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Contents lists available at ScienceDirect

Orthopaedics & Traumatology: Surgery & Research

journal homepage: www.elsevier.com

Technical note

Combining load sensor and robotic technologies for ligament balance

in total knee arthroplasty
Julien Bardou-Jacquet a,∗ , Jérome Murgier b , François Laudet c , Thierry Fabre c,d
a
Clinique Tivoli-Ducos, Institut de chirurgie robotique Euratlantique, 220, rue Mandron, 33000 Bordeaux, France
b
Service de chirurgie orthopédique, clinique Aguiléra, Ramsay santé, 21, rue de l’Estagnas, 64200 Biarritz, France
c
Service chirurgie orthopédique et traumatologique, CHU Bordeaux Pellegrin, place Amélie Raba-Léon, 33000 Bordeaux, France
d
BioTis Inserm U1076, 146, rue Léo-Saignat, 33076 Bordeaux, France

a r t i c l e i n f o a b s t r a c t

Article history: Good ligament balance in total knee arthroplasty (TKA) is thought to improve clinical results, but is
Received 9 November 2020 highly surgeon-dependent when performed without technological assistance. We therefore describe a
Accepted 24 February 2021 TKA technique using the Mako robotic arm (Stryker, Kalamazoo, Michigan, USA) as sole means of balanc-
Available online xxx
ing ligament tension by bone recuts associated to control by the VERASENSE load sensor (Orthosensor,
Inc, Dania Beach, Florida, USA). In this preliminary series of 29 patients, 27 (93%) showed a well-balanced
Keywords: knee in extension at end of procedure, and 23 (79%) showed a well-balanced knee in flexion and exten-
TKA
sion, without any periarticular soft-tissue release. The load sensor analyzes ligament balance after the
Robotic arm
Load sensor
initial bone cuts, and guides possible further femoral or tibial recuts. This technique enables quantifi-
Alignment able alignment and control of ligament tension. Collecting objective intraoperative data should improve
knowledge in placing TKA prostheses.
© 2021 Elsevier Masson SAS. All rights reserved.

1. Introduction optimal balance as described by Gustke et al. is achieved [11]

Balancing ligament tension in total knee arthroplasty (TKA)
presently involves implant positioning and periarticular soft-tissue
lengthening (or release). Positioning may be guided by various
principles [1]. Kinematic alignment [2] by joint resurfacing seeks
to restore pre-osteoarthritis knee anatomy [3], avoiding ligament
release surgery [4]. However, the ligament tension is not com-
pletely reliable or reproducible [5] and is liable to reproduce
certain extreme knee deformities [6]. Restricted kinematic align-
ment limits such reproduction of deformity, which may be caused
by osteoarthritis [7], but restores pre-osteoarthritis anatomy in
less than 45% of cases [8]. Complementary intraoperative ligament
release is then needed, but this lacks precision and reproducibility
[9] and, even with the help of intraoperative load sensors, does not
improve patient satisfaction [10].
We describe an original technique to deal with these issues.
After the bone cuts, ligament balance is controlled intraoperatively
by a load sensor positioned between the trial implants and, as
needed, one or two re-cuts are made using a robotic arm until
∗ Corresponding author.
E-mail address: jbardoujacquet@me.com (J. Bardou-Jacquet).
(Figs. 1 and 2).
2. Surgical technique
Planning is based on preoperative CT-scan and the principles of
restricted kinematic alignment [12] as defined by Blakeney et al.
[13] (Fig. 3 and movie).
The patient is positioned supine on a standard table without
tourniquet. Medial parapatellar arthrotomy is performed, and pas-
sive navigation sensors are positioned at the femur and tibia. Bone
morphing is performed and coupled to the preoperative CT-scan.
The collateral ligaments are tensioned ahead of the first bone
cuts, by millimetric incremental metal bone paddles, to compen-
sate for cartilage wear. The position of the implants (Triathlon
Cruciate Retaining, Stryker, Kalamazoo, Michigan, USA) is then
adjusted on the interface so as to obtain constant 18 mm spaces
between femur and tibia in extension and 90◦ flexion, given that
implant size is 18 mm throughout the arc of flexion. Adjustment
seeks to modify the femoral axis of rotation only as a last resort
[14], respecting the limits of restricted kinematic alignment, so far
as this is possible, as described by Blakeney et al. [13].
Bone cutting uses the Mako robotic arm (Stryker, Kalamazoo,
Michigan, USA), then trial implants are positioned. The VERASENSE
load sensor (Orthosensor, Inc, Dania Beach, Florida, USA) is then

https://doi.org/10.1016/j.otsr.2021.102889
1877-0568/© 2021 Elsevier Masson SAS. All rights reserved.

