• Soft tissue

• Department of Orthopaedic Surgery, Kyoto University Department of Orthopaedic Surgery, Kyoto, Japan

  Shuichi Matsuda

• Department of Orthopedic Surgery, Lyon University - Croix Rousse Hospital Department of Orthopedic Surgery, Lyon, France

  Sébastien Lustig

• Sports Science Institute of South Africa Orthopaedic Clinic, Cape Town, South Africa

  Willem van der Merwe

Shuichi Matsuda is Professor and Chairman of the Department of Orthopaedic Surgery at the Graduate School of Medicine, Kyoto University, Japan. Dr. Matsuda graduated from Kyushu University Medical School and subsequently received his PhD in biomechanics of the knee for a thesis entitled “Knee kinematics of posterior cruciate ligament sacrificed total knee arthroplasty”. He joined the staff at Kyushu University in 1997 and moved to his present position in Kyoto in 2012. Dr. Matsuda has served as Chair of the ISAKOS Knee Arthroplasty Committee, as a member of the International Congress for Joint Reconstruction (ICJR) Global Board, and on the International Coordinating Council of The Bone and Joint Decade 2010–2020. He is a member of the editorial boards of International Cancer Conference Journal, the Journal of Orthopaedic Science, and Knee Surgery and Related Research and an Associate Editor (Orthopaedic Surgery) of The Knee. He is the author of some 230 articles in peer-reviewed journals.


Sébastien Lustig is a Professor in the Department of Orthopaedic Surgery, Albert Trillat Center – Croix-Rousse Hospital, Lyon, France. Dr. Lustig completed his orthopaedic training in Lyon and then studied knee surgery with Dr. David Parker and Dr. Myles Coolican in Sydney, Australia. He began his practice in Lyon in 2006 at the Albert Trillat Center with his mentor, Professor Philippe Neyret, specializing exclusively in disorders of hip and knee joint. He completed his PhD in biomechanics in 2010, thanks to his research on computer-assisted surgery and total knee arthroplasty. Dr Lustig is actively involved in a number of international orthopaedic organizations. He is chair of the ESSKA Basic Science Committee (2014–6) and Deputy Chair of the ISAKOS Knee Arthroplasty Committee (2015–7). Performing over 400 arthroplasties per year, Dr. Lustig’s current practice focuses on hip and knee joint replacement. He has published over 80 studies in orthopaedic journals indexed on Medline and 50 chapters in orthopaedic textbooks.


Willem Maré van der Merwe is an Associate Professor in the Human Biology Department and Head of Research in the Sport Medicine Department at the University of Cape Town, South Africa. Dr. van der Merwe gained his MB ChB from the University of Free State and his Degree in Sports Medicine with Honors from the University of Cape Town before obtaining a Degree in Politics, Economics, and Philosophy at Oxford University. He completed his surgical training at the University of Cape Town in 1997, becoming a Fellow of the College of Surgeons (Orthopaedics). Dr. van der Merwe served as President of SASAKOS, the South African Society of Arthroscopy, between 2004 and 2008 and has been a member of the ISAKOS Knee Committee (2009–13) and the ISAKOS Executive Committee (Second Vice President). He has worked as a Consultant in the Knee Clinic, Victoria Hospital; the Sports Science Institute; and the Vincent Pallotti Hospital (all in Cape Town) and in Sports Science Day Surgery, Newlands.

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