Optimization of Extension Balance in Primary Total Knee Arthroplasty: a Stepwise Approach to the Correction of Flexion Contracture
Year: 2026
Type: article
Abstract: Introduction. Residual extension deficit after total knee arthroplasty (TKA) adversely affects gait, increases energy expenditure during walking, and reduces patient satisfaction. The choice of optimal surgical strategy—balancing soft-tissue release against additional resection of the distal femur—remains a subject of debate, as each additional amount of bone removal may result in elevation of the joint line and increase the risk of mid-flexion instability. Materials and Methods. This single-center prospective study included 104 patients who underwent primary TKA at the Multidisciplinary Clinic of Tashkent State Medical University between 2022 and 2024 and had a preoperative extension deficit of ≥10°. A stepwise intraoperative algorithm was applied: (1) removal of posterior osteophytes; (2) posterior capsular release; (3) release of the posterior cruciate ligament (PCL) in cases of a PCL-retaining technique or conversion to a posterior-stabilized (PS) implant; and (4) additional resection of the distal femur of up to 4 mm. The extension deficit was assessed intraoperatively after each step. Patients were stratified according to the Lombardi classification into mild (10–14°), moderate (15–30°), and severe (>30°) extension deficits. Results. The mean preoperative fixed flexion deformity (FFD) was 17.3° ± 8.4°, decreasing to 2.1° ± 2.6° at 12 months postoperatively. Removal of posterior osteophytes corrected the deficit by an average of 3.8°, posterior capsular release provided an additional correction of 4.1°, PCL release corrected a further 2.9°, and additional distal femoral resection resulted in 2.2° of correction per each millimeter of bone resection. Complete correction (≤5° of residual deficit) was achieved in 91.3% of patients. Additional resection of >4 mm was required only in the severe-deficit group (8 of 14 patients). In these patients, mid-flexion instability was more frequently observed at 12 months postoperatively (3 of 8 versus 0 of 96; p = 0.001). The KSS at 12 months was higher in patients who underwent ≤4 mm of additional resection (87.2 vs. 75.4; p = 0.002). Conclusion. A stepwise algorithm prioritizing soft-tissue release over additional bone resection enables acceptable functional extension to be achieved in 91% of cases while preserving the joint-line level. Additional distal femoral resection of >4 mm should be considered a last-resort measure, as it substantially increases the risk of mid-flexion instability.
Source: Journal of modern medicine
Authors: S.B. Madrakhimov, M.Yu. Karimov, J.Sh. Kayumov
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W7222802377
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