Please cite this article as: J. Bardou-Jacquet, J. Murgier, F. Laudet et al., Combining load sensor and robotic technologies for ligament
balance in total knee arthroplasty, Orthop Traumatol Surg Res, https://doi.org/10.1016/j.otsr.2021.102889
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Fig. 1. Bone re-cut algorithm.
Table 1
Patient data.
Mean
Age (years) 70 ± 9.5
BMI (kg/m2 ) 28 ± 3.5
IKSS objective/100 (18) 49 ± 14
IKSS satisfaction/40 15 ± 8
IKSS expectation/15 14 ± 2
IKSS functional/100 43 ± 12
BMI: body-mass index; IKSS: International Knee Society Score 2011 [18].
positioned between the trial implants. The arthrotomy is closed
[15] and sensor data are acquired blindedly at 90◦ and 10◦ flex-
ion without varus or valgus constraint [16], with one hand under
the thigh and the other under the heel. The present knee balance
criteria are those of Gustke et al. [17]: 22 to 200 Newtons (5 to
45 pound-force (lbf)) between femur and tibia, with 66 N (15 lbf)
difference between the lateral and medial side (Fig. 2).
According to these data, polyethylene insert thickness is
adjusted and/or re-cuts are made (Fig. 1). Re-cutting uses the
robotic arm 3D interface, half-millimeter by half-millimeter, with a
load sensor check between cuts. No ligament release is performed,
and the posterior cruciate ligament is conserved without release.
Once balance has been achieved [18], the patella is resurfaced. The
final implants (cemented or not) are then introduced.
3. Results
A prospective consecutive series of 29 patients (14 male, 15
female) were operated on for osteoarthritis of the knee (Table 1).
Intraoperative navigation findings before tensioning and bone cut
comprised a mean 5 ± 6◦ flexion contracture (range, −15◦ recur-
vatum to 19◦ flexion contracture), 140 ± 4.8◦ (range, 124–148◦ )
maximum flexion, and Hip-Knee-Ankle angle (HKA) 175 ± 5.9◦
(range, 160–187◦ ). After the first bone cuts, 17 of the 29 cases (59%)
showed imbalance in flexion and/or extension on the load sensor:
i.e., > 66 N difference between medial and lateral sides. One of these
Orthopaedics & Traumatology: Surgery & Research xxx (xxxx) xxx
17 patients (patient 1, Fig. 4) did not undergo re-cut as the differ-
ence was considered slight by the surgeon, who preferred to avoid
Range a distal femoral re-cut on a knee that was already in recurvatum.
45–89 Thus 16 of the 29 cases (55%) underwent 1 or 2 re-cuts (Table 2).
22–34 Re-cut depended on the load sensor data: in case of > 66 N inter-
31–87 compartment difference in flexion and/or extension, a 0.5 mm cut
4–32 was made to obtain balance (Fig. 1). The sensor was then repo-
6–15
sitioned to check the result. In all, 27 cases (93%) were finally
25–68
well-balanced in extension and 23 (79%) in flexion and extension
(Table 2) on the criteria described above. One case showing bal-
ance on the sensor after the first bone cuts was considered to
show laxity by the surgeon, who increased the polyethylene thick-
ness by 2 mm, finally inducing imbalance on the criteria of Gustke
et al. [11] (patient 2, Table 1). No soft-tissue release procedures
were performed. With the final implants in place, the navigation
data showed a mean 2.8 ± 4.4◦ flexion contracture (range, recurva-
tum 5◦ to 16◦ flexion contracture), 135◦ flexion (range, 127–139◦ )
and 178.4 ± 3.2 HKA angle (range, 168◦ –184◦ ). Mean surgery time
was 72 ± 10 minutes (range, 55–95 min). Twenty-eight of the 29
patients had a 9 mm polyethylene insert. All tibial components
were non-cemented; 2 femoral implants were cemented because a
femoral re-cut was done in rotation. There were no intraoperative
complications. Table 3 shows results at 4 months.
4. Discussion
The present preliminary series confirmed the feasibility of opti-
mizing ligament tension without periarticular soft-tissue release,
using only bone cuts with a robotic arm under intraoperative load
sensor control: the number of knees showing balance in flexion and
extension increased from 12 to 23 out of 29 (Table 3).
Ligament balance enhances patient satisfaction in TKA [18].
Implant positioning according to restricted kinematic alignment
provides better balance than mechanical alignment [19], but soft-
tissue release remains necessary to achieve a “balanced knee” (30%
of cases for MacDessi et al. [20]). Soft-tissue release does not ensure
precise and reproducible balance [10], which may be why patient
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Fig. 2. Tibial re-cut for medially tight knee in flexion and extension: a: the sensor shows > 15 lbf (66 N) difference between the medial and lateral compartments in 10◦ and
90◦ flexion; b: trial implant positioning according to first bone cuts; blue circle: cut bone thickness (mm); red circle: tibial varus in frontal plane; b’: to reduce medial force
in flexion and extension, the tibia is further cut by 0.5 mm medially in the frontal plane (blue circle); the center of rotation of the cut plane is shifted laterally (red arrow)
and 0.5◦ varus is added to the frontal cut plane (red circle); c: the knee is balanced, with medial-lateral difference < 15 lbf (66 N) (range, 5–45 lbf (22–200 N)).

