Posterior-stabilized total knee arthroplasty using the pre-cut technique achieves mid-flexion stability, but yields only a 50 % medial-pivot pattern

Kodai Hamaoka; Yasutoshi Ikeda; Yohei Okada; Tomoaki Kamiya; Kazushi Horita; Makoto Emori; Atsushi Teramoto

doi:10.1016/j.jor.2025.11.043

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doi:

10.1016/j.jor.2025.11.043

Posterior-stabilized total knee arthroplasty using the pre-cut technique achieves mid-flexion stability, but yields only a 50 % medial-pivot pattern

Kodai Hamaoka, Yasutoshi Ikeda, Yohei Okada, Tomoaki Kamiya, Kazushi Horita, Makoto Emori, Atsushi Teramoto

Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Hokkaido, Japan

⁎Corresponding author: Yasutoshi Ikeda. ikeda.yasutoshi@sapmed.ac.jp

Received: 2025-11-1, Accepted: 2025-11-28, Published: 2025-11-29

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

The mid-flexion stability in posterior stabilized (PS)- total knee arthroplasty (TKA) using the pre-cut technique and the relationship between surgical technique and knee kinematics are unclear. This study aimed to evaluate the virtual gap and intraoperative kinematics of PS-TKA using the pre-cut technique.

In this retrospective study, 55 patients who underwent PS-TKA for knee osteoarthritis with a navigation system using the pre-cut technique. The mean age at operation was 77.2 years, with 50 female patients. The implant was the Attune PS rotating platform, and a CT-free navigation system was employed. The virtual gap after implantation, as well as the intraoperative knee kinematics before bone cutting and after implantation, were measured using the navigation system. Intraoperative knee kinematics pattern was investigated whether medial pivot (MP) pattern or not.

No significant differences were observed in the virtual gap between the medial and lateral sides at any knee flexion angle after implantation. The lateral condyle moved significantly posteriorly during flexion compared to the medial condyle (60°–130°). Regarding knee kinematics after implantation, 50.9 % of patients were classified as having the MP pattern. The knee kinematic pattern after implantation was significantly influenced by the kinematic pattern before bone cutting (p < 0.01).

Keywords

Total knee arthroplasty

Pre-cut technique

Navigation system

TKA

PS

MP

ROM

SEA

FTA

AP

mLDFA

PROMs

KOOS

JKOM

FJS

COR

NMP

1 Introduction

Achieving equal extension and flexion gaps in total knee arthroplasty (TKA) yields successful clinical outcomes.¹ The pre-cut technique, introduced by Kaneyama et al.,² has emerged as a particularly effective surgical approach to optimize gap management in TKA. In this technique, a 4-mm posterior condylar pre-cut is performed before the final cutting of the posterior femoral condyle and evaluation of the extension and flexion gaps using the pre-cut trial component. Hence, component gap control using the pre-cut technique is useful in posterior-stabilized (PS)-TKA.³

Recently, patient dissatisfaction following TKA has emerged as a major concern, with 33–54 % of patients reporting suboptimal outcomes.⁴ Among the contributing factors, mid-flexion instability has garnered attention as a potential cause of joint gap laxity, dissatisfaction, and the need for revision surgery.⁵^,⁶ Intraoperative navigation systems have enabled continuous measurement of the “virtual gap” throughout the range from extension to flexion. This virtual gap is defined as the distance between the femoral component and the tibial osteotomy surface.⁷ However, to date, no studies have investigated mid-flexion stability in TKA using the pre-cut technique.

The relationship between clinical outcomes and knee kinematics after TKA has been reported, demonstrating that the intraoperative medial pivot (MP) pattern positively influences deep knee flexion and patient-reported outcomes.⁸ The severity of varus knee deformity and the preoperative knee kinematic pattern affect postoperative knee kinematics in PS-TKA.⁹ However, the relationship between the surgical technique and knee kinematics is unclear.

This study aimed to evaluate the virtual gap and intraoperative kinematics of PS-TKA using the pre-cut technique. We hypothesized that achieving comparable extension and flexion gaps intraoperatively using this technique would result in (1) consistent joint stability across the full range of motion, including the mid-flexion phase; and (2) an MP kinematic pattern following prosthesis implantation.

