The Role of Complete Posterior Cruciate Ligament Release in Flexion Gap Balancing for Total Knee Arthroplasty

Background: The sequence of posterior cruciate ligament (PCL) release in posterior-substituting designs, when performing gap balancing in total knee arthroplasty (TKA), is variable. We hypothesize that early complete PCL release during knee exposure will change the flexion balance to result in a uniform medial-lateral flexion gap symmetry at the time of implant placement.

Methods: Ten cadaveric knees were prepared for TKA using standard medial parapatellar approach. Medial and lateral flexion gaps were measured in the conditions of intact, partial (50%) resection, and full resection of PCL. Measurements were performed with both surgical navigation and a caliper. Flexion gap distances were reported for medial and lateral compartments in the 3 PCL conditions.

Results: Medial flexion gap increased after only complete release of the PCL (mean 3.94-5.05 mm). The lateral flexion gap increased as well (mean 4.17-4.67 mm). Complete PCL release resulted in a statistically significant increase in medial flexion gap compared to intact (P = .013) and partially released (P = .012) specimens. No significant differences were noted in lateral flexion gap change. Notable change in medial versus lateral gap (flexion gap symmetry) relationship occurred after just partial PCL release (P = .018).

Conclusion: Among the 3 PCL states, changes in flexion gap distance were most conspicuous in the medial compartment. This suggests gap balancing performed with incomplete PCL release will not accurately reflect gap distance after eventual PCL removal, thus supporting the hypothesis. It is recommended that the PCL should be released to the fullest extent possible before ligament tensioning for femoral component rotation in posterior-stabilized TKA.