Total knee replacement (TKA) surgery is an excellent and well-proven procedure for the treatment of end stage arthritis of the knee. Many refinements have taken place over time in an attempt to improve the components, wear qualities of the polyethylene, and the surgical technique to improve accuracy of component positioning, reduce patient pain, improve postoperative range of motion, ultimately improve results and to prolong the time until revision surgery may occur. This study examines the results of a gap balancing surgical technique in which components were implanted that had a posterior cruciate substituting design. This technique is performed with exacting alignment and balancing of the flexion and extension gaps prior to implantation of the knee components. The follow up is at a minimum of ten years.

515 consecutive knee replacements were followed prospectively for a minimum of ten years. The average age at surgery was 70 years, 73% of patients were female, with an average BMI of 31. All patients carried a diagnosis of osteoarthritis and a cemented, posterior stabilized design TKA (Balanced Knee System, Ortho Development) was implanted. All cases were performed by one of two experienced joint replacement surgeons.

The surgical technique demanded flexion and extension gap balancing as well as soft tissue balancing prior to finishing cuts being performed on the femoral side (See figures 1 and 2). Polyethylene spacers come in 1 millimeter increments.

28% of patients died postoperatively at an average of 7.4 years. These patients were older on average at the time of index surgery (76.6 years). None had undergone revision surgery. Of the remaining patients Knee Society scores (39 preop to 91 post op at ten years), function scores and range of motion all improved significantly. What's more, these results were not diminished at ten years. There were no component failures and less than 1% radiographic progressive lucent lines. Eleven revision surgeries (2.1 %) were performed with 2 acute superficial wound revisions, 3 late infections, one patellar tendon disruption from a fall at 7 years (BMI 45.7), 2 complete revisions performed elsewhere for unsatisfactory results, and 3 spacer exchanges for perception of postoperative laxity.

For the current study we also examined subgroups of the morbidly obese, octogenarians, and those with a preoperative valgus deformity of greater than 15%. At follow-up these subgroups fared very well with the exception of the heaviest BMI's being limited in range of motion because of soft tissue impingement.

Results suggest that this balancing technique gives excellent results with few complications at ten year evaluation. We believe that careful attention to bony and soft tissue balancing and equalization of gaps in flexion and in extension will prove beneficial for TKA longevity in even longer-term evaluation.

Figures 1 and 2 demonstrate gap balancing blocks and alignment rods in extension and in flexion