2 Materials and methods

2.1

2.1 Patients

This retrospective comparative study was approved by our Institutional Review Board (reference number: R6-9), and informed consent was obtained from all patients. The participants were 55 patients who underwent PS-TKA with a CT-free Navigation System (Brain Lab; Knee3) for medial knee osteoarthritis using the pre-cut technique at our hospital between December 2019 and December 2022.

The participants were 5 male and 50 female, with a mean age at operation of 77.2 ± 5.8 years (mean ± standard deviation) and a BMI of 25.9 ± 5.1 kg/m². The operated side was the right in 32 patients and the left in 23 patients. The follow-up period was 42.3 ± 11.7 months. All patients had Kellgren–Lawrence grade 4 preoperatively and were followed up for at least 2 years postoperatively. Patients with inflammatory arthritis, a history of ligament surgery, or revision cases were excluded.

2.2

2.2 Surgical procedure

All patients underwent TKA, which was performed by a single surgeon (Y.I). Patients underwent surgery under general anesthesia. The air tourniquet was inflated to 300 mm Hg during surgery. The implant was Attune®︎ PS rotating platform (Depuy, Warsaw, IN, USA), and the CT-free Navigation System was employed for accurate bone cutting and to measure the intraoperative virtual gap and knee kinematics. All knees were surgically exposed using a conventional medial parapatellar approach to allow optimal visualization of the joint structures. Minimal medial release was performed only for osteophyte resection. Distal femoral and tibial proximal resections were performed using the navigation system, perpendicular to the mechanical axis in the coronal plane. Proximal tibial resection was performed using a 3° posterior slope in the sagittal plane. Femoral rotation was determined using preoperative computed tomography (CT) in the axial plane as the angle between the posterior condylar axis and the surgical transepicondylar axis (SEA). A pre-cut guide was used for cutting 4 mm of the posterior femoral condyle. Osteophyte resection and soft tissue release were performed after the pre-cut, and the extension and flexion gaps were measured using a pre-cut trial and spacer block. Finally, the amount of the posterior femoral condyle bone cut was adjusted to equalize the gap between medial extension and flexion. If the extension and flexion gaps were equal, an additional bone cut (5 mm) was determined as the thickness of the posterior part of the implant (9 mm) minus that of the pre-cut (4 mm). If the flexion gap was 2 mm greater than the extension gap, the 2 mm flexion gap was compensated for by reducing the amount of the posterior bone cut by 2 mm. The patella was resurfaced in all the patients.

2.3

2.3 Evaluation of range of motion, radiographic parameters, and clinical outcomes

The patients were evaluated based on their range of motion and radiographic and clinical outcomes preoperatively and 2 years postoperatively.

The femoral tibial angle (FTA) and medial proximal tibial angle were measured using weight-bearing anteroposterior (AP) radiographs. The mechanical lateral distal femoral angle (mLDFA), hip-knee-ankle angle, and % of the mechanical axis were measured using full-length weight-bearing AP radiographs. The posterior tibial slope was measured using lateral-view radiographs. The radiographic parameters were measured using a picture-archiving communication system at our institute.

Clinical outcomes were evaluated through patient-reported outcome measures (PROMs) using the Knee injury and Osteoarthritis Outcome Score (KOOS),¹⁰ Japanese Knee Osteoarthritis Measure (JKOM),¹¹ and Forgotten Joint Score (FJS).¹²

2.4

2.4 Evaluation of virtual gap and kinematics

The virtual gap after implantation and the intraoperative knee kinematics before bone cutting and after implantation were measured using the navigation system. With the patella repositioned, the knee was fixed by placing the patient's heel on the examiner's palm, while the examiner's other hand was placed beside the calf for support with a tourniquet (or the knee was bent by slightly raising the heel to lift the femur¹³). Caution was practiced to avoid knee rotation during maximum extension and flexion. The navigation system automatically recorded the virtual gap and kinematics during continuous passive knee flexion every 10°.¹⁴ The intra- and interclass correlation coefficients for the reproducibility of this analytical method were >0.81.¹⁴