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Fig. 3. Preoperative CT planning for restricted kinematic alignment. Triathlon implant (Stryker, Kalamazoo, MI, USA), sparing the posterior cruciate ligament and with
constant femoral curvature angle. 1. 6.5 mm bone resection thickness (8.5 mm implant thickness minus 2 mm healthy cartilage). 2. Frontal deviation of the femoral implant
with respect to its mechanical axis, which should not exceed 5◦ varus/valgus. 3. 7 mm bone resection thickness (9 mm implant thickness minus 2 mm healthy cartilage). 4.
Frontal deviation of the tibial implant with respect to its mechanical axis, which should not exceed 5◦ varus/valgus. 5. Tibial medial resection thickness, reduced from 7 mm
to 4 mm so that tibial varus does not exceed 5◦ . The 7 mm lateral thickness is conserved, as the compartment is not worn. 6. Posterior tibial slope systematically at 3◦ . 7.
Implant sizes (1 to 7) and polyethylene thickness (mm).

Table 2
Ligament balance after bone cuts and use of load sensor: balanced if loading difference between medial and lateral femorotibial compartments < 66 N and load in each
compartment 22-200 N.

After first cut After re-cut or polyethylene alteration

◦ ◦ ◦ ◦
At 10 Flexion At 90 Flexion At 10 and 90 flexion At 10◦ Flexion At 90◦ Flexion At 10◦ and 90◦ flexion

Balanced Unbalanced Balanced Unbalanced Balanced Unbalanced Balanced Unbalanced Balanced Unbalanced Balanced Unbalanced

Total 13 16 18 11 12 17 27 2 24 5 23 6
Polyethylene 1 0 1 1 1 1 0 1
+2 mm
Tibial re-cut 0 8 0 8 0 8 8 8 8
only
(unbalanced at
10◦ and 90◦
flexion)
Frontal femoral 0 4 4 0 0 4 3 1 2 2 2 2
re-cut only
Horizontal 0 0 0 1 0 1 1 0 0 1 0 1
femoral re-cut
only
Tibial + femoral 0 3 1 2 0 3 3 0 2 1 2 1
re-cut
No change 12 1 1 11 1 1 1 11 1

Table 3
One-month follow-up data.

Number of patients Explanations

Walk without cane 19/29

Walk with 1 crutch 8/29 One with unbalanced ligament tension at end of procedure
Walk with 2 crutches 2/29 One 85 year-old and one 49 year-old using Fentanyl skin patches for > 1 year resistant
to analgesia
Complication 0 No infection, all wounds healed, no phlebitis, no fracture, no indication for
mobilization under general anesthesia or surgical revision
Total clinical extension 27/29 Patient with 16◦ flexion contracture at end of procedure showed no clinical flexion
contracture at 1 month
◦
10 clinical flexion 2/29 Intraoperative imbalance in flexion, loading greater medially
contracture
Flexion > 90◦ 23/29 Mean: 103◦ (range, 90–110◦ )
Flexion < 90◦ 6/29 Mean: 79◦ (range, 70–85◦ )

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Fig. 4. Data for knees unbalanced at end of procedure. HKA: Hip-Knee-Ankle angle; Var: Varus; Val: Valgus. Unbalanced knee: > 66 N loading difference between medial and
lateral femorotibial compartments and/or < 22 N or > 200 N load in each compartment.

satisfaction is not improved despite the use of an intraoperative interface enable reliable and reproducible 3D re-cutting to within
load sensor [21]. Load sensors assess ligament balance with the a half-millimeter [23,24]. Combining the 2 technologies optimized
trial implants in position [22]. In the present series, balance was balance in flexion and extension in 23 of the 29 knees. Five of the
sought in 2 steps, with no soft-tissue release. The robotic arm and its remaining 6 patients showed imbalance at 90◦ flexion (Table 2).

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This may have been due to the surgeon’s unwillingness to make
a femoral cut in rotation, liable to impair press-fit of the femoral
component. Such a 0.5 mm press-fit deficit should, however, be
weighed against the imprecision of classic cut guides, which is
of the order of a millimeter. Moreover, the imbalance was greatly
improved by re-cutting, and the difference can be considered neg-
ligible. A 2-year follow-up in a larger series could determine what
degree of intraoperative ligament imbalance is acceptable. In all
cases, bone re-cuts improved ligament balance and came closer to
meeting the criteria of Gustke et al. [17].
In the present technique, new technologies improved the pre-
cision of ligament balance. The strategy remains to be validated,
notably from the economic point of view, by long-term clinical
studies.
Disclosure of interest
Julien Bardou-Jacquet is a consultant with Stryker and Ortho-
sensor. J Murgier is an associate editor of Orthopaedics &
Traumatology: Surgery & Research and receives financial support
from Stryker and Smith & Nephew, unrelated to the present study.
Thierry Fabre receives financial support from Zimmer Biomet,
Corin and Orthojet, unrelated to the present study. François Laudet
declares that they have no competing interest.
Funding
None.
Author contributions
J. Bardou-Jacquet designed the technique, set up the study, col-
lected and analyzed the data, and wrote the article.
J. Murgier took part in article writing and critical re-editing
F. Laudet made the surgery movie.
T. Fabre took part in article writing and critical re-editing.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.otsr.2021.102889.
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