Flexion gap stabilization by oversizing posterior condylar offset in deep-dished total knee replacement does not compromise flexion: A single-surgeon, retrospective, observational, mid-term series

Orthop Traumatol Surg Res. 2019 Oct;105(6):1039-1045. doi: 10.1016/j.otsr.2019.04.008. Epub 2019 Jun 6.


Introduction: In total knee replacement surgery, medio-lateral knee balancing is recognized as the key to achieving satisfactory functional results. But it may not be enough to stabilize the flexion gap using deep-dished implants. We achieved flexion gap balance by oversizing the femoral component, thus increasing the posterior condylar offset (PCO). The purpose of this study was to describe the applicability of this technique and to test whether it produced adverse effects on medium-term outcomes. We hypothesized that it would not compromise the results if used properly. We therefore asked: (1) at how many cases of flexion gap balance would require oversizing the femoral component; (2) if femoral components oversizing would modify the mid-term results as per forgotten joint score (FJS) scores and whether flexion gain would be comparable to patients in whom it was not increased.

Materials and methods: Ninety-four patients (120 knees) were operated between September 2009 and 2011 (age 68±9 years) using the cementless Hyperflex version of the Natural Knees (Zimmer, Warsaw, IN, USA). Postero stabilization was achieved using deep-dished inserts. The Gender configuration has provided narrow inserts to better adapt the female anatomy. A special navigation system measured the displacement of the lateral and medial femoro-tibial contact points with infra-millimetric precision. Adopting a tibial cut first, gap-balancing technique with anterior referencing, the decision to oversize the femoral component relied on the 90° flexion drawer test, which showed more than 6mm sagittal laxity before the femoral bone cuts. Eighty-one (105 knees) patients were reviewed with average 63±27-month follow-up.

Results: Femoral components were augmented by 1 size in 60 cases and by 2 sizes in 7 cases. At final review, knees with an oversized femoral component (60) achieved the same results as those implanted with a non-oversized femoral component (n=45) in terms of mean flexion gain (-5°±34 versus -4°±23, p=0.78), mean FJS (63±26 versus 61±23; p=0.56).

Conclusion: Balancing the Flexion gap by oversizing the femoral component did not compromise flexion range and functional results.

Level of evidence: IV, Retrospective cohort study.

Keywords: Deep-dished total knee replacement; Femoral component size; Navigation; Primary total knee replacement; Sagittal balance.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Arthritis, Rheumatoid / surgery
  • Arthroplasty, Replacement, Knee / methods*
  • Chondrocalcinosis / surgery
  • Female
  • Femur / surgery
  • Humans
  • Knee Joint / physiopathology
  • Knee Joint / surgery
  • Knee Prosthesis*
  • Male
  • Middle Aged
  • Osteoarthritis, Knee / surgery*
  • Prosthesis Fitting / methods*
  • Range of Motion, Articular*
  • Retrospective Studies
  • Tibia / surgery
  • Treatment Outcome
  • Tuberculosis, Osteoarticular / surgery