The kinematic patterns and AP displacements of the medial and lateral femoral condyles were evaluated. All SEA positions were projected onto the tibial axial plane. The SEA node was defined as the center of rotation (COR).¹⁵ The COR was calculated at 10° and 90°. Patients with a medial COR were defined as having an MP pattern. Other patterns were defined as non-medial pivot (NMP) pattern.⁸

2.5

2.5 Statistical analysis

All statistical analyses were performed using EZR (version 1.61; Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (version 4.2.2; The R Foundation for Statistical Computing, Vienna, Austria). More precisely, it is a modified version of the R Commander, with frequently used biostatistical functions added.¹⁶ The virtual gap was analyzed using a two-factor repeated-measures analysis of variance to compare the flexion angles and the medial or lateral sides. A paired t-test was used for post-hoc analysis with Bonferroni correction. The t-test and Fisher's exact test were used to compare the continuous and categorical variables between the MP and NMP patterns. Statistical significance was set at p < 0.05. Statistical power calculations were performed using G*Power version 3.1.9.7,¹⁷ with the significance set at 0.05, effect size of 0.8, and power of 0.05. The minimum sample size required for the study was 52. With a sample size of 55, this study achieved a satisfactory level of statistical power (α = 0.05).

3 Results

Patient data are shown in Table 1. ROM, KOOS subscale scores, and JKOM (VAS and Total) significantly improved 2 years postoperatively. In all cases, no procedure-related complications, such as pin-site fracture or infection, were reported. The component gap with pre-cut trial was 5.3 ± 0.7 mm at extension and 6.7 ± 1.0 mm at flexion. For additional bone cuts after the 4 mm pre-cut of the posterior femoral condyle, a 5 mm cut (not posterior to the cutting level; total 9 mm cut) was performed in 23.9 % cases, 4 mm (total 8 mm cut) in 30.4 %, 3 mm (total 7 mm) in 30.4 %, and 2 mm (total 6 mm) in 15.2 %. The thicknesses of the inserts after implantation were 5 mm in 61.8 % cases, 6 mm in 21.8 %, 7 mm in 14.5 %, and 8 mm in 1.8 %.

Table 1 Patient data.

	Preoperative	Postoperative 2 years	p-value
ROM (°)
extension	−11.7 ± 8.1	−1.9 ± 4.3	<0.001*
flexion	112.6 ± 4.3	122.6 ± 11.7	0.015*
Radiographic parameters
FTA (°)	183.6 ± 5.8	174.5 ± 3.7	<0.001*
MPTA (°)	83.5 ± 3.0	88.6 ± 1.5	<0.001*
mLDFA (°)	90.1 ± 2.9	90.2 ± 1.8	0.833
HKAA (°)	−11.1 ± 6.1	−1.7 ± 3.6	<0.001*
%MA (%)	5.8 ± 22.8	43.3 ± 14.0	<0.001*
PTS (°)	7.0 ± 2.9	3.5 ± 2.5	<0.001*
PROMs
KOOS
Symptoms	51.1 ± 22.9	82.0 ± 15.0	<0.001*
Pain	43.2 ± 20.4	85.1 ± 17.8	<0.001*
ADL	55.4 ± 20.9	85.3 ± 16.3	<0.001*
Sports	18.1 ± 22.2	49.2 ± 32.7	<0.001*
QOL	30.9 ± 20.3	70.1 ± 21.5	<0.001*
JKOM
VAS	64.4 ± 25.5	11.1 ± 13.4	<0.001*
Total	47.8 ± 19.9	15.9 ± 13.5	<0.001*
FJS		65.1 ± 22.6

The virtual gap after implantation is shown in Fig. 1. No significant differences were observed in the virtual gap between the medial and lateral sides at any knee flexion angle after implantation.

The AP displacement of the femoral condyle after implantation is shown in Fig. 2. The lateral condyle moved significantly posteriorly during flexion compared to the medial condyle (60°–130°). In addition, the anterior sliding movements of the medial and lateral condyles during mid-flexion were lower after implantation. Regarding knee kinematics after implantation, 50.9 % of patients were classified as having the MP pattern (Table 2). In 69 % of knees, the knee kinematic pattern did not change before bone cutting or after implantation. The knee kinematic pattern after implantation was significantly influenced by the kinematic pattern before bone cutting (p < 0.01).

