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Tight in extension, balanced in flexion
8%
279/3529
Loose in extension and flexion
2%
86/3529
Balanced in extension, loose in flexion
88/3529
Balanced in extension, tight in flexion
85%
3007/3529
Loose in extension, balanced in flexion
1%
35/3529
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Recutting the proximal tibia with increased slope would help to balance a knee that is tighter in flexion than extension. The goals of sagittal plane balancing during primary total knee arthroplasty are to create a stable knee with equal flexion and extension gaps. The flexion gap is controlled by the posterior cut of the femur (and resultant implant size), the tibial cut, and the posterior cruciate ligament (PCL) and other surrounding soft tissue structures. Cutting the tibia with increased slope preferentially opens the flexion gap as a result of femoral rollback. In cruciate-retaining designs, recessing the PCL can also preferentially open up the flexion gap. Finally, decreasing the anterior-posterior size of the femoral implant by recutting to a smaller size would also preferentially open the flexion gap. Mihalko et al. reviewed soft-tissue balancing during total knee arthroplasty in the varus knee. They noted that intra-operative techniques used to balance the knee include femoral component rotation, osteophyte resection, soft-tissue release, and bone resection. The authors conclude that balancing the flexion and extension gap is critical to long-term success and patient satisfaction. Manson et al. reviewed sagittal plane balancing during total knee arthroplasty. They explained the differences between anterior and posterior referencing systems and the basics of gap balancing techniques. The authors provide an overview of the strengths and weaknesses of various system types and provide troubleshooting advice regarding intraoperative sagittal plane balancing. A measurement of the posterior tibial slope angle (PTSA) is shown in Illustration A. Incorrect Answers: Answer 1: Balancing the knee, in this case, would require resecting more distal femoral bone or releasing the posterior capsule. Answer 2: Balancing the knee, in this case, would require using a thicker polyethylene insert or adding medial and lateral augments to the tibial tray. Answer 3: Balancing the knee, in this case, would require increasing the size of the femoral component (AP dimension) with subsequent augmenting the posterior femur or taking slope out of the tibial cut. Answer 5: Balancing the knee, in this case, would require augmenting the distal femur.
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