Femoral condyle AP displacement after implantation Positive values indicate the anterior side of the tibial axial plane, whereas negative values indicate the posterior side. anteroposterior, AP.

Table 2 Knee kinematics before bone cutting and after implantation.

		After implantation		p-value
		MP pattern	NMP pattern
Before bone cut	MP pattern	17	6	0.006*
	NMP pattern	11	21

The MP and NMP patterns were compared in a subgroup analysis. The demographic data are shown in Table 3. The preoperative and 2-year postoperative radiographic parameters significantly differed, except for mLDFA (Table 4). All KOOS subscale scores and JKOM (VAS and total) scores significantly improved 2 years postoperatively. No significant differences in the PROMs were observed between the MP and NMP patterns at 2 years postoperatively (Table 5).

Table 3 Demographic data of the MP and NMP patterns.

	MP pattern (n = 28)	NMP pattern (n = 27)	p-value
Age (years)	78.4 ± 6.5	76.1 ± 4.8	0.144
Sex (male/female)	3/25	2/25	1.000
BMI (kg/m2)	25.8 ± 4.8	26.0 ± 5.4	0.898
Operated side (right/left)	17/11	15/12	0.787
Follow-up period (month)	41.3 ± 12.1	43.4 ± 11.5	0.493
Preoperative ROM (°)
extension	−11.5 ± 7.4	−12.0 ± 8.9	0.823
flexion	118.0 ± 25.4	107.3 ± 34.7	0.219
Postoperative 2 years ROM (°)
extension	−2.7 ± 5.5	−1.2 ± 2.6	0.204
flexion	122.9 ± 9.1	122.3 ± 14.1	0.861

Table 4 Radiographic parameters of the MP and NMP patterns.

	MP pattern (n = 28)	NMP pattern (n = 27)	p-value
	Mean ± SD	Mean ± SD	p-value
FTA (°)
preoperative	185.1 ± 5.2	182.2 ± 6.2	0.071
postoperative 2 years	175.2 ± 3.5	173.9 ± 3.9	0.225
MPTA (°)
preoperative	83.6 ± 2.6	83.4 ± 3.4	0.837
postoperative 2 years	88.6 ± 1.2	88.6 ± 1.7	0.879
mLDFA (°)
preoperative	90.0 ± 2.9	90.1 ± 3.0	0.889
postoperative 2 years	90.2 ± 1.5	90.1 ± 2.1	0.753
HKAA (°)
preoperative	−12.5 ± 5.0	−9.8 ± 7.0	0.114
postoperative 2 years	−2.4 ± 3.1	−1.0 ± 4.0	0.150
%MA (%)
preoperative	0.2 ± 18.4	11.5 ± 25.4	0.068
postoperative 2 years	40.2 ± 13.4	46.4 ± 14.1	0.115
PTS (°)
preoperative	7.0 ± 3.0	7.0 ± 2.8	0.984
postoperative 2 years	3.0 ± 2.2	3.8 ± 2.7	0.328

Table 5 Preoperative and postoperative 2-year PROM values of the MP and NMP patterns.

		MP pattern (n = 28)	NMP pattern (n = 27)	p-value
		Mean ± SD	Mean ± SD	p-value
KOOS	Symptoms
	preoperative	52.2 ± 26.2	50.0 ± 19.8	0.752
	postoperative 2 years	83.8 ± 11.4	80.6 ± 17.4	0.486
	Pain
	preoperative	44.8 ± 24.9	41.7 ± 15.8	0.627
	postoperative 2 years	87.1 ± 13.6	83.5 ± 20.8	0.508
	ADL
	preoperative	55.1 ± 24.3	55.6 ± 17.8	0.933
	postoperative 2 years	87.2 ± 13.6	83.8 ± 18.2	0.493
	Sports
	preoperative	16.5 ± 25.6	19.6 ± 19.1	0.658
	postoperative 2 years	48.9 ± 35.8	49.3 ± 30.9	0.971
	QOL
	preoperative	33.7 ± 25.3	28.3 ± 14.3	0.378
	postoperative 2 years	70.7 ± 21.3	69.6 ± 22.1	0.869
JKOM	VAS
	preoperative	62.8 ± 27.1	66.1 ± 24.3	0.693
	postoperative 2 years	11.5 ± 13.5	10.8 ± 13.7	0.881
	Total
	preoperative	49.0 ± 21.9	46.7 ± 18.3	0.696
	postoperative 2 years	15.2 ± 13.0	16.4 ± 14.1	0.763
FJS	postoperative 2 years	66.6 ± 25.4	64.1 ± 21.0	0.741

4 Discussion

The most important finding of this study was that PS-TKA using the pre-cut technique could achieve stability across the entire range of motion, including mid-flexion. However, approximately 50 % of patients exhibited an MP pattern after implantation.

The pre-cut technique enabled the evaluation of the component gap in the pre-cut trial and adjustment of the flexion gap by additional posterior femoral bone cuts. In PS-TKA, the flexion gap significantly increased in the medial and lateral sides after posterior cruciate ligament resection compared with the extension gap.¹⁸ Kawasaki et al. reported that in the pre-cut technique in PS-TKA, according to soft tissue release and cutting level adjustment of the posterior femoral condyle, the final component gap on extension did not significantly differ from that on flexion.³ In this study, the additional posterior femoral condyle bone cut was 3.6 ± 1.0 mm. If not adjusted using the pre-cut technique, the additional bone cut was 5 mm. As a result, 76 % of the patients in this study required adjustment for additional bone cuts.

The virtual gap in this study was measured using a navigation system rather than a tensor device. However, only a small difference was found in the lateral gap of extension between the virtual gap measured by navigation and the trial gap measured by the tensor device in the gap balancing technique in a previous study.⁷ Although the relationship between the gap measured by navigation and the tensor device at mid-flexion remained unclear, we considered that the navigation system may be a useful assessment tool for ROM.

Normal knee kinematics demonstrated MP motion and bicondylar rollback motion from extension to flexion using three-dimensional in vivo motion analysis. The lateral femoral condyle demonstrated consistent posterior translation during knee flexion in the normal knee.¹⁹ The proportion of patients exhibiting an MP pattern after implantation in this study was 50.9 %, which is comparable to previously reported findings where the proportion of the MP pattern was 48.6 % during gait and 63.1 % during deep knee flexion in PS-TKA mobile bearing assessed by video fluoroscopy.²⁰

Achieving the MP pattern in all cases after implantation is challenging, even with the pre-cut technique, as in the present study. Similar to the previous study, this study found an association between knee kinematics before the bone cut and after implantation.⁹ The varus deformity in this study was more severe than that in a previous study. The preoperative FTA in this study was 183.6°, and the postoperative FTA of MP in the previous study was 180.8°.⁹ The preoperative severe varus deformity may be one factor explaining why the proportion of MP pattern after implantation was only approximately 50 % as high in this study.

Attune®︎ with a gradually reducing femoral radius showed mid-flexion stability compared with PFC Sigma®︎ with a conventional design.²¹ Anterior displacement at mid-flexion using Attune PS with the pre-cut technique in this study was slight, as compared to Attune cruciate-retaining in a previous study.¹³ Thus, mid-flexion stability was achieved using Attune PS with the pre-cut technique in virtual gap and anterior displacement in this study.

The PROMs at 2 years postoperatively significantly improved with the MP and NMP patterns. However, there was no significant difference in the KOOS, JKOM, and FJS between them. A previous study reported that patient satisfaction and functional activities of the Knee Society score in the postoperative MP pattern were significantly better than those in the NMP pattern,⁸ which was not consistent with the clinical outcomes in our study. Although differences in the PROMs or prosthesis implants used may have affected the results, the reasons why our findings diverged from those of previous studies remain unclear. A notable strength of this study was that it was the first to assess both the virtual gap and intraoperative knee kinematics using the precut technique. Nevertheless, this study had some limitations. First, it did not evaluate the component gap using a tensor device or only the virtual gap. However, the difference between the virtual gap by navigation and the trial gap measured by the tensor device was small previously.⁷ Second, the number of patients was relatively small, and the follow-up period was not long. Nonetheless, the sample size was sufficient to achieve statistical significance. The mean follow-up period was 42 months. To ensure consistency in the timing of the assessment, it was set at 2 years postoperatively. Third, the assessment was performed under general anesthesia in the supine unloading position. However, the intraoperative knee kinematics evaluated using the navigation system correlated with the postoperative kinematics during loaded knee flexion using the 2D/3D registration technique.²² Fourth, most patients were female. However, the proportion of female TKA patients in Japan is high.²³ Fifth, knee kinematics may be affected by the implant design. Because the Attune®︎ PS rotating platform is not an MP design, only approximately half of the MP pattern was achieved.

5 Conclusion

PS-TKA using the pre-cut technique can achieve stability across the entire range of motion, including mid-flexion. However, the proportion of patients exhibiting an MP pattern after implantation was only approximately 50 %, and there was no significant difference in the PROMs between the MP and NMP patterns at 2 years postoperatively. Further studies are required regarding the implant design and surgical techniques to achieve the MP pattern.

Ethical statement

This retrospective chart review study involving human participants was conducted in accordance with the ethical standards of the relevant institutional committee and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

CRediT authorship contribution statement

Kodai Hamaoka: Writing-review & editing, Writing-original draft, Data curation, Formal analysis, Conceptualization. Yasutoshi Ikeda: Writing-review & editing, Data curation, Conceptualization, Project administration. Yohei Okada: Writing-review & editing. Tomoaki Kamiya: Writing-review & editing, Supervision. Kazushi Horita: Writing-review & editing. Makoto Emori: Writing-review & editing. Atsushi Teramoto: Writing-review & editing, Supervision.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

This study is not case reports and does not contain clinical images.

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Introduction

Materials and methods

Patients
Surgical procedure
Evaluation of range of motion, radiographic parameters, and clinical outcomes
Evaluation of virtual gap and kinematics
Statistical analysis

Results

Discussion

Conclusion

Informed consent

Ethical statement

CRediT authorship contribution statement

Funding

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[1] Winemaker M.J., . Perfect balance in total knee arthroplasty: the elusive compromise. J Arthroplast. 2002;17(1):2-10.
[Google Scholar]

[2] Kaneyama R., Higashi H., Oinuma K., Miura Y., Tamaki T., Shiratsuchi H., . Improvement of the gap adjustment in total knee arthroplasty using the posterior condylar pre-cut technique. J Knee Surg. 2019;32(10):1001-1007.
[Google Scholar]

[3] Kawasaki M., Kaneyama R., Suzuki H., et al . Component gap control during posterior-stabilised total knee arthroplasty using the posterior condylar pre-cut technique. J Exp Orthop. 2021;8(1):77.
[Google Scholar]

[4] Nam D., Nunley R.M., Barrack R.L., . Patient dissatisfaction following total knee replacement: a growing concern? Bone Joint Lett J 2014:96-100.
[Google Scholar]

[5] Minoda Y., Nakagawa S., Sugama R., Ikawa T., Noguchi T., Hirakawa M., . Midflexion laxity after implantation was influenced by the joint gap balance before implantation in TKA. J Arthroplast. 2015;30(5):762-765.
[Google Scholar]

[6] Vince K., . Mid-flexion instability after total knee arthroplasty: woolly thinking or a real concern? Bone Joint Lett J 2016:84-88.
[Google Scholar]

[7] Takagi H., Asai S., Kawashima F., et al . A gap balancing technique for adjusting the component gap in total knee arthroplasty using a navigation system. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2020;21:17-21.
[Google Scholar]

[8] Nishio Y., Onodera T., Kasahara Y., Takahashi D., Iwasaki N., Majima T., . Intraoperative medial pivot affects deep knee flexion angle and patient-reported outcomes after total knee arthroplasty. J Arthroplast. 2014;29(4):702-706.
[Google Scholar]

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Posterior-stabilized total knee arthroplasty using the pre-cut technique achieves mid-flexion stability, but yields only a 50 % medial-pivot pattern

Abstract